DOCSLIB.ORG

Telemedicine Management of Musculoskeletal Issues Nicole T

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Telemedicine Management of Musculoskeletal Issues Nicole T Telemedicine Management of Musculoskeletal Issues Nicole T. Yedlinsky, MD, University of Kansas Medical Center, Kansas City, Kansas Rebecca L. Peebles, DO, Ehrling Bergquist Family Medicine Residency Program, Offutt Air Force Base, Nebraska; Uniformed Services University of the Health Sciences, Bethesda, Maryland Telemedicine can provide patients with cost-effective, quality care. The coronavirus disease 2019 pandemic has highlighted the need for alternative methods of delivering health care. Family physi- cians can benefit from using a standardized approach to evaluate and diagnose musculoskeletal issues via telemedicine visits. Previsit planning establishes appropriate use of telemedicine and ensures that the patient and physician have functional telehealth equipment. Specific instructions to patients regard- ing ideal setting, camera angles, body positioning, and attire enhance virtual visits. Physicians can obtain a thorough history and perform a structured musculoskel- etal examination via telemedicine. The use of common household items allows physicians to replicate in-person clinical examination maneuvers. Home care instructions and online rehabilitation resources are available for ini- tial management. Patients should be scheduled for an in-person visit when the diagnosis or management plan is in question. Patients with a possible deformity or neuro- vascular compromise should be referred for urgent evaluation. Follow-up can be done virtually if the patient’s condition is improving as expected. If the condition is worsening or not improving, the patient should have an in-office assessment, with consideration for referral to formal physical therapy or spe- cialty services when appropriate. (Am Fam Physician. 2021;103:online. Copyright © 2021 American Academy of Family Physicians.) Illustration by Jennifer Fairman by Jennifer Illustration Published online January 12, 2021. history collection, virtual physical examination, and initial treatment options. Telemedicine has rapidly become a valuable tool during the coronavirus disease 2019 (COVID-19) Virtual Visit Preparation pandemic.1 Given that musculoskeletal issues are Before the visit, initial preparation includes con- a common reason for primary care visits,2,3 a stan- firming that the patient has functional audio- dardized examination to evaluate these issues via visual resources and providing instructions on telemedicine is useful. Video-assisted orthopedic ideal setting, camera angles, body positioning, consultation for selected patients is cost-effective and attire.6 The physician should review any and does not result in serious adverse events.4,5 previous imaging studies beforehand. Multiple This article discusses telemedicine methods telehealth platforms are compliant with the U.S. and techniques, including visit preparation, Health Insurance Portability and Accountability Act (HIPAA).7 A guide for preparing a medical Additional content at https:// www.aafp.org/afp/ 2021/ 0201/ practice for virtual visits was published previ- 8 CMEp147.html credit. for this article will be available when it is pub- ously in FPM. lishedCME This in print. clinical content conforms to AAFP criteria for Virtual Musculoskeletal Evaluation CME.Author See disclosure: CME Quiz No on relevant page 141. financial affiliations. Author disclosure: No relevant financial affiliations. Patients should be asked about the timing and characteristics of symptom onset, associated Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2021 American Academy of Family Physicians. For the private, noncom- Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2021 American Academy of Family Physicians. For the private, noncom- ◆ 1 mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. FebruaryJanuarymercial 12, 1,use 2021 of one Volume Onlineindividual 103, user Number of the website. 3 All other rightswww.aafp.org/afp reserved. Contact [email protected] for copyright questionsAmerican and/or permission Family Physician requests. TELEMEDICINE: MUSCULOSKELETAL ISSUES FIGURE 1 Acromiocla- A B Acromion Clavicle vicular joint Acromion Greater tuberosity Spine of Bicipital the scapula Sternocla- groove vicular joint Shoulder palpation positioning. (A) Anterior view. (B) Posterior view. trauma, location of pain, presence of swell- adhesive capsulitis or severe osteoarthritis.9,13,14 ing, subsequent course, and current status. Patients should also be asked about distal neuro- Functional impact on activities of daily living, vascular symptoms of the upper extremity, such employment, and recreational activities should as weakness or paresthesia. be established. Physicians should ask about pre- The virtual physical examination begins with vious injuries and surgeries, as well as previous inspection. The patient should wear a tank top management and response. or sports bra according to individual comfort. The virtual physical examination should The patient should be asked to face the camera include inspection, palpation, range of motion, and then slowly rotate their body 360 degrees strength, neurovascular assessment, and special so that the physician can observe the shoulder tests.9,10 Although certain maneuvers are difficult joint in all planes. The physician should look to perform virtually, modifications can provide for asymmetry, deformity, abnormal posture, useful information. It may be helpful for the overlying skin changes, atrophy, erythema, and patient to mirror the physician’s motions. ecchymosis. The physician should ask the patient to point SHOULDER to the area of maximal tenderness. The patient For shoulder problems, the physician should ask should be directed to use the contralateral hand if the patient’s primary concern is pain, weakness, to palpate the sternoclavicular joint, clavicle, or decreased range of motion. Pain in the absence acromioclavicular joint, acromion, and spine of of a recent traumatic event often indicates shoul- the scapula, as range of motion allows. Patients der impingement or calcific tendinopathy.11 Pain can also locate and palpate the bicipital groove with cross-arm adduction can indicate acro- and greater tuberosity of the humerus with direc- mioclavicular pathology.9,11,12 Weakness suggests tion from the physician (Figure 1). complete rotator cuff tear or nerve pathology. Shoulder abduction, forward flexion, exten- Decreased range of motion raises suspicion for sion, external rotation, and internal rotation 2 American Family Physician www.aafp.org/afp Volume 103, NumberOnline 3 ◆ JanuaryFebruary 12, 1, 2021 TABLE 1 Telemedicine Assessment of Upper Extremity Range of Motion Plane of range Normal range of active range of motion (Table 111) 11 of motion Patient body positioning* motion (degrees) should be assessed. Alterations of scap- Shoulder ular motion during abduction and Abduction Away from the camera 180 flexion indicate scapular dyskinesia or Extension 90 degrees to the side 45 to 60 weakness of the scapular stabilizing muscles. Flexion 90 degrees to the side for mea- 180 surement, away from the camera Strength testing can be performed for scapular stability by asking the patient to move their Internal Away from the camera for Apley Able to reach shoulder against gravity or by using rotation scratch test vertebral height common household items (Table 2). of T4-T8 Table 3 summarizes suggested rotator 9,11,15 90 degrees to the side, elbow 90 cuff strength tests. Neurovascular abducted to 90 degrees assessment can be completed by hav- External 90 degrees to the side, elbow 90 ing the patient perform a wall push-up rotation at the side so that the physician can look for 90 degrees to the side, elbow 90 scapular winging. Special tests of the abducted to 90 degrees shoulder, such as Speed test to check for proximal biceps tendinopathy and Elbow O’Brien test to detect labral pathology, Flexion Facing the camera, arm 135 to 150 abducted to 90 degrees can be performed using household items as resistance. Extension Same as flexion –10 to 0 Supination Facing the camera, elbow resting 75 to 90 ELBOW on table with arm to the side and elbow flexed to 90 degrees Virtual examination of the elbow begins with inspection of the affected Pronation Same as supination 75 to 90 side and comparison with the unaf- Wrist fected side, looking for erythema, Dorsiflexion 90 degrees to the side 70 deformity, swelling, ecchymosis, and overlying skin changes. The biceps and Palmar flexion Same as dorsiflexion 80 to 90 triceps should be checked for defor- Radial deviation Facing the camera 20 to 30 mity to evaluate for tendon rupture. Ulnar deviation Facing the camera 50 The patient should palpate over the *—Relative to the camera. lateral epicondyle, medial epicondyle, Information from reference 11. and olecranon to check for tenderness (Figure 2). Range of motion assess- ment is reviewed in Table 1.11 Strength of elbow flexion and extension can TABLE 2 be assessed using gravity or common household items (Table 2). Pain that Common Household Items That Can Be Used localizes to the lateral epicondyle with in Telemedicine Strength Testing wrist extension and supination while Item Approximate weight holding a weighted object is suggestive of lateral epicondylitis. Similarly, pain Roll of nickels, cup of sugar, or three C cell batteries 0.5 lb (0.23 kg) that localizes to the medial epicondyle Can of soup, block of butter, or
Load more

Recommended publications
  • Knee Examination (ACL Tear) (Please Tick)
    Year 4 Formative OSCE (September) 2018 Station 3 Year 4 Formative OSCE (September) 2018 Reading for Station 3 Candidate Instructions Clinical Scenario You are an ED intern at the Gold Coast University Hospital. Alex Jones, 20-years-old, was brought into the hospital by ambulance. Alex presents with knee pain following an injury playing soccer a few hours ago. Alex has already been sent for an X-ray. The registrar has asked you to examine Alex. Task In the first six (6) minutes: • Perform an appropriate physical examination of Alex and explain what you are doing to the registrar as you go. In the last two (2) minutes, you will be given Alex’s X-ray and will be prompted to: • Interpret the radiograph • Provide a provisional diagnosis to the registrar • Provide a management plan to the registrar You do not need to take a history. The examiner will assume the role of the registrar. Year 4 Formative OSCE (September) 2018 Station 3 Simulated Patient Information The candidate has the following scenario and task Clinical Scenario You are an ED intern at the Gold Coast University Hospital. Alex Jones, 20-years-old, was brought into the hospital by ambulance. Alex presents with knee pain following an injury playing soccer a few hours ago. Alex has already been sent for an X-ray. The registrar has asked you to examine Alex. Task In the first six (6) minutes: • Perform an appropriate physical examination of Alex and explain what you are doing to the registrar as you go. In the last two (2) minutes, you will be given Alex’s X-ray and will be prompted to: • Interpret the radiograph • Provide a provisional diagnosis to the registrar • Provide a management plan to the registrar You do not need to take a history.
    [Show full text]
  • Musculoskeletal Clinical Vignettes a Case Based Text
    Leading the world to better health MUSCULOSKELETAL CLINICAL VIGNETTES A CASE BASED TEXT Department of Orthopaedic Surgery, RCSI Department of General Practice, RCSI Department of Rheumatology, Beaumont Hospital O’Byrne J, Downey R, Feeley R, Kelly M, Tiedt L, O’Byrne J, Murphy M, Stuart E, Kearns G. (2019) Musculoskeletal clinical vignettes: a case based text. Dublin, Ireland: RCSI. ISBN: 978-0-9926911-8-9 Image attribution: istock.com/mashuk CC Licence by NC-SA MUSCULOSKELETAL CLINICAL VIGNETTES Incorporating history, examination, investigations and management of commonly presenting musculoskeletal conditions 1131 Department of Orthopaedic Surgery, RCSI Prof. John O'Byrne Department of Orthopaedic Surgery, RCSI Dr. Richie Downey Prof. John O'Byrne Mr. Iain Feeley Dr. Richie Downey Dr. Martin Kelly Mr. Iain Feeley Dr. Lauren Tiedt Dr. Martin Kelly Department of General Practice, RCSI Dr. Lauren Tiedt Dr. Mark Murphy Department of General Practice, RCSI Dr Ellen Stuart Dr. Mark Murphy Department of Rheumatology, Beaumont Hospital Dr Ellen Stuart Dr Grainne Kearns Department of Rheumatology, Beaumont Hospital Dr Grainne Kearns 2 2 Department of Orthopaedic Surgery, RCSI Prof. John O'Byrne Department of Orthopaedic Surgery, RCSI Dr. Richie Downey TABLE OF CONTENTS Prof. John O'Byrne Mr. Iain Feeley Introduction ............................................................. 5 Dr. Richie Downey Dr. Martin Kelly General guidelines for musculoskeletal physical Mr. Iain Feeley examination of all joints .................................................. 6 Dr. Lauren Tiedt Dr. Martin Kelly Upper limb ............................................................. 10 Department of General Practice, RCSI Example of an upper limb joint examination ................. 11 Dr. Lauren Tiedt Shoulder osteoarthritis ................................................. 13 Dr. Mark Murphy Adhesive capsulitis (frozen shoulder) ............................ 16 Department of General Practice, RCSI Dr Ellen Stuart Shoulder rotator cuff pathology ...................................
    [Show full text]
  • Mcmaster Musculoskeletal Clinical Skills Manual 1E
    McMaster Musculoskeletal Clinical Skills Manual Authors Samyuktha Adiga Dr. Raj Carmona, MBBS, FRCPC Illustrator Jenna Rebelo Editors Caitlin Lees Dr. Raj Carmona, MBBS, FRCPC In association with the Medical Education Interest Group Narendra Singh and Jacqueline Ho (co-chairs) FOREWORD AND ACKNOWLEDGEMENTS The McMaster Musculoskeletal Clinical Skills Manual was produced by members of the Medical Education Interest Group (co-chairs Jacqueline Ho and Narendra Singh), and Dr. Raj Carmona, Assistant Professor of Medicine at McMaster University. Samyuktha Adiga and Dr. Carmona wrote the manual. Illustrations were done by Jenna Rebelo. Editing was performed by Caitlin Lees and Dr. Carmona. The Manual, completed in August 2012, is a supplement to the McMaster MSK Examination Video Series created by Dr. Carmona, and closely follows the format and content of these videos. The videos are available on Medportal (McMaster students), and also publicly accessible at RheumTutor.com and fhs.mcmaster.ca/medicine/rheumatology. McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona McMaster Musculoskeletal Clinical Skills Manual TABLE OF CONTENTS General Guide 1 Hip Examination 3 Knee Examination 6 Ankle and Foot Examination 12 Examination of the Back 15 Shoulder Examination 19 Elbow Examination 24 Hand and Wrist Examination 26 Appendix: Neurological Assessment 29 1 GENERAL GUIDE (Please see videos for detailed demonstration of examinations) Always wash your hands and then introduce yourself to the patient. As with any other exam, ensure adequate exposure while respecting patient's modesty. Remember to assess gait whenever doing an examination of the back or any part of the lower limbs. Inspection follows the format: ● S welling ● E rythema ● A trophy ● D eformities ● S cars, skin changes, etc.
    [Show full text]
  • Knee Examination
    Checklist for Physical Examination of the Knee Muscuoskeletal Block -- Chris McGrew MD, Andrew Ashbaugh DO This handout is for use as a “rough” guide and study aid. Your instructor may perform certain maneuvers differently than depicted here. I acknowledge that this may be frustrating, but please try to be understanding of this inter-examination variability. A. Inspection 1) Standing - alignment, foot structure, hip/pelvis 2) Gait – Observe (is there a limp?) 3) Supine – effusion, erythema, quadriceps muscle (atrophy?) “Var us my pig” B. Palpation 1) Warmth, Crepitus, Effusion 2) Tenderness – medial/lateral joint lines, MCL, LCL, patellar facets, quadriceps insertions, patellar tendon, IT Band, pes anserine bursa Milk test for effusion Start at inferior pole of patella, drop down and move medially and laterally to joint lines. Then condyles and plateuas, Then patellar tendon. For patella check poles and facets. C. Range of Motion --Need to check both hip and knee ROM as hip pathology can refer pain to the knee. 1) Hip ROM: flexion, internal and external rotation 120 degrees Int Rot: Ext Rot: 0 degrees 30-40 40-60 2) Knee flexion and extension (know difference between AROM and PROM) 3) Hamstring flexibility (compare to other side) Popliteal angle test: hip flexed to 90, knee flexed to 90, then examiner passively extends knee till it reaches it resistance. D. Manual Muscle Testing / Neurovascular exam 1) Knee Extension/Flexion (MMT of quadriceps and hamstrings) 2) Distal Neurovascular: pulses, gross sensation, capillary refill. Dorsalis pedis pulse found best in line with the second toe. E. Special Tests 1) Patellar Examination a) Q-angle, be able to visualize varus or valgus b) Patellar compression/grind c) Patellar glide/tilt d) Apprehension sign Patellar compression/grind test (PFPS, chondromalacia patellae) Have patients knee bent at 20-30 degrees, hold their patella in place and have them slowly activate their quadriceps muscles and to stop if it hurts.
    [Show full text]
  • Knee Examination
    Knee Examination Video.(Was done by the department) ​ Objective: To be able to perform examination of the knee and to distinguish and identify an abnormal finding that suggests a pathology. Done By: Fahad Alabdullatif ​ Edited & Revised By: Adel Al Shihri & Moath Baeshen. ​ ​ ​ References: Department handout, Notes(by moath baeshen), Browse’s,433 OSCE Team. ​ Look ❖ Standing: ​ ➢ Expose both lower limbs from mid-thigh down. ➢ Comment on knee alignment while standing (varus/valgus /or neutral) and whither physiological or pathological). ➢ Look for abnormal motion of the knees while walking. ➢ Look for ankle and foot alignment and position. ➢ Gait. ❖ Supine ➢ Alignment ( physiological valgus, abnormal valgus, varus) ➢ Skin changes ➢ Varicose veins ➢ Swelling ➢ Muscle wasting (quadriceps) (Should be measured by a measuring tape guess) ​ ➢ Inspect the back of the knee. (Baker’s cyst) ​ Feel 1. Before touching the patient ask if he has any pain 2. Always compare to the other side ❖ Check and compare temperature ❖ Feel for any lumps or bumps in the soft tissue or bone around the knee – comment if present ➢ Baker's cyst (in popliteal fossa) ❖ Identify bony landmarks (femoral and tibial condyles, tuberosity, proximal fibula, patella and comment if ​ tender) (Best done with the knees flexed. Keep looking at the patient’s face.) (Tenderness over the tibial ​ tuberosity may indicate Osgood–Schlatter disease) ❖ Identify course of collateral ligaments and comment if tender ❖ Identify joint line in flexion of 80 - 90 degrees and comment if tender (Joint line tenderness = meniscus ​ ​ injury) (Identify the quadriceps tendon ​ ​ checking for a gap) ❖ You should know surface anatomy to localize the site of abnormality, in the exam the SP may points to an area that hurts, you should be able to identify it.
    [Show full text]
  • Soldier's Manual and Trainer's Guide
    STP 8-68W13-SM-TG 3 May 2013 SOLDIER’S MANUAL AND TRAINER’S GUIDE MOS 68W HEALTH CARE SPECIALIST SKILL LEVELS 1/2/3 HEADQUARTERS, DEPARTMENT OF THE ARMY DISTRIBUTION RESTRICTION: Distribution authorized to US Government agencies and their contractors only to protect technical and operational information from automatic dissemination under the International Exchange Program or by other means. This determination was made on 12 September 2011. Other requests for this documentation will be referred to MCCS-IN, 3630 Stanley Rd Ste 101 Ft Sam Houston, TX 78234-6100. DESTRUCTION NOTICE: Destroy by any approved method, i.e., shredding, pulping, or pulverizing, that will prevent disclosure of contents or reconstruction of this document.. This publication is available at Army Knowledge Online (https://armypubs.us.army.mil/doctrine/index.html). To receive publishing updates, please subscribe at http://www.apd.army.mil/AdminPubs/new_subscribe.asp. STP 8-68W13-SM-TG 1SOLDIER TRAINING PUBLICATION HEADQUARTERS No. 8-68W13-SM-TG DEPARTMENT OF THE ARMY Washington, DC 3 May 2013 SOLDIER’s MANUAL and TRAINER’S GUIDE MOS 68W Health Care Specialist Skill Levels 1, 2 and 3 TABLE OF CONTENTS PAGE Table of Contents………………………………….…………………………………………….i Preface………………………………………………………………..……………………….…..v Chapter 1. Introduction ........................................................................................................... 1-1 1-1. General .............................................................................................................. 1-1 1-2.
    [Show full text]
  • Orthopaedic Examination Spinal Cord / Nerves
    9/6/18 OBJECTIVES: • Identify the gross anatomy of the upper extremities, spine, and lower extremities. • Perform a thorough and accurate orthopaedic ORTHOPAEDIC EXAMINATION examination of the upper extremities, spine, and lower extremities. • Review the presentation of common spine and Angela Pearce, MS, APRN, FNP-C, ONP-C extremity diagnoses. Robert Metzger, DNP, APRN, FNP - BC • Determine appropriate diagnostic tests for common upper extremity, spine, and lower extremity problems REMEMBER THE BASIC PRINCIPLES OF MUSCULOSKELETAL EXAMINATION Comprehensive History Comprehensive Physical Exam THE PRESENTERS • Chief Complaint • Inspection • HPI OLDCART • Palpation HAVE NO CONFLICTS OF INTEREST • PMH • Range of Motion TO REPORT • PSH • Basic principles use a goniometer to assess joint ROM until you can • PFSH safely eyeball it • ROS • Muscle grading • Physical exam one finger point • Sensation to maximum pain • Unusual findings winging and atrophy SPINAL COLUMN SPINAL CORD / NERVES • Spinal cord • Begins at Foramen Magnum and • Consists of the Cervical, Thoracic, continues w/ terminus at Conus Medullaris near L1 and Lumbar regions. • Cauda Equina • Collection of nerves which run from • Specific curves to the spinal column terminus to end of Filum Terminale • Lordosis: Cervical and Lumbar • Nerve Roots • Kyphosis: Thoracic and Sacral • Canal is broader in cervical/ lumbar regions due to large number of nerve roots • Vertebrae are the same throughout, • Branch off the spinal cord higher except for C1 & C2, therefore same than actual exit through
    [Show full text]
  • Physical Examination of Knee Ligament Injuries..Pdf
    Review Article Physical Examination of Knee Ligament Injuries Abstract Robert D. Bronstein, MD The knee is one of the most commonly injured joints in the body. Joseph C. Schaffer, MD A thorough history and physical examination of the knee facilitates accurate diagnosis of ligament injury. Several examination techniques for the knee ligaments that were developed before advanced imaging remain as accurate or more accurate than these newer imaging modalities. Proper use of these examination techniques requires an understanding of the anatomy and pathophysiology of knee ligament injuries. Advanced imaging can be used to augment a history and examination when necessary, but should not replace a thorough history and physical examination. he knee joint is one of the most injuries because the current injury may Tcommonly injured joints in the be the sequela of a previous injury. body. Knee ligament injury and sub- Here, we present specific tech- sequent instability can cause consid- niques for the ligamentous exami- erable disability. Diagnosis of knee nation, including identifying injuries ligament injuries requires a thorough of the anterior cruciate ligament understanding of the anatomy and (ACL), the medial collateral liga- the biomechanics of the joint. Many ment (MCL), the lateral collateral specific examination techniques were ligament (LCL), the posterolateral cor- developed before advanced imaging, ner (PLC), and the posterior cruciate and several techniques remain as ligament (PCL), and describe the asso- accurate or more accurate than the ciated anatomy and biomechanics and From the Division of Sports Medicine, new imaging modalities. Advanced the methods that allow for increased Department of Orthopaedics, University of Rochester School of Medicine and imaging (eg, MRI) is appropriate to diagnostic sensitivity and accuracy.
    [Show full text]
  • General Physical Examination
    BLSA Operations Manual Volume I Section IV, page 1 GENERAL PHYSICAL EXAMINATION 1. Background and Rationale The physical examination is an important component of translational research. It yields noninvasive, inexpensive and informative data that contributes to clinically relevant diagnoses, prognosis, and assessment of risk. In addition, the physical examination is important to participants and promotes recruitment and retention in the study. 1.1 Objective The objectives of the physical examination are: 1) To document physical findings in the cardiovascular, musculoskeletal and nervous systems that are related to mobility in older adults 2) To screen participants for testing exclusion criteria to allow safe and meaningful completion of performance testing 1.1 Recommended Instrument(s) 1.2 Strengths and weaknesses of selected approach The strengths of the physical examination include ease of performance, non- invasive nature (i.e. low risk), and direct contact with participants. The weakness of the physical examination, in general, is related to the potential variation in assessment measures and the level of expertise of examiners, the lack of standardized assessment methods for research, and the subjective nature. These effects can be limited by implementing standardized protocols using published techniques when available, utilizing experienced nurse practitioners (NPs) and physicians, training the examiners in standardized fashion, and incorporating ongoing quality control programs that include direct observation and certification. 1.3 Analagous (past) measures used in the BLSA This is the first version of a fully standardized physical examination protocol that has undergone rigorous training, certification processes, monitoring and quality control checks. 1.4 Reliability/Validity Studies Limited studies are available on performing the physical examination for Version 1.0 BLSA Operations Manual Volume I Section IV, page 2 research purposes.
    [Show full text]
  • Osteotomy.Pdf
    Table of Contents About the Authors 5 Introduction 7 Basic Knee Anatomy 9 Understanding Lower Limb Malalignment 12 The Basics 12 Primary, Double, and Triple Varus 14 The Influence of Gait (How We Walk) on Forces in the Knee 18 What Happens in the Arthritis Process in the Knee Joint? 20 The Demise of Articular Cartilage 20 Types of Knee Arthritis 21 The Knee Examination 22 History 22 Where Does It Hurt? 22 Range of Knee Motion 23 Knee Ligament Tests 23 Meniscus Tests 25 Knee Joint Crepitus 25 The Patellofemoral Joint 26 Lower Limb Alignment and Gait Analysis 26 Muscle Strength and Function 26 Imaging Studies (X-rays, MRI) 26 Conservative Treatment: What You Should Have Already Tried 28 A Few Comments 28 Mild Arthritis Pain 29 Moderate Arthritis Pain 29 Severe Arthritis Pain 29 Choosing an Orthopaedic Surgeon in the United States 30 High Tibial Osteotomy for Varus (Bowed Leg) Malalignment 31 Indications 31 Contraindications 32 Timing of Knee Ligament Reconstruction if Required 33 Preoperative Planning 34 Choosing Between an Opening Wedge and Closing Wedge Procedure 35 Initial Steps for Both Osteotomy Procedures 36 Opening Wedge Osteotomy 37 Closing Wedge Osteotomy 40 Possible Complications 41 Expected Results 41 Distal Femoral Osteotomy for Valgus (Knock-Knee) Malalignment 42 Indications 42 Contraindications 43 Preoperative Planning 44 How the Operation May Be Done 44 Possible Complications 46 Expected Results 46 Limb Alignment Osteotomy Versus Partial Knee Replacement 46 Common Associated Operative Procedures 47 ACL Reconstruction 47 PCL
    [Show full text]
  • Lower Limb Orthopaedic Examination Workshop Mr Venu Kavarthapu, Mr Patrick Li
    1 Lower Limb Orthopaedic Examination Workshop Mr Venu Kavarthapu, Mr Patrick Li General Tips Movements: Hip- passive only. Knee-passive and active. Foot and ankle- passive and active. Spine- active only. Always consider examining (screening) the joint above and below as appropriate ______________________________________ Hip Examination (Common pathological conditions: Young adults: Sports injuries, Hip Impingement, Hip Dyspasia. Middle aged: Sports injuries, Hip Impingement, Hip Dyspasia, Osteoarthritis. Older patients: Osteoarthritis.) Pitfalls: Hip pain is generally felt in the groin, trochanter (lateral), anterior thigh, buttock (posterior trochanter) and knee regions. It is important to identify conditions such as Hip Dysplasia and Hip Impingement in young patients before they become severely symptomatic as the treatment is less invasive if identified early. Look for other sources of pain such as lower back, sacro-iliac joint, inguinal hernia etc. Standing Look from front Shoulder level Pelvis level Leg alignment (knee) Leg lengths Look from side Spine alignment Gluteal muscle bulk Attitude of hip and knee joints Look from behind Spine alignment Hindfoot Gait Antalgic gait Trendelenburg’s sign Spine screening Sitting Knee screening Look spine Supine Non-weight bearing alignment of legs Apparent leg length measurement True leg length measurement 2 Tenderness over trochanter, anterior hip region, other tender areas Movements: Thomas’ test (for fixed flexion deformity) Internal rotation and external rotation in hip flexion Internal rotation and external rotation in hip extension (look at knee caps) Abduction Adduction Prone position Hip extension Sacro-iliac joint tenderness Special situations Young Patient: Young patients with hip pain may have Hip Impingement Syndrome. Hip Impingement sign may be the only positive finding.
    [Show full text]
  • C:\Users\Susan\American Board of Family Medicine\ABFM Editors
    American Board of Family Medicine IN-TRAINING EXAMINATION Publication or reproduction in whole or in part is strictly prohibited. Copyright © 2019 The American Board of Family Medicine. All rights reserved. 1. A 42-year-old female presents for follow-up after being treated for recurrent respiratory problems at an urgent care facility. She is feeling a little better after a short course of oral prednisone and use of an albuterol (Proventil, Ventolin) inhaler. She has had a gradual increase in shortness of breath, a chronic cough, and a decrease in her usual activity level over the past year. She has brought a copy of a recent chest radiograph report for your review that describes panlobular basal emphysema. She does not have a history of smoking, secondhand smoke exposure, or occupational exposures. Spirometry in the office reveals an FEV1/FVC ratio of 0.67 with no change after bronchodilator administration. Which one of the following underlying conditions is the most likely cause for this clinical presentation? A) 1-Antitrypsin deficiency B) Bronchiectasis C) Diffuse panbronchiolitis D) Interstitial lung disease E) Left heart failure 2. An otherwise healthy 57-year-old male presents with mild fatigue, decreased libido, and erectile dysfunction. A subsequent evaluation of serum testosterone reveals hypogonadism. Which one of the following would you recommend at this time? A) No further diagnostic testing B) A prolactin level C) A serum iron level and total iron binding capacity D) FSH and LH levels E) Karyotyping 3. A 4-year-old female is brought to your office because of a history of constipation over the past several months.
    [Show full text]