Post on 16-Dec-2015
COMMON KNEE AND SHOULDER PROBLEMS
CLINICAL ASSESSMENT MRI IMAGING
MRI
PANACEA ? PANDORA’S BOX ?
MRI
INCEPTION 1980’S REVOLUTIONIZED EVALUATION OF STI SUPERB ST CONTRAST cf OTHER DI MULTIPLE PLANES
MRI 101
PROTONS ALIGN WITH MAGNETIC FIELD RFW DISTURB ALIGNMENT. ENERGY RELEASED DURING
REALIGNMENT MEASURED AND USED TO GENERATE IMAGE
RF SEQUENCES MANIPULATED TO HIGHLIGHT DIFFERENT TISSUES IN DIFFERENT WAYS
MRI 101 (continued)
TEMPTATION REALITY
SOPHISTICATED, ELEGANT TECHNOLOGY
ANATOMY TEXT-LIKE IMAGES
TEMPTING TO VIEW AS THE DEFINITIVE Ix
DEPENDING ON TISSUE, SENSITIVITY 80 – 95%
SPECIFICITY LESS THUS POTENTIALLY
SIGNIFICANT FALSE + AND FALSE -
MRI 101 (cont)
OTHER PROBLEMS
EXPENSIVE LONG WAITS -> CAN LEAD
TO UNNECESSARY DELAY IN RX
PATIENT INTOLERANCE PRESSURES TO ORDER
FROM PTS, PT, DC, LAWYER, ETC (might be easier to say “can’t order” than to spend time explaining why inappropriate)
TIME TO PROPERLY COMPLETE REQUISITION
ACUTE KNEE INJURIES
HISTORY:• MECHANISM OF
INJURY• SWELLING• MECHANICAL
SYMPTOMS• PAIN
MENISCAL TEAR
MECHANISM: Compression usually necessary, rotation, valgus
MEDIAL > LATERAL SWELLING: Gradual MECHANICAL SX: Clunking, locking PAIN: Not necessarily localized
MENISCAL TEAR
CLINICAL ASSESSMENT:SQUAT
MENISCAL TEAR
CLLINICAL ASSESSMENT:THESSALY TEST
MENISCAL TEAR
CLINICAL ASSESSMENT:JOINT LINE TENDERNESS
MENISCAL TEAR
CLINICAL ASSESSMENT:McMURRAY
ACUTE KNEE INJURY: ? XRAY
OTTAWA KNEE RULES
AGE > 55 ISOLATED TENDERNESS
OF PATELLA (NO OTHER BONY TENDERNESS)
TENDERNESS OF HEAD OF FIBULA
INABILITY TO FLEX KNEE TO 90 DEGREES
INABILITY TO BEAR WEIGHT IMMEDIATELY AND IN ER
(MASSIVE SWELLING)
MENISCAL TEAR: ?MRI
YES NO
EQUIVOCAL CLINICAL PRESENTATION AND NO IMPROVEMENT WITH PT
HIGH SUSPICION OF OTHER INJURY (ACL, PCL, SUBCHONDRAL)
CLASSICAL PRESENTATION
DEGENERATIVE CHANGES
MEDIAL MENISCAL TEAR
MCL SPRAIN
MECHANISM: VALGUS STRESS IF SIGNIFICANT SWELLING SUSPECT
ASSOCIATED INJURY IF SENSE OF INSTABILITY AND LITTLE PAIN
SUSPECT HIGH-GRADE INJURY
CLINICAL ASSESSMENT: VALGUS STRESS AT 30 DEGREES AND FULL EXTENSION (if gap at full extension, suspect MCL + ACL)
Gr 1: 1-5 mm, firm EF Gr 2: 6-10 mm, firm Gr 3: >10 mm, soft
MCL SPRAIN
MCL SPRAIN: ?MRI
YES NO
HIGH SUSPICION OF ACL OR PCL
ISOLATED MCL
MCL - MRI
NORMAL
MCL SPRAIN - MRI
GR 2 GR 3
ACL SPRAIN
MECHANISM: ROTATION, VALGUS, HYPEREXTENSION
SWELLING: IMMEDIATE, MASSIVE MECHANICAL SX: INSTABILITY PAIN: DIFFUSE
DO NOT MISS THIS
ACL SPRAIN
CLINICAL ASSESSMENT: LACHMAN TEST
Gr 1: 1-5mm > contralat
Gr 2: 6-10mm Gr 3: >10mm A=firm B=soft
ACL SPRAIN
CLINICAL ASSESSMENT: ANTERIOR DRAWER
ACL SPRAIN
CLINICAL ASSESSMENT: PIVOT SHIFT
Knee relaxed, full ext. Valgus stress to tibia with axial load and int rot. Knee flexed. Lat tibia subluxes, reduces with flex.
Gr 0: no detectable shift Gr 1: glide Gr 2: abrupt reduction Gr 3: temporary lock then
reduction
ACL SPRAIN
CLINICAL ASSESSMENT: PIVOT SHIFT
ACL SPRAIN: ?MRI
YES NO
HIGH LIKELIHOOD OF ASSOCIATED STI, SUBCHONDRAL INJURY, BONE BRUISING
“OLDER” PATIENT WHO IS BETTER MANAGED WITH PT, ACTIVITY MODIFICATION, BRACING
ACL TEAR
PCL SPRAIN
MECHANISM: DIRECT BLOW TO TIBIA WITH KNEE FLEXED, HYPEREXTENSION, VARUS/VALGUS STRESS IF FIRST LINE OF DEFENCE TORN
SWELLING: OVER 24 HR MECHANICAL SX: +/- INSTABILITY PAIN: DIFFUSE, POSTERIOR (RARELY SEEN AS ISOLATED INJURY)
PCL SPRAIN
CLINICAL ASSESSMENT: POSTERIOR SAG
PCL SPRAIN
CLINICAL ASSESSMENT: POSTERIOR DRAWER
PCL SPRAIN: ?MRI
YES:
HIGH LIKELIHOOD OF ASSOCIATED INJURY
PATELLAR DISLOCATION/SUBLUXATION
MECHANISM: VALGUS, ROTATION SWELLING: IMMEDIATE, MASSIVE MECHANICAL SX: NO UNLESS #
(SUBCHONDRAL #), ASSOC INJURY PAIN: DIFFUSE
PATELLAR DISLOCATION/SUBLUXATION
CLINICAL ASSESSMENT
PATELLAR TENDERNESS
MEDIAL SOFT TISSUE TENDERNESS
PATELLAR APPREHENSION TEST
PATELLA ALTA, “J” SIGN
PATELLAR DISLOCATION/SUBLUXATION
XRAY? MRI?
YES: R/O # NO, UNLESS SUSPICION OF SUBCHONDRAL #, ASSOCIATED STI
PATELLAR DISLOCATION/SUBLUXATION
ACUTE SHOULDER PROBLEMS: GLENOHUMERAL DISLOCATION
TUBS AMBRI
TUBS
MECHANISM: ABD/ER XR TO R/O # SHOULDER IMMOBILIZER FOR COMFORT;
D/C ASAP (CONSIDER ER BRACE) EARLY PT NO MRI
TUBS: RECURRENT
ANTERIOR APPREHENSION TEST/FOWLER’S RELOCATION SIGN
XR: AP, Y VIEW, AXILLARY, WEST POINT (BANKART), STRYKER NOTCH (HILL-SACHS)
REFER NO MRI
ANTERIOR APPREHENSION SIGN
FOWLER’S RELOCATION SIGN
AMBRI
GENERALIZED JOINT LAXITY LOAD AND SHIFT TEST, INFERIOR SULCUS
SIGN PT NO XR, MRI
LOAD AND SHIFT INFERIOR SULCUS
LABRAL TEAR
MECHANISM: DIRECT BLOW, DISLOCATION/SUBLUXATION, REPETITIVE OVERHEAD STRESS (MOST COMMON)
USUALLY ACCOMPANIES OTHER PATHOLOGY WHICH IS MAIN FOCUS OF RX: INSTABILITY, RC TENDINOPATHY/IMPINGEMENT
SLAP/BICEPS TENDINOPATHY
MECHANISM: FALL, LOAD IN FLEX/EXT, OVERHEAD OVERUSE
SX: PAIN, CATCHING WITH LOAD IN FLEX; CLICK; IMPINGEMENT; SENSE OF INSTABILITY
TEST
BICEPS TENDINOPATHY: SPEED’S
TESTS
SLAP: O’BRIEN’S, CRANK, PAIN PROVOCATIVE, COMPRESSION ROTATION, BICEPS LOAD
O’BRIEN’S
MRI?
LABRAL TEAR/SLAP BICEPS TENDINOPATHY
NO – NEED MRA NO – EASY CLINICAL DX, WON’T CHANGE RX, WORST CASE OUTCOME IS A COSMETIC PROBLEM
ROTATOR CUFF TENDINOPATHY, TEAR, IMPINGEMENT
MECHANISM SYMPTOMS
TRAUMA USUALLY OVERHEAD
OVERLOAD
PAIN: DIFFUSE, OFTEN SUPERIOR REFERRED TO DELTOID INSERTION
+/- CLICK IMPINGEMENT:
SEVERE PAIN WITH ELEVATION/IR
WEAKNESS: ?PAIN-INHIBITION
IMPINGEMENT EXAM: PAINFUL ARC +
HAWKINS NEERS
ROTATOR CUFF EXAM
SUPRASPINATUS: JOBE’S (EMPTY CAN)
ROTATOR CUFF EXAM
INFRASPINATUS
ROTATOR CUFF EXAM
TERES MINOR
ROTATOR CUFF EXAM
SUBSCAPULARIS: LIFTOFF (CAN ALSO DO BELLY PRESS) NO
ROTATOR CUFF: ?MRI
IF STRONG SUSPICION OF TEAR: YES
ROTATOR CUFF MRI
SS TENDINOPATHY SS TEAR