Transcript Clinical Studies I

Clinical Studies I
RHS 331
Dr. Ali Aldali, MS, PT
Tel# 4355010 - Ext: 478
Department of Physical Therapy
King Saud University
2008
Required Text:
• Outline of Orthopadics, by JOHN CRAWFORD
ADAMS and DIVID L. HAMBLEN.
•
ISBN: 0-443-07025-3
• There will also be other reading and
handouts assigned during the course of
the semester.
Orthopaedic Historical
• The term orthopaedic is derived from
Greek (straight child)or the Art of
Correcting and preventing Deformities in
Children.
Diagnosis of orthopaedic disorders
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As in other field of medicine and surgery,
diagnosis of orthpaedic disorders depends first
upon an accurate determination of all the
abnormal features from;
The history.
Clinical examination.
Radiographic examination and other methods
of imaging.
Special investigations.
History
In diagnosis of orthopaedic disorders the history is often first
importance.
a)
Personal history: name, age, sex, occupation, marital status,
and hobbies and recreational activities..
b)
Past history: any previous injury, trauma related to present
condition or non, hypertension (HTN), or DM (diabetic mellitus).
The effect of any previous treatment.
c)
Present history: the main chief complaint ( c/o) “as patient
stats”, the cause of problem, the behavior of symptoms from their
earliest beginning up to the time of consultation
(increase/decrease) what activities to improve the symptoms or to
make them worse (provoke), the severity of pain or other
symptoms(mild0modrate/sever), and pain scale (from 0= no pain
to 10= sever pain) any radiated symptoms to extremities.
Routine for clinical examination
• Exposure for examination:
It is essential that the part to be examined should be
adequately exposed and in a good light. Many
mistakes are made simply because the student or
practitioner does not insist upon the removal of
enough clothes to allow proper examination.
When a limb is being examined the sound limb
should always be exposed for comparison.
• SOAP approach.
Routine for clinical examination
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By Inspection:
deformity?
Shortening?
Swelling?
Wasting?
Scars?
Routine for clinical
examination
listen to what the patient tells you.
Inspection : look or observe the area (general bones
alignment and position of the parts to detect any
deformity, shortening, or unusual posture), (soft tissue;
note any visible evidence of general or local swelling, or
of muscle wasting), (colour of skin; look for redness,
cyanosis, pigmentation, loss of hair, or other changes),
(scars or sinuses; if a scar is present, determine from
its appearance whether it was caused by operation
(linear scar with suture marks), or injuries (irregular
scar))
Routine for clinical examination
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Palpation: feel gently the soft tissue for swelling, spasm or easted,
painful areas, temperature changes (warmth or cold) and the exact
site of any local tenderness.
Measure limb length and girth or circumference of a limb segment
on the two sides is often necessary especially in the lower limbs(.
Movement: move the limb to assess the rang of motion. Active
movement is observed first, then passive. The joint movements
information must be obtained on the following points:
What is the range of active movement?
Is passive movement greater than active movement?
Is movement painful?
Is movement accompanied by crepitation?
Is there any spasticity (stiff resistance to free movement)?
Stability of a joint (Stressing): strain the ligaments to look for
abnormal movements by especial tests for each segment.
Radiographs are useful, but do not replace any part of the clinical
examination. Methods of imaging: X-ray, US, CT scanning, or MRI
(magnetic resonance imaging)
Routine for clinical examination
The area must be fully exposed and properly prepared; a shoulder
cannot
be examined through a shirt or a knee through trouser.
When examining a limb, always compare the two and ask yourself
the
following questions:
1. Is one limb straighter or shorter than the
other?
2. Are the joints swollen?
3. Is there muscle wasting?
4. Are there any scars and, if so, are they
surgical or traumatic?
Routine for clinical examination
Measurement is part of inspection. To measure the distance
between bony points, choose fixed points that are easily
recognizable such as the anterior superior iliac spine or medial
malleolus, rather than variable points such as the umbilicus or
the center of the patella.
Palpation: firmer pressure will locate swelling and
tender areas, and show whether the patient is
apprehensive when the area is touched.
Apprehension is significant, particularly if the joint
is unstable.
Movement: always compare the range of
movement with the opposite limb.
Routine for clinical examination
Check the range of movement by asking the
patient to move the limb. The passive range can
then be measured to see how far the joint will
move, detect a lag or find which part of the
range is painful.
The Quality of movement is also important. Is the
movement free, or stiff? Smooth or noisy? Does
the joint feel loose and unstable? Is it sound?
These are subjective assessments and
judgment only come with experience.
Routine for clinical examination
Ligaments. Ligamentous instability, which is difficult to assess, is
detected by stressing the ligaments and looking for excess
movement.
Muscle power. Muscle weakness must be looked for and recorded.
The muscle power is graded according to the MRC (Medical
Research Council) scale which recognizes six grades of muscle
power:
Grade 0 – no power
Grade 1 (trace)- a flicker of movement only.
Grade 2 (poor)- enough power to move a joint with gravity eliminated.
Grade 3 (fair)- enough power to move a limb against gravity>
Grade 4 (good)- enough power to move a limb against gravity and
against moderate resistance.
Grade 5 (normal)- full and normal muscle power to move a limb against
gravity and against maximum resistance plus 3sec hold at the end.