PQRST Assessment Method

PQRST

P-provokes, Q-quality(dull), R-region, S-severity, T-time

HOPS)

History Observation Palpation Special tests; Evaluation

SAMPLE: S-signs and symptoms, A-allergies, M-medication, P-ast history, L- last meal, E-event prior

Neurological testing Nerve root CNS: central nervous system - assess using dermatomes, myotomes, and reflexes Dermatome - area of skin supplied by a single nerve root Activity Specific Functional Testing Typical, active movements performed during activity participation Movement should assess: strength, agility, flexibility, joint stability, endurance, coordination, balance, sport-specific skill performance.

SOAP notes: Subjective: What does the patient report? Symptom - information provided by the injured person regarding their perception of the problem) Objective: What do you observe(AT) Sign - measurable physical finding(bleeding, bruising etc) Assessment: diagnosis(Dx); progress, problem(not 100% diagnosed) Plan Treatment plan - prescriptions, follow up(i.e. exercises)

S.A.F.E: s-supervision, a-activity selection/instruction(at skill level), f-facility inspection, e-equipment inspection

Response to Force Small load: load is removed, material returns to its original shape Yield load: maximum load a material can hand without permanent deformation Failure: injury

Force and its Effects Two potential effects of force Acceleration - Some on hit you Deformation

Categories Axial: force that acts on the long axis of a structure Compression(outside): axial load that produces a crushing or squeezing force Tension(inside): axial force in opposite direction; pulling or stretching the tissues Shear(twising): force parallel to a plane passing through the object

Strain vs. Force Strain: amount of deformation object undergoes in response to applied force Result Compression - shortening and widening of tissues Tension - longer and narrower tissues Shear - internal changes to the structure

Element of Time Acute injury Results from a single force Macrotrauma - characterized by a definitive moment of onset Chronic injury Results from repeated loading over and over again Microtrauma Characterized by becoming more problematic overtime Threshold episode(noticing the injury)

Soft Tissues - Anatomic Properties Collagen Primary constituent of skin, tendon, ligaments Stronger than steel Protein substance strong in resisting tensile forces Wavy configuration that allows for elastic type deformation or stretch but*** Elastin Allows for added elasticity

oint Capsule Synovial joint Outer portion: fibrous, composed of primarily collagen Inner: synovial membrane Articular cartilage Covers ends of long bones, cushion to protect, no nerve or blood supply Acts like a sponge with synovial fluid as liquid squeezed out when stressed Help with shock absorption Receives nourishment from synovial fluid

Joint cavity: filled with synovial fluid, gets nutrients from membrane

Provides: cartilage = increased stability and low transmission, spreads out pressure Fat around a joint - cushion, and stability Synovial joint

Bursa Fluid filled sacs Reduce friction - Between ligaments and bone, tendons and skin, elbows, hips, shoulder, knee, quadriceps, etc.

Skin Injury Classifications Abrasions Scraping away layers of skin Shear force Blisters Accumulations of fluid between epidermis and dermis Shear force - rubbing Skin bruises Accumulation of blood within the skin Compression force Incision Clean cut(i.e. Paper cut) Laceration Irregular tear

Avulsions Complete separation of skin(Severe laceration) Punctures Penetration of skin and underlying tissue(I.e. Nail, needle)

Contusions Moi: compression May cause external damage to muscle, will rupture blood vessels, possible to rupture fascia(causing muscle to protrude) Signs and symptoms: Onset -acute Pain - localized Ecchymosis: superficial(discolouration) Restrictions in ROM

Strains Stretch or tear of a muscle(or tendon)

Cramp/Spasm Biochemical imbalance Spasm - involuntary contraction

Myositis Myo-muscle, itis - inflammation

Fasciitis What surrounds the muscles Inflammation of the fascia surrounding portions of a muscle Both chronic issue

Tendinopathy Pain and swelling in the tendon Tendonitis: inflammation of the tendon Tendonosis: degenerative changes, non-inflammatory(lack of blood supply)

P.R.I.C.E.M.M - protect, rest, ice(20 min. - decrease some swelling/muscle guarding), compression(decrease space of swelling), elevation(doesn’t fight gravity to fight swelling), modify mechanics(modify what you were doing, decrease chance of reinjury), medication(as needed, swelling/pain relief) Long Bones - Anatomic Properties

Types of Fractures Simple - Simple Bone breaks cleanly but ends do not break the skin Compound Breaks through skin Depressed Often on flat bones and broken part is driven inwards Transverse Fracture straight across bone Comminuted Fractures into many pieces Oblique Fracture along an angle Epiphyseal Fracture along growth plate (epiphysis of bone) → lead to growth problems Spiral S shaped fracture from excessive tension applied to a fixed bone Greenstick Bone breaks incompletely like a stick Avulsion Bone pulled off by an attached tendon or ligament Impacted Bone is impacted/driven into another piece of bone Indirect Fracture away from site of impact Longitudinal Fracture goes longitudinally across (long axis) the bone Countercoup Fracture occurs on opposite side

Classification of Nerve Injuries Tensile force injuries Connective tissue Nerve ruptures Grade 1: neuropraxia Localized conduction block, temporary loss of sensation and or motor Resolves in days or weeks Grade 2: axonotmesis Significant motor and mild sensory deficits Usually regain in 2 weeks Grade 3: neurotmesis Motor and sensory deficit

Acute stage Restrict pain Minimize secondary applications Protect from further injury Sub-acute stage Aim - to get active movement, painless ROM, Stimulate receptions Minimize muscle wasting Protection Circulation - blood flow(cleaning area) Chronic stage Control additional inflammatio

Overall Goals Regain normal(pain-free) ROM Regain normal strength/endurance Reagan proprioception(changing bases of support/stability) Retain cardiovascular endurance Home program Regain normal weight-bearing(if lower-body injury) Alter technique deficiency Protective taping/bracing Psychological attitude Surround areas(above/below)

3 articulations (single capsule) Humeroulnar (elbow joint) Trochlea of humerus with trochlear fossa of ulna Hinge joint; flexion and extension Humeroradial Capitulum of humerus with head of radius Gliding/Pivot (limited) ball and socket joint (Hinge joint) Lateral to humeroulnar joint Proximal radioulnar Head of radius with radial notch of ulna Pivot joint

Nerves Median Ulnar Radial

Blood vessels Brachial Radial Ulnar

Non-steroidal anti-inflammatory drugs

Olecranon Bursitis MOI Fall on a flexed elbow

Dislocation

Proximal radial head MOI Longitudinal traction of arm extended and pronated upper extremity S&S Inability to pronate and supinate pain free warrants immediate physician referral Ulnar dislocation MOI Hyperextension

Lunate Axial loading displaced lunate in volar direction S&S Point tenderness – dorsum of hand just distal to radius Thickened area on the palm palpable just distal to end of radius (proximal to the third metacarpal) Passive and active motion may not be painful Caution: bone into carpal tunnel – compression of median nerve Management: Immobilize, I., refer interphalangeal PIP, DIP, MCP

Strains Jersey finger Rupture of flexor digitorum profundus tendon from distal phalanx

Mallet finger Rupture of extensor digitorum longus tendon from distal phalanx

Tendinopathies Trigger finger Finger flexors contract, but are unable to re-extend

de Quervain's tenosynovitis Stenosing tenosynovitis of APL and EPB MOI: A forceful grasp, combined with repetitive use of thumb and ulnar deviation (golf, racquet sports) S&S Pain over radial styloid process ↑ with thumb and wrist motion Point tenderness over the tendons Pain with RROM thumb abduction Management:

Distal radius/ulna fracture Mechanism: axial loading; FOOSH Monteggia’s Distal ulna with associated dislocation of radial head Galeazzi's Distal radius with associated dislocation or subluxation of distal radioulnar joint Colles’ Distal metaphysis of radius, with displacement of distal fragment dorsally Smith’s Distal radius, with displacement of distal fragment toward palmar aspect Gymnast’s wrist Stress # to distal radial epiphyseal plate Carpal # Scaphoid Bennett # Proximal end of 1st metacarpal Boxer’s # 4 th & 5th metacarpal Phlangeal # S&S: normal fracture Concerns: Circulatory impairment (‘blanching’ and pulse) Nerve damage

Varus: medial side Move wrist and ulnar deviation Thumb side Prone position Stabilize forearm Moving wrist outwards into ulnar deviation Stressing radial collateral ligament Positive test: pain or laxity Anatomical position

Valgus: lateral side Move wrist into radial deviation (THUMB) Prone position

Special Tests Finkelstein’s test for de Quervain’s syndrome (tenosynovitis) Compare bilaterally Stabilize patients forearm Have patient doo ulnar deviation Deviate down Positive test: pain

Fracture assessment Fracture test Scaphoid compression test Lins up with metacarpal thumb Take thumb, compress and push in Positive tes: pain

Special Tests (cont’d) Phalen (wrist flexion) test - Carpal tunnel syndrome hold for 1 min Shoulders relaxed OR: Have examiner hold wrist in flexion for 1 min

Carpal tunnel compression test Examiners applied constant pressure across metacarpal tunnel for 30 seconds

Tinel’s sign -Nerve Quick tap Positive test: tingling or nerve sensation Pinch grip test - Nerve Positive test: if fingers straighten out after applied force