Podcast
Questions and Answers
PQRST
P-provokes, Q-quality(dull), R-region, S-severity, T-time
PQRST
P-provokes, Q-quality(dull), R-region, S-severity, T-time
True
HOPS)
History
Observation
Palpation
Special tests; Evaluation
HOPS)
History Observation Palpation Special tests; Evaluation
True
SAMPLE: S-signs and symptoms, A-allergies, M-medication, P-ast history, L- last meal, E-event prior
SAMPLE: S-signs and symptoms, A-allergies, M-medication, P-ast history, L- last meal, E-event prior
True
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.
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.
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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)
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)
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S.A.F.E: s-supervision, a-activity selection/instruction(at skill level), f-facility inspection, e-equipment inspection
S.A.F.E: s-supervision, a-activity selection/instruction(at skill level), f-facility inspection, e-equipment inspection
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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
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
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Force and its Effects
Two potential effects of force
Acceleration - Some on hit you
Deformation
Force and its Effects Two potential effects of force Acceleration - Some on hit you Deformation
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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
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
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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
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
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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)
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)
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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
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
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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
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
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Provides: cartilage = increased stability and low transmission, spreads out pressure
Fat around a joint - cushion, and stability
Synovial joint
Provides: cartilage = increased stability and low transmission, spreads out pressure Fat around a joint - cushion, and stability Synovial joint
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Bursa
Fluid filled sacs
Reduce friction - Between ligaments and bone, tendons and skin, elbows, hips, shoulder, knee, quadriceps, etc.
Bursa Fluid filled sacs Reduce friction - Between ligaments and bone, tendons and skin, elbows, hips, shoulder, knee, quadriceps, etc.
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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)
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)
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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
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
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Strains
Stretch or tear of a muscle(or tendon)
Strains Stretch or tear of a muscle(or tendon)
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Cramp/Spasm
Biochemical imbalance
Spasm - involuntary contraction
Cramp/Spasm Biochemical imbalance Spasm - involuntary contraction
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Myositis
Myo-muscle, itis - inflammation
Myositis Myo-muscle, itis - inflammation
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Fasciitis
What surrounds the muscles
Inflammation of the fascia surrounding portions of a muscle
Both chronic issue
Fasciitis What surrounds the muscles Inflammation of the fascia surrounding portions of a muscle Both chronic issue
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Tendinopathy
Pain and swelling in the tendon
Tendonitis: inflammation of the tendon
Tendonosis: degenerative changes, non-inflammatory(lack of blood supply)
Tendinopathy Pain and swelling in the tendon Tendonitis: inflammation of the tendon Tendonosis: degenerative changes, non-inflammatory(lack of blood supply)
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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
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
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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
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
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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
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
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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
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
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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)
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)
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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
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
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Nerves
Median
Ulnar
Radial
Blood vessels
Brachial
Radial
Ulnar
Nerves Median Ulnar Radial
Blood vessels Brachial Radial Ulnar
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Non-steroidal anti-inflammatory drugs
Non-steroidal anti-inflammatory drugs
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Olecranon Bursitis
MOI
Fall on a flexed elbow
Olecranon Bursitis MOI Fall on a flexed elbow
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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
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
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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
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
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Strains
Jersey finger
Rupture of flexor digitorum profundus tendon from distal phalanx
Strains Jersey finger Rupture of flexor digitorum profundus tendon from distal phalanx
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Mallet finger
Rupture of extensor digitorum longus tendon from distal phalanx
Mallet finger Rupture of extensor digitorum longus tendon from distal phalanx
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Tendinopathies
Trigger finger
Finger flexors contract, but are unable to re-extend
Tendinopathies Trigger finger Finger flexors contract, but are unable to re-extend
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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:
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:
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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
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
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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
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
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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
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
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Fracture assessment
Fracture test
Scaphoid compression test
Lins up with metacarpal thumb
Take thumb, compress and push in
Positive tes: pain
Fracture assessment Fracture test Scaphoid compression test Lins up with metacarpal thumb Take thumb, compress and push in Positive tes: pain
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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
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
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Carpal tunnel compression test
Examiners applied constant pressure across metacarpal tunnel for 30 seconds
Carpal tunnel compression test Examiners applied constant pressure across metacarpal tunnel for 30 seconds
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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
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
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