Lecture 1-VCS80630-Fall 2023-Ortho exam and diagnostic techniques-S.Malek.pdf

ORTHOPEDIC EXAMINATION AND DIAGNOSTIC TECHNIQUES Dr. Sarah Malek VCS 80630- Small Animal Surgery Fall 2023 LEARNING OBJECTIVES • Outline the steps in performing a complete orthopedic examination • Describe the details and order of a complete forelimb and hind limb orthopedic examination • Describ...

ORTHOPEDIC EXAMINATION AND DIAGNOSTIC TECHNIQUES Dr. Sarah Malek VCS 80630- Small Animal Surgery Fall 2023 LEARNING OBJECTIVES • Outline the steps in performing a complete orthopedic examination • Describe the details and order of a complete forelimb and hind limb orthopedic examination • Describe the diagnostic tools that are complementary to to the orthopedic examination • Describe tests specific to evaluating joint laxity in the stifle and hip joint for common pathologies ORTHOPEDIC EXAMINATION • Step 1: Preparation for examination • Patient information and medical history • Location • Assistant • Step 2: Perform examination • Step 3: Summarizing and conclusion PREPARATION FOR EXAMINATION • Patient information • Signalment • General history • Problem-specific history • Symptoms Obtaining a complete and relevant history is an art • Start, duration, fluctuations • Previous interventions and results Avoid tunnel vision based on this information Wednesday, October 18, 2023 5 PREPARATION FOR EXAMINATION Location for gait evaluation in dogs • • • • Distraction-free hallway Non-slippery flooring Adequate length Ability to evaluate • From two points of view • Bidirectional Wednesday, October 18, 2023 7 PREPARATION FOR EXAMINATION Gait evaluation in cats • • • • Distraction-free exam room Non-slippery flooring Small obstacles No escape route or hiding spots 10/18/2023 8 PREPARATION FOR EXAMINATION Location for palpation • Distraction-free area • Non-slippery surfaces • Padding for recumbent exam • Table for smaller patients • Floor for larger dogs PREPARATION FOR EXAMINATION Assistant • Animal handling skills • Necessary restraint only • Communication • Knowledge of steps and expectations • To pet or not to pet is the question 10/18/2023 10 ORTHOPEDIC EXAMINATION 1. Observation a) Distant b) Up close 2. Gait analysis a) Walk and trot 3. Palpation a) Standing b) Recumbent ORTHOPEDIC EXAMINATION 1. Observation • Posture (sitting and standing) • Symmetry • Behavior • Pain: cats versus dogs ORTHOPEDIC EXAMINATION 2. Gait analysis • First step: distinguishing ataxia from lameness • Perform concurrently or in sequence • Neurological exam • General physical exam ORTHOPEDIC EXAMINATION Gait analysis techniques • Subjective • Direct visual assessment • Objective (complementary tool) • Kinetic • Pressure sensitive walkway • Force plate • Kinematic ORTHOPEDIC EXAMINATION Subjective gait analysis • Bidirectional • In two planes • At walk and trot • Audiovisual aid • Home videos • Slow-motion videos ORTHOPEDIC EXAMINATION Grade lameness • Document for follow up • Detailed description • Be consistent if using grading systems ORTHOPEDIC EXAMINATION 3. Palpation • Detailed examination • Head to tail • Including spine, ribs and sternum • Distal to proximal in limbs ORTHOPEDIC EXAMINATION 3. Palpation • Assess symmetry • Masses, swelling, atrophy, disruption of structures • Localize pain • Gentle to firm pressure Tip: Leave known painful area for last • Unless: Aggressive patient ORTHOPEDIC EXAMINATION Work smarter not harder • Use commands and cues if relevant • Not all patients need full lateral recumbency • Stressed animals do better standing or sitting Use minimal necessary restraint to achieve your goal ORTHOPEDIC EXAMINATION Detailed limb examination • Start distal to proximal • Soft tissue palpation • Long bone palpation • Joint palpation • Periarticular structures • Effusion • Stability • Identify where to feel for joint effusion for each joint in fore and hind limbs • Describe stability tests for hip and stifle and what they are testing for FORELIMB EXAMINATION Homework: Detailed forelimb examination Fox DB. Orthopedic examination of the forelimb in the dog. Procedures pro: NAVC clinician's brief 2007. See Brightspace HIND LIMB EXAMINATION Homework: detailed hind limb examination • Fox DB. Orthopedic examination of the rear limb in the dog. Procedures pro: NAVC clinician's brief 2007. See Brightspace PALPATION UNDER SEDATION • Advantages • • • • Confirmation of awake findings Joint stability evaluation Aggressive patients Concurrent diagnostic imaging • Disadvantages • No pain assessment SUMMARIZING AND CONCLUSION Step 3 • Review findings • Request/review complementary diagnostic tests • Tentative diagnosis reached? • Yes • No • Repeat part or all steps of the orthopedic exam • Additional work up or tests necessary • Time for referral or treatment? GO TO POLLS Do you think clients should be present during the orthopedic exam? If yes, which part(s)? • Observation • Gait analysis • Palpation • Respond at: PollEV.com/sarahmalek124 on app OR • Text SARAHMALEK124 to 22333 once to join then text A,B, C for your response COMPLEMENTARY DIAGNOSTIC TOOLS Objective gait analysis Diagnostic imaging • Radiography • Computed tomography (CT) • Ultrasound • Magnetic resonance imaging (MRI) • Nuclear scintigraphy Cytology and histopathological evaluation Surgical evaluation ORTHOPEDIC EXAMINATION Quality medial record keeping • Detailed exam findings • Standardized terms and grading system • Efficiency during follow up exams • Legal ramifications GO TO POLLS Why do you think it is best to follow the examination steps described? • Respond at: PollEV.com/sarahmalek124 on app OR • Text SARAHMALEK124 to 22333 once to join then text A,B, C for your response ORTHOPEDIC EXAMINATION Does it really matter to follow steps during exam? • Details are not lost • Breaks down complex problems • Reduced misdiagnoses REFLECTION ON SKILLS: EXAMPLE Ortolani test in young dogs • Positive result is indicative of hip joint laxity • Early detection can prompt preventative measures • Juvenile pubic symphysiodesis (JPS) • Double or triple pelvic osteotomies Are you competent in performing the test? GO TO POLLS How do you think you can get better at performing orthopedic examination? • Respond at: PollEV.com/sarahmalek124 on app OR • Text SARAHMALEK124 to 22333 once to join then text A,B, C for your response ORTHOPEDIC EXAMINATION Examiner skills • • • • Practice skills Self-motivation Seek mentorship/CE Apply Experience Action Observation Examination setting • Optimize what you have Thinking REFLECTION ON SKILLS: EXAMPLE What do you think you need? • Reading/lectures • Discussion with peers • Observing • Doing • Teaching others TAKE HOME MESSAGES • Utilize a methodical approach when performing orthopedic examination • A successful orthopedic examination depends on both examiner’s skills and the exam setting • Awake and sedated exam findings can be complementary when performing orthopedic examination • Reflection and refining skills can help increase your efficiency