KIN 191B – Advanced Assessment of Upper Extremity Injuries

Injury Evaluation Process, Injury Nomenclature, Joint Anatomy and

Kinematics

Injury Evaluation

Clinical Evaluations• Generally occur in controlled environment with

access to evaluation tools, records, references (text and personnel) and time

• HIPS/HOPS process– History– Inspection/Observation– Palpation– Special Tests (ROM, stress tests (ligament/capsule),

neurovascular)

History• Etiology/MOI

• Unusual sounds/sensations

• Location of symptoms

• Onset/duration of symptoms

• Description of symptoms

• Prior history

• General health

Inspection• Gait, posture, movement patterns

• Gross deformity

• Swelling

• Discoloration

• Scars

• Skin/infection

Palpation• Sequencing

• Point tenderness

• Muscle spasm/trigger points

• Change in tissue density

• Crepitus

• Symmetry

• Tissue temperature

Range of Motion• Active range of motion

• Passive range of motion– End feels: pathologic vs. physiologic

• Resisted range of motion– Strength test vs. manual muscle exam (MME)

• Cardinal planes– Frontal, transverse/coronal, sagittal

Ligament/CapsularStress Tests

Special (“named”) tests

Neurological Tests

• Sensory function– Nerve root levels (dermatomes)– Peripheral nerves

• Motor function– Nerve root levels (myotomes)– Peripheral nerves

• Reflex testing

Vascular Evaluation

• Pulse points

• Capillary refill (distal extremities)

• Skin color

• Skin temperature

Field Evaluations

• Primary survey– ABCD’s– Activation of EMS/emergency plan

• Secondary survey– Abbreviated HIPS/HOPS process– Removal from field considerations

Injury Nomenclature

Tissue Differentiation

• Soft tissue injuries

• Bony injuries

• Neurovascular injuries

Soft Tissue Injuries

• Musculotendinous injuries

• Joint structure injuries

• Articular cartilage injuries

Musculotendinous Injuries

• Strains

• Tendonopathies

• Myositis ossificans

• Bursitis

Musculotendinous Injuries

• Strains– Caused by tensile forces (stretch beyond capacity) or

generation of more force than can be tolerated (eccentric)– 1st degree: microtrauma– 2nd degree: partial tearing– 3rd degree: complete tearing, loss of function

• Inability to generate force, typically has palpable or visible defect

Musculotendinous Injuries

• Tendonopathies (tendonitis, tenosynovitis)– Inflammatory condition, repetitive microtrauma– 1st degree: pain/slight dysfucntion during activity– 2nd degree: decreased function, pain after activity– 3rd degree: constant pain prohibiting activity– If prolonged, contributes to weakness of tendon– AROM limited at end range by pain, PROM limited when

stretched, RROM abnormal due to pain

Musculotendinous Injuries• Myositis ossificans– Formation of bone within muscle tissue – bodily error

during healing process– Typically associated with trauma to large muscles– Can see on x-ray (3 weeks), affects ROM and strength

• Bursitis– Irritation of fluid filled sacs, generally from friction or

trauma– Can enlarge to point of affecting ROM

Joint Structure Injuries

• Sprains

• Subluxation

• Dislocation

• Synovitis

Joint Structure Injuries• Sprains– Stretching/tearing of ligament/joint capsule– 1st degree: microtrauma, firm end point– 2nd degree: partial tearing, soft end point– 3rd degree: complete tearing, empty end point and loss of

function

• Subluxation– Partial/complete disassociation of joint structure which

may spontaneously reduce– Each episode increases likelihood of recurrence

Joint Structure Injuries• Dislocation– Complete disassociation of joint surfaces from rupture of

soft tissue restraints– Obvious deformity, may be open or closed– May be emergent conditions if neurovascular status is

compromised– Must evaluate with x-ray before reduction

• Synovitis– Inflammation of synovial membrane and/or joint capsule

Articular Surface Injuries• Osteochondral defects

– Fracture/softening of articular cartilage– Severity based upon depth of defect– Location plays key role (weight bearing)

• Osteochondritis dissecans (“joint mice”)– Dislodged fragments of bone in joint space– May present with locking/decreased ROM

• Arthritis– Osteoarthritis = degeneration of joint’s articular surface– Can lead to cartilage degeneration and exposure of bone

Bony Injuries

• Exostosis

• Apophysitis

• Fractures

• Stress fractures

Bony Injuries

• Exostosis– Growth of extraneous bone from body’s response to

Wolff’s law– May form mechanical block to normal ROM

• Apophysitis– “Growing pains”– Inflammatory condition involving growth plates especially

relative to attachment site of large/strong muscle/muscle group

Bony Injuries

• Fractures– Interruption in normal integrity of bony surface– Can occur in diaphysis, epiphysis, articular cartilage– Types: depressed, transverse, comminuted,

compacted, spiral, longitudinal, greenstick, avulsion

• Stress fractures– Chronic condition from repetitive stress/microtrauma– Attention to changes in workload, surfaces, footwear

Neurovascular Pathologies• Often associated with joint dislocation, bony

displacement or concussive forces

• Peripheral nerve injuries– Entrapment – mechanical, swelling– Stretch - traction

• Vascular injuries– Compression– Shear

Imaging Techniques

• Radiographs (plain film x-ray)– Best for bone injuries, joint surfaces/spaces

• Computerized tomography (CT scan)– Best for bony/articular cartilage injuries

• Magnetic resonance imaging (MRI)– Best for soft tissue injuries (ligaments, menisci)

Imaging Techniques

• Bone scan– Best for acute bony changes (stress fx), injection

• Ultrasonic imaging– Best for tendon/soft tissue imaging

Joint Anatomy

Joint Classifications

• Synarthrotic = immovable

• Amphiarthrotic = slightly moveable

• Diarthrotic = freely moveable– Synovial joints

Synovial Joints

• Characteristics of all synovial joints

• Types of synovial joints

Characteristics of Synovial Joints

• All synovial joints have the following characteristics– Joint capsule and/or ligaments– Joint capsule lined with synovial fluid– Opposing bone surfaces contain hyaline (articular)

cartilage– A joint space exists containing small amount of

synovial fluid

Characteristics of Synovial Joints

• Joint capsule/ligaments– Collagenous bundles that maintain joint position– Portions become slack/taut at different joint positions– Ligaments are intrinsic (thickenings of joint capsule) or

extrinsic (separate structures)– Ligaments strongest in middle, weakest at ends

• Joint capsule lined with synovial fluid– Secretes and absorbs synovial fluid

Characteristics of Synovial Joints

• Opposing bone surfaces contain hyaline cartilage– Cushions bone ends, can help provide static and/or

dynamic stability via shape– When healthy, has smooth, pearly appearance– Nourished by synovial fluid

• Joint space containing synovial fluid– Acts as natural lubricant and delivers nutrition to articular

cartilage

Types of Synovial Joints• Ball and socket

– Allow all possible movements– Hip, shoulder (GH)

• Hinge– Allow only flexion/extension– Elbow, ankle

• Pivot– Permit rotation about an axis– Atlantoaxial joint, proximal radioulnar joint

Types of Synovial Joints• Ellipsoidal

– Elliptical convex head in elliptical concave socket– Wrist (between proximal/distal carpal rows)

• Saddle– Reciprocally concavo-convex– Carpometacarpal joint of the thumb

• Gliding– Allow small back/forth, sideways movements– Intercarpal/intertarsal joints, intervertebral joints

Joint Kinematics

Joint Kinematics• Kinetics vs. Kinematics

– Kinetics is description of forces producing motion in the body• Dynamic muscular activity

– Kinematics is description of motions of the body• Pattern of joint movement

• Osteokinematics– Movement of joints in relation to one another– Primary movements

• Arthrokinematics– Movement of joint surfaces in relation to one another– Accessory movements