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COMMON KNEE AND SHOULDER PROBLEMS

COMMON KNEE AND SHOULDER PROBLEMS. CLINICAL ASSESSMENT. MRI IMAGING. MRI. PANACEA ?. PANDORA’S BOX ?. MRI. INCEPTION 1980’S REVOLUTIONIZED EVALUATION OF STI SUPERB ST CONTRAST cf OTHER DI MULTIPLE PLANES. MRI 101. PROTONS ALIGN WITH MAGNETIC FIELD RFW DISTURB ALIGNMENT.

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COMMON KNEE AND SHOULDER PROBLEMS

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  1. COMMON KNEE AND SHOULDER PROBLEMS CLINICAL ASSESSMENT MRI IMAGING

  2. MRI PANACEA ? PANDORA’S BOX ?

  3. MRI • INCEPTION 1980’S • REVOLUTIONIZED EVALUATION OF STI • SUPERB ST CONTRAST cf OTHER DI • MULTIPLE PLANES

  4. MRI 101 • PROTONS ALIGN WITH MAGNETIC FIELD • RFW DISTURB ALIGNMENT. • ENERGY RELEASED DURING REALIGNMENT MEASURED AND USED TO GENERATE IMAGE • RF SEQUENCES MANIPULATED TO HIGHLIGHT DIFFERENT TISSUES IN DIFFERENT WAYS

  5. MRI 101 (continued) temptation reality • SOPHISTICATED, ELEGANT TECHNOLOGY • ANATOMY TEXT-LIKE IMAGES • TEMPTING TO VIEW AS THE DEFINITIVE Ix • DEPENDING ON TISSUE, SENSITIVITY 80 – 95% • SPECIFICITY LESS • THUS POTENTIALLY SIGNIFICANT FALSE + AND FALSE -

  6. MRI 101 (cont) • EXPENSIVE • LONG WAITS -> CAN LEAD TO UNNECESSARY DELAY IN RX • PATIENT INTOLERANCE • PRESSURES TO ORDER FROM PTS, PT, DC, LAWYER, ETC (might be easier to say “can’t order” than to spend time explaining why inappropriate) • TIME TO PROPERLY COMPLETE REQUISITION OTHER PROBLEMS

  7. ACUTE KNEE INJURIES HISTORY: MECHANISM OF INJURY SWELLING MECHANICAL SYMPTOMS PAIN

  8. MENISCAL TEAR • MECHANISM: Compression usually necessary, rotation, valgus • MEDIAL > LATERAL • SWELLING: Gradual • MECHANICAL SX: Clunking, locking • PAIN: Not necessarily localized

  9. MENISCAL TEAR CLINICAL ASSESSMENT: SQUAT

  10. MENISCAL TEAR CLLINICAL ASSESSMENT: THESSALY TEST

  11. MENISCAL TEAR CLINICAL ASSESSMENT: JOINT LINE TENDERNESS

  12. MENISCAL TEAR CLINICAL ASSESSMENT: McMURRAY

  13. ACUTE KNEE INJURY: ? XRAY • AGE > 55 • ISOLATED TENDERNESS OF PATELLA (NO OTHER BONY TENDERNESS) • TENDERNESS OF HEAD OF FIBULA • INABILITY TO FLEX KNEE TO 90 DEGREES • INABILITY TO BEAR WEIGHT IMMEDIATELY AND IN ER • (MASSIVE SWELLING) OTTAWA KNEE RULES

  14. MENISCAL TEAR: ?MRI YES NO • EQUIVOCAL CLINICAL PRESENTATION AND NO IMPROVEMENT WITH PT • HIGH SUSPICION OF OTHER INJURY (ACL, PCL, SUBCHONDRAL) • CLASSICAL PRESENTATION • DEGENERATIVE CHANGES

  15. MEDIAL MENISCAL TEAR

  16. MCL SPRAIN • MECHANISM: VALGUS STRESS • IF SIGNIFICANT SWELLING SUSPECT ASSOCIATED INJURY • IF SENSE OF INSTABILITY AND LITTLE PAIN SUSPECT HIGH-GRADE INJURY

  17. MCL SPRAIN • CLINICAL ASSESSMENT: VALGUS STRESS AT 30 DEGREES AND FULL EXTENSION (if gap at full extension, suspect MCL + ACL) • Gr 1: 1-5 mm, firm EF • Gr 2: 6-10 mm, firm • Gr 3: >10 mm, soft

  18. MCL SPRAIN: ?MRI YES NO • HIGH SUSPICION OF ACL OR PCL • ISOLATED MCL

  19. MCL - MRI NORMAL

  20. MCL SPRAIN - MRI GR 2 GR 3

  21. ACL SPRAIN • MECHANISM: ROTATION, VALGUS, HYPEREXTENSION • SWELLING: IMMEDIATE, MASSIVE • MECHANICAL SX: INSTABILITY • PAIN: DIFFUSE

  22. DO NOT MISS THIS

  23. ACL SPRAIN • CLINICAL ASSESSMENT: LACHMAN TEST • Gr 1: 1-5mm > contralat • Gr 2: 6-10mm • Gr 3: >10mm • A=firm • B=soft

  24. ACL SPRAIN • CLINICAL ASSESSMENT: ANTERIOR DRAWER

  25. ACL SPRAIN • CLINICAL ASSESSMENT: PIVOT SHIFT • Knee relaxed, full ext. Valgus stress to tibia with axial load and int rot. Knee flexed. Lat tibia subluxes, reduces with flex. • Gr 0: no detectable shift • Gr 1: glide • Gr 2: abrupt reduction • Gr 3: temporary lock then reduction

  26. ACL SPRAIN • CLINICAL ASSESSMENT: PIVOT SHIFT

  27. ACL SPRAIN: ?MRI YES NO • HIGH LIKELIHOOD OF ASSOCIATED STI, SUBCHONDRAL INJURY, BONE BRUISING • “OLDER” PATIENT WHO IS BETTER MANAGED WITH PT, ACTIVITY MODIFICATION, BRACING

  28. ACL TEAR

  29. PCL SPRAIN • MECHANISM: DIRECT BLOW TO TIBIA WITH KNEE FLEXED, HYPEREXTENSION, VARUS/VALGUS STRESS IF FIRST LINE OF DEFENCE TORN • SWELLING: OVER 24 HR • MECHANICAL SX: +/- INSTABILITY • PAIN: DIFFUSE, POSTERIOR • (RARELY SEEN AS ISOLATED INJURY)

  30. PCL SPRAIN • CLINICAL ASSESSMENT: POSTERIOR SAG

  31. PCL SPRAIN • CLINICAL ASSESSMENT: POSTERIOR DRAWER

  32. PCL SPRAIN: ?MRI YES: • HIGH LIKELIHOOD OF ASSOCIATED INJURY

  33. PATELLAR DISLOCATION/SUBLUXATION • MECHANISM: VALGUS, ROTATION • SWELLING: IMMEDIATE, MASSIVE • MECHANICAL SX: NO UNLESS # (SUBCHONDRAL #), ASSOC INJURY • PAIN: DIFFUSE

  34. PATELLAR DISLOCATION/SUBLUXATION CLINICAL ASSESSMENT • PATELLAR TENDERNESS • MEDIAL SOFT TISSUE TENDERNESS • PATELLAR APPREHENSION TEST • PATELLA ALTA, “J” SIGN

  35. PATELLAR DISLOCATION/SUBLUXATION XRAY? MRI? • YES: R/O # • NO, UNLESS SUSPICION OF SUBCHONDRAL #, ASSOCIATED STI

  36. PATELLAR DISLOCATION/SUBLUXATION

  37. ACUTE SHOULDER PROBLEMS: GLENOHUMERAL DISLOCATION TUBS AMBRI

  38. TUBS • MECHANISM: ABD/ER • XR TO R/O # • SHOULDER IMMOBILIZER FOR COMFORT; D/C ASAP (CONSIDER ER BRACE) • EARLY PT • NO MRI

  39. TUBS: RECURRENT • ANTERIOR APPREHENSION TEST/FOWLER’S RELOCATION SIGN • XR: AP, Y VIEW, AXILLARY, WEST POINT (BANKART), STRYKER NOTCH (HILL-SACHS) • REFER • NO MRI

  40. ANTERIOR APPREHENSION SIGN FOWLER’S RELOCATION SIGN

  41. AMBRI • GENERALIZED JOINT LAXITY • LOAD AND SHIFT TEST, INFERIOR SULCUS SIGN • PT • NO XR, MRI

  42. LOAD AND SHIFT INFERIOR SULCUS

  43. LABRAL TEAR • MECHANISM: DIRECT BLOW, DISLOCATION/SUBLUXATION, REPETITIVE OVERHEAD STRESS (MOST COMMON) • USUALLY ACCOMPANIES OTHER PATHOLOGY WHICH IS MAIN FOCUS OF RX: INSTABILITY, RC TENDINOPATHY/IMPINGEMENT

  44. SLAP/BICEPS TENDINOPATHY • MECHANISM: FALL, LOAD IN FLEX/EXT, OVERHEAD OVERUSE • SX: PAIN, CATCHING WITH LOAD IN FLEX; CLICK; IMPINGEMENT; SENSE OF INSTABILITY

  45. TEST • BICEPS TENDINOPATHY: SPEED’S

  46. TESTS • SLAP: O’BRIEN’S, CRANK, PAIN PROVOCATIVE, COMPRESSION ROTATION, BICEPS LOAD

  47. O’BRIEN’S

  48. MRI? LABRAL TEAR/SLAP BICEPS TENDINOPATHY • NO – NEED MRA • NO – EASY CLINICAL DX, WON’T CHANGE RX, WORST CASE OUTCOME IS A COSMETIC PROBLEM

  49. ROTATOR CUFF TENDINOPATHY, TEAR, IMPINGEMENT MECHANISM SYMPTOMS • TRAUMA • USUALLY OVERHEAD OVERLOAD • PAIN: DIFFUSE, OFTEN SUPERIOR REFERRED TO DELTOID INSERTION • +/- CLICK • IMPINGEMENT: SEVERE PAIN WITH ELEVATION/IR • WEAKNESS: ?PAIN-INHIBITION

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