Physical Address

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Wrist and Hand

Clinical Summary and Recommendations Patient History Complaints Overall subjective complaints do not appear useful in identifying carpal tunnel syndrome. Only reports of “dropping objects” and “shaking hand improves symptoms” statistically altered the probability of the diagnosis and then only minimally (+LR [likelihood ratio] = 1.7 to 1.9, −LR = .34 to .47). Physical Examination Screening Physical examination cannot accurately rule in scaphoid fracture, but the absence…

Elbow and Forearm

Clinical Summary and Recommendations Patient History Complaints Little is known about the utility of subjective complaints with elbow pain. Physical Examination Range-of-Motion Measurements Measuring elbow range of motion has consistently exhibited good to high reliability for assessing flexion, extension, supination, and pronation. Strength Assessment Grip strength testing in patients with lateral epicondylalgia exhibits high interrater reliability. Special Tests In general, few studies have examined the diagnostic…

Shoulder

Clinical Summary and Recommendations Patient History Complaints Little is known about the utility of subjective complaints with shoulder pain. Although a report of trauma does not seem clinically useful, a history of popping, clicking, or catching may be minimally helpful in diagnosing a labral tear (+LRs [likelihood ratios] = 2.0). Physical Examination Range-of-Motion, Strength, and Muscle Length Assessment Measuring shoulder range of motion has consistently been…

Foot and Ankle

Clinical Summary and Recommendations Patient History Complaints No studies of acceptable quality have assessed either the reliability or diagnostic utility of items from the subjective history in patients with foot and ankle problems. Physical Examination Screening The Ottawa Ankle Rule for Radiography is highly sensitive for ankle and midfoot fractures in both adults and children. When patients can bear weight and have no tenderness on the…

Knee

Clinical Summary and Recommendations Patient History Complaints Little is known about the utility of subjective complaints with knee pain. The absence of “weight bearing during trauma” may help rule out a meniscal tear (likelihood ratio [LR] = .40). Symptoms in combination with examination findings may be optimized to identify patients at increased risk of knee joint effusion. Self-noticed knee swelling in combination with self-reported pain with…

Hip and Pelvis

Clinical Summary and Recommendations Patient History Complaints Several complaints appear to be useful in identifying specific hip pathologic conditions. A subjective complaint of “clicking in the hip” is strongly associated with acetabular labral tears. Reports of “constant low back/buttock pain” and “ipsilateral groin pain” are moderately helpful in diagnosing osteoarthritis (OA) of the hip. Physical Examination Range-of-Motion Measurements Measuring hip range of motion has consistently been…

Sacroiliac Region

Clinical Summary and Recommendations Patient History Questions The question “Is pain relieved by standing?” is the only question studied to demonstrate some diagnostic utility (+LR [likelihood ratio] of 3.5) for sacroiliac joint pain. Pain Location Recent evidence suggests that patients with sacroiliac joint pain commonly experience the most intense pain around one or both sacroiliac joints, with or without referral into the lateral thigh. Physical Examination…

Thoracolumbar Spine

Clinical Summary and Recommendations Patient History Complaints A few subjective complaints appear to be useful in identifying specific spinal pathologic conditions. A report of “no pain when seated” is the answer to the single question with the best diagnostic utility for lumbar spinal stenosis (+LR [likelihood ratio] = 6.6). “Pain not relieved by lying down,” “back pain at night,” and “morning stiffness for longer than 1/2…

Cervical Spine

Clinical Summary and Recommendations Patient History Complaints The utility of the patient history has been studied only in the context of identifying cervical radiculopathy. Subjective reports of symptoms were generally not helpful, with diagnoses including complaints of “weakness,” “numbness,” “tingling,” “burning,” or “arm pain.” The patient complaints most useful in diagnosing cervical radiculopathy were (1) a report of symptoms most bothersome in the scapular area (+LR…

Temporomandibular Joint

Clinical Summary and Recommendations Patient History Questions Screening instruments have been shown to be very good at identifying temporomandibular disorder (TMD) pain (+LR [likelihood ratio] of 33). A subject complaint of “periodic restriction” (the inability to open the mouth as wide as was previously possible) has been found to be the best single history item to identify anterior disc displacement, both in patients with reducing discs…

The Reliability and Diagnostic Utility of the Orthopaedic Clinical Examination

The health sciences and medical professions continue to focus on evidence-based practice defined as the integration of the best available research evidence and clinical expertise with the patient’s values. , Evidence should be incorporated into all aspects of physical therapy patient and client management, including the examination, evaluation, diagnosis, prognosis, and intervention. Perhaps the most crucial component is a careful, succinct clinical examination that can lead…

Elbow Disarticulation Amputation

Introduction Over the years, advances in upper extremity amputation management have included improved surgical techniques, preoperative management, postoperative management, and prosthetic management. In the past decade the greatest advances have occurred in prosthetic technologies, fabrication techniques, and components to more effectively replace the lost function of the extremity. Demographics Trauma is the leading cause of upper extremity limb loss, accounting for 80% of upper extremity amputations.…

Elbow Resection Arthroplasty

Introduction Elbow resection arthroplasty involves removal of the articulating ends of the distal part of the humerus, the proximal part of the ulna, and occasionally the radial head, and letting the soft tissue structures heal around the resected bone segments, hoping for enough stability to allow some function. With the advent of modern reconstructive procedures, resection arthroplasty of the elbow joint is seldom considered a primary…

Spastic Dysfunction of the Elbow

Cerebral Palsy Cerebral palsy (CP) is a nonprogressive perinatal injury to the developing central nervous system (CNS) causing abnormalities of movement and posture. The incidence of CP is 1 to 7 per 1000 children worldwide, and 2 to 3 per 1000 children in developed countries. The incidence has been fairly constant during the past 40 years; a lesser incidence due to improved prenatal and perinatal care,…

Flaccid Dysfunction

Introduction Flaccid paralysis of the elbow severely limits a patient's ability to position and stabilize the hand for function. Paralysis of elbow flexors (biceps, brachialis, and brachioradialis) makes reaching the face impossible. Most other extremity functions require frequently changing levels for lifting and carrying, also impossible with elbow flexor dysfunction. Elbow extension is necessary to work with the extremity above the horizontal position. Any overhead task…

Soft Tissue Coverage of the Elbow

Introduction Difficult-to-manage soft tissue defects about the elbow occur as a result of trauma, infection, extravasation of chemotherapeutic agents, cutaneous ulceration or necrosis, and limb-sparing tumor surgery (see Chapter 58 ). Treatment options are many, and appropriate management requires careful consideration of all alternatives. Coverage choices may include primary closure, skin grafting, local cutaneous flaps, fasciocutaneous transposition flaps, island fascial or fasciocutaneous flaps, local or distant…

Elbow Arthrodesis

Introduction/Indications There is little accommodation for the loss of elbow motion from adjacent joints, and extremity function is severely compromised after elbow fusion. As such, elbow arthrodesis is a procedure that is largely avoided even in the most complex clinical scenarios. The indications are currently limited to unsalvageable cases of sepsis, neoplasms, severe bone loss after multiple arthroplasties, flail instability, or high-energy trauma with no potential…

Interposition Arthroplasty of the Elbow

Introduction In my practice, interposition arthroplasty continues to be an essential option as salvage for end-stage arthritis of the elbow in the young patient. Selection and technique have changed little in the last 10 years. We have found no additional case series since our report. Historical Aspects The so-called functional arthroplasty, popularized by Hass, a variant of resection arthroplasty, might be considered the predecessor of interposition…

Anconeus Interposition Arthroplasty

Introduction Pain and disability resulting from posttraumatic, degenerative, or inflammatory radiocapitellar and/or proximal radioulnar pathology can be challenging to manage surgically. The anconeus arthroplasty offers a feasible surgical option to alleviate symptoms and to improve function of the radiocapitellar and/or proximal radioulnar joint. It is particularly attractive in the young patient when attempting to avoid prosthetic replacement and when there are few other options. Given this,…

Osteochondral Allograft Reconstruction

Introduction Today, several salvage options exist for severe articular or structural bone loss from trauma, tumor, infection, or failed prior intervention. The use of chondral grafting for articular problems is covered in Chapters 33 and 67 . In this chapter we review the use of osteoarticular allografts to address both articular and structural deficiencies. The graft may be either articular/metaphysial or articular The effectiveness is broadly…