4 Semiologia Aparato Locomotor

Continuation of Previous Study on Gait

Overview of Traumatic Semiotics

• The discussion is a continuation from a previous study on gait, focusing on semiology from a traumatological and orthopedic perspective. It emphasizes that while there are general similarities with medical semiology, specific functional tests differ and need to be learned today.

Understanding Traumatic Shock

• Following trauma, individuals may experience traumatic stupor characterized by discomfort and varying symptoms based on the person. This condition arises due to carbon dioxide accumulation in the body. Symptoms include tachycardia, nausea, vomiting, acidity, and dry mouth as responses from the neurovegetative system.

Local vs General Symptoms

• Trauma can lead to both general symptoms (e.g., shock types like neurogenic or hypovolemic) and local symptoms identifiable through Celso's signs: pain, redness, heat, swelling (tumor), plus Virchow's sign of functional limitation. These distinctions are crucial for examinations.

Differentiating Bruises and Hematomas

• Equimosis (bruises) results from vessel rupture leading to soft tissue infiltration; it appears as discoloration but does not require drainage. In contrast, hematomas involve blood accumulation creating a false tumor that necessitates surgical intervention for drainage. Understanding these differences is essential in clinical practice.

Age-Specific Examination Approaches

• The approach to examination varies significantly across age groups—children versus adults or seniors—due to differing comprehension levels and physical capabilities. For instance, children may not understand complex tasks like thumb-index opposition while older adults might have limitations affecting their ability to perform certain movements during assessments.

Importance of Anamnesis in Diagnosis

• Anamnesis plays a critical role in diagnosis alongside inspection techniques such as palpation and auscultation. Factors like patient age influence potential diagnoses; for example, knee pain in children differs vastly from similar complaints in elderly patients where osteoarthritis is more likely considered first due to age-related conditions.

Occupational Considerations in Injury Assessment

• A patient's occupation can provide insights into common injuries they may face; for example:

• Stevedores often suffer from lower back pain.

• Office workers frequently develop wrist tendinitis.

• Athletes might experience sprains or osteoarthritis due to their activities.

Understanding these occupational risks aids in accurate diagnosis and treatment planning.

Recreational Activities Impacting Health

• Pre-pandemic recreational habits often led individuals to engage in sports without regular training throughout the week which could result in serious injuries during weekend games due to lack of muscle conditioning or stretching routines prior to exertion activities such as football or basketball matches.

Patient Perception Influencing Diagnosis

• Patients' beliefs about their symptoms can guide diagnostic processes; for instance:

• A patient attributing low back pain after exposure to cold air suggests possible lumbago related to environmental factors.

• Recognizing how patients perceive their conditions helps clinicians narrow down potential causes effectively based on reported experiences during anamnesis discussions.

Diagnosis and Treatment in Clinical Practice

Importance of Accurate Diagnosis

• The primary goal is to achieve the most accurate diagnosis possible for effective treatment.

• Patient concerns about their incapacity must be addressed, even if functional limitations seem minimal. For instance, a patient with lumbalgia may have underlying worries that need exploration.

Conducting a Thorough Anamnesis

• A detailed anamnesis can reveal significant patient history, such as family cancer cases, which necessitates ruling out serious conditions like tumors or neoplasia.

• This process helps alleviate patient anxiety by ensuring comprehensive evaluation and care.

Clinical Examination Fundamentals

• Clinical examination relies on three key pillars: assessing the affected region first, investigating potential causes of symptoms (e.g., rheumatoid arthritis), and examining the rest of the body afterward.

• The environment for clinical examination should be well-lit and calming to help patients feel relaxed during assessment. Colors like white or light blue are recommended.

Patient Exposure During Examination

• Maximizing patient exposure is crucial; however, cultural sensitivities must be respected to avoid discomfort during physical examinations. Touching without visual confirmation can lead to misdiagnosis.

• Comparing limbs (upper/lower) visually aids in identifying abnormalities such as swelling or discoloration indicative of underlying issues.

Positioning in Orthopedic Exams

• Unlike general medicine exams typically conducted in a supine position, orthopedic assessments allow for various positions based on suspected conditions (e.g., sitting, standing). This flexibility enhances diagnostic accuracy.

Observational Insights During Inspection

• Inspect skin color and texture; redness may indicate inflammation while cyanosis suggests circulatory problems.

• Scars provide diagnostic clues: fine linear scars suggest surgical intervention while irregular ones may indicate trauma or infection pathways like fistulas.

Identifying Deformities and Conditions

• Recognizing deformities such as genu valgum (knees away from midline) versus genu varum (knees towards midline) is essential for proper diagnosis.

• Understanding these terms helps clarify the nature of limb alignment issues observed during inspection.

Role of Anamnesis in Diagnosis

• Anamnesis plays a critical role in trauma and orthopedics; it accounts for approximately 75% of diagnoses made.

• Following anamnesis with careful inspection leads to more precise conclusions regarding patient conditions before moving onto palpation techniques used traditionally by practitioners to assess temperature differences between limbs.

Assessment of Knee Joint Conditions

Importance of Temperature and Palpation

• The assessment begins with checking the temperature of the knees through palpation, noting any differences in warmth between the right and left knee.

• An increase in volume around a joint, such as the right knee, can indicate various underlying issues. This is compared to the left knee for diagnostic purposes.

Causes of Increased Volume in Joints

• Possible causes for increased joint volume include bone growth at epiphyses or swelling due to conditions like tumors or synovial membrane thickening.

• Thickening of the synovial membrane may result from chronic inflammation, such as rheumatoid arthritis or gout. This condition leads to an increase in synovial fluid production.

Identifying Fluid Presence

• The "signo del témpano de hielo" (iceberg sign) is introduced as a method to detect fluid presence within the knee joint by compressing the patella and observing its rebound effect. This indicates fluid accumulation inside the joint.

• Types of fluids that may accumulate include increased synovial fluid (sinovitis), blood (hemarthrosis), or pus (pioartritis). Each condition presents differently based on its cause and symptoms.

Clinical Differentiation Between Conditions

• Clinically differentiating between sinovitis and hemarthrosis can often be achieved through patient history rather than invasive procedures like aspiration; specific questions about trauma timing are crucial for diagnosis.

• A delayed swelling response after trauma suggests sinovitis, while immediate swelling points towards hemarthrosis due to direct injury causing bleeding into the joint space. Understanding these timelines aids diagnosis significantly.

Pain Localization and Further Examination Techniques

• Localized pain assessment helps narrow down potential diagnoses; specific areas of pain can indicate bursitis or tears depending on patient feedback during examination.

• Percussion techniques are discussed as part of physical examination methods; using fingers effectively can help assess muscle tension and identify abnormalities in soft tissue surrounding joints, particularly useful in lumbar assessments too.

Measurement Techniques in Physical Assessment

Percussion Technique

• The speaker describes a method of percussion using the index finger of the left hand to identify specific areas for examination, while the middle finger of the right hand is used to strike the phalanx.

• Emphasis is placed on focusing on a circumscribed region to obtain accurate sound resonance during percussion.

Importance of Measurements

• Accurate measurement is crucial for both upper and lower limbs; circumferences are measured consistently at specific points (e.g., around the knee).

• Consistency in measurement locations between limbs is essential for valid comparisons, such as measuring 20 cm below the tibia for leg circumference.

Length Measurements and Implications

• The length of lower limbs is more critical than that of upper limbs due to potential implications like claudication from limb length discrepancies.

• Absolute length measurements are taken from the iliac crest to the tibial malleolus, with attention given to any discrepancies indicating dismetria.

Relative Measurement Techniques

• In cases where one limb appears shorter due to conditions like flexion deformities, relative measurements can be employed by measuring from the umbilicus to the internal malleolus.

Range of Motion Assessment

• Assessing joint movement amplitude is vital; normal wrist flexion should be around 85 degrees. Comparisons between sides help identify limitations.

• Active movements are performed by patients themselves, while passive movements are conducted by examiners. Differences in these movements can indicate underlying issues.

Pain and Crepitation Indicators

• Pain during joint movement and crepitation sounds (like crushed cookies), particularly in osteoarthritis, serve as significant clinical indicators for diagnosis.

Muscle Power Evaluation

• Muscle power assessment follows established guidelines; comparing muscle strength across different groups provides insights into overall muscular health.

Evaluation of Muscle Power and Joint Stability

Assessing Muscle Power

• To evaluate muscle power, instruct the patient to flex their elbow. Clear communication is essential as patients may not understand the request.

• Normal muscle tone indicates a certain hardness; absence of this tone suggests severe weakness, warranting a score of zero.

• If the patient attempts to flex but cannot move, yet shows increased muscle tone (e.g., biceps), they receive a score of one.

• A score of two is given if the patient can flex against gravity while lying down but not when upright.

• Scores range from three (flexion against gravity) to five (flexion with significant resistance). Care must be taken with elderly patients regarding resistance applied.

Joint Stability Assessment

• Ligaments provide joint stability; assessing knee stability involves functional tests like valgus stress tests.

• Performing a valgus test checks for medial collateral ligament injury by moving the leg away from the body’s midline while stabilizing the knee.

• Conversely, varus stress tests assess lateral collateral ligament integrity by moving the leg inward against resistance.

Functional Tests for Hip and Pelvis

• The "Trendelenburg" test evaluates gluteal strength; if the pelvis drops on one side during single-leg stance, it indicates weakness in contralateral gluteus medius.

• The "Thompson" test assesses Achilles tendon integrity; squeezing calf muscles should elicit ankle plantar flexion. Lack of movement suggests tendon rupture.

Investigating Symptoms Beyond Localized Pain

• After examining an affected area (e.g., right knee pain), explore potential referred pain sources elsewhere in the body if no local symptoms are found.

• Referred pain can occur due to issues in other areas such as hip or lumbar spine problems manifesting as knee discomfort.

• Always consider systemic factors; comprehensive examination includes checking vital signs and overall health status beyond just musculoskeletal concerns.

Understanding Somatization and Diagnostic Techniques

The Nature of Somatization

• The speaker discusses the concept of somatization, where psychological issues manifest as physical symptoms. They emphasize that if no physical cause is found, the problem may be psychological rather than a deliberate act of deception.

• An example is given regarding individuals who experience intense pain without any apparent injury, highlighting how emotional distress can lead to real physical symptoms like muscle spasms.

• It is crucial to differentiate between somatic and psychological issues for effective treatment, as the approach will differ significantly based on the underlying cause.

Diagnostic Tools and Their Importance

• Various auxiliary examinations are introduced, such as X-rays for bone assessment and CT scans for deeper insights into bodily structures. These tools complement clinical diagnosis but do not replace it.

• Advanced imaging techniques like MRI are discussed for their ability to visualize soft tissues and joints, while ultrasound is noted for diagnosing conditions like tendon ruptures or bursitis.

Laboratory Tests and Pathological Analysis

• Clinical laboratory tests (e.g., blood tests) play a vital role in diagnosing conditions such as osteoporosis through bone density measurements and inflammatory markers.

• Pathological analysis involves examining tissue samples under a microscope to diagnose serious conditions like tumors or infections, emphasizing its importance in comprehensive diagnostics.

Electrical Testing and Imaging Comparisons

• Electrophysiological tests assess nerve conduction and muscle excitability, providing critical information about neuromuscular function alongside imaging studies like X-rays or MRIs.

• The speaker contrasts different imaging modalities (X-ray vs. MRI), noting that while MRIs provide detailed images of soft tissues, they can be costly compared to other methods.

The Role of Arthroscopy in Diagnosis

• Arthroscopy is highlighted as a preferred method over MRI for certain knee injuries because it allows direct visualization and treatment of pathologies during the procedure itself.

• The conclusion emphasizes the need for thorough interpretation of all diagnostic data collected from clinical exams to avoid premature conclusions based on single diagnoses.