opt - orthopaedic physical examination 2
DESCRIPTION
OrthoTRANSCRIPT
ORTHOPAEDIC PHYSICAL ORTHOPAEDIC PHYSICAL EXAMINATIONEXAMINATION
SUBLAB.ORTHOPAEDI & TRAUMATOLOGY
Principles of ExaminationPrinciples of ExaminationObtaining data from patient’s story (clinical
history); Preliminary data: name, sex, age, occupation Chief complaint Common musculoskeletal symptoms:
1. Pain2. Decrease in function3. Physical appearance
Past, Social, Economic, and Family History
Principles of Examination Principles of Examination While performing physical examination, approach
patient with
Kindness (cause no pain) Precision (observe patient's face and record findings) Style (be cheerful and timely)
Always
Look Feel Move
REGIONAL EXAMINATIONNeck Shoulder Elbow Wrist & Hand Back Hip Knee Ankle & Foot
Principles of ExaminationPrinciples of Examination
General Principles of TreatmentGeneral Principles of Treatment
1. First do no harm (primum non nocere)2. Base treatment on an accurate diagnosis
and prognosis3. Select treatment with specific aims4. Cooperate with the law of nature5. Be realistic and practical in your
treatment6. Select treatment for your patient as an
individual
Examination of the Neck 1. Observe the patient
as a whole. 2. Observe the neck
and shoulders from in front and behind.
3. Palpate the front and back of the neck with the patient seated and the examiner behind.
3
Examination of the Neck
4.Assess neck flexion by asking the patient to touch their chest with their chin.
5. Assess extension by asking the patient to look up and as far back as possible.
4. 5.
Examination of the Neck 6. Assess lateral flexion to both sides
by asking the patient to touch their shoulder with their ear.
7. Assess rotation by asking the patient to look over their shoulder, to the left and right.
8. Begin the neurological assessment of the upper limb by examining the motor system. This involves asking the patient to assume a certain position and not let you overcome it. Begin with shoulder abduction.
9. Shoulder adduction.
10. Elbow extension.
11. Elbow flexion.
12. Wrist extension.13. Wrist flexion.
14. Finger extension.15. Finger flexion
16. Thumb abduction.
17. Finger abduction
18. Elicit the reflexes of the upper limb beginning with the biceps jerk.
19. Triceps jerk20. Brachioradialis jerk.21. Assess co-ordination of
the upper limb. 22. Test sensation of the
upper limb and determine the distribution of any loss.
Examination of the Shoulder
1. Observe the whole patient, front and back.
2. Observe the shoulder.3. Observe the axilla
Erythema , Ecchymosis,SwellingSide to side comparison
Examination of the Shoulder 4. Palpate for tenderness over
the sterno-clavicular joint, clavicle, acromioclavicular joint, acromion process, supraspinatus tendon and the tendon of the long head of biceps.
5. Observe shoulder abduction from in front and behind, through the entire range of movement. Note the presence of difficulty in initiation or a painful arc.
Examination of the Shoulder 6. Secure the scapula to assess
gleno-humeral movement.7. Assess flexion and extension.
( no photos)8. Assess external rotation with
elbows in to the sides and flexed to 90º .
9. Assess internal rotation by asking the patient to place both hands behind the head.
Examination of the Shoulder
10. Assess internal rotation by asking the patient to reach over their opposite shoulder, behind the neck and behind the back.
Examination of the Shoulder
11. Test biceps function by asking the patient to flex the elbow against resistance.
12. Test serratus anterior function by asking the patient to push against a wall, looking for winging of the scapula.
13. Test for pain with palpation of subacromial Bursa - indicates impingement of the rotator cuff.
Examination of the Shoulder 14. The apprehension test
standing. Abduct, externally rotate and extend the patient's shoulder while pushing on the head of the humerus with the opposite hand to test for anterior subluxation or dislocation.
15. Apprehension test lying down.16. Assess any marked instability
in the shoulder.Anterior - instability (moves too far forward);Posterior - instability (moves too far back). (2 photos)
Examination of the Elbow
1. Observe the whole patient, front and back, looking especially for deformity.Swelling , Redness , Carrying Angle
Examination of the Elbow
2. Feel for tenderness.
Examination of the Elbow 3. Accentuate the pain of tennis elbow.
4. point of tenderness.
5. pain on resisted extension.
6. pain on passive stretch.
Examination of the Elbow
7. Examine extension. (To 00)
Examination of the Elbow
8. Examine flexion. ( To 1350)
Examination of the Elbow
9. Examine supination 10. Examine pronation. ( To 900) ( To 900)
Examination of the Elbow
11. Pivot shift of elbow (instability).
12. Provocative test for Cubital Tunnel Syndrome (puts tension on ulnar nerve at elbow).
13. Palpate the ulnar nerve.
Examination of the Elbow
Examination of the Wrist & Hand1. Observe the hand positioned on a
pillow or a table. Ensure you have adequate exposure.
2. Observe the palm of the hand.3. Observe the dorsum of the hand.4. Review the anatomy of the hand
noting the tip of the styloid process, the anatomical snuffbox bordered by extensor pollicis brevis and extensor pollicis longus tendons, the extensor tendons of the fingers and the head of the ulna.
5. Feel for tenderness. (no photos) 6. Test active movements of the wrist. (no photos)
7. A useful method for screening of flexion and extension of the wrists. (2 photos)
8. Test passive movements of the wrist beginning with extension. (700)9. Flexion. ( Nearly 900)
Examination of the Wrist & Hand
Examination of the Wrist & Hand
10. Radial deviation. 11. Ulnar deviation.12. Pronation. 13. Supination.
Examination of the Wrist & Hand
14. Test thumb extension. 15. Test thumb abduction.16. Test thumb adduction. 17. Test opposition.
Examination of the Wrist & Hand
18. Observe movement of fingers from extension to flexion. (2 photos)19. Test flexor digitorum profundus function by holding the proximal
interphalangeal joint extended and asking the patient to flex the finger. Successful finger flexion indicates the tendon is intact.
20. Test flexor digitorum superficialis function by holding the other fingers extended while asking the patient to flex the finger being tested. Successful flexion indicates the tendon is intact.
Examination of the Wrist & Hand
21. Assess joint hyperextension.22. Axial compression test.23. Asses ulnar nerve function with Froment's test. (choice of 2 photos)24. Asses ulnar nerve/interosseus muscle function by asking the patient to
abduct their fingers while slowly pushing the hands together until the weaker one collapses.
Examination of the Wrist & Hand24. Asses ulnar nerve/interosseus
muscle function by asking the patient to abduct their fingers while slowly pushing the hands together until the weaker one collapses.
25. Assess median nerve function. (UK sign for FP Lard FDP working)
26. Assess the function of the hand with the fine pinch grip (paperclip).
27. Flat pinch grip (key).28. Tripod grip (pen).29. Wide grip (mug).30. Power grip.
• PHALEN’S TEST – Compression of the median nerve at the wrist – The wrist flexed maximally for 60 seconds – Paresthesias in the median nerve distribution
suggest carpal tunnel syndrome • CARPAL TUNNEL PERCUSSION
– Tinel sign at the wrist
Examination of the Wrist & Hand
• FINKELSTEIN’S TEST
– Painless function of the abductor P.L , Ext P.B– Flex and ulnarly deviate the wrist, then push
the thumb into flexion – Sharp pain on the radial border of the wrist
de quervain’s disease
Examination of the Wrist & Hand
Examination of the Back1. Observe the patient
as a whole, front and back.
2. Ask the patient to walk on their toes.
3. Ask the patient to walk on their heels.
4. Back extension.
Examination of the Back5. Back flexion.6. Bony Excursion:
measure the distance between two bony points when standing.
7 Ask the patient to flex forward, the bony points should move at least 5 cm.
8. Lateral flexion
Examination of the Back9. Rotation (make sure to anchor
pelvis)10. FABER test.
Flexion Abduction External Rotation. Press firmly on the knee. Pain in the groin suggests a hip problem and pain in the back refers to the sacroiliac joint.
11 Straight leg ranging, dorsiflexion increases the sciatic stretch. Watch for pain and limitation. (2 photos)
12. Femoral stretch test: Hip extension and passive flexion of the knee. Watch for pain and limitation.
Examination of the Back
A Neurological examination including:
13. Knee extension.14. Knee flexion15. Knee jerk reflex16. Ankle jerk reflex.
Examination of the Back
17. Sensation18. Pain on compression of the head can often be
attributed to non-organic pathology.
Examination of the Hip1. Observe the whole
patient.2. Trendelenburg test
(normal).3. Positive Trendelenburg
Test.4. Ask the patient to walk
and observe their gait. (no photo)
5. Test iliopsoas function by asking the patient to lift their thigh off the seat against resistance.
Examination of the Hip
6. Ensure the Anterior Superior Iliac Spines are horizontal.
Examination of the Hip
7. Check the position of the medial malleoli.
8. Measure from the ASIS to the medial malleoli. (3 photos)
9. Measure the distance from the xiphisternum to the medial malleoli.
10. Feel for the femoral head. It is deep to the femoral pulse. (No photo)
Examination of the Hip
11. Thomas Test:Flex both hips to eliminate the lumbar lordosis. Extend the hip you are examining and if it is normal it should return to the bed. A fixed flexion deformity of the hip will not allow it to extend to the neutral position. (2 photos)
12. Check the patient is not compensating with a lumbar lordosis.13. Check the ASIS are horizontal again. Anchor leg over the edge of the bed and abduct the
other hip. (0 0 to 45 0) 14. Assess adduction. ( 200 to 300)
Examination of the Hip
14. Assess adduction.15. Internal rotation. (00 to 450) 16. External rotation . ( 00 to 450)
Examination of the Knee1. Observe the patient as a
whole. 2. Observe the knee joint
front and back. Note any genu valgum (a slight degree of which is normal) or genu varum.
3. Observe knee from side. Note any genu recurvatum
4. Ask the patient to squat
Examination of the Knee5. Assess patellae tracking
from extension to flexion. Note quadriceps action.
6. Patellar apprehension test. Apply lateral pressure to patellar as the patient flexes the knee. Observe facial expressions for fear of impending dislocation.
7. Observe the knee with the patient lying on the bed.
Examination of the Knee8. Pick a bony landmark on the
knee and measure a fixed distance from it to the approximate centre of the quadriceps.
9. Measure the circumference of the of the knee and leg.
10. Feel the temperature of the knee and leg.
11. Soloman's test. Lift the patella away from the femur. In synovial thickening it will be hard to grasp.
Examination of the Knee
12. Effusion: Tap Test. Push sharply on the patella and with an effusion it will strike the femur and bounce back.
13. Effusion: Feel for fluid fluctuance.
Examination of the Knee
14. Effusion: Bulge Test. Empty the suprapatellar pouch with pressure above the patella. Wipe hand along the medial side to displace fluid laterally. Compress the lateral side and watch for a bulge medially.
Examination of the Knee
15. Feel the superficial and posterior surface of the patella by pushing it medially.
16. To test for patello-femoral tenderness press patella against the femur and ask the patient to tighten their thigh muscles.
17. Palpate for tenderness with the knee flexed to 90°. Feel along the joint line, the ligaments and the tibial tubercle.
18. Assess extension of the knee.
Examination of the Knee19. Flexion.20. Internal and external
rotation of the knee is limited.
21. Test collateral ligaments by applying medial and lateral pressure to the lower leg which is tucked away under the examiners arm.
22. Look for posterior sag of the femur signifying posterior cruciate dysfunction.
Examination of the Knee
23. Anterior drawer test. Femur should not move forward significantly unless the anterior cruciate ligament is torn.
24. Posterior drawer test. (Posterior cruciate)25. Lachmans test.
Examination of the Knee26. MC test - lift leg off the bed
and if tibia drops there is cruciate dysfunction.
27. MacMurrays test.Place the thumb and finger on the joint line. Watching the patients face for pain, flex the leg, externally rotate the foot, abduct and extend leg to test for medial meniscal "clicks".Flex the leg, internally rotate and adduct for lateral meniscal "clicks". (2 photos)
28. Ask the patient to lie prone and examine the back of the knee.
Examination of the Foot & AnkleObserve patient as a whole
from front and back.1. From behind check hind-
foot alignment and "too many toes" sign (tib. post dysfunction).
2. & 3. Check for inversion (tibialis function) and eversion (peroneal function).
4. Single stance heel raise test.
Examination of the Foot & Ankle
5. Windlass test. 6. Coin test.7. Dorsi flexion. 8. Plantar flexion.
Examination of the Foot & Ankle
9. Mid foot abduction/adduction. 10. Extension fore foot.11. Flexion fore foot. 12. Tib. anterior test.
Examination of the Foot & Ankle
13. Tib. posterior test.14. Peroneal tendons test.15. Ankle instability - inversion test.16. Ankle instability - Anterior draw test.
Examination of the Foot & Ankle
17. Ankle instability - Posterior draw test.
18. Simmond's test for TA.
19. Examine the sole.20. Check pulses,
sensation, reflexes.
THANK YOUTHANK YOU