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Dr. Aruljoethy
Department
of
Orthopaedics
Basic rules in examination:
1. The entire area in question with one joint above and one joint below
must be exposed adequately and examined.
2. No Orthopaedic examination is complete unless the joint above, the
joint below, the same joint on the opposite side and a detailed
neurovascular examination is done.
3. Examination has to proceed with the differential diagnosis made at
the end of the history in mind.
4. Sequence in examination : Inspection, Palpation, Movements,
Measurements and Special tests.
tabular column showing the movements on the right and the left sides in
each direction and a column to record the difference found in each
direction. This tabular column can also depict the power in each group of
muscle. Eg. flexors, extensors, abductors etc.
When fixed deformities are found :
Movements in the opposite direction is not possible
Movements in the same direction as the deformity may be
possible
Eg: when fixed abduction deformity is seen to be present adduction at the
hip will not be present and vise versa.
RECORDING MOVEMENTS IN THE PRESENCE OF FIXED
DEFORMITIES:
If there is a fixed deformity in one direction of 20 degrees with further
movement in the same direction of 120 degrees possible, then the range of
movement is recorded as 20-120 degrees. This indicates that the joint has
a fixed deformity of 20 deg. and allows further movement in the same
direction of 120 deg. Now if the opposite joint has normal range of
movement of say 0-120 degrees in the same direction then on comparing
the two it is apparent that whereas there is a deformity of 20 deg. in the
affected joint and further movement in the direction in question is full and
normal.
PROBLEM: If the range of movement recorded is 30-100 deg. on the
affected side and 0-120 on the normal side for the same movement then
what is the conclusion??
ANSWER: Fixed deformity of 30 deg. and further movement is also
restricted by 20 deg. when compared to the normal side.
All movements should be recorded as RANGE of movements with a
definite start and end point mentioned in degrees.
MEASUREMENTS
All bony prominences should be marked with a marking pen on
both sides before measurement is done.
The tape should be placed gently on these points during
measurement. Care should be taken to ensure that the points
have not been moved under the examining fingers.
Apparent measurement:
From the Xyphisternum to the Medial malleolus: with the patient supine
and lying down as straight as possible.
True measurement of the entire limb:
Prerequisites:
The pelvis should be squared
Both the limbs have to kept in similar positions when measuring
From the ASIS to the medial malleolus on each side.
SEGMENTAL TRUE MEASUREMENTS
In the same position of a squared pelvis and both limbs in similar
positions the femoral and tibial measurements are individually taken as
follows.
(a) Femoral length: From the ASIS to the Medial joint line.
(b)Pass the palm of the hand under the lumbar region: this cannot be
done in a normal situation. If the palm can be passed under the
lumbar region it indicates excess lumbar lordosis.
2. With the palm under the lumbar back, flex the hip on the
unaffected side through its full range of flexion and continue to flex it
beyond till the lumbar back just touches the hand. Notice the hip on the
affected side flexing with this maneuver.
3. With the unaffected hip in the position of flexion as above, passively
extend the hip on the affected side as much as possible without
allowing the patient to arch his back. The angle that the back of the
thigh makes to the couch on the affected side is the amount of fixed
flexion deformity in that hip.
INSTABILITY TESTS:
Telescopy test : done for demonstrating a dislocated hip or unstable hip.
Trendelenberg test: to demonstrate an ineffective abductor mechanism
(Gluteus medius wekness, dislocated or destroyed head of femur,
nonunion of neck of femur, coxa vara, etc.)
Barlows test / Ortalanis test
SPECIAL LINES:
Nelatons line: A line drawn from the ischial tuberosity to the ASIS on
the same side. The line just touches the tip of the greater trochanter in
normal individuals. When the greater trochanter has moved proximally for
any reason, the line cuts the greater trochanter.
Shoemakers line: A line drawn from the greater trochanter to the ASIS
on the same side and extended on to the abdomen will cross the midline at
or above the level of the umbalicus. When the trochanter is high riding the
line passes below the umbilicus.
of
Orthopaedics
Common symptoms: Pain, swelling, deformity, locking of the knee,
giving way of the knee, crepitus or clicks at the knee.
Examination of the knee includes that of the hip and ankle on the same
side and the knee on the opposite side.
Examination of the knee is done from the front, side and the back with the
patient supine, prone and standing.
INSPECTION:
Attitude of the limb and the knee in specific
Shape of the knee : Prepatellar area, parapatellar gutters,
suprapatellar pouch and infrapatellar areas for evidence of swelling,
patellar prominence, position of the patella, swelling over the
popliteal area- over the midline and the sides (Bursal swellings).
Tibial tuberosity: look for the tibial tuberosity levels from the side
on both sides simultaneously with the hips flexed to 45 degs. and
knees flexed to 90 degs.
o When the tap of the patella on the condyle is felt- patellar tap test is
positive.
o Patella tap can be false-negative when:
Test is done in presence of fixed flexion deformity
Minimal fluid in the knee- fluctuation test- standing position
Tense joint with excess fluid in the knee
Absence of the patella- patellectomy
Faulty technique of eliciting a patellar tap
Palpating for the synovial membrane : The synovium is best
palpated over the superior part of the supra-patellar pouch. This is the
region where the synovium reflects on itself and hence synovial
hypertrophy is best felt here. It is placed about 3-4 finger breadths
above the superior pole of the patella. The supra-patellar pouch
occupies this entire region until the superior border of the patella.
o Start from the superior border of the patella and palpate the suprapatellar area moving in a proximal direction. In the presence of a
synovial hypertrophy it is felt at the superior part of the pouch as a
chord like structure that can be rolled underneath the palpating finger.
Palpation of the patella:
o
o
Palpate for clicks and thuds in the joint: Usually indicates possible
meniscal damage or presence of loose bodies in the joint. Also look for
MEASUREMENTS:
Measurement of the lower limb as detailed in examination of the hip.
o Apparent length
o True length
o Femoral and tibial length
Muscle girth
SPECIAL TESTS:
Varus and valgus stress tests: for the collateral ligaments
Varus stress test: For lateral collateral ligament
Done with the knee in 10deg flexion and in knee extension
position (neutral position)
Varus stress applied to the knee
Will produce pain over the femoral or fibular attachment of the
lateral collateral ligament or anywhere along the course of the
ligament depending on the site of tear of the ligament.
Valgus stress test: For medial collateral ligament
Done with the knee in 10 deg flexion and knee extension position
(neutral position)
Valgus stress applied to the knee
Will produce pain over the femoral or tibular attachment of the
medial collateral ligament or anywhere along the course of the
ligament depending on the site of tear of the ligament.
Apley grinding test: For integrity of the menisci.
Apley distraction test: For integrity of the collateral ligaments.
McMurrays test for the medial and lateral meniscus
For the medial meniscus:
Flex the knee through its full range of flexion
Externally rotate the tibia on the femur and extend the knee with a
valgus force applied at the knee
For the lateral meniscus:
Flex the knee through its full range of flexion
Internally rotate the tibia on the femur and extend the knee with a
varus force applied at the knee.
In both these tests, look for evidence of pain and/or clicks during
extension of the knee and at what degree of flexion the knee is in, when
patient complains of pain.
If the pain is reproduced with the knee still in more than 100
flexion, the meniscal tear may be placed more posteriorly
(posterior horn tear of the meniscus)
If the pain is reproduced with the knee in 70-100 of flexion, the
tear may be in the middle of the meniscus
If the pain is reproduced with the knee in less than 70 of flexion
the tear may be placed more anteriorly (anterior horn of the
meniscus)
Anterior drawer test: testing integrity of the anterior cruciate ligament
The test is done on the normal side first to determine the normal
range for the given patient.
o Hip place at 45 deg flexion and knee at 90 deg flexion
o Patient is explained to relax the hamstring muscles and this is looked
for, by feeling the hamstring muscles.
o The foot is stabilized and the tibia is stabilised with both hands of the
examiner at the level of the condyles of the tibia and gently pulled
forwards, anteriorly.
o Anterior translation of the tibia on the femur is looked for and
visually approximated.
o The same maneuver is done with the tibia in external rotation and
internal rotation.
o The test is done on the affected side and the amount of forward
translation of the tibia on the femur is compared to the normal side.
o If the amount of translation on the affected side is more the test
on the affected side is said to be positive.
Posterior drawer test: For testing the integrity of the anterior cruciate
ligament
o Procedure is similar to anterior drawer test except that a posterior
push is given to the proximal tibia and the posterior translation of the
tibia on the femur is looked for and compared.
Lachman test: For testing the integrity of the cruciate ligaments.
o With the knee placed in 30 deg of flexion, the lower end of the femur
and upper end of the tibia are held firmly by the examiner.
o With the femur stabilized in one hand the tibia is gently pulled
forwards on the femur.
o Forward translatory movement of the tibia on the femur is looked for
and compared to the normal side. This gives an insight to the integrity
of the anterior cruciate ligament
o The same procedure is done
Q angle : in genu valgum deformity
_________________________________
of
Twisting injury
Vertical compression
Examination:
Inspection
Attitude of the limb and ankle in specific
Examination of the ankle includes that of the knee and foot on the
same side and the ankle on the opposite side.
Examination of the ankle is done from the front, sides
(medial and lateral) and back with the patient supine, prone
and standing.
Look for swelling, scars, sinuses and describe the same
Look for deformity
Whether displaced medially \ laterally or anteriorly \ posteriorly
Excessive broadening-suggests inferior Tibio - Fibular Diastasis
Whether Plantarflexed \ Dorsiflexed
Also look for:
Fullness on either side of Tendo Achilles or bulge across the front
of the joint - suggestive of effusion
Wasting of muscle
Palpation
Local rise of temperature
R ange of Movements
Normal
Subtalar
Plantar Flexion
0 - 45
Dorsi Flexion
0 - 20
Inversion
0 - 15
Eversion
0 - 20
Measurement
Measure the tibial length
Medial Malleolus Head of first Metatarsal to Heel
Lateral Malleolus Head of fifth Metatarsal to Heel
Test for
fracture of tibia and/or fibula
Percussion
(Bump)
Anterior Drawer
(Clunk)
Kleiger's
Positive test
pain elicited in the fibula and/or
tibia around fracture site
Pain along the lower leg may
indicate a fracture of the tibia/ fibula
pain elicited in the tibia around
fracture site
increased laxity and pain,
palpable "clunk" under the ankle
mortise
laxity, medial/lateral pain over
deltoid or sydesmosis
pain, increased laxity
pain, increased laxity
lack or decreased PF
tingling, pain, parasthesia along
nerve distribution
burning, aching, general pain
within calf
of
Orthopaedics
Common symptoms : pain, deformity, neurological symptoms
Examination of the spine includes examination of the ENTIRE spine,
sacroiliac joint both lower limbs and a detailed neurological examination.
Per rectal examination is a must during spinal examination.
Examination of the spine is done from the back, front and the sides with
the patient in the standing, prone and supine positions.
NERVE ROOT
C2
C3
C7
C8
T1-2
T12-L1
L1-2
L4-5
S1-2
T1
T12
L1
L4
S1
SEGMENTAL LEVEL
Cervical spine
Upper thoracic T1-6
Lower thoracic T7-9
T10
T11
T12
L1
Add 1
Add 2
Add 3
L1-2
L3-4
L5
Sacral and coccygeal
Lateral margin of the body from the axilla to the iliac crest whether
there is increased concavity on either side when compared to the other.
Deformity of the spine in both the antero-posterior and the mediolateral plane (torticolis, scoliosis, kyphosis, lordosis). Scoliosis is
looked for by looking at the spinous process of the spine through the
entire length of the spine.
Evidence of tell tale signs in the lower back that may suggest an
under lying spina bifida.
Level of the area of ribs with the patient bending forwards in patients
with scoliosis.
PALPATION
Local rise of temperature
Tenderness : over the entire length of the spine and the sacroiliac joints.
Confirmation of all inspectory findings and detailing palpatory findings
wherever appropriate. Eg: regarding swelling, scars etc.
Complete detailed neurological examination and findings to be
written in a tabular format.
RANGE OF MOVEMENTS
Active and passive movements in all directions normally occuring
at all levels of the spine have to recorded in degrees.
Cervical : Flexion, extension. rotations, lateral flexion
Thoracic: rotational movements occur at this level
Costovertebral movements: Also indirectly reflects on the status of the
spine as the ribs are attached to the vertebrae. Disease process
involving the spine can affect these joints and present clinically with
restricted movements of the thoracic cage. This is measured by the
amount of chest expansion possible on inspiration. Normally this
would be in excess of 5-7 cms.
Lumbar: Flexion :
o Schobers test to quantify the amount of flexion
o Coin test: when the spine is affected, patient bends at the hip and knee
with the spine being straight and stiff.
Lumbar : Flexion, Extension, lateral flexion.
Sacroiliac movements : moves with the patient bending forwards in the
standing position and also during rotation of the spine.
MEASUREMENTS
Schobers test to quantify the movements occurring in the spine.
Limb length discrepancy in the lower limbs as this can lead to
symptoms in the spine.
SPECIAL TESTS
Lhermitts sign:
Used to identify a possible disc prolapse at the cervical spine level
With the patient sitting the hips and the cervical spine are flexed
simultaneously. In the presence of excruciating pain in the spine
radiating down both upper extremities a disc prolapse is a possibility.
TESTS FOR THE SACROILIAC JOINT
Pump handle test:
The patient is placed supine and the test is done on the unaffected
side first. The shoulder of the patient is steadied and the hip is flexed
through its full range of flexion with the knees flexed. The hip is then
forced further into the direction of flexion and towards the opposite
shoulder. Normal sacroiliac joint will not produce any discomfort with
this maneuver.
The same is done on the affected side. Pain is reproduced at the sacroiliac
joint on the affected side.
Genslens test:
With the patient supine, the affected hip and knee is flexed while the
unaffected side is allowed to hyperextend over the edge of the table. This
produces a rotational strain in the sacroiliac joint reproducing pain on the
affected side.
RECTAL AND VAGINAL EXAMINATION
This is an important part of examination of the spine especially in spinal
injuries to determine the extent of damage to the cord (complete or
incomplete) and also in evaluating the period of spinal shock.
Examination of the rectum also is important to look into the status of the
prostate. Malignancies of this organ can produces secondaries in the
spine.
Vaginal examination is important to look into the possibility of cervical
carcinoma, which again can present with secondaries in the spine.
of
o
o
o
Tests for
Anterior Drawer
Posterior Drawer
posterior GH instability
anterior instability
Apprehension Test
Instability
Clunk Test
labral tear
Sulcus Sign
multi-directional instability
AC Distraction
AC and/or coracoclavicular
ligament sprain
Grind Test
labrum tear
Drop Arm
O'Brien
Empty Can
Active Impingement
Hawkins-Kennedy
SLAP Lesion
supraspinatus weakness,
Impingement
Impingement of active
structures in shoulder
impingement of the
supraspinatus tendon
impingement of biceps or
supraspinatus tendon
SC ligament sprain and
instability
adduction/IR or abduction/ER
Dr. Aruljoethy
Department of Orthopaedics
Common symptoms: Pain, Stiffness, Deformity, Occasional locking
The Elbow joint is formed by the lower end of the humerus, upper ends of the
Ulna ( olecrenon) and the radius ( radial Head)
The ossification of the lower end of the humerus is important to be known.
The bony prominences around the elbow are the Medial epicondyle and Lateral
condyle. The head of the radius and the olcrenon process are also palpable.
INSPECTION
Attitude and Deformity of the limb : Cubitus Varus and Valgus
Carrying angle: The angle between the long axis of the arm o that of the
forearm with the limb in supination and neutral position in the plane of flexion
and extention.
The carrying angle should not commented upon with the limb in any degree of
flexion on in the presence of a flexion deformity.
Patient asked to stand with his hands by the side of the body and observe for
normal carrying angle : 8-10 deg in males and 11-15 deg in females.
Swelling:
Any swelling near the joint to be noted
Look for fullness of normal hollow on either side of Olecronon
Look for any swelling over the olecronon [eg: olecronon bursitis students /
miners elbow]
Tense effusion will show fullness of anticubital fossa
Look for any scars or sinuses and describe them
Muscle Wasting
PALPATION
RANGE OF MOVEMENTS
Flexion and extension
Additional tests:
Palpation of Ulnar Nerve
Cozens Test
Miltch Manuvuer
MEASUREMENTS:
Distance between the two condyles: Intercondylar distance
Distance between the Olecrenon and the two condyles: Medial and Lateral
Arm and forearm length
EXAMINATION OF THE WRIST JOINT
of
Orthopaedics
Common complaints: Pain, Swelling and deformity
Common fractures: Colles. Smiths, Bartons, Chauffers,
Epiphyseal injury
Some disease process: Rheumatoid, Keinbocks disease
Scaphoid,
Palpation:
Local rise of temperature
Tenderness: Soft tissue and bony, Joint line
Confirm Inspectory findings
Look for limb length discrepancy
Describe palpatory findings of swellings
Bony Points:
Lower end of Radius
Lower end of Ulna
Balottment of Ulnar head
Level of Styloids
Range of Movements:
Dorsiflexion [extension]
Palmar flexion
Radial Deviation
Ulnar Deviation
70 to 80
0 to 70
0 to 20
0 to 30