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Examination of Muscles, Tendons and Fasciae
https://t.me/med1917
Fig. 9.2: Finger deformity after burns contracture.
221
A
B
Figs 9.1A and B: Dupuytren’s contracture.
Mallet Finger/Base Ball Finger
It is fixed flexion deformity of terminal phalanx/distal
interphalangeal joint due to rupture of extensor tendon
of distal phalanx or avulsion fracture of the base of
the distal phalanx near its insertion. Injury by a hard
ball/object into the flexed finger tip is the cause. There
is inability to extend the tip of the finger; distal phalanx
of affected finger is 20° flexed; distal IP joint can
be flexed to 90° and when extended it comes upto
20° flexed position; it cannot be extended further and
straightened. It is serious handicap only to whom who
are in need of fine movements with fingers like
musicians, tailors, surgeons.
Rupture of Extensor Pollicis Longus
It is due to attrition of extensor pollicis longus tendon
causing sudden rupture with a snap while working
and later thumb becomes adducted with inability to
extend the terminal phalanx of the thumb. It is common
in females; seen in rheumatoid arthritis or as a
complication of Colles’ fracture.
Rheumatoid Arthritis of the Hand
Hands are commonly involved in rheumatoid arthritis.
Hypertrophy of the synovial membrane of the joints
is the initial feature. Overlying skin becomes shiny
and atrophic. W asting of muscles with swollen, spindle
shaped/fusiform joints and later development of
deformities occurs. Metacarpophalangeal joint is first
to get affected; later proximal interphalangeal joint.
Deformities are – deviation of finger towards ulnar
side at metacarpophalangeal joint (varus deformity
of 45°–60°) – ulnar drift; fixed flexion deformity of
wrist with ulnar deviation; fibrotic contraction of
interossei and lumbricals causing hyperextension of
the proximal interphalangeal joint and flexion of distal
interphalangeal joint – swan neck deformity; flexion
of proximal interphalangeal joint and hyperextension
of distal interphalangeal joint due to attrition of middle
slip of the extensor tendon – ‘boutonniere’ deformity ;
rupture of extensor tendons at wrist level causing
dropped finger (Figs 9.3 and 9.4).
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Fig. 9.3: Button hole/Boutonniere deformity. There is flexion
of proximal interphalangeal joint and hyperextension of distal
interphalangeal joint.
Fig. 9.4: Swan neck deformity. It is hyperextension of
proximal interphalangeal joint and flexion of distal interphalangeal joint.
Heberden’s Nodes
SRB’s Clinical Surgery
They are bony swellings close to distal interphalangeal
joints both in palmar and dorsal aspects. Dorsal aspect
is more common site. They are nonspecific even though
associated commonly with osteoarthrosis. They are
common in females. In males when it occurs it is usually
solitary may be of traumatic origin by sports like base
ball/cricket ball injury. All fingers may be involved but
not thumb. Index finger is most commonly affected.
They are nonmobile bone swellings. Radial deviation
of distal phalanx with osteoarthritis of distal interphalangeal joint is usual. Small adventitious bursae
may develop between swelling and skin. Often swelling
over proximal interphalangeal joint may also be
involved.
Ruptured Muscle Fibres
Unusual sudden excessive contraction of a normal
muscle or normal contraction of a degenerated muscle
can cause rupture of a muscle. Muscle rupture is
common in young athletes or in old people who does
unusual strenous work. Commonly affected muscles
are biceps brachii, quadriceps femoris. Pain, bruising,
swelling may appear after tear. But usually tear may be
unnoticed but later presents as muscle weakness,
swelling, and limp. In relaxed state, there will be a
depression at the site of the tear; when contracted
swelling will be seen or felt at the edge of the depression
which is firm and without any independent mobility.
Swelling is free edge of the contracted partially torn
muscle fibres. In complete tear, movement of muscle
will be absent. All adjacent joints, arterial and nervous
system should be examined. Chronic degenerative or
musculoskeletal diseases should be looked for. Rupture
of long head of biceps brachii: It occurs in bicipital
groove, usually spontaneous due to a degenerative
disease in elderly; presenting as either sudden pain in
upper arm or more commonly swelling due to bunching
of muscle when elbow is flexed. Rupture of the supraspinatus tendon occurs in elderly as a degenerative
disease; presenting as sudden pain and absence of
initiation of abduction. Initiation is done by body by
leaning towards the affected side. Later part of abduction of the shoulder is normal. Rupture of the Achilles’
tendon: It is seen in athletes like foot ball players where
violent undue contraction of the calf muscle occurs.
There may be arterial insufficiency of tendon also.
Swelling is seen or felt in the posterior lower part of
leg while plantar flexion of the ankle is typical.
Intramuscular Haematoma
Here injury is direct with a tear in the muscle which
also injures the intramuscular blood vessels. It is often
seen in people who take anticoagulants and who are
suffering from blood dyscrasias. Pain is very common
which is present at rest and aggravated by muscle
movements. Firm, tender well localised swelling in
the muscle is felt even in relaxed state. Tenderness
in the swelling disappears in few days but pain will
persist for few weeks while contracting the muscle.
This firm/hard swelling is longitudinally ovoid and
parallel to muscle fibres. Usually swelling is hard but
occasionally liquefaction of haematoma makes it soft
Examination of Muscles, Tendons and Fasciae
https://t.me/med1917
and fluctuant. On contracting the muscle swelling
which was well felt may become indistinct. Gastrocnemius is the commonest muscle affected.
Muscle Hernia
It is bulging out of the muscle especially during
contraction through a defect in its fibrous sheath
covering. This is obvious and significant only when
it occurs in muscles having thick fibrous sheath like
anterior compartment of leg, lateral abdominal and
back muscles. Size of hernia changes and depends
on the amount of contraction developed in the muscle.
When muscle is relaxed swelling is absent but a distinct
defect is palpable in the fascia. To diagnose muscle
hernia these two features are essential, i.e.– while
contracting a bulge felt through the defect; on relaxing
the distinct fascial defect is felt. Muscle hernia is
common in lumbar region and calf.
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for callus underneath. Muscle over a callus will function
normally; whereas ossified muscle is functionless.
Features of old fracture will be there with restricted
joint movements.
Tennis Elbow
It is lateral epicondylitis of the humerus presenting
as pain in latertal epicondyle of the humerus at the
attachment of common extensor forearm muscles.
When wrist is extended against resistance pain is
aggravated. There is localised tenderness at the lateral
epicondyle of the humerus (Refer Chapter 30, pg 685).
Golfer’s Elbow
It is pain and localised tenderness over the medial
epicondyle adjacent to origin of common flexor tendon
of the forearm which is aggravated by flexing the wrist
against resistance (Refer Chapter 30, pg 685).
Intra- or Intermuscular Lipoma
Lipoma can occur within the muscle or in between
muscles. Such lipoma may interfere with function of
the muscle. Swelling in the muscle which is smooth,
soft or firm with lobulations may be felt but when
contracted swelling often may become indistinct,
immobile and hard. Occasionally such lipoma which
was not palpable becomes suddenly palpable during
exercise due to its bursting out through muscle fibres
making it painful palpable swelling. Intra- or intermuscluar lipoma is common in back of the trunk as fat
content of these muscles are more than muscles in
other part of the body. Initially such lipoma is not
palpable and grows silently to attain large size. Usually
such lipomas are single.
Myositis Ossificans
It is calcification and eventual ossification of part of
the injured muscle which is usually associated with
fracture of adjacent bone. It is seen in lower part of
the brachialis muscle after supracondylar fracture of
the humerus or quadriceps femoris in fracture femur.
Features are: Inability to use the muscle; stif f adjacent
joint; painful forced movements. Ossified part attains
the involved muscle shape and is fixed to the underlying
bone. This ossified muscle is continuous with callus
underneath. Often this ossified muscle may be mistaken
Plantar Fasciitis
Tear or bony spur at the attachment of the plantar
fascia to the calcaneum causes unbearable pain in the
heel while walking.
Supraspinatus Tendinits
Supraspinatus muscle from its origin from supraspinous fossa of the scapula is inserted to upper
impression of the greater tubercle of the head of the
humerus. Degenerative process in this tendon often
with calcification is seen in middle aged or elderly
males causing pain in the shoulder during middle third
of the abduction and external rotation of the shoulder,
which occurs because when the head of the humerus
comes in contact with the acromion causes compression of the degenerated supraspinatus tendon. First
60° of abduction is painless; next 60° abduction is
painful; further abduction after 120° is painless causing
typical painful arc syndrome. Stiffness of shoulder
develops causing frozen shoulder. Pain gradually
subsides while stiffness increases; later stiffness
persists but pain subsides in 3 months; in further 3
months stiffness also slowly subsides. Spontaneous
rupture of the degenerated supraspinatus tendon can
occur. Calcification in the tendon can be confirmed
by X-ray.
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Volkmann’s Ischaemic Contracture
SRB’s Clinical Surgery
It is development of muscular infarction initially acute
later chronic causing subsequent contracture. There
is shortening of the long flexors of the forearm due
to ischaemic fibrosis of the muscle (aseptic muscle
necrosis and fibrosis). Causes: Supracondylar fracture
(commonest) injuring brachial artery which bleeds or
undergoes spasm causing raised pressure in the
compartment which again further compromises the
blood supply of the muscle; a tight plaster which
compresses the artery blocking the blood flow; arterial
embolism. Burns, closed forearm crush injury, intravenous chemotherapy are other causes. Features in
acute phase: Condition is common in young individual;
history of trauma is evident; pain in the forearm and
fingers (under the plaster is typical); loss of finger
movements (mainly finger extension); cold skin;
paraesthesia (due to ischaemia of median and anterior
interosseous nerves) severe burning pain or pins and
needles sensation due to ischaemic neuritis; absence
radial pulse; pallor; oedema of the forearm (puffiness).
Chronic phase: Once acute phase subsides gradually ,
pain disappears but deformity persists with inability
to extend fingers. By flexing the wrist fingers can be
Fig. 9.5: Volkmann’s sign in Volkmann’s ischaemic contracture. When wrist is flexed fully fingers can be extended at interphalangeal joints. It is not possible in Dupuytren’s contracture.
extended – V olkmann’ s sign. There is claw hand deformity . Fingers are in acutely flexed position. Forceful
passive finger extension is uncomfortable and often
painful. Metacarpophalangeal joint is extended
(Fig. 9.5).
Examination of Oral Cavity
https://t.me/med1917
Examination of
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10
Oral cavity is a wide area which includes lips, vestibule,
gums, teeth, cheeks, tongue, palate, and floor of the
mouth. Vestibule is a smaller outer portion bounded
externally by lips and cheeks; internally by teeth and
gums. Parotid duct opens into the cheek opposite the
crown of upper 2nd molar tooth. Numerous mucus
glands that are situated in the submucosa of lips and
cheeks open into the vestibule.
History taking begins with:
Name:
Age:
Sex:
Occupation:
Address:
Agriculturists who are constantly exposed to sunlight are prone to develop carcinoma lip—country-
man’s lip. Carcinoma oral cavity is more common in
males. Cleft lip and palate is seen in newborns. Mucus
cysts can occur at any age group. Australian Caucasians
commonly develop lip cancers. It is less common in
Negroes.
Oral Cavity
History
History of Present Illness
History of swelling: Mucus cyst of lip or cheek presents
as painless swelling of long duration. It is painless.
Duration, progress, presence of pain should be asked
for. Carcinoma often can present as swelling of short
duration. Lip cancer is slowly progressive and so may
have long duration. Carcinoma of cheek and tongue is
rapidly progressive and is having short duration. Minor
salivary tumour in palate and lip presents as swelling.
History of ulcer: Ulcer in the oral cavity is common.
It can be aphthous ulcer/syphilitic ulcer/traumatic
ulcer/tuberculous ulcer/malignant ulcer. Aphthous
ulcer is painful. Malignant ulcer is painless to begin
with but becomes painful once it infiltrates or gets
infected. Origin of ulcer, duration, progress should
be asked for.
History of pain: Site of pain, radiation, referred pain,
severity of pain, pain over the adjacent mandible,
whether pain restricts mouth opening or swallowing
should be asked for. Pain may radiate or get referred
to ear through lingual nerve or inferior alveolar nerve
(through auriculotemporal branch of mandibular
nerve). Dental ulcer on the margin of the tongue is
painful. Aphthous ulcer is painful. Tuberculous ulcer
may not have any pain. Retention cyst, leukoplakia,
early oral cancers are painless. In late cases of
carcinoma pain develops due to deeper infiltration (to
nerves), and sepsis.
Excessive salivation is common in oral cancers
especially in carcinoma tongue.
Inability to protrude the tongue out is common in
carcinoma tongue involving floor of the mouth or
infiltrating the genioglossus muscle.
Difficulty in speech is common in carcinoma tongue.
It is also often seen in painful aphthous ulcers.
Voice change or dysphagia may be the feature of
carcinoma posterior third of tongue.
Dentition, recent history of loosening of teeth, falling
of teeth is important as it may be due to underlying
carcinoma.
Bleeding, halitosis (foul smelling breath), altered
taste sensation, cough, haemoptysis are other history
to be asked. History of fever suggests infection,
bronchopneumonia (due to aspiration especially in
carcinoma tongue).
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Symptoms suggestive of local invasion (difficulty
in opening the mouth, mandibular pain, loss of
sensation in the chin or gums); cervical lymph nodal
spread (swelling in the neck, duration, pain, ulceration).
Past History
Past history of oral ulcers, treatment received in the
form of surgery, radiotherapy, chemotherapy has to
be noted. History suggestive of leukoplakia also should
be asked.
Personal History
Smoking, alcohol intake, spicy food, pan chewing
(betel nut, supari, Khaini, etc.) are important causes
for carcinoma. It is also important to note how long
patient keeps the pan in the cheek which will increase
the irritation. Reverse smoking is often related to
carcinoma hard palate.
SRB’s Clinical Surgery
General Examination
Detailed general examination is very essential.
Anaemia/oedema/jaundice/clubbing/lymphadenopathy/radial pulse/blood pressure/raise in temperature/attitude of the patient/nutritional assessment by
skin texture, subcutaneous fat, weight, body mass
index/any other relevant findings should be mentioned.
Cachexia signifies advanced malignancy. Halitosis
may be found. Temperature may be raised.
Local Examination
Inspection
Inspection of the oral cavity should be done using
proper and adequate light. A spatula should be used
eventually to inspect posterior aspect of the oral cavity.
Inspection is done in order – lips, cheeks, teeth, gums,
tongue, floor of the mouth, palate, tonsils, posterior
aspect (Figs 10.1A to D).
Inspection of the Lip
Lips are two fleshy folds lined by skin outside and
mucous membrane inside. Upper lip is bounded by
nose and nasolabial groove. Lower lip is bounded by
cheek and labiomental groove. Orbicularis oris forms
the muscular bulk of the lip which encircles the lip
and is supplied by facial nerve. Frenulum in the midline
in upper and lower lips joins lip to the gums. Vermilion
border is red border of the lip where skin part merges
gradually into the mucous membrane part. It contains
wet line inside and a dry line outside. Small rounded
nodule at the centre of the lowest part of the upper
lip is called as tubercle. A depression running from
tubercle to nostrils is called as philtrum. The corner
where upper and lower lips meet at right and left angles
are called as commissures of lip. 5 mm elevation of
mucous membrane posterior to commissure is called
as commissural papule. Upper lip drains into upper
deep cervical nodes. Centre of lower lip drains into
submental nodes then to upper deep cervical nodes.
Lateral part of lower lip drains into submandibular
lymph nodes then to middle cervical nodes. Lymph
from angles of mouth drains into both nodes of upper
and lower lips. Lips are red or reddish brown in young.
It is often brownish in smokers.
Cleft lip and cleft palate are obvious. Its type, side,
extent should be noted down. Macrocheilia is enlarged
lip which is common in upper lip may be due to lymphangioma or haemangioma (soft, bluish with compressibility and emptying is typical) (Figs 10.2 and
10.3).
Blackish pigmentation can occur in lip or cheek
in Addison’s disease. Bluish pigment spots are seen
in lower lip, cheek or palate in Peutz-Jegher’ssyndrome along with multiple polyps in the small
bowel, occasionally in colon inherited as autosomal
dominant familial disease.
Acute ulcers like aphthous ulcers can occur in lip.
Aphthous ulcers (aphthous – Greek – to set on fire;
in USA called as ‘Canker sor e’) are common in younger
age group; self limiting in 7-14 days; related to stress
or nutritional deficiency; are small, often multiple
superficial painful erosive lesions with whitish floor
with yellowish and hyperaemic margin. In cold weather
lips may get cracked mainly in the midline (Fig. 10.4).
Carcinoma lip is common in lower lip. It is slow
growing tumour initially may present as a proliferative/
nodular or ulcerative lesion with whitish flaques/red
areas/necrotic tissues over the surface (Fig. 10.5). This
lesion should be inspected in detail for margin (regular/
irregular/well defined/ill defined); edge (everted/
raised); floor; surrounding area; angles of the lip. Often
there will be oedema surrounding the lesion. Entire
Examination of Oral Cavity
https://t.me/med1917
227
A
C
Figs 10.1A to D: Proper inspection of the oral cavity is essential part of the examination. Often spatula/tongue
depressor and a good light source should be used to inspect the oral cavity.
lip may get enlarged. Discharge on the surface may
be serous/serosanguinous/purulent.
Minor salivary gland tumour can occur in upper
lip. It usually begins as a swelling in the upper lip;
slowly progressing eventually forming an ulcer over
the summit of the swelling. Primary syphilitic chancre
in the lip (common in upper lip) is pink painless macule
to begin with; becomes papule and later superficial
ulcer with thick crust on the floor and often ulcer may
be painful. These ulcers eventually heal with a
permanent fine superficial scar. Angular stomatitis
(cheilosis), syphilitic rhagades (secondary syphilis),
B
D
vitamin deficiency (riboflavin) ulcers, denture induced,
cracks due to allergy to dentures/lipsticks can develop
in the angles of the mouth (commissures). Perleche
(French – to lick) is angular stomatitis seen in children
as a simpler infection which does not extend to mucus
surface and heals without scarring. Stomatitis in
syphilis extends to mucous membrane and heals with
a scar.
Carbuncle of upper lip eventhough now rare; can
be dangerous due to development of fatal cavernous
sinus thrombosis due to spread of sepsis through
dangerous zone. It may cause thrombophlebitis of
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SRB’s Clinical Surgery
Fig. 10.2: Cleft lip and palate in a child.
Fig. 10.3: Haemagioma of upper lip.
ophthalmic plexus of veins leading into upper eyelid
oedema. Actinic cheilitis is common in lower lip; is
due to exposure to sun light; present as recurring small
blisters with epithelial exfoliation; recurrent lesions
are premalignant. Keratoacanthoma (molluscum
sebaceum) can occur in lower lip which is entirely
benign but mimics carcinoma. Retention mucus cyst
is common in lower lip which is blue, well localised;
smooth (fluctuant and transilluminating).
Inspection of the Cheek
It is large fleshy flap one on each side covering the
vestibule. It contains skin, superficial fascia with facial
Fig. 10.4: Aphthous ulcer over the lip and tongue.
Fig. 10.5: Carcinoma lip—proliferative lesion.
muscles, parotid duct, mucus glands, buccinator with
buccopharyngeal fascia, submucosa and mucous
membrane. Buccal pad of fat lies on the buccinator
partly deep and partly in front of masseter.
Cheek is inspected for leukoplakia, mucous cyst,
swellings, papilloma, and carcinoma (Fig. 10.6).
Pigmentation similar to lips can also develop in cheeks.
Leukoplakia is whitish patch in the mucosa of the oral
cavity that cannot be characterised clinically or
pathologically to any other disease. It is a premalignant
disease. It is common in smokers and who chew pan
(20%). It has got 4% chances of turning into malignancy .
Examination of Oral Cavity
https://t.me/med1917
Fig. 10.6: Cheek inspected using a spatula/depressor.
229
Fig. 10.8: Carcinoma lip and cheek.
Fig. 10.7: Severe mucositis mainly in cheek.
Erythroplakia, submucosal fibrosis are other
conditions to be looked for in cheek (Figs 10.7 and
10.8).
Carcinoma cheek needs special mention. Cheek
is common site of carcinoma in oral cavity . It can be
either ulcerative or proliferative lesion. Margin, size,
shape, edge, floor of the lesion and surrounding area
should be inspected. Once carcinoma infiltrates deep
into the pterygoid muscle, trismus develops.
Trismus is inability to open the mouth adequately .
Trismus is decreased interincisor distance between
upper and lower jaws (Figs 10.9A to 10.10B).
A
A
Figs 10.9A and B: Carcinoma cheek in two different patients.
Tongue depressor/spatula use is helpful in proper inspection
of the cheek.
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SRB’s Clinical Surgery
Tartar (precipitated calcium in saliva) deposition
occurs on lingual sides of lower incisors due to constant
exposure to calcium rich saliva from submandibular
salivary gland. Tartar may precipitate pyorrhoea
alveolaris (Fig. 10.11).
A
B
Figs 10.10A and B: Trismus in carcinoma cheek suggests
involvement of pterygoids and soft tissue. It is checked by
placing fingers (of patient ideally) perpendicularly between
opened jaws.
Grading of trismus: Interincisor distance more than
3.5 cm is – normal. Grade I is between 3.0–3.5 cm.
Grade II is between 2.0–3 cm. Grade III is less than
2 cm.
Inspection of Teeth and Gums
Teeth should be counted. Primary dentition is 20 in
children. Secondary permanent dentition is 32 in adult.
2 incisors; 1 canine; 2 premolars; 3 molars (2123).
Third molar tooth (total four) are last to erupt on each
sides at late teenage. One or more tooth may be absent;
changed spacing; deformities are common. T eeth may
be green in infants with jaundice; tetracycline given
in early childhood may stain the teeth. Excess fluorides
in drinking water may cause black pits in the teeth.
Transverse ridge with curved notching is seen in rickets.
Fig. 10.11: Oral cavity inspection always includes
inspection of dentition properly.
Tooth which is prevented from erupting by other
teeth is called as impacted tooth. Mandibular 3rd molar
is commonly impacted tooth (wisdom tooth).
Incompletely erupted mandibular 3rd molar commonly
suppurates and is dangerous, and is common cause
of trismus. Dead tooth is less white or bluish gray
and insensitive to ice placed over it. Hutchinson’ s teeth
are seen in congenital syphilis; only secondary
dentitions are affected; common in upper central
incisor; small notched incisor is typical. Screwdriver
tooth is also seen in congenital syphilis. Moon’ s molar
is dome shaped first molar – seen in congenital syphilis.
Gingivae or gums are mucous membrane covering
the alveolar process of the jaws. It is pink in colour
in healthy person. It is spotted with brown melanin
pigment in dark skin people and people from
Mediterranean region. It is pigmented in smokers, pan
chewers. Gingival margin is occlusal border at which
gingiva meets teeth. Free gingiva is gingival part
encircling the tooth forming a gingival sulcus. Attached
gingiva is mucosa which is firmly bound to the
underlying bone. Alveolar mucosa is movable vascular
mucosa and less attached to bone. Lips should be
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