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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5233_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 29
Orthopedic Examination
MahmoudMassoud andAshrafMohey
Abstract History taking, Examination scheme, Spine Examination, Shoulder
Examination, Elbow Examination, Hand & Wrist Examination, Hip Examination,
Knee Examination, Ankle & Foot Examination, Pediatric Examination, Brachial
plexus Examination, Check list OSCE, Orthopedic imaging, Relevant Orthopedic
History Taking. Personal history NAME/AGE/SEX/JOB/ADDRESS/SPECIAL
HABITS/DOMINANT HAND.Past history of Disease: DM/HTN—TB/Tumor—
Operations/Drugs.
Keywords Orthopedic · Bone · Joints · Examination · Deformity · Gait ·
Movement · History
• History taking
• Examination scheme
• Spine Examination
• Shoulder Examination
• Elbow Examination
• Hand & Wrist Examination
• Hip Examination
• Knee Examination
• Ankle & Foot Examination
• Pediatric Examination
• Brachial plexus Examination
• Check list OSCE
• Orthopedic imaging
M. Massoud (*) · A. Mohey
AFCM, Cairo, Egypt
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_29
299© The Author(s), under exclusive license to Springer Nature
300
M. Massoud and A. Mohey
Relevant Orthopedic History Taking
Personal history
NAME/AGE/SEX/JOB/ADDRESS/SPECIAL HABITS/DOMINANT HAND
Past History
Disease: DM/HTN—TB/Tumor—Operations/Drugs
Family history
DISEASES/DEFORMITIES
Obstetric history (FOR LADIES)
DURING PREGNANCY: DM/HTN/DURING DELIVARY/POST PARTUM
Develop history (PEDIATRICS)
Menarche age
C/O
Onset/course/duration
Abnormal Look
1. Swelling: (site, size, shape, surface, consistency).
2. Deformity.
Abnormal Feel
1. Pain: site, type, course, nature, radiation.
2. Deformity.
Abnormal Move
1. Tingling/Numbness: e.g.
Acute with activity ≈ structural abnormality After activity ≈ inammatory
Chronic/aching ≈ degenerative Night ≈ TB/Tumor.
2. Instability//Giving away (how many times).
3. Stiff//Locking
Others Affecting ADL (activity daily living)
Snap/click/clunk (non-signicant if not with one of chief c/o).
feed/WC—sleep/sex— work/driving.
GAIT:
• GENERAL: Rhythm, speed, limp, turning.
• PHASES: Heel-strike, stance, push-off, and swing.
Examination
General Rules ofExamination
• Greetings
• Introduce yourself
29 Orthopedic Examination
• Ask for consent of examination
• Necessary exposure one joint above and one joint below
• Thank the Patient at end
Should do Examination on4 Os
• Open (bared limb)
• Order
(standing-sitting- lying)
(supercial to deep) (proximal to distal)
• Opponent (MCL=LCL)
• Other side (The other limb) Comfort & easy
Rapid Screening Tests
The Shoulder Joint
Put the hand on the head, other shoulder and behind the shoulder (Fig.29.1a–c).
301
The Elbow Joint
Supination, Pronation, Flexion, extension (Fig.29.2a–c).
The Wrist Joint & theHand
Grasp, exion, extension of the ngers and the wrist.
ab c
Fig. 29.1 (a–c) Screening for the shoulder joint
302
abc
Fig. 29.2 (a–c) Screening for the elbow joint
ab c
M. Massoud and A. Mohey
Fig. 29.3 (a–c) Screening for the hip and knee joint
The Hip & Knee Joints
Squat, stand on one limb, cross leg position (Fig.29.3a–c).
Ankle Joint
Gait, stand on heels, stand on tip toeing (Fig.29.4a–c).
Hyper Laxity
Beighton score, is a system used to assess joint hypermobility. It involves a series of
maneuvers to test the exibility of various joints in the body, such as bending the
thumb backward to touch the forearm or hyperextending the knees and elbows.
Each maneuver is assigned a point, and a total score is calculated. Higher scores
indicate greater joint hypermobility (Fig.29.5a–c).
29 Orthopedic Examination
ab c
Fig. 29.4 (a–c) Screening for ankle joint
303
a
b
Fig. 29.5 (a–c) Examination for laxity of the joints
c
304
M. Massoud and A. Mohey
Examination oftheShoulder Joint
Most Common Clinical Conditions
• Frozen shoulder.
• Recurrent or acute dislocation shoulder.
• Rotator cuff tear.
• Bicipital tendonitis.
• Rupture of the long head of biceps.
• Osteoarthritis.
• Referred pain from near or far lesions.
Mechanism ofInjury
Certain mechanisms of injury result in characteristic patterns of structural damage.
E.g. Fall on outstretched hand → anterior dislocation of shoulder → Fracture of
proximal humerus
General: SCHEME+Cx spine
Hyperlaxity: SCHEME
Gait: as before and we will examine cervical spine
Type of Pain:
* Aching pain → degenerative changes
* Sharp pain/catching pain → ACJ pathology → subacromial impingement
* Pain after activity → inammatory arthropathy → tendinosis Night pain → rotator
cuff lesion → glenohumeral arthritis → adhesive capsulitis → infectionLook
A: alignment (shoulder drop).
S: symmetricity/muscle wasting (supra-infraspinatus) injury suprascapular. N.
S: skin (Fig.29.6a, b).Move:
Active (exion extension/Abduction, Adduction/internal, external rotation)
The range of movement of the shoulder joint in degrees is as follows:
• Flexion: 0–180 degrees
• Extension: 0–60 degrees
• Abduction: 0–180 degrees
• Adduction: 0–45 degrees
• Internal rotation: 0–70 degrees
• External rotation: 0–90 degrees (Fig.29.7a–d).
Muscle Power
Medical Research Council Scale Grade Description;
0 no contraction
a
b
cd
29 Orthopedic Examination
Fig. 29.6 (a, b) Inspection of the shoulder joint
ab
305
Fig. 29.7 (a–d) Inspection for movement of the shoulder joint
1 icker or trace of contraction
2 active movement with gravity eliminated
3 active movement against gravity
4 active movement against gravity and resistance
5 normal power
306
cd
M. Massoud and A. Mohey
a
b
Fig. 29.8 (a–d) Lift off test
Rotator Cuff Examination
Active against resistance Passive (lag test) Drop arm tests supraspinatus (Abduction
0/900) IS (external rotation in Adduction) T minor (external rotation in Abduction)
subscapularis (left off test).
Lift off Test
The patient stands and places the dorsum of the hand against mid-lumbar spine. The
patient then lifts his hand away from the back. An inability to perform this action
indicates a lesion of the Subscapularis muscle (Fig.29.8a–d)
Special Test: Specic toc/o (Passive)
Impingement Neer’s sign: While the patient is sitting or standing, the examiner passively elevates the patient’s internally rotated arm in the plane of the scapula (about
30° from the coronal plane) (Fig.29.9a, b).
29 Orthopedic Examination
307
a
Fig. 29.9 (a, b) Serratus and Pectoralis major tests
b
ab
Fig. 29.10 (a, b) Left off test
Drawer tests: for subluxation and dislocation: These are performed to quantify
the amount of anterior and posterior laxity.
While standing behind the patient, use one hand to stabilize the shoulder girdle
by holding on to the scapula with your thumb and coracoid with your index nger
and, with the other hand, hold on to the humeral head (Fig.29.10a, b).
The SLAP TEST: patient is positioned in 90° of shoulder abduction, and 65–70°
of elbow exion and the forearm in a neutral position
Biceps Tendon Hold the arm in 10° of internal rotation and run your thumb just
distal to the anterior edge of the acromion (Fig.29.11a)
Acromio-Clavicular joint: Follow the clavicle laterally to its end. Usually, one
can feel the articulation between the acromion and clavicle (Fig.29.11b).
Serratus Anterior (Long Thoracic Nerve C5, 6, 7) Stand behind the patient and
ask him to push against the wall with arms at the level of the shoulder. If weak or
308
M. Massoud and A. Mohey
a
c
b
d
Fig. 29.11 Tests for Biceps tendon “a”, Acromioclavicular joint “b”, Serratus anterior muscle “c”
and Latissimus Dorsi muscle “d”
paralyzed, the medial border of the scapula moves away from the chest wall “scapular winging” (Fig.29.11c).
Latissimus Dorsi (Thoracodorsal Nerve C6, 7, 8).
Ask the patient to abduct the arm to 90°. The examiner applies resistance to the
point of the elbow and asks the patient to pull the elbow down to the side. The other
hand feels for the contracting muscle (Fig.29.11d).
Trapezius Tenderness and trigger points may be elicited, which are usually associated with cervical spine pathology.
Deltoid (Axillary Nerve C5, 6) Ask the patient to abduct the shoulder to 90° and
hold the position. The anterior, middle, and posterior bers are now palpable.
Rhomboid (Dorsal Scapular Nerve C5).
The patient is asked to pull the shoulders back, while the examiner applies resistance to the spine of the scapula (Fig.1.17).
Pectoralis major (Lateral Pectoral Nerve C5, 6).
Stand facing the patient, who is instructed to place the hands on the hips and
press rmly.