ORTHOPAEDIC PHYSICAL EXAMINATIONSUBLAB.ORTHOPAEDI & TRAUMATOLOGY
Principles of ExaminationObtaining data from patients story (clinical history); Preliminary data: name, sex, age, occupation Chief complaint Common musculoskeletal symptoms:PainDecrease in functionPhysical appearance Past, Social, Economic, and Family History
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)
Look Feel Move
Principles of Examination REGIONAL EXAMINATIONNeck Shoulder Elbow Wrist & HandBackHip Knee Ankle & Foot
General Principles of TreatmentFirst do no harm (primum non nocere)Base treatment on an accurate diagnosis and prognosisSelect treatment with specific aimsCooperate with the law of natureBe realistic and practical in your treatmentSelect treatment for your patient as an individual
Examination of the Neck Observe the patient as a whole. Observe the neck and shoulders from in front and behind. 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 90 .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 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).
Examination of the Elbow 13. Palpate the ulnar nerve.
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)
Examination of the Wrist & Hand7. 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 & Hand10. Radial deviation. 11. Ulnar deviation.12. Pronation. 13. Supination.
Examination of the Wrist & Hand14. Test thumb extension. 15. Test thumb abduction.16. Test thumb adduction. 17. Test opposition.
Examination of the Wrist & Hand18. 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 & Hand21. 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.
Examination of the Wrist & HandPHALENS 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 & HandFINKELSTEINS TEST
Painless function of the abductor P.L , Ext P.BFlex and ulnarly deviate the wrist, then push the thumb into flexion Sharp pain on the radial border of the wrist de quervains disease
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 BackA Neurological examination including:13. Knee extension.14. Knee flexion15. Knee jerk reflex16. Ankle jerk reflex.
Examination of the Back17. 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 Hip6. Ensure the Anterior Superior Iliac Spines are horizontal.
Examination of the Hip7. 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 Hi