Ortho Special Test

8/3/2019 Ortho Special Test

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ROTATION HANDOUT

FAMILY MEDICINE RESIDENTS

ORTHOPEDICS ROTATION

Gaetano P. Monteleone, Jr., M.D.

Dept of Family Medicine

West Virginia University School of [email protected]

PHYSICAL EXAM SKILLS

Consider Magee’s Orthopedic Physical Assessment and Hoppenfeld’s Examination of the Spine

and Extremities for further exam techniques in orthopedic medicine.

I. ANKLE

• Range of Motion (ROM)

Dorsiflexion (0-20°)

Anterior tibialis, Toe extensors (hallucis longus, digitorum longus).

Plantar flexion (0-50°)

Gastroc/soleus unit, Posterior tibialis, Toe flexors (hallucis longusand digitorum longus).

Inversion (0-35°)

Anterior tibialis

Eversion (0-15°)

Peroneus longus and brevis

• Special Tests

1. Anterior Drawer- measure

translation (in mm)



ROTATION HANDOUT

FAMILY MEDICINE RESIDENTS

ORTHOPEDICS ROTATION

Gaetano P. Monteleone, Jr., M.D.

Dept of Family Medicine

West Virginia University School of [email protected]

2. Talar Tilt- measure opening (in degrees)

3. Side-to-side (Cotton test)- especially for syndesmosis sprains

• Side-to-side (Cotton) test- place examining hand under the plantar aspect of the foot/ankle,

with your thumb under one malleolus and your

middle finger under the other malleolus. Place a

medial and lateral-directed force (not

inversion/eversion stress as in the talar tilt test) onthe ankle. Assess if translation and assess quality of

endpoint. There may be a few mm of motion with a

syndesmosis sprain. An alternative to this is to

passively externally rotate the foot. Pain with this

maneuver will occur in a syndesmosis sprain.

4. Proximal squeeze test- also for syndesmosis sprains

• Proximal squeeze test- examiner squeezes mid-shaft of tibia/fibula. Pain in the

syndesmosis area may indicate a syndesmosis sprain.

5. Neurovascular

Compare to unaffected ankle!



Ho3rotat Revised 7/13/983

II. KNEE

• Inspection- deformity, effusion, ecchymoses, erythema, Q angle, muscle asymmetry

(atrophy).

• Palpation

a. Anterior- patella, patellar tendon, quadriceps tendon, joint line, tibial tubercle.

b. Medial- patellar retinaculum, MCL (origin and insertion), meniscus, pes

anserine tendons, pes anserine bursa, medial femoral condyle, medial facet of the

patella.

c. Lateral- patellar retinaculum, LCL, lateral meniscus, iliotibial band (inserts at

Gerdy's tubercle), lateral femoral condyle.

d. Posterior- hamstring tendons, posterior joint line (posterior horns of the

meniscus, popliteal fossa (neurovascular structures, Baker's cyst).

e. Joint line tenderness- posterior joint line tenderness more sensitive for

meniscal injury than anterior. Anterior joint line tenderness may reflect anteriorknee pain syndromes, osteochondritis dessicans, etc. In addition, joint line

tenderness is most sensitive if not associated with an ACL tear.

N.B. When palpating joint line, internal tibial rotation renders the lateral meniscus more

palpable, external tibial rotation renders the medial meniscus more palpable.

• ROM/Flexibility- include hamstring flexibility. Decreased ROM (especially extension)

may represent a tear that flips up and blocks full extension, AKA "locked knee."Tight

hamstrings must be assessed.

• Special Tests for Patellofemoral problems

a. Patellar apprehension test- patient supine:examiner provides lateral distraction to the

patella; positive test is apprehension that the

patella will dislocate.

b. Patellar grind/compression tests- patient

supine: active, isometric contraction of the quads

by patient with posteriorly directed force placed

on the patella by examiner. Positive test is



Ho3rotat Revised 7/13/984

reproduction of the patients pain with this maneuver.

c. Q (quadriceps) angle- measure of genu valgus (knock-kneed). The angle

created by two lines: one drawn from the middle of the patella and the tibial

tubercle, and the other line from the middle of the patella and the ASIS of the

iliac crest. Normal in males is < 10°

, females < 15°. Patients with high Q angles

are at increased risk for patellofemoral conditions.

d. "J" sign- patient in seated position: patient

slowly extends knee to 0°. Normally, examiner

observes the patella gliding proximally with

extension. A positive J sign is observed when as

the knee approaches full extension, the patella will

not only glide proximally, but will lateralize in the

final degrees of extension (inverted "J"). Patients

with malalignment or poor biomechanics will

demonstrate a positive J sign. May indicate

instability.

• Special Tests for Ligamentous

abnormalities

Grading system for most ligament sprains/tears:

Grade Histology/Translation Endpoint

1 Fibers stretched, no laxity Good

2 Few fibers torn, some laxity Fair

3 Many fibers torn, much laxity

Poor, soft

a. Valgus/varus stress tests @ 0° and 30° of flexion: tests MCL/LCL,

respectively. Instability during valgus stress with the knee in complete extension

demonstrates both and MCL and ACL tears.

b. Lachman's test for ACL. Knee in 30°of flexion. Outside hand stabilizes the

femur, inside hand around the tibia at the tibial tubercle.

An anteriorly-directed force is applied. Assess for

translation (in mm) and endpoint (good, fair, poor). Thisis the most accurate exam maneuver for ACL tears

acutely. False negative tests occur when hamstring

spasm with tense effusion, bucket-handle tears of

meniscus. False positive test with PCL tear.



Ortho Rotation Handout Revised 11.4.045

c. Anterior/posterior drawer tests- for ACL and PCL, respectively. The knee is

flexed to 90°, hip at 45° with feet flat on exam table; examiner may sit on foot,

apply an anteriorly or posteriorly-directed force. Maintain thumbs at joint line.

Assess for translation and quality of endpoint. The a nterior drawer is generally

not as helpful as the Lachman and pivot shift tests for ACL integrity. In addition,

it requires more motion to an acutely injured knee. The posterior drawer test, on

the other hand, is the most helpful test for PCL integrity.

d. Pivot shift test- for ACL integrity. Start with knee straight and an examining

hand under heel of foot. Turn the foot into internal rotation with one hand, place a

valgus-directed force at the knee with the other hand. At the same time, bring the

knee from extension to flexion. A palpable clunk appreciated at 30° of flexion at

the joint line represents the tibia reducing on the femur in ACL-deficient knee.

This may be quite uncomfortable for the acutely injured patient. It requires

significant relaxation on the part of the patient, and they probably won't let you do

it a second time (so get it right the first time!). This is the most accurate test for

chronic tear of the ACL (> 6 months).

e. Posterior sag sign- have patient lying relaxed and supine, with knees in

position similar to the anterior/posterior drawer tests. Inpatients with a PCL tear, the tibial tubercle will sag

posteriorly relative to the other tibial tuberosity. The

quadriceps active test- for PCL integrity involves the

same position. Active contraction of the quadriceps will

shift the tibial tubercle anteriorly (back to neutral) in a

patient with a PCL tear. Figure at right describes the

posterior sag and the quadriceps active tests.

f. Apley's distraction test- patient lying prone, knee




flexed to 90°, examiner stabilizes posterior femur in one hand and distracts the

foot upward. At the same time, the foot should be rotated internally and

externally. Reproduction of patients pain may indicate MCL/LCL sprain or tear .

A variation to this is Apley's compression test. Performed similarly to the

distraction test, the examiner produces a compression force from the heel directedinto the exam table. Again, reproduction of pain with internal/external rotation of

the foot is a positive test. This may indicate possible meniscal pathology.

Note: in patients with open growth plates, positive Lachman's test, valgus/varus tests may

actually represent opening of tibial or femoral growth plate fracture.

• Special tests for Meniscal tears

a. McMurray test- positive test indicated by a palpable or audible clunk. Pain is

not diagnostic. This test performed by palpating bilateral joint lines with the pt

supine. The examiner produces internal/external tibial rotation while flexing and

extending the knee. Simultaneously, the examiner produces a valgus or varus-directed force.

The value of this and other clinical exam tests for the meniscus has been questioned. The

positive predictive value approximates 85%, for audible/palpable click. The positive predictive

value is higher in the medial meniscus and lower for the lateral meniscus.




b. Apley's compression test positive for pain. Pt prone. Knee flexed to 90°. The

examiner produces a compression force directed toward the exam table. Note

distraction stress may stretch the collateral ligaments and create pain. This may

distinguish MCL vs medial meniscus injury.

III. HIP

Physical Exam

• Inspection- deformity, ecchymoses, erythema, muscle asymmetry (atrophy).

• Palpation- Anteriorly palpate the ASIS, AIIS, pubic symphysis, neurovascular structures

(femoral artery, vein and nerve), musculature; Laterally palpate the iliac crest, greater

trochanteric bursa; posteriorly palpate the PSIS, gluteal muscles, greater sciatic notch,

ischial tuberosity and bursa, SI joint, L-spine.

• Range of Motion (ROM)- flexion (0-120°), extension (0-30°), abduction (0-45°),

adduction (0-30°), external rotation (0-50°), internal rotation (0-40o)

• Special tests-

a. FABER test (Flexion, ABduction, External Rotation at the hip)- Pt places leg in

figure of four position. Place the examining ankle on the contralateral knee and relax the

knee out with external rotation of the hip. Tests for hip muscle flexibility, SI joint

pathology.

b. Trendelenberg sign- have pt stand on affected leg. Normal and negative test is an

inclination of the contralateral PSIS. An abnormal (positive) test results in a drooping of

the contralateral PSIS. May indicate gluteus medius weakness.

c. Ortolani’s and Barlow’s hip clunk for developmental dislocation of the hip (DDH).

Ortolani’s opening of the hips (abduction/external rotation) reduces a dislocated hip;Barlow’s closure of the hips (adduction/internal rotation) dislocates the hip again. These

tests are best performed during the first few weeks of life. After that, false negative tests

can occur due to muscular spasm, etc.

d. Limb length discrepancy- measure ASIS to medial malleolus in cm. Compare both

sides. Some discrepancy is normal. Correct for more than 1.0-1.5 cm. Most (90%)

discrepancies due to soft tissue tightness, inflexibility rather than actual difference in

bone length.

e. Neurovascular assessment-. Femoral artery, nerve; nerve roots L1-S1.

f. L-spine exam- a good hip exam includes an L-spine exam as well.

IV. BACK

Physical Exam

• Inspection- deformities, scoliosis, erythema, ecchymosis, gait, heel and toe walking

• Palpation- point tenderness (bony and soft tissue)

• Range of Motion- measure forward flexion in inches from the floor




N.B. Signs of slow deliberate gait, decreased lumbar lordosis and limited range of motion

are important. However, they have low diagnostic utility, since many causes of acute low

back pain will manifest these signs.

• Neurovascular Assessment (most important is L4-S1): individually test heel and toewalking. Minor asymmetry is common. A positive test should show marked asymmetry.

Nerve Root Sensory Reflex Motor

L4

Anterolateral thigh

Medial ankle

Patellar Tibialis anterior

L5

Posterolateral thigh

Dorsum of ankle

? Posterior tibialis Extensor hallucis

longus

S1

Lateral ankle Achilles Peroneus

Cross innervation is common and may result in misinterpretation. For screening

purposes, extensor hallucis longus (L5) is most important. Remember that differentiating a

peripheral nerve abnormality is necessary. Posterior tibialis and gluteus medius muscles are

innervated by L5 nerve root, but not the peripheral peroneal nerve. Note, these tests have only

moderate sensitivity and specificity for nerve root irritation.

• Special Tests

a. Straight leg raise (SLR) + ankle dorsiflexion: pt supine, raise leg to 30-60° ; + test is

pain that radiates into the calf. Also, crossed SLR = SLR in unaffected limb exacerbates

radicular pain in affected limb.

b. Modified SLR (? Lasegue's test): hip flexed to 90°, knee flexed to 90°, this should

not cause pain if HNP; examiner then extends the knee until nerve root is stretched. Pain

with knee extension may indicate nerve root irritation demonstrated with HNP or

impingement with OA.

c. Bowstring sign: SLR until pain, then flex the knee. This should reduce/extinguish pain

if nerve root irritation.






• Palpation- systematic palpation of bones and joints (SC joint, AC joint, clavicle,

acromion, scapula, greater tuberosity of humerus). Palpation of muscles groups of the

shoulder. Direct palpation of the insertion of the supraspinatus is best achieved by

palpating the anterior shoulder with the humerus in slights extension.

• Special tests-

a. Cross chest (hyperadduction) test- for

AC joint pathology. Affected hand to

contralateral shoulder. Pain at AC joint

diagnostic.

b. Neer's sign (forward

flexion/internal rotation) for

subacromial impingement.

c. Hawkin's sign (90° abduction and 45° of horizontal adduction, then

humeral internal rotation) for subacromial impingement.

d. Apprehension test (sitting position)- Pt is lying supine with humerus

abducted to 90o and externally rotated to 90o. Apprehension test produces

apprehension that shoulder will come out of joint. Tests for underlying

instability.

e. Yergason's test- resisted forearm supination testing biceps tendon pain.

f. Speed's test (for biceps tendinitis)- performed with elbow extended,

forearm supinated, and forward elevation of the humerus to approximately

60° with manual resistance. Pain recreated in bicipital groove constitutes




positive test for biceps tendon pain.

g. Relocation test (Jobe)- with the patient in the same position as in d. The

Jobe relocation test, position patient as in apprehension test, then grasp

proximal humerus and apply anterior displacement followed by posterior

displacement. Pain with anterior displacement followed by relief of painwith posterior displacement constitutes a positive test for anterior

instability.

h. Modified "Lachman's" of the shoulder- with patient in supine position,

examiner places one hand behind proximal humerus while gently grasping

the humerus at the bicondylar axis at the elbow. Patient's humerus is

abducted approximately 120°. With the elbow held steady the examiner

gently translocates the humeral head anteriorly, evaluating for amount of

excursion and quality of end point. Shoulder with anterior instability may

show increase in laxity and difference in end point quality compared to

unaffected side. Patient must be completely relaxed.

i. Sulcus sign- with patient seated and arm held

relaxed at side, examiner grasps lower humerus

and applies an inferior force. Space or 'sulcus'

may appear depending on amount of inferior

instability. Compare with opposite arm.

j. Labral "clunk" test- same position as the test

in 'h'. The examining hand behind the humeral

head palpates for a "clunk" as the other hand

moves the humerus in a rotary motion, in effecttrying to trap the labral tear between the

humeral head and glenoid. This is analogous to the McMurray's test for

meniscal tears of the knee.




Quick Guide to Neurologic Status to the Extremities

UPPER EXTREMITY

Root Reflex Motor Sensory

C 5 Biceps Deltoid , Biceps Lateral Arm

C 6 Brachioradialis Wrist Extension, Biceps Lateral Forearm,

Thumb/index finger

C 7 Triceps Wrist Flexion, Triceps Middle finger

C 8 ---- Interossei, Finger

Flexion

Medial Forearm,

Ring/pinky finger

T 1 ---- Interossei Medial Arm

Peripheral nerve Motor Sensory

Radial nerve Wrist Extension Dorsal thumb/index web space

Ulnar nerve Abduction pinky Distal ulnar pinky

Median nerve Thumb: pinch, opposition, and

abduction

Distal radial index

Axillary nerve Deltoid Lateral Arm

Musculocutaneous nerve Biceps Lateral Forearm

LOWER EXTREMITY

Root Reflex Motor Sensory

L 4 Patellar Anterior Tibialis Medial Leg & Foot

L 5 None-? Post Tibialis Ext Hallucis Longus Lateral Leg,

Dorsum Foot

S 1 Achilles Peroneus L & Br Lateral Foot






1° · trapezius CN XI

· levator scapulae (C3-4)

2° · rhomboids

H. Scapular Protraction

1° · serratus anterior (C5-7) long thoracic n.

I. Scapular Retraction

1° · rhomboids (C5) dorsal scapular n.

II. Elbow

A. Flexion (0-150°)

1° · biceps (C5-6) musculocutaneous n.

· brachialis (C5-6) musculocutaneous n.

2° · brachioradialis

· supinator

B. Extension

1° · triceps (C7) radial n.

2° · anconeus

C. Supination

1° · biceps (C5-6) musculocutaneous n.

· supinator (C6) radial n.

D. Pronation

1°

· pronator teres (C6) median n.· pronator quadratus (C8-T1) anterior interosseous n.

III. Wrist

A. Flexion (0-80°)

1° · flexor carpi radialis, FCR (C7) median n.

· flexor carpi ulnaris, FCU (C8) ulnar n.

B. Extension (0-70°)

1° · extensor carpi radialis longus, ECRL (C6) radial n.

· extensor carpi radialis brevis, ECRB (C6) radial n.

· extensor carpi ulnaris, ECU (C7) radial n.

Lower Extremity




I. Hip

A. Abduction (0-45°)

1° · gluteus medius (L5) superior gluteal n.

2° · gluteus minimus

B. Adduction (0-30°)

1° · adductor longus (L2-4) obturator n.

2° · adductor brevis & magnus

C. Flexion (0-120°)

1° · Iliopsoas (L1-3) femoral n.

2° · Rectus femoris

D. Extension (0-30°)

1° · gluteus maximus (S1) inferior gluteal n.

2°

· hamstrings

E. External Rotation (0-50°)

1° · gluteus maximus (L5-S 2) inferior gluteal n.

· obturator m (L3-S1) obturator n.

2° · piriformis

F. Internal Rotation

1° · adductors (L2-4) obturator n.

2° · gluteus medius and minimus

II. Knee A. Flexion (0-135°)

1° · semimembranosus (L5) tibial n.

· semitendinosus (L5) tibial n. } Hamstrings

· biceps femoris (S1) tibial n.

B. Extension

1° · quadriceps (L2-4) femoral n.

III. Ankle

A. Dorsiflexion (0-20°)

1° · tibialis anterior (L4) deep peroneal n.

· extensor hallucis longus (L5) deep peroneal n.

· extensor digitorum longus (L5) deep peroneal n.

B. Plantar flexion (0-50°)

1° · gastroc/soleus (S1-2) tibial n.

· peroneus longus & brevis (S1) superficial peroneal n.

2° · flexor hallucis longus

· flexor digitorum longus } (L5) tibial n.




· tibialis posterior

C. Inversion (0-35°)

1° deep peroneal n.· tibialis anterior (L4)

D. Eversion (0-15°)

1° revis (S1) superficial peroneal n.· peroneus longus & b



Common Xrays Ordered in the Sports Medicine Clinics

Ankle AP

Lateral

Mortise (20° internal rotation)

C-spine AP

Lateral

Obliques X 2

? Trauma Open mouth (Fuchs) view

Lateral flexion/extension views (must be done at NCBH)

Elbow AP

Lateral

Optional = radial head view, obliques X 2

Foot AP

Lateral

Oblique

Forearm PA

Lateral

Oblique

Hand PA

LateralOptional = oblique

Hip AP pelvis

Lateral of L-spine

Frog leg lateral

Knee AP Weightbearing (if ? DJD)

Lateral

Merchant (or other tangential view: ie- sunrise)

Tunnel /notch (? OCD)

Leg AP tibia/fibula

Lateral tibia/fibula

Optional = oblique tibia/fibula

L-spine AP

Lateral

Obliques X 2



18

Standing AP and lateral if ? listhesis

Shoulder Trauma AP with IR/ERAxillary lateral (West Point) view

Scapulolateral "Y" view

Impingement AP with IR/ER

Axillary lateral

Supraspinatus outlet (Alexander) view

Instability include True AP

AC joint AP with caudal tilt (15°)

Wrist PA

Lateral

Oblique

Optional = scaphoid view (AP with ulnar deviation) and

carpal tunnel view

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Ortho Special Test