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ORTHOPAEDIC PHYSICAL ORTHOPAEDIC PHYSICAL EXAMINATIONEXAMINATION

SUBLAB.ORTHOPAEDI & TRAUMATOLOGY

Principles of ExaminationPrinciples of ExaminationObtaining data from patient’s story (clinical

history); Preliminary data: name, sex, age, occupation Chief complaint Common musculoskeletal symptoms:

1. Pain2. Decrease in function3. Physical appearance

Past, Social, Economic, and Family History

Principles of Examination 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)

Always

Look Feel Move

REGIONAL EXAMINATIONNeck Shoulder Elbow Wrist & Hand Back Hip Knee Ankle & Foot

Principles of ExaminationPrinciples of Examination

General Principles of TreatmentGeneral Principles of Treatment

1. First do no harm (primum non nocere)2. Base treatment on an accurate diagnosis

and prognosis3. Select treatment with specific aims4. Cooperate with the law of nature5. Be realistic and practical in your

treatment6. Select treatment for your patient as an

individual

Examination of the Neck 1. Observe the patient

as a whole. 2. Observe the neck

and shoulders from in front and behind.

3. 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 90º .

9. Assess internal rotation by asking the patient to place both hands behind the head.


10. Assess internal rotation by asking the patient to reach over their opposite shoulder, behind the neck and behind the back.


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

1. Observe the whole patient, front and back, looking especially for deformity.Swelling , Redness , Carrying Angle


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.


7. Examine extension. (To 00)


8. Examine flexion. ( To 1350)


9. Examine supination 10. Examine pronation. ( To 900) ( To 900)


11. Pivot shift of elbow (instability).

12. Provocative test for Cubital Tunnel Syndrome (puts tension on ulnar nerve at 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)

7. 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 & Hand


10. Radial deviation. 11. Ulnar deviation.12. Pronation. 13. Supination.


14. Test thumb extension. 15. Test thumb abduction.16. Test thumb adduction. 17. Test opposition.


18. 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.


21. 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.

• PHALEN’S 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


• FINKELSTEIN’S TEST

– Painless function of the abductor P.L , Ext P.B– Flex and ulnarly deviate the wrist, then push

the thumb into flexion – Sharp pain on the radial border of the wrist

de quervain’s 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 Back

A Neurological examination including:

13. Knee extension.14. Knee flexion15. Knee jerk reflex16. Ankle jerk reflex.

Examination of the Back

17. 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 Hip

6. Ensure the Anterior Superior Iliac Spines are horizontal.


7. 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)


11. Thomas Test:Flex both hips to eliminate the lumbar lordosis. Extend the hip you are examining and if it is normal it should return to the bed. A fixed flexion deformity of the hip will not allow it to extend to the neutral position. (2 photos)

12. Check the patient is not compensating with a lumbar lordosis.13. Check the ASIS are horizontal again. Anchor leg over the edge of the bed and abduct the

other hip. (0 0 to 45 0) 14. Assess adduction. ( 200 to 300)


14. Assess adduction.15. Internal rotation. (00 to 450) 16. External rotation . ( 00 to 450)

Examination of the Knee1. Observe the patient as a

whole. 2. Observe the knee joint

front and back. Note any genu valgum (a slight degree of which is normal) or genu varum.

3. Observe knee from side. Note any genu recurvatum

4. Ask the patient to squat

Examination of the Knee5. Assess patellae tracking

from extension to flexion. Note quadriceps action.

6. Patellar apprehension test. Apply lateral pressure to patellar as the patient flexes the knee. Observe facial expressions for fear of impending dislocation.

7. Observe the knee with the patient lying on the bed.

Examination of the Knee8. Pick a bony landmark on the

knee and measure a fixed distance from it to the approximate centre of the quadriceps.

9. Measure the circumference of the of the knee and leg.

10. Feel the temperature of the knee and leg.

11. Soloman's test. Lift the patella away from the femur. In synovial thickening it will be hard to grasp.

Examination of the Knee

12. Effusion: Tap Test. Push sharply on the patella and with an effusion it will strike the femur and bounce back.

13. Effusion: Feel for fluid fluctuance.


14. Effusion: Bulge Test. Empty the suprapatellar pouch with pressure above the patella. Wipe hand along the medial side to displace fluid laterally. Compress the lateral side and watch for a bulge medially.


15. Feel the superficial and posterior surface of the patella by pushing it medially.

16. To test for patello-femoral tenderness press patella against the femur and ask the patient to tighten their thigh muscles.

17. Palpate for tenderness with the knee flexed to 90°. Feel along the joint line, the ligaments and the tibial tubercle.

18. Assess extension of the knee.

Examination of the Knee19. Flexion.20. Internal and external

rotation of the knee is limited.

21. Test collateral ligaments by applying medial and lateral pressure to the lower leg which is tucked away under the examiners arm.

22. Look for posterior sag of the femur signifying posterior cruciate dysfunction.


23. Anterior drawer test. Femur should not move forward significantly unless the anterior cruciate ligament is torn.

24. Posterior drawer test. (Posterior cruciate)25. Lachmans test.

Examination of the Knee26. MC test - lift leg off the bed

and if tibia drops there is cruciate dysfunction.

27. MacMurrays test.Place the thumb and finger on the joint line. Watching the patients face for pain, flex the leg, externally rotate the foot, abduct and extend leg to test for medial meniscal "clicks".Flex the leg, internally rotate and adduct for lateral meniscal "clicks". (2 photos)

28. Ask the patient to lie prone and examine the back of the knee.

Examination of the Foot & AnkleObserve patient as a whole

from front and back.1. From behind check hind-

foot alignment and "too many toes" sign (tib. post dysfunction).

2. & 3. Check for inversion (tibialis function) and eversion (peroneal function).

4. Single stance heel raise test.

Examination of the Foot & Ankle

5. Windlass test. 6. Coin test.7. Dorsi flexion. 8. Plantar flexion.


9. Mid foot abduction/adduction. 10. Extension fore foot.11. Flexion fore foot. 12. Tib. anterior test.


13. Tib. posterior test.14. Peroneal tendons test.15. Ankle instability - inversion test.16. Ankle instability - Anterior draw test.


17. Ankle instability - Posterior draw test.

18. Simmond's test for TA.

19. Examine the sole.20. Check pulses,

sensation, reflexes.

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