Clinical- Orthopedics examination

General Orthopedic Examination Scheme

Introduce yourself

Exposure: to joint above

Standing

1-    Look From back,  From side, From Front    

·          Skin → Scars, sinuses                   ·   SCT → swelling                                                  

·          Muscles → Wasting or Spasm

·          Bones   →  Deformity                    

2-         Walk (Gait)  امشى لحد الباب وارجع 

·           Normal (most propably)

·           Abnormal (Antalgic بيعرج , Trendlenberg بيرقص, Half Shut knife)

3-         Feel  For tenderness

·           Bony landmarks

·           Soft tissue

4-         Move

·           Range → full ….-….) / limited (….-….)

·           Pain → painful/ painless

5-         Special Tests

6-         Measure

Supine

1-    Look       

2-       Feel  For tenderness

·           Bony landmarks

·           Soft tissue

3-      Move

·           Range → full ….-….) / limited (….-….)

·           Pain → painful/ painless

4-      Special Tests

5-      Measure

Prone   مفيش وقت

1-        Look       

1-                 Feel  For tenderness

·           Bony landmarks

·           Soft tissue

2-            Move

·           Range → full ….-….) / limited (….-….)

·           Pain → painful/ painless

I would like to finish my examination by:

1-         Examination of joint above & joint below.

2-         Examination of neurovascular status of both LLs.

3-         Ask for X-ray (Bilat. & 2 views).

Investigations

Lab:  ESR, CRP, ASOT, Rheumatoid profile, HLA-B27 (for ankylosing spondyolitis)

X-ray: plain X-ray bilat. & 2 views at least

CT: If suspect fracture (better 3D CT) 

MRI: If suspect pathology

   TTT

Conservative ttt: bed rest, analgesic (NSAIDs), lifestyle modification (wt.loss), physioth.

Surgery: if failed conservative ttt inform of ……..

                          -after general assessment for fitness to surgery

N.B. urgent surgery may be needed (e.g, in dislocations, foot drop, cauda equine lesion)

Lumbar Spine Examination

Introduce yourself

Exposure: naked except underware

Standing

1-    Look

                       From back     

·          Skin → Scars, sinuses                   ·   SCT → swelling                                                               Muscles → - Erector spinae spasm (Rt/ Lt/ Bilat.) (usually opposite to side disc)

·          Muscles → Erectoe spinae spasm   - LLs muscles (check later by measurement)

·           Bones   → - Leveling of iliac crest → Leveled/ Pelvic tilt toward (Rt/Lt)

                               - Soliosis toward (Rt/Lt) (keep n. away from n.root)

                       From side

                           ·           Bones: → Lumbar lordosis → N/ flattened, N Dorsal Kyphosis

7-         Walk (Gait)  امشى لحد الباب وارجع 

·           Normal (most propably)

OR  ·           Half-shut knife

OR  ·           High steppage (foot drop) (rare & emergency)

8-         Feel  

·           Erector spinae spasm

·           Spine segment tenderness at level of …… (iliac crests = L4)

             Iliac crests, PSIS, Lumbo-sacral junction

9-         Move

·           Forward flexion → range & Pain (N= 5cm from floor or touch toes)

·           Extension → range & Pain (N= 10-30 degrees)

·           Lateral flexion → range & Pain (N=30 degrees or touching knee)

·           Rotation (while sitting to fix pelvis) → range & Pain (N=  45 degrees) (Th.V.)

Supine

5-    Tests

1-   Straight Leg Raising test (SLR)1  4 Parts    الوجع فين

       →   passive SLR → +ve & limited at …. Degrees / –ve (N= 80°, <60° → Positive)                                            

       →  10 degree below and Sciatic stretch test 2→ +ve or –ve

       →   Hip internal & external rotation 3 (at 90-90 position) → range & pain

       →   Sacroiliac joint strain (FABER test = Flex. + Abduction + Ext.Rot.)

               (figure of 4 position, hand on knee & hand on iliac crest) → +ve / -ve

  

 1 SLR: Elevate leg to 90 ^o  & If pain < 80^o ask about site (below knee → +ve & Above knee → -ve)

2   Sciatic stretch test: After SLR, 10° below to relieve pain + dorsiflexion of the foot → pain & Patient flexes his extended knee to relieve the pain

3  Hip rotation: hip 90 ^o - knee 90^o, hand on knee & other moves leg (inside → ext. rot.) (outside → int.rot.)

2-    Rapid Neurological examination

·          Sensation (Dermatomes) close eyes, compare both sides & ask

                    L1 = below skin crease

                    L2 = upper thigh

                    L3 = lower thigh

                    L4 = inner side of leg

                    L5 = outer side of leg →1^st dorsal web (autonomus area of L5)

                    S1 = plantar foot

                    → there is hypothesia on segment… (Rt /Lt) side or both equal

·          Power (Myotomes) against resistance & compare both sides

                     L2 = hip flexion

                     L3 = knee extension

                     L4 = ankle dorsiflexion

                     L5 = big toe dorsiflexion

                     S1 = ankle plantar flexion        

                  → there is weakness on segment… (Rt/Lt) side or both good power

·          Reflexes   preserved or lost & compare both sides

                     → Knee reflex (L2,3,4) look at quadriceps → preserved or lost

                     → Ankle reflex   (S1)    look at calf ms       → preserved or lost

Prone   مفيش وقت

·      Femoral stretch test (L2,3,4 root) flex knee & extend hip

           → pain infront thigh = +ve =high disc prolapse

I would like to finish my examination by:

1-         Examination of joint above (dorsal & cervical spine) & joint below (hip).

2-            Examination of peripheral pulsation (to exclude vascular claudication).

3-         ask for X-ray.

4-         Examination of abdomen (to exclude abdominal causes of back pain).

5-         Exclude CAUDA EQUINA by:

                     ONE question → sphincter function (retention early & incontinence later)

                                TWO tests      → sphincter tone (S2)

                                                       → saddle area sensation (S2,3,4)

Hip Joint Examination

Introduce yourself

Exposure:  naked except underware

Standing

1-    Look

                 From back     

·        Skin  → Scars, sinuses                  ·   SCT → swelling                                                                      Muscles → Erector spinae wasting or spasm

·        Muscles → Gluteal ms wasting (lost buttock crease)                          

·        Bones → - Leveling of iliac crest → Leveled/ Pelvic tilt toward (Rt/Lt)

                    - Soliosis toward (Rt/Lt) (Compensatory & opposite to pelvic tilt)

             (Scoliosis with pelvic tilt is compensatory to adduction deformity)

                 From side

·         Skin  → Scars, sinuses                  ·   SCT → swelling

·         Bones → Lumbar lordosis →N/ Exaggerated (compensatory to FFD), dorsal kyphosis.

From front 

·         Skin  → Scars, sinuses                  ·   SCT → swelling

·         Trendlenberg test                  

2-       Tests

           Trendelenburg test (S.S.S)1  → -ve/  +ve = abductor deformity   اقف على رجلك ال.....

3-       Walk (Gait)     امشى لحد الباب وارجع according to Trendlenberg test

If Trendlenberg test +ve → Trendlenberg gait

If Trendlenberg test  -ve →  Antalgic gait

4-        Feel  (Standing or Supine) 

·         Hip joint (skin crease) → pain= arthritis    

·         Greater trochanter → pain= trochanteric bursitis    

Supine

  Look Confirm       Feel (if not done standing)

5-        Move active then passive (fix pelvis)

·        Thomas test 2 → +ve = fixed flexion deformity or –ve

·        Flexion → range & Pain (N= 0-140 ^o)

·        Extension (I will test later in prone) → range & Pain (N= 0-10 ^o) (skip if FFD)

·        Abduction (fix pelvis by hand & elbow) → range & Pain (N= 0-45 ^o)

·        Adduction (fix pelvis by hand & elbow) → range & Pain (N= 0-30 ^o) 

·        Internal rotation (hip 90°& knee 90°- fix knee-leg out) → range & Pain (N= 0-40 ^o)

·       External rotation (hip 90° & knee 90° -fix knee -leg in) → range & Pain (N= 0-40^o)

1 Trendlenberg test: Standing on one leg tests the abductors of supporting leg (gluteus medius & minimus) which pull on

the pelvis → other side to rise (Normal is negative test) [SSS= sound site sag]

2 Tomas test: left hand behind back (to feel flattening of hyperlordosis) flex hip to abdomen & notice flexion of other hip (>10^o → +ve)

6-        Measure   (square the patient with pelvis 90 degrees to long body axis)

·      Apparent length (from Xiphisternum to Med. maleollus)→ No/ shortening on (Rt/Lt) side of …. cm  → If no true shortening = adduction deformity

·       True Length (from ASIS to Medial maleollus)→ No/ shortening on (Rt/Lt) side of … cm 

                                      = shortening of femur or tibia

·       (if true shortening) Do rough test (Knee 90^o& look from side)→ femoral or tibial

·       (if femoral shortening) measure Supratrochanteric length (from greater trochanter to point same line opposite ASIS)  → supra-trochanteric or infra-trochanteric

  

I would like to finish my examination by:

1-         Examination of joint above (lumbar spine) & joint below (knee).

2-         Examination of neurovascular state of both LLs.

3-         Ask for X-ray

  

         

                        

Knee Joint Examination

Introduce yourself

Exposure:  Both Knees / Examine both knees (mirror image)

Standing

1-    Look

 From front     

·          Skin → Scars, sinuses                   ·   SCT → swelling                                           

·          Muscles → Quadriceps muscle wasting                          

·           Bones →  Genu Varus , Genu valgum

From side

·          Skin → Scars, sinuses                   ·   SCT → swelling

·          Bones →  Genu recurvatum , Flexion deformity

From back (popliteal fossa)

·          Skin → Scars, sinuses                   ·   SCT → swelling (+/-) pulsatile    

2-    Walk (Gait) امشى لحد الباب وارجع

·    Normal        

OR  ·    Antalgic    

Supine                       

3-    Feel     

·         Tenderness (Bony Land Marks & soft tissue):

→ quadriceps ms, quadriceps tendon, patella (patellar grinding test in 2 directions), patellar tendon, tibial tuberosity

→ med. femoral condyle, med.tibial condyle, lat. femoral condyle, lat. Tibial condyle.

→ med. collateral lig., lat. Collateral lig. → head of fibula  

           

·          Effusion:    Start by     Patellar tap test (moderate effusion)

if patellar tap –ve → Fluid shift test [Stroke test] (small effusion )

if patellar tap +ve → Fluctuation test (large effusion)  

4-     Move

·          Extension (Active then Passive) → range & Pain (N= 0^o)

·          Flexion (Active then Passive) → range & Pain (N= 0-135 ^o) (buttocks to heels 1.5 cm)

5-     Measure Quadriceps Circumference (15 cm above patella) → equal/ wasting on (Rt/Lt) side  

 

6-     Tests  

            Knee stability tests

1- Active Straight Leg Raising test (SLR) → +ve = weak extensor apparatus/ –ve

2- Medial & Lateral Collateral ligaments (at 20°)

  · Stress valgus1 Knee 0°: support leg medial and push on lateral knee medially.

     Stress valgus1 Knee 20°:

         →  no opening joint= -ve = intact

→ opening joint= +ve → confirm by other side (if bilat.=laxity, unilat.=torn)

  · Stress varus: Knee 0°: support leg lateral and push on medial knee laterally.

     Stress varus  Knee 20°:

         →  no opening joint= -ve = intact

→ opening joint= +ve → confirm by other side (if bilat.=laxity, unilat.=torn)

3- Anterior & Posterior Cruciate ligaments (at 90° + sit on pt. toes)

· posterior sag test: -ve/ +ve → PCL injury at sagged side (Rt/Lt) 

· Posterior drawer test: push tibia (for PCL)

· Anterior drawer test: pull tibia (for ACL)

· Lachman test   · Pivot shift (Painful- only idea)

Mac Murray test 2 (for medial & lateral menisci) not sure test

· Med. meniscus: maximum flex→ ext. rot with extension  → click or pain = +ve 

· Lat. meniscus: maximum flex→ int.rot. with extension → click or pain = +ve 

                                     

                

Prone   مفيش وقت

 Back of knee (popliteal fossa) 1- Flexed → Popliteal region 

2- Extended → Palpate for bursa

 I would like to finish my examination by:

1-         Examination of joint above (hip) & joint below (ankle).

2-         Examination of neurovascular state of both LLs.

3-         Ask for X-ray

4-         Examin back of knee (popliteal fossa) 1- Flexed → Popliteal region 

2- Extended → Palpate for bursa

      

                                              

1 Grasp knee with one hand (heels on lateral side of the knee), grasp lower tibia with the other hand, push the tibia laterally

2 Leg is flexed, loosen hamstring by rotatory mvt, Foot internally/externally rotated, and Hip is adducted, clicks or

pain are felt while leg is smoothly extended. If +ve compare because bilat.= lax & unilat.= inj. meniscus

 

Shoulder examination (rare)

Introduce yourself

Exposure: Expose upper half of body &both shoulders & examine from behind pt.

1-     Look

·          Skin →Scars, sinuses                   ·   SCT → swelling               

·          Muscles → Swelling or Wasting (Deltoid, Supraspinatus, Infraspinatus, Trapezius, Pectoralis)

·          Bone → Deformity (Sterno-clav. j., Clavicle, Acromio-clav. j., winging scapula,).

2-     Feel Bony land marks & soft tissue (for tenderness)

·          Sternoclavicular j., clavicle, +/- coracoid, acromioclavicular, acromion, spine of scapula (if protruding= wasting supra- & infra-spinatus), supraspinatus, infraspinatus, head of humerus, 

                                                     (coracoid is 1.5 inch below lateral end of clavicle in deltopectoral groove)

3-     Move

·         Forward flexion → range & Pain (N=180°)

·         Extension → range & Pain (N=60°)

·        Abduction → range & Pain (N=180°)  →

           0-15° = supraspinatus,

15-90° = deltoid (gleno-humeral j. mainly)

90-180° = trapezius, Rhomboides & Levator scapulae (scapulo-thoracic j. mainly)

·        Adduction → (N= blocked by body)

·        Medial (internal) rotation → range & Pain (N=80°) fix elbow at body & forearm inside

·        Lateral (external) rotation → range & Pain (N=80°) fix elbow at body & forearm outside

4-     Muscle strength

·  Pectoralis major ☺”Push your hands in your waist.”   ·  Trapezius ☺“Raise your shoulders.”

·  Serratus Anterior  ☺“Push against the wall.”

5-          Special tests

·        Painful arc (supraspinatus tendonitis)

·        Apprehension test (for recurrent shoulder dislocation) -if asked only

Reduction of Dislocated Shoulder (TEAR)

Traction  - External rotation -  Adduction - Rotation (Internal)

Elbow Examination (very rare)

Introduce yourself

Exposure: Up to shoulder & hand supinated (palms up)

1-        Look

·          Skin → Scars, sinuses                   ·   SCT → swellings (joint or localized olecranon bursa)

·          Muscles ( flexors & extensors forearm) → Wasting

·          Bone → Deformity Cubitus valgus = exaggerated carrying angle (N= 10-15° valgus)

                                            Cubitus varus = decreased carrying angle

                                            Cubitus recurvatum = hyperextension elbow

3-        Feel  TT

·          Temperature

·          Tenderness: over bony prominences & ulnar n.

-  Olecranon bursitis

-  Tennis elbow: pain over common extensor origin (lat. Epicondyle) due to extensor use

                -  Golfer’s elbow: pain over common flexor origin (med. Epicondyle) due to flexor use

4-        Move

·        Flexion→ range & Pain (N= 145 degrees)

·         Extension   → range & Pain (N hyperextension upto 15 degrees)

·         pronation & supination (start at mid-prone position)

5-                 Special tests  (elbow stability tests) (elbow extended because no locking unlike knee)

      ·         Stress valgus test: elbow extended, support wrist and push on lateral elbow medially      

      ·         Stress varus test: elbow extended, support wrist and push on medial elbow laterally

               If opening in med.side → +ve valgus test, lat. Side → +ve varus test

Hand Examination (Rheumatoid or Nerve inj.)

Introduce yourself

Exposure: Up to elbows & hand supinated

1-        Look

·          Skin → Scars (esp, palm & wrist), sinuses       ·   SCT → swellings & nodules(imp)

·          Muscles → Wasting (Dorsal interossei, Thenar, Hypothenar)

·         Bone → Deformity (Ulnar dev. MPJ & compensatory radial dev. wrist 1, MPJ swellings 2, finger drop, hyper-extended finger, Swan-neck 3, Boutonniere deformity 4, Z-thumb 5, Mallet finger 6, Piano-key 7)

2-        Feel  TT

·          Temperature

·          Tenderness: Joints, knuckles, tendons.

3-        Move (wrist, MPJ, PIPJ) Active then Passive (to complete range)

·          Wrist: flexion, extension & circular movement

·          Fingers movements: - Flexion & Extension (at MPJ)  - Abduction & Adduction (acc. to middle finger axis) (Middle finger has abd. on 2 sides & no add.)

·          Thumb movements (hand on table): - Abduction (upward) & Adduction

                                                                     - Flexion & Extension (at IPJ)  & Opposition

·         Tendon: FDS & FDP

4-        Nerve

5-        Special tests  (tests for carpal tunnel syndrome & nerve injury)

	Ulnar n. inj.	Median n. inj.	Radial n. inj.
Look	-Claw hand -Wasted hypothenar eminence -Wasted interossie (guttered dorsum of hand)	-Ape hand (thenar wasting)	-Wrist drop
Sensory Assessment (autonomus area of  nerve)	-Loss of sensation of  Little finger	- Loss of sensation of index finger	-Loss of sensation of 1st dorsal interosseus space
Motor Assessment	-Palmar interossie (card test) 9 -Dorsal interossie (spread test) 10 -Adductor pollicis (froment test) 11	-Opponens pollicis 12       -Abductor pollicis brevis 13 (hand on table)     + Phallen test 14 & Tinnel test 15 (in carpal tunnel synd.)	Fix proximal joint then -Finger ext. at MPJ → Lost -Wrist ext. → Weak or Lost (acc.to level) - Finger ext. at PIPJ → preserved extension by lumbricals (supplied by median & ulnar n.)
Level of inj (If asked only)	- Scar - Ulnar paradox - FCU - med. ½ FDP	- Scar - FDS - lat. ½ FDP - Pronator teres & quadratus	- Scar - Wrist ext.→ weak in post. Interosseus inj. & Lost in main radial inj.

                                                                                                                                                                   

1 Ulnar deviation of fingers (MPJ) & compensatory radial deviation of Wrist (Zig-Zag mech.) (pathognomonic to rheumatoid hand)

2 MPJ swellings (nodules or subluxation of head metacarpals)

3 Swan-neck: rupture tendon FDS → PIPJ extended & DIPJ flexed by FDP (compens)

4 Boutonniere deformity: rupture central slip of extensor expansion → PIPJ flexed & DIPJ extended by 2 distal slips

5 Z-thumb:  rupture Fl.Poll.longus tendon → MPJ flexed & IPJ extended

6 Mallet finger: rupture extensor tendons → DIPJ flexed & cannot be extended except passively (IPJ normal)

7 Trigger finger (Stenosing tenosynovitis): inflamm.nodule prevent active extension of finger PIPJ & DIPJ(cannot be extended except passively with lag & snap)

8 Piano key sign: subluxation of lower radio-ulnar joint → popup lower ulna

9  Card test: Piece of paper between fingers - PAD

10 Spread test: Prevent pushing of spread fingers - DAP

11 Fromet’s test: Piece of paper between index & thumb & try to catch against resistance → Flex. instead abd, thumb

12 Opponens polices: Oppose patient’s thumb & little finger, ask him to stop you from pulling the fingers apart

13  Abd.poll.br..: Hand on table & Abd. Thumb against resistance

14 Phalen test: flex. Wrist → tingeling & pain

15 Tinnel test: tapping on median n. under flexor retinaculum → tingeling & pain