Transcript examination of extremities

DR. Müge Bıçakçıgil Kalaycı
YÜH. Romatoloji BD.
General Considerations
 The patient should be undressed and gowned as
needed for this examination.
 The examination may not be appropriate
(e.g. performing ROM on a fractured leg).
 The musculoskeletal exam is all about anatomy.
 Think of the underlying anatomy as you obtain the
history and examine the patient.
General Considerations
 When taking a history for an acute problem ;
always inquire about ;
 mechanism of injury,
 loss of function,
 onset of swelling (< 24 hours), and
 initial treatment.
General Considerations
 When taking a history for a chronic problem
always inquire about ;
 past injuries,
 past treatments,
 effect on function, and
 current symptoms.
General Considerations
 The cardinal signs of musculoskeletal disease are:
pain,
 redness (erythema),
 swelling,
 increased warmth,
 deformity, and
 loss of function.
General Considerations
 Always begin with ;
 inspection,
 palpation and
 range of motion,
regardless of the region you are examining.
General Considerations
 Specialized tests are often omitted unless a specific
abnormality is suspected.
 A complete evaluation will include a focused
neurologic exam of the effected area.
Vascular
Pulses
 Check the radial pulses on both sides. If the radial
pulse is absent or weak, check the brachial pulses.
 Check the posterior tibial and dorsalis pedis pulses on
both sides. If these pulses are absent or weak, check
the popliteal and femoral pulses.
Edema, Cyanosis, and Clubbing
 Check for the presence of edema (swelling) of the
feet and lower legs.
 Check for the presence of cyanosis (blue color) of
the feet or hands.
 Check for the presence of clubbing of the fingers.
Lymphatics
 Check for the presence of axillary lymph nodes.
 Check for the presence of inguinal lymph nodes.
Inspection
 Look for scars, rashes, or other lesions.
 Look for asymmetry, deformity, discoloration, or
atrophy.
 Always compare with the other side.
 Varus - distal extremity deviates medially from the
joint (bow-legged)
 Valgus - distal extremity deviates laterally from the
joint
 Often in a fracture or disclocation there is an obvious
deformity about the joint or bone.
 Swelling - suspect if normal landmarks about the joint
are not apparent, or the normal contour of the
extremity is altered.
 Wasting - muscle wasting can result from neurologic
or muscular disease or injury. Bony landmarks often
more prominent.
 Discoloration:
• Erythema, or redness, is a sign of inflammation.
• Ecchymosis, or bruising, can be secondary to superficial
bruising, or may indicate damage to the underlying
muscle, ligament, or bony structure.
 The examination of the patient begins when tha
patient first enters the room.
 How is the patient's posture?
 Does the patient appear uncomfortable?
 Are there any obvious joint deformities?
 How is the patient's gait?
Palpation
 Examine each major joint and muscle group in
turn.
 Identify any areas of tenderness.
 Identify any areas of deformity.
 Always compare with the other side.
 During palpation,
 changes in temperature,
 palpable deformities,
 crepitus and
 tenderness.
 Temperature
 Use the back of your hand
 Deformities
 Palpate using your finger pads.
 Is there a palpable deformity?
 An increased joint space - dislocation.
 An irregular enlargement- due to




arthritis,
deposition of inflammatory material,
an old injury, or
more rarely a tumor.
 Crepitus
 Grinding or rubbing sensation or sound.
 Due to bony or cartilaginous structures moving across
each other, or due to
 tendons moving across each other.
 Tenderness
 Pain with palpation is usually an indicator of injury or
inflammation.
 The severity of the pain is usually a marker of the
severity of the underlying condition.
 Fractures, dislocations and complete tears of ligaments
or tendons are usually very painful.
 Acute inflammatory arthritis due to gout or infection is
also exquisitely painful.
 Mild sprains or contusions tend to be less painful.
 Pain from chronic conditions such as rheumatoid
arthritis or osteoarthritis, while sometimes severe, is
usually less painful
Range of Motion
 Start by asking the patient to move through an active
range of motion (joints moved by patient).
 Proceed to passive range of motion (joints moved by
examiner) if active range of motion is abnormal.
 Active ROM
 Ask the patient to move each joint through a full
range of motion.
 Note the degree and type (pain, weakness, etc.) of
any limitations.
 Note any increased range of motion or instability.
 Always compare with the other side.
 Proceed to passive range of motion if
abnormalities are found.
 If there is injury or pain, begin with normal side
first.
 Assess one joint at a time.
 Observe the patient for pain, smoothness of
motion, and any unusual movements.
 Palpation during passive (or active) ROM may reveal
crepitus.
 Be sure to have the patient tell you if the ROM
becomes painful.
 Discrepancies between active and passive ROM may
be due to weakness, pain or joint disorder.
STRENGTH TESTING
 If pain or injury, begin with normal side.
 Isolate the joint about which you are testing strength.
 Compare one side to other.
 0 - No active movement
 1 - Muscle contraction, no movement
 2 - Full active ROM with gravity eliminated
 3 - Full active ROM Movement against gravity
 4 - Full active ROM against partial resistance
 5 - Full active ROM overcome full resistance
 Reported, for example as "Strength in the upper
extremity was 5/5"
 SPECIAL MANEUVERS
 Clinicians perform special maneuvers when they are
hypothesis testing, i.e., they are concerned about a
specific condition or injury.
Shoulder
r
Look
Feel
Move
Tests
Look for any asymmetry of scapulae,
posture, or muscle wasting.
Palpate over the midpoint of each
trapezius and the supraspinatus to
identify tender spots.
Palpate over the acromioclavicular joint
line, glenohumeral joint line, and
bicipital groove.
Actively elevate arms into air.
Actively place hands behind head.
Actively place hands behind back.
Steady scapula and with the elbow at 90
degrees rotate internally and externally;
then passively abduct, flex, and
internally and externally rotate the
shoulder.
There are several methods to establish if
there is impingement
Abduction and external rotation.
Adduction, extension and internal rotation.
External rotation
Internal rotation.
Flexion.
Elevation.
Extension.
Abduction.
Adduction.
 Range of Motion
 Abduction (150 degrees)
 Forward flexion (180 degrees)
 Extension (45 degrees)
 External Rotation (90 degrees), elbow at 90
degrees
 With arm comfortably at side
 With arm at 90 degrees abduction
 Internal rotation (90)
 Some common special maneuvers for the upper
extremity include:
 Shoulder
 Impingement test
 Drop test
 Hand and wrist
 Tinel and phalen's (for carpal tunnel)
 Finkelstein's maneuver (for deQuervain's tenosynovitis)
SPECIAL MANEUVERS
 The Neer
impingement sign:
 This maneuver
narrows the space
between the acromion
and the humeral head.
If a patient has
impingement of a
rotator cuff tendon (or
a tear), they will
usually have increased
pain with this test.
 The drop test:
 Gently abduct the arm above ninety degrees, if pain
allows. Ask the patient to maintain the arm in the this
position, warn the patient and then drop the arm. In a
patient with a rotator cuff tear, they will often not be
able to maintain the arm's position and it will fall.
ELBOW JOINT
Elbow
Look
Feel
Move
Look for any swelling or deformity. Joint
swelling is first apparent in the paraolecranon groove. The olecranon is a
common site for bursitis and
rheumatoid nodules.
Palpate over the para-olecranon groove
for synovial swelling or tenderness.
Palpate over the medial and lateral
epicondyles for tenderness.
Assess the laxity of the skin if
considering hypermobility.
Passively extend and flex the elbow and
look for hyperextension.
Palpate over the medial and
lateral epicondyles for tenderness.
Elbow flexion.
Elbow
extension
Assess for elbow
hyperextensibility.
 RANGE OF MOTION
 Flex and extend, and supinate and pronate.
 Normal elbow range of motion
 Extension: 0 degrees
 Flexion: 150 degrees
 Pronation: 70 degrees
 Supination: 90 degrees
HAND AND WRIST
Wrist
Look
Look for any swelling or deformity.
Swelling over the dorsum is of the joint or extensor tendon
sheath.
Look for squaring of the palm base because of swelling of the
carpometacarpal joint seen in osteoarthritis. Typical deformities
in established rheumatoid arthritis are volar subluxation and
radial deviation at the wrist with dorsal subluxation of the ulnar
styloid.
Feel
Palpate over the joint line for tenderness or synovial swelling.
Move
Passively flex and extend the wrist.
Assess for hypermobility by passively moving the thumb toward
the volar aspect of the forearm with the wrist in full flexion.
Use resisted flexion, extension, or pronation if assessing
epicondylitis at the elbow.
Stress
Assess stability of the inferior radioulnar joint by demonstrating
movement with pressing down on the radial head—the piano key
sign.
Wrist flexion.
Wrist ulnar movement.
Wrist extension.
Wrist radial movement.
Resisted active wrist extension to test for lateral
epicondylitis.
Resisted active wrist flexion to test for medial epicondylitis.
Hands
Look
Look for any swelling or deformity. Is the swelling specific to joints or
tendons or is it diffuse?
Look for any associated clues. Much can be learned from the hand.
Look for wasting of the small muscles; inspect the skin, nails, and
nail beds.
Typical deformities in established rheumatoid arthritis are ulnar
deviation of the fingers at the metacarpophalangeal joints,
hyperextension at the proximal interphalangeal joint with flexion at
the distal interphalangeal (swan-neck deformity) joint or flexion at
the proximal interphalangeal joint with hyperextension at the distal
interphalangeal joint (boutonniere deformity). A Z-deformity of the
thumb can be seen in systemic lupus erythematosus.
Hands
Feel
Move
Palpate over each joint line for tenderness or
bony or synovial swelling. Squeezing across
all the knuckles together can be used as a
composite assessment for tenderness of the
metacarpophalangeal joints.
Palpate the tendon sheaths during
movement to detect crepitus or tendon
nodules. Feel the quality of the skin for
induration, thickening, or laxity.
Actively make a tight fist with palmar aspect
uppermost to see if all fingers fully flex and
estimate strength of grip by observing the
blanching of the palmar surface of the hand
on release of the fist.
Actively make a firm pinch grip between the
thumb and the fingers individually.
Passively extend the fifth finger to assess for
hypermobility.
Assess
supination.
Assess pronation.
Actively make a fist.
Release grip and observe palm for
blanching.
Palpate the metacarpophalangeal joints.
Palpate the proximal interphalangeal joints.
Squeeze across the metacarpophalangeal
joints.
Palpate the tendon sheaths.
Assess grip strength.
Assess pinch grip.
Assess for hypermobility of the thumb and wrist.
Assess hyperextensibility of fifth finger.
 Normal wrist range of motion
 • Extension - 70 degrees
 • Flexion- 90 degrees
 • Radial deviation (abduction) - 20 degrees
 • Ulnar deviation (adduction) - 55 degrees
 Normal hand range of motion
 • MCP hyperextension - 30 degrees
 • MCP flexion - 90 degrees
 • PIP and DIP extension - 0 degrees
 • PIP and DIP flexion - 90 degrees
 • Oppostion - thumb should touch the 5 th MCP.
 Passive ROM of the hand is frequently not performed.
Special TestsSnuffbox Tenderness (Scaphoid)
 Identify the "anatomic snuffbox"
between the extensor pollicis longus
and brevis (extending the thumb
makes these structures more
prominent).
 Press firmly straight down with your
index finger or thumb.
 Any tenderness in this area is highly
suggestive of scaphoid fracture.
 Neurologic Tests
 Phalen's Test (Median Nerve)
 Ask the patient to press the backs
of the hands together with the
wrists fully flexed (backward
praying).
 Have the patient hold this position
for 60 seconds and then comment
on how the hands feel.
 Pain, tingling, or other abnormal
sensations in the thumb, index, or
middle fingers strongly suggest
carpal tunnel syndrome.
Neurologic Tests
 Tinel's Sign (Median Nerve)
 Use your middle finger or a reflex hammer to tap over
the carpal tunnel.
 Pain, tingling, or electric sensations strongly suggest
carpal tunnel syndrome.
EXAMINATION OF SPINE
 Landmarks helpful in identifying
spinal levels include:
 • C7 and T1 - prominent spinous
processes
 • T7 to T8 - inferior angle of
scapula typically located at this
level
 • L4 - an imaginary line across the
tops of the iliac crests crosses L4
 PHYSICAL EXAMINATION
 Examination of the spine includes inspection,
palpation and range of motion. Strength testing of the
spine is not a part of the typical physical examination.
 Observe the patient from the back, with the back
exposed. The patient could either be wearing only
undergarments, or a gown that is not tied in the
back.
 Normal Findings
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
Shoulders (left and right should be equal height)
Scapulae (left and right should be equal height)
Iliac crests (left and right should be equal height)
Hands at equal height.
 Unequal heights of any of these structures might
indicate scoliosis (congenital or acquired), leg-length
discrepancy or spinal pathology.
 Observe the patient from the side, identifying the
normal cervical and lumbar concave curves, and the
convex curves of the thoracic and sacral spine.
 Scoliosis - curvature of spine - congenital,
developmental, acquired
 Note the slight curvature to this patient's spine, and note
that the right scapula is raised relative to the left. The
curvature is seen more clearly on the X-ray:

Lordosis - increased or "swayback" curve in lumbar
area


Pregnancy, muscle imbalance, obesity
Kyphosis - increased or "humback" curve in thoracic
area

Osteoporosis, posture, congenital
 Palpation:
 Palpate the spinous processes and the paraspinous
musculature, assessing for tenderness, swelling,
warmth, and muscle tone.
 Range of motion
 The examiner asks the patient to flex, extend, laterally
bend and rotate (or turn) the cervical spine and the
"back" (primarily the lumbar, thoracic and sacral
spine). Begin from the neutral position, with the
patient standing up straight (can assess range of
motion of the cervical spine with the patient seated).
 Cervical spine range of motion:
 Flexion - 45°
"Touch chin to chest"
 Extension - 55° "Tilt your head back as far as you can"
 Lateral bending (right and left) - 40° "Try to touch your
ear to your shoulder without moving your shoulder"
 Rotation (right and left) - 70° "Turn your head towards
your shoulder"
 Back range of motion:
 Flexion - 90° "Try to touch your toes without bending
your knees"
 Extension - 30° "Lean back as far as you can"
 Lateral bending (right and left) - 35° "Lean to your side"
 Rotation (right and and left) - 30° "Twist to your side"
 Examiner may need to stabilize patients pelvis to
prevent rotation at the pelvis.
Left-right rotation
Extension
Lateral bending
 Special Maneuvers:
 Straight leg raise (SLR)
 Purpose: Used to evaluate back pain that radiates into
leg (sciatica). Places tension on sciatic nerve and
inflamed nerve root
 Technique: Patient supine, legs straight. Hold heel, and
passively lift affected leg with knee straight. Talk with
patient to be sure their leg muscles remain relaxed.
Repeat with other leg.
.
 Findings: Positive test is reproduction of sciatic-type pain
when hip is flexed between 30° and 70°. Dorsiflexion of
foot may aggravate pain. If SLR of leg opposite the affected
leg causes pain in the affected leg, patient is very likely to
have a ruptured disc
 LOWER EXTREMITIES
Lower extremity
• Observing the gait is an important part of
assessing the lower limbs.
• Examination should be done with the person
lying on a bench.
• Measure leg length if a pelvic tilt when
standing suggests shortening or if there is a
discrepancy in position of medial malleoli with
straightened pelvis.
Assess leg length by relative position of medial malleoli with
straightened pelvis.
Hip
Look
Observation of the person walking will have given some
information about the hips. There may be wasting of the buttock
or thigh muscles from disuse.
Feel
Palpation should be used to clarify the origin of any symptoms.
The “hip” is used to describe symptoms anywhere in the
hindquarter.
Tenderness is usually related to tendinitis or bursitis.
Move
With the person supine, actively and then passively flex the hip
as far as possible with the knee in flexion looking for
contralateral movement.
With the hip passively flexed to 90 degrees, rotate it internally
and externally by holding the foot, supporting the thigh, and
moving the lower leg inward and outward, careful to not inflict
pain. Internal rotation is often affected first in disorders of the
hip joint.
With the person lying supine with the leg fully extended, hold
the contralateral anterior superior iliac spine to prevent
movement of the pelvis and passively abduct and adduct the leg.
With the person lying prone or on the side, passively extend the
straightened leg.
Hip flexion—active.
Hip flexion—passive, looking for
contralateral movement.
Internal rotation.
External rotation.
Abduction.
Adduction.
Patrick's test-FABER
Flexion, ABduction, and External Rotation
of the hip.
FADIR testFlexion-ADduction-Internal Rotation
 Range of motion:
 Either active or passive. In patient with pain, active
should precede passive ROM.
 Flexion (with knee bent) - 120°
 Flexion (with leg straight) - 90°
 Extension - with patient lying on side, lying prone or
standing - 15°
 Abduction - 45°
 Adduction - 30°
 Rotation - with knee flexed to 90°
 Internal 40°
 External 45°
Knee
Look
Feel
Observation of the person walking will
have given some information about the
knees. There may be wasting of the thigh
muscles from disuse. There may be
instability. Look for any swelling and its
exact site because it may relate to the joint
or periarticular structures. Look for any
deformity. Typical deformities are fixed
flexion, valgus, or varus.
Palpate for tenderness or swelling and
establish the affected structures. Palpate
the joint line for tenderness. Assess for
articular swelling and effusion by the bulge
sign or patella tap .Palpate for a popliteal
cyst.
Knee
Move
Stress
With the person supine, passively flex the
knee as far as possible with the hip in
flexion. If the hip is also abnormal, hang
the leg over the side of the bench to
examine flexion of the knee without hip
flexion.
With the person lying supine, fully extend
the leg in an attempt to touch the back of
the knee onto the bench. Assess passively if
the knee will hyperextend.
Anterior and posterior stability should be
tested to assess the cruciate ligaments.
Medial and lateral stability should be
tested to assess the collateral ligaments and
for loss of joint space.
The bulge sign in the knee. The back of the hand gently
pushes the fluid from one side of the knee to the other,
filling out the “dimples” on either side of the patella. This is
most helpful in detecting small knee effusions.
The patellar tap. One hand is used to cup the patella and
compress the suprapatellar pouch, and the fingers of the other
hand press down on the patella to feel for cross-fluctuation.
Knee flexion.
Knee extension.
 Range of motion:
 Passive or active. If patient has pain, active should
proceed passive.
 Expected ROM:
 Flexion - 130°
 Extension - 0° (neutral) to 15° (hyperextension)
 Mediolateral instability
 Purpose: evaluate the medial and collateral ligaments.
 Technique:

Medial collateral ligament: with the knee flexed at 30°
(or in neutral position), apply a valgus stress to the
knee.


Lateral collateral ligament: with the knee flexed at 30°
(or in neutral position), apply a varus stress to the
knee.
Compare injured to normal side.
 Positive finding - pain, with evidence of joint space
widening in comparison to normal side. Pain alone
suggests possible strain of ligament, without disruption
of the fibers.
Stress the cruciate ligaments.
(anterior and posterior drawer
test)
Stress the collateral ligaments.
Foot and ankle
Look
Observe the feet when standing and during walking. Look for a
normal longitudinal arch and during the gait cycle look for
normal heel strike and take off from the forefoot. Look for any
callosities beneath the metatarsal heads and for any swelling
and redness of the toes.
Swelling of the metatarsophalangeal joints can separate the toes
and daylight becomes visible between them. Look for any
deformities.
Deformities include pes planus (flattening of the longitudinal
arch), pronation of the foot, valgus deformity of the hindfoot
(eversion of the subtalar joint, pes cavus (high longitudinal
arch), talipes equinovarus, hallux valgus, subluxation of the
metatarsophalangeal joints, and “claw,” “hammer,” and “mallet”
deformities of the toes.
Foot and ankle
Feel
Symptoms may relate to the joint; the periarticular bone; the
tendons, their sheaths and insertions; or bursae. Palpate for
tenderness or swelling and establish the affected structures.
Squeeze across the metatarsus, and if there is tenderness,
examine the metatarsophalangeal joints individually.
Move
Actively flex and extend the ankle.
Actively invert and supinate and then evert and pronate the foot.
Passively deviate the heel medially (inversion) and laterally
(eversion) by grasping the heel between the examiner's thumb
and index finger of one hand and moving it while anchoring the
lower leg with the other hand.
Passively rotate the forefoot on the hindfoot by grasping the
Move forefoot between the examiner's thumb and fingers while
anchoring the heel with the other hand to assess the midtarsal
joint.
See if the patient is able to stand on the toes, which requires an
intact posterior tibialis tendon.
Metatarsal squeeze.
Ankle flexion.
Ankle extension.
Inversion and supination.
Subtalar inversion.
Eversion and pronation.
Subtalar eversion.
Midtarsal rotation.
Assessing the first metatarsophalangeal joint.
 Range of Motion:
 Expected ROM - neutral position of foot and ankle
is with foot at 90° to leg.
 Dorsiflexion - 20°




"Point your toes towards nose"
Ankle joint: Plantarflexion - 45 "Point toes towards
floor."
Inversion (sole points "in") - 30°
Eversion (sole points "out") - 20°
Flex and extend toes.
 Strength:
 Dorsiflexion - patient flexes up against your hand.
 Plantarflexion - patient flexes down against your hand
Schober test
10 cm
15 cm