MMMCA GUIDE TO EXAMINATION OF JOINTS

Basic rules in examination:

The entire area in question with one joint above one joint below must be exposed adequately and examined.

No Orthopaedic examination is complete unless the joint above, the joint below, the same joint on the opposite side and a detailed neurovascular examination is done.

Examination has to proceed with the differential diagnosis made at the end of the history in mind.

Sequence in examination : Inspection, Palpation, Movements, Measurements and Special tests.

EXAMINATION OF THE HIP

Common symptoms: Pain, swelling, stiffness, deformity, limb length discrepancy, altered gait

Examination of the hip should be done with the patient supine,prone and in standing positions.

Examination of the hip includes examination of the knees andthe spine.

From the front with the patient supine: Attitude of the limb: position of various joint :

direction and degree

Deformity of the hip if any and details therein.

Spine : evidence of exaggerated lumbar lordosis : level of the shoulders

ASIS : Level of the anterior superior iliac spines : Abduction /adduction deformities

Femoral triangle examination : swellings and its description

Presence of : swellings, scars and sinuses, dilated veins and description of each as on inspection of the hip and entire limb

Muscle wasting

Limb length discrepancy

Other bony prominences: levels of patella, position of the patella (rotational deformities of the limb- level of deformity- comparison with amount of rotation of the foot) and level of medial malleolus.

From the front with the patient standing:

GAIT of the patient

Level of the shoulders: May indicate the presence of limb length discrepancy.

From the side:

Evidence of deformity in the spine : normal spinal curvatures and deformities in the spine: lordosis or kyphosis

Trochanteric area : examination for any swellings.

Findings on the lateral aspect of the hip and limb :swellings, scars, sinuses etc with detailed description of each as on inspection.

From the back:

Deformities in the spine : Scoliosis

Kyphosis / Gibbus

Levels of the posterior superior iliac spines

Sacral dimples: levels of the sacroiliac joints

Level of the Gluteal and thigh folds: indication to limb length discrepancy / DDH

Findings on the posterior aspect of the hip and limb : swellings, scars, sinuses etc with detailed description of each as on inspection.

Look for evidence of deformity of the limb and detail out the direction of the deformity and amount of deformity if seen.

Inspection of the limb with respect to neurovascular status of the limb to be done.

PALPATION

Local rise of temperature over the area of interest: all differential diagnosis to be considered in this respect

Tenderness over the area of interest: all differential diagnosis to be considered in this respect

Confirm all inspectory findings individually with all relevant details: {ALL INSPECTORY FINDINGS IN THE SPINE AND THE BACK} eg. Regarding the spinal deformities, swelling, scars, sinuses, limb length discrepancy etc….

Look for presence of lymph nodes whenever appropriate.

Bony prominences: ASIS, Greater trochanter (height, tenderness, width, surface of the greater trochanter in comparison to the opposite side), patellar height, medial malleolar level.

Bony irregularities: Look for presence of bony irregularities and details of where such irregularities are palpated. Also look for any evidence of deformity of the bone and record direction of the deformity.

Palpate for all peripheral pulses and look for motor and sensory disturbances in areas concerned.

Vascular sign of Narath: In conditions where the head or neck of the femur are not in place or are destroyed as a complication of a disease process, the femoral pulsation on the affected side is less well felt.

When increased lumbar lordosis is present : indicates primary spinal deformity or an underlying fixed flexion deformity of the hip. The degree of deformity has to be measured in degrees by doing the THOMAS test.

When ASIS is found to be at different levels indicates: spinal deformity leading to pelvic obliquity or a fixed abduction or adduction deformity of the hip leading to obliquity of the pelvis. When ASIS on the affected side is at a lower level it indicates an ABDUCTION deformity on the hip and when at a higher level indicates an ADDUCTION deformity in the hip.

The degree of the deformity has to be measured by SQUARING THE PELVIS and unmasking the deformity. Deformity has to be quantified in degrees.

MOVEMENTS:

All ranges of movements, in all directions normally possible in the joint, has to be measured in degrees. Movements have to be recorded in a tabular column showing the movements on the right and the left sides in each direction and a column to record the difference found in each direction. This tabular column can also depict the power in each group of muscle. Eg. flexors, extensors, abductors etc.

When fixed deformities are found :

Movements in the opposite direction is not possible

Movements in the same direction as the deformity may be possible

Eg: when fixed abduction deformity is seen to be present adduction at the hip will not be present and vise versa.

RECORDING MOVEMENTS IN THE PRESENCE OF FIXED DEFORMITIES:

If there is a fixed deformity in one direction of 20 degrees with further movement in the same direction of 120 degrees possible, then the range of movement is recorded as 20-120 degrees. This indicates that the joint has a fixed deformity of 20 deg. And allows further movement in the same direction of 120 deg. Now if the opposite joint has normal range of movement of say 0-120 degrees in the same direction then on comparing the two it is apparent that whereas there is a deformity of 20 deg. in the affected joint and further movement in the direction in question is full and normal.

PROBLEM: If the range of movement recorded is 30-100 deg. on the affected side and 0-120 on the normal side for the same movement then what is the conclusion??

ANSWER: Fixed deformity of 30 deg. and further movement is also restricted by 20 deg. when compared to the normal side.

All movements should be recorded as RANGE of movements with a definite start and end point mentioned in degrees.

MEASUREMENTS

All bony prominences should be marked with a marking pen on both sides before measurement is done.

The tape should be placed gently on these points during measurement. Care should be taken to ensure that the points have not been moved under the examining fingers.

Apparent measurement:

From the Xyphisternum to the tip of Medial malleolus: with the patient supine and lying down as straight as possible.

True measurement of the entire limb:

Prerequisites:

The pelvis should be squared

Both the limbs have to kept in identical positions when measuring

From the ASIS to the medial malleolus on each side.

SEGMENTAL TRUE MEASUREMENTS

In the same position of a squared pelvis and both limbs in similar positions the femoral and tibial measurements are individually taken as follows.

(a) Femoral length:

From the ASIS to the Medial joint line.

The medial joint line is palpated

with the knee in about 10-30 deg. of flexion when possible. the tibial tuberosity is identified and the examining fingers are run proximally on the

tibia along the flare of the tibia. A depression is felt as the fingers run proximally which is placed perpendicular to the

axis of the femur on the medial and lateral aspects of the knee. This represents the medial and lateral joint line.

This is confirmed by then moving the joint into flexion and extension whenever possible with the examining fingers still placed on the medial and lateral joint lines. The movements are appreciated to be occurring at that level confirming it to be the joint lines.

(b) Tibial length:

From the medial joint line to the medial malleolus.

(c) Measurement of the girth of the limb: To be done in the presence of muscular wasting / Swelling.

SPECIAL TESTS

Thomas test

Used to unmask and quantify fixed flexion deformity in the hip

Procedure: With the patient supine on a hard surface eg: examination table:

1. Look for evidence of excessive lumbar lordosis by:(a) looking for light passing through and through the lumbar area (between the back

and the couch).(b) Pass the palm of the hand under the lumbar region: this cannot be done in a

normal situation. If the palm can be passed under the lumbar region it indicates excess lumbar lordosis.

2. With the palm under the lumbar back, flex the hip on the unaffected side through its full range of flexion and continue to flex it beyond till the lumbar back just touches the hand. Notice the hip on the affected side flexing with this maneuver.

3. With the unaffected hip in the position of flexion as above, passively extend the hip on the affected side as much as possible without allowing the patient to arch his back. The angle that the back of the thigh makes to the couch on the affected side is the amount of fixed flexion deformity in that hip.

INSTABILITY TESTS:

Telescopy test : done for demonstrating a dislocated hip or unstable hip.

Trendelenberg test: to demonstrate an ineffective abductor mechanism (Gluteus medius

wekness, dislocated or destroyed head of femur, nonunion of neck of femur, coxa vara, etc.)

Barlow’s test

Ortolani’s test

SPECIAL LINES:

Nelaton’s line: A line drawn from the ischial tuberosity to the ASIS on the same side. The line

just touches the tip of the greater trochanter in normal individuals. When the greater trochanter

has moved proximally for any reason, the line cuts the greater trochanter.

Shoemaker’s line: A line drawn from the greater trochanter to the ASIS on the same side and

extended on to the abdomen will cross the midline at or above the level of the umbalicus. When

the trochanter is high riding the line passes below the umbilicus.

Kotari’s line: To quantify the amount of abduction or adduction deformity that may be present

in the involved hip.

1. The two ASIS are joined by a line without squaring the pelvis. 2. The midline is drawn passing through the umbilicus.3. A perpendicular line is drawn to the midline from the ASIS on the affected side. 4. The angle line1.makes with line 3. is the angle of deformity in the hip.

EXAMINATION OF THE KNEE

Common symptoms: Pain, swelling, deformity, locking of the knee, giving way of the knee, crepitus or clicks at the knee.

Examination of the knee includes that of the hip and ankle on the same side and the knee on the opposite side.

Examination of the knee is done from the front, side and the back with the patient supine, prone and standing.

INSPECTION:

Attitude of the limb and the knee in specific

Shape of the knee : Prepatellar area, parapatellar gutters, suprapatellar pouch and infrapatellar areas for evidence of swelling, patellar prominence, position of the patella, swelling over the popliteal area- over the midline and the sides (Bursal swellings).

Tibial tuberosity: look for the tibial tuberosity levels from the side on both sides simultaneously with the hips flexed to 45 degs. and knees flexed to 90 degs.

HORSE SHOE SHAPED swelling- suggests effusion in the knee.

Bursal swellings around the knee.

Swellings, scars, sinuses, deformity : details of all these. Muscular wasting

Limb length discrepancy

GAIT of the patient if he is able to walk.

PALPATION:

Local rise of temperature

Tenderness over the suspected site.

Confirm all inspectory findings by palpation. All swellings, scars etc. have to be palpated and palpatory findings have to be detailed out.

Confirm the levels of the bony prominences

Look for evidence of any bony irregularities or thickening of the bone (lower femur and upper tibia and fibula)

Look for any lymph node enlargements.

Patellar Tap :

Pre requisites: Knee has to be kept in neutral position

o “Milk” the supra-patellar pouch empty.o Push the patella down onto the femoral condyles.o FEEL the patella tapping on the femoral condyles

o When the tap of the patella on the condyle is felt- patellar tap test is positive.

o Patella tap can be false-negative when:

Test is done in presence of fixed flexion deformity Minimal fluid in the knee- fluctuation test- standing position Tense joint with excess fluid in the knee Absence of the patella- patellectomy Faulty technique of eliciting a patellar tap

Palpating for the synovial membrane : The synovium is best palpated over the superior part of the supra-patellar pouch. This is the region where the synovium reflects on itself and hence synovial hypertrophy is best felt here. It is placed about 3-4 finger breadths above the superior pole of the patella. The supra-patellar pouch occupies this entire region until the superior border of the patella.

o Start from the superior border of the patella and palpate the supra-patellar area

moving in a proximal direction. In the presence of a synovial hypertrophy it is felt at the superior part of the pouch as a chord like structure that can be rolled underneath the palpating finger.

Palpation of the patella:

o Shape of the patella o Shape of the patellao Tenderness of the patella :

prepatellar tenderness retropatellar tenderness: medial and lateral aspect retropatellar grating: patello-femoral arthritis

o Gap in the continuity of the quadriceps mechanism:

Attachment of the quadriceps to the patella Patella itself In the patellar ligament At the level of the tibial tuberosity

Palpate for clicks and thuds in the joint: Usually indicates possible meniscal damage or presence of loose bodies in the joint. Also look for evidence of crepitus in the joint by moving the knee through flexion and extension.

MOVEMENTS:

All ranges of movements, in all directions normally possible in the joint, has to be measured in degrees. Movements have to be recorded in a tabular column showing the movements on the right and the left sides in each direction and a column to record the difference found in each direction. This tabular column can also depict the power in each group of muscle.

MEASUREMENTS:

Measurement of the lower limb as detailed in examination of the hip.o Apparent lengtho True lengtho Femoral and tibial length

Muscle girth

SPECIAL TESTS:

Varus and valgus stress tests: for the collateral ligamentso Varus stress test: For lateral collateral ligament

Done with the knee in extension (neutral position) Varus stress applied to the knee Will produce pain over the femoral or fibular attachment of the lateral

collateral ligament or anywhere along the course of the ligament depending on the site of tear of the ligament.

o Valgus stress test: For medial collateral ligament Done with the knee in extension (neutral position) Valgus stress applied to the knee

Will produce pain over the femoral or tibular attachment of the medial collateral ligament or anywhere along the course of the ligament depending on the site of tear of the ligament.

Apleys grinding test: For integrity of the menisci.

Apleys distraction test: For integrity of the collateral ligaments.

McMurray’s test for the medial and lateral meniscus

1. For the medial meniscus: - Flex the knee through its full range of flexion - Externally rotate the tibia on the femur and extend the knee with a valgus force

applied at the knee2. For the lateral meniscus:- Flex the knee through its full range of flexion - Internally rotate the tibia on the femur and extend the knee with a varus force

applied at the knee.

In both these tests, look for evidence of pain and/or clicks during extension of the knee and at what degree of flexion the knee is in, when patient complains of pain.

- If the pain is reproduced with the knee still in more than 100 flexion, the meniscal tear may be placed more posteriorly (posterior horn tear of the meniscus)

- If the pain is reproduced with the knee in 70-100 of flexion, the tear may be in the middle of the meniscus

- If the pain is reproduced with the knee in less than 70 of flexion the tear may be place more anteriorly (anterior horn of the meniscus)

Anterior drawer test: For testing the integrity of the anterior cruciate ligament

The test is done on the normal side first to determine the normal range for the given patient.

o Hip place at 45 deg flexion and knee at 90 deg flexion

o Patient is explained to relax the hamstring muscles and this is looked for, by

feeling the hamstring muscles.

o The foot is stabilized and the tibia is stabilised with both hands of the examiner at

the level of the condyles of the tibia and gently pulled forwards, anteriorly.o Anterior translation of the tibia on the femur is looked for and visually

approximated. o The same maneuver is done with the tibia in external rotation and internal

rotation.o The test is done on the affected side and the amount of forward translation of the

tibia on the femur is compared to the normal side.o If the amount of translation on the affected side is more the test on the

affected side is said to be positive.

Posterior drawer test: For testing the integrity of the posterior cruciate ligament

o Procedure is similar to anterior drawer test except that a posterior push is given to

the proximal tibia and the posterior translation of the tibia on the femur is looked for and compared.

Lachman test: For testing the integrity of the cruciate ligaments.o With the knee placed in 30 deg of flexion, the lower end of the femur and upper

end of the tibia are held firmly by the examiner.o With the femur stabilized in one hand the tibia is gently pulled forwards on the

femur.o Forward translatory movement of the tibia on the femur is looked for and

compared to the normal side. This gives an insight to the integrity of the anterior cruciate ligament

o The same procedure is done

Q angle : in genu valgum deformity

Intercondylar distance: in genu varus deformity

Intermalleolar distance : in genu valgum deformity

EXAMINATION OF THE SPINE

Common symptoms : pain, deformity, neurological symptoms

Examination of the spine includes examination of the ENTIRE spine, sacroiliac joint both lower limbs and a detailed neurological examination. Per rectal examination is a must during spinal examination.

Examination of the spine is done from the back, front and the sides with the patient in the standing, prone and supine positions.

Bony landmarks in spine examination:

Occiput C2-3:Mandible C3:Hyoid cartilage C4-5: Thyroid cartilage C6: Cricoid cartilage C7: Vertebra prominence T3: Spine of the scapula T7: Xiphoid, tip of the spine (inferior angle of the scapula) T10: Umbalicus L1: Spinal cord ends L3: radiologically: largest transverse process L4: Iliac crest

Important to understand:

Levels and exiting nerve roots

All nerves exit through the spinal nerve root foramina They are placed in the upper third of this foramina : important to know with respect to

disc prolapse and level of neurological involvement. There are 7 cervical vertebrae and 8 cervical nerve roots. The first pair of spinal nerves go out between occiput and C1. Hence between C7-T1 the exiting nerve root is C8.

Between T1-2 the first thoracic nerve root goes out and from there on the same pattern is followed until the sacral levels.

LEVEL NERVE ROOT

C1-2 C2

C2-3 C3

C6-7 C7

C7-T1 C8

T1-2 T1

T12-L1 T12

L1-2 L1

L4-5 L4

S1-2 S1

Vertebral and segmental level:

During birth the entire length of the vertebral canal is occupied by the spinal cord. With growth there is a differential growth in the rate between the bony vertebral column and the spinal cord and hence in adults the spinal cord ends at inferior border of L1 vertebra. The nerve roots continue to respective levels to exit as the cauda equina. Hence between C1 and L1 all segments of the cord are placed. During fractures of the vertebral column, the bony level and neurological levels hence do not match.eg: Fracture at T8 vertebra does not mean involvement of T8 segment of the cord. At this level is placed the T11 segment of the cord and hence neurological level would be T11 downwards.

The following chart would present a simple way of remembering which vertebral would represent what segment of the spinal cord and so from what level downwards to expect a neurological involvement:

VERTEBRAL LEVEL SEGMENTAL LEVEL

Cervical spine Add 1

Upper thoracic – T1-6 Add 2

Lower thoracic – T7-9 Add 3

T10 L1-2

T11 L3-4

T12 L5

L1

Sacral and coccygeal

Eg: -Vertebral injury at C4 : neurological examination will reveal involvement of the cord from C5 downwards.

-Vertebral injury at T4: would reveal involvement from T6 downwards

- Vertebral injury at T8 would reveal involvement from T11 downwards.

- Vertebral injury at T10 would involve L1 downwards

- Vertebral level L1 would involve the sacral and coccygeal

segements

INSPECTION

Attitude of the entire spine

Placement of the head (occiput and the gluteal cleft should be in a straight line)

Level of the shoulders.

Level of the inferior angle of the scapula (corresponds to T7 level normally)

Lateral margin of the body from the axilla to the iliac crest – whether there is increased concavity on either side when compared to the other.

Deformity of the spine in both the antero-posterior and the medio-lateral plane (torticolis, scoliosis, kyphosis, lordosis). Scoliosis is looked for by looking at the spinous process of the spine through the entire length of the spine.

Evidence of “tell tale” signs in the lower back that may suggest an under lying spina bifida.

Evidence of café- au- lait spots that may suggest neurofibromatosis. This condition is associated with various deformities of the bone.

Level of the posterior superior iliac spine.

Level of the sacral dimples indicating region of the sacroiliac joints.

Level of the anterior superior iliac spine. Level of the area of ribs with the patient bending forwards in patients with scoliosis.

In the presence of scoliosis, asking the patient to bend forwards would differentiate between a structural and a non-structural scoliosis.

Any swellings, scars, sinuses etc on inspection should be detailed out.

Muscle wasting in the back and in the limbs.

Gait of the patient

Evidence of neurological deficit in the limbs.

Inspection of the femoral triangle area is important in spinal examination as tuberculous abscess can track to the femoral triangle and present as a swelling in this region.

PALPATION

Local rise of temperature

Tenderness : over the entire length of the spine and the sacroiliac joints.

Confirmation of all inspectory findings and detailing palpatory findings wherever appropriate. Eg: regarding swelling, scars etc.

Complete detailed neurological examination and findings to be written in a tabular format.

MOVEMENTS

Active and passive movements in all directions normally occuring at all levels of the spine have to recorded in degrees.

Cervical : Flexion, extension. rotations, lateral flexion

Thoracic: rotational movements occur at this level

Costovertebral movements: Also indirectly reflects on the status of the spine as the ribs are attached to the vertebrae. Disease process involving the spine can affect these joints and present clinically with restricted movements of the thoracic cage. This is measured by the amount of chest expansion possible on inspiration. Normally this would be in excess of 5-7 cms.

Lumbar: Flexion : o Schober’s test – to quantify the amount of flexion

o Coin test: when the spine is affected, patient bends at the hip and knee with the

spine being straight and stiff.

Lumbar : Extension, lateral flexion.

Sacroiliac movements : moves with the patient bending forwards in the standing position and also during rotation of the spine.

MEASUREMENTS

Schober’s test to quantify the movements occurring in the spine.

Limb length discrepancy in the lower limbs as this can lead to symptoms in the spine.

SPECIAL TESTS

FOR EVIDENCE OF COMPRESSION ON THE CORD OR NERVE ROOT

Straight leg raising test:

o Used to identify presence of a lower lumbar or upper sacral disc- L3/4/5, S1

With the patient supine it is important to first confirm that there is no evidence of increased lumbar lordosis. Then with the symptomatic limb kept straight the non-symptomatic limb is raised gently into flexion at the hip with the knee in extension. Normally, upto beyond 60 deg of flexion at the hip in this manner, there is no discomfort noticed. Discomfort at this point even on the normal side may be due to stretching of the hamstring muscle or may indicate a possible pathology in the sacroiliac joint. Patient here would complain of pain over these areas.

Now the non-symptomatic side is placed on the bed and the symptomatic side is flexed in a similar manner. When the patient complains of a radiating pain over the course of the sciatic nerve

in the arc between 0-60 of flexion at the hip, it is indicative of cord or root compression.

STEP 2: If for example the patient complains of pain at 40 deg. then reduce the flexion by 10 degrees and then in this position passively dorsiflex the ankle. If the patient complains of similar pain coming on again then it is confirmative of a pressure over the cord or nerve root. This second part of the test is called as the LASEGUE’S SIGN.

Femoral nerve stretch test:

o Used to identify prolapse of a upper lumbar disc

With the patient prone the hips in neutral position, the knee is flexed. If the patient complains of pain in the front of the thigh over the course of the femoral nerve it indicates a possible disc irritating the cord or root at a higher lumbar level.

Lhermitt’s sign:

o Used to identify a possible disc prolapse at the cervical spine level

With the patient sitting the hips and the cervical spine are flexed simultaneously. In the

presence of excruciating pain in the spine radiating down both extremities a disc prolapse is a

possibility.

TESTS FOR THE SACROILIAC JOINT

Pump handle test:

The patient is placed supine and the test is done on the unaffected side first. The shoulder of the patient is steadied and the hip is flexed through its full range of flexion with the knees flexed. The hip is then forced further into the direction of flexion and towards the opposite shoulder. Normal sacroiliac joint will not produce any discomfort with this maneuver.

The same is done on the affected side. Pain is reproduced at the sacroiliac joint on the affected side.

Genslen’s test:

With the patient supine, the affected hip and knee is flexed while the unaffected side is allowed to hyperextend over the edge of the table. This produces a rotational strain in the sacroiliac joint reproducing pain on the affected side.

RECTAL AND VAGINAL EXAMINATION

This is an important part of examination of the spine especially in spinal injuries to determine the extent of damage to the cord (complete or incomplete) and also in evaluating the period of spinal shock.

Examination of the rectum also is important to look into the status of the prostate. Malignancies of this organ can produces secondaries in the spine. Vaginal examination is important to look into the possibility of cervical carcinoma, which again can present with secondaries in the spine.

EXAMINATION OF THE SHOULDER

Common symptoms presented with are pain, swelling and deformity around the shoulder.

Although we know the shoulder to be the gleno-humeral joint, in reality, it is a complex of 4 joints. Movements of the shoulder are commonly thought of as movements occurring in the gleno-humeral joint alone. This in not true. The movement actually occurs jointly at the acromio-clavicular, sterno-clavicular, gleno-humeral and the scapulo-thoracic joints. Hence examination of the shoulder joint would include examination of all the above-mentioned joints and areas around it, as pain from any of these joints could present with restriction of movement at ‘the shoulder’.

Pain around the shoulder could be due to pathologies in other areas like, the neck, internal organs – lung, diaphragm and the heart or from the upper back.

Pain arising from pathology in the shoulder, may present early, as pain in the upper arm or forearm. The proximity of the large vessels and nerves of the upper limb to the shoulder makes it possible for patients with pathology around the shoulder to present with symptoms pertaining to these structures.

Examination of the shoulder includes examination of the upper back, neck, axilla, upper limb and respiratory & cardiac systems.

INSPECTION:

(With the arm by the side of the body wherever possible):

Attitude of the limb and the shoulder in specific

Shape of the shoulder: The shoulder has a rounded contour to it due to the head of the humerus within the glenoid and the bulk of the deltoid muscle. The shoulder should be examined from the front, back and the side.

Examination from the front:

o The shape of the shoulder

o The clavicle: Being a subcutaneous bone the shape of the clavicle and the

adjacent, acromio and sternoclavicular joints can be inspected.

o Suparclavicular area

o The front of the chest : The pectoral muscle: wasting

o The anterior axillary fold:

presence of swelling Level of the fold as compared to the opposite side.

o Swellings, scars, sinuses, deformity: details of all these.

Examination from the side:

- The shape of the shoulder- Swelling on the anterior, posterior or lateral aspect of the shoulder.- The acromion bone

Examination from the back:

- Examination of the scapula and upper back for swellings, scars, sinuses, deformity: details of all these.

- Spine of the scapula: deformity - Wasting of the suprascapular and/or infrascapular muscle (seen as wasting above and

below the spine of the scapula).- Angle of the scapula: superior and inferior: level on comparison to the opposite side.- Medial border of the scapula: evidence of ‘winging’ of the scapula.- Level of the posterior axillary fold: compare with opposite side.

Examination of the axilla:

- Swelling in the axilla: In traumatic situations it may well be the dislocated head of the humerus.

- Scars, sinuses: details of all these.

Limb length discrepancy in the upper limb

PALPATION

Local rise of temperature Tenderness over the suspected areas Confirm all inspectory findings Look for evidence of bony irregularities Confirm the levels of the bony prominences Complete neurological and vascular examination

Examination of the neck, elbow, cardiac and respiratory system to be done in detail.

MOVEMENTS

o All range of movements of both shoulders, both active and passive to be recorded in

all direction in degrees.

MEASUREMENTS

o Apparent and true measurements of the upper limb to be recorded

o Axillary circumference

o Hamilton’s ruler test

SPECIAL TEST

o Apprehension test

EXAMINATION OF THE ELBOW

History:

Pain

Stiffness

Deformity

Occasional Locking

1. Inspection

Attitude:

Patient asked to stand with his hands by the side of the body and observe for normal carrying angle [i.e., 10 to 20] < Males > Females

Swelling:

Any swelling near the joint to be noted

Look for fullness of normal hollow on either side of Olecranon

Look for any swelling over the olecranon [eg: olecronon bursitis – students / miners elbow]

Tense effusion will show fullness of antecubital fossa

Muscle Wasting:

Any pathology which joint motion will result in muscle wasting

2. Palpations

Local rise of temperature – inflammation

Tenderness and can indicate diagnosis by itself

Eg: tenderness over origin of Common Extensors - Tennis Elbow

Tenderness over origin of Common Flexor – Golfers Elbow

Bony Points

Lower part of humerus

Upper part of ulna and radius

For thickening or irregularity

Three bony points:

Olecronon tip, Medial and Lateral epicondyle

Form a triangle when flexed

In straight line when extended

Swelling – usual pattern

Exam of supra trochlear Lymphnode

3. Movements

Two components

Hyper extension

4. Additional tests

Palpation of Ulnar Nerve

Cozen’s Test [Thomson’s]

Miltch Manuvuer

EXAMINATION OF THE WRIST JOINT

History:

Like most other joints history is similar – pain, swelling etc

1. Inspection:

Attitude Position:

Common deformity is flexion and ulnar deviation of wrist and fingers. E.g. Rheumatoid arthritis

Swelling:

Can be due to effusion by uncommon

The swelling is commonly due to effusion into tendon sheath this has to be differentiated

Eg: Tendon sheath swelling extends both proximally and distally beyond the joint

Eg: Compound palmar ganglion [Tubercular tenosynovitis]

A circumscribed small swelling on the dorsum of wrist is nothing but a ganglion

Deformity:

Manus varus and valgus

Madelung’s deformity

Sinus:

Tuberculor Sinus

2. Palpation

Swelling:

Cross fluctuation

Tenderness:

Joint Line

Over tendons sheath

Bony Points:

Lower end of Radius

Lower end of Ulna

Balottment of Ulnar head

Level of Styloids

3. Movements:

Dorsiflexion [extension] - 70 to 80

Palmar flexion - 0 to 70

Radial Deviation - 0 to 20

Ulnar Deviation - 0 to 30

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