Download hand Physical Exam Vascular assessment: radial ,ulnar, digital

 hand Physical Exam
 Vascular assessment: radial ,ulnar, digital arteries using a Doppler technique. capillary refill in each finger (<2
sec).temperature of fingers , pulse oximeter.
o Allen test to check competence of palmar arch: Press firmly on radial & ulnar arteries, patient open &close fingers
actively several times. Take pressure off 1 artery, observe for vascular refill in digits within 15 seconds. (A slow or
absent refill suggests vascular obstruction or an incomplete arch.)
 Neurologic assessment:
o median nerve. Sensation on volar tip of thumb. 2-point examination (<5 mm). Patient to appose thumb to little finger
(motor ).
o ulnar nerve. Sensation on volar tip of little finger. patient to cross fingers (motor branches of the ulnar nerve
innervate intrinsic
o radial nerve. no motor branch in hand. sensation is tested on the dorsal aspect of the hand in the first web space.
 Assessment of bones, tendons, and ligaments: Each bone is palpated to rule out a fracture. Swelling can be variable.
o Check each joint for active and passive ROM (2):
 IP thumb joint: 0-80‫آ‬°, MCP thumb joint: 0-50‫آ‬°
 DIP and MCP finger joints: 0-90‫آ‬°, PIP finger joints: 0-100‫آ‬°
 Wrist: 80‫آ‬° of flexion and 70‫آ‬° of extension
 Tinel sign: Percussion over median nerve at wrist produces numbness, tingling, pain in thumb ,index ,middle fingers. Test for
CTS.
 Phalen test: Flexion of the wrist completely for 1 min produces numbness, tingling, and pain in the hand. Test for CTS.
 Aspiration of the wrist joint (2 approaches):
o Dorsal approach: Insert a needle between 3rd compartment (EPL) & 4th compartment (EDC &extensor
indicis proprius).
o Palpate Lister tubercle, introduce needle just distal to it; flexing wrist facilitates entry.
 wrist examination Physical Exam
 Inspection: Bilateral comparison, exposure of entire upper extremity, cervical spine. observe patient's wrist movements and
determine whether motion is smooth and natural or stiff and jerky. lesions, swellings, or scars observed
 Palpation of skin: Extensive localized warmth may indicate infection, dryness (anhidrosis) suggest nerve damage.
 Palpation of bones:
o Radial styloid process: Lies lateral when palm faces anteriorly Its most prominent point proximal to wrist joint.
o Anatomic snuffbox: depression distal slightly dorsal to radial styloid process , visualize when patient extends thumb
laterally
o Scaphoid: on radial aspect of wrist ,forms floor of snuffbox. Tenderness to palpation over snuffbox suggests a
fracture
o Trapezium: on radial side of wrist , articulates with 1st metacarpal. palpable saddle-like trapezium1st metacarpal
joint .
 Grind test: for 1st CMC joint degenerative joint disease. stabilizes CMC joint with 1 hand and, with other,
axially loads patient's proximal phalanx and MCPJ. examiner's 1st hand then moves metacarpal base
laterally in several directions against trapeziometacarpal joint, to exacerbate symptoms.
o Capitate: Largest carpal bones. Palpable proximal to base of 3rd metacarpal (largest ,prominent of metacarpal bases).
o Lunate: proximal to capitate, in proximal carpal row, articulates proximally with radius and distally with capitate. .
frequently dislocated , 2nd often fractured wrist bone. lunate, capitate, base of the 3rd metacarpal are in line with
each other , covered by ECRB tendon, which inserts into the base of the 3rd metacarpal.
o Ulnar styloid process: palpated at distal aspect of ulna medially and posteriorly .A groove on its distal tip houses
ECUtendone
o Triquetrum: distal to the ulnar styloid process
o Pisiform: small sesamoid bone lies anterolateral to triquetrum, sits within FCU tendon. It's medial border of the
tunnel of Guyon
o Hook of the hamate: dorsal and radial to pisiform. Forms (radial) border of tunnel of Guyon, encompasses ulnar
nerve and artery
 Finkelstein test: for stenosing Quervain tenosynovitis in compartment I tendons (abductor pollicis longus &EPB). Passive
hyperflexion of thumb MCP and IP joints make a fist with thumb tucked inside other fingers. Then examiner stabilizes
patient's forearm with 1 hand and deviates patient's wrist in an ulnar direction with other hand. Sharp pain felt in tunnel
region strongly supports
 Palpation of palmar aspect of the wrist:
o Palmaris longus: Bisects anterior wrist; its distal end also is the anterior surface of the carpal tunnel. To palpate :
patient flex wrist and touch tips of the thumb and small finger together in apposition;
o Carpal tunnel: deep to palmaris longus , defined proximally by pisiform & tubercle of scaphoid , distally by hook of
hamate & tubercle of trapezium
 transverse carpal ligament, part of the volar carpal ligament, runs between those bony prominences ,forms
fibrous sheath containing carpal tunnel anteriorly within fibro-osseous tunnel.
 Posteriorly, carpal tunnel is bordered by carpal bones.
 compartment transports the median nerve and the finger flexor tendons from the forearm to the hand.
 (CTS) can restrict motor function and sensation along the median nerve distribution of the hand. Patients
note discomfort over the wrist and numbness of the thumb and the index and middle fingers. paresthesias
at night.
 To support a diagnosis of CTS, reproduce:
 (Tinel sign) Pain in the median nerve distribution by tapping over the volar carpal ligament
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 (Phalen test)Symptoms by flexing the patient's wrist to its maximal degrees and holding for at least
1 minute
o Flexor carpi radialis:
 tendinitis cause pain over flexor aspect of wrist. tender over FCR tunnel (from 3 cm proximal to wrist to
main insertion of FCR on base of 2nd metacarpal).:resisted wrist flexion & radial deviation of wrist.
o Vascular anatomy:
 radial artery radial to FCR tendon.
 ulnar artery proximal to pisiform before it crosses wrist on anterior aspect of ulna. it providing dominant
blood supply
ROM (use bilateral comparison to evaluate patient's restrictions):
o Flexion (70_80°), Extension (70-80°)
o Radial deviation (~20°) , Ulnar deviation (~30°)
o Supination (90°) , Pronation (90°)
Motor testing:
o Wrist extension (C6) ,
o Flexion (C7) ,
o Supination (C5, C6) ,
o Pronation (C6, C8, T1)
Sensation : (test volar & dorsal aspects of wrist , compared results with those of contralateral wrist)
Peripheral innervation (test sensation in median, ulnar, radial nerve distributions in hand)
Elbow Physical Exam
Initial assessment: Assess completely contralateral elbow, neck, shoulder, wrist. complete neurovascular examination of
extremities.
Inspection: Expose both UL from shoulder girdle to hand, inspecting for asymmetry anteriorly and posteriorly.
o elbow-carrying angle :5-10° of valgus for males and 10-15° of valgus for females.
Palpation: Localize pain to anatomic structure with digital palpation.
ROM and strength testing:
o Compare active and passive ROM.
 Flexion: 140-150°, Extension: 0-10° of hyperextension, Supination: 90°, Pronation: 80-90°
o Activities of daily living require 30-130° of flexion, 50° of supination, 50° of pronation.
o Test isometric strength bilaterally
Elbow effusion: Palpate elbow laterally in center of anatomic triangle formed by lateral epicondyle, radial head, tip of
olecranon.
o Effusion indicate intra-articular abnormality , can be accompanied by loss of elbow extension.
Lateral epicondylitis (tennis elbow) :Repetitive overuse of the wrist and finger extensors .Tenderness to palpation of lateral
epicondyle
o Resisted wrist extension test with forearm in pronation. pain near lateral epicondyle.
Medial epicondylitis (golfer's elbow):
Resisted flexion/supination test: patient's elbow in slight flexion , forearm in full supination. Test resisted wrist flexion
and/or pronation against resistance. pain is reproduced at medial epicondyle.
Olecranon bursitis: secondary to trauma, hemorrhage, sepsis, rheumatologic condition. Effusion can present with or without
erythema , tender to palpation over tip of olecranon.
Instability :
o UCL insufficiency (valgus stress test):Secure wrist between examiner's forearm and trunk. Flex elbow to 30° , valgus
stress. Palpate UCL along its course from medial epicondyle toward proximal ulna. ↑ medial joint-space opening
with loss of a firm endpoint suggests UCL insufficiency.
o RCL insufficiency (posterolateral rotatory instability test) : supine , shoulder flexed overhead, ER humerus to
stabilize it. Grasp forearm in full supination & elbow extension, slowly flex elbow while applying a slight valgus→
palpable clunk, posterior prominence of radial head, obvious dimple in skin proximal to radial head as the elbow
subluxates.
Valgus extension overload :Overuse injury in throwing athlete
o associated with UCL insufficiency, intra-articular loose bodies, radiocapitellar articular cartilage injury
o Caused by posterior medial impingement of ulnohumeral articulation and compression of radiocapitellar joint during
throwing motion .Passive hyperextension of elbow reproduces pain posteromedially.
Elbow arthritis: presents with flexion contracture (incomplete passive and active extension), pain at terminal extension,
limitation in elbow flexion. Elbow effusion variable.
Cubital tunnel syndrome: compression of ulnar nerve at elbow, presents with pain, numbness ,paresthesias in distribution of
ulnar nerve, Symptoms worsen with prolonged elbow flexion
o Tinel sign: Tapping ulnar nerve at posterior aspect of medial epicondyle reproduces radicular pain &/or paresthesia
down ulnar aspect of forearm/hand.
Distal biceps rupture: Nonpalpable biceps tendon, Pain to palpation in antecubital space
o Popeye sign: biceps resembles Popeye muscle when resisted elbow flexion. also occurs with proximal biceps tendon
rupture.
Shoulder Physical Exam
Assess cervical spine , elbow, contralateral shoulder. Perform a complete neurovascular examination of extremities.
Inspection: Expose both UL from shoulder girdle to hand, inspecting for asymmetry, atrophy, scapular winging.
Palpation: SCJ, clavicle, AC joint, coracoid, acromion, GHJ, bicipital groove, greater ,lesser tuberosities
 ROM:
o Compare active and passive ROM.
o Forward flexion: 180°, Extension: 50-60°
o adduction and abduction.: Distinguish glenohumeral motion from combined glenohumeral and scapulothoracic
motion . Abduction: 160-180°
o External rotation: 80-9O°, Internal rotation: 60-80°,
 Biceps tendinitis: Pain to palpation in bicipital groove, found anteriorly on shoulder with arm at 10° IR
o Yergason test: resisted forearm supination with elbow flexed at 90°. reproduced pain in bicipital groove.
 Speed test: elbow extended, forearm supinated, shoulder flexed at 60°, patient to resist additional forward flexion of shoulder.
 Subacromial bursitis: Presentation similar to rotator cuff tendinitis. subacromial crepitus.
 Rotator cuff tear : Diffuse, dull, aching pain localized over deltoid and upper arm, Pain with overhead activities, Tenderness
to palpation over greater tuberosity of humerus
o Test individual strength rotator cuff muscles for weakness &/or pain.
 Supraspinatus: active arm elevation in plane of scapula with patient's thumb pointing down.
 Infraspinatus and teres minor: active ER, patient's arm at side , elbow flexed at 90°.
 Subscapularis (belly press test): Place both patient's hands on his/her belly; patient press belly inward while
thrusting elbows forward→elbow cannot be actively moved forward.
o Neer sign: Elevate while stabilizing scapula. Pain at maximal elevation
o Hawkins test: elbow flexed at 90°, forward flex shoulder to 90° ,IR humerus. pain is reproduced on contact of
greater tuberosity with acromion.
o Painful arc: Active abduction in coronal plane , positive with pain at 60-100° of abduction :tendinitis and small
rotator cuff tears
o Drop-arm test: Inability to hold arm up when passively positioned into an elevated position Suggests a large tear
o Weakness, inability to elevate, passive ROM that exceeds active ROM also suggest rotator cuff tear.
o Popeye sign: Also occurs with distal biceps tendon rupture
 Shoulder instability :History of previous dislocations, Patient complains of instability with or without pain.
o Anterior instability: Apprehension with 90/90 positioning (abduction , external rotation)
o Posterior instability: Apprehension with humeral forward flexion in internal rotation
o Load and shift test: humerus in a neutral position on glenoid, axially load humerus and shift head anteriorly and
posteriorly. Excessive translation resulting in palpable subluxation and/or dislocation is a positive finding.
o Sulcus sign: elbow flexed, inferior traction to arm, skin dimpling near lateral acromion.: inferior instability.
o AC joint arthritis/AC separation : Palpable point tenderness, Palpable step-off ( separation) ,Joint effusion
o Cross-body adduction test: shoulder at 90° of flexion, passively adduct arm. pain is reproduced at AC joint.
 Labrum abnormality: pain deep in shoulder & with overhead activities. anterior or posterior joint line tenderness.
o Active compression test: arm cross-body adduction test. elbow extended, humerus IR (thumb down), test resisted
humeral elevation. Positive : Pain when in IR but relieved when repeated in ER (thumb up).
o Pain localized deep in shoulder is indicative of biceps or labral abnormality.
o Pain at top of shoulder indicates AC abnormality.
o Pain elsewhere is equivocal.
 Glenohumeral joint arthritis: Start-up pain on initiation of activity, Palpable joint-line tenderness, Decreased active and
passive ROM, Active and passive ROM are equal. Pain at extremes of motion in all planes, Glenohumeral crepitus with
motion
 Adhesive capsulitis: Palpable joint line tenderness, Severely ↓ ROM, Active and passive ROM are equal. Pain with motion in
all planes
 cervical Physical Exam
 Motor examination:
o Levator scapulae: Resisted elevation (C3, C4, sometimes C5)
o Deltoids: Shoulder abduction (C5)
o Biceps: Arm flexion (C6)
o Wrist extension (C6)
o Triceps: Elbow extension (C7)
o Wrist flexion (C7)
o Finger extension (C7)
o Finger flexion and thumb adduction (C8)
 Deep tendon reflexes: abnormal reflex indicative of spinal stenosis or nerve root compression.
o Reflex amplification is symptom of spinal stenosis with myelopathy, diminished reflexes indicate nerve root
compression.
 Biceps (C5),
 Brachioradialis (C6),
 Triceps (C7)
 Sensation: C2, C3, C4 sensation should move from posterior to anterior neck.C5-T2 has very specific dermatomes :
 C5: Lateral shoulder
 C6: Radial 2 digits
 C7: Middle finger
 C8: Ulnar 2 digits
 T1: Medial forearm
 Inspection: Posture of head, body, motion, gait, Pain, Scars on anterior or posterior neck
 Bony palpation: Anterior :tenderness, lumps, asymmetries, or misalignments.
 surface landmarks to localize cervical spine level:
 Hyoid bone: C3 vertebral body
 Superior notch of thyroid cartilage: C4 vertebral body
 1st cricoid ring: C6 vertebral body (swallowing allows easier palpation.)
 Carotid tubercle: C6 transverse process (2 carotid tubercles of C6 vertebra should be palpated separately
because simultaneous palpation can restrict the flow of both carotid arteries).
 Trachea: Make sure no deviations are present from midline and palpate for abnormalities.
 Bony palpation: Posterior
o Occiput:(Inion) .Spinous processe of C7 and T1 (most prominent).All spinous processes should be aligned. Any
deviation may be secondary to a unilateral facet dislocation.C3-C5 may be bifid.
o Facet joints: 2.5 cm lateral to spinous processes, most common joint involved in osteoarthritis is C5-C6.
 Soft-tissue palpation: Anterior: Sternocleidomastoid ,Parotid gland ,Lymph nodes ,Thyroid gland, Carotid pulse
Supraclavicular fossa.
 Soft-tissue palpation: Posterior:
o Trapezius: Evaluate for lymph nodes, palpable only because of pathologic causes
o Greater occipital nerves: If palpable, may be secondary to whiplash injury.
o Ligamentum nuchae: Inion to C7 spinous process
o ROM:
o Flexion and extension:50% occurs between the occiput and C1, remainder is distributed from C2-C7.Slightly greater
motion occurs at the C5-C6.Tests sternocleidomastoid muscle (flexor) and paravertebral extensor and trapezius
(extensors)
o Rotation:50% occurs between C1-C2, remainder is evenly distributed in remainder of the cervical spine. To examine,
rotate chin 60-80° to right and left. Tests sternocleidomastoid muscle (primary rotator)
 Lateral bending: Evenly distributed throughout cervical spine , not a pure movement but, rather, functions in conjunction
with rotation. To examine, touch ear to ipsilateral shoulder without moving shoulder; normal lateral bending is 45°.Tests
scalene .
 Special maneuvers to help to identify the cause of the cervical spine symptoms:
o Modified Spurling maneuver :Extend neck ,rotate head to 1 side as axial pressure is applied. specific for cervical root
compression
o Distraction test : vertical traction to head in slight flexion and extension.Symptoms of compressed roots may regress
temporarily.
o Lhermitte test :Patient flexes head forward. If shooting pain is noted down the arms and/or legs: anterior
compressive lesion
o Hoffmann test: Rapidly flex the nail of middle finger. If muscles of hand and thumb flex: UMNL (myelopathy).
o Static/dynamic Romberg test : patient stands with hands out and palms up (arms in 90° of flexion).Proprioceptive
deficit is present if the patient loses balance with the eyes closed or if the arms rise slowly above the parallel.
 Cervical truma Physical Exam
 assessment of airway, breathing, circulation .hemodynamically stable ,life-threatening injuries ruled out.cervical ,, chest, pelvis
XR
 initial neurologic examination (patient in a neck collar) careful documentation: time of injury, time , details of field & hospital
examin.
o Sensory examination: Evaluate dermatomes, light touch, pin prick, temperature, and perianal sensation.
o Motor examination:
 Upper extremities: Grade deltoids, triceps, biceps, wrist flexors &extensors, finger abductors & adductors,
grip strength.
 Lower extremities: Test iliopsoas, quadriceps, hamstrings, hip abductors/ adductors, TA, EHL,
gastrocnemiussoleus
o Do not use phrases such as moves everything or feels everything
o Rectal examination: assess tone, volitional control, and sensation to light touch and pin prick.
 Examine head / neck for tenderness and pain on motion. If painful, immobilize head /neck until adequate physical/radiologic
examinations.
 Suggested motor checkpoints:
o C4: Diaphragm
o C5: Deltoid and elbow flexors
o C6: Wrist extensors
o C7: Elbow extensors
o C8: Finger flexors (profundus)
o T1: Intrinsics (finger abductors)
o L2: Hip flexors
o L3: Knee extensors
o L4: Ankle dorsiflexors
o L5: Great toe extensors
o S1: Ankle plantar flexors
o S4-5: Voluntary anal contraction
 Suggested sensory checkpoints:
o C2: Occiput
o C4: Tip of shoulder
o C5: Regimental patch (lateral shoulder)
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o C6: Thumb
o C7: Long finger
o C8: Little finger
o T1: Medial epicondyle
o T4: Nipples
o T10: Umbilicus
o L1: Groin
o L3: Patella
o L4: Medial malleolus
o L5: Great toe and first web space.
o S1: Lateral heel
o S2: Popliteal fossa
o S3: Ischial tuberosity
o S4-5: Perianal
Lumber Physical Exam
Gait: Look for: 1)Antalgic gait .2)Muscle wasting / weakness .3)Signs of hip /knee problems .4) ,Trendelenburg sign
(abductor weakness with ipsilateral pelvic tilt when leg is lifted off ground)
Inspection:
o fluidity of motion , any associated pain, redness, hair patches, birthmarks or skin markings such as caf au-lait spots
o Analyze patient's posture and inspect the curvature of the lumbar spine.
 normal lordosis absent in paravertebral ms spasm .Gibbus deformity . weak anterior abdominal wall
exaggerated lordosis
o Structural scoliosis: patient's tendency to favor 1 side while standing ,fixed curve and no change with flexion or
recumbency.
o Sciatic scoliosis: more diffuse curve that worsens with flexion and by limited flexion that disappears with
recumbency
o Spondylolisthesis: A palpable step from 1 spinous process to another ,also present with segmental tenderness or
nerve root injury
o NF: May impinge on the spinal cord and roots .Often accompanied by caf-au-lait spots
o Spina bifida: Absence of spinous processes, along with birthmarks, excessive port wine marks, or a tuft of hair,
o AS: pain and stiffness in SIJs, spreads to spine, leads to ossification of spinal ligaments; spine may fuse.
Palpation:
o Bony (anterior):Vertebral body &disc: L4, L5, S1 (abdominal palpation: below aortic bifurcation)
 Sacral promontory: L5-S1 (abdominal palpation through the linea alba below the umbilicus)
 Bony (posterior):Spinous processes of the lumbar & sacral region. Iliac crest: L4-L5, Posterior superior iliac
spine: S2
o Soft tissue
ROM evaluation:
o Motion between L5-S1 >motion between L1-L2
o Flexion: Anterior longitudinal ligament relaxes as supraspinous &interspinous ligaments, ligamentum flavum&
posterior longitudinal ligament stretch
o Extension: Posterior ligaments relax as the anterior longitudinal ligament stretches
o Lateral bending
o Rotation
o Resisted movement tests of flexion, lateral bending, and rotation
o Passive movement tests: when patient does not have full ROM. Do not test for passive flexion bcz aggravation of
disc herniation.
o Root irritation from disc herniation: Deviation to painful side with spine flexion
Waddell signs: 3 of the following 5 signs indicate a malingering patient :
o Nonanatomic superficial tenderness , Nonanatomic weakness and sensory findings
o Simulation tests (pain with axial loading or rotation of the spine)
o Overreaction: Cogwheeling or jerky muscle relaxation
o Inappropriate response to provocative maneuvers with distraction (i.e., supine versus seated SLR test)
Rectal examination checks for: Tone. Volition. Anal wink (stroke perianal skin, feel anal sphincter contraction around finger)
o Bulbocavernosus maneuver: Signals end of spinal shock (Pull on Foley catheter in urethra or pull on glans penis; feel
anal wink.)
o Light touch & pin-prick perianal sensation: S2-S4 (If sensation absent, mass lesion such as disc or tumor pressing on
nerve roots.)
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Root
T12, L1-L3
L2-L4
L4
L5
S1
 Upper motor neuron disorders:
 Table 1 Motor Examination of the Lumber Spine
 Muscle Group
 Iliopsoas
 Quadriceps
 Tibialis anterior
 Extensor hallucis longus
 Gastrocnemius
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Action
Hip flexion
Knee extension
Foot dorsiflexion
Big toe extension
Foot plantarflexion
o Hoffman sign: Nip nail of patient's middle finger. positive : flexion of terminal phalanx of thumb , 2nd, 3rd phalanx of
another finger.
o Babinski sign: Stroke plantar lateral foot. positive (extended great toe while other toes plantarflex and splay) rule out
cervical or thoracic myelopathy
o Loss of any of superficial reflexes:abdominal, cremasteric, or anal reflex,
o Sustained clonus of patellar or Achilles reflex or hyperreflexia
 Motor examination :Systematically examines the nerve roots Muscle wasting and weakness suggests nerve root compression.
 Reflex tests :Loss of patellar or Achilles reflex suggests ipsilateral nerve root compression.
 Disc
 L3-L4
 L5-S1
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Nerve Root
L1
L2
L3
L4
L5
S1
S2-S5
 Table 2 Reflex Tests of the Lumbar Spine
 Root
 Reflex
 L4
 Patellar reflex
 S1
 Achilles reflex
 Muscles
 Anterior tibialis
 Peroneus longus
and brevis
 Table 3 Sensation Tests of the Lumbar Spine
 Area of Skin Innervation
 Groin, upper anterior thigh, posteromedial leg
 Anterior mid-thigh; lateral groin
 Anterior thigh above knee cap, posterolateral lower leg
 Anteromedial shin
 Dorsum of foot, anterior aspect lower leg
 Lateral foot
 Perianal
 Sensation tests :Pin-prick testing , 2-point discriminatory sensibility on LL .Vibration sensibility and temperature sense also
are tested.
 Nerve root tension tests:
 SLR test :Raise leg of supine patient slowly by supporting foot slightly above malleoli and keeping the knee
extended, reproduces sciatic-type radicular leg pain , relieved when knee is bent , exacerbated by foot
dorsiflexion. Differentiating radiculopathy from tight hamstring pain is important
 Cross-leg SLR test: less sensitive , more specific for lumbar disc herniation ,positive (flexion of 1 leg with
pain in contralateral leg or buttocks ) suggests disc herniation axillary or medial to the root.
o Femoral nerve stretch test: prone, hip is extended with knee slightly flexed. Pain radiating down front of thigh
indicates L3-L4 nerve root irritation.
o Patrick (FABER) test: for SIJ by Flexing, Abducting, ,ER hip : SIJ pain.associated with pelvic trauma or infectious
disease
 Muscle strength grading:
o 5: Normal strength
o 4: Weakness with resistance, full movement against gravity
o 3: Full ROM against gravity but marked weakness against resistance
o 2: Full ROM with gravity eliminated
o 1: Flicker of tendon unit
o 0: No movement
 Spine truma Physical Exam
 Documentation of each examination is important :deteriorating neurologic assessments often provide the 1st clue of an
underlying injury.
 Document initial examination and compare it to the results of the examination in the field.
 Inspect : visible bruising, deformity, or step-offs around spine.associated injuries (e.g., seat-belt marks).
 Palpate entire spine for tenderness.
 Grade the motor examination on a 0-5-point scale.
 Assess the sensory levels.
o T4: Nipple line
o T7: Xiphoid process
o T10: Umbilicus
o T12: Inguinal crease
o L1: Proximal 1/3 anterior thigh
o L2: Middle 1/3 anterior thigh
o L3: Over superior portion of patella
o L4: Over medial malleolus
o L5: Over dorsum of 3rd toe
o S1: Over dorsum of small toe
 Assess the reflexes.
o L4: Patellar reflex
o L5: No reflex
o S1: Gastrocnemius-soleus reflex
 Perform a rectal examination: Tone ,Volition ,Perianal light touch /pinprick sensation (S2-S5) ,Bulbocavernosus reflex
,Anal wink reflex
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Hip Physical Exam in child: Preambulatory Infants
General notes: relax the baby, the family should be allowed to feed or soothe the infant.
Inspection and palpation: Excess thigh folds on 1 side may indicate LLD.
Tests and measurements:
o Ortolani & Barlow detect hip instability in newborns 3 ms old. After 3 ms, capsule laxity↓,muscle tightness ↑ ,so that
hip cannot be relocated by Ortolani maneuver.
o Ortolani maneuver: sign of entry as femoral head reduces into acetabulum: baby supine , knees fully flexed, flex
hips to a right angle ,place long finger of each hand laterally along axis of femur over greater trochanter. Place
thumb of each hand on inner side of thigh opposite lesser trochanter. Lift thighs into midabduction and exert
forward pressure behind greater trochanter, using middle finger on 1 side, while other hand holds opposite femur
and pelvis steady. If femoral head clunks or slides forward into acetabulum, hip has been relocated into
acetabulum.
o Barlow maneuver: sign of exit as femoral head subluxates or dislocates from acetabulum: With fingers in same
position as for Ortolani maneuver, exert backward and outward pressure with thumb on inner side of thigh as hip is
adducted. If femoral head clunk or slips out over posterior lip of acetabulum the hip is unstable.
Galeazzi (Allis) sign: Indicates LLD secondary to a unilateral hip problem: baby supine on a firm table, flex knees and hips ,
put feet flat on table. knee on side of shorter limb will be lower than the knee of normal limb.
ROM :baby supine on a firm table, flex knees and hips to 90°.Abduct legs (78‫آ‬°)Extension 0-20°, flexion: 140°, IR,ER: 5880°
Hip Physical Exam: Ambulatory Children
Initial procedures: patient disrobe. Examine lumbar spine, knee. Check the neurovascular status.
Standing: Measure pelvic tilt. Place hands on patient's iliac crests. Any difference in level indicate LLD Look for muscle
atrophy. pain and endurance
o Trendelenburg test: patient to stand on 1 leg. Any contralateral pelvic tilting indicates weak abductors or an irritable
hip.
Gait examination: Observe from in front of and behind patient, asymmetry. walk child down & back. Note any asymmetries
(e.g., stride lengths, duration of stance or swing phases).
o Pathologic gaits:
 Antalgic (painful) gait: Short strides and a shortened stance phase on the painful side ,caused by hip, back,
or other lower limb problems
 Trendelenburg gait: bending trunk over affected hip( pelvic tilt during stance phase), patient shifts center of
gravity over hip to unloading weak hip abductors or to decrease the joint reactive forces that irritate the
affected hip
 Gluteus maximus gait: Lurching backward during stance phase of involved side, shifts center of gravity
posteriorly to compensate for weak hip extensors.
 LLD gait: Abnormal up& down motion , true LLD >2 cm bends longer leg excessively or stands on toes of
shorter leg.
Supine: Positioning inspect leg for symmetric rotation, flexion, adduction. LLD: measure from inferior edge ASIS to inferior
edge of ipsilateral medial malleolus on both sides.
Isolating hip pathology :Roll test: supine, gently roll leg internally and externally. Guarding or stiffness on 1 side + ve
ROM :
o Flexion (120-130°) : supine , knee fully flexed, place 1 hand on contralateral pelvis. Flex hip until movement in
contralateral pelvis is noted. angle between femur and examining table is the hip flexion.
 IR: 45-50° (20-70°), ER 40° (25-60°): prone, flex knees 90°.Rotate legs IR,ER. angle between each leg
&line perpendicular to the tabletop
o Abduction (40-50°): supine , hip in extension, place 1 finger on contralateral ASIS. Abduct hip until finger feels
pelvis tilt.
Flexion contracture:
o Thomas test (normal, 0°):supine, maximally flex both hips.Allow femur on ipsilateral side to fall into as much
extension as possible, while holding other hip up. angle between femur and examining table is residual
flexion
o Staheli test (normal: 0°):for spastic patient
 Have patient lie in prone (providing a way to flatten lumbar spine and level pelvis) position with the
hip flexed over the end of the table.
 1 hip remains flexed at 90‫آ‬°.
 Gradually extend the other hip while palpating the ipsilateral pelvis.
 As soon as pelvic motion is detected, measure the amount of residual hip flexion, which represents the
flexion contracture.
 Normal values in the infant: Birth, 213 ;°‫ آ‬months, 11‫آ‬°; ≥6 months: 3‫آ‬°
Muscle strength:
o Hip flexors (iliopsoas : L1-L3): patient sit with knees flexed to 90°. Push against anterior thigh while patient flexes 1
hip.
o Hip extensors (gluteus maximus : S1): prone, push against posterior thigh while patient elevates femur off table.
o Hip abductors (gluteus medius and minimus : L5):lie on 1 side. Push against lateral knee of top leg while patient
elevates it.
o Hip adductors (adductors longus, brevis, magnus, gracilis ,pectineus : L2-L4):supine, push against medial thigh while
the patient pushes that leg toward the midline.
Adult Hip Physical Exam
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o Compare active and passive ROM. Note guarding, pain, and spasm.
 flexion: 110-120°, extension: 10-15°, Abduction (40-50°), Adduction: 20-30°, IR: 15-45°, ER: 40-65°
Weakness, muscle atrophy, decreased sensation, and asymmetric deep tendon reflexes suggest spine abnormality.
hip Osteoarthritis :presents with start-up pain, morning stiffness, deep groin pain ,Hip flexion with simultaneous IR
reproduces groin pain. decreased active and passive ROM: Hip flexion contracture is common. Radiographs: Joint space
narrowing and osteophyte
Greater trochanteric bursitis: presents lateral hip pain, exquisitely tender to palpation of greater trochanter. Resisted hip
abduction reproduces lateral hip pain.
Buttock and posterior hip pain: Indicates lumbar spine abnormality until proven otherwise
o Radicular pain produced by deep palpation of sciatic nerve differentiates sciatica from intra-articular abnormality.:
lateral decubitus position, flex hip and knee to 90°. Palpate nerve midway between greater trochanter and the
ischium.
Labral tears/femoroacetabular impingement : Young athletic patients, presents groin pain during or after activity, Hip
flexion with simultaneous IR reproduces groin pain. Radiographs normal. MRI confirm diagnosis. rule out inguinal hernia.
Trendelenburg test (to evaluate strength of gluteus medius muscle):patient perform a single-leg stand on affected side and try
to maintain pelvis level with floor. If pelvis tilts to maintain the single-leg stand: abductor weakness or hip joint pain,.
Thomas test (to evaluate flexion contracture):supine, place your hand under lumbar spine , bring 1 leg up into full flexion.
patient hold it there by grasping knee with both hands. Bring other leg into full extension. Any loss of extension is a flexion
contracture.
Knee Physical Exam in child
Initial assessment: Assess contralateral knee. referred pain from spine or hip. Perform a complete N/V extremities.
Inspection: erythema, effusion, abrasion. muscular atrophy. Assess gait: Antalgic gait:
o Anterior: standing valgus or varus deformity. In adolescence, normal standing alignment is slight valgus (5-10°),
Physiologic alignment 5° of valgus for males and 7° for females.
o Lateral: incomplete extension resulting from flexion contracture or excessive hyperextension (recurvatum
deformity).symmetry of tibial tuberosities.
o Palpation: warmth , tenderness along medial & lateral joint lines, medial &collateral ligaments, patella , supporting
ligaments, femoral & tibial condyles, tibial tubercles.
Testing for effusion: mild joint effusion or fluid collection in the bursae..
Patellar assessment:
o Inhibition test: To determine if anterior knee pain is secondary to pressure in the patellofemoral joint. With the patient
supine and knee extended, have the patient do a straight-leg raise. Hold the patella to prevent it from ascending
along the femoral sulcus. Any pain is a positive test, which may indicate a patellofemoral disorder.
o J sign: Observe patella as patient actively extends knee. knee extends:patella remains in femoral sulcus as it ascends
along the axis of femur. knee reaches full extension; patella deviates laterally like upside-down J a positive J sign.
Menisci assessment:
o McMurray test: Flex knee and hip maximally, apply a valgus (varus) force to knee.ER/IR foot and passively extend
knee. palpable, painful snap or pop during extension suggests a tear of the medial (lateral) meniscus.
ROM:
o Flexion (normal, 130-140°): patient sit or lie prone and fully flex each knee. angle between leg & thigh.
o Extension (normal, 5°):supine with extended knees, stabilize thigh , lift foot.angle between leg and table.
Ober test: Assesses flexibility of iliotibial band. lying on unaffected side, stabilize pelvis with 1 hand ,abduct and extend
hip with the knee flexed. Support ankle , allow thigh to drop. If thigh does not become parallel to table, the test is
positive.
Stability tests: AP stability is provided by ACL and OSD. Mediolateral stability is provided by the MCL and LCL.
o Neurovascular examination:
o Sensation: light touch and pinprick in peroneal, superficial peroneal, and tibial nerve distributions.
o Motor: Apply resistance while patient: Dorsiflexes /plantarflexes foot. Inverts / everts foot. Dorsiflexes / plantarflexes
great toe
o Pulses: Check popliteal, dorsalis pedis, and posterior tibial pulses.
Adult Knee Physical Exam
o ROM: Normal = 0-155°
 Flexion contracture: Incomplete passive and active extension
 Extension lag: Full passive extension with incomplete active extension
Palpation: knee at 90° of flexion, palpate along course of patellar and quadriceps tendons, medial and lateral joint lines, MCL,
LCL,ITB.
Knee effusion: Warmth indicate active inflammation
o Marked : hemarthrosis (fracture, ligamentous or meniscal tear) or inflammation (arthritis, gout, infection).
o Blot test: Press patella against femoral groove. If large effusion patella to rebound as it flows back in.
Prepatellar bursitis: fluctuant, painful subcutaneous swelling anterior to the patella with anterior knee pain
Popliteal Baker cyst: Painful swelling of popliteal fossa. Usually indicates intra-articular pathology
ITBS: Lateral knee pain, localized over lateral epicondyle ,seen as an overuse injury in runners and cyclists
o Ober test: lying on unaffected side with hip and knee flexed to 90°, stabilize pelvis. affected leg abducted and
extended, lower it into adduction. If iliotibial band is tight, leg will remain in abducted position and/or the patient
may complain of lateral knee pain.
Patellar fracture, patellar tendon/quadriceps tendon rupture: Palpable defect of affected structure Extension lag
Patellofemoral syndrome: Anterior knee pain with standing from a seated position, squatting, or stair-climbing
o Q angle: Angle of ASIS, patella, and tibial tubercle .>15‫آ‬° suggest patellar instability.
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o Medial and lateral glide test: affected knee extended, determine number of quadrants patella will translate over
trochlear groove.
 <1 quadrant medially suggests lateral patellofemoral compression syndrome.
o Apprehension test: affected knee in full extension, translate patella laterally. Apprehension suggests patella
instability.
o Grind test: Press patella distally against trochlear groove Then patient contract quadriceps while palpating for crepitus
indicative of patellofemoral arthrosis .
Ligamentous instability:
o Mechanism of injury may indicate cause of instability.
 ACL: Noncontact, twisting/pivoting motion with foot firmly planted and audible pop
 PCL: Dashboard injuries
 MCL/LCL: Extreme valgus/varus force about the knee
o Ligament tears frequently are accompanied by an acute hemarthrosis. Knee feels like it gives out or buckles.
o Varus and valgus stress test (MCL/LCL) :
o knee flexed to 30°, place 1 hand on patient's distal thigh ,other, grasp patient's ankle. Apply varus/valgus stress in
coronal plane with knee 30° of flexion. If unstable :collateral ligament has been injured. Grades: 1, <5 mm; 2, 5-10
mm; 3, >10
o Lachman test (ACL) :sensitive test for ACL integrity. patient's knee relaxed and flexed at 30‫آ‬°, place 1 hand on the
distal thigh and the other on the proximal tibia. Then translate the tibia anteriorly. Test is abnormal if there is >5
mm of translation and/or >3 mm difference between the values for the affected and uninjured knees.
o ADT,PDT (ACL/PCL) :knee in 90‫آ‬° of flexion and neutral rotation, stabilize foot. Place both hands around proximal
tibia and attempt to translate tibia anteriorly and posteriorly on femur. Subluxation anteriorly :ACL instability.
subluxation posteriorly suggests PCL instability. Grades: 1, <5 mm; 2, 5-10 mm; 3, >10 mm
o ER test (posterolateral corner):prone. Simultaneously compare affected and normal knees. Starting at 0° of knee
flexion, ER tibia and observe thigh foot angle. Look for excessive ER (>10°) on affected side. Repeat at 30° and
90°.
 ↑ER only at 30‫آ‬° of knee flexion indicates an isolated PLC injury.
 ↑ER at 30‫آ‬° and at 90‫آ‬° of knee flexion indicates posterolateral corner and PCL insufficiency.
Meniscal pathology :episodic painful mechanical symptoms that may present with knee locked in flexion. focal tenderness to
palpation on affected joint line (best examined with the knee flexed at 90‫آ‬°).
o McMurray test: supine , knee in full flexion,IR tibia and apply a valgus force to load lateral meniscus. Then passively
extend knee to 0° of flexion while palpating lateral joint line. positive if audible or palpable click is produced
during extension. Reposition knee in full flexion and repeat test with tibia in ER by applying varus force and
palpating medial joint line to test medial meniscus. Pain may be associated with this maneuver.
o Apley compression / dislocation test: prone , knee flexed at 90°, grasp heel and axially load tibia while
simultaneously ER/IR foot.
 Pain localized to the medial joint line with compression and rotation suggests medial meniscus abnormality.
 Pain localized to the lateral joint line with compression and rotation suggests lateral meniscus abnormality.
Knee arthritis :morning stiffness ,soreness. Intra-articular swelling variable. Osteophytes ,crepitus may be palpable. Flexion
contractures with reduced ROM and marked functional limitations are common. Late stages associated with pseudolaxity on
valgus/varus testing.
Foot &ankle Physical Exam
standing position: Viewed from behind, alignment of the hindfoot can be determined as varus, neutral, or valgus.
 More lateral toes :too-many-toes sign, implies presence of flatfoot with arch collapse and midfoot abduction.
 Assess gait pattern for steppage (dropfoot), circumduction, scissoring, or antalgia.
o Double- and single-limb heel rises allow evaluation of dynamic foot function: TP strength, arch reconstitution, and
balance.
seated position:
o Vascular assessment: dorsalis pedis , posterior tibial pulse behind the medial malleolus.Examine for venous stasis,
pitting edema.
o Sensory and neurologic examination:
 Dorsal foot (superficial peroneal nerve)
 1st dorsal web space (deep peroneal nerve)
 Medial border of foot (saphenous nerve)
 Lateral border of foot (sural nerve)
 Plantar foot (tibial nerve)
 Patient's ability to feel 5.07 Semmes- Weinstein monofilament on plantar foot correlates with protective
sensation .
 Check reflexes and evaluate for Babinski sign and clonus.
o Motor examination: Test strength and palpate tendons.
 Ankle dorsiflexion (tibialis anterior)
 Ankle plantarflexion (gastrocnemius–soleus complex)
 Eversion (peroneals)
 Inversion in plantarflexion (tibialis posterior)
 Flexion and extension of the distal phalanx of the great toe (flexor and extensor hallucis longus); evaluate
active and passive motion.
 Ankle plantar and dorsiflexion, with any hindfoot deformity passively corrected
 Hindfoot inversion and eversion to assess subtalar motion
 Chopart joint abduction/adduction while stabilizing the hindfoot
 Assess Lisfranc joint with palpation and plantar- and dorsiflexion of the tarsometatarsal joints.
 Assess motion at the MTP and toe joints.
o Palpation:
 Medial and lateral malleoli (fracture)
 Ankle joint for tenderness, effusion (osteochondral lesion, synovitis)
 PTT along its course posterior to the medial malleolus to insertion on navicular (tendinitis)
 Navicular tuberosity 2 cm distal and plantar to medial malleolus (accessory navicular, stress #, talonavicular
pathology)
 Achilles tendon and retrocalcaneal bursa along posterior ankle and hindfoot for defects, nodules, thickening,
swelling, and tenderness (tendinitis, tear)
 Peroneal tendons posterior to lateral malleolus to brevis insertion on base of 5th metatarsal, where longus
passes through plantar groove of cuboid (tendinitis, 5th metatarsal base #); also assess for tendon
subluxation with foot circumduction.
 Sinus tarsi ~1 cm distal to lateral malleolus (subtalar joint pathology)
 Tenderness along the tip of medial or lateral malleolus (ligament sprain)
 Tenderness between the tibia and fibula proximal to the ankle joint (syndesmosis injury)
 Palpate plantar fascia, originating at base of heel (plantar fasciitis, especially if tenderness is accentuated
with toe DF)
 Base of the 2nd metatarsal (Lisfranc injury)
 Plantar MTP joint of the great toe (sesamoiditis, sesamoid fracture)
 Plantar lesser toe MTP joints (metatarsalgia)
 Metatarsal interspaces (neuroma)
 Specific tests and examinations:
o Anterior drawer test (ankle instability):Try to sublux the talus anteriorly from tibia.Foot dorsiflexed stresses the
ATFL.
o Thompson test:With the patient in the prone position, squeeze the posterior calf.Loss of foot plantarflexion implies
disruption of the Achilles tendon .
o Coleman block test:Helps determine if varus hindfoot deformity is flexible or rigid The patient stands on a block with
the 1st ray unsupported; if the hindfoot deformity corrects, then it is flexible .
o Lesser toe deformities: Assess location of calluses.if correctable or not (flexible versus rigid). MTPJ stability with
modified drawer test, trying to sublux and reduce proximal phalanx on metatarsal head.
o Hallux valgus: Assess location of the calluses. tenderness over medial eminence. MTP motion with deformity
corrected. hypermobility of 1st tarsometatarsal joint by stabilizing lateral foot and attempting to translate 1st
metatarsal plantar and dorsal. lesser toe deformities that could contribute to symptoms.