Download Examination of the Shoulder

Examination of the Shoulder
The preliminaries: Introduce yourself to patient, ask for
permission to examine. Ensure adequate exposure but
consider patient modesty also. Ensure good lighting, and
good positioning of bed.
In supraspinatus impingement or tear, passive
range is greater than active range as active
range is limited by pain and/or weakness;
limitation is usually only in one movement e.g.
abduction.
In frozen shoulder, passive and active range of
movements are equally restricted, and usually
in more than one type of movement.
LOOK
1.
General appearance and vitals – any pallor, what
is the BP, and HR.
2.
Scars over shoulder, in axilla
3.
Swelling
- Bump(s) over sternoclavicular joint, clavicle,
acromioclavicular joint
- Effusion points in the axilla – remember to look
4.
Sinuses
5.
NOTE: for assessment of range of abduction
and flexion, it is important to fix the scapula and
note the glenohumeral joint movement;
increased scapulothoracic movement may
compensate for decreased mobility at the
glenohumeral joint.
a.
Deformity – asymmetry between two shoulders
- Foreshortening of the shoulder joint indicates
previous clavicular fracture, acromioclavicular
joint problem
Abduction (raise both arms to meet above the
head) – also assess “painful arc” of 60 to 120
degrees for supraspinatus impingement.
b.
Adduction (cross-shoulder – get patient to touch
other shoulder with hand, observe how far the
hand can reach).
6.
Discolouration – redness, bruising, etc
c.
Flexion and extension.
7.
Muscle wasting – squaring of the shoulder
(deltoids); hollowing of supra- or infraspinous fossa
d.
Internal rotation (place hands behind back and
see how which level the patient’s extended
thumb can reach e.g. inferior angle of scapula –
T7).
1.
Warmth
e.
2.
Tenderness
- Start from SC joint, go along clavicle to AC joint,
then ballot AC joint
- Follow back to spine of scapula, and palpate in
supraspinous and infraspinous fossae for
tenderness
- Locate coracoid process anteriorly, palpate that
(short head of biceps, coracobrachialis)
- Head of humerus
- Greater tuberosity (particularly supraspinatus
insertion)
- Bicipital groove – tendon of long head of biceps
External rotation (with elbows tucked close to
sides and flexed 90 degrees, rotate outwards).
FEEL
MOVE
1.
Range of movements:
- Get patient to do actively; if there is any
restriction of a particular movement, proceed to
assess passive range – this assesses if the
decrease in range is due to pain, joint stiffness or
muscle weakness.
2.
Power of rotator cuff muscles:
- Abduction (supraspinatus): Keep the shoulder in
30 degrees flexion so that the humerus is in line
with the scapula (isolates supraspinatus?) and
then place the shoulder in 30 degree abduction
with the elbow flexed completely. Examiner
presses down on patient’s elbow while patient
resists.
-
Flexion and extension.
-
Internal rotation (subscapularis) – Gerber’s lift-off
test: get patient to place hands behind back, then
examiner presses the hand against the patient’s
back while patient attempts to lift his hand off. If
patient is unable to place hands behind back due
to restricted ROM, perform the belly press test,
where patient presses palms against his or her
abdomen and examiner attempts to pull the hand
off the abdomen.
-
External rotation (infraspinatus and teres minor).
SPECIAL TESTS
Supraspinatus impingment tests:
1.
Painful arc (between 60 to 120 degrees of passive
abduction classically, as greater tuberosity hits
acromion and the supraspinatus is caught in
between).
2.
Jobe’s test (or beer can test) – with the arm
abducted 90 degrees and in neutral rotation,
internally rotate the arm, like inverting a beer can
held in the hand.
3.
Hawkin’s test – with the arm flexed 90 degrees and
elbow flexed 90 degrees, internally rotate the arm.
Supraspinatus tear:
-
Abduction paradox and Drop-off sign – patient is
unable to initiate abduction of the shoulder, but
when arm is passively abducted to more than 90
degrees, he or she is able to maintain abduction by
deltoid action. When the arm is passively adducted
to less than 90 degrees of abduction and the
examiner lets go of the arm, the arm will fall to the
patient’s side as he is unable to maintain the
abduction.
Biceps tendinitis (tendon of long head of biceps)
1.
Speed’s test – with elbow fully extended and
forearm supinated, the patient flexes his shoulder
against resistance on the arm; test is positive when
there is pain localised to the bicipital groove.
2.
Yegarson’s test – with elbow flexed to 90 degrees
and forearm pronated, patient attempts to supinate
forearm against resistance; test is positive when
there is pain localised to the bicipital groove.
FINISH with assessment of neurovascular status of the
upper limb, and examine the cervical spine.
Examination of the Hand
The preliminaries: Introduce yourself to patient, ask for
permission to examine. Ensure adequate exposure, remove
all accessories. Ensure good lighting, and good positioning
by placing patient’s hands on a pillow.
The focus of hand examination is the 5 different tissues
in the hand – (1) Skin and subcutaneous tissue; (2)
Muscle and tendon; (3) Blood vessels; (4) Nerves; and
(5) Bones and joints. Note which tissue(s) the
pathology lies in.
RADIAL NERVE
2.
MOVEMENTS
1.
LOOK
Observe hands in supinated and pronated positions (palmar
and dorsal surfaces)
1.
Scars
2.
Swellings
- Lumps and bumps on the hand – describe site, size,
shape, borders, surface, consistency, fluctuance if
any, transilluminability, mobility (along tendon
course or perpendicular to the course), increase or
decrease in size with flexion
- Common DDx of any lump: ganglion, PVNS,
implantation dermoid, pyogenic granuloma
3.
Sinuses
4.
Deformity
Loss of hand cascade (little finger is most flexed, index
finger least flexed, in resting position of hand)
- Joint contractures if any
- Rheumatoid features
5.
Discolouration
6.
Muscle wasting
Thenar eminence, hypothenar eminence
Wasting of the interossei  guttering
Feel joints of hands for:
Tenderness
Nodules
Joint line irregularity
Subluxation
Quick screening tests
- With forearm supinated (palms face-up), get patient
to fully flex fingers – tests patency of flexor tendons
and nerves.
-
-
2.
With forearm pronated (dorsum face-up), observe
for any wrist and/or finger drop, then get patient to
extend wrist and fingers fully – tests patency of
ECRB, ECRL and ECU for wrist, EDC for the MCP
joints, intrinsics for the PIP and DIP joints.
With elbows tucked in close to patient’s sides, get
patient to pronate and supinate forearm to check
range of movement – assesses proximal and distal
radioulnar joint, and biceps action.
Assessment of active and passive range of
movements
- If active range of movements < passive range of
movements, there is muscle weakness (nerve palsy),
tendon rupture, or tendon adhesion to surrounding
tissue.
-
If passive range of movement is restricted, there is
joint contracture.
-
Symmetry of movements is a useful guide to
whether there is abnormality.
NERVE TESTING
3 impt functions: SENSORY, MOTOR, and AUTONOMIC
FEEL
1.
Tenderness over:
- Anatomical snuffbox – base (scaphoid); borders
(EPL, APL, EPB)
- Distal radio-ulnar joint – check for subluxation
(piano-key sign)
- Lister’s tubercle on dorsum of distal radius scapholunate junction is just distal to this landmark
- Radial and ulnar styloids
-
Sensory: pinprick sensation over area supplied by nerve;
most sensitive testing is using 2 point discrimination.
-
Motor: Power of muscle(s) supplied by nerve.
-
Autonomic: Skin warmth, dryness. Use a plastic pen
and rub over finger supplied by that nerve; normally
there should be feeling of friction, but if autonomic supply
is lost the pen will slide smoothly over the skin.
I. Sensory supply:
- Dorsal surface of radial 3½ digits and corresponding
area of dorsum of hand.
-
Test the dorsal aspect of the first web space.
II. Motor supply:
- The most distal extensor muscle supplied by the
posterior interosseous nerve is the extensor indicis
propius (EIP) but this cannot be tested accurately due
to the tendon slip from EDC to the index finger.
-
Instead, the next most distal muscle, the EPL, is tested
instead – place the hand flat on a table and get the
patient to lift his thumb off the table (retropulsion). If
EPL function is intact all other muscles supplied by
radial nerve should be intact.
-
EDC testing – get patient to extend MCP joints and flex
the PIP and DIP joints (like making a claw) to isolate
action of the EDC.
-
Higher lesions e.g. shaft of humerus fracture result in
paralysis of the wrist extensors (ECRL, ECRB, ECU)
and wrist-drop results i.e. low lesions of radial nerve do
not result in wrist-drop, so be careful.
-
Triceps function is usually preserved unless lesion is
very high up; shaft of humerus # usually does not result
in triceps paralysis.
MEDIAN NERVE
I. Sensory supply:
- Palmar surface of radial 3½ digits and corresponding
area of palm, over thenar eminence
-
Cutaneous branch to thenar eminence is given off
before carpal tunnel, thus there is no loss of sensation
over the thenar eminence in CTS
-
Test tip of index and middle fingers and thumb, and
thenar eminence
II. Motor supply:
- Intrinsics – test the abductor pollicis brevis (APB) by
getting patient to abduct thumb (in a plane
perpendicular to the plane of the palm) against
resistance. The APB is the thenar muscle that is solely
supplied by the median n. 99% of the time; the other
two muscles may receive cross-supply from the ulnar n.
-
-
Anterior interosseous nerve supplies FPL, pronator
quadratus and radial half of FDP
 Testing FDP: Fix middle phalanx of index finger
and get patient to flex the DIPJ
 Testing FPL: Flexion of the IP joint of the thumb
while fixing the proximal phalanx
 OK sign: Ask patient to make an “OK” sign by
forming a circle with the thumb and index finger;
this action involves flexion of DIPJ of index finger
and IPJ of thumb, so if there is anterior
interosseous nerve palsy these two joints are
extended (like holding a needle) and the OK sign
cannot be made properly. The FDS is still intact,
however, since the patient is able to flex his PIPJ
of the index finger.
Testing the FDS and its tendons (supplied by median
nerve proper): Fix the distal phalanges of the fingers
adjacent to the finger being tested, and get patient to
flex the PIP joint of the finger being tested.
of the hand. This tests action of adductor pollicis,
and if there is paralysis of this muscle the patient
will attempt to compensate by flexing the thumb to
hold the paper in place. Compare to normal side.
 Wartenburg sign – ask patient to hold fingers
adducted and extended; the little finger will
become abducted in paralysis of the intrinsics as
the adduction ability of the palmar interossei is lost,
and the extension action of the extensor digiti
minimi (EDM) pulls the little finger into abduction.
-
III. Other tests:
- Tinel’s sign: tap on the ulnar nerve as it runs behind
medial epicondyle; if patient has had operation to
anteriorly transpose ulnar nerve, then tap anterior to
the medial epicondyle. Positive when there are
shooting pains along the course of the ulnar nerve.
-
III. Others:
- Tinel’s sign: tap over proximal edge of the palm, where
the carpal tunnel is located. Positive sign is when there
is shooting pain and numbness radiating towards the
radial 3.5 digits.
-
Phalen’s test: examiner’s thumb is placed over the
carpal tunnel and patient’s wrist is flexed for 30
seconds. Positive when numbness over radial 3.5 digits
is reproduced by this test.
ULNAR NERVE
I. Sensory supply
- Dorsal and palmar surfaces of ulnar 1½ fingers and
corresponding areas of palm and dorsum of hand
- Cutaneous branch to the dorsum of the hand is given
off before the wrist, so there is sparing of sensation
over that area in an ulnar nerve lesion at the wrist.
- Test the little finger, over the hypothenar eminence,
and over medial side of the dorsum.
II. Motor supply
- Intrinsics
 Test the first dorsal interosseous – abduction of
the index finger against resistance
 Froment’s sign – get patient to hold on to a piece
of paper placed between thumb and radial border
FDP of the little finger: hold middle phalanx of little
finger and get patient to flex the DIP joint of the finger.
Ulnar nerve subluxation: place a finger on the ulnar
nerve and slowly passively flex patient’s elbow, feeling
for anterior subluxation of the ulnar nerve
VASCULAR EXAMINATION
- Colour of the skin (pink, or dusky, or pale)
- Capillary refill (should be <2 seconds)
- Temperature
- Tissue turgour
- Allen’s test is optional: Get patient to clench fist tightly,
place fingers of each hand on radial and ulnar arteries
respectively, then get patient to open hand and examiner
releases one hand, noting the time that is required for
the hand to turn pink. Then release the other side to
allow hand to reperfuse, and repeat for the other artery.
OTHER TESTS
Finklestein’s test – for DeQuervain’s tenosynovitis
Patient closes fist with thumb tucked under clenched
fingers.
Holding arm outstretched with forearm in neutral
rotation i.e. thumb facing upwards, patient is told to
ulnar deviate the wrist.
Positive test is when there is pain localised to the
radial styloid region.
If done properly, the Finklestein’s test is a very
sensitive test for DeQuervain’s.
FINISH with examination of the cervical spine.
APPROACH TO THE HAND EXAMINATION:
Start off with a quick screen – expose both hands up to
elbow, look at the plantar aspect with hands open, then
ask patient to close hand, the look at the dorsal aspect
By this time you should have ascertained the problem:
1. A lump
2. Deformity – arthritis
3. Nerve palsy
Approach to nerve palsies:
1. Which nerve is involved?
2. What level is the nerve involved?
3. What is the cause?
Ulnar nerve
Look:
Claw hand
Wasting of the first dorsal interosseous, guttering
Test:
Abduction of index finger (first dorsal interosseous)
Adduction (cross the first two fingers)
FDP of the little finger
Froment’s sign
Sensation to little finger, hypothenar eminence
Site of lesion: FDP and sensation to hypothenar lost in
elbow lesion, preserved in lesion at wrist
Cause: Carrying angle of elbow
Lacerations over medial aspect of elbow
Thickened ulnar nerve
Ulnar nerve subluxation
Median nerve
Look:
Wasting of thenar eminence
Test:
FPB (abducting thumb)
FDP and FPL (making OK sign)
FDS (flexion of PIPJ)
Sensation to index finger, thenar eminence
Site of lesion: Carpal tunnel spares thenar sensation, FDP,
FPL, FDS but affects FPB; AIN lesion hits
FDP, FPL; high lesion loses all
Cause: Tinel’s and Phalen’s at carpal tunnel
Radial nerve
Look:
Finger drop with or without wrist drop
Test:
EPL (retropulsion of thumb)
Extension of fingers (EDC)
Extension of wrist (ECR, ECU)
Extension of elbow (triceps brachii)
Sensation over first web space
Site of lesion: PIN lesion will cause finger drop but not wrist
drop and no sensory loss; spiral groove
injury will cause wrist drop and sensory loss
Cause: Humeral neck fracture most common
Examination of the Hip
The preliminaries: Introduce yourself to patient, ask for
permission to examine. Ensure adequate exposure but
consider patient modesty also. Ensure good lighting, and
good positioning of bed.
With patient lying supine, knees fully extended:
3.
Deformity of the hip – fixed adduction or abduction
deformities; asymmetry in attitude of the limb
4.
Obvious swelling(s)
- Hernia can cause hip pain – look for it
GAIT AND RELATED TESTS
1.
2.
Get patient to walk a distance – notice if there is any
obvious antalgic or Trendelenburg gait, of if one of the
limbs appear shorter than the other
Types of gait:
- Antalgic – shorter stance phase on painful side
- Trendelenburg – when supporting body weight on
abnormal side, hip sags on the opposite side and
patient thrusts torso towards affected side
- Weak gluteus maximus – patient leans
backwards to keep hip in full extension when the
weak side is in stance phase
- Hand-to-knee – patient places hand on thigh to
keep knee extended due to weak quadriceps
- High-stepping gait – due to foot drop (common
peroneal nerve palsy)
Trendelenburg test:
- Get patient to stand in front of you and place both
hands on top of your own (palms down on your
palms up)
- Then make patient stand on one foot at a time, lifting
the other off the floor
- If the side that the patient is supporting his weight on
has a pathology, the patient’s hip will sag towards
the opposite side and his hand will press harder on
that side to lever himself
Causes of positive Trendelenburg test:
- Fulcrum problems e.g. hip OA, AVN
- Lever arm problems e.g. NOF#, coxa vara
- Effort problems e.g. weak abductors
LOOK
With patient standing:
8.
Scars
9.
Swelling
10. Sinuses – in the gluteal folds, make sure to check
11. Discolouration – redness, bruising, etc
12. Muscle wasting – gluteal muscles
FEEL
o
Feel for temperature – any increased warmth
o
Palpate for tenderness – locate hip joint 2cm below and
lateral to midpoint of inguinal ligament; greater
trochanter
MOVE
3.
Thomas’ Test for fixed flexion deformity of the hip
- Place patient’s legs at 90 degree knee flexion
- Then place your hand under patient’s lumbar region
- Get patient to flex one leg at the hip until the lumbar
lordosis is obliterated (back pressing your hand to
the bed) and then ask patient to hold on to the
flexed leg at the knee
- Ask patient to fully extend the other leg to see if
there is any fixed flexion of the hip
- Repeat with the other side
- Be consistent in performing the test – amount of
pressure of lumbar region on the hand should be
equal when testing either side
NOTE: if patient has a knee contracture, shift him
such that his knee joint lies over the edge of the
bed, to accurately assess for FFD of the hip
4.
Range of movements:
- Hip movements are mostly assessed passively
- While during Thomas’ test, also assess degree of
full hip flexion on either side (normal is 140 degrees
flexion)
- Abduction and adduction – place hand on the ASIS
to assess movement of the hip joint when the pelvis
is not moving (normal range is 45 degrees abduction
and 30 degrees adduction)
- External and internal rotation – flex hip and knee to
90 degrees each, place left hand on knee pressing
downwards to fix pelvis (normal is 50 degrees
external rotation, 40 degrees internal rotation)
NOTE: If patient cannot flex hip due to pain,
internal and external rotation of the hip can be
assess with patient in prone position and the
knee flexed
-
Turn patient to the prone position to assess
extension of the hip
LIMB LENGTH MEASUREMENT
Square the pelvis for true length measurement; ensure axes
of both lower limbs are at right angles to the line joining the
two ASIS. If not possible to square pelvis due to contracture
on one side then arrange the other limb in the same position
when measuring true length for that limb.
True length:
- Locate ASIS by feeling laterally from the pubic tubercle;
the ASIS is the first bony prominence that the hand feels
- Measure from ASIS to medial malleolus (use the same
relative point on the malleolus on either side e.g.
superior border, midpoint, etc)
- If one side has an abduction contracture, then place the
other leg in the same relative position when measuring
true length; same for other deformities
Relative length
- For measurement of relative limb length just ask patient
to adopt the most comfortable position: “shoulders above
hip above feet”
- Locate xiphoid process and then measure from that point
to the medial malleolus on either side
Contractures and apparent length discrepancy
- Adduction deformity results in shortening of the
abnormal side
- Abduction deformity results in lengthening of the
abnormal side
Galeazzi’s test
Place the lower limbs side by side with knees flexed 90
degrees, with the heels in line
This screening test helps to assess if the shortening is
due to femur or tibia or both
Bryant’s triangle
If shortening is in the femur, it is important to assess if
the shortening is above or below the greater trochanter
Bryant’s triangle is formed by a line joining the ASIS
and the greater trochanter, a line dropped vertically
from the ASIS, and a line running horizontally across
from the greater trochanter
Shortening of the horizontal line on one side as
compared to the other indicates shortening above the
greater trochanter
FINISH with examination of the neurovascular status of the
lower limb, and examination of the spine and knee joints
Examination of the Knee
The preliminaries: Introduce yourself to patient, ask for
permission to examine. Ensure adequate exposure but
consider patient modesty also. Ensure good lighting, and
good positioning of bed.
8.
Feel for temperature gradient over the knee joint,
and any difference in temperature compared to the
other knee
9.
Feel the articular surface of the patella for
tenderness, osteophytes.
LOOK
With patient standing:
10. Other swellings e.g. cysts around the knee,
osteophytes in OA knee
13. General appearance and vitals – any pallor, what
is the BP, and HR.
14. Deformity – varus or valgus
- measure intercondylar distance (normal <5cm)
and intermalleolar distance (normal < 2cm)
1.
16. Swelling
- effusion w/ obliteratn of medial parapatellar fossa
- cyst e.g. Baker’s cyst over popliteal fossa
18. Discolouration – redness, bruising, etc
5.
6.
Fixed flexion deformity of the knee
- Ask patient to push down on examiner’s hand
placed in the popliteal fossa to see if patient is
able to press hand against bed
5.
-
7.
Fluid shift (sensitive for small amounts of fluid) –
stroke medial parapatellar fossa to empty it of
fluid, then press on lateral side to see if medial
fossa fills again
Patellar ballottement/tap – with left hand pressing
on suprapatellar pouch, use thumb and index
finger of right hand to press down on patellar; test
is positive when patellar hits femur with a tap
Muscle wasting over quadriceps (vastus medialis is
most prominent)
- Measure girth of quadriceps 10cm (or 4
fingerbreadths) about the superior border of the
patella – “objective assessment of wasting”;
significant if difference is greater than 2 cm.
Palpate for tenderness with one thumb:
- Tibial tuberosity
- Patellar tendon
- Around either side of the patella
- Quadriceps tendon around the superior border of
the patella
- Medial and lateral joint lines, one at a time
- Femoral condyles
Active range of movements:
- Get patient to flex knee all the way and then
extend, looking for any restriction of full flexion or
extension
6.
Passive range of movements:
- If patient has restricted range of movements,
assess if there is a joint contracture or muscle
weakness
7.
Crepitus
- Feel with hand over patella during passive
movement
Effusion – obliteration of medial parapatellar fossa
-
4.
Collateral ligaments
test in full extension (where capsular elements
and other ligaments are also taut and restrict
displacement) and in 30 degrees flexion
(where only the MCL and LCL are responsible
for preventing displacement
5.
McMurray’s test
- Start with knee in full flexion
- To test medial meniscus, externally rotate tibia
with your right hand at the ankle, and apply
valgus force at the knee with your left hand, then
extend the knee
- To test lateral meniscus, internally rotate tibia
and apply varus force at the knee, then extend
- Repeat the test, looking out for palpable or
audible click in the knee during extension
6.
Other special tests that can be done:
- Quadriceps active test for PCL – with patient’s
knee joint in 90 degree flexion and examiner
sitting on patient’s foot, get patient to contract
quadriceps muscle; positive when tibia shifts
forward eliminating the posterior sag appearance
MOVE
19. Muscle wasting – quadriceps
LOOK AND FEEL
With patient lying supine, knees fully extended:
Lachman’s test
With knee in 20-30 degrees flexion, place left
hand on thigh pressing downwards, and right
hand under the proximal calf with thumb over
the joint line pulling the tibia towards you
Also testing for ACL, but more sensitive test
With knee flexed to 90 degrees:
15. Scars over anterior and posterior aspect of knee
17. Sinuses
3.
SPECIAL TESTS
With legs placed in 90 degrees flexion and aligned (heels in
the same line):
1.
Posterior sag sign
- look for posterior sag of tibial tuberosity on the
femoral condyles  posterior cruciate injury
2.
Anterior drawer test
- Sit on patient’s foot, use both hands to splint the
hamstrings, with thumbs on the joint line, and pull
towards you
- In ACL tear, there will be no end-point on pulling
forward
-
Pivot shift for ACL – with lower limb adducted
and knee extended, patient is told to relax and
the leg is internally rotated with valgus force
applied to the knee, and then flexed; positive
when tibia suddenly shifts forward on femur with
a click sound (NOTE: test is painful, thus don’t do
it during exam)
-
Patellar apprehension test for recurrent patellar
dislocation – push the patella laterally while
flexing and extending the knee joint; positive
when patient feels like patella is about to
dislocate
FINISH with assessment of neurovascular status of the
lower limb, and examine the hip and ankle joints for any
pathology.
Examination of the Cervical Spine
The preliminaries: Introduce yourself to patient, ask for
permission to examine. Ensure adequate exposure but
consider patient modesty also. Ensure good lighting, and
good positioning of bed.
LOOK
20. General appearance and vitals – any pallor, what is
the BP, and HR.
21. Deformity – namely tilting of the head (‘wry neck’)
- Causes: torticollis (congenital), PID, inflamed neck
glands, cerebellar dysfunction, ophthalmologic
disorders, congenital scoliosis, atlanto-axial rotatory
dislocation, etc.
SPECIAL TESTS
o For cervical spondylosis:
1. Spurling’s and Davidson’s tests
- Spurling’s: Active extension, lateral flexion and
rotation of patient’s neck towards the affected
side with axial pressure results in reproduction
of radicular symptoms e.g. shooting pains down
the arm, numbness and weakness.
- Davidson’s: Subsequent abduction of the arm
on the affected side (with neck still extended,
laterally flexed and rotated) results in relief of
the radicular symptoms.
2.
22. (Scars, sinuses, swellings)
- E.g. cervical lymph nodes
FEEL
11. Palpate for tenderness along spinous processes and
interspinous ligaments
- At the same time palpate for any step deformity
(high-grade listhesis), and ligamentous gap (more
applicable for trauma).
12. ‘Trigger points’
- Points along the neck musculature that are
extremely tender with radiation; reproduces patient’s
usual pain symptoms (myofascial pain syndrome?).
o
o
13. Palpate paravertebral muscles for spasm
MOVE
8.
9.
Flexion-extension:
- 50% of this movement occurs at the atlanto-occipital
junction.
- In flexion, the patient’s chin should touch the chest.
- In extension, the line joining the patient’s chin to the
posterior occipital protuberance (occipitomental line)
should form an angle of at least 45 degrees to the
horizontal (usually more than 60 in young patients)
Lateral flexion:
- Check symmetry of movements
10. Rotation
- 50% of this movement occurs at the atlanto-axial
joint
- As with lateral flexion, check for symmetry of
movements on both sides
Motor function
4.
Sensory function – Important to compare with chin and
not chest since pathology is in the cervical region and
the chest belongs to thoracic dermatomes.
5.
Proprioception – big thumb
6.
Cerebellar function – dysmetria, dysdiadochokinesia
7.
Myelopathic hand:
(i) Thenar atrophy
(ii) Hoffmann’s sign
- The examiner holds the patient’s middle finger
between thumb and index finger (hold patient’s
right hand with examiner’s left hand, index
finger of examiner on volar surface of patient’s
finger and thumb over dorsal surface) and flicks
the patient’s distal phalanx downwards with his
thumb.
- Positive sign is when there is reflex flexion of
the thumb and index finger of the patient.
Cervical compression and distraction
- Axial loading of the cervical spine results in
radicular symptoms, especially while performing
the Spurling’s test.
- Distraction of the neck (pull the head superiorly)
relieves the symptoms.
For cervical myelopathy:
- Lhermitte’s sign: When patient is asked to actively
flex his or her neck, there are electric shock-like
sensations that run down the centre of the patient’s
back and shoot into the limbs.
For thoracic outlet syndrome:
- Adson’s manoeuvre: With one hand palpating the
patient’s radial pulse, get the patient to extend his
neck actively and then rotate it towards the side
being tested. Positive result (indicating interscalene
compression of the subclavian neurovascular bundle)
is when there is diminished pulse, sometimes with
distal pain in the affected upper limb.
NEUROLOGICAL EXAMINATION (esp. if susp myelopathy)
UPPER LIMB:
1. Tone, clonus
2.
3.
Reflexes – biceps, triceps, brachioradialis
- If the cervical myelopathy occurs at C5 or C6 the
‘inverted supinator reflex’ is present – this is where
there is diminished elbow flexion but increased
finger flexion on tapping the brachioradialis tendon
due to spastic finger flexors; this is associated with
hyper-reflexic triceps jerk.
-
For cervical involvement above C5, elicit Shimizu’s
sign (scapulo-humeral reflex) by tapping on spine of
scapula or acromion with a tendon hammer; the
reflex is hyperactive when the scapula elevates or
the humerus becomes abducted.
(iii) Grip and release test
- Ask patient to quickly flex fingers into a fist and
extend, repeatedly, to accomplish 20 cycles in
10 seconds.
- In patients with cervical myelopathy the
movement is slow, difficult and incomplete.
(iv) Finger escape sign
- When patient is asked to keep fingers adducted
and extended, the ulnar two fingers drift into
flexion and abduction within 30 seconds.
LOWER LIMB
1. Tone, clonus
- Usually there is increased tone in the lower limbs in
cervical myelopathy.
2.
Reflexes – Knee jerk, ankle jerk, plantar reflexes
- Usually hyper-reflexic in cervical myelopathy.
3.
Motor
- Decreased in cervical myelopathy.
4.
Sensation
- Decreased in cervical myelopathy.
5.
Proprioception and cerebellar function
- Gait is usually broad-based and clumsy, check
Romberg’s.
PR EXAMINATION
For saddle anaesthesia, anal wink reflex, anal tone.
Examination of the Thoracolumbosacral Spine
The preliminaries: Introduce yourself to patient, ask for
permission to examine. Ensure adequate exposure but
consider patient modesty also. Ensure good lighting, and
good positioning of bed.
LOOK
With patient standing:
23. General appearance and vitals – any pallor, what
is the BP, and HR.
24. Scars over back
25. Swelling
- E.g. meningocoele, visible spasm of paravertebral muscles, lumps and bumps
26. Sinuses
- Over lumbar triangle of Petit (bordered by
latissiumus dorsi, iliac crest, and external
oblique), or groin region for pus tracking along
psoas
27. Deformity
- Cervical spine: torticollis, flexion, hyperextension
-
-
Thoracic spine:
 Kyphosis – angular (gibbus, caused by
infection like TB), or smooth (caused by
Scheuermann’s disease in adolescents, or
multiple osteoporotic compression fractures in
old ladies)
 Scoliosis – with rib hump; note side of curve
convexity
15. Percuss for tenderness
- Pain on percussion relates to pathology in the
antr vert body, may indicate infection or tumour
- Do a renal punch to exclude renal pathology
29. Muscle wasting – not much to see actually
FEEL
14. Palpate for tenderness along spinous processes
- At the same time palpate for any step deformity
(high-grade listhesis), and ligamentous gap
(more applicable for trauma)
1.
MOVE (mostly passive)
NOTE: There are no “normal” range of movements in the
spine, but assessment of ROM helps establish a baseline
range that is useful for future monitoring of disease
progress or efficacy of treatment
11. Flexion-extension:
- For flexion, do Schoeber’s test for spinal
excursion – mark the level of the PSIS and a
point 10 cm about it – the increase in distance
when bending forwards should be >5cm.
2.
Passive dorsiflexion
- Following SLR positive, lower the limb a little
such that there is no more radicular pain, then
passively dorsiflex the patient’s ankle
- Is more specific than a simple SLR, because
positive SLR can be due to causes other than
PID e.g. hamstring tightness
3.
Bowstringing test
- With hip flexed ~100 degrees, knee flexed 80-90
degrees, locate the biceps femoris tendon on the
lateral side of the popliteal fossa
- Press on the tendon as a control test – there
should not be any pain
- Subsequently press medial to the tendon (within
the lateral region of the popliteal fossa) where the
common peroneal nerve runs
- Positive test is not just when there is pain at then
point of pressure, but when the pain radiates
proximally and/or distally from the point of
pressure.
- Most useful confirmatory test of nerve rt tension
4.
Lasegue test
- With knee and hip flexed to 90 degrees each,
slowly extend knee and look out for radicular pain
- This test is not commonly performed
12. Lateral flexion:
- If patient can reach below knees should be
normal
13. Rotation
- Make patient sit down to fix pelvis, then rotate
- Angle between line joining shoulders and line
joining ASIS is the extent of rotation
NEUROVASCULAR EXAMINATION
7.
Reflexes
- Knee jerk, ankle jerk, plantar reflex
8.
Sensation by dermatome
- Anterior thigh for L2
- Anterior aspect of knee for L3
- Medial surface of leg for L4
- Big toe dorsum for L5
- Lateral aspect of heel for S1
- Popliteal fossa for S2
9.
Power
- Particularly knee extension for L4; ankle and big
toe dorsiflexion for L5; ankle and big toe
plantarflexion for S1
10. Pulses
11. PR
- Saddle anaesthesia (S3, 4, 5)
- Inspect anal orifice for tone (“crow’s feet”)
- Anal wink reflex – scratch perianal skin and
watch for anal wink
- Put finger in rectum to assess anal tone
Straight leg raising test (SLR)
Keeping the knee extended, slowly raise the leg
being tested, checking patient’s face to assess
pain
- Stop when patient complains of pain – positive
SLR is when there is pain radiating into the lower
limb (radicular pain)
- Take note of angle at which radicular pain occurs
- Also assess cross-SLR – patient complains of
radicular pain in the affected side when the
normal lower limb is being raised  this indicates
a large central PID? And is quite specific for PID?
-
16. Palpate paravertebral muscles for spasm
Lumbar spine:
 Transverse
lumbar
crease
and
hyperextension – high-grade spondylolisthesis
 Scoliosis if any
28. Discolouration – bruising, hairy patch over sacrum,
café-au-lait spots, neurofibromata
NERVE ROOT TENSION SIGNS
FABER TEST
- for sacroilitis – in young male, may indicate
ankylosing spondylitis
- flex, abduct and externally rotate the hip (“figure of 4”)
FINISH by offering to examine the hip joint.