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Deformity Description Interpretation

Mallet finger /

thumb Flexed DIP

Caused by: damage to extensor tendon due to:

Trauma or Rheumatoid Arthritis (RA)

Boutonniere Hyperextended DIP &

flexed PIP

Caused by: the central slip of the extensor tendon detaches from the middle phalanx due to: Trauma or RA

Swan neck Flexed DIP &

hyperextended PIP RA and others

Heberden’s nodes HD

Hard dorsolateral nodules of DIP may associate with deviation of distal phalanx

Osteoarthritis (OA)

Bouchard’s nodes

BP Like Heberden’s but of PIP OA

Dupuytren’s contracture

Flexion deformity of the fingers at MCP and IPs with nodular thickening in the palm

DM, epilepsy, alcoholism, hereditary, repetitive trauma

IP: Interphalangeal joint, DIP: Distal IP, PIP: Proximal IP, MCP: Metacarpophalangeal joint.

Note: RA: affects wrist, MCP, PIP OA: Affects: DIP, PIP To the examiner“There is / is no swelling, erythema, muscle atrophy,

deformity, contractures, skin changes or crepitus. The patient looks comfortable, relaxed, moving his/her … joint normally/ looks apprehensive with limited ….

joint movement..”

2. Palpation:

of:

All joints with thumb and index finger. Also capillary refill.

“Mr./Ms. .., I’m going to feel your hand, if you feel pain tell me.”

To the examiner“There is / is no warmth/coldness, nodules, effusion, or joint tenderness. Normal capillary refill at < 3sec. The skin is normal in thickness, soft, normal moisture. No muscular fasciculation or tremor.”

Range of Motion:

1- “Mr./Ms. .., make a fist with each hand with the thumb across the knuckles, and then open your hands and spread your fingers.”.

During flexion: normal fingers should flex to the distal palmar crease.

Extension: to 00 … Continued

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

2- Thumb: Flexion, extension, abduction, adduction and opposition across the fingers:

“Mr./Ms. .., now move your thumb like this… then….”

3- Passive motion of all fingers for flexion/ extension at:

MCP (Flexion: intrinsics / Extension: communis),

PIP (Flexion: flex. dig. superficialis / Extension: lat. bands of ext. dig.), DIP (Flexion: flex. dig. profundus / Extension: lat. bands of intrinsics), Flexor digitorum superficialis:

Restrict movement of 3 fingers with your fingers. Patient’s palm up. Ask him to flex the free finger and look for PIP flexion.

“Mr./Ms. .., let me hold these fingers. Now, flex the free one.”

Flexor digitorum profundus:

Restrict movement of proximal and middle phalanges of all fingers with your fingers. Patient’s palm up. Ask him to flex the all finger and look for DIP flexion.

“Mr./Ms. .., okay, now all fingers. Flex the terminal parts.”

To the examiner“Normal fingers range of motion with no pain or crepitus / There is movement limitation in first finger DIP.”

5. Special Tests:

Finkelstein test for De Quervain’s Disease:

De Quervain’s disease is tenosynovitis of abductor pollicis longus & extensor pollicis brevis. Patient will feel weakness of grip and pain at the base of the thumb, which is aggravated by some wrist movements.

“Mr./Ms. .., again make a fist with each hand with the thumb across the knuckles closing the fingers over the thumb.. now deviate your hand inward like this.” pain reproduced.

To the examiner“Finkelstein test for De Quervain’s disease is negative/

positive.”

6. Sensations:

Sensory and motor of radial, median, and ulnar nerves at the hand.

To the examiner“As I already checked all the motion of the fingers actively, Motor neurological innervations are intact. / There is motor loss of posterior interosseous branch.”

- “Mr./Ms. .., let me check the sensation in your hand.” Light touch, pain &

2-point.

… Continued

159 The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

- “I’m going to feel your skin with this cotton on several points of your fingers. I want you to say ‘yes’ when you feel it just like this,

okay…. Let us start, close your eyes.

- “Now, I’m going to feel your skin with this paper pin. Again, say

‘yes’ when you feel it, close your eyes.

- “Mr/Ms ..,now tell me if you feel this pin on your skin.., close your eyes, Is it one or two pins?adjust distance between the pin heads at 2 mm.To the examiner“Radial, Ulnar, & median nerves light touch, pain & 2

point discrimination sensations are intact.

Nerve Sensory Motor

Radial C6 Dorsum of first web space Extension of fingers, thumb & wrist

Posterior interosseous branch

None Thumb extension

Ulnar C8

- Dorsum of small finger tip,

- Palmar of small finger &

medial aspect of ring finger

- Finger abduction &

adduction,

- Opposition of little finger,

- wrist flexion

Median C7

- Dorsum of index, middle fingers tip.

- lateral aspect of ring finger,

- Palmar of index & ring fingers

- Thumb IP flexion, - Index & middle fingers flexion,

- Wrist flexion

Anterior interosseous branch

None Flexion of index &

middle finger

Lateral terminal branch

None Thumb opposition

END Hand Exam, Wrap up

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

* Spine (Back pain):

Cervical spine:

As any joint sub model plus:

1. Inspection:

for deformity:

1- In normal sitting position, nose should be in line with manubrium &

xyphoid. From side, earlobes should be in line with acromion process.

Look on the neck from the front, and then move to look from the side.

To the examiner“There is / is no swelling, erythema, muscle atrophy, deformity, contractures, skin changes or crepitus.

There is no neck tilting or rotation. Neck is mobile &

not short.”

2- Venous obstruction of upper limbs: Check for vein distension, skin discoloration, ulcers.

“Mr/Ms.., let me have a look on both your arms.”

To the examiner“There are no distended veins, ulcers or skin color

changes.”Continued

- Thoracic spine pain: rotates around the trunk along the intercostal nerves.

- Upper lumbar spine pain: may be felt in front of the thighs & knees.

- Lower lumbar spine pain: may be felt in the coccyx, hips, buttocks, as well as shooting down the back of the legs to the heels and feet.

- Intensifies with movement.

- Worse with sneezing or coughing: Herniated vertebral disc.

- Associated with numbness or tingling in lower limbs: ?Nerve root lesion.

- DDX: Age related

- Degenerative (90% of all back pain):

1. Mechanical: degenerative, facet. }Increased with 2. Spinal stenosis: congenital, osteophyte, central disc}standing.

3. Peripheral nerve compression: disc herniation. Increased with bending.

- Others:

1. Infection. (Osteomylitis)

2. Cauda Equine syndrome (large central disc herniation) Surgical emergency.

3. Neoplastic (Mets).

4. Trauma: fracture (compression/distraction/translation/rotation).

5. Osteoporosis

6. Spondyloarthropathies (e.g. ankylosing spondylitis)

7. Referred: Aortic aneurysm/rupture (surgical emergency), Renal

(CVA),Pancreas.

161 The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

2. Palpation:

You can palpate the neck standing in front of the patient or from behind.

Use both hands and compare sides. Palpate for:

1. Tenderness.

2. Trigger points.

3. Muscle spasm.

4. Skin texture.

5. Bony and soft tissue abnormality.

- Posterior aspect:

1- External occipital protuberance

2- Spinal processes and facet joints of vertebrae. (No gap = Stable) 3- Mastoid process.

- Lateral aspect:

1- Transverse processes and facet joints of vertebrae.

2- Lymph nodes.

3- Carotid arteries.

4- Temporomandibular joints &

mandible.

“Mr/Ms.., let me feel your neck.”

To the examiner“There is no tenderness or muscle spasm, no pain with movement. Skin texture, soft tissue and bony structures felt normal.”

Range of Motion:

- Active: “Now I want to check your neck movements.”

- Flexion (900): “Will you please touch your chin to your chest”

- Extension (700): “Now put your head back.”

- Side flexion (20-450): “Touch each shoulder with your ear without raising your shoulders.”

- Rotation (70-800): “Now turn your head to the left…and right.”

- Passive: “Now let me move your neck in the same movements to feel it… relax your neck.”

Repeat the above movements to feel the ‘end feel’: Normally: Tissue stretch.

To the examiner“Active and passive range of motion is normal. End feel is normal tissue stretch.” … Continued

Cord injury in spinal trauma:

1. Tenderness over spinous processes.

2. Paraspinous swelling.

3. Gap between spinous processes.

4. Neurological paradoxical breathing:

Chest in with breathing (paralysis).

5. Flaccid limbs with no response to painful stimuli and no reflexes.

6. Painless urinary retention/ priapism.

3 types of spine trauma:

1. Vertical compression:

Objects falling on head:

stable.

2. Hyperextension: Only unstable if interspinous lig. ruptured (a gap).

3. Shearing injury: head rotation: unstable.

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

3. Power Assessment/Isometric Movements:

For muscle power and neurological weakness originating from the cervical nerve roots.

Each of the following contractions should be held for 5 sec against resistance:

Compare sides. Stop movement when pain is felt.

“Mr/Ms.., now, I’m going to ask you to do some movements of your neck, shoulders, arms, and hands against my hands asking you to keep them in that position for 5 sec to check your power, okay?

- Neck flexion C1-2:

“Will you please touch your chin to your chest again.”

- Neck side flexion C3:

“Touch each shoulder with your ear without raising your shoulders.”

- Shoulders elevation C4:

“Shrug both your shoulders.”

- Shoulder abductions C5:

“Now, raise both your arms from the sides straight above your head. Now hold your palms together and bring your arms down slowly to your side.”

- Elbow flexion &/or wrist extension C5/6:

“Bend both your elbows / extend your wrists.”

- Elbow extension &/or wrist flexion C7/6:

“Extend both your elbows / flex your wrists.”

- Thumb extension &/or ulnar deviation C8:

“Extend your thumbs like this / deviate your hands internally like this.”

- Abduction &/or extension of fingers T1:

“Spread/ fan out your fingers.”

To the examiner“Normal symmetrical muscle power, no weakness.”

6. Sensation and Reflexes:

Both arms:

- Sensation: “Mr/Ms ..,I’m going to feel your skin with this cotton on several points on your body. I want you to say ‘yes’ when you feel it just like this, okay. Let us start, close your eyes.” Never ask the patient if he/she is feeling the touch every time you touch the skin so he wont know if you are touching or not.

C2: Jaw angle.

C4: Shirt collar area. .

C6 (Radial): Dorsum of first web space (Thumb).

C7 (Median N):.Index finger palmar or dorsal aspect.

C8 (Ulnar N): Little finger palmar or dorsal aspect.

To the examiner“Sensation is normal.” … Continued

163 The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

- Reflexes: “Mr/Ms .., now, I’ll check your reflexes. I’m going to strike this hammer gently on some points near your joints, Okay?”

Biceps tendon reflex C5, 6:

- See reflexes in neurological examination chapter.

“Mr/Ms .., I’ll start here with your elbow. Relax your arm in this position….(Set the forearm, strike, and watch twice). Now the other one….”

To the examiner“Biceps tendon reflex is normal/ diminished/

increased.”

Brachioradialis tendon reflex C5, 6:

- See reflexes in neurological examination chapter.

“Mr/Ms .., now here near your wrist.(Set the forearm, strike, & watch twice).Now the other one...”

To the examiner“Brachioradialis tendon reflex is normal/ diminished/

increased.”

Triceps tendon reflex C6 - 8:

- See reflexes in neurological examination chapter.

“Mr/Ms .., now here at the back of your arm.…. (Set the forearm, strike, and watch twice).Now the other one….”

To the examiner“Triceps tendon reflex is normal/ diminished/

increased.”

END Cervical Exam, Wrap up

Thoracic spine:

As any joint sub model plus:

1. Inspection:

in standing position on uncovered back.

“Mr/Ms .., Let me have a look on your back, Will you please stand up here. I’m going to uncover your back.”

To the examiner“There is / is no swelling, erythema, skin changes, hair spots, muscle atrophy, rib humps or deformity. Chest is symmetrical, no lordosis, kyphosis or scoliosis.

Shoulders and iliac crests are at the same height bilaterally.”

Gait: “Now let us check your gait, okay,…”

“Will you please stand up here and walk straight ahead”

“Stop and return to me now on tiptoe”

“Now walk away again but this time on your heels.”

“Stop, return by walking in tandem gait with one foot placed in

front of the other.”Continued

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

To the examiner“Gait is normal, there is no shuffling, spastic movements, wide stance, foot drop, or steppage.”

2. Palpation:

in standing position on uncovered back

- Palpate spine, ribs, scapulae posteriorly, costal cartilages, sternum, and clavicles.

- Squeeze the chest from the sides and front back asking the patient for pain.

“Now I’ll squeeze your chest.. Do you feel any pain?.. now?.”

To the examiner“There is / is no warmth, nodules, effusion, bony or soft tissue tenderness. The skin is normal in thickness, soft, normal moisture. No muscular fasciculation or tremor.”

Range of Motion: in standing position on uncovered back for thoracic (T) and lumbar spine (L).

Active: “Now I want to check your back movements.”

- Forward flexion (T: 20-450, L: 40-600):

“Will you please bend forward and touch your toes …I’ll measure how far is this from the floor.” Normally up to 7 cm.

- Extension (T:25-450, L: 20-350):

“Now, I’ll hold your pelvis from the sides… arch your back backward.”

- Side flexion (T: 20-400, L: 15-200):

“Now, slide your right hand down your leg…I’ll measure how far is this from the floor…. now the same with the left hand.” Compare - Rotation (T: 35-500, L: 3-180):

“Now, sit down here. Without moving your pelvis rotate towards your right side… now towards the left side.” Compare.

- Chest expansion: Place a tape measure around the patient’s chest at the level of the nipples and measure the difference between rest and full inspiration. Normally => 4 cm.

“Now, I’m going to measure your chest expansion with breathing.

Let me place the measuring tape around you(measure)….Take a deep breath in and hold it(measure).”

Passive: “Now let me move your back in the same movements to feel it

… relax your back.”

To the examiner“Active and passive range of motion is normal. End feel is normal tissue stretch.”

… Continued

165 The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

3. Power Assessment/Isometric Movements:

Patient is still sitting now.

Each of the following contractions should be held for 5 sec against resistance:

Compare sides.

“Mr/Ms.., now, I’m going to check your power, okay.. I’ll place my leg behind your buttocks, and wrap you with my arm. I’m going to do the same movements you just did but don’t let me move you, resist me.” Do flexion, extension, side flexion, and rotation. Stop movement when pain is felt.

To the examiner“Normal symmetrical muscle power, no weakness.”

6. Sensation and Reflexes:

Both legs.

Sensation:

L5: Foot dorsum S2: Medial posterior thigh.

“Mr/Ms ..,I’m going to feel your skin with this cotton on several points on your leg. I want you to say ‘yes’ when you feel it just like this, okay. Let us start, close your eyes.”

Never ask the patient if he/she is feeling the touch every time you touch the skin so he wont know if you are touching or not.

To the examiner“Sensation screen is normal.”

Reflexes:

“Mr/Ms .., now, I’ll check your reflexes. I’m going to strike this hammer gently on some points near your leg joints, Okay?”

Patellar tendon reflex (Knee jerk) L2 - 4:

“Mr/Ms .., I’ll start here at your knee.…. (Set the leg, strike, and watch twice).

Now the other one….”

To the examiner“Patellar tendon reflex is normal/ diminished/ increased.”

Achilles tendon reflex (Ankle jerk) S1 - 2:

“Mr/Ms .., now your ankle... (Set the foot, strike, and watch twice).Now the other one….”

To the examiner“Achilles tendon reflex is normal/ diminished/ increased.”

END Thoracic spine Exam, Wrap up

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

Lumbar spine:

As any joint sub model plus:

1. Inspection:

in standing position on uncovered back See thoracic spine.

In infants: look for spina bifida: (vertebral deformity & skin bulge over lumbosacral spine, hairy patches, pigmented spots.).

2. Palpation:

In supine position on uncovered back palpate for:

Umbilicus, inguinal areas, iliac crests, symphasis pubis

“Mr/Ms .., lie down here flat on your back please. I want to feel your abdomen.”

In prone position on uncovered back palpate for:

Spine, sacrum, coccyx, iliac crests, ischial tuberosities, para vertebral muscles.

“Mr/Ms .., now turn on your stomach, back up please. I want to feel your back.”

To the examiner“There is / is no warmth, nodules, effusion, bony or soft tissue tenderness. The skin is normal in thickness, soft, normal moisture. No muscular spasms or fasciculation.

No hernia.”

Range of Motion: as thoracic

See thoracic spine “Now I want to check your back movements. Please stand up here.”

3. Power Assessment/Isometric Movements:

Patient is still sitting now.

See thoracic spine plus the following leg movements:

“Mr/Ms .., now, lie down here again flat on your back. I want to check your legs power.”

Hip Flexion L2: Place your hand on his knees and slightly push down.

“Flex both your hips, lift your legs up.”

Knee extension L3: Bend the knees up on the bed and hold the feet to the bed.

“Now, extend both your knees, lift your feet up.”

Knee flexion S2: With the knees still bended up on the bed, hold the back of the legs & pull.

“Now, flex both your knees, pull my hands.”

Ankle Dorsiflexion L4: Extend the patient’s legs. Pull the dorsum of the feet down.

“Now, pull my hands with your feet only.” … Continued

167 The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

Great toe extension L5: Pull the dorsum of the great toes down.

“Now, pull my hands with your big toes only.”

Ankle planter flexion S1 (or Ankle eversion or hip extension): Push both feet up.

“Now, push my hands with your feet only.”

To the examiner“Normal symmetrical muscle power, no weakness.”

5. Special tests:

1- Straight Leg Raising Test: For Sciatic N. (L4-S3) stretch Sciatic N. dermatome:

- Anal and perianal area.

- Posterior part of the medial aspect of the thigh and leg.

- Anterior surface of shin and dorsum of foot.

With the patient lying supine, the hip is medially rotated & adducted, &

the knee extended. Raise the leg straight up (hip flexion) until back or leg pain is reproduced.

- Document:

- The degree of elevation at which pain reproduced, usually < 700. - Pain quality and dermatome distribution.

Then lower the leg slowly and stop at the point of pain relief. At this position, dorsiflex the foot, pain reproduced.

“Mr/Ms .., now, lie down here again flat on your back. I want to do some tests on your legs… Keep your leg straight, I’ll rotate it and bring it internally.. now I’ll raise it.. Tell me exactly where you start to feel pain.” Patient felt pain: stop and measure the angle.

“Tell me where do you feel the pain?… How does it feel like?…

Now, I’ll lower it slowly tell me the point at where the pain

disappears… I’ll back bend your foot.. Any pain?.. Does it feel the same?.”

Crossed Straight Leg Raising Test:

Repeat the above with the unaffected leg. Symptoms will be reproduced at the affected leg: Lumbar disc herniation.

“Now, we’ll do the same with the other leg”

To the examiner“Straight Leg Raising Test is positive/ negative for sciatic N. root irritation at 500. No / Positive crossed Straight Leg Raising Test for Lumbar disc

herniation.”

The Physical Examination Interview: Musculoskeletal Examination

Musculoskeletal Examination: …Cont.

2- Femoral Stretch test: For femoral N. (L2-4) stretch.

Femoral N. dermatome:

- Anterior surface of thigh and shin.

Have the patient lie prone on the stomach. Raise the leg straight (hip extension) with one hand under the thigh and the other on the leg to maintain knee extension.

“Mr/Ms .., now, roll over on your stomach. I’ll repeat the same movements on your legs… Keep your leg straight,.. now I’ll raise it..

“Mr/Ms .., now, roll over on your stomach. I’ll repeat the same movements on your legs… Keep your leg straight,.. now I’ll raise it..