INTRO
Greet, Introduce, Explain, Permission (GIEP)
Wash & Warm hands.
Sitting down
Adequate exposure
GENERALINSPECTION
Age, gender, ethnic group, height, weight, built, nutrition
E.g. Mr. Chan is a middle aged Chinese man of average height and built. He is well nourished and of average weight. He is conscious, alert, and co-operative. He is not in any distress, no general discoloration and he is not in obvious pain.
Mention:
(1) conscious (2) alert
(3) co-operative
(4) distress / restlessness (5) not in obvious pain (6) no general discoloration (pallor)
INSPECTION
3D inspections (front, side and behind)
Start with normal
Sitting down comfortably
Proper exposure and warm hands (1) Shape
• Discoloration
• Scars
• Abrasion Shoulder
(3) Attitude Levels of shoulder
Hanging / supported (4) Movement
This is done by asking the patient to unbutton his / her shirt to see if there are any limitations in movement.
(5) Symmetry Compare the two shoulders
PALPATION
Tenderness
Exploration
Joints
tendons
ligaments
ligaments
Bursae
compare
Comment on:
pain
deformities – swelling, temperature & mass
intact bones
(1) Sternoclavicular Joint (5) Infraclavicular Fossa
(2) Clavicle (6) Acromion
(3) Acromioclavicular (7) Greater Tuberosity
(4) Spinous (Scapula)
Note: (Extra)
Triangle Of Symmetry 1. Corocoid (Thumb) 2. Acromion (2nd Finger)
3. Greater Tuberosity (Middle Fingers)
MOTION
To see if the patient is able / unable to perform certain motion
Range of movement
0°=anatomical position
Comment: “range of movement is from zero (0) to…” – on your findings, not what’s the normal
(1) Abduction Look from anterior
(2) Adduction
(3) Extension Look from lateral
(4) Flexion
(5) Internal Rotation Look from posterior (6) External Rotation Look from anterior (7) Extension On Internal Rotation
(8) Flexion On External Rotation
SPECIAL TEST
(1) Apprehension test
= 90° abduction and light extension PLUS 90° external rotation Done in shoulder dislocation
(2) Neer’s test (RARE!) Bursitis - subacromial impingement
- acromion processes impinge on bursa
(3) Hawkin’s test (RARE!) Rotator cuff injuries
INTRO
Greet, Introduce, Explain, Permission (GIEP)
Wash & Warm hands.
Lie down flat
Adequate exposure
GENERALINSPECTION
Age, gender, ethnic group, height,
weight, built, nutrition Comment especially on:
Pallor
Pain
Distress
INSPECTION
3D inspections (front, side and behind)
Start with normal
Proper exposure and warm hands (1) Shape
• Discoloration
• Scars
• Abrasion Shoulder
• Laceration
(3) Attitude Standing / supine
(5) Movement – Gait Ask the patient to walk.
Antalgic gait
= associated with painful leg or foot Short leg gait
= the patient will dip down the short leg on walking or bear weight bearing
Scissor gait
= legs are adducted. Seen in cerebral palsy Waddling gait
= proximal myopathy High stepping gait
= foot drop
Trendelenburg's
= pelvis tilts down to the opposite site instead tilts up. Seen when hip is painful, weak, dislocated or fractured
Stiff leg
= whole leg swung outwards to clear ground to compensate (circumduction). Seen when hip / knee arthrosed or cannot bend.
(6) Symmetry Compare the two hips on standing.
PALPATION
Tenderness
Exploration
Skin temperature
Comment on:
pain
deformities – swelling, temperature & mass
intact bones (1) Pubic Symphysis (6) Femur Head (2) Pubic Crest (7) Ischial Tuberosity (3) Pubic Tubercles (8) Iliac Tubercle
(4) ASIS (9) Iliac Crest
(5) Greater Trochanter Note: (extra)
Some of us did muscle on palpation which includes; gluteus, quadriceps, adductors and hamstrings.
MOTION
To see if the patient is able / unable to perform certain motion
Range of movement
0°=anatomical position
Comment: “range of movement is from zero (0) to…” – on your findings, not what’s the normal
(1) Abduction Look from anterior
(2) Adduction
(3) Extension Look from lateral
(4) Flexion
(5) Internal Rotation Look from posterior (6) External Rotation Look from anterior (7) Extension On flexion of knee
(8) Flexion On flexion of knee
MEASUREMENT
**square the pelvis first!!
(2) True length –
ASIS to upper part of medial maleolus
(3) Apparent length –
xiphisternum to upper part of medial maleolus
see next page (extra) for more info
Fig. 10.41 True and apparent lengths of the lower limbs.
Apparent length True length
True shortening Seen in:
Can be due to old fractures of femur or tibia.
Apparent shortening Seen in:
Adduction contracture of the hip which has to be compensated for by tilting of the pelvis.
SPECIAL TEST
(1) Thomas test
The test must be performed with the patient lying face up a hard surface.
Place your left hand palm upwards under the patient's lumbar spine.
Passively flex both the patient's legs (hips and knees) as far as possible.
Keep the non-test hip maximally flexed (you will feel that the lordotic curve of the lumbar spine remains eliminated). Now ask the patient to extend the test hip.
Incomplete extension in this position indicates a fixed flexion deformity at the hip
Picture on right shows Thomas test on left leg.
Thomas's test measures fixed flexion deformity (inco-mplete extension). This deformity may be masked by compensatory movement at the lumbar spine or pelvis and increasing lumbar lordosis.
(2) Trendelenburg's test
Stand in front of the patient and ask the patient to stand on one leg for 30 seconds and to repeat with another leg.
Normally, the iliac crest on the side with foot off the ground should rise.
The test is abnormal if the hemipelvis falls below the horizontal line.
It maybe caused by gluteal weakness or inhibition from hip pain e.g. osteoarthritis or structural abnormality e.g. coxa vara
Trendelenburg's sign. Powerful gluteal muscles maintain the position when standing on the left leg; weakness of the gluteal muscles results in pelvic tilt when standing on the right
(3) Straight leg test
Greater trochanter Site of shortening
The exact site of shortening is important. Firstly it is important to determine if it is above or below the knee. This is best assessed by flexing both knees to 90°, as illustrated.
Normal
Above the knee Below the knee
Shortening above the knee
In assessing shortening above the knee, it is important to decide whether it occurs above the greater trochanter, or below the trochanter in the femoral shaft itself
Shortening above the greater trochanter can be determined by:
1. Placing one's thumbs on the AS IS with the middle fingers on the tip of the greater trochanters (both side) and compare, using the sense of proprioception (muscle sense).
2. Bryant's Triangle is drawn as follows. The patient lays supine and a line drawn from the ASIS down towards the bed. A second line is then drawn from the ASIS to the tip of the greater trochanter. The third side of the triangle is a horizontal line, drawn proximally from the greater trochanter in the line of the femur to meet the first line drawn. This third line shows the amount of upward or downward displacement of the hip compared to the normal side.
Normal Superior displacement Inferior displacement
ASIS
1. CERVICAL
INTRO Greet, Introduce, Explain, Permission (GIEP) Wash & Warm hands.
Sitting down
Adequate exposure
INSPECTION
(1) Swelling (2) Skin
• Redness
• Discoloration
• Scars
• Abrasion Shoulder (3) Neck deformity
(4) Torticolis
Torticollis / wryneck
muscles of the neck contract ~ neck is twisted to an unnatural position cause:
-protective spasm due to trauma -tonsillar infection
-vertebral body disease -sternomastoid tumor (infant)
(5) Congenital webbing of the neck
Webbing of the neck
Absence of 1 or more cervical vertebrae
e.g. Turner's Syndrome
(6) Symmetry Check asymmetry in supraclavicular
fossa
PALPATION
Tenderness
Swelling
Comment on:
pain
deformities – swelling, temperature & mass
intact bones
MOTION
(1) Extension – look up Look from lateral
(2) Flexion – look down
(3) Rotation – look to right / left Look from “above”
(4) Lateral flexion - ask patient to tilt head onto Look from anterior
his right / left shoulders
*abnormalities may be due to cervical spondylosis 2. THORACIC & SACRAL
INTRO
Greet, Introduce, Explain, Permission (GIEP)
Wash & Warm hands.
Standing
Adequate exposure
INSPECTION
(1) Deformities
Scoliosis = lateral bending
Kyphosis = AP bending
Gibbus = localized kyphosis
Lumbar curvature / lordoisis
Swelling
Gibbus: TB of spine (2) Skin
• Scars
• Sinuses
• Color change
• Hair tuft
• Discoloration
• Dimpling at base of spine
• Soft tissues swelling
1. Hair tuft. discoloration or dimpling at the base of the spine indicates spina bifida
2. Soft tissue swelling may be due to:
-infection -trauma -tumors
PALPATION
Comment on:
pain
deformities – swelling, temperature
& mass
intact bones
Feel for bony contour
(1) Tenderness
Seen in:- fracture - TB - Infection (2) Muscle wasting
(3) Muscle pain (4) Steps
MOTION
(1) Extension
- lean backwards (2) Flexion
- touch your toes with your knees straight (3) Lateral Flexion
- slide your hands at the side of your hip try to touch your knee
(4) Rotation
- ask the patient to sit and to twist around to each side
SPECIAL TEST
(1) Schober’s Test
A point is marked 10cm above a line connecting the dimple of Venus.
5cm below the line
Upper end is anchored.
Ask pt to try and touch toes (flex).
Norm >5-10cm
Pathology indicates ankylosing spondylitis
(2) Straight Leg Raising Test Stretch Test – Sciatic Nerves (A) neutral position
(B) straight leg raising limited by prolapsed disc
(C) tension increased by dorsiflexion of foot (D) root tension relieved by flexion at knee
(3) Stretch Test – Femoral Nerves