Clinical Signs And Tests

Question 1

How elicit Neer’s sign

Answer 1

Pain when maximally internally rotate shoulder then passively forward flex it. Indicate subacromial impingement of rotator cuff muscle tendons by superior structures (AC joint, acromion, CA ligament)
Pain at 80°

Question 2

How elicit Neer’s test?

Answer 2

No pain when do same maneuver as neer’s sign. After subacromial corticosteroid injection. Indicate subacromial tendon impingement.

Question 3

How do Hawkins Kennedy test and what is significance?

Answer 3

Pt forward flex shoulder to 90 degrees W/ elbow flexed 90 degrees. Examiner internally rotate shoulder by moving forearm down and in. Pain = subacromial impingement.

Question 4

How do scarf test and significance?

Answer 4

Aka cross body adduction test

adduct shoulder across body. Pt place hand on contralat shoulder, examiner push elbow superiorly to press acromion against lat end clavicle. Pain = acromioclavicular joint involvement.

Question 5

Finkelstein test and significance.

Answer 5

Pt flex thumb across palm and wrap fingers around it. Examiner adduct/ulnar deviate wrist. Pain over radial styloid= de quervain’s stenosing tenosynovitis.

Question 6

Phalen test and significance

Answer 6

Pt place dorsal surfaces hands together then fully flex wrist (reverse prayer). Hold 30-60 seconds. Pain = carpal tunnel syndrome

Question 7

Tinel test and significance.

Answer 7

Percuss gently over ulnar carpal tunnel just distal to wrist crease overlying carpal bones. Paraesthesia in median nerve distribution - carpal tunnel syndrome.

Question 8

Mills test and significance

Answer 8

Pt probate forearm, flex wrist and extend elbow from flex while Examiner palpate lat epicondyle. Tender and pain - tennis elbow (lat epicondylitis)
Put stress on ECRB

Question 9

Cozens test + significance

Answer 9

Pt elbow flex 90 degrees. Examiner 1 hand over lat epicondyle, other hold patient’s hand in radial deviation with forearm pronated. Pt then asked to extend arm against resistance. Pain = tennis elbow

Question 10

How do ortolani test and significance

Answer 10

Abduct hip to try reduce femoral head into acetabulum. Safe. Test for developmental dysplasia of the hip

Question 11

How do Barlow test and significance.

Answer 11

Adduct hip and push downwards to try dislocate femur head from acetabulum -unsafe. Test for DDH.

Question 12

Trendelenburg test and significance.

Answer 12

Pt stand on abnormal leg for 30 seconds. Normal contralat hip sag down = weak hip abductors (gluteus medius and minimus)

Question 13

Gower’s sign and significance

Answer 13

Use hands to push on legs to stand up. Indicate proximal muscle weak

Question 14

How perform examination of the knee?

Answer 14

Look
• skin; scars, trauma, erythema, bruising, psoriasis plaques, sinus/cloaca
• soft tissue: swelling, muscle atrophy, asymmetry, body weight (risk factor)
• bones: varus, valgus, deformity , patellar position in centre , knee hyper extension (cruciate ligament injury) , fixed flexion, Q angle
• gait: antalgia, stride length, muscle weakness

Feel
• skin: warmth, tender, sensation
• soft tissue: pes anserine ,patellar tendon, iliotibial band tenderness; effusion: patella balloting, milking / tap (effusion), baker’s cyst in popliteal fossa; quadriceps wasting
Pulses: popliteal, dorsalis pedis, post tibial
• bones: joint line tenderness, patellar tenderness, tibial tuberosity ( elevation and tender: osgood schlatter disease) head fibula

Move
• active and passive flexion (sciatic n) and extension (femoral n): normal 10° extension to 13o° flexion
• rotation: in full extension, minimal rotation. At 90° flexion, 45° external rotation and 30° internal
• abduction, adduction: 0 in extension, at 30° flexion a few degrees of passive motion possible
• crepitus

Special tests
• ACL: Lachman’s test most sensitive, ant drawer test, pivot shift
• PCL: post drawer most accurate, posterior sag sign, reverse pivot shift
• mcl: valgus stress test
• LCL: varus stress test
Meniscus: McMurray’s test, Apley’s grinding test, Thessaly test
• patella: patellar apprehension test,

• neurovascular examination

Question 15

Describe Lachmann’s test

Answer 15

• Most sensitive test for ACL laxity or rupture..
• flex knee to 30° and hold lower leg with dominant hand, with thumb on tibial tuberosity and fingers over calf
• nondominant hand, hold thigh just above patella
• pull tibia forward on femur with dominant hand while left hand stabilise femur
. Significant anterior movement tibia on femur = ACL laxity or rupture

Question 16

Describe anterior drawer test

Answer 16

• Supine with knee flexed to 90°
• wrap hands around prox tibia with fingers around back of knee joint and rest forearm down pts lower leg to fix its position, thumb over tibial tuberosity
• pull tibia anteriorly
• significant anterior movement of tibia on femur = ACL laxity or rupture

Question 17

Describe posterior drawer test

Answer 17

• Supine with knee flexed to 90°
• wrap hands around prox tibia with fingers around back of knee joint and rest forearm down pts lower leg to fix its position, thumb over tibial tuberosity
• push tibia posteriorly
• significant posterior movement = PCL laxity or rupture

Question 18

Describe pivot shift test

Answer 18

• Supine with legs relaxed in extension
• grasp heel of leg and other hand lateral on proximal tibia just distal to knee
• apply passive valgus stress while maintaining internal rotation of tibia and flexing knee to 25-30°
• feel subluxation of lateral tibial plateau as it reduces to normal position =ACL injury (best to elicit under anaesthesia)

AKA test of McIntosh

Question 19

Describe reverse pivot shift test

Answer 19

• Supine with legs flexed at knee to 90
• grasp heel of leg and other hand lateral on proximal tibia just distal to knee
• apply passive valgus stress while maintaining external rotation of tibia and extending knee
• feel subluxation of tibia as it reduces to normal position =PCL injury (best to elicit under anaesthesia)

Question 20

Describe posterior sag sign

Answer 20

• Flexed knee to 90 while supine
• inspect lateral knee for evidence of post sag: backward displacement of tibia
• present = PCL injury

Question 21

Describe varus stress test

Answer 21

• Pt supine with legs extended
• hold ankle between elbow and side, (same side as examining leg eg if examine right leg, use right hand) and palm (same side as examining leg ) over medial knee
. Other hand (opposite side as examining leg ) a bit lower down over lateral aspect lower limb, with fingers reaching up to palpate lateral knee joint line
• push steadily outward with same side palm while push in with opposite side palm while palpating lateral knee joint line with fingers of opposite side hand
• If abduction or adduction possible felt by palpable gap in lateral joint space secondary to varus force = LCL laxity or rupture

Question 22

Describe valgus stress test

Answer 22

• Pt supine with legs extended
• hold ankle between elbow and side, (same side as examining leg eg if examine right leg, use right hand) and other palm (opp side as examining leg ) over lateral knee
. hand (same side as examining leg ) a bit lower down over medial aspect lower limb, with fingers reaching up to palpate medial knee joint line
• push steadily inward with opp side palm while push out with same side palm while palpating medial knee joint line with fingers of same side hand
• If abduction or adduction possible felt by palpable gap in medial joint space secondary to valgus force = MCL laxity or rupture

Question 23

Describe McMurray’s test

Answer 23

To examine right knee (use OPP hands if examining left)
• pt supine
. Passively flex knee as far as possible
• hold pt r knee with l hand, with thumb over medial aspect and finger over lateral aspect of joint lines
. Hold r foot by sole with R hand
• create valgus (med meniscus) or varus (lat meniscus) stress on knee joint with L hand by apply out/inward pressure as if trying to abduct/adduct leg whilst fixating and externally/internally rotating foot. At same time slowly extend knee joint.
• click and discomfort = medial/ lateral meniscus tear

Question 24

Describe patellar apprehension test

Answer 24

• pt knee fully extended supine
. Apply lateral directed pressure to patella while slowly flexing knee
• active resistance or pain = previous patellar instability and dislocation

Question 25

Describe Thesally test

Answer 25

• Pt stand on affected leg and flex other leg at knee to 20°
• ask pt to rotate knee medially and laterally 3 times each direction
• joint line discomfort or locking or catching = injured meniscus

Question 26

Describe Apley’s grinding / compression test

Answer 26

• Patient prone with knee flexed to 9o
• one hand on foot, other on tibia
• compress knee into tibia then internally and externally rotate tibia
• medial joint line pain = medial meniscus injury,
Lateral joint line pain = lateral meniscus injury

Question 27

Describe patellar grind test / Clarke’s sign

Answer 27

• Pt supine with knees extended
• compress patella posteriorly and inferiorly, then ask pt to contract quads
• apprehension / pain/ crepitus = patellofemoral syndrome eg osteoarthritis

Question 28

How assess flexor digitorum superficialis?

Answer 28

Isolate other fingers by holding top of fingers, then ask patient to flex at proximal interphalangeal joint

Question 29

How assess flexor digitorum profundus?

Answer 29

(Median nerve)

Hold fingers at proximal interphalangeal joints to inactivate them then ask patient to flex distal

Question 30

How do shoulder examination?

Answer 30

1. Introduce and consent

2.look
• skin: scars, bruising
• soft tissue: weight, wasting trapezius and deltoid, wasting supra and infra spinatus
• bones: asymmetry shoulder girdle (scoliosis, arthritis, #, dislocation), abnormal bony prominence, scoliosis, winged scapula (patient push against wall- serratus anterior muscle weak due to long thoracic nerves injury)

3. Feel
   • skin: temperature
   • soft tissue: swellings rotator cuff in extension, biceps tendon in external rotation tone
   • bones: sternoclaviculaer joint, clavicle, acromiodavicular joint, acromion ( most superolateral prominence), coracoid process (inferomedial to clavicular tip) head humerus, greater tubercle humerus, spine of scapula

4 move - normal first - active and passive - pain, power
• external rotation and abduction: hands behind head with elbows pointing to side
. Internal rotation and adduction: hands behind back and reach as far up spine as possible
• flexion: 150-180°
• extension: 40°
• abduction: 180°
• adduction: 30-40°
• ext rotation: 80-90° (elbows at sides at 90° flex while move forearms out )
• int rotation: can reach t4-t8 (hand behind back and reach up)

5. Special tests
   • Neer’s sign (impingment rotator cuff at 80° )
   • painful arc (impingement supraspinatus at 60-12o° abduction)
   • scarf test /cross body adduction (AC joint )
   • Hawkins test (impingement)
   • popeye sign (long head biceps prox tendon rupture)
   • speed’s test (biceps)
   • drop arm sign (full thickness rotator cuff tear esp supraspinatus, most specific )
   • apprehension test (shoulder instability)
   • sulcus test (multidirectional instability)
   • Obrien’s steering wheel test (slap lesion)

Question 31

How do painful arc test?

Answer 31

• Abduct arm passively to Max
• ask patient to lower arm slowly back
• pain at 60-120° abduction = supraspinatus impingement

Question 32

Describe speed’s test

Answer 32

• Attempt to forward elevate shoulder against resistance while elbow extended and forearm supinated
• pain in bicipital groove = biceps tendinitis

Question 33

Describe shoulder apprehension test

Answer 33

• Shoulder 90° abduction and externally rotated passive

* apprehension = anterior instability

Question 34

describe sulcus test

Answer 34

• Pt stand relaxed with arm at side
• examiner pull arm inferiorly
• sulcus/infolding beneath acromion process/superior humeral head = multidirectional shoulder instability

Question 35

Describe o’brien’s steering wheel test

Answer 35

Aka active compression test
• pt forward flex arm to 90° while elbow extended
• adduct arm 10-15° across body
• pronate forearm so thumb point down
• examiner apply downward force to wrist while patient resists
• patient then supinate forearm and examiner repeat test
• “deep” pain in glenohumeral joint while forearm pronated but not supinated = slap tear (superior labrum from anterior to posterior)

Question 36

!!! Describe drop arm sign

Answer 36

• Passive elevate arm in scapular plane to 90
• ask patient to slowly lower arm
• arm drop to side due to weak/pain = supraspinatus tear
Most specific test for full thickness rotator cuff tear

Question 37

What is Wartenberg’s sign?

Answer 37

hand flat on surface pronated with digits extended and abduct. Ask pt to adduct fingers. Positive = inability to adduct 5th finger when extended = ulnar nerve palsy

Question 38

How test radial nerve at mcp joint?

Answer 38

Extend mcp while IPJs flexed so that lumbricals (ulnar and median nerve) don’t take over.

Question 39

Describe galeazzi test /sign

Answer 39

Aka Allis sign or skyline test
• infant supine, hips flexed to 45, hips flexed to 90 with feet flat on examining surface
• knees at unequal heights = hip dislocation on side of lower knee, specifically sensitive for DDH..
And limb length discrepancy.

Question 40

Describe modified hippocratic technique

Answer 40

• Ant shoulder reduction technique

* same as hippocratic, but foot moved to chest wall.

Question 41

Describe the kocher method

Answer 41

• Method of anterior shoulder dislocation
• adduct upper arm to body with elbow extended and shoulder 90° externally rotated. Apply traction
• suddenly addict upper arm across body and force internal rotation
• contraindicated postmenopausal women or osteoporotic bone! Very high risk humeral neck #

Question 42

Describe the Cunningham method

Answer 42

• Nonsedative technique
• massage trapezius, then deltoid, then biceps
• theory = if patient’s muscle spasm can resolve, the shoulder will reduce without using sedatives.

Question 43

How examine for knee effusion (2)

Answer 43

• Patellar tap
• compress suprapatellar pouch with one hand to squeeze any fluid from pouch into joint
• with other hand, patella tapped sharply back onto femoral condyles
• Patella felt striking femur and bouncing off again (type of balottement) = effusion

Or fluctuation test: thumb and finger around patella while pushing fluid from suprapatellar pouch with other hand-positive = finger and thumb pushed apart.

Question 44

Name a test for slap lesion

Answer 44

0 brien’s steering wheel test

Question 45

Name 1 special test for the patella

Answer 45

Patellar apprehension test (previous dislocation)

Question 46

Name 1 special test for the lateral collateral ligament

Answer 46

Varus stress test

Question 47

Name 1 special test for the medial collateral ligament

Answer 47

Valgus stress test first in extension then 15 degrees flexion

Question 48

Name 3 special test for the menisci

Answer 48

• McMurray test
• Apley’s grinding test
• Thessaly test

Question 49

Name 3 special test for the anterior cruciate ligament

Answer 49

• Lachman test most sensitive
• anterior drawer test
• pivot shift test

Question 50

Name 3 special test for the posterior cruciate ligament

Answer 50

• posterior drawer test most accurate
• posterior sag sign
• reverse pivot shift

Question 51

Describe the Thomas test

Answer 51

• Pt supine, pt hold knee to chest to point that lumbar spine felt flexing (lordosis disappear),
• clinician assess whether thigh of extended leg maintains full contact with surface
• if thigh of extended leg raise = decrease flexibility in rectus femoris or iliopsoas or both. = hip flexion contracture (fixed flexion deformity) or psoas syndrome, common in athletes.

Question 52

How do elbow examination?

Answer 52

Look
• cubitus varus and valgus
• fixed flexion deformity
• rheumatoid nodules, psoriasis etc

Feel
• biceps

Move
• flexion 0-145°
• extension 0°
• pronation 0-85°
• supination 0-90°

Special tests
• medial epicondylitis (golfer’s elbow): active wrist flexion against resistance
• lateral epicondylitis (tennis elbow): active wrist extension against resistance, mill’s test, cozen test
• medial ulnar collateral ligament: valgus stress test
• lateral ulnar collateral ligament: lateral pivot shift test or posterolateral apprehension test
• radial collateral ligament: chair push up test

Question 53

Name 3 special tests that can be performed to test rotator cuff impingement

Answer 53

• Neer’s sign (80)
. Painful arc (supraspinatus at 0-15)
• Hawkins test

Question 54

Name a special test for the Ac joint

Answer 54

Scarf test / cross body adduction

Question 55

Name 2 special tests for the biceps

Answer 55

• Popeye sign (long head prox tendon rupture)

* speed’s test

Question 56

Name 2 special test for shoulder stability

Answer 56

• Apprehension test

* sulcus test (multidirectional instability)

Question 57

Name a special test for slap lesion

Answer 57

O’brien’s steering wheel test

Question 58

Identify pathology picture 144 trauma section and type of scan.

Answer 58

LODOX
• unstable floating left knee
• left midshalft tib-fib comminuted fracture
-Tibia shortened, Valgus angulation, 80% apposition
- fibula shortened, Valgus angulation, 80% apposition
• distal oblique left femur fracture with shortening, o apposition, varus angulation

Question 59

Identify pathology picture 145 trauma section

Answer 59

C7 and t1 spinous process fractures

• loss of posterior spinous line and don’t converge at a point.