Examination of Limbs

Question 1

Examination of limbs

General format (Look)

Answer 1

Look for:

• Swelling
• Deformity:
• Angular deformities in the sagittal plane (i.e. flexion or hyperextension deformity)
• Angular deformities in the coronal plane (i.e. varus or deviation of the distal segment towards the midline and valgus or deviation of the distal segment away from the midline)
• Rotational or torsional deformities in the transverse plane (i.e. medial or lateral rotation)
• Redness
• Nodules (e.g. rheumatoid nodules)
• Skin rashes or lesions (e.g. psoriasis)
• Muscle wasting
• Scars of previous surgery, trauma or infection
• Asymmetrical or symmetrical abnormalities (symmetrical involvement seen in rheumatoid arthritis).

Question 2

Examination of limbs

General format (Feel)

Answer 2

Feel for:

• A difference in temperature in and around the joint. Use the back of your hand to assess temperature; feel proximal and distal to the potentially abnormal area.
• There is usually a temperature gradient away from the heart so that the thigh is normally warmer than the knee, which is warmer than the shin.
• Tenderness – you should look at the patient’s face while palpating
• Swelling, which you will have detected on inspection. Feeling for swelling at this stage would confirm what you have seen, but also determines the nature of the swelling

Question 3

Examination of limbs

General format (Move)

Answer 3

• Active movement, i.e. that performed by the patient, should be observed first
• followed by passive movement

Question 4

Examination of limbs

Shoulder

Answer 4

• Subscapularis is a medial rotator of the shoulder
• teres minor and infraspinatus are lateral rotators of the shoulder
• Gleno-humeral abduction is initiated by supraspinatus and the deltoid abducts the arm beyond the initial 15°
• The upper fibres of trapezius elevate the scapula, its middle fibres retract the scapula, and the lower fibres depress the scapula
• Teres major is also a medial rotator of the shoulder, but also extends the arm at the shoulder joint
• Pectoralis major flexes, adducts and medially rotates the arm at the shoulder joint
• Pectoralis minor pulls the tip of the shoulder inferiorly and protracts the scapula.
• Serratus anterior protracts the scapula and maintains close apposition of the inferior angle of the scapula against the thoracic wall.
• Latissimus dorsi adducts, medially rotates and extends the arm at the shoulder.

Question 5

Examination of limbs

Elbow

Answer 5

• The medial and lateral epicondyles are equidistant from the olecranon; lines connecting these points should form an isosceles triangle.
• If not, this may suggest a previous elbow injury. Tenderness over the common flexor and extensor muscle origins may indicate an epicondylitis, ‘golfer’s’ and ‘tennis’ elbow respectively.
• Epicondylitis may affect the extensor origin (tennis elbow and associated pain on resisted dorsiflexion of the wrist) or the flexor origin (golfer’s elbow and associated pain on resisted palmar flexion of the wrist).

Question 6

Examination of limbs

Forearm, wrist and hand

Answer 6

• The radius and ulna have a proximal and distal radio-ulnar articulation.
• Pronation and supination of the hand occurs as a result of the radius rotating about the ulna and at the radiocapitellar joint.
• The hand is supinated when the palm faces anteriorly and is pronated when it faces posteriorly.
• Supination is produced by the action of biceps and supinator. Pronation is produced by pronator teres and pronator quadratus located at the proximal and distal ends of the forearm respectively.

Question 7

Examination of limbs

Muscles acting on the hip

Answer 7

Muscle compartments of the thigh

• Anterior: rectus, sartorius and vasti
• Posterior: biceps, semimembranosus and semitendinosus
• Medial: adductor magnus, longus and brevis, and gracilis

The adductors are supplied by the obturator nerve (with the exception of magnus, which also receives a supply from the tibial division of the sciatic nerve), the vasti by the femoral nerve and the hamstrings by the sciatic nerve.

Question 8

Examination of limbs

Knee

Answer 8

Patellar instability tests

• Check patellar tracking. If there is a history of patellar instability, a patellar apprehension test can be performed by attempting to displace the patella (usually laterally).
• Compare your findings with those of the opposite knee, but remember that some conditions cause bilateral abnormalities.

Ligament laxity tests
Abduction (valgus) and adduction (varus) tests

Meniscal tests

• The most common signs associated with a meniscal tear are the presence of a small effusion, reproduction of joint margin pain when squatting down and joint margin tenderness. To detect joint margin tenderness, ask the patient to flex the knee to 90°.
• The lateral joint margin is located just proximal to Gerdy’s tubercle. The medial joint margin is at the same level on the other side.
• Meniscal tears are most common in the middle and posterior third of the meniscus, so tenderness is frequently maximal posteriorly.

Question 9

Examination of limbs

Foot and ankle

Answer 9

Muscle compartments of the lower leg

• Anterior: tibialis anterior, extensor hallucis longus and extensor digitorum longus
• Posterior: gastrocnemius, soleus, tibialis posterior, flexor hallucis longus and flexor digitorum longus
• Lateral: peroneus longus and brevis

Feel for the dorsalis pedis and posterior tibial pulses, which may be reduced and point to an ischaemic cause for the patient’s pain, or be of relevance when considering the potential for wound healing if surgery is being contemplated.

Question 10

Examination of limbs

Spine

Answer 10

• The femoral nerve stretch test is tested as follows: the knee is flexed to 90°, the pelvis stabilized by one of the examiner’s hands, and with the other hand the hip is extended whilst the knee is held flexed
• The straight leg raising test is performed by keeping the knee extended and at the same time passively flexing the hip.
• The tibial nerve stretch test is also performed while the patient remains supine. The hip is flexed to 90° and the knee is extended.

Question 11

Neurological assessment of the upper limb

Answer 11

Examination of the peripheral nervous system should follow these steps:

• Observation of the limb
• Passive movement of the joints in the area to be examined to detect any fixed deformity that will affect motor testing. This also allows evaluation of muscle tone
• Manual motor testing of the muscles innervated by the nerve(s), beginning proximally and proceeding sequentially to the most distal muscles
• Testing of the sensory branches/dermatomes supplied by the nerve(s)
• Reflexes.
  *

Question 12

Neurological assessment of the upper limb

Assessment of motor function of peripheral nerves

Answer 12

Radial nerve:

• A high radial nerve palsy will produce loss of extension at the wrist, fingers and thumb, whereas a lesion of the posterior interosseous nerve will produce loss of extension of the fingers and thumb, and loss of thumb abduction, but the wrist is spared.
• To test the nerve, begin proximally by testing triceps, brachioradialis and the radial supinator. Then proceed to the distal muscles innervated by the posterior interosseous nerve.

Median nerve:

• Begin by testing the forearm muscles supplied by the nerve (flexor pollicis longus, flexor digitorum profundus and the radial half of the flexor digitorum superficialis) as described above.
• In the hand, the median nerve supplies the thenar muscles apart from adductor pollicis (ulnar nerve).
• The thenar muscles abduct and oppose the thumb. To test these, ask the patient to move their thumb upwards away from the palm (abduction) and to touch the little finger with the thumb (opposition).

Ulnar nerve:

• In the hand this nerve supplies the hypothenar muscles. To test adductor pollicis ask the patient to grip a piece of paper or card between the thumb and the palm.
• If there is an ulnar nerve palsy, the IPJ and MCPJs of the thumb will flex as the patient tries to grip the paper (Froment’s sign).
• The same piece of paper or card can be used to test the interossei. Ask the patient to grip it between the little and ring fingers whilst holding the fingers extended.
• The first dorsal interosseus muscle can be tested by asking the patient to abduct the extended index finger against resistance.

Question 13

Neurological assessment of the lower limb

Answer 13

Movement Innervation

Hip flexion L1 L2

Knee extension L3 L4

Knee flexion L5 S1 S2

Hindfoot inversion L4

Great toe dorsiflexion L5

Ankle plantarflexion S1 S2

Reflex Innervation

Abdominal T8–T12

Knee L2–L4

Ankle S1 S2