Ortho/MSk PACES Flashcards
1
Q
What is the most basic management of an trauma injury
A
Reduce
Restrict
Rehabilitate
2
Q
What are the clinical signs of a fracture?
A
Pain
Swelling
Crepitus
Deformity
Adjacent structural injury to nerves/vessels/ligament/tendons
3
Q
What should always be mentioned in your management plan of any traumatic presentation?
A
Pain relief
4
Q
How can you control swelling
A
Ice
5
Q
What structures run in the limb
A
Nerves
Vessels
Ligaments
Tendons
6
Q
What are the three functions of nerves (thinking about orthopaedic conditions causing neuro compromise)
A
Sensory
Motor
Autonomic
7
Q
How may a vessel injury present in a traumatic injury
A
Think about the 6 Ps
8
Q
What is ‘displacement’
A
loss of bone alignment along its long axis
9
Q
What is ‘angulation’
A
a specific type of displacement where the distal portion of the bone points off in a different direction
10
Q
What does a bone technetium-99 scan tell you
A
technetium is taken up by metabolically active tissues
11
Q
what are the three options for activity on a bone tecnetium-99 scan?
A
metabolically active tissues:
osteoblasts trying to heal a fracture
white cells
tumour
12
Q
How do you describe a fracture radiograph
A
Clinical history
Fracture type
Fracture location
Fracture displacement
Anything else
13
Q
what is an avulsion injury?
A
where the joint capsule, ligament, tendon or muscle attachment site is pulled off from the bone
14
Q
what are the rough definitions of displacement
A
over 1cm = definitely displaced
at a joint surface, anything over 2-4mm is displaced
15
Q
what is the difference between translation and angulation
A
translation = a line drawn down the centre of the bone is not continuous
angulation = a line drawn down the centre of the bone is angled at the fracture
16
Q
What are the three main types of fracture?
A
Complete (all the way through the bone)
Incomplete (the whole cortex is not broken)
Salter-Harris (involves the growth plate)
17
Q
what does transverse fracture look like on x-ray
A
straight through
18
Q
oblique fracture x-ray
A
straight through, but on a slope
19
Q
spiral fracture appearance
A
cork screw
20
Q
commisurated fracture appearance
A
in several pieces
21
Q
bowing fracture appearance
A
incomplete, with the long bone bent
22
Q
buckle fracture appearance
A
incomplete fracture, with the fracture on the concave surface
23
Q
greenstick fracture appearance
A
incomplete fracture, with the fracture on the convex surface
24
Q
what are the three parts of the bone
A
diaphysis
metaphysis
epiphysis
25
label the parts of a bone
26
what is the general rule when describing angulation?
You are comparing the distal component displacement relative to the proximal component for the distally broken bit
27
what are the final 'other things' to talk about when describing a fracture x-ray?
joint involvement (requires different treatment)
other fractures
underlying bone lesion
28
what is the orientation of most x-rays in orthopaedics
AP
29
is the tibia (big bone) lateral or medial usually
tibia is medial usually
30
what is the name given to lateral displacement
valgus (away from the midline)
31
what is the name given to medial displacement
varus (towards the midline)
32
how do you tell if a fracture is translated or not
is there still contact between the fracture location bit
33
Go through the management algorithm for reducing a fracture
34
What are the two different ways you can reduce a fracture
either closed (manipulation or traction) or open (make a cut in the skin and push the bones back into position)
35
What are the potential ways of reducing a fracture through a closed method
manipulation (used in most cases nowadays)
traction (either through skin or pins into the bone) -> not used too much as patient is in bed for too long
36
What are the ways in which you can restrict a fracture after reducing it?
Most of the time:
plaster (closed method)
fixation (sticking metal in)
37
What's the difference between internal or external fixation?
Internal = fixation by sticking metal under the skin and then closing it
external = sticking metal into the bone through the skin and part of it sticks out still
38
What are the two broad types of internal fixation?
either intramedullary (through the bone) - pins or nails
or extra medullary (around the bone) - plates/screws or pins
39
What are the two main intramedullary devices
pins and nails
40
What are the main types of extra medullary devices
plates/screws
pins
41
What are the two main types of external fixation?
monoplanar (in a straight line)
multiplanar (in circular)
42
What are the principles of orthopaedic rehabilitation
use -> pain relief + retrain
move
strengthen
weight bear
43
What type of fixation is this
external fixation -> on the surface of the wrist
(not internal fixation as doesn't go through the medulla of the bone)
44
Why is external fixation used?
Enables you to see and treat infection very quickly
-> hence you use in extensive soft tissue injuries or complex periarticular fracture
45
How do you classify surgical complications?
Local and General
Immediate, within 24h, early <30d, late >30d
46
What are the general complications of a fracture/any surgery?
Fat embolus
DVT
Infection
Prolonged immobility -> UTI, chest infections, bedsores
47
What are the specific complications to a fracture?
Damage to local structures: nerves, vessels and tendons
Non-union / Mal-union (healing in a wonky position)
Infection
48
What are the causes for a fractured neck of femur?
osteoporosis (older)
trauma (younger)
combination
49
types of NOF fracture by location
50
What is the anatomical boundary between extra vs intra-capsular NoF fractures
the trochanteric line is the boundary
51
what anatomical feature is used to look for NOF fractures?
schenton's line i.e. the smooth semi circle
52
What is the usual management of an extra capsular NOF fracture?
if minimal risk to blood supply and AVN, internal fixation with plate and dynamic hip screw
53
What are the management options for an intracapsular NOF fracture?
if undisplaced: less risk to blood supply - fix with screws
displaced: 25-30% risk AVN, replace in older patients, reduce and fixation with screws if young
54
What is the difference in uses of hemiarthroplasty vs total hip replacement?
hemiarthroplasty used if patient is less suitable for surgery (i.e. less mobile, more co-morbidities, older etc)
55
What is the difference between a total hip replacement and a hemiarthroplasty?
THR = femoral head replaced + cup inserted
Hemiarthroplasty = femoral head inserted into native cup
56
What are the three most important factors for a NOF fracture?
age, activity levels, risk of AVN
57
What is the definition of osteoarthritis?
chronic condition resulting in wear of the articular cartilage presenting as pain, swelling, stiffness
58
What is the significance of rest/night pain in osteoarthritis?
could herald infection/tumour
mostly just severe osteoarthritis -> indicates severe pain
59
How do you measure disability caused by osteoarthritis?
walking distance
stairs
giving way
what does it stop them from doing what they want to do
60
what do you always need to remember to ask with any Msk/rheum joint history?
are other joints affected?
61
What is the basic structure of an orthopaedic assessment?
look
feel
move
special tests
62
Should you do a special test in ortho if you think it may hurt the patient?
No, ask the examiner first
63
most likely reason for this knee scar?
total knee replacement
64
what is the angle of flexion in ortho exam?
just make sure you don't say 180 degrees for a straight leg
65
what is an antalgic gait?
way of walking to minimise pain
66
What is the basic structure for investigations in an ortho exam?
weight bearing plain x-ray (AP/lateral views)
if soft tissue, MRI
bloods
67
What is the conservative management of osteoarthritis
analgesics
physiotherapy
walking aids
avoidance of exacerbating activity
injections (steroid/viscosupplementation) - mostly for wet arthritis / inflammatory arthritis
68
What is the operative management of osteoarthritis
replace (knee/hip)
realign (knee/big toe)
excise (toe)
fuse (big toe)
synovectomy (rheumatoid)
denervate (wrist)
69
what type of hip replacement is done for OA?
pretty much always THR
70
what causes joint effusion
Anything that irritates the synovial lining
- synovitis
- inflammatory conditions
- torn ACL
- torn meniscus
71
shoulder MSk exam: look
scars
swelling
deformity
muscle wasting (supra/infra)
72
shoulder MSk exam: feel
clavicle
ACJ
humeral head
73
shoulder MSk exam: move
flexion + extension
abduction (thumb pointing up)
internal rotation
hand behind head (sun-lounger)
hand behind back
74
shoulder MSk exam: special tests
resisted external rotation
resisted abduction
belly press
impingement
adduction
instability
75
how do you test the infra/teres minor
resisted external rotation
76
how do you test the supraspinatus
resisted abduction
77
how do you test the subscapularis
belly press
78
how do you test the ACJ
adduction
79
what are the shoulder conditions in a 15-45 year old
dislocation / fractures
80
what are the shoulder conditions in a 45-60 y/o
impingement
dislocation
ACJ OA
Rotator cuff tears
fractures
81
what are the shoulder conditions in a >60y/o
glenohumeral OA
impingement
cuff tears
fracture
82
hip examination: look standing
scars
wasting
deformity
muscle wasting (gluteal)
alignment
83
hip examination: look walking
from front: antalgic / short leg
trendelenberg
from the side: heel strike, toe off, time spent in stance phase
84
How do you do trendelenberg?
tell patient : 'I'm going to put my hands on your pelvis'
place middle 3 fingers on ASIS and ask patient to put their hands on your arms
stand on one leg, pelvis drops on the side opposite to the stance leg (weak hip abductors) -> SOUND SIDE SAGS
85
hip examination: feel
femoral pulse
assess temperature evenly down both legs
greater trochanter
leg length discrepancy (true or false)
86
hip examination: move
Thomas's test (fixed flexion)
flexion
abduction
adduction
internal and external rotation
87
hip examination: special tests
leg length discrepancy
Thomas' test
88
hip conditions 15-45 y/o
developmental dysplasia
89
hip conditions 45-60y/o
osteoarthritis
avascular necrosis
impingement
90
hip conditions >60
OA
post total hip replacement
91
why do you need to check the buttocks in a hip exam
big scar in THR may go around the back
92
knee examination: look standing
scars
swelling
wasting
deformity
alignment
93
knee examination: look walking
antalgic
varus/valgus
94
knee examination: feel
quads muscle bulk
effusion
joint line palpation
95
knee examination: move
extension + lift off bed then you take the weight
flexion
posterior sag
patellofemoral tracking
96
knee examination: special tests
posterior sag
anterior draw
lachmann's
LCL and MCL at 0 and 20 degrees
97
knee conditions 15-45y/o
patellofemoral maltracking
ACL/PCL
Meniscal tears
fractures
98
knee conditions 45-60 y/o
OA + young person things
99
knee conditions 60+
OA
100
intro spiel for ortho exams
Wash hands
Introduce yourself
Consent
Ask about any areas of pain
101
what should you look out for by the bedside when examining the lower limb
orthotics
walking aids
insoles for shoes
102
where do you expose the patient to in a hip examination
ask to expose to the groin (I.e. lift shorts up)
103
before you lie the patient on the bed in a hip exam what should you do?
ask the patient about pain when lying flat
104
first thing to assess after putting the patient on the bed in a hip exam
femoral pulse first then greater trochanter
105
what would be a cause of pain when palpating the greater trochanter?
trochanteric bursitis
106
what special test do you do between the feel and move sections of a hip exam?
leg length discrepancy + Thomas test
107
how do you measure leg length discrepancy
measure apparent leg length on both
start by put measuring tape on xiphisternum and measuring down to the medial malleolus
108
how do you measure true leg length discrepancy
measure from ASIS down to medial malleolus (top)
109
what is Thomas' test for?
fixed flexion of the hip
110
how do you do Thomas' test?
place palm of hand under the small of the back
ask patient to initially flex both knees up and hold them there
then them to lower one leg down to the bed
look at the angle between the couch and the long axis of the femur
111
what would a positive Thomas' test look like?
femur makes an angle to the bed
when you try to extend the hip down, you'd lose the small of the back gap (lumbar lordosis)
112
how do you assess hip flexion
lying flat on bed, bend hip up with patient holding their knee, place your hand in small of the back again, see what the max degree of flexion is whilst maintaining lordosis
can do both sides of hip from the right of the patient
113
what is the key when examining abduction and adduction of the hip?
you need to stabilise the contralateral ASIS to ensure the pelvis is not moving
114
how do you find the ASIS?
move from inferior to superior
115
how do you assess hip abduction / adduction?
take leg at the ankle whilst other hand is on contralateral ASIS, watch the patients face, test abduction then adduction second
116
in what position do you assess hip internal/external rotation
1: legs straight, cup the heels with your hand, internally rotate both sides simultaneously
switch thumb side then externally rotate
2: bend hip and knee to 90 degrees, move ankle out and in (internal rotation of the hip = moving ankle away laterally)
117
what do you assess after doing hip internal/external rotation?
feel for dorsalis pedis + posterior tibial pulses in feet
swipe down lateral calf for gross sensory assessment
118
differentials for groin pain?
hip pathology
hernia
vascular compromise
referred pain from back
119
how would you complete the hip examination
assess neurovascular status
offer to test the other limb
offer to test the joints above and below
120
what modification do you make to the format of the knee exam
best to examine the patient standing first, and walk them in that position so you can assess gait
121
what do you look for first in a knee examination
look for overall posture, any varus or valgus alignment
look at feet, are the arches present
122
what do you ask the patient to do whilst standing in a knee examination?
stand on toes
123
what positions do you look at the patient from in a knee examination
first look from front, then look from side, then on back
scars, wasting, swelling or erythema
124
what are you looking for on the back view of a knee exam
bakers cyst (popliteal fossa)
muscle wasting of the calves or hamstring
125
after you've looked at the knee, what do you ask them to do next?
from side first then from the front:
assess gait
look for heel strike and toe off, different pathological gaits
126
after watching the patient's gait in knee examination, what do you do?
move patient onto the couch, look from the end of the bed for surgical scars
127
what is the first thing you feel for in a knee exam
feeling for quadricep muscles
ask patient to pull toes towards their head on both sides and push knee down into your hand
feel for vastus medialis, lateralis and then intermedialis (in the middle superiorly)
128
after you've felt the quads in a knee examination, what next?
test for any knee effusion
129
how do you test for knee effusions?
sweep test: milk the fluid by moving your hand superiorly on the medial aspect of the knee, then from laterally above the kneecap, then back down inferiorly
patellar tap test: tap the patellar with right index finger whilst you've stabilised the knee joint
cross-fluctuance test: pinch the kneecap with fingers then move from side to side
130
after you've tested for a knee effusion, what do you do?
straight leg, lift leg off bed and ask to take their weight
then passively flex the knee whilst feeling for a crepitus, see how far they can go
131
what position do you use for assessing knee flexion?
ask patient to bring their toes towards their head, push knee down into hand,
lift leg up straight (approx 20 degrees), then bend knee as far as it will go
132
what position do you assess anterior draw in
80 degrees flexion
133
what is the first thing to do before doing anterior draw
look from the side for a posterior sag
134
positioning for anterior draw
sit on edge of the foot gently
ensure the hamstrings are relaxed
feel for the joint line, thumbs beneath the joint line
135
what positioning do you use for Lachman's test
left thigh under patient's right thigh just above popliteal fossa
left hand over the femur in supracondylar region
other hand on the tibial tuberosity with hand wrapped around the leg
136
what movement do you do in lachman's test
move your lower hand up and down
137
what is the preferred method for assessing the collateral ligaments of the knee
control the lower tibia using your own armpit
thumbs on the joint lines
138
what movements do you do when assessing the collateral ligaments of the knee
leg fully extended move the knee varus then valgus
then do the same at 30 degrees of flexion
139
what do you do after moving the joint in a knee examination when they're lying down
feel for pulses
test gross sensation
140
what do you do after you've finished the lying down part of the knee examination?
sit patient on the side of the couch:
assess for patellar maltracking
141
how do you assess for patellar maltracking
ask patient to straighten the knee then move it back down again
do this whilst your feeling the patella with your thumb and index finger
142
what is the sergeant's patch?
area supplied by the axillary nerve on lateral shoulder
143
what do you look for on shoulder examination?
from front first:
asymmetry in pectoral girdle, deltoids or trapezius
check for scars, swelling, deformity or muscle wasting
from side: check deltoid muscle contour
from back: check for winging of scapula / trapezius
144
what do you palpate first in a shoulder examination
from front:
one hand stabilising the shoulder
palpate from sternum along the clavicle then assess for tenderness along the acromioclavicular joint
feel the muscle bulk of the deltoids
145
after you've palpated the shoulder anteriorly, what do you do next?
palpate posteriorly:
feel for bulk of the supra and infraspinatus muscles
feel along the spine of the scapula and along the medial border of the scapula
146
what is the first thing you move in a shoulder examination?
ask patient palms out to front, thumbs outwards, bring up towards the side as far as they can go and back down again.
147
what is the main thing to note about movement in a shoulder examination?
passive + active movements (the patient copies your movements in active)
148
after you've got the patient to demonstrate abduction of the shoulder, what do you do?
passive internal / external rotation
ask patient to tuck elbows by side and move hands out then back in again
149
what movements do you test after active internal rotation / external rotation for shoulder exam?
compound / screening movements
hand behind head with elbow as far back as possible
then hand behind the back, with thumb as high up as they can go
150
what first passive movement do you assess in the shoulder?
bring arms to 90 degrees, then slowly raise the arm upwards to assess limit
(stabilising the shoulder and watching the patient's face)
151
how do you assess for supraspinatus weakness in a shoulder exam?
empty can test
thumbs pointing down, arms straight and downwards
ask patient to push against your hand
152
after assessing supraspinatus weakness, what do you check for in shoulder exam?
external rotation against resistance
then internal rotation against resistance
153
what instruction do you give to test internal rotation against resistance?
bring your hand into your belly as hard as you can
154
after testing internal/external rotation against resistance, what do you do?
scarf test:
palpate greater tubercle, ask about pain, then move straight arm medially, check for pain
155
what do you do after scarf test in shoulder exam?
Hawkins sign: with elbow bent to 90 degrees, bring wrist parallel to the ground
156
what is Hawkins sign positive in?
subacromial impingement
157
after testing for subacromial impingement (Hawkins sign), what do you do in shoulder exam
ask patient to push against the wall, without lifting shoulders too high
show patient the hand position first
then check for winging of the scapula
158
after you've asked the patient to push against the wall, what do you do?
do dislocation tests:
sulcus sign - look along proximal humerus then pull down on the arm to see whether there's inferior laxity and a sulcus appears
159
what dislocation test for shoulder comes after sulcus sign?
apprehension test
160
what is the positioning for the apprehension test of shoulder?
patient lying on couch
stabilise the shoulder joint with your right hand to make sure it doesn't inadvertently dislocate
move the wrist backwards
repeat with stabilisation at the elbow afterwards
161
what is the first thing to do in a spinal examination
inspection: from the back
look for scars, muscle wasting at the bottom of the back
162
if you suspect scoliosis on inspection of a back examination, what movement can you ask the patient to do to accentuate this?
lean forward, look for a rib hump (where one rib is higher than the other)
163
what do you feel for in a spinal examination?
ensure patient is not in any pain first
palpate temperature first
then feel spinous processes and sacroiliac joints for tenderness and alignment
palpate paraspinal muscles for abnormal muscle bulk and pain
164
what movements do you first do in a back examination
with your hand on their lower back ask the patient to:
lean backwards as much as possible and look up towards the ceiling (extension)
slide their hand to the left and downwards, then to the right side (lateral flexion)
165
after testing extension + lateral flexion in a back examination, what do you do?
assess rotation of the back:
position hands on the patient's hip and ask them to turn to the left, then turn to the right
166
what comes after doing movements standing up in a back exam?
offer Shober's test
167
how do you do schober's test?
feel for posterior superior iliac spines, make a mark in midline at this level, 5cm below and 10cm above
then ask patient to bend over, and the gap between the furthest away points should increase by 5cm+
168
what do you do after doing shober's test in a back exam?
assess gait:
from front and back (look at pelvis)
walk normally first, then on heels, then ask to walk on toes
169
what do you do after checking gait in a back exam?
lay the patient flat (ask for pain first)
do straight leg raise
170
how do you do a straight leg raise?
lift leg straight up until full flexion, or pain is elicited
then dorsiflex the foot passively
do this on both sides
171
what do you do after straight leg raise in back exam
test sensation:
L1: medial thigh (high)
L2: middle portion of thigh
L3: knee
L4: medial calf
L5: big toe
S1: little toe
S2: back of thigh
172
what comes after sensation in a back examination?
test power lying down:
hip flexion, knee flexion and extension, heel flexion and extension, ankle eversion and inversion (against one finger)
173
what do you test after checking motor function in a back exam?
knee / ankle jerk reflexes
174
what do you check after doing reflexes in a back examination?
check pulses in the feet
175
what is the second position you need to put the patient on the couch in for a back examination?
ask patient to lie on their front, do femoral stretch test
176
how do you do a femoral nerve stretch test
last thing in a back examination:
with patient prone, passively flex knee and extend the hip
ask for any pain
177
first step in a neck examination
patient sitting down, look from the front at the neck for scars / wasting etc
then look from the side and then from the back
178
positioning for the feel aspect of a neck examination?
place left hand on patients forehead, use right hand to feel along the back of the spine (from bony prominence at C7 and go up to C1)
179
after palpating C1-C7 bones, what do you do in cervical neck examination?
feel trapezius muscles bilaterally
check wasting of deltoids
180
after you've done the initial feel bit of the cervical neck examination, what type of exam do you then start doing?
turns into a neurological examination
181
what is the first thing you check after palpating the neck in a cervical spine examination?
check sensation + symmetry
C5: deltoids
C6: back of the thumbs
C7: middle fingers
C8: little fingers
T1: inside of the forearm
T2: inside of the upper arm
182
what movements do you check in a cervical neck examination (neuro part)
testing the nerve root function:
C5: shoulder abduction (deltoid)
C6: wrist extension
C7: elbow extension
C8: finger flexion
T1: finger abduction
183
what are the ortho movements you do in a cervical spine exam?
get them to mirror your movements first:
neck flexion to touch chin to chest,
neck extension to look up towards ceiling
right and left rotation
then right and left lateral rotation
184
what comes after you've done the active movements in a neck ortho examination?
test for spurling sign:
passively extend neck then tilt to one side and push down
ask about pain
185
what comes after doing movements in a spinal examination?
reflexes: bicep, brachioradialis, triceps
186
what comes after checking reflexes in a spinal exam?
check tone in arms (slow and fast)
187
what are the three parts of the foot?
188
where does the achilles tendon insert into?
calcaneus bone
189
what's the first thing to test in an ankle examination?
examine gait from front and side
examine arch formation standing flat and on tip-toes
ask patient to stand on heels
190
after examining gait/heels what should you do in an ankle examination?
check for scars, wasting, erythema of ankle
191
what position do you ask the patient to take after looking at the ankle joint whilst standing?
ask them to take a seat, then ask them to show you the soles of the feet (support them as they do this)
192
how do you do the feel part of an ankle exam?
start superiorly from medial and lateral malleolus -> palpate the bony landmarks systematically (forefoot / mid foot / hind foot)
then check the tendons: palpate achilles tendon and heel of the foot (plantar fascia)
193
what position do you do the move aspect of an ankle exam in?
sitting, support the feet
194
what active movements do you test in the ankle joint
active movement
dorsi flexion ('point toes far back as you can')
plantar flexion (point your toes like a ballerina)
195
what passive movements do you test in the ankle joint
dorsiflexion (you need to be on your knees, and you hold onto the sole of the foot, pushing it back)
plantar flexion do the opposite
196
what movements come after passive dorsiflexion/plantarflexion
assess the subtalar joints
197
how do you assess the subtalar joints?
stabilise the talus (place your fingers over the top of the foot) then passively invert and evert the foot from the heel using your other hand
198
after assessing the subtalar joints in an ankle exam, what should you do next?
ask the patient to bring the soles of their feet facing each other, then facing away
testing eversion and inversion
199
what should you do after testing active eversion / inversion of the ankle
check passive big toe dorsiflexion and plantar flexion
200
what special test comes after big toe dorsiflexion/plantarflexion?
silfverskiold test
201
how do you do silfverskiold test?
ask patient to dorsiflex ankle maximally
ask them to relax knee
gradually flex the knee then lower it back down again
should be no change in dorsiflexion
202
what second special test should you do in an ankle exam?
palpate achilles tendon then do Thomson test:
squeeze the calf, and it should cause contraction of the achilles tendon and plantarflexion of foot
203
what comes after special tests in ankle?
look at the tendons -> absolute load of waffle, just have a feel about
test foot dorsi flexion against resistance, big toe flexion, ankle eversion and inversion, plantar flexion
204
What are the three screening questions that need to be asked before doing a GALS examination
Do you have any pain, swelling or stiffness in your muscles, joints or back?
Can you dress yourself completely without any difficulty?
Can you walk up and down stairs without any difficulty?
205
How do you assess Gait in a GALS examination
Ask patient to walk a few steps, turn, then walk back. Observe gait for symmetry, smoothness and the ability to turn quickly
With patient in anatomical position, observe from behind, from the side, and from in front for muscle bulk, limb/spine alignment, swellings
206
How do you assess the arms in a GALS screen
Ask patients to:
-> put their hands behind their head
-> straighten out their arms completely
-> observe back of the hands here for swelling/deformity + nails
-> ask patients to turn hands over so in supination
-> ask patient to make a fist and then to squeeze your fingers
-> ask patient to bring each finger in turn to meet the thumb
-> gently squeeze MCP joints to check for tenderness
207
How do you assess the legs in a GALS screen
Patient lies on couch then:
Whilst feeling over the knee joint line, ask patient to flex and extend each knee in turn
With the hip and knee flexed to 90 degrees, assess internal rotation
Check for knee effusion
Inspect feet for deformity
Squeeze MTP joints for tenderness
208
How do you examine the spine in a GALS examination
With patient standing, inspect from behind for evidence of scoliosis + from the side for abnormal lordosis or kyphosis
Ask patient to tilt their head to each side, bringing the ear towards the shoulder
Ask patient to bend to touch their toes (feeling the small of their back as they do this)
209
What is the basic structure of a hand examination?
Introduction
Look
Feel
Move
Function
210
In what positions do you do the ‘look’ part of a hand/wrist examination
Palms facing downwards first
Then palms turn over
211
What do you look for in the ‘look’ part of a hands examination
Deformity
Swellings
Check skin for thinning/bruising/rashes
Check nails for psoriatic changes
Check muscle wasting and look at elbows
212
What is onycholysis ?
Separation of nail from nail bed
213
What is nail pitting?
when small round depressions or notches appear in the nails
-> common in psoriasis / eczema
214
What do you feel for in a hand exam (palms facing upwards)
Feel for peripheral pulses
Feel for bulk of the thenar and hypothecate eminences and for tendon thickening
Assess median and ulnar nerve sensation by touching over thenar and hypo thenar eminences, then index + little fingers respectively
215
What do you feel for in a hand exam (palms facing downwards)
Assess radial nerve sensation by light touch over the thumb and index finger web space
Using back of your hand, assess skin temperature
Gently squeeze MCP joints to assess for tenderness, then PIP/DIP joints
Palpate the wrists then run your hand up the ulnar border (rheumatoid nodules)
216
What movements should you get the patient to do in a hand exam
Ask patient to:
-> straighten their fingers fully
-> make a fist
Assess wrist flexion and extension actively (ask them to make the prayer sign, then press backs of their hands together)
Assess thumb abduction (median nerve) and finger spread power (ulnar nerve)
217
What additional test should you do if history + examination suggests carpal tunnel syndrome?
Phalen’s test (forced flexion of the wrists for 60 seconds)
-> in a positive test, it reproduces the patients symptoms
218
How do you assess muscle function in a hand exam
Ask patient to grip your two fingers to assess power grip
Ask patient to pinch your finger to assess pincer grip
