Orthopaedic history and examination Flashcards
a patient is complaining of lower limb joint pain, what is it important to find out in history of presenting complaint?
site of pain, referred pain
quality-less important, but sharp groin pain more suggestive of hip OA, dull ache more suggestive of bone malignancy?
intensity/severity- /10, has this changed-progression, what does it stop you from doing-walking distance
-what stops you from walking any further-?joint pain ,SOB or cramping calf pain suggestive of IC- or also spinal stenosis, venous claudication, OA or IV disc herniation.
-and general mobility status, requirement of walking aids?
,up and down stairs, getting in and out of chair/shower/car, AODL, work, heavy work, night pain, amount of analgesia required, activity limitation e.g. exercise
onset-sudden or insidious-so when did it start and how long did it take to reach maximum pain, duration of pain, time of day pain in worse
differential questions in knee pain?
knee locking-meniscal, OA
knee giving weigh-meniscal, OA
chronic knee pain up and down stairs-patellofemoral joint-OA
knee stiffness-inflammatory arthropathy e.g. RA
immediate post trauma swelling-ACL tear
important consideration in history of upper limb pain history?
age
hand dominance
occupation
functional requirements
what is the cause of a ‘popeye’ sign?
ruptured proximal tendon of long head of biceps brachii, origin of which is the supraglenoid tubercle of the scapula
test specific for teres minor pathology?
Hornblower’s test: pt holds their arm in 90 degrees of abduction and 90 degrees of external rotation. +ve test if arm falls into internal rotation or patient unable to actively ER arm against resistance.
what is rotator cuff impingement and how can it be tested for in the shoulder examination?
impingement occurs when the acromion process of the scapula rubs against the tendon of supraspinatus and the subacromial bursa, causing irritation and pain.
the impingement syndrome, also known as chronic tendonitis, occurs in patients usually aged between 40 and 50 who present with a history of recurrent anterior shoulder pain following vigorous or unaccustomed activity (subacute tendinitis), the pain settling down with rest or anti-inflammatory treatment, only to recur when more demanding activities resumed. characteristically pain worse at night, pt cannot lie on affected side, and simple activities e.g. dressing can be restricted by pain and slight stiffness. May be coarse crepitation or palpable snapping over rotator cuff when shoulder passively rotated, which can indicate partial tear or marked cuff fibrosis.
Tests:
Painful arc: arm passively abducted to max. abduction, pain between 50 and 130 degrees, and pt asked to slowly bring arm back down to side.
Jobe’s test (empty can test): arm abducted to 90 degrees, and angled forwards at 30 degrees (in plane of scapula), and IR with thumb pointing to floor. arm pressed whilst pt asked to maintain position. if pain or weakness, test positive for supraspinatus impingement or weakness.
Neer impingement sign: raised arm of patient between flexion and abduction whilst using other hand to prevent scapula motion, with pain elicited as greater tubercle impinges against acromion. test: +ve if marked improvement in pain following LA injection into SA space.
Hawkin’s sign: arm in 90 degrees abduction, elbow 90 degrees flexion, and internally rotate whilst adducting arm, which drives greater tubercle under CA ligament.
what test can be used to detect a supraspinatus tear?
drop arm test:
arm passively elevated in scapular plane to 90 degrees and pt then asked to slowly lower arm to their side. +ve test when arm drops quickly to their side due to muscle weakness/pain.
how can subscapularis be tested for?
Gerber’s lift off test:
hand brought around back to lumbar spine, with palm facing outwards. examiner places their hand against patients hand whilst patient tries to lift their hand away from their back. inability to do this is +ve test for subscap pathology as arm in IR.
if can’t do this can do belly press test, where pt places hand on their tummy with palm, maintaining shoulder in IR. If elbow drops back so does not remain in front of trunk then +ve.
test for infraspinatus?
ER so can do ER lag sign: elbow passively flex to 90 degrees, and wrist held to rotate shoulder to max ER. Pt asked to hold arm in that position, +ve test if arm starts to drift into IR.
how can ACJ pathology be assessed for?
cross-body adduction test/scarf test:
examiner adducts arm across chest with arm in 90 degrees of flexion, test is +ve if pt complains of pain.
how can shoulder joint instability be examined?
apprehension test: stand behind pt and abduct arm to 90 degrees, slowly ER shoulder with 1 hand whilst using other hand to push head of humerus forwards with thumb. apprehension, fear or refusal to continue evidence of chronic anterior instability of shoulder.
jerk test: pt shoulder over edge of exam counch and flex both shoulder and elbow to 90 degreees, and with 1 hand on elbow push downwards and attempt to sublux head posteriorly. a jerk/jump will be felt if this occurs (instability).
multidirectional instability: sulcus sign at superior portion of humeral head with affected arm pulled inferiorly.
what tests of the upper limb can be used to assess for cervical cord compression (UMN lesion?) producing cervical radiculopathy?
Hoffman’s test: flicking the nail of the middle finger causes clasping of thumb and index finger.
Spurling’s test: lateral flexion of neck to side of pain, extend a little bit then apply axial pressure-push down on head, if causes pain then positive test.
if patellar reflex absence, which diagnosis is more likely between IV disc herniation and spinal stenosis?
spinal stenosis
what evidence of neurofibromatosis may be examined for during inspection in a spine examination and why?
cafe-au-lait spots
neurofibromatosis associated with scoliosis
commonest scoliosis?
a protective scoliosis in the lumbar region secondary to a prolapsed IV disc
note if shoulders and hips are level
if pt with scoliosis on standing sits and the scoliosis disappears, what does this indicate?
that the scoliosis is mobile, may be secondary to leg shortening
when is tenderness over lumbar muscles most likely?
if protective muscle spasm in cases of prolapsed IV disc and mechanical back pain
what are we looking for on spinal examination?
asymmetry-look at head, shoulders, pelvis
scoliosis
scars
muscle wasting
kyphosis and lordosis from side, ?normal cervical lordosis, thoracic kyphosis and lumbar lordosis
observe gait-?trendelenberg, antalgic, high-stepping
ask to walk on tip toes-S1
ask to walk on heels-L5
what are we palpating for on spinal examination?
spinous processes-localised or generalised bony tenderness? note most prominent C7, suprscapular T3, infrascapular T7, level of iliac crest L4 and PSIS S2
SI joints
paraspinal muscles-localised or diffuse? spasm?-e.g. unilateral protective spasm in IV disc herniation
movements tested on spine examination?
cervical spine-flexion and extension-touch chin to chest and look up to ceiling (occiput and C1), rotation (C1-C2) (turn head to look over shoulder) and lateral flexion (C2-C7)-can you move your head down to touch your ear to your shoulder, keeping your shoulders still
thoracic spine-rotation- ask pt to sit and hold their pelvis down, then ask them to turn their body to look over their shoulders
lumbar-forward flexion-keep legs straight and try and touch your toes, then lean back as far as comfortable (extension)
then lateral flexion- keeping your legs straight, can you run your R hand down your R leg as far as it will go, and rpt for other side.
special tests to perform in spinal examination?
schober’s test for AS: draw a line between the PSISs and then measure 10cm above this line and mark. then asp pt to try and touch their toes keeping legs straight and now measure distance between the 2 marks, should be at least 15cm or more, less than this suggestive of restricted lumbar spinal forward flexion suggestive of AS.
can mark 5cm below aswell and measure distance-should then be 20cm or more*
nerve tension: cervical cord compression: spurling sign-applying axial pressure with neck lateral flexion and extension causes pain
lumbar spine-straight leg raise test for sciatica-with 1 hand on knee and 1 on heel of foot leg keeping knee straight, ask when get pain, then DF foot-see if pain increased (lasegues sign?)-full sciatic nerve stretch test, then flex knee to see if pain lessens. raise leg until pain then stop and record angle. sensitive test.
positive straight leg raise test would be an angle less than 80-90 degrees of leg elevation produces pain in buttock, thigh and calf, ? pain just in back-negative?, despite small angle producing pain (30-40 degrees). if less than 30 degrees and pain, not due to disc prolapse as nerve root not stretched in this range.
?lasegues sign +ve if angle leg can be raised before pain is less than 45 degrees*
crossover sign-CL leg straight leg raise test causes pain in affected leg (specific).
how can findings of spinal examination be summarised?
spine curvature normal with normal cervical lordosis, thoracic kyphosis and lumbar lordosis
no tenderness to palpation of spinous processes or paraspinal muscles
good ROM
would like to perform full peripheral neurological exam./vasc exam.
examine hips?
request appropriate investigations
what does Hoffman’s sign provide evidence of?
UMN lesion-cervical cord compression?*
what examination should complete back pain presentation?
DRE-examine anal tone and voluntary anal contraction
