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
