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MRCS B Examinations and practical skills > Spine and shoulder examination > Flashcards

Spine and shoulder examination Flashcards

1
Q

Spine: Look

A

General inspection
Closer inspection of spine (anterior/posterior/lateral)
Adam’s forward bend (accentuates scoliosis)

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2
Q

Spine: Feel

A

-Temperature
-Spinal processes and sacroiliac joints
-Paraspinal muscles
-Sacroiliac joints
-Chest expansion if kyphoscoliosis

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3
Q

Spine: Move

A

Cervical spine: Flexion, extension, lateral flexion, rotation
Lumbar spine: Flexion, extension, lateral flexion
Thoracic spine: rotation

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4
Q

SPine: Special tests:

A

-Schober’s
-Sciatic stretch
-Femoral stretch

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5
Q

Spine: To complete examination:

A

-Neurovascular examination of the upper and lower limbs.
-Examination of the hip and shoulder joints.
-Bloods if indicated
-PR and bladder scan if concerned
-Further imaging if indicated (e.g. X-ray/MRI).

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6
Q

Carrying out schober’s test

A
  1. Identify the location of the posterior superior iliac spine (PSIS) on each side-follow iliac crest
  2. Mark the skin in the midline 5cm below the PSIS.
  3. Mark the skin in the midline 10cm above the PSIS.
  4. Ask the patient to touch their toes to assess lumbar flexion.
  5. Measure the distance between the two lines.
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7
Q

Shober’s test interpretation

A

If a patient has normal lumbar flexion the distance between the two marks should increase from the initial 15cm to more than 20cm.

Reduced range of motion is associated with conditions such as ankylosing spondylitis.

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8
Q

Sciatic stretch test (Straight leg raise)

A
  1. Position the patient supine on the clinical examination couch.
  2. Holding the patient’s ankle, raise their leg by passively flexing the hip whilst keeping the patient’s knee fully extended.
  3. The normal range of movement for passive hip flexion is approximately 80-90º.
  4. Once the patient’s hip is flexed, dorsiflex the patient’s foot.

Ask pt: it it worse on dorsiflexing
Is it better on flexing knee

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9
Q

Sciatic stretch test interpretation

A

The sciatic stretch test is considered positive if the patient experiences pain in the posterior thigh or buttock region.

A positive test is suggestive of sciatic nerve irritation (e.g. secondary to lumbar disc prolapse).

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10
Q

Carrying out femoral stretch test

A
  1. Position the patient prone on the clinical examination couch.
  2. Flex the patient’s knee to 90º and then extend the hip joint.
  3. Finally, plantarflex the patient’s foot.
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11
Q

Femoral stretch test interpretation

A

The femoral nerve test is considered positive if the patient experiences pain in the thigh and/or inguinal region.

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12
Q

Define kyphosis

A

Kyphosis refers to an anterior curvature of the spine.

It should be assessed when inspecting the lateral aspect of the spine.

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13
Q

Describe three abnormalities which may be noted on posterior inspection of the spine

A

Spinal alignment: inspect for lateral curvature of the spine indicative of scoliosis
Abnormal hair growth: spina bifida occulta
Scars: discectomy, laminectomy, spinal fusion

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14
Q

Name the sign and describe its typical clinical features

A

Scoliosis involves abnormal lateral curvature of the spine.

Clinical features:

Mild disease is usually asymptomatic
Severe scoliosis can be associated with back pain and impaired respiratory function

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15
Q

Describe how movement of the thoracic spine is assessed during a spine examination

A

Rotation of the thoracic spine is assessed during a spine examination.

To assess rotation of the thoracic spine:

Ask the patient to sit on the side of the clinical examination couch and cross their arms across their chest
Then ask them to turn to the left and the right as far as they are comfortably able to

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16
Q

Describe the movements of the lumbar spine which are assessed during spine examination and explain how you would instruct the patient to perform these movements

A

Movements of the lumbar spine assessed during a spine examination include:

Flexion: ask the patient to touch their toes whilst keeping their legs straight.
Extension: ask the patient to lean back as far as they are comfortably able
Lateral flexion: ask the patient to slide their hand down the outer aspect of the ipsilateral leg as far as they are able

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17
Q

Describe three things that are assessed during the posterior inspection of the spine

A

Things to assess on posterior inspection of the spine include:

Spinal alignment: inspect for lateral curvature of the spine indicative of scoliosis
Iliac crest alignment: leg length discrepancy, hip abductor weakness, scoliosis
Muscle wasting: wasting of the paraspinal muscles
Abnormal hair growth: spina bifida
Bruising: recent trauma or surgery

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18
Q

Describe the purpose of Schober’s test

A

Schober’s test is used to identify restricted flexion of the lumbar spine.

A positive test is commonly associated with a diagnosis of ankylosing spondylitis.

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19
Q

Name three abnormalities which may be identified when examining the spine of a patient with ankylosing spondylitis

A

Clinical signs associated with ankylosing spondylitis include:

Stooped posture and/or loss of a normal lumbar lordosis (between 20-45º) on lateral inspection
Sacroiliac joint tenderness
Reduced range of motion of the lumbar spine (commonly assessed using Schober’s test)

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20
Q

Describe three things to assess during lateral inspection of the spine

A

Assess the following during lateral inspection:

Cervical lordosis: hyperlordosis is associated with chronic degenerative joint disease (e.g. osteoarthritis)
Thoracic kyphosis: normally between 20-45º (hyperkyphosis is associated with Scheuermann’s disease)
Lumbar lordosis: loss of normal lumbar lordosis is associated with sacroiliac joint disease (e.g. ankylosing spondylitis)

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21
Q

List 5 causes Kyphosis

A

Causes of kyphosis include:

Congenital kyphosis
Postural kyphosis
Osteoporosis: compression fractures
Scheuermann’s disease: congenital wedging of the vertebrae
Spinal tumours

22
Q

Describe normal curvature of the spine

A

-Cervical and lumbar: lordosis
-Sacral and thoracic: kyphosis

23
Q

Shoulder: Look

A

General inspection (clinical signs, objects or equipment)
Closer inspection of shoulder (anterior, lateral, posterior)

24
Q

Shoulder: Feel

A

Temperature
Shoulder joint

25
Q

Shoulder: Move

A

Compound movements

Active:
-Flexion
-Extension
-Abduction
-Adduction
-External rotation
-Internal rotation
-Scapular movement

Passive
-Repeat above movements passively

26
Q

Shoulder: Special tests

A

-Supraspinatus assessment
-Painful arc (impingement syndrome)
-External rotation against resistance
-Internal rotation against resistance (Gerber’s lift off test)
-Scarf test

27
Q

Describe how you would complete examination (shoulder)

A

Neurovascular examination of the upper limbs.
Examination of the joints above and below (cervical spine and elbow joint).
Bloods
Further imaging if indicated (e.g. X-ray and MRI).

28
Q

Components of the shoulder girdle which should be palpated in a shoulder examination include:

A

Sternoclavicular joint
Clavicle
Acromioclavicular joint
Acromion
Coracoid process of the scapula
Head of the humerus
Greater tubercle of the humerus
The spine of the scapula

29
Q

What compound movements are used in shoulder examination

A

External rotation and abduction of the shoulder joint: Ask the patient to put their hands behind their head and point their elbows out to the side.

Internal rotation and adduction of the shoulder joint: Ask the patient to place each hand behind their back and reach as far up their spine as they are able to.

30
Q

Describe how you would test shoulder adduction

A

Instructions: Ask the patient to keep their arms straight and move them across the front of their body to the opposite side.

31
Q

Describe how you would test shoulder internal rotation

A

Instructions: Ask the patient to place each hand behind their back and reach as far up their spine as they are able to.

32
Q

Describe how you would assess scapular movement

A

Instructions: Ask the patient to abduct their shoulder, whilst you simultaneously palpate the inferior pole of the scapula. Assess the degree and smoothness of scapular movement.

On average 50-70% of the scapula’s initial movement occurs at the glenohumeral joint.

If the glenohumeral joint’s movement is reduced due to injury or inflammation then the majority of abduction will occur via increased scapular movement over the chest wall.

33
Q

Describe supraspinatus special test assessment

A

This clinical test assesses the function of the supraspinatus muscle.

  1. Abduct the patient’s arm to 90° and then angle the arm forwards by approximately 30° so that the shoulder is in the plane of the scapula.
  2. Internally rotate the arm so that the thumb points down towards the floor.
  3. Now push down on the arm whilst the patient resists.
34
Q

Describe interpretation of supraspinatus test

A

This test assesses for weakness and/or impingement of supraspinatus. Weakness may represent a tear in the supraspinatus tendon or pain due to impingement.

35
Q

Describe The painful arc (impingement syndrome)

A

This clinical test assesses for impingement of supraspinatus.

  1. Passively abduct the patient’s arm to its maximum point of abduction.
  2. Ask the patient to lower their arm slowly back to a neutral position.
36
Q

Describe interpretation of the painful arc

A

Impingement or supraspinatus tendonitis typically causes pain between 60-120° of abduction, however, this test is not specific as many other conditions can cause pain in this arc of motion and therefore it should not be used in isolation for diagnosis.

37
Q

Describe external rotation against resistance

A

This clinical test assesses the function of the infraspinatus muscle and teres minor.

  1. Position the patient’s arm with the elbow flexed at 90°and in slight abduction (the abduction tests whether the patient can keep the arm externally rotated against gravity).
  2. Passively externally rotate the arm to its maximum.
38
Q

Describe interpretation of external rotation against resistance

A

Pain on resisted external rotation may suggest tendonitis (infraspinatus/teres minor).

If the arm falls back to internal rotation or there is a loss of power it may suggest a tear in the infraspinatus or teres minor tendon, muscle wasting and/or a lower motor neurone lesion (suprascapular or axillary nerve).

39
Q

Internal rotation against resistance (Gerber’s lift-off test)

A

This clinical test assesses the function of the subscapularis muscle.

  1. Ask the patient to place the dorsum of their hand on their lower back.
  2. Apply light resistance to the hand (pressing it towards their back).
  3. Ask the patient to move their hand off their back.
40
Q

Internal rotation against resistance (Gerber’s lift-off test) Interpretation

A

This clinical test assesses the function of the subscapularis muscle.

  1. Ask the patient to place the dorsum of their hand on their lower back.
  2. Apply light resistance to the hand (pressing it towards their back).
  3. Ask the patient to move their hand off their back.
41
Q

Internal rotation against resistance interpretation

A

If the patient is unable to move their hand off their back this may indicate pathology of the subscapularis muscle (e.g. tendonitis/tear) or a subscapular nerve lesion.

42
Q

Scarf test

A

The scarf test assesses the function of the acromioclavicular joint.

  1. Passively flex the shoulder joint to 90° and ask the patient to place the hand on the side you are examining on to the contralateral shoulder.
  2. Apply resistance to the elbow in the direction of the contralateral shoulder.
43
Q

Scarf test interpretation

A

If the patient experiences pain the test is considered positive and suggestive of acromioclavicular joint pathology (e.g. osteoarthritis).

44
Q

Describe the typical mechanisms of an inferior shoulder dislocation

A

Direct loading force onto a fully-abducted arm
Forceful hyper-abduction of the arm (e.g. sudden grasp of an object above their head while falling)

45
Q

Name the sign and describe its aetiology

A

Scapular winging is characterised by the protrusion of the scapula as a result of ipsilateral weakness of the serratus anterior muscles secondary to a long thoracic nerve injury.

Scapular winging is most noticeable when patients push against a wall with both hands spaced shoulder-width apart.

46
Q

Name the sign present and some possible causes

A

Deltoid wasting can be caused by disuse atrophy (e.g. after a stroke) or secondary to an axillary nerve injury.

47
Q

Describe the clinical features of shoulder impingement syndrome (SIS)

A

Shoulder impingement syndrome (SIS) involves the inflammation of tendons of the rotator cuff muscles as they pass through the subacromial space. SIS is most often associated with supraspinatus tendonitis. Symptoms of SIS include pain, weakness and a reduced range of active movement in the affected shoulder (normal passive range of motion is preserved). Symptoms are usually exacerbated by overhead movement of the limb, typically during abduction between 60-120°, which is referred to as a ‘painful arc’ of movement.

48
Q

Describe axillary nerve palsy

A

Axillary nerve palsy is typically caused by shoulder dislocation. Clinical features include loss of sensation over the lateral deltoid region (known as the regimental patch) and deltoid muscle weakness (loss of shoulder abduction).

49
Q

Describe adhesive capsulitis

A

Adhesive capsulitis involves stiffness and pain in the shoulder joint associated with a significant reduction in the range of both active and passive movement. Palpation of the joint does not typically cause pain and clinical examination reveals a significantly reduced range of active and passive movement. The underlying aetiology is unclear however risk factors include surgery, prolonged immobility and trauma.

50
Q

Describe abnormalities found on posterior inspection of shoulder

A

Scars: look for scars indicative of previous trauma or surgery
Trapezius muscle asymmetry: disuse atrophy, spinal accessory nerve lesion
Supraspinatus and infraspinatus asymmetry: chronic rotator cuff tear, suprascapular nerve lesion
Scoliosis
Winged scapula: long thoracic nerve lesion

51
Q

Describe abnormalities noted on lateral inspection of shoulder

A

Abnormalities of the shoulder which may be noted on lateral inspection include:

Scars: previous trauma or surgery
Deltoid wasting: disuse atrophy, axillary nerve injury

52
Q

Describe abnormalities noted on anterior inspection of the shoulder

A

Abnormalities of the shoulder which may be noted on anterior inspection include:

Scars: surgery, joint trauma
Bruising: trauma, surgery
Asymmetry of the shoulder girdle: scoliosis, arthritis, fractures, dislocation
Swelling: effusion, dislocation
Abnormal bony prominence: fracture, dislocation
Deltoid wasting: disuse atrophy, axillary nerve injury

MRCS B Examinations and practical skills (13 decks)

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