Clinical
Orthopedic
Edited by :
Dr.Soran Mohamad Gharib
2008
1
Principles of Fracture treatment:The fundamental principles of fracture are ( Reduction,
Immobilization and Rehabilitation)
І- Reduction: it is done if (Necessary) ba st there is no
need to it, so do it in good (acceptable) alignment i.e out any
shortening or overlap or angulation after reduction, so get
acceptable alignment and prevent Malunion.
Reduction is necessary only in (displaced or angulated
fractures)
- Methods of Reductions: by (manipulation, mechanical
traction, open reduction, closed under image intensifierscreen).
1)Manipulation: Manipulation is done in reverse direction
i.e if there is internal rotation of fracture do external rotation
and if abduction do adduction and it is better to reduced
under general anesthesia, by simply grasping in fragment
through soft tissue, to disimpact them if necessary, and then
to adjust them as nearly as possible to their correct position
Occasionally, however reduction is not achieved because of
soft tissue interposition or because it is impossible to obtain a
sufficient hold on one or other fragments so do open reduction.
2) Mechanical traction: This is used mainly in fracture of
femur shaft, because of bulky m. that exerts a strong
displacing force. By this we put a traction at tibia or lower end
of femur and put wts, and pulley to pull on limb, try to tilt bed,
lift foot of bed “so body wt acts as counter traction” .
There are 2 types of mechanical traction
a)Skin Traction: put elastoplast on limb end in cord and
we pass a cord on a pulley, and then pull traction by wt.
depend on thigh m. skin can not tolerate move than 5 kg.wts.
b)Skeletal traction: because in skin traction we can not
use >5kg so if we need more wt, then we insert an instrument
“steinmanpin” is inserted (1) inch distal and (1) inch behind
tibial tubercle and this is attached to a loop called (sterup)
tight loop on a cord is attached at end of cord. If we fail to
reduce fracture by these methods then we try 3rd type which is
3) Open (operative) Reduction: In this method surgeon
exposes bone-ends and realigns them. This obviously converts
a simple (closed) fracture to a compound (opened) fracture is
danger of infection and nonunion.
- Indications of open reduction:
2
1) Soft tissue interposition between two fragments.
2) Failure of conservative method especially spiral
fracture.
3) If fracture is inside joint or a piece of bone has been
trapped inside Joint.
Once we reduce fracture, we’ve to hold this reduction by
immobilization.
П – Immobilization :- Indicated when necessary and
indications are :
1) prevention of displacement or angulation.
2) Prevention of movement
3) Relief of pain
*
Methods of Immobiliazation:
A) External Fixation: it includes
1)
POP ( Plaster of Paris): This is Standard
method for most fracture. It is hemi hydrated Ca Sulfate.
It reacts with water to form hydrated Ca Sulfate and
Liberating heat ( Exothermic reaction).
2)
Immobilization by Continuous traction with
Splintage: In some POP it is impossible to hold fragments
in proper position by pop especially if fracture is oblique
or spiral because elastic pull of m. tend to drown distal
fragments upwards. So it overlaps proximal fragments. In
Such cases pull of m. must be balanced by continuous
traction on distal fragment.
3) External fixation –When there is compound
comminuted.
B) Internal Fixation: The methods are:
1) Metal plate held by screws as in long bone.
2) Bone graft held by screws: Screws to hold small
fragments in place or to hold against redisplacement when
overall immobilization is achieved by a plaster Caste
3) Intramedually rods and nails used for fracture of
long bones.
4) Oblique Transfixation screws.
5) Suture by wire as in small fracture in epicondyle.
3
6) Circumferenial wire or band and suture through soft
tissue.
7) Closed Femoral nailing and tibial nailing.
8) k wire fixation-post reduction per cutaneous wire.
Indication of external fixation:
1)
If fracture is as severe soft tissue damage.
2)
If fracture as arterial injury.
3)
Severe comminuted fracture.
4)
Infected fracture in internal fixation is contra
Indic.
5)
Severe multiple injuries to reduce risk of
complication.
Complications:
1)
2)
3)
Loosing of pins (Fixation)
Pin tracted infection .
Destruct of fracture.
Indications of internal fixation:
1)
When closed method impossible as in case of
spiral fracture.
2)
Poor. bl. Supply as in sub capital fracture of a
neck pf femur.
3)
Multiple injuries ( as in upper and lower limbs
fractures).
4)
Pathological fracture ( in order to make life
easier and mobilize it ) e.g female breast ca, have
metastases to humerus, so by metal bone and cement we
do in fixation.
5)
When accurate reduction is necessary ( in
fracture involving articular surfaces).
6)
When early mobilization is needed, especially
in old patient-to prevent bed sore, DVT, pull embolism,
chest infection.
7)
To avoid un-union ( as in sub capital fracture
of femur or fracture of scaphoid bone so reduce it and fixed
it to avoid non-union.
4
Complication of internal fixation
1) Infection as wound infection and pull embolism
2) Non-union as a result if poor fixation or poor inetal
use.
Rehabilitation
Important factor
Advantage to:
1)
2)
3)
4)
to all patient
Resp
Bowel
Urinary
Limbs
reduce oedema
Preserve joint movement
Restore muscles power
Guid the patient to normal activity
Causes of delayed union:
l/infection 2/abnormal or in adequate support
3/0vertraction 4/early mobilization of the Joint
5/inadequate bl. supply. 6/intact follow bone (e.g. fractt. of
^ tibia while the fibula is intact, s.t in this condition we
excise a segment from the fibula to promote union)
Causes of non-union:
1/too large gape( excess. traction or b. loss) 2/soft
tis.interposit. 3/infection 4/lose of apposition 5/solution of
fract. hematoma (synovail fluid washes ^ hematoma
preventing union as in fract. Of fem. neck) 6/usage of bad
quality metal of int. fix. 7/destruction of b. by turn.
Complications of fracture
They are either general or local
complications.
local complication of fractures
1 – Early local complication of fractures
a) bone complications :(infection)
b) * skin complications fract. Blisters)
c) M. complications ( tearing)
5
d) * Hawmarthrosis :(bl. In ^ j.)
e) Vascular complications : ( complete or partial)
f) N. complications : (cut or pressure)
g) *Visceral damage : (e.g. bladder inj. In pelvic fract.)
2 – late local complication of fractures :
( in bone)
i)
Avascular Necrosis : ( Xray appearance)
ii)
Delay union : ( causes)
iii) Non- union : (2 types & Rx)
iv) Mal – union
v)
Shortening ( growth disturb. & physeal inj.)
(In soft tis *)
i)
bed sore
ii)
myositis ossificans
iii) tendonitis : ( friction synovitis)
iv) tendon rupture
v)
n. compression
(in joints)
i)
J. instability
ii)
J. stiffness (3 causes ) & 3 conditions:
1 – sudeck’s atrophy
2 – osteoarthrosis
3 – myositis ossificans
General complications of fracture :
I-shock:as a result of ^ fract.shock may occure & it is either :
(a) Neurogenic shock: due to pain. Rx by immobilization
either
by splintage or tie ^ limb to ^ other one or to ^
chest or truck
to avoid mov., also give analgesics
(morphine,pethidine )
(b) Hypovolemic shock:^b.is vascular,so damage
bleeding
into ^ soft tis. Shock will be ^ result of loss of blood . (
eg.
Closed fract.Of ^ femur
IL of blood will be lost
inside ^
tis./ more bleeding in pelvic fract. / also even
more in
Compound fract.)
6
II-Crush Syndrome:occurs esp.in comp.fract.& as a result of
massive
Damage to ^ m. The acid myohematin is released to
bl.Circulation, this
Either causes*blockage to^ renal tubules
acute ren.Failure OR
causes
* spasm of ^ renal vess. With anoxia of ^ ren. Tis.
acute
tubular
necrosis.
Crush synd. Occurs also if we leave ^ tourniquet for a long
time(>
6hr.). If this happens we should amputate ^ limb before releasing
tourniquet to avoid passage of myohematin into ^ circulation ( so
you
should state ^ time of placing ^ tourniq.)
In this synd. We should deal with ^ ren. Failure by decreasing
prot.
Intake,increase CHO intake,& do electrolyte balance, high caloric
food
& renal dialysis.
III-Venous Thrombosis & Pulmonary Embolism: about 5% of pat.
with
DVT will develop pul. Thromboemb., esp in pelvic fract. The
.
IV- Infection: occurs esp. in comp. fract. That may cause osteitis
by
Staph.,pseoudomonus, E.coil.This can be Rx by proper AB.
Tetanus: dead tis. Is a good media for growth of Clostridia
tetani.
So we need good wound excision & cleaning, & give a
booster
Dose of tet. Toxoid.
Management :
7
Prophylaxis with active imm. Of poplution & use of
booster
Dose after injury. Active? Imm. By giving anti - toxin
serum of
Human type (horse type not use bec. Of anaphylaxis )
In established tet. Give i.v. fluid balance,& assist
ventilation.
Gas gangrene :Clostridia welchii (anaerobic m.o).In this case
we
Excise all ^ dead tis.+ debris, so if we receive a wound after
6hr.
Of inj. Or a contaminated wound those should kept open.
Give proper AB C is crystalline penicillin.
If we see dust color,swollen wound with special odour
&
Crepitus under ^ skin. We should open ^ wound if it is
sutured,
Excise dead tis., give AB,& s.t. hyperbaric O2 is effective.
& if severe infection we have to sacrifice ^ limb by
amputation.
V-Fracture Fever: increase in temp.by 0.50 C as a result of
absorption of
Fract. Haematoma.
VI- Fat Embolism: takes place during ^ 1st 3 days. As a result of
Liberation of small fatty molecules in ^ circulation, as
chyomicrones C
May be > 10um in diameter pass into ^ general circulation &
aggregate
Into cap. & might go to ^ alveoli & pul. Cap.
Anoxia.
8
Clinical orthopedic examination
1.The Back
A) With the patient upright
• Stand Face to face
• Stand behind the patient.
•Movements
B) With the patient prone (remove the pillow)
C) With the patient supine
2.The Hip
With the patient:
( upright, sitting, lying down, In supine position)
3.The Knee
With the patient: upright, Sitting, supine, prone
Nerve examination
[Supply , Inspection , Power .Sensation)
I.Radial Nerve (more motor)
2.Ulnar Nerve
3.Median nerve
4.Femoral nerve (2 cm, has 12 branches) 5.Sciatie nerve
(L4,5 & S1, 2,3)
Cervical spine examination
• Inspection, skin, S.C tissue (swelling, scar)
• Feel:
• Movement: (Flexion, Extension , lat. Rotation, lat.
Flexion)
• Neurological exam: supply of the upper limb
(C5,6,7,8&T1) Examine roots of the nerves by : power,
reflex , sensation
The back:
A- with the pateint upright
a- stand face to face
1. Physique and posture.
2. Symmetrical tow sides or not,
3. Scars on the chest or abdomen.
4. Wasting of thigh
b) Stand behind the patient,
1 General Posture and shape.
2. Stand upright or lean to one side.
3. Pelvis level
9
4. One leg shorter?
5. Hyper kyphosis?
6. Hyper lordosis?
7- scoliosis
8. Scar, hair, lump (spina bifida occulta)
9. Stand on his toes.
10. Stand on his heals.(to assess balance & M.power)
Movements *
1-Extension(hands on trunk & knee straight) - :2. Flexion
(look at arc & measure lumbar excursion)
; decreased in Ankylosing spondylitis
3 - Lateral flexion.(slid,his hand dawn)
j 4Rotation,(anchor the pelvis of the pat. In neutral position &
ask the pat. To twist to one side then to another side)
B)With the patient prone (remove thepillow)
1. Look for glutei wasting.
2 Feel spinous processes..
(Kyphus=TB of spine or Step= spondylolithesis).
3. Then 3 fingers from midline(artic!ar process& facet J.)
4. Femoral stretch test (pain in ant. thigh).
femoral stretch test :
This is a test for irritation of higher nerve roots - L4 and
above.
The patient is positioned lying face downwards, and with
the knee flexed, the hip is lifted into extension. Lumbar root
irritation tension may cause pain to be felt in the front of
the thigh and the back.
5- hamstring power.(feel the M.)
6. Gluteus maximus power. (feel it)
7. Saddle area sensation.(S3&4)
8. Anal reflex. (S4&5)
,9. Popliteal & tibial pulses.
c- with the patient supine:
1-Look for muscle wasting. ,
10
2. Examine the hip.
3. FABER Test (Hips/Sacroiliac Joints)
FABER stand for Flexion, Abduction, and external Rotation
of the hip (and finally press). This test is used to distinguish
hip or sacroiliac joint pathology from spine problems.
1. Ask the patient to lie supine on the exam table,
2. Place the foot of the effected side on the opposite knee
(this flexes, abducts, and externally rotates the hip).
3. Pain in the groin area indicates a problem with the hip
and not the spine,
4. Press down gently but firmly on the flexed knee and the
opposite anterior superior iliac crest
5. Pain in the sacroiliac area indicates a problem with the
sacroiliac joints.
FABER test
This is a test for evidence of hip arthritis. In this
manoeuvre:



the
the
the
the
the
patient's pelvis is stabilized by placing a hand on
iliac crest (the side furthest from the examiner).
patient flexes his hip joint (the hip joint nearest to
examiner)
patient's flexed hip is slowly abducted
If there is early hip osteoarthritis then the abduction of the
flexed hip will be restricted and painful. An alternative
manoeuvre is to internally rotate the hip with both hip and
knee flexed to 90 degrees - internal rotation of the hip joint
is the first restriction of movement to occur in hip disease.
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4 straight leg Raising (L5/S1 nerve Roots)
*Ask the patient to lie supine on the exam table with the
knees straight
*Grasp the leg near the heel and raise the leg slowly towards
the ceiling.
*Pain in an L5 or SI distribution suggests nerve root
compression or tension (radicular pain, which may be due
to disc prolapse).
11
• Dorsiflex the foot while maintaining the raised position of
the leg
• Increased pain strengthens the likelihood of a nerve root
problem.
*Repeat the process with the opposite leg.
* Increased pain on the opposite side indicates that a
nerve root problem is almost certain.
Or straight leg raising (SLR) test :
This is a test for lumbosacral nerve root irritation for
example, due to disc prolapse.
With the patient laid on their back:




raise one leg - knee absolutely straight - until pain is
experienced in the thigh, buttock and calf
record angle at which pain occurs - a normal value
would be 80-90 degrees - higher in people with
ligament laxity
perform sciatic stretch test - dorsiflex foot at this point
of discomfort - test is positive if additional pain results
flexing the knee will relieve the buttock pain - but this
is restored by pressing on the lateral popliteal nerve
Severe root irritation is indicated when straight raising of
the leg on the unaffected side produces pain on the affected
side. A central disc prolapse is likely with risk to the cauda
equina and consequently, of bladder dysfunction.
Pain upon straight leg raising before the leg is raised 30
degrees cannot be due to disc prolapse as the nerve root is
not stretched within this range. Another explanation of
nerve root irritation must then be sought.
Lasègue's sign is said to be positive if the angle to which the
leg can be raised (upon straight leg raising) before eliciting
pain is <45°
12
Bowstring Test
This is carried out in asimilar manner to a traight leg
raising test , once the patient exprences symptoms the
knee is flexed by approximately 20 degree this leads to pain
relief in the patient with nerve root irritation , thumb or
finger pressure is then applied to the popliteal area , if this
recreates the patients radicular symptoms , it is
indicative of nerve root tension
5. Neurological exam,
- Knee extension (L3,L4).
- Big toe dorsiflexion (L5).
-Planter flexion(S1)
-Foot inversion (L5).
-Foot eversion (S1)
-Knee reflex( L3.L4)
-Ankle reflex (S1)
-Sensation.(foucH&pinprick)
The Hip
Expose from groin to toes
A- with the patient upright( face to face)
1.posture
2. Symmetrical lower limbs
3. One limb shorter or thinner.
4. Pelvis level.
5. Scar.
6. Swelling.
13
7. Trendelenburg test
Trendelenburg's sign :
A Trendelenburg's sign is a gait adopted by someone with
an absent or weakened hip abductor mechanism.
During the step, instead of the pelvis being raised on the
side of the lifted foot, it drops. Thus it is seen as the
patient's pelvis tilting towards the lifted foot, with much
flexion needed at the knee on the affected side in order for
the foot to clear the ground.
Note that the lesion is on the contralateral side to the
sagging hip.
A positive Trendelenburg sign is found in:




subluxation or dislocation of the hip
abductor weakness
shortening of the femoral neck
any painful hip disorder
A weak abductor mechanism may also be demonstrated by
Trendelenburg's test
8. Gait.(phases of gait= heel strike, stance phase, swing
phase)
*•-. • ''.-•"'• -'"-'•
B) With the patient sitting
iliopsoas function (flex hip against resistance)
c- with the patient lying down in supine position
1- the pelvis should be horizontal i.e both ASIS at the same
level
2. Shortening.
3. Scars & sinuses.
4. Swelling or wasting
5. Limb rotate?
6.Measure the apparent length
7. Measure real length,.
8- feel for landmarks (ASIS , greater trochanter , iliac crest0
9- movement
14
1- flexion
Thomas test: to detect fixed flexion deformity, place
your left hand in the hollow of lumbar spine, flex the hip &
knee of the unaffected side until lumbar spine straighten , if
hip of affected side lifts up from the bed so it is fixed flexion
deformity of affected hip) .then flex the hip & knee of
affected side to see range of flexion of affected hip
Or Thomas test:
A test for hip flexion contracture. The uninvolved flexed leg
is held against the chest of the supine patient to flatten the
lumbar lordosis. If a hip flexion contracture is present in the
opposite leg it will not remain flush with the examination
table. The angle formed between the involved leg and the
examination table equals the number of degrees of flexion
contracture present
Thomas test (positive)
Thomas test (negative)
15
iii) Abduction, normally the range is 45 degree ( fix pelvis
and draw
angle between the longitudinal axis of both lower limbs)
iv) Adduction, normally the range is 30° (fix pelvis & draw
angle between the longitudinal "axis of both lower limbs)
v) Lateral & medial rotation
vi) Extension (in prone position)
the knee:
expose from groin to toes
- A- with the patient upright
1. General shape & posture of Lower Limb.
2 Scars.
3. Swollen knee.(traumatic , pain , weakness) or nontraumat/c(inflam.ldegeneration)
4. Quadriceps wasting.
5. Normal feet or deformity = bilateral valgus(RA), bilateral
varus (OA)
6. Gait.
7. Ask her to squat.
B-with the patient sitting
With the knee over the edge of the couch.
1. Look at patellae.(for; squint patella)
2- ask to extend the knee.( observe movement of patella)
c-with the patient supine
1. Redness of skin.
2. Scars.
3. Knee swelling.
4. Muscle wasting
5. Measurements of the girth.
6. Valgus or varus.
7. Flexion deformity. '
8. Ask to press against the couch,
9. Feel for skin temperature.
16
10. Synovea! thickening. (Solomon'stest by the name of
orthopedician).
(Grasp the patella by thumb and middle finger& lift it away
from femur)
11. feeling for fluid:
i) Patellar tap.(moderate amount of fluid)
ii) Cross fluctuation.
iii) Bulge test.(small amount of fluid)
iv) The hollow test.
12) Tenderness
13) Movements
I) Flexion. ( ii) Rotation (with knee slightly flexed)
bulge test for fluid in the knee joint :
The bulge test is used to determine the presence of fluid in
the knee joint. It is useful when only a little fluid is present
in the joint.
The suprapatellar bursa is first emptied of fluid by
squeezing distally from about 15 cm above the patella. The
medial compartment of the knee join is emptied by pressing
on the side of the joint with the free hand. The hand is then
lifted away and then the lateral side is sharply compressed.
If the test is positive, a ripple is seen on the flattened,
medial surface.
The test is negative if the effusion is tense - up to 120 ml.
patellar tap
The patellar tap is a test for fluid in the knee joint. This test
is likely to be positive with moderate amounts of fluid.
Excess fluid is squeezed out of the suprapatellar pouch with
the index finger and the thumb. These are advanced distally
17
from a level about 15 cm above the knee to the level of the
upper border of the patella.
Then, using the tips of the fingers of the free hand, the
patella is hit squarely and with force downwards.
If the test is positive then the patella can be felt striking the
femur with a click and bouncing off again.
If the effusion is small or tense then the tap test will be
negative.
The patellar apprehension test: reveals recurrent
dislocation of the patella where the patient shows
apprehension because he or she knows that the movement,
which simulates that of dislocation, is going to be painful.
The knee is extended and the patella is pushed laterally. To
reproduce the mechanics of dislocation, the knee is then
slowly flexed. In recurrent dislocation of the patella, even
slight movement can induce resistance and anxiety to
further movement.
The apprehension can manifest in a variety of manners,
from tension in the muscles to a shout of alarm.
(a) Looking for an effusion: The examiner's hands are
placed on either side of the patella, with the thumb
and middle to little fingers stroking the synovial fluid
towards the patella, while the index finger is used to
elicit the patellar tap: The patella is at first pressed
down and submerged under the synovial fluid, and will
strike the trochlea, producing a tap. As the pressure is
relieved, the patella will bob up like an ice cube in a
drink
18
(b) Looking for a fixed flexion deformity: The patient is
positioned supine and made to relax. The examiner
grasps both the patient's heels and supports them at a
height of 10 cm above the examination couch. This is
the best position for screening for a flexion deformity,
which is a major feature of knee pathology. This
sensitive and straightforward method is ideal for
screening purposes. It does not, however, lend itself to
a quantification (in degrees) of the deformity. Also,
since the patient's feet are braced against the
examiner's abdomen, the examiner may seek to reduce
the flexion deformity by pressing down on the patient's
knees
Patellar tests;'
- Apprehension sign
The patient is positioned supine, with the knee flexed
between 0° and 30°. The examiner firmly pushes the
patella in a lateral direction. The patient, who knows
19
and apprehends the dislocation that will be produced
by this manoeuvre, will stop the examiner. Results are
recorded as + or 0.
Pathophysiology: Between 0° and 30° of flexion, the patella
is at its highest point in the trochlea. Pressure from the
medial side will push the patella in a lateral direction,
causing it to dislocate from the trochlear groove. This will
cause not only pain, but apprehension on the part of the
patient
This sign may be elicited in recurrent dislocation; it is highly
suggestive, and particularly useful in patella alta. As Henri
Dejour puts it, "You can't get near their kneecaps."
- Patellar grind test
The examiner's hand is placed on the front of the knee. The
patient performs flexion-extension. The examiner will feel a
crepitus, and may even notice the patella catching. The
crepitus is difficult to interpret. If there is nothing more
20
than a positive grind test, a diagnosis of OA or of cartilage
damage cannot be made
.
- McMurray's test: Forced flexion and external rotation
with compression of the medial joint line will elicit pain
in the medial meniscus. The hand pressed over the
joint line will feel a click. The test may be reversed, to
examine the lateral meniscus. Or
- McMurray's test :
This is a rotation test for demonstrating a torn meniscus.
The tear may cause a pedunculated tag of meniscus which
may become jammed between the joint surfaces.
Held by one hand which is placed along the joint line, the
knee is flexed to 90ø while the foot is held by the sole with
the other hand. The ankle is internally rotated and the knee
extended. The manoeuvre is repeated with external rotation
of the ankle and at varying degrees of knee flexion.
A tag, caused by a tear will cause a palpable or even audible
click on extension of the knee.
The 'normal' leg must be checked for completeness: clicks
can arise from normal tendon movement
.iii) McMurray's Test (meniscal injury):
For medial minisci, lat rotate & abduct knee then do flexion
& extension of the joint and vice versa for lateral menisci
Apley's grinding test: For this test, the patient is
positioned prone, with his or her knee flexed. Compression
and external or internal rotation may be painful, showing
that the medial or the lateral meniscus are torn. This test is
always checked, by performing rotation without
compression. This manoeuvre should not cause discomfort,
unless the collateral ligaments are affected
21
..
iv) Vulgus stress (medial collateral L.)knee should be slightly
flexed.
(a) Medial instability in extension
The examiner grasps the patient's heel (not the ankle or the
leg) with one hand, while the other hand is placed against
the lateral aspect of the patient's knee. A brisk valgus stress
is imparted and immediately released. Medial instability is
demonstrated if the medial joint line opens up (Fig. 25).
Sometimes the most characteristic phenomenon is a little
click as the knee reduces after the stress test. Sometimes, it
is difficult to decide whether there is instability.
v) Varus stress (lateral collateral L.) knee should be slightly
ftexed.
valgus and varus stress tests:
These tests attempt to reveal instability to medial or lateral
displacement within the knee.
22
The valgus test involves placing the leg into extension, with
one hand placed as a pivot on the knee. With the other
hand placed upon the foot applying an abducting force, an
attempt is then made to force the leg at the knee into
valgus. If the knee is seen to open up on the medial side,
this is indicative of medial ligament and / or cruciate
ligament damage.
The varus test involves applying forces to the knee in the
opposite direction. Widening of the joint on the lateral side
is indicative of lateral ligament and / or posterior cruciate
ligament deficiencies.
Variations of these tests involve placing the knee in varying
amounts of flexion and rotation
b) Lateral instability in extension
The examiner grasps the patient's heel with one hand, while
exerting pressure against the inside of the knee with the
other hand. The varus stress applied will cause lateral
gaping in the laterally unstable knee. Lateral joint gaping is
physiological. It is the asymmetry of the gaping that
constitutes the abnormal finding.
(c) Anterior drawer in 90° flexion, or direct anterior
drawer
The examiner sits on the patient's foot, which has been
placed in neutral position. The knee is in 90° flexion.
The index fingers are used to check that the
hamstrings are relaxed, while the other fingers encircle
the upper end of the tibia and push the tibia forwards
If a direct anterior drawer is obtained, the ACL will be
torn. However, for this sign to be elicited, peripheral
structures such as the medial meniscus or the
meniscotibial ligament must also be damaged. This
ligament forms a wedge, in 90° flexion, preventing
anterior tibial translation. The finding of an anterior
drawer is conclusive evidence of an ACL tear. However,
not every ACL tear will be associated with a positive
anterior drawer test
23
The posterior drawer test: is used to test the posterior
cruciate ligaments.
The knee is flexed to 80 degrees and the examiner sits upon
the end of the foot to steady it. An attempt is then made to
jerk the tibia backwards. Maximum displacement of more
than 1cm may indicate rupture of the posterior cruciate
tendon. This might have been predicted if there was
observation of the tibia subluxing upon the femur.
vi) Cruciate ligaments:
knee flexed, look at tibia.
=> Drawerf test {Antenor/Posterior Drawer Test) (Cruciate L)
;
Ask the patent to lie supine on the exam table with knees
flexed to 90 degrees and feel flat on the table, f
1. Sit on or otherwise stabilize the foot of the leg being
examined
.
2. Grasp the leg just below the knee with both hands and
pull forward
3. If the tibia moves out from under the femur, the anterior
cruciate ligament may be torn.
4. without changing the position of your hand, push the
leg backward.
•
•'- "•- .-'
-." -..
•
•
•
,"
^^a^•fcjfc**^.^ "
. . -.
_,
5. If the tibia moves back under the femur, the posterior
cruciate ligament may be torn
24
=> Lachman Test (Cruciate L.) (move tibia backward &
foreword): ;
'
1 Ask the patient to lie supine on the exam table.;
2 Grasp the thigh with one hand and the upper tibia with
the other hand , hold the knee in about 15 degree of flexion
3 Ask the patient to relax and gently pull forward on the
tibia.
1
".;•"• --•= -''."'". ' • I ;
*
:
'"-.•' ~ '
"
;
4 The normal knee has distinct end point. If the tibia moves
out from under the femur, the anterior cruciate ligament
may be torn.
i
5 -Repeat the test using posterior stress. i:,
6 The normal knee has a distinct end point. If the tibia
moves back under the femur, the posterior cruciate
ligament may be torn.
• Note:The Lachman Test is used by athletic trainers on the
field to check for cruciate ligament injury. It is very accurate
and can be done on an acutely injured knee (when the
patient cannot tolerate bending the knee for a drawer test).
14) Feel posterior surface of patella.
15) Patello-femoral tenderness test.
D) With the patient prone
1) Scar or Swelling
2) Grinding Tesf (for meniscal tear)
3) Distraction Test,(for collateral & cruciate ligament tear)
Nerve examination:
Radial Nerve (More motor)
1. Triceps
2. Supinator
25
3.brachioradialis
4. Abductor policis longus
5. All extensors of forearm
Examination:
I) A) Inspection •
1. Wrist drop
2. Wasting of triceps
3. Wasting of forearm extensors
B.) Power ;
1. Extension of the wrist
2. Extension of M.C.P.joint
3. Supination against resistance (in extension)
4. flexion of Brachioradialis (in mid prone position)!
5. Triceps (extension of elbow)
Note:
- Do the movement on your self in front of the pat.
-Let the pat. imitate you .
-Do it against the resistance on the pat.
Ill) C)sentsation
1st cleft dorsally
Ulnar nerve:
Supply
flexor carpi ulnaris
1/2 of flex. Dig. Prof.
Hypothenar mm
interossei.
2 medial lumbricals
Add policis
Sensory for medial 1/3 of palm & 1 1/2 of fingers.(ant.ly&
post ly)
Examination:
A- Inspection
Hypothenar wasting
Claw hand
Interossei wasting (spl.y in the 1st dorsal interosseus)
Medial forearm wasting
Trophic ulcer
B- power:
26
Paper between little & ring fingers (do it bilaterally)
Abduct index against resistance (1st dorsal interosseous)
Abduct Little finger against resistance (abd. Digiti minimi)
Froment's test (adductor pollicis) , do it bilaterally.
c- sensation :
Medial 1/3 of hand (palmar & dorsal)
Media 1 1/2 of fingers (palmar & dorsal)
Median nerve:
Supply:
1-All forearm flexors except that by ulnar nerve.
2.Pronator teres.
3-.Pronator quadratus,
4-Thenar M.
5.lateral 2 lumbricals.
6.Sensation:lat. 2/3 of palm
& 3 1/2 of fingers till nail beds. •
Exam,
:
A) inspection j
1-Lat. Forearm wasting
2.
Thenar wasting,
3. Index extension|(benediction attitude due to loss of
flexion of . inlerph.j. of index)
4-trophicchanges
B )Power.
1-Abductor pollicis brevis (palpatr-Bulk- tone of thenar M.)
2. Flex. Poll. Long, (distal)
3. Flex. Dig. Profundus (reach^dislaj IP.J.)
4. Pronation against resistance (in extension)
C) Sensation: lat. 2/3 of palm &3 1/2 of lingers till nail
beds.
Some special tests of median n
Phalens Test (Median Nerve)
1. Ask the patient to press the backs of the hands
together with the wrists fully flexed (backward praying).
,2. Have the patient hold this position for 60 seconds
and then comment on how the hands feel.
27
• 3. Pain, tingling, or other abnormal sensations In the
thumb, Index, or middle fingers strongly suggest carpal
tunnel syndrome.
j
.Tinel's Sign (Median Nerve)
1. Use your middle finger or a reflex hammer to tap over
the carpal tunnel.
2. Pain, tingling, or electric sensations strongly suggest
carpal tunnel syndrome.
Femoral nerve:
(2cm , has 12 branches)
Supply:
1.
2.
3.
Quadriceps (fastidious M.)
iliopsoas
Sensation
• Front of thigh
• Medial aspect of leg (skin of the shin)
• Medial aspect of foot.
Exam
- Quadriceps wasthg
- Extension of knee against resistance( feel the muscle)
- iliopsoas against resistance (should be in siting position)
-Sensation (mentioned)
,: ;
Sciatic nerve:((L4, 5&S1,2,3)
Supply:
-Hamstrings (3M. biceps femoris,semitendinosis,
semimembrinosis)
-all muscles below knee
- iSensation: below knee.
Examination:
inspection:
28
- Wasting of hamstrings
- Wasting of leg muscles
Foot drop
Trophic ulceration
Power: o flexion of knee (Hamstrings & gastrocnemus)
o flexion of ankle
o extension of ankle
Sensation: below knee specially the lat. Half of the leg &
foot.
cervical spine examination(all chest & upper
limb)
inspection:(look)skin,S.C tissue (swelling, scar)
Feel Tenderness of spinous process &Tenderness of the
facet J. (1 finger lat. To the cervical spines)
Movement:(assisted active)
]
1.
Flexion: ask the pat,;To touch the chine to the chest.
2.
Extension: tell the pat To look to the roof of room.
3.
lat. Rotations &lat Flexion: compare both sides
> Neurological exam: supply of upper iimb (C 5, 6,7, 8 &
T1). Examine roots of the nerves by power, reflex ,
sensation.
Power:
1.
2.
3.
4.
5.
6.
C5 = abduction of the shoulders (against resistance)
C6 = extension of the wrist
C7 = flexion of the wrist
C7 = extension of the fingers
C8 = flexion of fie fingers (close the hand)
T1 = abductidn of the fingers
29
-reflex
- biceps reflex =C5
;-brachioradialis (it doesn't cross the wrist J.)=C6
-Triceps-C7
-Sensation: Do sensory screen with light touch & pinprick
&. vibration &joint position sense. Dermatomes in the upper
limb:
1. Shoulders (C4)
';
2. Forearms :lnner aspect (T1) .outer aspect(C6)
3 Hand Thumbs (C6),and little fingers (C8) & (C7) in
between of them
Edited by :
Dr.Soran Mohamad Gharib
2008
Sources :
1-Lectures by dr baxtyar rasul , collected by sarteep
izzat
2-hamilton baileys physical signs
3- outline of fracture
4-norman browse
5- short practice of surgery
6- internet
30