Orthopedics II – Midterm Review
MUSCLE GRADING
5- Normal
4- Good
3- Fair
2- Poor
1- Trace
0- Zero
Complete range of motion against gravity with full resistance
Complete range of motion against gravity with some resistance
Complete range of motion against gravity
Complete range of motion against gravity eliminated
Evidence of slight contractility. No joint motion.
No evidence of contractility
It is not fair to only test in one area. You need to take it through the full range of motion.
Start testing at 3. Have the patient see if they can go through the full range of motion. Then see if some
resistance can be given and then apply a little more resistance and see if the patient can complete it.
5 or 4 are acceptable.
You might need to move the patient to get them in the right position to perform the test.
If you were testing the muscle before it might be a different position for performing the grading
of the muscle.
When testing the abduction you can test the muscle in the prone position, but when grading the
muscle they have to lie on their side.
Many times you are testing for strength and symmetry (ROM).
Biceps – C5  bicep flexion
Triceps – C7 elbow extension
Wrist extension – C6
Wrist flexion – C7
Digital Extension – C7
Gripping (8) – C8
Fan/ in between fingers – T1
Deep tendon reflex (DTR) – note if there is reinforcement used, so if testing again you can recreate the
results again.
 Distract the patient while testing since sometimes people can inhibit the reflex
 Physical reinforcement can also be applied. For a patellar distraction the grip their hands and
try to pull them apart. This can also try to allow a DTR.
4+
3+
 Very brisk, hyperactive; often indicative of disease; often associated with clonus (rhythmic
oscillations between flexion and extension)
 Brisker than average; possibly but not necessarily indicative of disease
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Orthopedics II – Midterm Review
2+
1+
0
 normal; average
 Somewhat diminished; low normal
 no response
Usually a person who is a well trained athlete will have diminished reflexes.
Coffee drinking could increase them.
Alcohol and marijuana can cause the reflexes to diminish.
Biceps tendon - C5
Brachio Radialis – C6
Triceps tendon – C7
Dermatomes
Always check the unaffected side first.
Ask the patient if they can feel the sharp or dull pain. If they can not differentiate then you can see there
is decreased in sensation.
HOMEWORK!!  Due Friday the 21st
3 different types of dermatomal maps – compare and contrast the 3 sources
You can do 1 – 4 pages of work. Also you can do written, table, or other forms of comparing.
Tri 4 proficiency Check Sheet handed out. Dr. O’Brian to do tests. Sign up sheet with Linda. (this is
required to complete orthopedics)
Neurological Tests
C5 – deltoid
If wanting to see if the nerve root then test other muscles with C5 Innervation
When testing the bicep you use your thumb at crease at elbow. Due not stretch the bicep because this
will diminish the reflex. Hit your thumb nail with the hammer. 5 fingers should come up with the test.
Epaulette (little shoulder) is the area with the True axillary nerve innervation
Brachio radialis is an elbow flexor.
C6 will flex the fingers and thumb
C7 will flex middle finger dermatome,
C8 dermatome is medial forearm
T1 dermatome is medial arm, motor is interossie on fingers
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Orthopedics II – Midterm Review
Read Chapter on cervical and lumbar. In the Hoppenfeld book.
1-19-05
Talked about inclinometers. Many different kind. (inclinometer is a goniometer and a goniometer is not
always an inclinometer.
Taking Measurements
Take 3 measurements with each range and they should be within 10% of each other. Average them and
then round to the nearest 5.
Normal Values of ROM.
Cervical, Shoulder, elbow, knee, ankle, wrist
Regional Exam
 Inspection  antalgic posture, lesions of skin, asymmetry,
 Palpation  tissue tone, swelling
 ROM
o Active  what the patient can do
o Passive or over passive  you can apply a little more ROM without pain
 Orthopedic
 Neurologic
o Sensory/motor/reflex DTR/superficial (skin (babinksi sign is testing the plantar reflex
and is called babinksi’s sign when there is abnormal extensor) or mucosa)/pathologic
Differential Diagnosis
 consider the likely possibilities
 rule in or rule out with Examination and relevant questions in History
 Decide which Special tests may be informative
 “Clinically Indicated” if the test results will affect your treatment plan
X-ray is necessary on children sometimes when your treatment would change on the information
received from the X-ray.
Special tests
 X-ray
 Other imaging
 Lab
o Blood
o Urine
o Other (hemoccult)
 EMG, Nerve Conduction Velocity, etc.
1-21-04
Coding
 these are located in the conditions manual
 800 codes  trauma, 700  subluxation
 these codes allow you to talk to the payer and other doctors
 Cervical strain and sprain are the same code (however there are differences)
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Orthopedics II – Midterm Review
o Strain  muscular injury by definition
o Sprain  is a ligamentous injury
Grading
 1 (ONE)
o Simple strain/sprain – minimal disruption of adjacent fibers
o 1-10% fiber damaged
o Decreased motion due to swelling (sometimes)
o Minimal pain, splinting, minimal palpatory pain
o Trigger points, some loss of ROM (due to swelling or pain)
o Fixation & decreased joint play in spine
 2 (TWO)
o Moderate strain/sprain – partial tearing of the ligaments or muscle, hemorrhage,
marked pain & splinting
o Mechanical stimulation of nociceptors along with chemicals given off by damage
o 11-50% fiber damage – this can add to sloppy motion (hyper mobile)
o Stretching ligaments results in pain
o Athletic injury, lifting, trauma
o Same clinical picture as above but more severe
o Discoloration will be present and can be worse when lymphatic drainage is not
present. (RICE) Rest, Ice, Compression, Elevation
o Elevation can help with discoloration
o The more immobilized the are the less the lymphatics will work
 3 (THREE)
o Severe strain/sprain – may be complete laceration
o Refer for surgical evaluation (51-100% Fiber damage)
 At 100% rupture you must referral out
 At 51- 65% it may be feasible to treat the patient
 A complete strain is not manageable either (ACL)
o Ecchymosis
o Some say that there is no pain due to no tension, but there is due to other problems
o Marked dysfunction
o Palpate torn muscle
Tendons are more vascular that ligaments
Differential diagnosis testing (BE ABLE TO REPRODUCE THIS CHART)!!! (NMS)
Passive ROM
 STRAIN  mid to no pain except at end range (muscle stretch)
 SPRAIN  Pain – ligaments are stretched
Active ROM
 STRAIN  painful (decreased ROM due to pain)
 SPRAIN  Painful (decreased ROM due to pain)
Isometric Contraction
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Orthopedics II – Midterm Review
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
STRAIN  Pain
SPRAIN  Mid or No Pain
STRAIN  muscle
SPRAIN  ligamentous
Inclinometers
Lumbar
Lateral Bending  Subtract the inferior from the superior one (coronal plane)
Make sure that both are in the same orientation and plane.
Flexion  support them as in belts test and watch for the hips to move.
Extension  make sure that they keep the lower body stationary and focus the motion on the
area being tested (Lumbar)
Cervical Spine
Flexion / Extension Cranium & at T1
Lateral bending
Cranium & at T1
Need ROM equipment (read intro plus ch 1&2 from hoppenfeld)
5 cervical documentations for ROM
ROM
Cervical Orthopedics Lab
 Valsalva  individual is going to hold breath and bear down. This increases intrathecal
pressure. (this will show space occupying lesion) (DO NOT PERFORM IF KNOWN
CARDIOVASCULAR DISEASE IS PRESENT)
 Spinal percussion  tap down the spinouses to try and reproduce the pain. This helps with
localizing the pain and with knowing where the subluxations are present. (spinous can show
level, interspinous level reproduction can show CT problem / ligament sprain)
 O’Donoghue maneuver  Resisted motion (compare with passive  this can show
ligamentous problems)
 Maximal cervical compression test  involves rotation and lateral bending and the patient
is instructed only on this test
 Foraminal compression test straight down in axis and this will compress the IVF. Do one
face forward and one on each rotational side
 Jackson compression test Lateral bending trying to close joints on concave side (BE
CAREFUL WITH THIS TEST)
 Spurlings test doctor drops hand onto his other hand that is placed on patients head.
(lateral bending with some rotation / extension)
 Cervical Distraction  should relieve pain when distraction is done
 Swallowing test 
 Rust’s sign
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Orthopedics II – Midterm Review
Cervical Facet syndrome – usually this type of fixation will be localized and is not dermatomal, but can
be scleratomal (signs will follow spurlings test and relief will be given in cervical distraction)
IVF – radicular symptoms, and present in compression
Ligamentous problem – signs on distraction (pain)
Tissue healing and repair
 deals with rabbit ligaments from Woo
 What is normal tissue healing?
Clinical Phases of Recovery
 Phase 1: acute inflammation
o First 72 hours
o Hematoma/inflammation
o Redness, pain, heat, swelling
o White cells, phagocytes, and later
o Fibroblasts are active at the site of injury
 Phase II: repair/ regeneration of cellular matrix
o 28-72 hours until 6 weeks
o Inflammation subsides and healing begins  caution patient since the area may feel
better even though it is not totally healed
o Organization of blood clot
o Granulation tissue and fibroblasts produce extracellular matrix (disorganized)
o Increase in collagen concentration/elastin appears
 Phase III: remodeling / maturation
o May require 12 months or more (ins. Will normally try to take away the patients
money for care, yet they are not the one responsible)
o Vascularity and cellularity decrease
o Density of collagen increases, fibrils increase in diameter
o Tensile strength may be only 50-70% after the healing is complete (this can set the
stage for re-injury
 Phase IV: Maturation
o Woo, et al
o Rabbit MCL
o Timing details of healing are ligament and individual specific
o May be influenced by systemic and local factors
Patient had whiplash from accident
 aka: cervical acceleration/ deceleration injury (CAD)
 CODE = 847.0, this code can be manipulated to fit a little better
 Cervical Strain (muscle)
 Cervical Sprain (ligament)
 Strain/Sprain implies injury to both, often misused
 If strain or sprain treat correctly, do not use strain/sprain freely
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Orthopedics II – Midterm Review
Picture  of accident of rear end crash
Acceleration
 Torso is thrown forward and the head cannot follow so it hyper extends
 Lap belt keeps the body from ramping (pelvis lifts up and cervical spin is then the fulcrum
 Lumbar can also hyperextend.
 The seat is accelerating forward, this can cause the leg and knee to go backward and the force
can be thrown into the hip
Deceleration
 body forward, seat belt holds person (it may save the persons life, but it can destroy tissue
and produce injury)
 Now head is going forward due to deceleration, the seat belt holding you in, and the
extensors firing with a flexion response. Plus sometimes the seat can help catapult the head
forward again
Temperomandibular joint can be over stretched. Try extending with your mouth closed. Then try it with
your mouth open.
The symptoms are the same between the joint and cervical damage. So, make sure you are
looking for the damaged joint as this can be affected by the accident.
Make sure you evaluate all the cranial nerves too. (this takes 90 sec)
Funduscopic exam. You actually look at the nerve and tissue.
OBGYN, kidney, spleen, abdominal exam.
Terms
Active care – directed to ward returning the patient from an injury or illness to pre clinical status




relief care  rendered to reduce symptoms to a tolerable level and improve function
Therapeutic care  directed to further reduce symptomatology and improve function
through correction of subluxation and its various component. This should enable a patient to
perform most normal daily activities without frequent reoccurrences
Rehabilitative care  restoration of strength and stability
Supportive care  permanent, on going problem
Acute – sharp, poignant, having a short and relatively severe course. Acute in this instance is meant to
designate the new condition in less than 12 months
 mild  no major joint involvement, a slight strain in back or neck with no prior history
 Moderate  this condition usually requires rehabilitative care, but may not require
supportive care in the mil-to-moderate case.
 severe  severe, may reach maximum medical improvement (MMI), permanent change is
structure
Chronic – persisting over a long period of time, more than 12 months, reoccurring condition
 Mild  without acute exacerbation, this condition may require little or no intensive relief
care, but will require therapeutic, rehabilitative and supportive care
 Moderate  with acute exacerbation, this condition will require all four levels of care
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Orthopedics II – Midterm Review

Severe  with serious acute exacerbation, this condition requires extended periods of all
four levels of treatment
Using the orthopedic tests you can see if your treatments are making a difference. With each level, mil
to severe, a level of care will be determined for each. How long you do each type of care whether relief,
therapeutic, rehab, or supportive care. Each will be different.
TOS  read the shoulder chapter in Evans (4 syndromes listed below)
There are several specific types of TOS
Scalene anterior syndrome
Looking at the scalene and the compression which is sometimes called the interscalene pressure
The floor is the 1st rib. Anterior and middle scalene make the walls of the triangle
C2- C5 and T1 will be the effecting vertebrae.
There can also be clavicle involvement sometimes, so look for it.
Symptoms  C7-T1 distribution of problems and it is called a plexopathy. The chief complaint in
paresthesia which would be tingling or pain.
Subclavian artery is also involved. So this TOS is a neuro/vascular problem. In order for the blood to
move through a high velocity high pressure jet is formed. (this can blow out the blood vessel wall and
even possibly start an aneurysm. Sometimes there will be a sound with this (a train or blowing across the
top of a bottle sound), but normally there should not be any sound unless it is coming from the heart.
It can be positional or permanent depending on the movement.
Know the fundamentals of this for your practice. That way you can manage the area appropriately.
BRUIT  French word for sound
Costo-clavicular compression
 Anterior weight bearing of the head and low shoulders. The patient will show this posture
 The clavicle is very mobile and is a major role in shoulder complaint.
 Pec major, clavicular, platisma, SCM, all attach to the Clavicle Bone
 Scoliosis  this will also cause torque on the clavicle
 A broken clavicle can heal with large cartilage bundle. This could also cause compression at
some point.
TESTS



retraction and rotation is one test
exaggerated military stance
Bringing the clavicle down
Double crush syndrome  more than one sight of compression and the clavicle is compressing it
Pec minor/ coraco syndrome, Hyperabduction syndrome
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Orthopedics II – Midterm Review




pec minor attaches to the coracoid process and to the 3rd-5th ribs.
The nerves are wrapped around the artery (axillary)
Hyper abduction will aggravate the syndrome the most
Postural component and chief complaint always makes up the TOS syndrome
Cervical Rib
 an anomaly which is just an enlargement of the cervical TP at C7
2/2/05
Anterior Head Carriage
 Extensors are working all the time, weakness of the deep flexors.
 Use kickball and flex your neck to your chest, flexing joint by joint. Also doing abdominal,
core work in order to change the posture.
Stabilize the sternum Figure 3-62
Soto Hall – Doctor will flex head
This can show cord problems
With this watch for knee flexion
Lhermitte’s sign Figure 3-47
Passively flex head and neck  if the patient experiences sharp radiating pain or paresthesia…this could
show cord involvement
Nattzigers Test Figure 3-52
Looking for back up of venous pressure with radicular pain…this would show pain from space
occupying lesion  do not apply bi lateral pressure on the neck (principle the same as valsalvas
Swallowing Test Figure 3-70
Direct esophageal problems or space occupying lesion. this can also be a test for people with normal
mechanical activity
Rust’s Sign Figure 3-56 (NB TEST)
They are holding the weight of the cervical spine up because the neck is not stable…this could happen
with a diver and this could be a sign of a fractured atlas
While laying down they hold their head up is also the same sign.
Read the book by next wed. 2-9-04
Whip Lash
 make sure you are not fictitious with findings
 some victims get a lawyer so you might have to communicate the records to other people
 Hyperflexion / hyperextension
 Know what windows might have been cracked and if their head hit it. (door window or
windshield) this could cause mild traumatic brain injury
 Inside the cranium
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Orthopedics II – Midterm Review
o The frontal bone will slam into the frontal cortex. Then the brain slams back into the
occiput. (this term is called contra coup. The head continues the slam back in forth in
the calvarium until the energy is dissipated.
Common Symptoms of PCS (post conclusive syndrome) (40 – 60% of the time some of these
symptoms will arise.
 light headedness (top one)
 Vertigo/Dizziness (top one)
 Neck pain
 Headache
 Photophobia
 Phonophobia
 Tinnitus
 Impaired Memory
 Easy Distractibility
 Impaired Comprehension – this is hard on a
 Forgetfulness
 Impaired Logical Thought
 Difficulty with New or Abstract concepts
 Insomnia
 Irritability
 Easy fatigability
 Apathy
 Outbursts of Anger
 Mood Swings
 Depression
 Loss of libido
 Personality change
 Intolerance to alcohol – this can also be a sign of a person who has had a stroke
These are all significant if the symptoms carry on over time
Patients who have chronic pain for any reason can sometimes come up with some of these syndromes.
PET  positron electron transmission
 this looks at the brain to see what frequencies are going on
CMT  Chiropractic manipulative treatment
 98940  Chiropractic manipulative treatment (CMT) : spinal, one to two regions
 98941  spinal, three to four regions
 98942  spinal, five regions
 98943  extraspinal, one or more regions
Fee Facts  this is a reference book that can be found in the library
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Orthopedics II – Midterm Review
Sensory motor and reflex testing, cervical spine, TOS, ROM (KNOW THIS FOR LAB)
FEB 22nd lab test, Feb 23rd written
2-7-05
Types of shoulder problems
Strain – muscle
Shoulder sprain – rotator cuff sprain (ligamentous)
Bursitis  zip lock bag with some oil in it w/ no air. This is kind of how the bursa work. Since there is
synovial fluid in it when synovitis occurs the fluid swells and can rupture.
Abnormal movement usually causes this. Bursitis is usually a secondary trauma. (subdeltoid bursa and
subacromial bursa  moves with humerous head and would reproduce pain if shoulder is brought back)
Tendonitis  just means inflammation of the tendon. This can be caused by low grade irritation.
(biceps long head tendon has a transverse ligament that covers it.
4 different muscles to consider  supraspinous, infraspinous, teres minor, subscapular
Flexion, Extension, Abduction  , Adduction  can be inhibited by breast or abdomen, internal and
external rotation  bend arm at elbow and then measure
Dawbarns sign  palpating the bursa, come inferior to acromian with pressure posterior and rotate arm
back (this should create pain)
Then abduct shoulder with palpation  this will give relief to patient
Appley’s test (scratch test)  sometimes a camera might help with showing the patient the
abnormalities. Reach behind back from above and below. (you can mark spinouses to measure
differences. There should also be no pain with this test.) – deep knee bend is the equivalent for the lower
extremity.
Yergason’s test  palpating long head of biceps tendon (palpate on anterior side of the humerous)
looking at elbow flexion and forearm supination
Speed’s test  shoulder flexion and supinator resisted (palpate long head of bicep tendon)
Transverse Humeral ligament test  looks a lot like the shoulder ROM – internally and externally
rotate the arm…seeing if the biceps tendon is coming out of the groove
Abbott-Saunders  palpate the transverse humeral ligament (long head) abduct the shoulder then
swing it into external rotation…is the ligament staying in the groove
Ludington’s Test  procedure used for inspection and palpation of the biceps – patients hands on head
and then ask them to flex (used to see if a tendon has ruptured)
Codman’s sign or Codman’s drop arm  if the patient has a torn rotator cuff (most common tear is
supraspinatous) then the arm will not be able to stop at 90° when the doctor lets go. This is to test the
integrity of the rotator cuff and bursa involved.
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Orthopedics II – Midterm Review
Supraspinatous press test 4-65  tests for deltoid strength and supraspinatous – move arms in anterior
and externally rotate from being abducted at 90°.
120% from glenohumeral joint
60% rotation from 30% at AcromioClavicular (AC) joint and 30% at SternoClavicular (SC) joint
Impingement syndrome – chronic / repetitive
Supra spinatous tendon and long head tendon of the biceps
Great tuberosity and acromian process
- rolling and sliding of the joint is needed
o if it can roll but not glide and the humerous stays high, then it is lacking inferior slide (this is
common too)
o pure abduction  supra spinatous, flexion  long head
o calcific tendonitis  there is calcium there to try and reinforce the area that has been
chronically weakened (it is also radiopaque)
o Bursa is also nearby – the calcification can rupture the bursa
 Acute is smaller, Chronic is bigger calcification
Adhesive capsulitis
Passive and active motion is equal and reduced
MUA  manipulation under anesthesia
Treatment protocol  adjustment how often
Exercise protocol  all exercises should be performed vigorously at least 8 times a day. Joint motion
should be carried into painful range. (pendulum and circular swing)
Osteoporosis  make sure you are careful with this
Rotator cuff tear 
Subscapularis is torn and on the verge of tearing are the subscapularis and infraspinatous tendons.
Ludingtons Test
Rupture of Biceps brachii  this can happen with trauma, or with tendon degeneration
It Ends up as a big lump of flesh in arm. Function is lost also
De Quervains Disease  Stenosing Tenosynovitis
Tendons that have a synovial sheath around it. And when narrowing happens the tendon then begins to
wear. In the extensor retinaculum there is inflammation
Usually cause pain in the snuff box
Finkle Steins Test checks for this
Involve abductor pollicis longus & Extenser pollicis brevis
Trigger finger  Stenosing Tenosynovitis
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Orthopedics II – Midterm Review
Proximal to the distal metacarpal hand…what happens is that the tendon cannot slide through the
retinaculum. It meets resistance
Ganglionic cyst of the wrist
Synovial hernia, a blow out form some synovial sheath. Begnin. Some people slam this with a book to
make it go away or if it gets adjusted it could be corrected
Dupuytrens contracture  palmar apenuroisis is all over grown, they do not know what causes this.
Conditions manual 124-125pg (NB part 2)
Finish shoulder up in lab
Shoulder dislocation
This will not require guessing in the acute situation.
Bryant’s sign 4-29
Inspection finding. We are to be looking at the axilla. The inferior portion will be more inferior on the
side of dislocation. This could also be present in a scoliotic patient.
In a patient who has it there will be a step off from the acromion process.
Calloway’s Test 4-30
Tape measure used to check to see if there is asymmetry. An increased measurement could be from
swelling. Atrophy can cause decreased measurement.
Hamiltons test 4-46
Straight edge and go from lat. Epicondyl and touch the acromion process then the humerus has shifted
Dugas Test 4-40
Patient places the hand on opposite shoulder. Then have patient bring elbow down to chest wall. This
could not happen if a dislocation was present.
Mazion Shoulder Maneuver 4-53
Hand on chest of opposite shoulder. Then lift the shoulder up. From chest up across brow. This is a test
would increase pain if present.
Apprehension test 4-25
Used for the old dislocation to see how intact the shoulder is and to see what type of reaction the patient
will have. This should illicit a pain or fear response. You need to be able to see the facial response of
fear. There are really three tests, Anterior, posterior, and another.
House maids knee  the knee blows out and is swollen. Pre-patellar bursitis
Olecranon bursitis  students elbow
Ischial bursitis  deep pain and tenderness over ischial tuberosity
Acillobursitis
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Orthopedics II – Midterm Review
VBAI  RED BOOK pg 37 MEMORIZE THIS
5Ds and 3Ns ataxia also exists
1. Dizziness – know this from vascular and neurology etiology. Different things cause you to be dizzy.
2. Drop Attacks – loss of consciousness (syncope). Could be due to drop in blood pressure.
3. Diplopia – vision problems /
4. Dysarthria – speech problems
5. Dysphasia
6. Ataxia of gait
7. Nausea – possible vomiting
8. Numbness
9. Nystagmus
(Transient ischemic attack) TIA  short term ischemic attack to the brain
Stroke  permanent neurological damage (brain cells destroyed). Typically when these happen there is
no recognizable cause or event that set the causes for the stroke.
A common site is between C1 and C2 area. Rotational stretching is the main ideology. C2 and C3 is
another common area too.
Vascular accidents with cause  childbirth, anesthesia, yoga, hanging up laundry, backing car up,
dental work, amusement rides, break dancing, swimming, beauty parlor, football, intercourse, tai chi,
star gazing, sleeping position.
Intimal tearing of the arteries can cause the damage that could create a stroke condition.
Thrombus can cause additional problems if things build up. Then if it breaks loose it becomes an
embolism.
Dissecting aneurysm is when the blood starts filling up into the vascular tissue
Infarct stroke
Wallenburg syndrome  1895. the vessel most commonly associated PICA (posterior inferior
cerebellar artery)
Lockdens syndrome  middle portion of basilar artery (persistive vegetative State)
In your history look for(smoking, oral contraceptives,
Heart disease is not the number one cause of death now in country. It is number one in heart problems
though.
Warfarin  used ion heart problems
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