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11 results

  • 22 - Examination of the knee
  • from Section 5 - Orthopaedic surgery
  • Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
  • Book: Physical Examination for Surgeons
  • Published online: 05 July 2015
  • Print publication: 25 June 2015, pp 175-189
  • View extract

    Summary

    Checklist

    WIPER

    • Patient standing in shorts or underwear; hip and ankle joints exposed.

    Physiological parameters

    Gait

    • Asymmetry of spine and pelvis

    • Antalgic gait and walking aids

    • Soles of footwear

    Tape

    • Quadriceps diameter: muscle bulk

    Look

    • Skin: scars, erythema, ecchymoses, sinuses, skin creases

    • Soft tissues: wasting of quadriceps, swelling in popliteal fossa, knee effusion

    • Bone:

    • deformity or asymmetry

    • pelvic tilt

    • posterior subluxation of the tibia on the femur

    • varus/valgus deformities of the knee

    • flexion deformity or recurvatum

    Feel

    • Skin: temperature, tenderness

    • Soft tissues:

    • knee effusion and ‘ bulge ’ test

    • patellar tap test

    • popliteal fossa: Baker's cyst, popliteal artery aneurysm

    • tendons: quadriceps tendon, patella tendon, pes anserinus, collateral ligaments and menisci, iliotibial band

    • pulses, capillary refill, neurology

    • Bone:

    • tibial tuberosity and patella

    • femur, tibia and joint line

    • origin and insertion of collateral ligaments

    Move

    • Active:

    • straight leg raise

    • flexion and assess for crepitus

    • extension against gravity

    • Passive

    • flexion

    • hyperextension

    • Resisted

    • flexion

    Special tests (* = essential tests)

    • Patella: patella apprehension test,* patella tracking test, Clarke's test

    • Collateral ligaments: valgus/varus pressure* (knee flexed at 30° flexion and extension)

    • Menisci: McMurray's test*

    • Cruciate ligaments: posterior sag test,* anterior & posterior drawer test,* Lachman's test,* pivot shift test, dial test

    To complete the examination…

    • Examine the joint above (hip joint) and the joint below (ankle joint).

    • Check full neurovascular status of the lower limb.

    • Order appropriate radiographs and further imaging.

    Examination notes

    How do you measure quadriceps diameter in order to assess wasting?

    • Locate the tibial tuberosity. This is found on the proximal anterior tibia and demarcates the insertion of the patella tendon.

    • Mark a point 20 cm proximal to this landmark, which is mid-thigh. (A longer measurement may be required in very tall individuals.)

  • 18 - Examination of the shoulder
  • from Section 5 - Orthopaedic surgery
  • Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
  • Book: Physical Examination for Surgeons
  • Published online: 05 July 2015
  • Print publication: 25 June 2015, pp 140-151
  • View extract

    Summary

    Checklist

    WIPER

    • Patient standing in shorts or underwear with shoulder girdle exposed (bra to remain on in women).

    • Expose upper limb and cervical spine.

    Physiological parameters

    • Observe for spinal lordosis, kyphosis or scoliosis.

    Look

    • Skin: erythema, scars, sinuses, symmetry of skin creases or skin elevation from underlying fracture

    • Soft tissues:

    • joint and soft tissue swelling

    • wasting of deltoid, biceps, supraspinatus and infraspinatus muscles

    • Bone: prominence of acromion, clavicular asymmetry or deformity

    Feel

    • Skin: temperature, tenderness, sensation

    • Soft tissues:

    • muscle mass: trapezius, deltoid, triceps, biceps and biceps tendon

    • ligaments: coracoclavicular ligaments

    • radial and ulnar pulses, capillary refill time

    • sensation in ‘regimental badge' area (axillary nerve) and in hand

    • Bone:

    • sternoclavicular joint

    • clavicle: deformity or malunion

    • acromioclavicular joint

    • coracoid process

    • spine and borders of the scapula

    • greater tuberosity of humerus

    • margins of glenoid cavity

    • cervical spine

    Move

    • Active and passive:

    • flexion/extension

    • internal/external rotation

    • abduction/adduction

    • Resisted:

    • deltoid

    • serratus anterior (winging of the scapula)

    • pectoralis major

    • trapezius

    Special tests (* = essential tests)

    • Acromioclavicular test*

    • Impingement test*

    • Instability and apprehension test*

    • Rotator cuff test*

    • Biceps tendon test

    • SLAP test

    • Thoracic outlet syndrome tests

    To complete the examination…

    • Examine the joint above (cervical spine: up to 30% of shoulder pain is referred from the cervical region) and the joint below (elbow).

    • Check full neurovascular status of the upper limb.

    • Order appropriate radiographs and further imaging.

    Examination notes

    What do you look for during initial observations?

    1. • Assess the skin quality and contours of the shoulder girdle, clavicle and scapula.

    2. • The soft tissues mass and muscle bulk are evaluated for evidence of muscle loss from disuse atrophy, found around the scapular from rotator cuff atrophy or pectoral muscles anteriorly. Deltoid muscle atrophy can also be found in axillary nerve injury.

  • 17 - Cervical spine injury: assessment in trauma
  • from Section 5 - Orthopaedic surgery
    • By James Pegrum, University of London Sports & Exercise Department, London, UK, Chris Lavy, University of Oxford, Oxford, UK
  • Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
  • Book: Physical Examination for Surgeons
  • Published online: 05 July 2015
  • Print publication: 25 June 2015, pp 138-139
  • View extract

    Summary

    Rules

    1. • All trauma patients have a C-spine injury until proven otherwise.

    2. • Patient's neck can be cleared by radiographic or clinical means.

    Clinical clearance requires:

    1. No high-risk factors regarding the injury, such as:

    1. a. diving or axial injury

    2. b. fall from height >3 feet (90 cm)/five steps

    3. c. high-speed car collision >60 mph (97 km/h)

    4. d. bike or recreational vehicle collision

    2. No high-risk factors regarding the patient:

    1. a. age >65 or <16

    2. b. intoxicated or altered mental status

    3. c. GCS <15

    4. d. abnormal neurology

    5. e. no distracting injuries

    6. f. midline cervical tenderness

    Clinical clearance system

    1. Completion of ATLS primary survey.

    2. History regarding the event and evaluation of the patient for risk factors.

    3. Assessment for the presence of distracting injuries (presence of distracting injuries requires cervical imaging).

    4. Full neurological examination.

    5. In-line immobilisation of C-spine and removal of collar.

    6. Second assessor palpates cervical spine. If there is no pain the patient is then asked to actively rotate the head left and right.

    7. If there is still no neck pain or numbness/tingling in the limbs the cervical spine can be cleared without radiographic evaluation.

    Radiographic clearance system

    • Cervical spine radiographs (See Chapter 49, Cervical spine x-ray):

    • AP and lateral views.

    • All C1–7 and superior aspect of T1 vertebrae must be visualised.

    • Swimmer's view or traction on arms (if traumatic injury permits) are needed if standard views are inadequate.

    • Current recommendations are for computed tomography (CT) imaging.

  • 21 - Examination of the hip
  • from Section 5 - Orthopaedic surgery
  • Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
  • Book: Physical Examination for Surgeons
  • Published online: 05 July 2015
  • Print publication: 25 June 2015, pp 162-174
  • View extract

    Summary

    Checklist

    WIPER

    • Patient standing in shorts or underwear, back and knees exposed.

    • Access is required to the groin, thighs and gluteal region.

    Physiological parameters

    Gait

    • Asymmetry of spine

    • Gait: antalgic, short leg, Trendelenburg gait

    • Walking aids

    Test

    • Trendelenburg's test

    Tape: leg length

    • Apparent leg length (xiphisternum to medial malleolus)

    • True leg length (ASIS to medial malleolus)

    Look

    • Skin:

    • scars, erythema, ecchymosis

    • sinuses and alignment of skin creases

    • psoas abscess draining in sub gluteal fold

    • Soft tissues: swelling or wasting of glutei and quadriceps.

    • Bone:

    • deformity or asymmetry: shortening of leg; external or internal rotation of hip

    • pelvic tilt

    • valgus or varus knee, lordosis, kyphosis, scoliosis

    Feel

    • Skin: temperature, tenderness, sensation.

    • Soft tissues:

    • adductor tenderness, bursitis

    • pulses, capillary refill time

    • sensation and movement

    • Bone:

    • greater trochanter

    • midpoint of inguinal ligament (hip joint)

    • pubic bone and symphysis

    • femoral shaft

    • tenderness or mobility

    Move

    • Active and passive:

    • flexion/fixed flexion

    • internal rotation (foot moves outwards)

    • external rotation (foot moves inwards)

    • extension (press thigh onto bed)

    • abduction/adduction whilst stabilising pelvis (palpating contralateral ASIS)

    • Resisted:

    • flexion

    • adduction

    Special tests (* = essential tests)

    • Thomas's test*

    • Impingement sign*

    • Straight leg raise*

    • FABER test

    • Sciatic nerve stretch test

    • Ober's test

    To complete the examination…

    • Examine the joint above (back and sacroiliac joint) and the joint below (knee).

    • Check full neurovascular status of the lower limb.

    • Order appropriate radiographs and further imaging.

    Examination notes

    What do you look for during gait and initial observations?

    1. • Look for an antalgic gait or the use of any walking aids.

    2. • Inspect the soles of the shoes for the pattern of wear.

    3. • In the setting of possible neck of femur fracture, gait and weight-bearing activities should not be examined.

  • 23 - Examination of the ankle
  • from Section 5 - Orthopaedic surgery
  • Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
  • Book: Physical Examination for Surgeons
  • Published online: 05 July 2015
  • Print publication: 25 June 2015, pp 190-202
  • View extract

    Summary

    Checklist

    WIPER

    • Patient standing in shorts or underwear; ankles and feet exposed with shoes and socks removed.

    • Access is required to the spine, hip and knees to carry out a full biomechanical assessment.

    Physiological parameters

    Gait

    • Antalgic gait

    • Walking aids or orthotics

    • Observation of footwear

    Look

    • Skin: scars, erythema, corns and callosities, skin or toe nail changes

    • Soft tissues: swelling, proximal disuse muscle atrophy

    • Bone:

    • foot: deformity, asymmetry, pes cavus, pes planus, equinus ankle, everted foot

    • heel: calcaneal valgus/varus

    • toes: toes number and alignment, overriding toes, hammer toes, hallux valgus, bunions

    Feel

    • Skin: temperature, tenderness, sensation

    • Soft tissues:

    • anterior: extensor tendons, pulses, capillary refill time

    • sides: lateral and medial tendons and ligaments; sinus tarsi

    • posterior: Achilles tendon

    • plantar aspect: plantar fascia

    • Bone:

    • bone and joint contours: proximal fibular head and neck; talus and calcaneum

    • Ottawa ankle rules for suspected ankle fractures

    Move

    • Active:

    • plantarflexion/dorsiflexion

    • eversion/inversion

    • Passive:

    • plantarflexion/dorsiflexion

    • eversion/inversion

    • Resisted:

    • ankle plantarflexion/ankle dorsiflexion

    • big toe flexion/big toe dorsiflexion

    • inversion/eversion

    Special tests (* = essential tests)

    • Coleman block test*

    • Anterior drawer test*

    • Talar tilt – medial and lateral tilt of talus while holding the heel (test medial and lateral ligaments)*

    • Neuroma squeeze test (for Morton's neuroma)*

    • Tinel's sign

    • Simmonds – Thompson test

    • To complete the examination…

    • Examine the joint above (knee) and the joint below (mid and forefoot).

    • Check full neurovascular status of the lower limb.

    • Order appropriate radiographs and further imaging.

    Examination notes

    What changes are inspected in the skin?

    The quality of the skin around the foot and the presence and site of any ulcers will point the examiner towards underlying neuropathic, venous or arterial pathology.

    1. • Scars from previous ankle open reduction and internal fixation will be sited over their respective malleoli.

    2. • Anterior ankle approaches are used in trauma surgery, ankle replacement or fusion operations.

  • 19 - Examination of the elbow
  • from Section 5 - Orthopaedic surgery
    • By James Pegrum, University of London Sports & Exercise Department, London, UK, Chris Lavy, University of Oxford, Oxford, UK
  • Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
  • Book: Physical Examination for Surgeons
  • Published online: 05 July 2015
  • Print publication: 25 June 2015, pp 152-153
  • View extract

    Summary

    Checklist

    WIPER

    • Patient standing in shorts or underwear with thorax exposed.

    Physiological parameters

    Look

    • Skin: erythema, scars, carrying angle

    • Soft tissues: biceps and triceps brachii mass, swelling or wasting; common flexor and extensor origins

    • Bone: asymmetry, epicondyles, valgus/varus deformity

    Feel

    • Skin: temperature, capillary refill time, tenderness, sensation

    • Soft tissues: pulses, tendons, common flexor and extensor origins, biceps brachii, triceps tendon

    • Bone: bone and joint contours, epicondyles, radial head, olecranon

    Move

    • Active

    • flexion/extension

    • supination/pronation

    • Passive

    • flexion/extension

    • supination/pronation

    • Resisted

    • flexion tests biceps brachii muscle and C5/C6 myotome

    • extension tests triceps brachii muscle and C7 myotome

    • supination tests biceps and supinator muscles

    • pronation tests pronator teres and pronator quadratus muscles

    Special tests

    • Common flexor origin tendinopathy (medial epicondyle – golfer's elbow):

    • resisted wrist flexion with the elbow extended and hand in a supinated position

    • Common extensor origin (lateral epicondyle – tennis elbow):

    • resisted middle finger extension with elbow pronated and flexed at 90° tests extensor carpi radialis brevis

    • resisted index finger extension with elbow pronated and flexed at 90° tests extensor carpi radialis longus

    • Valgus and varus testing to stress collateral ligaments

    To complete the examination…

    • Examine the joint above (shoulder) and the joint below (wrist).

    • Check full neurovascular status of the upper limb.

    • Order appropriate radiographs and further imaging.

  • 15 - Examination of gait
  • from Section 5 - Orthopaedic surgery
    • By James Pegrum, University of London Sports & Exercise Department, London, UK, Chris Lavy, University of Oxford, Oxford, UK
  • Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
  • Book: Physical Examination for Surgeons
  • Published online: 05 July 2015
  • Print publication: 25 June 2015, pp 128-129
  • View extract

    Summary

    Overview of the gait cycle

    1. 1. Stance phase – 60% of cycle

    2. • Heel strike – flat foot – mid-stance – heel off – toe off

    3. 2. Swing phase – 40% of cycle

    4. • Acceleration – mid-swing – deceleration

    5. What is the lower limb biomechanical assessment used for?

    6. A lower limb biomechanical assessment analyses the link between the structure, function, strengths and weaknesses of the lower limb joints and muscles. Lower limb pain can be caused or referred from a number of joints. A comprehensive examination is needed to identify the numerous contributing pathological processes, which may need to be treated concurrently with physiotherapy, orthotics, injections or surgery.

    7. What is the difference between open and closed kinetic chains?

    8. In open kinetic chain assessment the joint is able to move freely, either by active movement or by passive movement by the examiner. Closed kinetic chain is the assessment of gait and lower limb function whilst it is in contact with the ground.

    9. What is the normal gait cycle?

    10. A gait cycle is the sequence that starts with the heel strike of one foot and ends with the subsequent floor contact of the same foot. The gait is defined as a series of rhythmical and alternating movements of the trunk and lower limbs that result in forward progression of the centre of gravity.

    11. During increasing walking speeds and running the swing phase increases and the stance phase decreases until the ratio of stance to swing phase reverses.

    12. What are the commonly used terms?

    13. • A step length is the distance from one heel strike to the contralateral heel strike.

    14. • A stride length is the distance between two heel contacts of the same foot, and in a normal gait it is double the step length.

  • 16 - Examination of the cervical and thoracic spine
  • from Section 5 - Orthopaedic surgery
    • By James Pegrum, University of London Sports & Exercise Department, London, UK, Chris Lavy, University of Oxford, Oxford, UK
  • Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
  • Book: Physical Examination for Surgeons
  • Published online: 05 July 2015
  • Print publication: 25 June 2015, pp 130-137
  • View extract

    Summary

    Checklist

    WIPER

    • Patient standing in shorts or underwear. Access is required to the neck and thoracic cage.

    Physiological parameters

    Gait and balance

    • Smoothness and symmetry

    • Sagittal balance

    Look

    • Skin: erythema, scars (posterior and anterior), alignment of skin creases

    • Soft tissues: swelling; wasting of paraspinal muscles, intervertebral spaces

    • Bone: scoliosis, kyphosis, lordosis, rib cage asymmetry, shoulder girdle

    Feel

    • Skin: temperature, tenderness, sensation

    • Soft tissues: paraspinal muscle bulk and spasm

    • Bone: spinous processes, facet joints, sacroiliac joints, coccyx

    Move

    • Active:

    • flexion/extension of spine

    • side flexion of spine

    • rotation of spine

    Special tests (* = essential tests)

    • Spurling's nerve root compression test*

    • Axial compression test*

    • Disc test: Valsalva manoeuvre*

    • Neurological examination*

    • Thoracic outlet syndrome (see Chapter 26)

    • Waddell's behavioural signs

    To complete the examination…

    • Examine the shoulder, lumbar spine and sacroiliac joint.

    • Check full neurovascular status of the lower limb.

    • Order appropriate radiographs and further imaging.

    Examination notes

    What do you look for during gait and initial observations?

    Look at the sagittal and coronal planes of the patient. In the sagittal plane a vertical line should be drawn through the ear, shoulder, hip, knee and ankle. This quick screening test helps identify any spinal deformity, for example found in ankylosing spondylitis.

    What signs should be identified in examining the skin?

    The skin needs to be assessed for signs of systemic disease:

    1. • Café-au-lait spots found in neurofibromatosis.

    2. • Psoriasis, cutaneous vasculitis or nodules found in rheumatoid arthritis.

    3. • Evidence of steroid use with striae, telangiectasia, skin thinning and bruising.

    4. • Scars: evidence of previous cervical spine surgery via a posterior or an anterior approach (where a scar is found in the skin crease medial to the sternocleidomastoid).

    How should the soft tissues be inspected?

    The symmetry of the surrounding soft tissues and muscles are assessed:

    1. • Anteriorly: the scalene, sternocleidomastoid and pectoralis muscles.

    2. • Posteriorly: the paraspinal muscles (levator scapulae, trapezius, rhomboid and trapezius muscles) are palpated.

  • 64 - The disabled patient
  • from Section 10 - Non-communicable diseases
  • Edited by David Mabey, London School of Hygiene and Tropical Medicine, Geoffrey Gill, University of Liverpool, Eldryd Parry, Martin W. Weber, Christopher J. M. Whitty, London School of Hygiene and Tropical Medicine
  • Book: Principles of Medicine in Africa
  • Published online: 05 March 2013
  • Print publication: 02 January 2013, pp 578-583
  • View extract

    Summary

    Introduction

    This chapter is different to many others in this book. It is not concerned with specific diseases, their pathology and treatment, but rather with the chronic effect of disabling diseases on patients and their community, and the role that the health worker has in helping those who have disabling conditions. Most health workers in Africa will be involved in some way with people who have disabilities, but even if their direct professional involvement is minimal, they will always be looked at as role models for the community's relationship with disabled people. Therefore, every health worker must understand the subject of disability and how to promote the rehabilitation and employment of the disabled, if they are to be of help to them. The focus is on the individual person, not on the disability.

    If health workers are seen to focus on the disability, and not the person, then the community is likely to do the same, and disabled people may feel labelled by their disability. If, however, the health worker focuses first on the person, rather than on his or her disability, then the community is also likely to adopt the same attitude. People with disabilities may then become more welcomed and integrated into the community.