Segmental arid peripheral nerves of the limbs
Brachial plexus Cervical part 1 2 Branches from roots 1 3 Branches from trunks 1 A Axillary part 14 Branches from cords 1 4 Assessment of brachial plexus lesions 17-18 Axillary nerve 1 9 Radial nerve 19-21 Ulnar nerve 21-24 Median nerve 24-27 Lower limb myotomes 27 Lower limb dermatomes 7 Lumbosacral plexus 28 Femoral nerve 29 Common peroneal nerve 29 Tibial nerve 30-31 Sciatic nerve 3 1 Lateral cutaneous nerve of thigh 32 Neurological control of the bladder 32 The roots of the brachial plexus...
tfa vuiniwal ukihopaedic examination
8.37. Suspected prolapsed intervertebral disc Functional overlay, continued 5 Note the amount of rotation required to produce pain in the back. Now ask the patient to keep his hands firmly at his sides and repeat the major part of the movement will now take place in the legs. Pain occurring with the same amount of apparent rotation again suggests overlay. In many centres, if three or more of the preceding tests are positive surgery is considered to be contraindicated. 8.38. Suspected prolapsed...
The Mature Foot Summary Of The Key Stages In Examination 1318
13.16. Movements Examine the mobility 13.17. Gait Examine the gait, with and withoul shoes. If indicated, screen the ankles, knees, hips and spine examine the circulation, and carry out a neurological examination. Note the footprint and examine the shoes. 13.18. Investigations Study the results of special investigations, e.g. radiographs, serum uric acid, sedimentation rate, rheumatoid factor etc. 13.19. Inspection General Note whether the foot is normally proportioned. If not, look at the...
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8.82. Radiographs 30 To assess the severity of a scoliotic curve, and to allow its progress to be monitored it is necessary to measure the deformity. The Cobb method is most popular, although it is difficult to obtain consistent results with it. First, find the upper and lower limits of the primary curve by drawing tangents to the bodies and noting where the disc spaces begin to widen on the concavity of the curve. 8.83. Radiographs 31 Now erect perpendiculars from the vertebrae that form the...
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8.73. Radiographs 21 Normal localized lateral view of the lumbosacral junction. 8.74. Radiographs 22 Look for evidence of spondylolisthesis. In the normal spine the pars interarticularis P lying between S the superior and I the inferior articular facets is intact, and a vertical raised from the anterior margin of the sacrum lies in front of L5. spondylolisthesis is suspected, the lateral should always be taken with the patient standing. Note any defect P and any forward slip U . The deformity...
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Pain on dorsal and medial side of foot Tight shoes and stockings, Ingrowing toe nail Cuneiform exostosis Peroneal flat foot Freiberg's disease Pes cavus Verruca pedis Anterior metatarsalgia Plantar neuroma Pes cavus Verruca pedis Tarsal tunnel syndrome 'Normal foot' Vertical talus Knock knees Valgus heels Neurological disturbance Torsional deformities of the tibia In all age groups, this is due to muscle imbalance often from a neurological disorder, e.g. spastic diplegia, poliomyelitis,...
The cervical spine
Postural neck pain 34 Acute neck pain in the young adult 34 Cervical spondylosis cervical osteoarthrosis Osteoarthritis of the cervical spine 34 Thoracic outlet syndrome 35 Whiplash and extension injuries of the neck 35 Barre-Lieou syndrome 36 Rheumatoid arthritis in the cervical spine 37 Klippel-Feil syndrome 37 Neoplasms in the cervical region 37 nspection and palpation of cervical spine 38 Examination of cervical spine movements 39 Diagnosis of thoracic outlet syndrome 40-41 Diagnosis of...
The tibia
Common causes of pain in the anterior aspect of the lower leg 246 Osteitis of the tibia 246 Bone tumours 246 Anterior tibial compartment syndrome 246 Stress fracture of the tibia 246 Medial tibial syndrome shin splints 247 Tabes dorsalis 247 Common causes of pain in the posterior aspect of the lower leg 247 Guide to commoner causes of leg pain 248
medial tibial syndromeshin splints
In this condition pain on the medial side of the shin in sportsmen may be severe, and there is usually tenderness along the posteromedial border of the lower part of the tibia. In a number of cases the symptoms may arise from stress fractures of the tibia, but in others the pathology is less clear. Other causes include compartment syndromes, fascial hernias, interosseous membrane tears, periosteal avulsions, tendinitis, muscle sprains and periostitis. Where symptoms are of a chronic nature, and...
clinical orthopaedic examination
3.13. Movements 7 If lateral flexion cannot he carried out without forward flexion, this is indicative of pathology involving the atlantoaxial and atlanto-occipital joints. 3.14. Movements 8 Rotation 1 Ask the patient to look over the shoulder. The movement may be encouraged with one hand and movement of the shoulder restrained with the other. Normally the chin falls just short of the plane of the shoulders. 3.15. Movements 9 Rotation 2 Again a spatula may be used as a pointer for measurement....
Anterior Metatarsalgia
In anterior metatarsalgia there is complaint of pain under the metatarsal heads. The condition is particularly common in middle-aged women and is also often associated with some splaying of the forefoot. Symptoms may be triggered by periods of excessive standing or an increase in weight, and there is often a concurrent flattening of the medial longitudinal arch. Weakness of the intrinsic muscles is usually present, so that there is a tendency to clawing of the toes hyperextension of the toes at...
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Extensive blanching. Most or all fingers affected. Frequent episodes, summer and winter Occupation changed to avoid further exposure to vibration because of severity of signs and symptoms See also under Rheumatoid arthritis. Mallet finger In a mallet finger the distal interphalangeal joint is held in a permanent position of flexion the deformity may be moderate or complete. The patient is unable to extend the distal joint of the finger, either not at all or only incompletely. The problem is...
Guide To Painful Conditions Around The Ankle
Sprain of lateral ligament Complete tear of lateral ligament Ankle fracture, fracture of the fifth metatarsal base Tibiofibular diastasis Ruptured Achilles tendon tendo calcaneus Complete tear of lateral ligament Secondary osteoarthritis e.g. previous ankle fracture Osteochondritis tali Rheumatoid arthritis Primary osteoarthritis Footballer's ankle Secondary osteoarthritis e.g. from osteochondritis tali Tenosynovitis Achilles tendinopathy Snapping peroneal tendons 12.1. Inspection 1 Look for A...
Dermatome
2.8. Myotomes 6 A single segment again, namely TI. is involved in producing abduction and adduction of the fingers these movements are carried out by the small muscles intrinsics of the hand. Note In testing for myotomes the ability to perform the above movements should be assessed by MRC grading, and note made of the segments affected. Often the defect can be localized to a single segment. 2.9. Dermatomes Note that the middle finger is supplied by C7, and that there is a regular, easily...
Exostoses
Apart from the exposure and prominence of the medial side of the first metatarsal head commonly seen in association with hallux valgus and referred to as a first metatarsal head exostosis , several exostoses may give rise to trouble in adolescence 1. Calcaneal exostosis Prominence of the calcaneus above and to the sides of the Achilles tendon insertion may cause problems with friction against the counter of the shoe blisters, calluses, difficulty in shoe fitting . Where the exostosis is...
Plantar Digital Neuroma Mortons Metatarsalgia
A neuroma situated on one of the plantar digital nerves just prior to its bifurcation at one of the toe clefts may give rise to piercing pain in the foot. It most commonly affects the plantar nerve running between the third and fourth metatarsal heads to the third web space, but any of the digital nerves may be affected. It most commonly occurs in women, particularly in the 25 45-year age group, and is often treated by excision of the affected nerve. Division of the intermetatarsal ligaments in...
Adult Flat Foot
Gradual flattening of the medial longitudinal arch incipient flat foot may occur in those who spend much of the day on their feet. This is often associated with an increase in body weight and the degenerative changes of ageing in the supporting structures of the arch. When these changes are rapid, they give rise to pain 'medial foot strain' . Secondary tarsal arthritic changes may also give rise to pain in long-standing flat foot, and are associated with loss of movement in the foot rigid flat...
Anatomical Features 1
Fig. 13.A. Tripod action of the foot To maintain perfect ground contact each foot acts as a tripod, with the legs of the tripod being represented by the calcaneus and the heads of the first and fifth metatarsals. To maintain balance, the centre of gravity in front of S2 must fall within the area covered by one or both feet, and to facilitate this each foot must be capable of movement in two planes. Fig. 13.B. Planes of movement 1 In the x-uxis nearly all of the movement occurs in the ankle, and...
Hallux Valgus
In adolescence, and particularly in girls, where there is competition between the rapidly growing foot, tight stockings and often small, high-heeled, unsuitable shoes, valgus deformity of the great toe first appears. In some cases a hereditary short and varus first metatarsal may contribute to the problem. As the deformity progresses, the drifting proximal phalanx of the great toe uncovers the metatarsal head, which presses against the shoe and leads to the formation of a protective bursa...
B
3.34. Radiographs 8 Proximal cranial migration of the odontoid process is also commonly seen in rheumatoid arthritis. In the adult this may be assessed by noting lhe distance between the pedicle P of C2 shown hatched and a line connecting the spinous process S with the arch A of CI. If this is less than 11.5 mm. proximal migration is considered to be present. pharyngeal shadow, which normally lies fairly close to the bodies of the vertebrae as at A . Displacement suggests a retropharyngeal...
Additional Investigations
Occasionally a firm diagnosis cannot be made on the basis of the history and clinical examination alone. The following additional investigations are often a Arthroscopy may give much useful information, and in conjunction with the clinical examination will permit a firm, accurate diagnosis to be made in the majority of cases. Incorrect diagnoses are most common in lesions involving the menisci in their posterior thirds. An increasing number of conditions are amenable to arthroscopic surgery,...
Sinusitis And Osteitis
11.4. Inspection 4 General bone thickening Extensive thickening of bone is characteristic of Paget's disease and longstanding osteitis. In the latter case there are usually other signs, such as scarring or sinuses. 11.5. Inspection 5 Tibial shape Note any abnormal anterior curvature tibial kyphosis , possibly secondary to Paget's disease, malunited fracture, syphilis or rickets. Rickets affects the distal half of both tibia and fibula, and there are associated lateral and torsional deformities....
Radioulnar Synostosis
5.6. Inspection 6 The carrying angle may be measured with a goniometer. Average values of carrying angle Males 11 range 2 -26 Females 13 range 2 -22 . 5.7. Movements 1 Extension A Full extension, 0 , is present if the arm and forearm can be made to lie in a straight line. B Loss of full extension is especially common in osteoarthritis, rheumatoid arthritis, and old fractures particularly of the radial head involving the elbow joint. 5.8. Movements 2 Hyperextension If the elbow can he extended...
lij clinical orthopaedic examination
8.103. Pathology 15 The radiographs show a regular dorsal kyphosis associated with anterior vertebral lipping and a degree of osteoporosis. Diagnosis senile kyphosis. 8.104. Pathology 16 The spinous process of L5 and less obviously SI , along with associated posterior elements, is absent. Diagnosis spina bifida occulta. The only disturbance noted in the lower limbs was a bilateral pes cavus. 8.105. Pathology 17 The radiographs shows a dorsal scoliosis associated with an anomaly of a vertebral...
The shoulder
Anatomical features 50 Common pathology arouna the sioulder 52 'Frozen shoulder' idiopathic adhesive capsulitis of the shoulder 53 Calcifying supraspinous tendinitis 53 Osteoarthritis of the acromioclavicular joint 54 Osteoarthritis of the glenohumera joint 54 Rheumatoid arthritis of the shoulder 54 Instabilities of the shoulder joint 54 Recurrent allocation of the shoulder 54 rtfections around the shoulder 55 Miscellaneous conditions around the shoulder 55 Assessment of combined shoulder and...
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Anatomical features 74 General points 74 Important relations 74 Elbow function 75 Tennis e bow 75 Cubitus varus and cubitus valgus elbow instability 75 Tardy ulnar nerve palsy 75 Ulnar neuritis and the ulnar tunnel syndrome 76 Osteoarthritis and osteochondritis d'ssecans 76 Rheumatoid arthritis 77 Tuberculosis of the elbow 77 Myositis ossificans 77 Inspection 78 Movements 79 Palpation 80-81 Tennis elbow tests 8 1 -82 Radiographs 82-84 Pathology 84-87 Aspiration of the elbow joint 87 The...
B 1
12.40. Radiographs 3 In the standard AP and lateral projections do not mistake A the common os trigonum accessory bone and B the epiphyseal line of the fibula for fractures. The amount of tibiofibular overlap C is dependent on positioning and any diastasis. The os fibulare D is thought to represent an avulsion of the anterior talofibular ligament, and may be associated with instability. 12.41. Radiographs 4 The articular margins of tibia and talus should appear as two congruent circular arcs....
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Although usually suspected following history taking, clinical examination and the study of appropriate radiographs, the diagnosis is made largely by a process of elimination it is back pain which is not due to a prolapsed intervertebral disc or any other clearly defined pathology. The patient is usually in the 20 15-year age group, and complains of dull backache aggravated by activity. There is often a history of morning stiffness which is gradually relieved as the patient moves about. Physical...
The wrist
Study of the wrist cannot be separated from that of the hand, and in many cases careful examination of both may be required. complications occurring after colles' fracture_ Considering the incidence of Colles' fracture, the commonest of all fractures, it is surprising that complications from this injury are not seen more frequently nevertheless, they do occur and are of importance. Excluding initial weakness of the wrist, the commonest complaints are of residual deformity, restriction of...
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4.42. Integrity of the long head of biceps Support the patient's elbow with one hand. Grasp his wrist and ask him to pull toward his shoulder while you resist this movement. If the long tendon of biceps is ruptured, the belly of biceps will appear globular in shape. Compare the two sides. 4.43. Deltoid power Ask the patient to try to keep the arm elevated in abduction while you press down on his elbow look and feel for deltoid contraction. Traction injuries of the axillary nerve resulting in...
J
3.31. Radiographs 5 Look at the disc spaces and the related margins of the vertebrae. Note A disc space narrowing, B anterior lipping, C posterior lipping all typical of cervical spondylosis . Note any evidence of vertebral fusions, D . typical of ankylosing spondylitis. 3.32. Radiographs 6 Note the presence A of an osteophyte or marginal fracture, suggestive of an extension injury of the neck B fracture of a spinous process, suggestive of a flexion injury of the cervical spine. Syringomyelia...
Achilles Tendinopathy
This generally results from excessive repetitive overload of the tendon to a degree that exceeds its capacity to recover. The preferred term ' endinopathy' includes a number of conditions which may only be differentiated by direct inspection and histological examination of the tendon or surrounding structures. These include tendinitis, where there is a clear inflammatory process involving the tendon tendinosis, where there is collagen degeneration within the tendon and paratendinitis, when...
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8.25. Movements flexion 7 Flexion in the thoracic spine may be measured with the upper point 30 cm from the previous zero mark. Thoracic flexion is not great, and is normally in the order of 3 cm. NB to exclude the possibility of overlay, repeat these measurements with the patient distracted, sitting up, and leaning forward on the examination couch. 8.28. Movements lateral flexion 2 Alternatively, measure the angle formed between a line drawn through Tl, SI and the vertical. The average range...
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10.78. Posterior cruciate ligament 2 With the leg still in 20 flexion, ask the patient to lift the heel from the couch while you observe the knee from the lateral side. Any posterior subluxation should normally correct during this extension of the knee, confirming the diagnosis. 10.79. Posterior cruciate ligament 3 Place the thumb on one side of the joint line and the index on the other to help you assess any tibial movement. Try to pull the tibia forwards with the other hand. If the posterior...
Preface
The ability to make a good clinical examination can only be mastered by practice, and I have no doubt that the basic techniques are best learned by performance under supervision. Unfortunately, the size of student classes in relation to teaching staff, and the not infrequent dearth of an adequate range of suitable clinical cases, makes this ideal difficult to achieve in practice. Many students may acquire only a sketchy knowledge of the techniques of examination, which are fundamental to...
Trendelenburg Test
Where there is significant true shortening the heels will not be level the discrepancy is a guide to the amount of shortening and the pelvis will not be tilted. The site and amount of shortening must now be further investigated. Begin by hooking the thumbs under the anterior spines. Feel for the greater trochanters with the fingers. If the distance between the thumb and fingers is shorter on one side, this suggests that the pathology lies above the trochanters. 9.15. Shortening examination 5 II...
Lull
9.62. Gluteal muscles Test the power in gluteus maximus by asking the patient to extend the hip against resistance, at the same time feeling the tone in the contracting muscle. 9.61. Gluteal muscles Test the power of the hip abductors with the patient lying on his side, attempting to abduct the leg against resistance. 9.63. Aspiration The hip may be aspirated by inserting a needle above the trochanter, allowing for femoral neck anteversion. Alternatively, a needle may be passed into the joint...
The Delayed Trendelenburg Test
b Edinburgh method An AP film is taken with the child's legs held parallel, with slight traction and no external rotation. Centre the beam at a standard distance of 100 cm. Measure the gap between the most medial part of the femur and the lateral edge of the ischium. This is normally 4 mm over 5 mm is suspicious 6 mm is regarded as diagnostic of DDH. Proximal migration can also be measured in the same film. 9.71. Developmental dislocation of the hip DDH The older child 1 Appearance A The...
Peripheral Nerves
The brachial plexus has a most extensive distribution, and the order in which the nerves come off is of value in determining the site of any lesion. This is of particular importance in traumatic lesions, where the prognosis and treatment are closely related to the level of injury. The first branches of the plexus to be given off arise from the nerve roots themselves. Two important branches in this category are 1. The nerve to the rhomboids dorsal scapular nerve . It arises from the C5 root...
Patella Skyline View
10.123. Radiographs 5 Note any joint space narrowing indicating cartilage loss N , lipping L , marginal sclerosis S . cysts C , loose bodies H , varus or valgus these are all common in osteoarthritis . Do not mistake a bipartite patella B for fracture bipartite patella, if present, affects the outer quadrant . Note any abnormal calcification, as in Pellegrini-Steida disease J , calcified meniscus K , and pseudogout. 10.124. Radiographs 6 Look for alterations in bone texture e.g. in Paget's...
the spine anatomical features
The complex relationships of the components of a typical vertebra may be illustrated by an exploded diagram shown here after Kapandji . The bony elements comprise the vertebral body 1 , composed of cancellous bone covered with an outer shell of cortical bone the horseshoe-shaped neural arch 2 two articular masses or processes 3 which take part in the facet interarticular joints the transverse processes 4 and the spinous processes 5 . When these components are brought together they form a...