Handout for practical examination of orthopaedics for 4th year students
Dear students! With this short work my goal was to give a little help for preparing to the practical examination of orthopaedics. Only those patient examination methods and definitions were included, which were declared as the most important by my fellows and me.
Peter Kellermann MD
General part
Examination of muscle tone (atonic, spastic paresis, plegia)
Muscles of the moving apparatus always have a base tone. Examining the muscle in relaxed phase it is:
- hypotonic or atonic, if its tone is lesser than normal (cause can be: primary muscle disease, motoneuron damage)
- spastic, if its tone is increased (cause can be: central nerve system disturbances /pyramidal or extrapyramidal disease/)
Examination: muscle itself must be palpated, and resistence against passive motion is evaluated. (Passive motion: we make the joint of the patient move, not him)
Examination of muscle strength from 0 til 5
Strength of the given muscle is examined. Muscle strength is:
- 0: no activity of the muscle during attempt of motion
- 1: fasciculation, but no active movement
- 2: active movement can be achieved only when gravity is absent (horizontal plane, or underwater movement)
- 3: extremity can be held against gravity
- 4: stronger than 3, but not full strength
- 5: full muscle strength
Axis of extremities (direction, range)
Bones and joints of the extremities can deviate from normal axis to valgus, varus, ante- and retrocurvation and axial rotation.
- valgus: distal part of the extremity deviates to the side from midline (for example „X” knees)
- varus: distal part of the extremity deviates to the midline
- antecurvation: convexity of the curve is forward (deviation is backward!)
- retrocurvation: convexity of the curve is backward
- axial rotation: rotation on the axis of the extremity. For example: internal rotation of the calf means that feet rotate inwards against each other while patellae look directly forward.
Range of deformity is given in degrees.
Contracture (direction, range)
- definition: decrease of passive range of motion (ROM) at the joint.
- direction: from which position full ROM can not be reached til the normal endpoint of joint motion (example: when knee cannot be extended totally, it means flexion contracture)
- range: degrees.
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Measuring of circumference of extremities
Circumference is measured on both sides, on the same height. Result is given in centimeters, and the distance between the measured height and a well defined bony point (patella apex, ant. sup. iliac spine) must be declared. In case of muscle circumference, decrease is pathologic (hypotrophy), in case of joint, increase is abnormal (intra-articular fluid).
Examination of intra-articular fluid
Joint fluid is examined mainly in the knee, because it is a big joint covered with few soft tissue, and quite much fluid can develope inside of it because of the many bursae connected to the joint cavity. At the patient examination knee is fully extended, and we try push down the patella onto the patellar surface of the femur (knocking down, so called ballotation)
- In case of normal condition (no extra fliud in the joint) the patella „sits” on the surface of the femur, it cannot be pushed down.
- In case of few fluid the patella cannot be ballotated, only if we use our other hand to place it on the top of the suprapatellar bursa and push down the few fluid under the patella, so it is lifted a little bit, and now it can be pushed down (ballotated).
- At medium amount of fluid patella is ballotable, joint circumference is bigger than on the other side (see question above).
- At mass fluid big pressure in the joint can make ballotation sign impossible. Increased joint circumference can be measured and resembled to the contralateral side (of course swelling can occur on the other side as well).
Special part:
Spine - chest: description of their shape
Examination of spine shape consists of description of:
- physiological (sagittal) curves: cervical and lumbar lordosis and dorsal kyphosis
- anatomic variations of the above curves (flat back, round back, sway back, pustual kyphosis)
- possible curve(s) in the frontal plane, see at topic scoliosis below.
Examination of chest shape consists of description of:
- symmetry of the chest
- normal anatomic variations (athletic, asthenic, emphysematic)
- possible deformations: pigeon breast (pectus carinatum; the sternum lies more frontally than the ribs), funnel chest (pectus excavatum; the sternum lies deeper then the ribs), rib prominence (prominence shows convexity of the scoliosis)
Right sided rib prominence from back, and the bony deformation Normal, round, sway and flat back
Description of scoliotic patient (curves, compensated or not, mobility)
Scoliosis is curve of the spine in the frontal plane. It is always pathologic. At examination of scoliotic patient we describe:
- level and range of the curve(s)
- other typical signs: rib prominence (at bending forward, see above), asymmetrical paravertebral muscles, shoulder on one side stands higher than on the other side, waist triangle (triangle between body and arm) asymmetry
Scoliosis is compensated, if the midpoint of the skull stands on the same vertical line as the midpoint of the sacrum. It is not compensated, when the skull lies lateral from the midline of the sacrum.
Mobility: lifting of the arm on the concave side plus bending the chest to the convex side the pathological curve can be diminished. If this decrease is marked, the scoliosis is mobile.
Examination of movement of the spine
Range of motion (ROM) should be checked independetly on the cervical, dorsal and lumbar part on three axes (bending forward-backward: flexion-extension, bending to side: lateralflexion, rotation). Range can be given in degrees, or by the Schober's sign: putting two marks onto the skin i.e. at the level of the lumbosacral joint and 10 cm higher at postural position, we measure these marks at full forward bended position as well. The distance is increased up to 15 cm normally.
cervical spine movements: a: flexion-extension back movements: lateralflexion and
b: lateralflexion c: rotation rotation
back movements: flexion and extension Schober's sign: increase between the markpoints at flexion
Examination of shoulder movement (passive, active)
The shoulder girdle motion consists of the glenohumeral motion and the motion of the claviculo-scapular girdle. The full ROM is evaluated at both three axes:
- abduction, adduction (at adduction the arm is placed in front of the chest)
- flexion, extension
- internal and external rotation (the elbow is in 90 degree flexion, and the forearm is moved)
a,b: abduction c: flexion-extension e,f: external and internal rotation at adduction and at 90 degree abduction
The gleno-humeral joint ROM can be examined separately by pressing the clavicula and scapula down onto the chest with our hand.
Examination of elbow movements
The humero-ulnar joint moves in one axis (flexion and extension). ROM is 0-150 degrees.
Examination of forearm movements
The motion is pronation (palm downward) and supination (palm upward) both 90 degrees. The radius rotates around the fixed ulna. Neutral position is when the thumb looks upward while the elbow is bended to 90 degree flexion. See figure above.
Examination of wrist joint movements
The wrist joint is the radiocarpal joint, but ROM of the wrist is magnified by two other joints: the intercarpal and the carpo-metacarpal joints. The full ROM of the three joints is evaluated. Movements:
- palmarflexion and dorsiflexion (extension)
- ulnarduction and radialduction
There is NO rotation in the wrist
Examination of the hand, functional tests
1st ray: ROM of the saddle joint (carpo-metacarpal joint), metacarpo-phalangeal (MP) joint and interphalangeal (IP) joint is examined.
Other rays: MP, proximal and distal interphalangeal (PIP, DIP) joints are checked.
Functional tests are used to evaluate the perpiheral nerve and muscle functions. Some tests:
- median nerve test: the thumb (pollex) is opponed (turned against the 5th finger tip) and a sheet of paper is held between them. At median nerve lesion the m. opponens pollicis function is damaged.
- ulnar nerve test: the 2-5th fingers are abducted and adducted (opened and closed to each other), movement is produced by the interosseal muscles.
- radial nerve test: extension of the fingers, movements is done by the long forearm extensors. No muscles in the hand belong to the radial nerve.
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Examination of hip movements
Ball-and-socket joint, movements include 3 axes. Examination is performed on supine position, except for extension (supine). Movements:
- flexion-extension
- abduction-adduction
- external-internal rotation.
At checking of ab-adduction and rotation the anteior superior iliac spine of the opposite side is held by our hand to control whether the pelvic bone is moving instead of the hip joint.
a: flexion-extension c: ab-adduction f: external and internal rotation
Examination of knee movements
Main movement is the flexion and extension. Hyperaxtension below 5 degrees is not pathological, but the opposite side has to be checked as well for comparison. In the position of 90 degree flexion some internal and external rotation is also possible, about 30-40 degrees.
Knee joint instability tests
These tests show us the integrity or possible instability of the main knee ligaments: the anterior and posterior cruciate ligament (LCA and LCP) and the medial and lateral collateral ligament (LCM and LCL). Instability tests:
- valgus stress: checks integrity of the LCM. Examination is performed in full extension of the knee joint.
- varus stress: checks integrity of the LCL. Examination as by LCM.
- anterior drawer sign: shows the instability of the LCA. Examination in 90 degree flexion.
- Lachmann test: also an LCA instability test, but examination is made in 15-20 degree flexion.
- posterior drawer sign: shows the instability of the LCP. Examination in 90 degree flexion.
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Examination of ankle movements
Ankle joint is formed of three bones: tibia and fibula formes the so-called „ankle fork”, and distal surface is the talus. Movements: flexion (plantarflexion) til 40-50 degrees, and extension (dorsiflexion) up to 20-30 degrees. Active ROM (performed by the patient himself) and passive ROM (checked by us) should be evaluated.
Examination of subtalar and metatarsal joint movements
Subtalar joint consists of three bones: the talus, calcaneus and the navicular. Movement are inversion and eversion. The midfoot has tight joints with poor ROM, some degrees of flexion-extension and pronation-supination is available.
eversion-inversion in the subtalar joint pronation-supination in the midfoot (calcaneus is fixated!)
Description of foot deformities
Every joint has its typical type of deformation (contracture). The main deformities are:
- in the ankle joint: equinus (flexion) contracture and extension contracture
- in the subtalar joint: varus (inversion), i.e. at clubfoot, and valgus (eversion), i. e. at flatfoot
- in the midfoot: collapse of the longitudinal arch (pes planus): at flatfoot, and elevation of the longitudinal arch (cavus foot): at neuro-muscular imbalance.
- pes abductus: at flatfoot
- pes adductus: at clubfoot
- at the forefoot: hallux valgus (bunion deformity), hammer toe (at 2nd to 5th toes, metatarso-phalangeal joint is in extension contracture, proximal interphalangeal joint is in flexion contracture)
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Examination of forefoot joint movements
In controversy of the fingers of the hand, at the foot the metatarso-phaangeal (MP) joints have more extension (dorsiflexion), about 70 degrees, and less plantarflexion: about 40 degrees. The dorsiflexion is needed at the toe-off phase of the gait cycle. In the 1st toe interphalangeal (IP) joint and in the 2nd to 5th proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints only plantarflexion is possible. Active and passive ROM should be examined.
Examination of flatfoot
Flatfoot = pes planus. If the heel is in valgus position, the deformation is called pes plano-valgus.
At the examination we check the feet in loaded (standing) position from forward and also from backward. Heel valgus, collapse of the longitudinal arch, and pes abductus is evaluated. Mobile flatfoot can be actively corrected by the muscles of the foot at tiptoe position, while rigid flatfoot looses this possibility. Then transversal arch is examined for possible arch collapse.
Examination of own reflexes on the lower extremity
At reflex examination the tendinous attachment of the muscles is hit by reflex hammer. The reflex answer is a contraction on a certain muscle. Own reflex: the contraction is on the same muscle, the tendon of which was hit by the reflex hammer.
The most important own reflexes on the leg:
- patella reflex (segment L2-L4 of the lumbar spine): own reflex of the quadriceps muscle. Examination is performed by knee in 90 degree flexion and the calf is hanging free (i.e. sitting on a high examination table). We hit onto the patellar tendon between the patella apex and the tibial tuberosity. The reflex answer is a well defined, immediate extension in the knee joint.
- Achilles reflex (segment S1): own reflex of the gastrocnemius muscle. Most simple way of examination is when the patient lays at prone position, and the foot hangs free at the end of the examination table. We hit onto the Achilles tendon, the answer is a relatively slow plantarflexion movement of the ankle joint.
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Examination of own reflexes on the upper extremity
Most important own reflexes are:
- biceps reflex (segment C5-C6): elbow is in mild flexion on a table, forearm is fully supinated. Our left thumb is placed onto the radial attachment of the biceps muscle, and we hit onto our nail of the thumb with the reflex hammer.The effect is a flexion in the elbow joint.
- Brachioradial reflex (segment C6): At elbow in 90 degree flexion we hit onto the processus styloideus radii near the wrist joint. The effect is contraction of the muscle, flexion of the elbow joint.
- Triceps reflex (C8): patient sits on a chair, his arm is placed onto the top of the back of an other chair, and the forearm is hanging down free. The tendon of the triceps muscle is hit by the reflex hammer near the olecranon. The effect is extension in the elbow joint.
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Measuring of lower extremity length (absolute, relative, functional)
Difference between the length of the two extremities is much more important on the leg than on the hand, because leg length difference causes overload on every joint of the lower extremity, and especielly on the lumbar spine.