50-19.10examination of extremities

8/3/2019 50-19.10examination of Extremities

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Mge Bakgil MD.

Yeditepe University

Rheumatology Division.


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General Considerations

y The patient should be undressed and gowned asneeded for this examination.

yThe examination may not be appropriate

(e.g. performing ROM on a fractured leg).

y The musculoskeletal exam is all about anatomy.

y Think of the underlying anatomy as you obtain thehistory and examine the patient.


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y The cardinal signs of musculoskeletal disease are:pain,

y redness (erythema),y swelling,

y increased warmth,

y

deformity, andy loss of function.


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y Always begin with ;

y inspection,

y palpation and

y range of motion,

regardless of the region you are examining.


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y Specialized tests are often omitted unless a specificabnormality is suspected.

y Acomplete evaluation will include a focusedneurologic exam of the effected area.


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Vascular

Pulses

y Check the radial pulses on both sides. If the radial

pulse is absent or weak, check the brachial pulses.

y Check the posterior tibial and dorsalis pedis pulses onboth sides. If these pulses are absent or weak, check

the popliteal and femoral pulses.


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Edema, Cyanosis, and Clubbing

y Check for the presence of edema (swelling) of thefeet and lower legs.

y Check for the presence of cyanosis (blue color) ofthe feet or hands.

y Check for the presence of clubbing of the fingers.


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Lymphatics

y Check for the presence of axillary lymph nodes.

y Check for the presence of inguinal lymph nodes.


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Inspection

y Look for scars, rashes, or other lesions.

y Look for asymmetry, deformity, discoloration, oratrophy.

y Always compare with the other side.


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y Varus - distal extremity deviates medially from thejoint (bow-legged)

y Valgus - distal extremity deviates laterally from thejoint

y Often in a fracture or disclocation there is an obviousdeformity about the joint or bone.


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y Swelling - suspect if normal landmarks about the jointare not apparent, or the normal contour of the

extremity is altered.

yWasting - muscle wasting can result from neurologicor muscular disease or injury. Bony landmarks often

more prominent.


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y Discoloration:

Erythema, or redness, is a sign of inflammation.

Ecchymosis, or bruising, can be secondary to superficialbruising, or may indicate damage to the underlyingmuscle, ligament, or bony structure.


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y The examination of the patient begins when thepatient first enters the room.

y How is the patient's posture?y Does the patient appear uncomfortable?

y Are there any obvious joint deformities?

y

How is the patient's gait?


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Palpati

ony Examine each major joint and muscle group inturn.

y Identify any areas of tenderness.

y Identify any areas of deformity.



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y During palpation,

y changes in temperature,

y palpable deformities,y crepitus and

y tenderness.


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y Temperature

y Use the back of your hand

y Deformities

y Palpate using your finger pads.

y

Is there a palpable deformity?y An irregular enlargement- due to

y arthritis,

y deposition of inflammatory material,

y

an old injury, ory more rarely a tumor.


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y Crepitus

y Grinding or rubbing sensation or sound.

y Due to bony or cartilaginous structures moving acrosseach other, or due to

y tendons moving across each other.

y Tenderness

y Pain with palpation is usually an indicator of injury orinflammation.

y The severity of the pain is usually a marker of theseverity of the underlying condition.


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y Fractures, dislocations and complete tears of ligamentsor tendons are usually very painful.

y A

cute inflammatory arthritis due to gout or infection isalso exquisitely painful.

y Mild sprains or contusions tend to be less painful.

y Pain from chronic conditions such as rheumatoidarthritis or osteoarthritis, while sometimes severe, isusually less painful


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Range of Motion

y Start by asking the patient to move through an active

range of motion (joints moved by patient).

y Proceed to passive range of motion (joints moved byexaminer) if active range of motion is abnormal.


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yActive ROM

y Ask the patient to move each joint through a full

range of motion.y Note the degree and type (pain, weakness, etc.) of

any limitations.

y Note any increased range of motion or instability.


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y Proceed to passive range of motion if

abnormalities are found.y If there is injury or pain, begin with normal side

first.

y Assess one joint at a time.

y Observe the patient for pain, smoothness ofmotion, and any unusual movements.


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y

PassiveROMy Ask the patient to relax and allow you to support

the extremity to be examined.

y Gently move each joint through its full range of

motion.

y Note the degree and type (pain or mechanical) ofany limitation.

y

If increased range of motion is detected, performspecial tests for instability as appropriate.



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y Palpation during passive (or active) ROM may reveal

crepitus.y Be sure to have the patient tell you if the ROM

becomes painful.

y Discrepancies between active and passive ROM may

be due to weakness, pain or joint disorder.


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STRENGTHTESTING

y If pain or injury, begin with normal side.

y Isolate the joint about which you are testing strength.

y Compare one side to other.


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y SPECIALMANEUVERS

y Clinicians perform special maneuvers when they are

hypothesis testing, i.e., they are concerned about aspecific condition or injury.


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y Some common special maneuvers for the upperextremity include:

y Shouldery Impingement test

y Drop test

y Hand and wrist

y Tinel and phalen's (for carpal tunnel)


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y SHOULDERJOINT

y It has an incredibly

wide range of motion,due to the complexstructures of theshoulder girdle.


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y PALPATION:

y Palpate the acriomoclavicular joint, the acromion, the

scapular spine, and the bicipital groove.y Palpate the muscles about the shoulder.


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y STRENGTHTESTING

y Routinely test flexion, extension and abduction.

y If indicated (pain, other complaints), check internaland external rotation, and adduction.


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y ACTIVE AND PASSIVE RANGE OF MOTION

y Observe the patient abducting, flexing and extending

their shoulder.y Evaluate external rotation by having the patient place

their hand behind the head.

y Evaluate internal rotation by asking the person to

touch his fingers at the back.


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y Range of Motion

y Abduction (150 degrees)

y Forward flexion (180 degrees)y Extension (45 degrees)

y External Rotation (90 degrees), elbow at 90

degreesy With arm comfortably at side

y With arm at 90 degrees abduction

y Internal rotation (90)


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SPECIAL MANEUVERSy The Neer

impingement sign:

y This maneuver

narrows the spacebetween the acromionand the humeral head.If a patient hasimpingement of a

rotator cuff tendon (ora tear), they willusually have increasedpain with this test.


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y The drop test:

y Gently abduct the arm above ninety degrees, if pain

allows. Ask the patient to maintain the arm in the thisposition, warn the patient and then drop the arm. In apatient with a rotator cuff tear, they will often not beable to maintain the arm's position and it will fall.


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ELBOW JOINT


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y A- Olecranon

y B - Lateral Epicondyle


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y INSPECTION

y Inspect the elbows with the arm in a neutral, anatomic

positiony Observe the carrying angle (the angle of the forearm

on the upperarm).

y PALPATION

y Be able to palpate the lateral and medial epicondyles,and the olecranon process.


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y RANGE OF MOTION

y Flex and extend, and supinate and pronate.

y Normal elbow range of motiony Extension: 0 degrees

y Flexion: 150 degrees

y Pronation: 70 degrees

y Supination: 90 degrees


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HAND AND WRIST


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y PalmarHand

y A- Distalwrist crease

y B - Thenareminence

yC -Hypothenareminence


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y Dorsal Hand

y A- Carpometacarpaljoint

y B -Metacarpophalangeal

joints

y C - Proximalinterphalangeal joints

y D - Distalinterphalangeal joints

y E - Interphalangeal jointof thumb


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y INSPECTION

y At rest, the fingers will be slightly flexed and almost in

parallel.y Inspect the dorsum of the hand and wrist for swelling.

y Inspect the palmar expect for thenar or hypthenarwasting.

y Inspect each joint for swelling, discoloration anddeformity.


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y PALPATION

y Palpate the radial and ulnar styloid, and the

radiocarpal and radioulnar joints.y Palpate the anatomic snuffbox.

y Palpate the CMC joint, and the lateral and medialaspects of each MCP, PIP and DIP joint.

y The joints of the wrist and hand are commonlyaffected in osteoarthritis and rheumatoid arthritis.Other common conditions affecting the hand andwrist are ganglion cysts and Dupuytren's contractures


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y In osteoarthritis palpation will reveal tenderness andbony growths (osteophytes) that enlarge the joints -particularly the DIP and PIP joints. These are calledHeberden's nodes and Bouchard's nodes, respectively


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y In rheumatoid arthritis the synovium of the joint isinflamed, leading to tenderness and bogginess aboutthe joint, in addition to warmth and redness.

y Later in the course of the disease, the bony andligamentous structures supporting the joint aredamaged, and joint deformity results.


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y Ganglion cysts are common, and arise from thesynovium.There are frequently found on the dorsumof the wrist, but can arise from the MCP and otherjoints as well. They only require treatment if they arepainful.


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y Dupuytren's contracture is a localized thickening ofthe palmar fascia, most frequently affecting the fasciaoverlying the 4 th and 5 th metacarpals. It can lead tohand contracture, deformity and decreased function.


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y RANGE OF MOTION

y Assess pronation and supination of the forearm

yAssess flexion, extension, abduction and adduction ofthe wrist.

y Assess flexion of the MCP joints with the PIP jointsextended, and have the patient make a fist to assess

flexion of the PIP and DIP joints, and spread the handout to assess extension of the PIP, DIP and MCP joints.

y Have the patient oppose the thumb to the small finger


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y Normal wrist range of motion

y Extension - 70 degrees

y Flexion- 90 degrees

y Radial deviation (abduction) - 20 degrees

y Ulnar deviation (adduction) - 55 degrees


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y Normal hand range of motion

y MCP hyperextension - 30 degrees

y MCP flexion - 90 degrees

y PIP and DIP extension - 0 degrees

y PIP and DIP flexion - 90 degrees

y Oppostion - thumb should touch the 5 th MCP.

y Passive ROM of the hand is frequently not performed.


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STRENGTH TESTING

y Test wrist flexion and extensiony Grip strength

y Opposition - have the patient touch thumb to smallfinger, and try to pull your finger through. (median

nerve)y Key grip strength - have patient grip a thin object

(piece of paper or name tag works well) between histhumb and the proximal phalanx of index finger, andresist you as you try to pull the object from his grasp.(median nerve, collateral ligament)

y Finger abduction - have patient spread fingers outagainst resistance.(ulnar nerve)


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S

peci

alT

ests-Snuffbox Tenderness (Scaphoid)y Identify the "anatomic snuffbox"

between the extensor pollicis longus

and brevis (extending the thumbmakes these structures moreprominent).

y Press firmly straight down with your

index finger or thumb.y Any tenderness in this area is highly

suggestive of scaphoid fracture.


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y Neurologic Tests

y Phalen'sTest (MedianNerve)y Ask the patient to press the backs

of the hands together with thewrists fully flexed (backward

praying).y Have the patient hold this position

for 60 seconds and then commenton how the hands feel.

y Pain, tingling, or other abnormalsensations in the thumb, index, ormiddle fingers strongly suggestcarpal tunnel syndrome.


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Neurologic Tests

y Tinel's Sign (MedianNerve)

y Use your middle finger or a reflex hammer to tap over

the carpal tunnel.y Pain, tingling, or electric sensations strongly suggest

carpal tunnel syndrome.


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EXAMINATIONOF SPINE


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y Landmarks helpful in identifyingspinal levels include:

y

C

7 andT

1 - prominent spinousprocesses

y T7 toT8 - inferior angle ofscapula typically located at this

levely L4 - an imaginary line across the

tops of the iliac crests crosses L4


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y PHYSICAL EXAMINATION

y Examination of the spine includes inspection, palpationand range of motion. Strength testing of the spine is nota part of the typical physical examination.


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y Observe the patient from the back, with the backexposed.The patient could either be wearing only

undergarments, or a gown that is not tied in theback.y Normal Findings

y Shoulders (left and right should be equal height)

y

Scapulae (left and right should be equal height)y Iliac crests (left and right should be equal height)

y Hands at equal height.


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y Unequal heights of any of these structures mightindicate scoliosis (congenital or acquired), leg-lengthdiscrepancy or spinal pathology.

y Observe the patient from the side, identifying thenormal cervical and lumbar concave curves, and theconvex curves of the thoracic and sacral spine.


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y Scoliosis - curvature of spine - congenital, developmental, acquiredy Note the slight curvature to this patient's spine, and note that the right

scapula is raised relative to the left. The curvature is seen more clearly onthe X-ray:


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y Lordosis - increased or "swayback" curve in lumbarareay Pregnancy, muscle imbalance, obesity

y Kyphosis - increased or "humback" curve in thoracicarea

y Osteoporosis, posture, congenital


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y Palpation:

y Palpate the spinous processes and the paraspinous

musculature, assessing for tenderness, swelling,warmth, and muscle tone.


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y Range of motion

y The examiner asks the patient to flex, extend, laterally

bend and rotate (or turn) the cervical spine and the"back" (primarily the lumbar, thoracic and sacralspine). Begin from the neutral position, with thepatient standing up straight (can assess range ofmotion of the cervical spine with the patient seated).


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y Cervical spine range of motion:y Flexion - 45 "Touch chin to chest"

y

Extension - 55 "T

ilt your head back as far as you can"y Lateral bending (right and left) - 40 "Try to touch your

ear to your shoulder without moving your shoulder"

y Rotation (right and left) - 70 "Turn your head towardsyour shoulder"


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y Back range of motion:y Flexion - 90 "Try to touch your toes without bending

your knees"

y Extension - 30 "Lean back as far as you can"

y Lateral bending (right and left) - 35 "Lean to your side"

y Rotation (right and and left) - 30 "Twist to your side"

y

Examiner may need to stabilize patients pelvis toprevent rotation at the pelvis.


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Extension

Lateral bending

Left-right rotation


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y Special Maneuvers:

y Straight leg raise (SLR)

y Purpose: Used to evaluate back pain that radiates intoleg (sciatica). Places tension on sciatic nerve andinflamed nerve root

y Technique: Patient supine, legs straight. Hold heel, andpassively lift affected leg with knee straight. Talk withpatient to be sure their leg muscles remain relaxed.Repeat with other leg.

y Findings: Positive test is reproduction of sciatic-type painwhen hip is flexed between 30 and 70. Dorsiflexion of foot

may aggravate pain.


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y LOWEREXTREMITIES


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HIPy Can assess entire lower extremity, observing the

hips, knees, ankles and feet.

y

Observe for symmetry, deformity anddiscoloration.

y Can assess hip strength by watching patient risefrom a chair.

y Individuals needing to use their arms to push up fromthe chair, or who have to "rock" themselves out of thechair have muscle weakness of the proximal hipmusculature.


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y Palpation:

y Palpate the iliac crest and greater trochanter.y

In the patient with hip pain, palpate the glutealmusculature as well as the hip and thigh musculature.

y In the patient with pelvic pain, palpate the symphysispubis, ischial tuberosities, the posterior superior iliaccrest.


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y Range of motion:

y Either active or passive. In patient with pain, active

should precede passive ROM.y Flexion (with knee bent) - 120

y Flexion (with leg straight) - 90

y Extension - with patient lying on side, lying prone orstanding - 15

y Abduction - 45

y Adduction - 30

y Rotation - with knee flexed to 90

y Internal 40

y External 45


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y KNEE

y Inspection:

y

Evaluate for swelling, discoloration, deformity. Identifythe landmarks about the knee.

y Inspect the quadriceps muscle for atrophy. Atrophy iscommon in chronic knee conditions.


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y Palpation:

y Evaluate for warmth, tenderness, crepitus and fluid.

y

Identify the tibial and femoral condyles in order topalpate the tibiofemoral joint space medially andlaterally.

y Palpate the patella

y Palpate the popliteal space (swelling may indicateBaker's cyst )


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y Range of motion:

y Passive or active. If patient has pain, active should

proceed passive.y Expected ROM:

y Flexion - 130

y Extension - 0 (neutral) to 15 (hyperextension)


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y Presence of f luid:

y Ballotement: With knee extended, apply downwardpressure on the suprapatellar pouch with one hand,and with the other hand push the patella firmly downagainst the femur. Atapping or clicking will be felt ifan effusion is present, and as you slowly releasepressure, you will feel the patella "floating" upwards


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y Mediolateral instabilityy Purpose: evaluate the medial and collateral ligaments.

y T

echnique:y Medial collateral ligament: with the knee flexed at 30

(or in neutral position), apply a valgus stress to theknee.


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y Lateral collateral ligament: with the knee flexed at 30(or in neutral position), apply a varus stress to the

knee.

y Compare injured to normal side.

y Positive finding - pain, with evidence of joint spacewidening in comparison to normal side. Pain alonesuggests possible strain of ligament, without disruptionof the fibers.


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y FOOT and ANKLE

y Inspection:

y

Evaluate for symmetry, deformity, discoloration.y In patients with diabetes, assess for ulcers, which can

often lead to osteomyelitis (bone infection).

y It is often helpful to observe the foot and ankle during

weight-bearing


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y Palpation:

y Evaluate for warmth, tenderness and crepitus. Palpatethe achilles tendon, medial and lateral malleoli


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y .


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y

Range of Motion:y Expected ROM - neutral position of foot and ankle

is with foot at 90 to leg.y Dorsiflexion - 20 "Point your toes towards nose"

y Ankle joint: Plantarflexion - 45 "Point toes towardsfloor."

y Inversion (sole points "in") - 30

y Eversion (sole points "out") - 20

y Flex and extend toes.


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y Strength:

y Dorsiflexion - patient flexes up against your hand.

y

Plantarflexion - patient flexes down against your hand


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y FABERTest (Hips/Sacroiliac Joints)

y FABER stands for Flexion, ABduction, and ExternalRotation of the hip.

y This test is used to distinguish hip or sacroiliac jointpathology from spine problems.

y Ask the patient to lie supine on the exam table.

y

Place the foot of the effected side on the opposite knee(this flexes, abducts, and externally rotates the hip).


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y Pain in the groin area indicates a problem with the hipand not the spine.

y Press down gently but firmly on the flexed knee andthe opposite anterior superior iliac crest.

y Pain in the sacroiliac area indicates a problem with thesacroiliac joints.


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FADIR TESTy (Hips/Sacroiliac Joints)

y FADIRstands for

F

lexion,AD

duction, andInternalRotation of the hip.


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Schober test

10 cm 15 cm

50-19.10examination of extremities

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