Clinical Assessment and Examination in Orthopedics

Clinical Assessment and
Examination in Orthopedics
SECOND EDITION
C Rex
MB MS Orth DNB Orth FRCS (Edin)
MCh Orth (Liv) FRCS Trauma and Orth (Edin)
Chief Surgeon and Head

Department of Orthopedics
Rex Ortho Hospital
Coimbatore, Tamil Nadu, India
Forewords
S Rajasekaran
Charles SB Galasko
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© 2012, C Rex
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Clinical Ass essment and Examination in Orthopedics
First Edition: 2002

Second Edition: 2012
ISBN: 978-93-5025-642-8
Printed at
Dedicated to
The wisdom of my teachers,
The gratitude of my patients,
The love of my parents and
my family who have immeasurably enriched my life
Foreword to the Second Edition
The basis of successful management of any orthopedic patient depends on a firm diagnosis,
assessment of his disability and understanding of his needs and expectations. Although modern
advances in diagnostic and imaging modalities have opened up new and exciting avenues for
evaluating a disease, these can never replace good history taking and a sound clinical examination.
Investigations like MRI are so sensitive that many normal changes are projected as pathology leading
to over-diagnosis and many unnecessary treatment. Further, patients with similar imaging results
have different disability and symptoms. It is always wise to fully understand the patient and evaluate
the disease clinically before any plans for treatment is made.
I am glad to note that each chapter has been written in a systematic pattern starting from good
history taking and proceeding to a stepwise clinical examination following the wise principle of
‘look, feel, move and document’. Each chapter also has clinical tests specific to the region and
pathology well explained and illustrated. The theoretical basis of each of these tests is also clearly
explained and this will be very useful to young doctors in training.
I have known the author Dr Rex personally for many years and being the good clinician that he
is, it is no wonder that he has brought out this book which would not only be useful to training
doctors but also be a ready-reference to all practicing orthopedic surgeons.
S Rajasekaran
Chairman
Department of Orthopedics
Ganga Hospital, Coimbatore, Tamil Nadu, India
Foreword to the First Edition
The basis of orthopedic surgery is the clinical examination, including history of the patient followed
by the relevant investigations. Unless the clinician is able to take a proper history and conduct the
clinical examination in a systematic fashion, he/she will neither be able to make the correct diagnosis
nor be aware of the relevant necessary investigations required to reach the correct diagnosis and
discuss the optimum management with the patient. This book is aimed at undergraduate students
and orthopedic trainees and serves its purpose in detailing the techniques of examination of the
different regions. The basis of the examination of each region is based on the history, followed by
Alan Apley’s classical method of examination—look, feel, move. The author and the editors of the
individual chapters, all of whom are experienced surgeons in their specific field, have then described
specific tests and conditions. Orthopedics is a visual subject with inspection playing an important
role in clinical examination. It is for this reason that the book has been well illustrated, such that the
student will gain much more from the text.
We live in an era of increasingly sophisticated investigations and the development of molecular
biology, genetics, tissue engineering, etc. all of which will have a major impact in the delivery of
orthopedic services but if the patient is to obtain the maximum benefit from these developments
which are likely to revolutionize the practice of orthopedic surgery, the orthopedic surgeon must
still be able to examine the patient and make a diagnosis. Unless the surgeon can reach a reliable
differential diagnosis, the relevant investigations are not likely to be undertaken and the correct
diagnosis is not likely to be made. Unless the correct diagnosis is made, the advances in orthopedic
surgery will be meaningless. The basis of diagnosis will continue to be the clinical examination as
laid down in each chapter of this book.
Charles SB Galasko
Professor of Orthopedic Surgery
University of Manchester, UK
Consultant Orthopedic Surgeon
Salford Royal Hospitals NHS Trust and
Central Manchester and Manchester Children’s University Hospitals NHS Trust
Past President, British Orthopedic Association
Past Vice President, Royal College of Surgeons of England
Past Chairman, Joint Committee on Higher Surgical Training
Sir Arthur Sims, Commonwealth Professor
Preface to the Second Edition
Overzealous response from orthopedic trainees and recent advances has made me to write this
second edition. Though examination techniques are same, the recent thinking and diagnosis of
various new conditions because of explosion of knowledge and array of investigation has thrown
light to many new facts compelling a clinician to diagnose by simple examination. As medicine is
evolving and advancing everyday our understanding on clinical assessment and examination has
also improved a lot.
The book is aimed at orthopedic trainee and junior consultants to sharpen their clinical skills and
to follow a methodical approach in examination. I have taken every effort to update this second
edition with more illustrations on demonstration techniques, clinical pictures with obvious diagnosis
and additions of some of the advancement made in subspecialties like shoulder and wrist.
The book must be simple and easy for understanding so that it enables a trainee to rapidly acquire
knowledge in history taking and examination in a systematic way. Repeated practice will bring
perfection and, when one masters the technique it takes no time to arrive at a right diagnosis. I have
put together all the essential parts of clinical assessment in a nutshell to diagnose common orthopedic
conditions. In history taking, importance is given for patient’s disability, patient’s perception of
nature of illness and patient’s expectation in order to device a treatment plan. The sequence of
examination has been described in a more practical way applying the conventional system of look,
feel and move, and when patient stands, sits and lies down.
The doctor can win the patient’s confidence by the way he/she communicates to the patient,
handling the patient with utmost care and by a smooth clinical examination. Well dressed doctor
with a compassionate approach and an authoritative talk to the patient is essential to win the patient’s
confidence. A short note on clinical findings has been described on common disease conditions at
the end of each chapter.
Every attempt has been made to give self-explanatory illustrations on examination techniques.
Each chapter has been edited by eminent experts in their respective field to keep pace with the
standard and recent advances in their field, so that the reader gets the maximum benefit. I welcome
suggestions to bring out an even better next edition by filling the lacunae. I hope this book will
fulfill the requirement of an orthopedic trainee.
C Rex
Preface to the First Edition
As medicine is evolving and advancing everyday, our understanding on clinical assessment and
examination has also improved a lot. This book is aimed at orthopedic trainee and junior consultants
to sharpen their clinical skills and to follow a methodical approach in examination.
I have taken every effort to make this book simple and easy for understanding so that it enables
a trainee to rapidly acquire knowledge in history taking and examination in a systematic way.
Repeated practice will bring perfection and, when one masters the technique it takes no time to
arrive at a right diagnosis. I have put together all the essential parts of clinical assessment in a
nutshell to diagnose common orthopedic conditions. In history taking, importance is given for
patient’s disability, patient’s perception of nature of illness and patient’s expectation in order to
device a treatment plan. The sequence of examination has been described in a more practical way
applying the conventional system of look, feel and move when patient stands, sits and lies down.
The doctor can win the patient’s confidence by the way he/she communicates to the patient, handling
the patient with utmost care and by a smooth clinical examination. A short note on clinical findings
has been described on common disease conditions at the end of each chapter. Every attempt has
been made to give self-explanatory illustrations on examination techniques. Each chapter has been
edited by eminent experts in their respective field to keep pace with the standard and recent advances
in their field, so that the reader gets the maximum benefit. I welcome suggestions to bring out an
even better next edition by filling the lacunae. I hope this book will fulfill the requirement of an
orthopedic trainee.
C Rex
Acknowledgments
I would like to acknowledge my teachers, fellow colleagues, my team of Orthopedic Junior

Consultants and trainees for the guidance and help received in the preparation of this manuscript.
I immensely thank Professor S Rajasekaran, Department of Orthopedics, Ganga Hospital,
Coimbatore, Tamil Nadu, India for readily accepting to write the foreword for the second edition
and spending his valuable time in spite of his busy schedule. He has been my guiding light and
mentor. I vow him a lot for what I am now.
I would like to thank Mr Reginald T, our Senior Physiotherapist for compiling and timely
preparation of the manuscript.
This project could not have been successfully completed within the prudent and dutiful efforts of
the many individuals whom I acknowledged in the previous edition and the present edition here.
Contents
1. Hist ory Taking and Clin ical Examinatio n .............................................................. 1

• History Taking 1
• Examination of Swelling 3
• Examination of Ulcer 4
• Examination of Bone and Soft Tissue Tumors 5
• Examination of Bone and Joint Infection 6
2. Exam in ation of Inj ured Patient ............................................................................... 8

• Introduction 8
• Initial Management of the Trauma Patient 8
• History 10
• Examination 11
• Special Note 14
3. Examinatio n of Patient wit h Bone and Joi nt Injur ies ......................................... 17

• History 17
• Examination 18
• Specific Conditions 19
4. Examination of Neurom uscular Disease ............................................................. 22

• History 22
• Examination 22
• Upper Limb 23
• Lower Limb 23
• Special Tests 25
5. Examination of Shou lder ...................................................................................... 27

• History 27
• Clinical Examination 29
• Strength Test 32
• Impingement Tests 35
• Biceps Test 37
• Acromioclavicular Tests 38
• Instability Tests 38
• Neck Examination 40
• Neurovascular Examination 41
• Common Conditions Affecting Shoulder 41
6. Examin ation o f Elb ow ........................................................................................... 45

• Look 45
• Feel 46
xviii Clinical Assessment and Examination in Orthopedics
• Move 47
• Measure 48
• Stability Tests 48
7. Examin ation of Wris t ............................................................................................. 52

• History 52
• Clinical Examination 52
• Look 53
• Feel 53
• Move 53
• Assessment of Instability 53
• Assessment of Radial Wrist Pain 57
• Assessment of Ulnar Wrist Pain 60
• Assessment of Dorsal Wrist Pain 61
• Assessment of Palmar Wrist Pain 62
• Assessment of Distal Radioulnar Joint (DRUJ) 62
8. Examin ation of Hand ............................................................................................. 66

• Look 67
• Feel 68
• Move 68
• Examination of the Hand with Lacerations 71
• Traumatic Amputations and Microsurgery 72
• Hand Infections 72
9. Examin ation of Peri pheral Nerves and Br achi al Plexus .................................... 74

• Look 74
• Feel 75
• Move 75
• Neurological Examination 76
• Examination of Individual Nerves 76
• Median Nerve 76
• Ulnar Nerve 78
• Radial Nerve 79
• Compression Neuropathy 80
• Suprascapular Nerve Entrapment 83
• Brachial Plexus Injury 83
• Examination of the Brachial Plexus 84
• Lower Limb Nerve Injury 86
10. Ex amination of Spi ne ............................................................................................ 87

• Clinical Red Flags in Back Pain 88
• Thoracolumbar Examination 90
Contents xix
• Neurofibromatosis (von Recklinghausen's Disease) 100

• Examination of the Cervical Spine 104
11. Examin ation of Hip .............................................................................................. 109

• Presenting History 109
• General Examination 110
• Patient Standing 111
• Supine on Couch 112
• Lateral on Couch 118
• Prone Examination 118
• Conditions Affecting Hip 119
• Sacroiliac Joint (SIJ) Stress Test 123
12. Examin ation of Kn ee ........................................................................................... 125

• Presenting Complaint 125
• Local Examination 126
• Special Tests to Assess Joint Stability 130
• Patellofemoral Joint Problems 134
• Special Note 135
13. Examination of Ankle and Foot .......................................................................... 142

• Presenting Complaint 142
• Past History 143
• Family History 143
• Personal History 143
• Treatment History 143
• Examination 143
• Local Examination 146
• Ankle 150
• Subtalar Joint 151
• Midtarsal Joint 152
• Tarsometatarsal Joints 152
• Achilles Tendon 152
• Tibialis Posterior 153
• Dorsiflexors 154
• Peroneals 154
• Heel 156
• The Great Toe 156
• Great Toenail and Nail Bedproblems 157
• Metatarsal Region 157
• Lesser Toes 159
14. Examinatio n o f Rotation al Deformi ties in Low er Li mb .................................... 167

• History 167
• Examination 167
Index ...................................................................... ........................................................... 171

1 History Taking and
CHAPTER Clinical Examination
The art of history taking and clinical examination in a systematic fashion should be learnt to arrive at a right
diagnosis and management. This is learned over a period of time and by repeated practice.
Looking at the patient as he/she walks into the impressive to the patient, and the patient must
room, gives an overall picture and sometimes the feel he/she is in the right place, in safe hands
personality of the patient. Introduce yourself to and getting good care.
the patient; ask the name of the patient,
accompanying attendees and their relationship. HISTORY TAKING
Some patients may feel more shy and
embarrassed to talk of their problems in front of Present Complaint
others. Patient’s inhibition to discuss in front of Ask the patient what is his main problem and
others must be appreciated, and, if necessary, what made him to come and see you, the
more private and confidential discussion should duration of each salient complaint must be
be held. charted in chronological order.
The doctor must be very alert and listen to
each and every word, the patient says. It is a good History o f Present Complaint
practice to document the history as the patient
The full details of the presenting complaint from
relates it.
the time it started must be asked for, the progres-
The doctor must have lot of patience and
sion of the symptoms, severity and associated
perseverance with difficult patients in eliciting
symptoms must be recorded. Quantify the
history. Conversation should be guided,
disability due to the problem in terms of day-to-
avoiding any leading questions. The questions
day activities, job-related or hobbies and ask the
should be worded in simple language and
patient what activities he/she cannot do? Ques-
patient-understanding of the questions should
tions about the abnormal system or any symptoms
be ensured.
of possible diagnosis must be asked for.
Always explain to the patient what you are
going to do and why you are doing it, in all stages
Previous History
of examination to alleviate anxiety. Eye to eye
contact, getting attachment to patient’s version This should include any similar problems in the
of the cause and extracting the major problem past, illness like diabetes, hypertension,
for which the patient has come today is rheumatism, asthma, allergy, tuberculosis, chest
important. Patient must be examined gently, and heart problems, and dyspepsia or peptic
without eliciting pain and the environment made ulcer disease (as most of the patients need anti-
comfortable. The doctor should be confident and inflammatory tablets).
2 Clinical Assessment and Examination in Orthopedics
Treatment Histo ry symptom which gives a clue to the diagnosis, it

must be evaluated in detail.
Enquire about all the treatments the patient has
a. Site of pain—localized or diffuse: Ask the patient
had including medicines like nonsteroidal anti-
to denote the maximum point of pain and also
inflammatory drugs, steroids, physiotherapy,
the extent of pain.
plasters, orthosis, intra-articular steroid injections,
b. Time and mode of onset: It is good to know
etc. and find out the effect of each treatment. Ask
what triggered the pain at the time of onset
for any allergy to medicines. History of previous
and find out what patient was doing at that
surgeries are important.
time. The pain might have begun suddenly
or insidiously.
Family History
c. Severity of pain : This can be assessed in
Enquire about the general family health, patient’s own words as mild, moderate and
occurrence of any familial or hereditary diseases, severe. Find out whether the patient is able
and support from the family in terms of to carry out the daily routine and can perform
psychological and financial aspects. the job, this again indicates the severity. Does
the pain wake-up or keep the patient awake
Social and Occupational History at night or does it force the patient to lie still,
Marital status, type of place where he/she lives, this also indicates the severity.
presence of stairs at home and toilet facilities d. Nature of pain: It is good to qualify the pain
(Indian or Western toilet—this is important in as aching, stabbing, burning, throbbing,
patients with hip or knee pathology) must be constricting or gripping pain, or pricking pain.
recorded. History of consanguineous marriage is e. Progression of pain: Has the pain gone worse,
important in the presence of congenital anomalies remained same or decreased in time? Is the
in their offspring. Exact nature of occupation— pain constant or present on and off?
sedentary or heavy manual work, the hobbies and f. Radiation: Find out the direction and exact site
the patient’s leisure activities must be noted. of radiation from the site of origin.
g. Aggravating and relieving factors: Ask this
Personal History question directly to the patient and also
document what happens to the pain on joint
Alcohol consumption, smoking habits, dietary
movements, on walking, standing, body
habits and sexual life must be recorded. Always
posture and exercises. Is this pain related to
quantify the amount of smoking and alcohol
any food intake (e.g. gout)? The relief of pain
intake.
with analgesics, fomentation and other means
should be noted.
Patient’s Expectatio n
h. Patient’s opinion on cause of pain: This may
The patient’s expectation is an important factor throw some light on the cause and also some
in the treatment plan. Expectation of each patient insight into the patient’s problem.
is different and sometimes may not be realistic.
Some patients might seek an advice just for History of Swelling
reassurance rather than for treatment. This must
a. First notice : When did the patient notice
be identified and treated accordingly.
the swelling or lump (it may not be the time
when it first appeared). Patient might have
History of Pain
noticed due to pain or might have noticed at
Pain is what the patient feels and tenderness is the time of bath, or someone might have
what the doctor elicits. As pain is an important pointed it out.
History Taking and Clinical Examination 3
b. Symptoms associated with lump: Pain, pressure • Measurements

symptoms—neurological, vascular or • Neurovascular status
affecting movements of adjacent joints. Local examination of each part of locomotor
c. Progression of the lump: Getting bigger or system is discussed in detail in subsequent
smaller, or disappearing and reappearing in chapters.
different positions, at different times, etc.
d. Any other swelling EXAMINATION OF SWELLING
e. Patient’s opinion on cause of swelling.
Similar sequence is followed in the history of • Site
an ulcer. • Size
The history most of the time gives the most • Color (Figs 1.1 and 1.2).
probable diagnosis. An experienced clinician • Temperature
modifies the examination by specifically looking • Tenderness
for signs that will confirm or refute the • Shape: Hemispherical, oblong, kidney-
provisional diagnosis. If clinical signs do not shaped, pear-shaped, etc.
favor the diagnosis then he returns to the normal • Surface: Smooth, irregular, bosselated or
routine. But all students must strictly follow the lobular
pattern of examination. Also be aware, common • Edge: Well-defined, indistinct
problems are common. Do not think of rare • Consistency: Soft (like an ear lobe), firm (like
diagnosis as we may be rarely right and keep tip of nostril), hard bony hard, variegated–
things simple and easy. different consistency in different parts of
swelling
Clinical Examination
General Examination
The general examination analyzes the patient as
a whole. General build, mental state, presence of
anemia, jaundice, cyanosis, clubbing, skin and
nail changes (pitting in Psoriasis), pedal edema,
fever, multiple bone or joint deformities and any
generalized manifestation of a disease must be
recorded.
Local Examination
Examining the area of symptomatology and
examination of appropriate system causing the
symptoms add more information of the disease
and the possible diagnosis. This follows the
foolproof systematic approach of:
• Inspection (Look)
• Palpation (Feel)
• Movements—Active and passive movements. Fig. 1.1: Spreading cellulitis of thigh marked by
Joint range of movements are measured with redness, swelling and warmth of skin and
goniometer subcutaneous tissue
Fig. 1.2: Necrotizing fascitis showing blackening and Fig. 1.3: Paget’s test: Forehead swelling of 2 cm tested
blistering of skin due to gangrene with redness above for fluctuation by fixing the swelling with examiner’s
(For color version, see Plate 1) index finger and thumb and with the other hand index
finger the center of the swelling was pressed to feel
• Fluctuation: In cystic swelling small tense the fluid displacement (For color version, see Plate 1)
swelling is tested for fluctuation by fixing the
swelling’s outer margin with one hand and to move. Swelling superficial to muscle remains
with one finger press on the middle of the same in size and have free mobility.
swelling to elicit fluctuation—Paget’s test • Fixity: To skin or bone.
(Fig. 1.3). Large cystic swelling should be • Regional lymph nodes
checked for cross-fluctuation in two planes • State of arteries, nerves, bones and joints.
(right angle to each other) to differentiate
from pseudo- fluctuation in soft swelling like
EXAMINATION OF ULCER
lipoma.
• Reducibility • Site
• Pulsatility: True expansile pulsations are from • Size, shape
aneurysms and vascular tumors. Transmitted • Color
pulsations can be felt on swelling over major • Warmth
arteries. • Tenderness
• Transillumination: Light will pass through • Base or floor: It is the surface of the ulcer. It
clear fluid. Using a pen torch in a darkroom can be of healthy red granulation tissue or
one can demonstrate a flare in clear fluid- gray dead tissue or exposed muscles/tendons
filled sac. • Edge Sloping edge—In a healing ulcer
• Plane of the swelling: Relationship to surrounding Punched out edge—In trophic ulcer
structures—Can skin be pinched separately? (syphilis, neuropathy, spina bifida)
Swelling deep to muscle becomes less Undermined edge—In tuberculosis
prominent on muscle contraction and difficult Rolled out edge—In basal cell carcinoma
Everted edge—In squamous cell Occupational History

carcinoma
Exposure to radioactive materials, chemicals, etc.
• Depth: The fixity to deep structures is
indicated by the mobility of the ulcer
General Examinatio n
• Discharge: Serous or serosanguinous or
purulent General build, anemia, jaundice, cyanosis,
• Regional lymph node clubbing, generalized lymphadenopathy.
• State of arteries, nerves, bone and joints.
Systemic Examination
EXAMINATION OF BONE AND Examination of the lungs, abdomen, pelvis and
SOFT TISSUE TUMORS nervous system, if necessary.
Bone sarcomas are common in children and Loc al Examination (Fig. 1.4)
adolescents while secondaries and myelomas are
common in elderly population. Examination of the swelling is done as described
before, special points to be noted in tumors are:
Presenting History
1. Aggressiveness—A tense rapidly growing
tumor with shiny skin, engorged veins and
1. Pain—Onset, duration, nature, aggravating variable consistency is typical of aggressive
and relieving factors. tumor.
2. Swelling—Onset, duration, progress, change 2. Skip lesions—Look for satellite lesions in the
in size and other swellings. same extremity.
3. Pathological fracture—Trivial injury causes 3. Pressure effects—Neurovascular impairment
fracture. or limitation of range of movements.
4. Distant site problems —Symptoms from 4. Regional lymph node involvement.
metastasis: lung symptoms, symptoms of 5. Auscultation—Listen for a bruit in suspected
hypercalcemia or neurological deficit from vascular swellings, telangiectatic osteogenic
local spread. sarcoma, vascular secondaries, etc.
Origin of tumors in various parts of bone is
Past History illustrated in Figure 1.5.
Any significant medical illness, previous
malignancies treated like carcinoma prostate,
lung, thyroid, kidney, etc., radioactive isotope
treatment or irradiation.
Family History
Hereditary disease like autosomal dominant von
Recklinghausen’s disease, diaphyseal aclasis,
multiple lipomata, etc.
Personal History
Smoking, alcohol, mental status and social
background. Fig. 1.4: Ewing’s sarcoma from pelvis
Fig. 1.5: Origin of tumors in various parts of bone
EXAMINATION OF BONE the lower limb, pathological fracture or exuberant

AND J OINT INFECTION growth from ulcer (Marjolin’s ulcer).
In the history onset of first episode, the progress,
Ac ut e Ost eom yel it is /Jo in t Sepsis the treatment taken including various antibiotics and
This is more common in children but can occur surgical procedures must be taken elaborately.
in adults who are immunosuppressed or drug Osteomyelitis starting in childhood will naturally
addicts. Child who is not well, irritable, having affect the growth of the bone and can cause soft-
high fever, suddenly not moving the limb tissue tightness. History of any immunosuppressive
(pseudo-paralysis) with septic foci in the body disease or drugs (steroids/chemotherapy), smoking,
should arise high suspicion of acute osteomyelitis alcohol, diabetes, sickle cell disease and tuberculosis
or joint sepsis. Joint sepsis is more common in must be asked for. Enquire about constitutional
the hip, which presents with inability to move symptoms, weight loss, etc.
the limb, flexion attitude of the limb, gross General Examinatio n
restriction of movements with pain and spasm.
Patient or parents may attribute it to a fall. General build, anemia, jaundice, cyanosis, generalized
Acute osteomyelitis presents with sudden lymphadenopathy, septic focus in the body.
onset of pain, swelling, inflammation and loss of
function and should be diagnosed clinically. Local Examination
Both osteomyelitis and joint sepsis should be Look
treated aggressively by investigating full blood
count, ESR and blood culture with antibiotics, Look for gait (in lower limb involvement),
and if necessary, emergency surgical drainage. deformity, leg length discrepancy, skin and soft
Ultrasound scan may be of good help to establish tissue status—ulcer or sinus, puckered scar or
the diagnosis. wound healed by secondary intention.
Chronic Osteomyeliti s (Figs 1.6A and B) Feel
Patient can present with pain, discharging sinus, Feel for warmth, tenderness in soft tissue and
difficulty in using the limb or weightbearing in bones, bony thickening, soft tissue indurations,
Figs 1.6A and B : Diaphyseal sequestrum in chronic osteomyelitis of humerus
percussion of the bone causes deep severe pain, Move

abnormal mobility in pathological fracture or Test active movements first and then passive
infected non-union, adjacent joints for stiffness movements. Do not attempt movement in an
and deformity, distal neurovascularity, acute infection (very painful). Look for stiffness,
regional lymph nodes and other focus of abnormal mobility, subluxation or dislocation in
infection. chronic infection.
2 Examination of
CHAPTER Injured Patient
INTRODUCTION treating then re-evaluating life-threatening

injuries, which is followed by a detailed survey
Trauma is the leading cause of death in the first
for all injuries sustained (Table 2.1).
four decades of life and the third most common
in all ages. In addition to the deaths caused many
Ai rw ay w it h Cer vi cal Spine Co nt ro l
more people are temporarily or permanently
disabled as a result of accidents. On first contact with the patient, the airway is
Clearly the best way of approaching the checked at the same time as protecting the
management of trauma is prevention or the cervical spine. The patient is asked if they are all
minimization of its effects (e.g. compulsory use right and an appropriate response will quickly
of motorcycle helmets). These areas lie with confirm that there is an adequate airway with
governmental bodies and equipment manufac- ventilation and cerebral perfusion. The cervical
turers. The physician’s main role is to identify spine is protected with a rigid collar, head blocks
and treat any injuries sustained, while preventing and tapes. A spine board may be used for transfer
secondary injuries occurring. purposes, but it should be removed as quickly
These latter two areas have been addressed as possible to prevent pressure sores developing.
with the inception of the Advanced Trauma Life Initial airway management involves clearing the
Support (ATLS® ) course in 1980 and its upper airway of obstructions (e.g. saliva, blood,
subsequent revisions. The traditional approach to dentures or teeth) and improving its patency, by
treatment of patients is to take a full history with simple airway maneuvers (e.g. jaw thrust or chin
examination and perform investigations prior to lift supplemented with an oral or nasopharyngeal
treatment, as taught at medical schools. However,
the ATLS ® approach seeks to identify and Table 2.1: A TLS® approach to managing
simultaneously treat immediate life-threatening the trauma patient
conditions in a predictable order. The aim of this
Primary survey
section is to describe the assessment of a patient
1. Airway with cervical spine control
with musculoskeletal trauma according to the 2. Breathing
ATLS® framework of trauma management. A 3. Circulation with hemorrhage control
formal review of the ATLS® course is not 4. Disability
appropriate here and the reader is recommended 5. Exposure
to attend a locally organized course. 6. Re-evaluation
7. Adjuncts to the primary survey
INITIAL MANAGEMENT OF THE Secondary survey
TRAUMA PATIENT 1. History
Managing a trauma patient follows a logical 2. Examination
3. Adjuncts to the secondary survey
sequence aimed at simultaneously identifying,
Examination of Injured Patient 9
airway). Supplemental oxygen (15 liters per major vessel injury and diaphragmatic injury.
minute via a mask with reservoir bag) is given. Identification of these requires examination along
A definitive airway is one where a cuffed with additional tests, both of which are often
endotracheal tube has to be inserted, which may based on a high index of suspicion and are
be inserted via the oral or nasal route. A surgical described in detail at the end of this chapter.
airway may be created in the emergency situation
by cricothyroidotomy. The decision about which Circulation with Hemorrhage Control
method of airway management is best, lies out
with this discussion. Further evidence of a spinal injury may also be
found on assessment of the circulation, where
Breathing neurogenic shock may be present. Neurogenic
shock classically presents with a low blood
Breathing problems follow on logically from
pressure, bounding pulses, a warm periphery and
management of the airway. The first indication of
sometimes bradycardia. The findings are due to
a musculoskeletal injury may be compromise to
peripheral vasodilatation due to loss of
breathing due to a cervical spine injury, especially
sympathetic tone, and should not be confused with
if this is above the supply to the diaphragm
“spinal shock” which refers to the temporary total
(C3,4,5). Treatment of such lesions in the ATLS®
approach commences before breathing difficulties loss of function of the spinal cord. Care must be
may have been identified, as the cervical spine has taken in solely attributing a low blood pressure to
already been immobilized to prevent further a spinal injury, as the most common cause of
injury as a part of the airway management. It hypotension following trauma is hypovolemia.
should be noted that clearance of the cervical spine Hypovolemia must be treated appropriately before
of injury might occur a long time after admission, attending to neurogenic shock. Hypovolemia may
even with normal cervical spine radiographs. be caused by other musculoskeletal injuries such
Other causes of breathing difficulties can broadly as major pelvic disruption (especially open book
be grouped into those due to chest injuries and and vertical shear fractures), major vascular
those occurring outside the chest. Immediately hemorrhage (arterial or venous) and crush injuries
life-threatening chest injuries include major associated with myoglobin release causing
airway obstruction, tension pneumothorax, flail hypovolemia, metabolic disturbances, disseminated
chest, open pneumothorax and massive intravascular coagulation (DIC) and renal failure.
hemothorax. Other injuries lying outside the chest However, other common causes include intra-
that can affect breathing are mainly of neurological abdominal bleeding and massive hemothorax, it
origin and include head injuries or alcohol/drug may also be mimicked by tension pneumothorax
intoxication. Routine examination should identify and cardiac tamponade. The other causes of shock
the majority of these injuries prior to radiographs are seen less commonly in the acute trauma
being taken. Breathing difficulties are treated by situation. Evaluation again is performed by routine
ventilatory support as required along with specific clinical examination, although it is often
treatment for the underlying injury, the majority supplemented by radiographic and more complex
of which will be by conservative means. investigations. Treatment is aimed at replacing the
Other chest injuries which can be life- lost fluid (initially with crystalloid and
threatening but are often only picked up on the subsequently blood) along with prevention of
secondary survey are: simple pneumothorax, further blood loss (which may require splintage
hemothorax, pulmonary contusions, lower or direct pressure for musculoskeletal injuries or
airway injuries, multiple rib fractures, cardiac or operation for visceral injuries).
Disability are removed and the patient is covered and

warmed appropriately to ensure a normal body
Neurological compromise is often due to head
temperature is maintained.
injury, but may also be due to poor cerebral
Further details of the examination and
perfusion resulting from an inadequately treated
treatment of all of these problems are fully
airway, breathing or circulatory problem. Within
addressed in the ATLS® course. In addition,
the brain the injury may be due to either a focal
variations in patient subgroups (e.g. children, the
or diffuse lesion. Assessment is initially
elderly and pregnancy) are also covered.
performed by assessing the Glasgow coma scale,
Following re-evaluation of the patient adjuncts
(Table 2.2) pupillary responses and observation
to the primary survey are performed, which
of localizing signs. A more detailed neurological
include cervical spine (where appropriate), chest
assessment follows later. Treatment is aimed at
and pelvic radiographs. The secondary survey
preventing further injury by providing adequate
follows and includes the history and
cerebral perfusion and oxygenation, along with
examination. For the purposes of this chapter
identifying and treating the appropriate focal
these will be considered only in the light of
lesions by referral to the neurosurgeons.
musculoskeletal trauma.
Exposure
HISTORY
This precedes the comprehensive secondary
Knowledge of the mechanism of trauma is
survey and allows a formal full assessment of the
extremely important in identifying the nature
patient. Wet, soiled or chemical coated clothes
and severity of specific injuries. It may also
dictate the treatment plan.
The most important determinant of severity
Table 2.2: The Glasgow coma s cale
of injury is the amount of energy transferred at
Response Description Numerical the time of the accident. The kinetic energy
value imparted (½ mv2) is determined by the velocity
Eye opening Spontaneous response 4 (v) at the time of impact (e.g. simple fall vs. hit by
Response to speech 3 a car at 70 mph) and mass (m) of the colliding
Response to pain 2 bodies (e.g. handgun bullet vs. car). This will be
modified by the direction of the applied force (e.g.
No response 1
glancing blow vs. head on impact) and the effects
Motor response Obeying response 6 of any protective devices (e.g. crash helmet).
Localized response 5 The location of the accident is of special
Withdrawal 4 importance as the environment can influence
Abnormal flexion 3 both general (e.g. hypothermia) and local (e.g.
Extension 2 farmyard contamination of open injuries) factors,
No response 1 which may influence treatment.
Verbal response Oriented conversation 5 Certain associations exist between some
accident mechanisms and injury patterns (e.g.
Confused conversation 4
dashboard injury and posterior dislocation of the
Inappropriate words 3
hip). In addition, some injury patterns are
Incomprehensible 2
associated with each other (e.g. calcaneal fracture
sounds
and lumbar spine vertebral body fracture) and
No response 1
where one is found the other must be excluded.
The symptoms experienced by the patient at muscles, nerve supply and vascular status). In
the time of injury and immediately afterwards addition, only aspects relating to trauma will be
must be sought. Clearly, immediate pain and described, for a full description of the examination
localized bony tenderness raises the possibility of a particular joint or region the reader is directed
of a fracture, however, in anterior cruciate to the appropriate chapter elsewhere in this book.
ligament injuries only a pop may be felt, but this Fractures and dislocations are probably the
is usually followed by immediate swelling of the most commonly encountered musculoskeletal
knee and inability to weight bear. Associated injuries. The other injuries indicated below are
symptoms must also be sought within all systems sometimes seen in isolation especially in
in the affected limb or area (e.g. median nerve penetrating trauma; however, they are more
symptoms following supracondylar fracture of commonly seen in combination with underlying
the elbow). Finally, if there is a delay in fractures or dislocations.
presentation, symptoms may develop suggesting
a chronic lesion (e.g. joint instability following Fractures and Dislocations
ligament disruption).
• Inspection: The limb should be inspected for
The history is completed with a detailed past
swelling around the fracture site and there
medical and surgical history, family and social
may be an associated effusion with an
history, allergies and current/previous medi-
underlying joint injury. Deformity of the limb
cations. For acute injuries the time of the accident
may be clear although only shortening or
as well as the details of the last drink and meal
rotation may be evident. The skin should be
are very important.
assessed (see below).
• Palpation: The limb should be palpated for
EXAMINATION
tenderness without causing excessive
Examination will be considered in relation to the discomfort to the patient, including pelvic
trauma patient and the pattern of examination is springing which should be performed only
similar for injuries to all tissues (Table 2.3). once. Abnormal movement and crepitus is
Although this section is artificially divided for classically described at the site of fractures but
clarity, many tests are common to more than one should not be elicited. Muscle spasm may be
system or pathology (e.g. testing active range of found in some cases and is especially
movement assesses the bones, adjacent joints, associated with dislocations and spinal
column fractures (paraspinal muscles).
Table 2.3: Pattern of examination of the
Deformity may only be identified on
musculoskeletal system palpation (e.g. a step in spinous processes in
spinal dislocations).
a. Inspection • Active then passive movements: These move-
b. Palpation ments should be attempted, but in fractures
c. Movement Active and passive
this is frequently not possible due to pain. In
d. Special clinical tests Ligament testing
Neurological examination dislocations some movement is often possible
Rectal examination and a block to a particular range of movement
e. Adjuncts Doppler studies should be sought (e.g. external rotation in
Compartment pressure posterior dislocation of the shoulder).
monitoring • Special clinical tests: These tests include
Radiographs assessment of the ligaments in joint injuries.
Ultrasound scan There should be routine examination of the
MR scan neurovascular status of the limb (see below) to
exclude associated injuries (e.g. axillary nerve • Where

Where the
the skin
skin has bee
beenn breac
breached
hed the init
initial
ial
palsy after shoulder dislocation and popliteal examination is really limited to inspection. No
artery injury after knee dislocation). Compart- wound overlying a suspected fracture should
ment syndrome should also be excluded (see be pro
probed
bed in the cas
casual
ualty
ty dep
depart
artmen
ment.t. It
below)
below).. Som
Somee spe
specifi
cificc inj
injurie
uriess dic
dictat
tatee that othe
otherr should be photographed if possible and
areas should be assessed; these include covered with a betadine or saline soaked
abdominal/urological examination in pelvic dressing. This dressing should not be
fractures and complete neurological including disturbed by anyone until the patient is taken
rectal examination in spinal injuries. to the operating theater. Further examination
• Further tests and imaging studies: These will be should however be directed at identifying any
dictated by the examination findings. underlying injury (e.g. tendons, nerves or
vessels). Knowledge of local anatomy is
Skin imperative in determining which structures
are likely to have been injured.
• The ski
skin
n overl
overlyin
yingg any
any injur
injury
y may
may have
have been
been
breached. Associated swelling and contami-
Muscles and Tendons
nation should be assessed. In addition, it may
be clear that the underlying bone has been Direct injury to muscles may occur due to
exposed. Where open fractures are identified disturbance by fracture fragments from within or
the severity of injury is determined not only from any source of penetrating injury. Muscle belly
by the size and contamination of the wound injuries tend to be less of a problem in the long-
but also the degree of underlying soft tissue term unless there is an additional compartment
and bony injury. Grading of these injuries is syndrome (see below) or the injury is very
described and that for tibial fractures is extensive. Tendon injuries however are more likely
presented in (Tables 2.4A and B). to occur and can result in significant disability.
Table
Table 2.4A:
2.4A: Gustilo gr ading of op en fractures of th e tibia
Type I : An open
Type open fra
fractu
cture
re wit
with
h a wou
woundnd les
lesss than
than one
one cent
centim
imete
eterr long
long and cle
clean.
an.
Type II : An open
open fractur
fracturee with
with a lacer
laceration
ation more than oneone centim
centimeter
eter long
long withou
withoutt extensive
extensive soft tissue
tissue
damage, flaps or avulsions.
Type III : Either an open
open segmental
segmental fracture,
fracture, an open fracture
fracture with
with extensive
extensive soft tissue damage,
damage, or a
traumatic amputation.
Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open
fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg [Am] 1976;58(4): 453-58.
Table
Table 2.4B:
2.4B: Gust ilo grading of t ype III (severe)
(severe) open fr acture
Type III A : Adequate

Adequate soft
soft tissue
tissue coverage
coverage of a fractur
fractured
ed bone
bone despite
despite extensi
extensive
ve soft
soft tissue
tissue laceratio
laceration
n or
flaps, or high-energy trauma irrespective of the size of the wound.
Typee III B : Exte
Typ Extensiv
nsivee soft tissue
tissue injury
injury with
with periost
periosteal
eal stripp
stripping
ing and
and bony exposu
exposure.
re. This
This is usually
usually
associated with massive contamination.
Typee III C : Ope
Typ Openn fractu
fracture
re assoc
associat
iated
ed with
with arter
arterial
ial inju
injury
ry requi
requirin
ring
g repair
repair..
Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: A
new classification of type III open fractures. J Trauma 1984;24(8): 742-46.
• Inspection: This will reveal associated skin Hg (i.e. well below systolic blood pressure). Not
lacerations, which should raise the suspicion all compartments within the injured limb need
of a local tendon injury. A divided tendon end be affected.
affected. There are only two classical
classical findings
may be visible in the wound although they in compartment syndrome: pain that is out of
can be confused with deep fascia, periosteum proportion to that expected for the injury (e.g.
or joint capsule. The distal limb may adopt a whole calf rather than at the fracture site), which
posture suggestive of a tendon injury (e.g. often requires excessive analgesia, and pain on
middle finger droop compared to the passive stretching of the affected muscle
remaining fingers due to extensor tendon compartment.
laceration). However, this should not be • Inspection: This rarely reveals much to
relied upon, as the abnormal position also indicate a compartment syndrome. There
relies upon gravity or an unopposed muscle may be some swelling, although this is often
action, which may be inhibited by pain. limited by the dense fascia that surrounds the
• Palpation: It is not often of use in assessment compartment. Any bandaging, plasters or
of muscle and tendon injuries. However, splints should be checked prior to any further
closed tendon ruptures can be indicated by examination for tightness, as they can mimic
tenderness (e.g. rupture of the long head a compartment syndrome. Release of these
of bice
biceps)
ps) and
and defect
defect (e.g.
(e.g. tendo Achill
Achilles
es (from top to bottom the whole way down to
rupture). skin) should alleviate symptoms related to
• Moveme
Movement:nt: It is clearly important and involves any tightness very quickly.
actively testing (both for movement and • Palpation: It is again relatively unrewarding
power) the muscle or tendon that is suspected as tenseness of the compartment is not always
of damage. Care must be taken to isolate the present.
muscle or tendon to be tested to ensure that • Movem Movement:
ent: Involving stretching of the affected
other groups are not working (e.g. FDS and muscles is extremely painful. The patient will
FDP in the hand). try to avoid active movement and minimal
• Special clinical tests: These are usually not passive stretching of the affected compartment
required, as the next step having identified will be very painful.
the lesion is to formally explore the area. • Neurological and vascular examination: These
• USS/MRI: If there is any doubt as to whether may be entirely normal and abnormal
an injury is present or not, especially in closed findings only tend to develop late.
injuries, then ultrasound or magnetic • Simple compartment pressure: Monitors are
resonance imaging can help. now available and can be extremely useful in
the situation where the patient is unconscious
Compartment Syndrome (e.g. in intensive care). They can also help
where local anesthetic nerve blocks have been
A compartment syndrome may develop
used (e.g. sciatic nerve block following tibial
following any form of injury and does not require
r equire
nailing).
an underlying fracture to be present. It is
increasingly associated with high levels of tissue
Vascular
injury and is thus more commonly associated
with open rather than closed fractures. Vascular injuries can occur in isolation due to
Compartment syndrome occurs where the penetrating trauma. However, they are more
pressure within the affected muscle compartment commonly associated with local bony injuries,
rises above the capillary perfusion pressure of that by pe n et r at i on or en t ra pm en t i n f r ac t u r e
compartment. This may only be around 30 to 50 mm fragments or joint dislocations.
• Inspection: The limb may appear pale. There • Movement of the relevant muscle groups may
may not be a large amount of blood loss or be affect
affected.
ed. Howeve
However, r, local
localized
ized pain may
hematoma, as the vessel may be compressed make examination difficult.
by the fracture rather than divided. If there is • Neurological examination: It should be conducted
external bleeding the wound should not be carefully. The usual steps of tone, power,
probed but external pressure applied. Other reflexes, sensation and coordination should be
injuries may also be apparent. sought, although may need to be modified in
• Palpation: It may reveal the limb to be cool. the light of other injuries. The aim of examination
The peripheral pulses may be absent although should be to isolate whether a patient has a
this is not always the case. The opposite side spinal or peripheral nerve lesion, followed by
should be checked for comparison and any determining the level or nerve affected. It should
difference should be treated as significant. be rem
rememb
embere
eredd tha
thatt mo
more
re tha
than
n on
onee les
lesio
ion
n mi
migh
ghtt
Capillary refill may also be delayed, but can be presen
presentt (e.g.
(e.g. brachial
brachial plexus
plexus injury
injury)) or that
be normal where there is a good collateral the lesion may not be complete.
circulation (e.g. around the elbow in brachial • Special investigations such as nerve conduction
artery injuries). studies and EMG’s are usually unhelpful in
• Movemen
Movement: t: The patient may be unwilling to the acute situation, as changes take several
move the limb due to pain in the affected limb, days to weeks to become established.
although complete paralysis
paral ysis is a very late sign.
• Neurological examination: This may be Systemic
unremarkable initially. Later the patient will
In addition to the local injuries indicated above
develop paresthesia with associated reduction
several systemic problems can occur as a result
in sensation. As indicated above, muscle
of musculoskeletal trauma.
power is usually preserved until late.
In the acute situation the assessment and
• Simple investigations: These include the use of
treatment of all of these (e.g. hypovolemia, crush
hand-held Doppler probes. More
syndrome) are well covered in the ATLS® course.
sophisticated Duplex ultrasound scans or
Some secondary problems can occur after the
more commonly, the “gold standard”
admission of the patient (e.g. fat embolism,
arteriogram will identify the lesion.
ARDS, DVT, and PE). Occurrence of most of these
problems is minimized by adequately assessing
Nerves and treating the patient in the first few hours after
In a similar fashion to vessels and tendons, nerves admission following trauma.
can also be injured in an open or closed fashion.
Open injuries should raise the suspicion of an SPECIAL
SPECIAL NOTE
underlying nerve injury. Closed injuries are often
Chest Injuries
associated with nerve injuries (e.g. fibula neck
fracture with common peroneal nerve palsy). Life-threatening chest injuries are:
• Inspection: This may indicate an abnormal • Air irw
way obs
obstr
truc
ucti
tion
on
posture of the limb (e.g. foot drop in common • TeTens
nsio
ionn pn
pneu
eumo
moththor
orax
ax
peroneal nerve injury). Associated fractures • Ope pen
n pne
pneu umo
moth
thor
oraax
or lacerations may be evident. • Mas assi
sivve hemo
hemoththor
oraax
• Palpation: It will reveal little apart from • Flail chest
associated injuries. • Carardi
diaac tam
tampo
pona
nade
de
Other potentially life-threatening injuries are: absent breath sounds and a dull note on
• Pulmonary contusion percussion on the involved side. Treated by rapid
• Myocardial contusion infusion of colloids, crystalloids or blood and
• Tear of major vessels
• Traumatic rupture of diaphragm (Fig. 2.1)
• Tracheobronchial tree injury
• Esophageal trauma.
Tension Pneumothorax (Fig. 2.2)

It should be diagnosed clinically and should not
wait for X-ray to confirm. This results from one-
way air leak from lung or chest trauma inside or
outside. Patient presents with acute distress,
difficulty in breathing, tachycardia, hypotension,
tracheal shift to opposite side, decreased chest
movements, hyperresonant note on percussion,
distended neck veins, obliteration of liver
dullness on right side and cyanosis in late stages.
Inserting a wide-bore needle in the 2nd
intercostal space in the midclavicular line does
immediate decompression. Definitive treatment
is by inserting a chest tube intercostal drainage
Fig. 2.2: Pneumothorax right lung with
(ICD) in the 5th intercostal space just anterior to collapsed lung
midaxillary line.
Massive Hemothorax (Fig. 2.3)

This results from rapid accumulation of blood in
the pleural cavity (more than 1500 ml). This is
identified by signs of hypovolemic shock with
Fig. 2.1: Diaphragmatic rupture with migration of Fig. 2.3: Hemothorax right lung with
fundus of stomach into left chest cavity horizontal fluid level
ICD. Autotransfusion from ICD may be 45° angle, aiming towards tip of left scapula with
considered in severe bleed. If the blood loss in ECG monitoring.
the ICD is more than 200 ml/hour, thoracotomy
Pelvic Injuries
may be necessary.
Signs of hypovolemia should be looked for,
Flail Chest patient should be resuscitated with fluids and
blood and if necessary unstable or open-book
This occurs from fracture of the chest wall
type of pelvic fractures should be stabilized with
resulting in a segment with no bony continuity
external fixator. Sometimes arteriogram and
with the rest of the bony cage. This causes
embolization or surgery may be needed to
paradoxical movement of the segment during
control bleeding.
inspiration and expiration. Patient will have
Pubic ramus fractures can result in damage
tachypnea, tachycardia, poor air entry, abnormal
to urethra, which is identified by puerperal
chest movements and crepitus of fracture. Most
of these patients have associated serious lung hematoma, blood at urethral meatus and inability
contusion and ventilator support may be to void urine.
necessary to prevent hypoxia. Per-rectal examination can identify rectal
injuries or floating prostate from urethral
disruption.
Cardiac Tamponade
Colorectal injuries may necessitate colostomy.
This is diagnosed by Deck’s triad. Sacral plexus injuries are not uncommon.
1. Elevated CVP with engorged neck veins Open pelvic fractures have a high mortality
2. Decreased systolic pressure due to severity and other associated injuries.
3. Muffled heart sounds. Have a definite plan for management of
Electromechanical dissociation in the absence pelvic fractures or the approach to the fracture
of hypovolemia suggests cardiac tamponade. site may be jeopardized by external fixator
Initial fluid resuscitation followed by pericardio- application (pin tract infection) or suprapubic
centesis which is done by subxiphoid route, at cystostomy (for Phannelstein’s incision).
3 Examination of Patient with
CHAPTER Bone and Joint Injuries
Examination should begin as discussed in the In case of recurrent dislocation of shoulder

Advanced Trauma Life Support (ATLS) protocol first episode is very important to differentiate
by initial assessment and resuscitation in previous traumatic and atraumatic dislocation.
chapter. Once the patient is stable, history and Adult pedestrian hit by car can present with
specific examination of the injured part can be triad of:
done. a. Leg fracture (fracture upper end of tibia)
b. Head injury (patient thrown on bonnet of car
HISTORY and head smashes the wind screen)
c. Wrist fractures (patient thrown off the car
Mechanism of Injury lands on the ground with arm stretched).
It is important to know the exact mechanism of Nightstick fracture of ulna due to assault
injury to identify the nature of fracture, happens in reflex, protective action of flexing the
ligamentous injuries and associated injuries. elbow to ward-off blows to the face or chest.
Throwing action in sports (cricket, base-ball,
Examples javelin, discus, etc.) can cause SLAP (superior
labral anterior posterior) tear of glenoid labrum
A fall from a height can present with calcaneal in shoulder.
fracture, but one needs to assess the spine, pelvis
and long bones of leg for fracture. Pain, Swelling, Deformit y
Dashboard injury can present with posterior and Abnorm al Movements
dislocation hip and one needs to assess the knee
for posterior cruciate ligament injury. Pain, swelling, deformity and abnormal
Fall on outstretched hand (FOOSH injury) can movements corresponding to the site of fracture.
present with various fractures starting from
finger fracture, scaphoid fracture, wrist fracture, Open Fractur e
forearm fracture, elbow dislocation, humerus In open fracture the following history are taken
fracture, shoulder fracture/dislocation and into consideration:
clavicle fracture. a. Time since injury.
Sudden deceleration can produce anterior b. Time since the patient had last oral feed –
cruciate ligament tear especially in sports and solids/liquids, important in planning time of
games, avulsion fractures or transverse fracture surgery in case of emergency surgery.
patella. Twisting injury to the knee with the foot c. The site of the accident for contaminants.
on the ground can cause collateral ligament and Example—(i) Farm wounds of whatever size
meniscal injury. are considered type III (Gustilo’s). These
wounds may have aerobic and anaerobic Example 2: Posterior dislocation of hip
organisms; hence appropriate antibiotics presents with flexion, adduction and internal
should be administered in addition to rotation of the limb.
adequate debridement. • Deformity: Abnormal appearance of the
Example—(ii) Industrial accidents. Crush injured limb due to fracture and hematoma
injury hand may be contaminated with with change in normal alignment is noted.
grease, chemicals or other foreign materials, • Limb Length Discrepancy
which need appropriate treatment.
d. High or low energy injury. In road traffic Feel
accidents speed at the time of impact gives a
Local bony tenderness: Ask the patient to point the
clue to the severity of soft tissue damage in
site of maximum pain. Look at the face of the
addition to the obvious fracture. Commi-
patient and feel for tenderness. This is helpful in
nuted—segmental fractures implies severe
localization of the site of injury in bony bruise or
soft tissue damage.
fracture or ligamentous avulsions.
Distal Neurovascular Symptoms Muscle spasm: This can be seen and felt on feeling
the fracture site and on any trivial movements.
Weakness or complete loss of power, altered or
absent sensation, pain out of proportion to Abnormal mobility: Most of the fractures are
fracture (compartment syndrome—In tibial obvious by their abnormal mobility and it is
fractures, supracondylar humerus fracture). wrong to elicit this sign as it causes pain. Patient
must be made comfortable with immediate
EXAMINATION splintage and analgesics. In nonunion this sign
can be elicited with or without pain.
Look
Crepitus: Bony crepitus from movement at
• Attitude of the limb: Most of the time the fracture site can be felt but should not be elicited.
fracture is obvious but a single bone fracture Both the above signs are much appreciated
of forearm or leg or an undisplaced fracture at the time of splinting.
may be deceptive in appearance.
Example 1: Fracture neck of femur presents Deformity: The deformity can be due to bone itself
with shortening and external rotation of the or soft-tissue tethering and tightness, Example:
lower limb (Fig. 3.1). In malunited fracture tibia, tendoachilles
becomes tight causing equinus deformity.
Examination of overlying skin and soft tissue: In
acute fracture the management depends on the
status of soft tissue envelope. Presence of
blistering or tense swelling is a contraindication
for implant surgery. An abrasion over the
incision site that is more than 8 hours old since
the time of injury should be considered infected
rather than contaminated with organisms, and
surgery should be deferred until it fully heals.
Splinting and elevation decreases the swelling
and surgeon should wait for optimum skin
Fig 3.1: Fracture of neck of femur condition to operate.
Examination of Patient with Bone and Joint Injuries 19
In chronic cases assessing the skin condition with fracture may find it difficult to move and
is important to avoid skin flap necrosis or wound fracture must be suspected if there is painful
breakdown postoperatively. limitation. Any pain-provoking maneuver
Open fracture needs assessment as described should not be done.
by Gustilo and Anderson to grade the severity. Adjacent joint movements should be checked
It is a surgical emergency and should be debrided in delayed union or nonunion or malunion for
and stabilized within 6 hours from the time of post-traumatic stiffness.
injury. Input from a plastic surgeon may be
Example: Fracture lower end of femur causes
helpful in the management of wound closure.
tethering of quadriceps in callus and limitation
History of any infection at the time of primary
of knee flexion.
treatment is very important for a treatment plan.
Again a patient who had multiple operations
Measure
must be assessed carefully by planning the
incision to avoid skin problems. Discharging Limb length discrepancy: In a displaced fracture
wound or sinus needs special consideration or dislocation this is obvious. In malunion or non-
while planning surgery. union, assessment of shortening or lengthening
(e.g. femoral shaft fracture in children) is
Distal neurovascular examination: Any fracture can
important.
cause neurovascular impairment. This should be
checked. Deformity: Measurement of angle of deformity in
an old fracture is important. This must be
Example:
expressed in three planes. Malunion or nonunion
Humeral shaft fracture can cause radial nerve
needs 3-dimensional assessment to understand
palsy (Holstein–Lewis fracture).
the mechanical axis and to plan for correction.
Supracondylar fracture can cause injury to
brachial artery, radial, median or ulnar nerves
and compartment syndrome of forearm. SPECIFIC CONDITIONS
Upper tibia fracture is prone for compartment Compartment Syndrome
syndrome of leg, due to tear of anterior tibial
artery as it pierces the interosseous membrane. This is due to decreased perfusion from increase
Fracture dislocation of the knee can produce in interstitial pressure, impending micro-
popliteal artery injury. circulation in a closed osseofascial compartment.
Hip dislocation can cause sciatic nerve injury. Compartment syndrome can occur in closed or
Talar dislocation can cause compression of open fractures (17%), crush injuries, tight
posterior tibial artery or nerve and skin necrosis. bandages, burns, exercise-induced, etc.
Compartment syndrome is characterized by
Examination of adjacent joints: Dislocation or severe pain out of proportion to the fracture;
ligamentous injuries to the joints should be tense tender swelling; passive stretching of the
specifically looked for as it can be easily missed. involved muscle group causes pain; pins and
Example: Fracture shaft of femur can be needles and numbness due to nerve involvement,
associated with hip dislocation or head or neck
and rarely absent pulse. Symptoms are due to
fracture of femur. ischemia of muscles and nerves. The differential
pressure of 20 mm less than diastolic pressure in
Move
the compartment is diagnostic of impending
As a quick screening, active movements of all compartment syndrome. This needs urgent
four limbs are tested in initial assessment. Patient fasciotomy.
In anterior tibial compartment syndrome, Ad ul t Res pi rat or y Di st res s Sy nd ro me

there is pain along the anterior compartment of (ARDS)
the leg with swelling, tenderness and flexing the
toes causes increasing pain. Numbness in deep It is a syndrome of acute, diffuse infiltrative
peroneal nerve distribution, that is first web lung lesions accompanied by severe arterial
space can be present. hypoxemia due to an overwhelming systemic
The posterior tibial compartment syndrome inflammatory response.
ARDS has the following four findings in a
can be of deep posterior compartment or
patient with acute respiratory failure:
superficial posterior compartment or
a. Severe hypoxemia, refractory to oxygen
involvement of both. This causes severe pain in
therapy. The PO2 is less than 75 percent in
the calf, swelling, pain on passive extension,
patients receiving >50 percent oxygen.
numbness in the posterior tibial nerve
b. Diffuse fluffy pulmonary infiltrates involving
distribution (deep compartment) and along sural
both lungs.
nerve distribution (superficial compartment). c. The absence of increased pulmonary capillary
The peroneal compartment syndrome causes hydrostatic pressure (presence indicates a
pain, swelling on the lateral aspect of the leg, cardiogenic cause).
stretch pain and numbness along the superficial d. The lung demonstrates diffuse alveolar
peroneal nerve distribution, that is dorsolateral damage and generally becomes stiff with
aspect of foot and lower leg. reduced lung-thoracic compliance.
Volkmann’s ischemic contracture of forearm ARDS commonly develops in the following
affects the flexor muscles and sometimes extensor conditions—polytrauma, multiple fractures, lung
muscles due to compartment syndrome. Tight contusion, fat embolism, prolonged hypotension,
long finger flexors due to ischemic contracture sepsis, gastric aspiration, drug overdose and
produce a tenodesis effect, extension of wrist massive blood transfusion.
results in finger flexion, flexion of the wrist The mortality rate is 50 to 60 percent.
results in extension of fingers. This is called
Volkmann’s sign. Deep Vein Throm bosi s and
In established case, contracture of muscles Pulmonary Embolism
causes deformity like claw toes and pes cavus in
the feet and claw hand with flexion contracture Orthopedic surgeries in the lower limb, especially
of the wrist. hip/knee replacement or fracture neck of femur
patients are prone for deep vein thrombosis.
Fat Embolism High-risk patients are those with previous
history of deep vein thrombosis, obesity,
This happens in long bone fractures due to immobilization, pregnancy and women on oral
abnormal movement at fracture site, can also be contraceptive pills, malignancy, varicose veins,
from medullary reaming for nailing. Presents with hypercoagulable states and congestive cardiac
altered sensorium, chest pain, breathlessness, failure. Thrombosis of calf veins, popliteal veins
fever, petechial hemorrhages in the upper half of or femoral veins result in sudden onset pain and
the body and subconjunctival hemorrhage. The swelling of the lower limb, low grade fever, calf
oxygen saturation drops and can be checked with tenderness, muscles that contain thrombosed
pulse oximeter to know the extent of hypoxia. veins becomes hard and tender, and Homan’s
Examination of Patient with Bone and Joint Injuries 21
sign (stretch pain in calf muscle) can be positive. postphlebitic syndrome (hyperpigmentation
A large swollen limb that is made pale by tense with swelling of lower leg with varicose eczema
edema is called phlegmasia alba dolens or milk and prone to venous ulcers) due to damage of
leg. When venous thrombosis blocks all main the venous valves.
proximal veins the skin become congested and Pulmonary embolism can be massive or
blue, and is called phlegmasia cerulea dolens. minor. It manifests with sudden onset chest pain,
The incidence of clinical deep vein thrombosis is difficulty in breathing, tachypnea, pleuritic
less than that confirmed with venogram and crepitation, hemoptysis, engorged neck veins,
Doppler ultrasound scan. tachycardia, ECG changes and sometimes
The complications of deep vein thrombosis sudden collapse. Massive pulmonary embolism
are pulmonary embolism which may be fatal and can be fatal.
4 Examination of
CHAPTER Neuromuscular Disease
Many of the common neuromuscular diseases and progression of the condition is important to
that require orthopedic assessment and differentiate between congenital/developmental
treatment manifest in childhood. These include and acquired conditions.
cerebral palsy, myelodysplasia (spina bifida) and
poliomyelitis. As ses sm ent of Ac ti vi ti es o f Daily Li vi ng
As with any group of disorders, a systematic
This includes verbal and non-verbal communi-
approach is required to evaluate, diagnose and
cation ability, personal hygiene, dressing,
treat these conditions.
mobility and recreation.
HISTORY Family History
Birth History and Milestones Family history of gait abnormalities which is
Cerebral palsy is often associated with pre- relevant in muscular dystrophies and has
maturity and low birth weight. The birth is often important implications for future pregnancies.
difficult, and the child requires resuscitation and There is also an undetected chromosomal
ventilation. The abnormality in spina bifida is anomaly which predisposes siblings to cerebral
usually obvious, but may be subtle involving palsy.
lumbosacral skin changes in isolation. Delay in
Past History
the normal motor milestones is often the first sign
of an underlying neuromuscular disorder. These Immunization, previous illness, treatment and
include head control at 3 months, sitting balance current nonskeletal conditions.
at 6 months, standing at 10 months and walking
at 12 months. Treatment Histo ry
Previous treatment may have a significant effect
Presenting Complaint
on the current examination and subsequent
This usually involves delay or loss of motor management. This includes physiotherapy,
skills including sitting, standing or walking. orthotic and surgical intervention.
There are often associated delays in speech and
Knowing patient’s or parents’ expectation.
language development and generalized medical
conditions including siezures. Abnormal
EXAMINATION
patterns of walking, loss of walking ability and
disorders of balance may be associated with the These children require a general examination in
onset of neurological disease. The time of onset addition to a specific musculoskeletal assessment.
Examination of Neuromuscular Disease 23
General
General Examinati on Feel
a. Walkin
Walking g aids
aids or splint
splints:
s: Use
Use of rollat
rollator
or or Feel for muscle tone and power, tenderness and
frame, wheelchair, stick or splints (AFO, distal pulses.
KAFO, DAFO) suggests the available motor Differentiate between upper motor neuron
power (Fig. 4.1). (UMN) and lower motor neuron (LMN) lesion.
b. Look for tru
truncal
ncal asym
asymmetr
metry,
y, dysm
dysmorp
orphic
hic UMN lesion LMN lesion
facies, contractures or wasting of upper or
lower limbs, use of incontinence pads/ 1. Hypertonia of — Hypotonia and
nappies (in spina bifida). muscle-rigidity fasciculations
2. Exa
xagggerated dee
deep — Absent de
deep re
reflexes
UPPER LIMB reflexes
In the upper limb the various deformities may 3. Babinski’s sign– — Absent
happen due to spastic hand, Erb’s palsy, Volkmann’s positive
ischemic contracture or totally flail limb. Upgoing plantar
reflex
Look
Move
In the spastic upper limb, there may be internal
rotation and adduction deformity of the Assess for fixed deformities by active and passive
shoulder, flexion of the elbow, pronation of the movements.
forearm, flexion at wrist and MCPJ, and thumb
in palm deformity affecting palmar hygiene. Function
Assess the ability to position the hand in space,
behind the head and to reach the back passage.
This assesses the functional range of movement
of the shoulder and elbow.
Hand function is assessed by power grip, key
pinch, tip-to-tip pinch and stereognosis.
LOWER LIMB
In the lower limb the deformity may involve
contractures at the ankle, knee and hip. There
may be an associated gait abnormality.
Look
1. Gait:
Gait: Scisso
Scissoring
ring gait
gait,, hemiple
hemiplegic
gic gait,
gait,
crouched gait, jump knee gait, high stepping
gait, wide-based gait (Figs 4.2A and B).
2. Ass
Assess
ess an
an exagge
exaggerate
rated
d lumbar
lumbar lord
lordosis
osis in
fixed flexion deformity of the hip, adducted
hip, flexed knee or hyperextended knee, foot
deformities (equinus, calcaneus, cavus, varus
Fig. 4.1: Walking aid—child with rollator or valgus), and forefoot and toe deformity.
A B
Figs 4.2A
4.2A and B : Flexed hip with normal knee gait and crouched gait respectively
3. Skin
Skin and
and sof
softt tiss
tissue
ue con
condit
dition
ion:: or hamstring tightness. Remember muscle
a. Abno
Abnormal
rmalityity of the
the butt
buttock
ock and low
lower
er crossing two joints should be tested for
spine (Spinal dysraphism). contracture by putting the muscles to stretch
str etch
b. Scars, trophic ulcers or callosities on the by appropriate movements in both the joints
foot (Spina bifida or spinal cord lesion). simultaneously.
c. Mu
Muscscle
le wa
wast sting
ing (P
(Pol
olio
io).
). a. Phe
Phelp’
lp’ss gracili
graciliss test—pa
test—patietient
nt is placed
placed
d. Cal
Calff muscle
muscle hypertr
hypertrophy
ophy (Duc
(Duchen
henne/
ne/ prone, knees flexed and hips abducted as
Becker’s muscular dystrophy). far as possible. Each knee is then gradually
extended; the hip will adduct if the gracilis
Feel is tight.
b. Adductor tightness—with
tightness—with hip flexed and
Feel for muscle tone, tenderness and assess distal knee flexed, abduct the hip.
pulses. c. Med
Medial ial hams
hamstri
tring
ng tight
tightnes
ness—w
s—withith hip
hip
abducted and knee flexed, knee is
Move extended and tightness of medial
Assess for fixed deformities and contractures in hamstrings is felt by palpation.
each region. d. Hams
Hamstring
tring tight
tightness—
ness—strai
straight
ght leg raise
test.
3. Abd
Abduct
uction
ion cont
contrac
racture
ture:: This
This may be duedue to
Hip
Iliotibial-band tightness and can be tested by
1. Thomas
Thomas test
test for fixed flexi
flexion
on deform
deformity
ity of
of the
the Ober’s test. The knee is flexed with the th e hip in
hip. the neutral position. The knee is extended and
2. Add
Adduct
uction
ion contr
contractu
acture:
re: It can be
be due to abduction of the hip indicates a positive test
primary adductor tightness, gracilis tightness (Fig. 4.3).
Examination of Neuromuscular Disease 25
4. Rectus
Rectus femo
femoris
ris tight
tightnes
nesss (Dunca
(Duncan n Ely’s
Ely’s prone
prone determines the fixed flexion deformity. A
rectus test): In the prone position the knee is fixed flexion deformity at the hip may give
flexed, with a positive test the hip flexes and an apparent flexion deformity at the knee.
causes rising of the buttock (Figs 4.4A and B). Popliteal angle can be measured by keeping
5. Rot
Rotati
ation
on of the
the hip,
hip, torsion
torsion of
of the tibi
tibiaa and the
the hip and knee at 90 degrees and slowly
foot thigh angle are assessed using Staheli’s extending the knee to measure the hamstring
rotational profile (discussed in Chapter 14). tightness in spastic cerebral palsy. More than
50° is pathological (Fig. 4.6).
Knee 2. Quadriceps tightness: This can cause limitation
of flexion. In isolated rectus femoris tightness
1. Knee flexion deformity (Fig. 4.5): The angle
flexion of the knee will be more limited with
between
betwee n the thigh and lower leg segme
segmentnt
hip extended than with hip in 90º flexion.
gives a measure of fixed flexion deformity.
Bringing the patient’s knee to the edge of the
An kl e
couch so that the thigh segment is flat on the
couch and then extending the knee Silfverskiold’s test: This differentiates between
gastrocnemius or soleus contractures. Ankle
movements are influenced by the position of the knee
because gastro
gastrocnemius
cnemius crosses both joints
joints.. In
gastrocnemius contracture dorsiflexion of the ankle
is limited with knee extension and more dorsiflexion
of ankle is possible on knee flexion. In soleus
contracture the dorsiflexion of the ankle remains the
th e
same irrespective of the position of the knee joint.
In all these patients assess the spine fo forr
deformity and range of motion.
SPECIAL
SPECIAL TESTS
Gower’s Sign
The patient attempts to rise from a sitting
Fig. 4.3: Ober’s test position. The sign is positive if they use their arms
A B
Figs 4.4A
4.4A and B : Prone rectus test
Cerebral Palsy
Nonprogressive neuromuscular disorder with
onset before age of 2 years, resulting from injury
to immature brain. The cause is idiopathic but
can be due to prenatal sickness of mother,
intrauterine factors, perinatal infection (TORCH
infection—Toxoplasmosis, rubella, cyto-
megalovirus and herpes simplex), prematurity
(commonest), hypoxia and meningitis. Patient
can present with diplegia (more extensive
Fig. 4.5: Measurement of knee flexion deformity
keeping thigh flat on the edge of the couch (For color
involvement of lower extremity than upper
version, see Plate 1) extremity), hemiplegia (involves the upper and
lower extremity of same side with spasticity) or
can be total body involvement. The physiologic
character of presentation can be spastic (most
common type with increased muscle tone and
hyperreflexia with slow restricted movements
because of cocontraction of agonist and
antagonist), athetosis (slow writhing
involuntary movement in succession), ataxia
(inability to coordinate muscles for voluntary
movement with unbalanced wide base gait) and
mixed type.
Fig. 4.6: Popliteal angle
Obstetric Palsy
to climb on the legs and thighs to stand. This Brachial plexus palsy due to stretching or
demonstrates proximal muscle weakness and is contusion at the time of birth. It can be of Erb
highly suggestive of muscular dystrophy in a Duchenne palsy which is the most common with
child. Proximal muscle weakness in elderly may best prognosis. It involves lesion of C5, 6 roots
be due to osteomalacia. affecting deltoid, rotator cuff, elbow flexors, wrist
and hand dorsiflexors resulting in Waiter’s tip
Meryon’s Sign position. Klumpke’s palsy is from lesion of C8,
T1 roots with deficit of wrist flexors, intrinsic
The patient is lifted by holding under the arms.
hand muscles and Horner’s syndrome. Total
The sign is positive if the patient slips through
plexus lesion is from C5 to T1 with complete
because of shoulder girdle weakness.
motor and sensory deficit and flail arm. Obstetric
palsy is common in forceps delivery, large babies,
Romberg’s Sign
shoulder dystocia, breech position and
The patient is asked to stand with the feet prolonged labor. Ninty percent of them resolve
together, with eyes closed. Unsteadiness with maintaining passive range of movement
indicates a posterior column lesion (Friedreich’s exercises. Lack of biceps function 6 months after
ataxia-pes cavus). Unsteadiness with the eyes injury and Horner’s syndrome carry a poor
open indicates a cerebellar lesion. prognosis.
5 Examination of Shoulder
CHAPTER
The approach and sequence of examination of (deltoid region) by using the palm of other hand.
shoulder have changed a lot in recent years. A Some patients present with scapular area pain in
shoulder girdle problem can be in glenohumeral rotator cuff problem. Patients presenting with pain
joint, acromioclavicular joint, sternoclavicular joint over the supraclavicular area and along the side
and scapulothoracic joint. One must get an idea of the neck may be having referred pain from a
of what the problem is from the age and presenting neck problem. Radicular pain (brachialgia)
symptoms. In young adults the most common radiates along the nerve distribution and can
problem is instability. Instability can be defined extend below the elbow up to the fingers. In
in simple terms as symptomatic laxity. It is a acromioclavicular joint pain it is well localized and
spectrum of disease ranging from just pain to frank the patient often points with a finger over the joint
dislocation. Joint laxity without symptoms is not (Fig. 5.1). A history of aggravating or relieving
abnormal. In middle age the shoulder pain can be factors should be asked for. Rest pain, night pain
due to subacromial impingement syndrome, and inability to lie on the affected side indicate
rotator cuff tendonitis, calcific tendonitis or frozen the severity and nature of problem. Night pain is
shoulder. In old age rotator cuff tear, frequently present with rotator cuff disease,
glenohumeral arthritis and secondaries in glenohumeral arthritis and frozen shoulder.
proximal humerus should be considered. At any Sudden acute excruciating pain without trauma
age infection like tuberculosis (caries sicca type) may be due to acute calcific tendinitis. Pain along
can happen. In elderly patient severe rotator cuff the medial aspect of scapula can be due to
arthropathy can present with destruction of joint
with bony debris, this condition is called
Milwaukee shoulder. Neuropathic shoulder can
occur in diabetic patients and in syringomyelia.
HISTORY
Ag e, Occ upati on and Dom in ant Hand

In any upper limb problem these three
parameters decide the management.
Pain
Onset, duration, site and nature of pain. Patient Fig. 5.1: Pointing site of pain in
refers most of the shoulder pain to the upper arm acromioclavicular joint problem
trapezius myofascitis or spine disease. Patient with gradual onset indicative of an attrition rupture
full pain free range of movement of shoulder joint most likely secondary to impingement or intrinsic
with no clinical abnormality may have referred cuff degeneration. If weakness follows an injury
pain from neck or lesion in and under the to the shoulder then it is important to consider
diaphragm or from heart disease in case of left neurological injury to the brachial plexus,
shoulder pain. particularly the axillary or suprascapular nerves.
Patient often describe the shoulder as being weak
Limitation of Activities or stiff and the movement limited by pain. It is
important to abolish pain by local anesthetic
What stops the patient from doing the day-to-day injection before assessing power. History of neck
activities like feeding, shaving, dressing, combing pain and stiffness may help in identifying patients
the hair and perineal hygiene—Is it pain or stiffness with weakness secondary to nerve root
or weakness must be asked. This may affect the compromise. Brachial plexus injuries are the result
normal work, hobbies or lifting heavy weights. of violent blunt trauma to the head and neck,
penetrating injuries to the posterior triangle of the
Swelling neck or both injuries and should be fairly obvious.
A family history of shoulder weakness occurring
Diffuse swelling on top of the shoulder can be bilaterally starting in early adulthood and
subacromial effusion, which can be differentiated associated with facial weakness is typical of facio
from shoulder joint effusion by absence of scapular humeral dystrophy. Patients complain
fullness in axilla (inferior recess of the joint). of instability, inability to maintain the arms in an
Localized swelling on top of the shoulder can be elevated position for a long time. Suprascapular
due to acromioclavicular dislocation. nerve entrapment is associated with a diffuse
posterolateral shoulder pain and weakness of
Stiffness abduction and external rotation. Confirmation
requires EMG.
Patient presents with inability to lift the arm up,
difficulty to reach the things on the shelf, inability
Instability
to comb the hair, difficulty in fastening the brassiere
on the back and difficulty to reach the buttocks. It Feeling of joint coming out in certain positions,
may be caused by primary or secondary frozen previous dislocations and the nature of first
shoulder, post-traumatic stiffness—shoulder hand dislocation must be recorded. Sudden jerk or
syndrome, osteoarthritis, rheumatoid arthritis and dead arm sensation on raising the arm in racquet
rotator cuff arthropathy. sports due to transient subluxation causing
numbness and tingling can be a presenting
Weakness feature. Any instability 3 points to be noted are
the degree (subluxation/dislocation), onset
Weakness around the shoulder can be due to
(traumatic, atraumatic, overuse) and direction
intrinsic problems with the rotator cuff like partial
(anterior, posterior, multidirectional). The most
or complete tear or neuromuscular problems like
common glenohumeral instability being anterior
cervical radiculopathy, brachial plexus injuries,
and unidirectional.
entrapment of suprascapular nerve or muscular
dystrophy. In patients with suspected cuff
Catch o r Pseudolocking
pathology, being the most common, it is important
whether the shoulder weakness followed a single This can be a symptom of instability, labral tears
traumatic event suggesting an acute tear or was a or from loose bodies.
Examination of Shoulder 29
Deformity deformities— winging of scapula, and

swelling. Inspect from front for shoulder
This can be from acromioclavicular dislocation,
symmetry, fullness of supraclavicular area, any
or fracture of clavicle, Sprengel's deformity or
scars, prominent acromioclavicular joint, head
pseudoarthrosis of clavicle or unreduced
and neck alignment and arm position, wasting
shoulder dislocations or sequelae of obstetric
of deltoid or small muscles of the hand.
palsy.
Inspect from back for any wasting of
spinati. It is difficult to assess minimal wasting
Miscellaneous
of supraspinatus because of overlying
Involvement of other joints, neck pain with trapezius muscle. The most common cause of
radiation to the arms along the dermatome, loss infraspinatus wasting is a rotator cuff tear.
of weight, loss of appetite and constitutional Look for winging of scapula. With paralysis
symptoms. of serratus anterior scapula tends to migrate
Other relevant history must be recorded proximally and its inferior angle moves
including patient's expectation (Table 5.1). medially. In contrast if trapezius is paralysed
the scapula migrates downwards with inferior
CLINICAL EXAMINATION angle moving laterally (Figs 5.2A to D) .
Asking the patient to push against a wall will
Shoulder examination should conform to the
elicit winging. Mild winging is often
following sequence:
secondary to intrinsic glenohumeral problem
1. General examination
like instability. Severe winging is most
2. Rotator cuff strength tests
commonly neurologic injury. Ask the patient
3. Impingement tests
to raise the arm sideways up and above the
4. Biceps tests
shoulder. This abduction movement will give
5. Acromioclavicular tests
a clue to the range of abduction, any painful
6. Instability tests.
arc (patient may describe the feeling of pain
at one particular range usually from 60° to
Look
120°) and also look for the scapulothoracic
Expose the patient up to waist with the patient rhythm. With normal abduction the scapula
standing or sitting. Difficulty in undressing can glides smoothly. In rotator cuff tear or joint
be noted. Patient takes off the tops on the pathology there will be abnormal
unaffected side first and then the affected side. scapulothoracic rhythm. The scapula starts to
Look for attitude, muscle wasting, move early in abduction.
Table 5.1: Typical shoul der disor ders in vario us age-group s
Newborn/infant Adolescent/young adult Older adult

Clavicular fracture Traumatic instability Partial tear of the rotator cuff
Torticollis Acromioclavicular-joint separation Complete tear of the rotator cuff
Septic arthritis Clavicular fracture Arthritis of the acromioclavicular joint
Osteomyelitis Dislocation of the sternoclavicular joint Fracture of the proximal humerus
Sprengel deformity Tenosynovitis Calcific tendinitis
Klippel-Feil syndrome Atraumatic instability Subacromial bursitis
Cleidocranial dysostosis Subacromial bursitis
Figs 5.2A to D: Different forms of winged scapula: (A) Winging of right scapula; (B) Normal position of the
scapula; (C) Paralysis of the serratus anterior; the scapula migrates superiorly and medially; (D) Paralysis of
the trapezius; the scapula migrates inferiorly and laterally (For color version Fig. 5.2A, see Plate 2)
The rhythm disturbance is well noted on clavicle, acromioclavicular joint, subacromial

bringing the arm down from full abduction when area, angle of acromion, shoulder joint line,
we can see rippling movement of scapula with coracoid process, biceps tendon in bicipital
asymmetry. groove (Fig. 5.3) , spine of scapula and
Swelling which is horseshoe shaped around tenderness along cervical spine. The biceps
the acromion is classical of subacromial bursitis. tendon is well felt by grasping the patient's
Ganglion cyst of acromioclavicular joint can arise elbow from back with one hand and turning the
from ACJ arthritis or massive rotator cuff tear. arm alternately into external and internal
Fluid filled sac due to rotator cuff massive tear rotation. The tendon can be felt slipping under
can happen in rotator cuff arthropathy the fingertips above and lateral to coracoid
(Milwalkee shoulder) or in rheumatoid arthritis process. Rotator cuff pathology causing
or in exudative joint tuberculosis. tenderness is best felt by extension and internal
rotation of the arm (Fig. 5.4) and feeling the
Feel greater tuberosity below and in front of the
acromion (Codman's point). Also feel for any
Feel for warmth, tenderness, swelling or localized tenderness in the muscles or any
irregularity in soft tissue or bony contour. tender palpable nodules (fibromyositis). Feel for
Standing at the back of the sitting patient start the position of humeral head and coracoid
from sternoclavicular joint palpate along the process and along the proximal humerus. Axilla
Fig. 5.3: The long tendon of the biceps is palpated in Fig. 5.4: The supraspinatus tendon and the subacromial
the bicipital groove with the arm in external rotation bursa are palpated with the arm in extension
should not be forgotten. In axilla feel the Ask the patient to clasp both hands behind the
humeral head, fullness of inferior recess in head and to take the elbow back as far as possible,
shoulder effusion, abnormal mass and axillary this tests active functional external rotation or keep
lymphadenopathy. the arm by the side of the body, bend the elbow
90° and ask to turn the forearm out to assess
Move external rotation (normal range 0 to 45°).
Active abduction, forward flexion, external Ask the patient to take the hand behind the
rotation and internal rotation should be assessed. back and to reach as high as possible in the
Full range of movements indicates normal midline to assess internal rotation. This can be
shoulder and passive movements need not be mentioned in terms of internal rotation to the
tested. Always compare with opposite normal greater trochanter, buttocks, or lumbosacral
shoulder. junction or to appropriate spine level (normal
Ask the patient to lift the arm sideways to range if tested in 90 degrees abduction is 0 to 55°)
know the active abduction. Abduction is lateral (Figs 5.6 to 5.8). Restriction of internal rotation is
movement of arm to go above shoulder and hand common in adhesive capsulitis, glenohumeral
to reach over the head (normal range 0 to 180°) arthritis and tight posterior structures in atheletes
(Fig. 5.5). of throwing sports. In the last condition internal
Ask the patient to lift the arm forward; this rotation in 90° abduction reveals more tightness.
checks active flexion (normal range 0 to 130°) Crossed arm adduction in forward flexion is
and similarly asking the patient to take the arm restricted in tight posterior structures, a
back as far as possible checks extension (normal maneuver used to elicit acromioclavicular
range 0 to 40°). joint pain.
Fig. 5.5: Testing active abduction of shoulder Fig. 5.6: Testing internal rotation of shoulder
Passive abduction is done in case of restricted

active abduction to know the available free range
of movement at the shoulder joint and to assess
the painful arc. In rotator cuff tear active
abduction may not be possible but passive
movement may be full in early stages.
True glenohumeral movement can be
assessed by fixing the scapula, press on the spine
of scapula with the fingers and the thumb
holding the inferior angle of scapula, the other
hand can passively abduct the patient's arm. The
normal glenohumeral movement is only 90° and
is restricted in adhesive capsulitis (Fig. 5.9).
STRENGTH TEST
It is very difficult to accurately separate the
different elements by clinical testing but a gross
assessment of each muscle strength can be done. Fig. 5.7: Testing external rotation of shoulder
down, fully pronated. Patient should hold the

arm in the position against resistance and at the
same time feel for the muscle above the spine
of scapula (Fig. 5.11).
Subscapularis Test
Subscapularis is the internal rotator of the
shoulder and can be tested by Gerber's lift off
test. Patient should internally rotate the arm to
keep the hand against the buttock and try to lift
off from back. Inability to do this indicates weak
or torn subscapularis (Fig. 5.12).
Fig. 5.8: Testing functional external
rotation of shoulder
Try to push the examiner's hand back against
resistance to assess the strength. It can also be
grossly tested by keeping the arm adducted to
the chest, elbow at 90°, forearm in midprone
Fig. 5.9: Fixing the scapula while testing

glenohumeral movement
Fig. 5.10: Testing trapezius
Assess the strength of the deltoid by active
resisted abduction and feel for the muscle in the
lateral aspect of upper arm. This gets affected in
axillary nerve palsy after dislocation of the shoulder.
To test trapezius muscle ask the patient to
shrug both shoulders up and now push both
shoulders down against resistance. This gets
affected in spinal accessory nerve injury (Fig. 5.10).
Rotator Cuff Strength Assessment

Supraspinatus Test
(Jobe Test or Empty Can Sign)
Ask the patient to keep the arm forward flexed Fig. 5.11: Supraspinatus stress test
30° and abducted 90° with thumb pointing (For color version, see Plate 2)
position and pushing the hand internally against Active external rotation with the arm at the
resistance. Good power indicates normal side of body in a 90° flexed elbow can be
pectoralis major and subscapularis (Fig. 5.13). compared to passive external rotation. Difference
When there is pain or limitation of passive in external rotation between passive and active
movement, the Gerber's test will not be possible. movement indicates massive rotator cuff tear
In that case a belly press test or Napoleon sign (infraspinatus) or suprascapular nerve palsy —
can be done. In this test, ask the patient to place "external rotation lag sign".
their hands on the abdomen and examiner External rotation in 90° abduction is
passively bring forward the elbows so that they important in throwing sports and inability to
are anterior to the coronal plane of the body. The externally rotate in 90° abduction or inability to
patient is asked to push the hands hard into their hold a passive position of external rotation with
abdomen. If either arm falls behind the coronal the arm at 90° of abduction indicates massive
plane of the body, then this is suggestive of rotator cuff tear (infraspinatus and teres minor)
weakness of the subscapularis. — "horn blower's sign".
External Rotator Strength Test Drop Ar m Test

(Infraspi natus and Teres Minor Test)
This detects whether there is any tear in the
Keep the arm by the side of the body, elbow at rotator cuff but is not fully reliable. First, ask the
90°, forearm in midprone and push the hand patient to fully abduct his arm and then to lower
externally against resistance (Fig. 5.14). it slowly to his side. If there are tears in the rotator
cuff (especially in supraspinatus), the patient will
be unable to lower the arm smoothly and the arm
will drop down to the side at 90°of abduction. If
Fig. 5.12: Gerber's lift-off test Fig. 5.13: Testing internal rotators of shoulder
patient is able to hold the arm in abduction, a initiate abduction but if the arm is passively lifted
gentle tap on the forearm will cause the arm to he or she can hold it abducted using the deltoid
drop to the side. In complete tear of the and the remaining intact cuff (Tables 5.2 and 5.3).
supraspinatus the patient may not be able to
initiate abduction and can do trick movements IMPINGEMENT TESTS
like swaying the body to the affected side for
Hawkin's Test
initial abduction and then with the help of deltoid
can lift the arm further (Fig. 5.15). Arm in 90° forward flexion, elbow bent to 90°
The abductor paradox—with a complete tear of with the patient relaxed using forearm as a lever
supraspinatus tendon, patient will be unable to internally rotate the arm supporting the elbow
with one hand. Sharp catchy pain indicates
impingement syndrome (Fig. 5.16).
Neer's Imping ement Sign

With one hand raise the affected arm in forward
flexion while the other hand supports the
shoulder. Forward flexion in the scapular plane
can elicit pain when shoulder goes beyond 90° due
to abutment (forward flexion painful arc). This
causes pain due to impingement of the greater
tuberosity against the coracoacromial arch and is
seen in subacromial impingement syndrome
(supraspinatus tendonitis, bursitis, partial tear of
Fig. 5.14: Testing external rotators of shoulder rotator cuff) or calcium deposition (Fig. 5.17).
Fig. 5.15: Drop arm test Fig. 5.16: Hawkin's test

Table 5.2: Musc le testing chart
Muscle Innervation Myotomes Technique for testing
Trapezius Spinal accessory C2-C4 Patient shrugs shoulders against resistance

Sternomastoid Spinal accessory C2-C4 Patient turns head to one side with resistance
over the opposite temporal area
Serratus anterior Long thoracic C5-C7 Patient pushes against a wall with an
outstretched arm
Scapular winging is observed
Latissimus dorsi Thoracodorsal C7-C8 Downward/backward pressure of the arm
against resistance. Muscle palpable at inferior
angle of the scapula during cough
Rhomboids Dorsal (C4) C5 Hands on hips pushing elbows backward
against resistance
Levator scapulae Scapular
Subclavius Nerve to subclavis C5-C6 None
Teres major Subscapular (lower) C5-C6 Similar to latissimus dorsi; muscle palpable
at lower border of the scapula
Deltoids Axillary C5-C6 (C7) With arm abducted 90 degrees, downward
pressure is applied. Anterior and posterior
fibers may be tested in slight flexion and
extension
Subscapularis Subscapular (upper) C5 Arm at side with elbow fixed to 90°. Examiner
resists internal rotation
Supraspinatus Suprascapular C5 (C6) Arm abducted against resistance (not
isolated). With arm pronated and elevated 90°
in the plane of scapula, downward pressure
is applied
Infraspinatus Suprascapular C5-C6 Arm at side with elbow flexed 90°. The
examiner resists external rotation
Teres minor Axillary C5-C6 (C7) Same as for the infraspinatus
Pectoralis major Medial and lateral C5-T1 With arm flexed 30° in front of the body, the
pectoral patient adducts against resistance
Pectoralis minor Medial pectoral C8, T1 None
Coracobrachialis Musculocutaneous (C4)C5-C6 (C7) None
Biceps brachii Musculocutaneous (C4)C5-C6 (C7) Flexion of the supinated forearm
against resistance
Triceps Radial (C5) C6-C8 Resistance to extension of the elbow
from varying positions of flexion
Table 5.3: Neurologi c l evel In upper lim b

Level Motor Sensory Reflex
C5 Deltoid Lateral deltoid Biceps
Biceps (partial)
C6 Biceps Thumb Brachioradialis
ECRL and ECRB Biceps
C7 Triceps Middle finger Triceps
Wrist flexors
Finger extension
C8 Finger flexors Ulnar border —
Little finger
T1 Intrinsics Medial side —
Proximal part of arm
Dermatomes in the upper limb:

C5-lateral deltoid
C6-thumb
C7-middle finger
C8-little finger
T1-inner aspect of the proximal part of the arm
Neer's Injection Test

In patients with painful arc, inject 10 ml of 1
percent lignocaine into the subacromial area and
wait for 5 minutes. If the painful arc disappears
it is diagnostic of impingement syndrome.
Coracoid Impingement Sign

In coracoid impingement syndrome palpation in
the region of coracoid causes discomfort. This sign
is elicited by abducting up to 90° in coronal plane
and maximally internally rotating the arm to cause
pain—"tennis serve follow-through " position. Fig. 5.17: Neer's impingement sign
BICEPS TEST
Speed's Test (Palm-up Test)
Tenderness can be elicited along the groove due
to inflamed bicipital sheath (but beware because Forward elevation of the upper extremity
it is often tender to palpate near the coracoid try between 60 to 90° with the elbow in extension
to see if the tenderness moves as the shoulder and the forearm in supination against resistance
and biceps moved, and therefore, is rotated). causes pain at the long head of biceps (Fig. 5.18).
Yergason's Test Flexion Adduction Test

Do resisted supination of the hand with the elbow Taking the arm across the chest towards the
in flexion. Pain may be felt at the long head of biceps. opposite shoulder with a bent elbow can cause
pain at acromioclavicular joint (Fig. 5.19).
Lipp man Test
INSTABILITY TESTS
Examiner palpates the bicipital groove
approximately 3 cm distal to the shoulder with the Instability is symptomatic inability to maintain
patient's elbow flexed at a right angle. One can the humeral head in glenoid.
provocate biceps tendon subluxation or dislocation Before testing ask the patient whether he can
by palpation of relaxed muscle. This is generally dislocate the shoulder himself, to know if there
painful for the patient. This can also be is a voluntary component.
demonstrated with slow adduction and abduction
while palpating the tendon (Gilcrest test). Generalized Li gament Laxit y
Assess for generalized ligament laxity as
ACROMIOCLAVICULAR TESTS
discussed in Chapter 12 (Patellofemoral joint
Patient localizes the pain at acromioclavicular joint. problem).
Terminal Painful Arc Sulcus Sign

Pain during terminal abduction of 160° to 180°, Patient sitting with arms relaxed by the side of
indicates acromioclavicular joint pathology. the body, with the elbow flexed to 90°, give a
downward axial force along the humerus by
holding the elbow. The sulcus sign appears
between the acromial arch and head of humerus
laterally. The sulcus test demonstrates the degree
of inferior capsular laxity and tests the superior
glenohumeral ligament and coracohumeral
ligament. Always compare with other side
(Fig. 5.20).
Fig. 5.18: Speed test to evaluate the

long head of the biceps Fig. 5.19: Acromioclavicular joint stress test
Anterior Translation Test (Load and Shift Test) glenohumeral ligamentous complex. By
progressive external rotation and abduction there
Patient sitting, arm by the side of the body,
is less translation anteriorly, as inferior
patient relaxed with forearm over the lap,
glenohumeral ligament becomes taut. Similarly
examiner standing from back, with one hand
by int er nal rota ti on of the ar m po ster ior
hold the scapula with fingers in the front of
translation is diminished with intact posterior
shoulder over coracoid and thumb in the back
capsular structure. With arm at the side inferior
over the angle of acromion, with the other hand
restraints are superior ligamentous structures. In
hold the head of humerus. Perform the anterior
90° abducted position, the primary restraint to
translation test. The amount of anterior
inferior translation is the inferior glenohumeral
translation is graded. Grade 1-humeral head
ligament.
rides up the glenoid slope but not over the rim;
Grade 2-humeral head rides up and over the
Ap pr ehen si on Test
glenoid rim but reduces spontaneously when
stress is removed; Grade 3-humeral head rides Arm in 90° abduction, external rotation and
up and over the glenoid rim and remains extension with slight forward pressure placed on
dislocated on removal of stress. Comparison proximal humerus, look at patient's face for
must be made to the asymptomatic contralateral apprehension or pain or feeling of instability. This
side. This test can also be performed in supine can be done in sitting or supine position. This
position while examining the patient under indicates anteroinferior instability (Fig. 5.22). Pain
anesthesia (Fig. 5.21). alone in apprehension position especially in an
Although translation is assessed initially in overhead athelete is strongly suggestive of
neutral position with the arm by the side, supine
load and shift testing in varying arm positions
give more information of anterior and posterior
Fig. 5.20: Sulcus sign Fig. 5.21: Anterior translocation test

posterosuperior glenoid labral pathology or Posterior Load and Shift Test

internal impingement—posterior glenoid labrum
To assess posterior instability. Flex the shoulder
in contact with articular surface of rotator cuff at
90°, flex the elbow fully and in slight adduction
the anterior edge of infraspinatus.
give an axial load along humerus holding elbow
with one hand and neck of scapula with other
Jobe's Relocation Test and Release Test
hand. Feel for posterior subluxation or
The apprehension test is supplemented by dislocation. Push/pull (Norwood) and posterior
relocation maneuver. Patient supine, bringing the drawer test (Gerber) can also confirm the
shoulder to edge of the couch perform the posterior laxity (Fig. 5.24).
apprehension test as described above. Simply Young patients with instability problem can
pushing the humeral head back with the sometime present with shoulder pain due to
examiner's fingers can relieve the apprehension. secondary impingement (abnormal head of
This permits further external rotation and humerus movement and impingement against
extension. This relocation manoeuvre eliminates acromial arch).
any chance of anterior subluxation. Silliman-
Hawkin's release test is releasing the backward NECK EXAMINATION
pressure of humeral head suddenly in extreme
Neck should be examined to rule out any
external rotation that causes rebound
radiating pain to the shoulder especially in
apprehension and sometimes dislocation. This
bilateral shoulder pain, pain radiating to the arm
test is best avoided in more apprehensive
below elbow and pain predominantly over
patients. This test can also be positive with pain
suprascapular area.
from internal impingement rather than
Pain in left shoulder can be a referred pain
apprehension (Fig. 5.23).
from heart and upper gastrointestinal problem.
The apprehension test and relocation test can
Pancoast tumor should also be considered in
be positive for instability, for pain, or for both.
elderly patient with supraclavicular pain and
Positive tests for instability indicate anterior
swelling.
instability. Positive test for pain indicates
posterosuperior labral pathology or internal
impingement.
Fig. 5.22: Apprehension test Fig. 5.23: Jobe's relocation test

Macrotrauma of rotator cuff leading to tear

is common in elderly patients, e.g. an elderly
patient with fall on outstretched hand and not
able to lift the arm up with no fracture or
dislocation is most likely to have cuff tear. The
clinical presentation can be of pain-constant or
night pain, weakness or loss of function. Physical
examination will demonstrate tenderness at
subacromial area, sometimes ACJ and biceps
tenderness, painful abduction arc usually from
90 to 120 degrees and positive impingement
signs verified by impingement tests. Rotator cuff
strength tests, ACJ tests and biceps test should
be done for complete assessment.
Fig. 5.24: Posterior stress test
Calcific Tendinitis
NEUROVASCULAR EXAMINATION
Calcific deposits in the rotator cuff tendons are
usually seen in fifth or sixth decade. Acute stage
For completion, examination of neurological is characterised by severe pain, patient holding
system and vascular system of the upper limb the arm to the side of the chest and not allowing
should be done. even the slightest movement. Local tenderness
may be present. In the chronic stage the pain is
COMMON CONDITIONS AFFECTING less and symptoms and signs of impingement
SHOULDER may be present.
Rotator Cuff Disease
Bicipital Tendinitis
It is a spectrum of pathology ranging from
inflammation in subacromial bursa and rotator Biceps tendon serves as humeral head
cuff to partial or complete tear and eventually depressor. It can be affected in variety of
rotator cuff arthropathy (secondary OA with disorders—biceps tendonitis, subluxation or
proximal migration of humeral head). This is due dislocation of tendon and rupture of biceps
to impingement of rotator cuff insertion against tendon. Tendinitis and rupture occur almost
the coracoacromial arch. This microtraumatic universally as a result of impingement and
process results in pain and dysfunction and is rotator cuff disease. Subluxation of biceps
called subacromial impingement syndrome. tendon occurs with the disruption of
Bigliani has desribed 3 acromial morphologies: subscapularis attachment to the lesser
• Type 1: Flat acromion; tuberosity as the adjacent transverse humeral
• Type 2: Curved acromion; ligament is disrupted. Always perform the
• Type 3: Hooked acromion. Gerber's lift off test in suspected subluxation.
The type-3 acromion is most commonly The other causes of subluxation include primary
associated with impingement. Anterior acromial rupture of transverse humeral ligament or
spur and inferior osteophytes at ACJ, unfused fracture of greater or lesser tuberosity. In
acromial epiphysis (Os acromionale) and ruptured long head of biceps the muscle stands
anterolateral overhang of coracoid process are with a bulge in the middle of the arm—Popeye's
causes of impingement. sign.
Superior Labral Anteroposterior (SLAP)

Lesion
Patient can present with pain, clicking or popping
in the shoulder, common in athletes with overhead
throwing sporting activities. The abnormality is
at the site of origin of the long head of biceps from
the superior labrum both anteriorly and
posteriorly. Clinical examination may
demonstrate positive Speed or Yergason's test.
O'Brien's test or active compression test is
very sensitive and specific test for SLAP lesion.
Ask the patient to hold the arm in 90° forward
flexion, 10° adduction and full internal rotation
of the arm and resist downward force of the arm.
Patient should point out the site of pain to
differentiate from acromioclavicular joint pain.
This pain should disappear on external rotation
of the arm in the same position on resistance.
Anterior slide test: With patient standing with Fig. 5.25: Slide test: Position of the hands and arms
the hands on the hips and thumbs pointing for the anterior slide test
posteriorly, place examiner's one hand over the
affected shoulder with the index finger over the
anterior aspect of acromion. With examiner's other
hand behind the patient's elbow, apply force in
an anterosuperior direction. Instruct the patient
to push back against this force. Sudden pain in
the anterosuperior shoulder typically experienced
during exercise or a palpable snap phenomenon
is indicative of a SLAP lesion (Figs 5.25 and 5.26).
Biceps load test can also be done to diagnose
superior labral and SLAP lesions. With patient
supine shoulder abducted to 120° and maximally
externally rotated the forearm in maximum
supination and elbow placed at 90° of flexion,
forceful flexion against resistance done to elicit
pain in the shoulder.
Osteoarthritis Shoulder
This can be primary OA usually with intact rotator
cuff or secondary OA from trauma, cuff tear
arthropathy, infection or avascular necrosis of
humeral head. Patient present with pain, stiffness
and clinically there is local tenderness along Fig. 5.26: Slide test: Application of force for the
anterior and posterior joint line, and limitation of anterior slide test
glenohumeral movements. Pain is worse on Painless clicks are quite common in shoulder
recumbence as the distraction force in upright especially in frozen shoulder. Painful click can
position is absent. Functional limitation of arise from SLAP lesion.
rotational movements is more noticeable than Matsen described 2 acronyms:
limitation of glenohumeral abduction as • TUBS—Traumatic, Unilateral, Bankart's
scapulothoracic joint compensates this movement. lesion and treatment is Surgery.
• AMBRII—Atraumatic, Multidirectional,
Rheumatoid Arthri tis Bilateral and treatment is Rehabilitation or
Characterized by polyarticular involvement, Inferior capsular shift and closure of rotator
pain, swelling, morning stiffness and restriction cuff interval.
of movements. Feeling of insecurity, apprehension in certain
positions, joint subluxation or dislocation, pain
Shoulder Instability due to secondary impingement and dead arm
syndrome (momentary subluxation) are some of
Common in young adults and varies from pain the features. Stability tests must be done to
to frank dislocation due to laxity of identify anterior, posterior or inferior laxity.
capsulotendinous structures. First episode must Traumatic anterior dislocation of shoulder
be clearly documented for mode of injury, is characterized by loss of normal contour
mechanism, direction of dislocation. Number of (Figs 5.27A and B), bony mass (humeral head)
subsequent dislocation and movement that in front of the shoulder, inability to internally
precipitate are noted. If there is no history of rotate, hand not able to touch the opposite
trauma it is important to ask if the patient can shoulder and shortening of arm segment
voluntarily dislocate. (posterior angle of acromion to lateral
Figs 5.27A and B: Anterior dislocation of shoulder

epicondyle). Duga's sign will be positive where years. The cause is unknown, occurs in middle
the patient is unable to touch the contralateral age female population but more common in
shoulder with the hand of the affected arm. Dead diabetic patients, thyroid disorders and post
arm syndrome is associated with anterior surgical. Other than primary idiopathic frozen
subluxation. shoulder secondary causes include impingement
Posterior dislocation is common in electric syndrome, rotator cuff tear, calcific tendonitis
shock or following fits. Loss of shoulder contour and following trauma (post-traumatic stiffness).
with limitation of external rotation is characteristic. Frozen shoulder is a diagnosis of exclusion of
other conditions in shoulder and is a rare
Frozen Should er (Adhesive Capsuliti s) condition.
This disorder evolves in three stages:
Shoulder Crepitus
Stage 1 is characterized by diffuse pain
gradual in onset. Stage 2 is characterized by Crepitus can arise from subacromial, gleno-
stiffness, affects activities of daily living with humeral or scapulothoracic articulation. Common
limitation of all movements more specifically causes of crepitus about the shoulder are rotator
forward flexion and external rotation limitation. cuff tear, glenoid labral tears, glenohumeral
Stage 3 is thawing, with gradual return of osteoarthritis, scapulothoracic bursal scarring or
motion. It is a self-limiting condition with natural exostosis emanating from ribs or under surface
history of the disease lasting for 18 months to 2 of scapula.
6 Examination of Elbow
CHAPTER
Elbow joint is a complex structure consisting of angle is more than 15°, swelling, scars, skin color,
three separate articulations: The humeroulnar, wasting of radial muscles (mobile wad-
humeroradial and proximal radioulnar joint. brachioradialis, extensor carpi radialis longus
Humeroulnar joint is a hinge joint allowing and brevis) or ulnar muscles of forearm, or small
flexion and extension. Forearm rotation of muscles of hand. Cubitus varus is commonly due
supination and pronation is at radioulnar joint. to childhood trauma such as malunited
Introduce yourself and ask the name, age, supracondylar fracture or early physeal closure
occupation and the dominant hand. The medially. Cubitus valgus is commonly due to
presenting complaint of any elbow problem can lateral condyle nonunion or malunion or due to
be of pa in, sti ff nes s, swe ll in g, de fo rmi ty, physeal damage.
instability and neurological symptoms. Level of Ask the patient to show both elbows with
activities must be assessed to know the loss of hands reaching the shoulder (flexion of elbow).
function like hand to mouth, for perineal hygiene, In a flexed elbow assess for deformity and bony
lifting and carrying things and job-related prominences—medial epicondyle, lateral
activities. History of injury, other joint problems epicondyle and tip of olecranon.
and other relevant medical history are important.
Various disorders can be caused by acute
injuries, chronic stressors, degenerative disorders
and systemic disorders. In repetitive motion
clearly defined clinical syndrome like tennis
elbow can happen in patients like electrician,
carpenter or racquet sports. Patient's expectation
should be known.
LOOK
From the Front
With both elbows fully extended, arms by side
and palms facing forward look for the long axis
of the upper arm and forearm which forms a
lateral valgus angle called carrying angle. The
physiologic range for this angle is between 10 to
15° in women and 5° in men. Look for the
deformity—cubitus varus—the angle is less than
5° (Fig. 6.1) or cubitus valgus (Fig. 6.2) —the Fig. 6.1: Cubitus varus
Fig. 6.2: Cubitus valgus of left arm Fig. 6.3: Palpable structures in the elbow region
Swellings like olecranon bursitis (fluctuating Start from the medial side (Fig. 6.3). A tender
swelling over tip of the elbow), rheumatoid medial epicondyle should be tested for pain on
nodule (a firm swelling over the olecranon and resisted wrist flexion in supination. This indicates
subcutaneous border of ulna) or gout (ruddy medial epicondylitis (Golfer's elbow) or injury
complexion) can be assessed. to medial epicondyle. Medial supracondylar line
of humerus can be palpated superior to the
From Side epicondyle. Wrist flexors arise on this and
Ask the patient to straighten the arms out and occasionally a small bony prominence will be
look tangentially from the side for limitation of palpable which can compress the median nerve.
terminal extension or hyperextension. Ulnar nerve is palpated behind the medial
Swelling and scars should be noted. epicondyle in the groove between medial
epicondyle and olecranon for thickening and
From Back tenderness. Tinel's sign—pins and needles or
sharp sensation along the ulnar nerve
Look for swellings, scars and abnormal bony distribution can be elicited by gentle percussion
prominences by comparing the opposite side. of the nerve. It can get injured in supracondylar
Fullness on either side of olecranon at the or epicondylar fractures. Recurrent subluxation
insertion of triceps can be due to effusion of the of the ulnar nerve should be tested by assessing
joint. the stability in flexion and extension movements.
Thickening of the nerve can occur in Hansen's
FEEL
disease and hypertrophic neuropathy.
Ask the patient for tender spot and look at the Tenderness over the olecranon and radial
patient when you feel. head should be assessed. Radial head tenderness
Examination of Elbow 47
is assessed by supination-pronation of the extensor carpi radialis brevis inserts into 3rd
forearm and is best felt in 90° flexion of the wrist metacarpal base. Mills test is again helpful where
and 2.5 cm distal to lateral epicondyle and any full volar flexion of the wrist with full extension
abnormal subluxation or dislocation (radiocapitellar of the elbow cause pain when there is tightness
joint) can be felt (Fig. 6.4). of the extensor carpi radialis brevis. Lateral
Lateral epicondyle tenderness is then supracondylar line can be palpated where
assessed. Lateral epicondylitis (Tennis elbow) is extensors of wrist arise, and this bony margin
assessed by Cozen's test (Fig. 6.5), where resisted can be palpated up to deltoid tuberosity.
extension of the wrist in pronation causes pain Bony thickening should be appreciated.
at the lateral epicondyle. Resisted extension of Synovium and effusion of the joint can be well
the middle finger causes pain at the extensor felt in a triangular space between lateral
carpi radialis brevis origin (lateral epicondyle) epicondyle, olecranon and radial head.
as it is the usual pathological muscle. Testing the The anterior aspect of cubital fossa can be
middle finger extension causes pain because palpated for any abnormal mass and biceps
tendon. The biceps tendon, brachial artery and
the median and musculocutaneous nerves pass
through this region from lateral to medial.
MOVE
Active movement: Test both arms simultaneously.
Ask the patient to touch both shoulders with the
hands with arm in abduction to assess active range
of full flexion (0 to 135°) or for any limitation.
Extension (0 to - 5°) is assessed by similarly asking
the arm to stretch out in abduction (Figs 6.6 and
6.7). Forceful passive extension causing posterior
elbow pain suggests bony or soft tissue
impingement in the olecranon fossa. In throwing
atheletes recurrent valgus extension overload
Fig. 6.4: Palpating the annular ligament cause impingement of proximal medial olecranon
leading to osteophyte formation and pain.
Supination and pronation is assessed by keeping
Fig. 6.5: Cozen's test Fig. 6.6: Testing elbow extension

both elbows by the side of the body, forearm flexed and tip of olecranon, from the back by holding
to 90° and asking the patient to show the palms with the thumb, middle finger and index finger
up for supination (90°) and palms down for of the examiner respectively. Normally this forms
pronation (90°) (see Figs 7.3E and F). an isosceles triangle and their relationship is
Passive movement: If the active movements are full
altered in elbow dislocation, fractures of
there is no need to test passively. In restricted epicondyle and condylar fracture of humerus;
active movements passive movement is done to unaltered in supracondylar fracture (Fig. 6.8). In
analyze the range and the nature of restriction, extension these points form a straight line.
like bony block with definite end point or elastic The length of the arm is measured from
block with mushy end point from soft tissue posterior angle of acromion to lateral epicondyle
tightness. and forearm is measured from lateral epicondyle
to tip of radial styloid.
MEASURE
STABILITY TESTS
With elbow flexed 90° assess the distance between
3 bony prominences, medial, lateral epicondyle Medial collateral ligament injury is assessed by
valgus stress in supination (Fig. 6.9) for abnormal
opening up of the joint space. Always compare
with opposite elbow.
Lateral collateral ligament injuryis assessed
by either varus stress in supination or valgus
stress in full pronation (Fig. 6.10).
Patient with extensive lateral ligament
complex injury may complain of recurrent
Fig. 6.7: Testing elbow flexion
Fig. 6.8: Relation of three bony points Fig. 6.9: Varus-valgus stress test
painful clicking or locking on extension of the give rise to apprehension. Subluxation of radius
elbow. Posterolateral rotatory subluxation can be and ulna from humerus causes a prominence
present and this is demonstrated by lateral pivot posterolaterally and a dimple between radial
shift test of O'Driscoll where axial compression, head and capitellum. When the elbow is at
valgus stress and supination of the forearm done approximately 40º flexion, ulna suddenly reduces
(Fig. 6.11). with a visible palpable clunk giving rise to
apprehension.
Ap pr ehen si ve Sign Neurological examination consisting of motor
Asking the patient to rise from a chair using the strength, reflex testing and sensation testing are
arms to push them into standing position may done.
reproduce symptoms of instability as it involves
axial load, valgus and supination of the forearm. SPECIFIC CONDITIONS
Similar situation occurs in performing press-ups.
Supracondylar Fracture
This will reproduce the patient's symptoms and
It occurs commonly in children. Pain and
swelling at the lower end of humerus is present
with limitation of elbow movements. Clinically
the three bony points (olecranon, tip of medial
and lateral epicondyle) are not altered. Check for
distal neurovascular compromise and
compartment syndrome. In malunited
supracondylar fracture the most common
deformity is the gun-stock deformity due to
cubitus varus. The distal fragment is in varus,
posteriorly tilted and internally rotated causing
excessive extension and limitation of flexion. The
internal rotation of the shoulder will reveal the
amount of excessive internal rotation due to
malunion on comparison with the other
Fig. 6.10: Evaluating the collateral ligaments
shoulder. There will be corresponding limitation
of external rotation.
Posterior Dislocation o f Elbow

This can occur at any age. There will be alteration
in the relationship of the three bony points. The
triceps may be very prominent and the joint will
be swollen due to effusion. Gross restriction of
elbow movement with pain will be present.
Check for distal circulation and nerve function.
It can be associated with elbow fracture.
Pulled Elbow
It occurs in children below 5 years and is
Fig. 6.11: Lateral pivot shift test produced by traction injury due to lifting or
holding the baby's forearm. The radial head enlargement of the elbow. Clinically there can
subluxes inferiorly under the annular ligament be increased warmth with bony thickening and
and the child keeps the arm still and cries with abnormal hard mass in front and back of the
pain. Sudden supination-pronation movement elbow. Restriction of elbow movements with
can easily reduce this with a clunk. hard end-point rather than resilience in soft tissue
tightness is felt. It is common in the substance of
Myositis Ossificans (Heterotopic brachialis muscle.
Ossifi cation ) (Fig. 6.12)
Elbow joint is notorious for formation of Olecranon Bur sit is (Fig. 6.13)
abnormal bony mass in the soft tissue following Swelling of the bursa at the olecranon tip that is
an injury. This results in stiffness and cystic, well-localized and translucent. If it is
Fig. 6.12: Myositis ossificans in chronic unreduced dislocated elbow
Fig. 6.13: Olecranon bursitis Fig. 6.14: Rheumatoid nodule on extensor aspect of
(For color version, see Plate 2) forearm (For color version, see Plate 2)
inflamed then signs of inflammation will be Congenital Radioulnar Synostosis

present. Parents complain of child not turning the hand
around and always keeps forearm in one position.
Rheumatoid Nodules (Fig. 6.14) There will be no supination-pronation movement
Rheumatoid nodules is present on the due to proximal union of radius and ulna. Can have
extensor aspect of the elbow and forearm, limitation of elbow extension due to developmental
over the subcutaneous border of olecranon. defect of radial head. It can be associated with other
The nodule is firm in consistency and may be congenital anomalies such as developmental
multiple. dislocation of hip and clubfoot.
7 Examination of Wrist
CHAPTER
Wrist is a composite joint formed by radiocarpal Limitation of Activities

joint, ulnocarpal joint, midcarpal joint and distal
This must be quantified in terms of daily activities
radioulnar joint. A focused history and well-
and difficulty in performing jobs, pursuing
performed physical examination of the wrist
hobbies and leisure activities.
requires knowledge of anatomy and pathology
of this area. Based on physical examination, one
Neurological Symptoms
should be able to make a diagnosis or narrow
the differential diagnosis dramatically. This Weakness, numbness, pins and needles, altered
examination is a summation of anatomical sensation.
locations where symptoms are provoked by
palpation and where signs, often with symptoms, Clicks
are produced by manipulation.
Snapping sound from carpal instability or tendon
subluxation.
HISTORY
Age, dominant hand and occupation: It is important Deformity
to know all the three features as it decides the
Dinner fork deformity in Colles' fracture, deformity
treatment for a problem.
from malunion or nonunion of distal radius, caput-
ulna deformity in rheumatoid arthritis or any
Chief Complaints
congenital deformities, etc. (Fig. 7.1).
Pain
Miscellaneous History
Onset, duration, site, nature, at rest or activity
related, aggravating and relieving factors. Injury, other joint involvement and constitutional
symptoms.
Swelling Past history, family history, personal history
and treatment history must be asked in routine
Onset, duration, site, progression, variation in
way.
size, any other swellings, localized or diffuse
around the wrist joint, painful or painless and What is patient's expectation?
other history as discussed in Chapter 1.
CLINICAL EXAMINATION
Stiffness
Expose upper limbs, screen neck, shoulder and
Early morning stiffness, inability to hold things, elbow for any obvious abnormalities or scars.
or perform routine jobs, subjective weakness, loss Positioning the patient in sitting and placing the
of wrist movements. hand on a table is helpful.
Examination of Wrist 53
Fig. 7.2: Palpation of radial and ulnar styloid

(For color version, see Plate 2)
MOVE
Active range of following movements are
assessed: Dorsiflexion, palmar flexion, ulnar
Fig. 7.1: Ulnar club hand
deviation, radial deviation, supination,
pronation, full fist formation and full extension.
LOOK If all movements are present, it is not necessary
to check passive movements (Figs 7.3A to F).
From Front, Back and Sides Normal range of dorsiflexion is 0 to 70°,
palmar flexion 0 to 80°, ulnar deviation 0 to 30°
Attitude of the forearm, wrist and the hand, the
and radial deviation 0 to 20°.
shape, swellings, skin color changes, scars,
Fixed deformities must be noted and assessed
deformities, wasting of small muscles of the
to know whether the deformity is same in all
hand, pulp atrophy, sweating and nail changes
positions of adjacent joints.
are noted.
ASSESSMENT OF INSTAB ILITY
FEEL
Examine the normal wrist first to identify the
Ask the patient for most tender spot and examine
degree of laxity.
it last. Look at the patient's face. Define the
anatomical spot for tenderness, most of the time
Pseudostabili ty Test (Modif ied Fisk's
this gives the pathoanatomical diagnosis.
Forward Shift Test)
Swellings are examined as discussed in Chapter
1. Feel the tip of styloid processes of radius and Firmly grip on distal forearm and with other hand
ulna. Normally radial styloid is more distal than grasp the carpometacarpal joints. Patient must be
the ulnar styloid. Put the nail beds of thumb at very relaxed and the hand is pressed firmly
90° to the long axis of forearm, one at radial palmarward. The wrist should be in neutral
styloid and other at ulnar styloid. Comparing the position. Assess the laxity by comparing with the
respective levels of these land marks give a normal side. Normally there must be palmar
clinical measure of ulnar variance (Fig. 7.2). translation and if there is any acute pathology in
Figs 7.3A to F: (A) Testing dorsiflexion; (B) Palmar flexion; (C) Ulnar deviation;
(D) Radial deviation; (E) Supination and (F) Pronation
the wrist this normal translation will not happen findings, with emphasis being on asymmetry on
due to spasm of muscles (Fig. 7.4). bi la ter al ex am ina ti on . Th e ma ne uv er is
performed starting with the wrist in slight
Scapholunate (SL) Instabili ty extension and ulnar deviation. The examiner
grasps the wrist from the radial side, placing a
Kirk Watson's Test (Scaphoid Shift Test)
thumb on the palmar prominence of the scaphoid
Scaphoid shift is a provocative maneuver rather while wrapping fingers around the distal radius
than a test, because it does not offer a simple for counterpressure. The wrist is then passively
positive or negative result, but rather a variety of moved into radial deviation and slight flexion by
Fig. 7.4: Pseudostability test Fig. 7.5: Kirk Watson's test
the examiner's other hand. The examiner's thumb articular cartilage. It will also produce symptoms
resists the attempt of the scaphoid tuberosity to when an occult dorsal ganglion or an occult
rotate volarly, creating a dorsally directed scaphoid fracture is present. Because the test
subluxation stress. This subluxation stress causes produces a dorsal displacement of the scaphoid
the proximal pole of the scaphoid to "shift" and traction on the SL ligament, if an occult
dorsally in relation to other bones of the carpus dorsal ganglion is present, the test will generally
and the distal radius even in normal wrists be painful. Likewise, thumb pressure produces
(Fig. 7.5). The degree of the shift is related to the a force that begins on the tuberosity of the
amount of examiner pressure, the degree of scaphoid and travels up the longitudinal axis of
scaphoid flexion, the amount of ligamentous the scaphoid. This test will produce a painful
laxity, and the status of the scapholunate (SL) stimulus if any fracture exists, and should be
ligament. A ruptured SL ligament allows the considered a mandatory test for all cases
proximal pole to move more dorsally and diagnosed as "clinical scaphoid fracture".
frequently rest on the dorsal lip of the radius.
The maneuver is best done with the patient's Scapholunate Test (Shear Test)
wrist flexed, because this causes the scaphoid to One hand of examiner holding the scaphoid,
be angled to such a degree that the proximal pole index finger over the scaphoid tuberosity volarly
may be only partially constrained by the bony and thumb over the dorsum of the scaphoid area,
architecture of the dorsal lip of the radius. As examiner's other hand holding lunate with
the thumb pressure is withdrawn, there may be thumb over the dorsum press the lunate forwards
a palpable "clunk" as the scaphoid returns to its and scaphoid tuberosity dorsally. Abnormal
normal position. Pain that replicates the patient's increased mobility with extreme pain when
symptoms or asymmetrical laxity when compared to the normal side indicates
comparing with the contralateral wrist, are scapholunate instability. The lunate is felt distal
considered significant findings. The scaphoid to Lister's tubercle in mid-dorsum (Fig. 7.6).
shift maneuver is usually considered a test for
SL rupture and scaphoid instability; however, Lunotriquetral (LT) Instability
this test is also important for assessing the The LT Compression Test
articular cartilage status of the proximal pole of
scaphoid and radial facet, with a gritty sensation Load the LT joint in an ulnar-to-radial direction,
or clicking suggesting chondromalacia or loss of eliciting pain with LT instability or degenerative
Fig. 7.6: Scapholunate ballottement test Fig. 7.7: Triquetrolunate ballottement test
joint disease. The examiner's thumb applies a Radiocarpal Instability

radially direct pressure on the triquetrum just
The anteroposterior drawer test can be used to
distal to the ulnar styloid at the "ulnar snuffbox,"
assess for instability of either the radiocarpal or
the space between the tendons of flexor carpi
midcarpal joints. The examiner stabilizes distal
ulnaris and extensor carpi ulnaris. This maneuver
forearm with one hand while the other hand
is similar to the radiocarpal glide test described
grips the metacarpals, applying longitudinal
for radiocarpal instability (Fig. 7.8).
traction and an anteroposterior force.
force . A "drawer"
is elicited though the radiocarpal or midcarpal
Reagan's Shear Test
joint, and compared with the contralateral side.
Thumb dorsally on lunate, index finger applies The radiocarpal glide will test the articular
pressure to triquetrum volarly. This causes pain surface of the proximal carpal row and the
and abnormal mobility in triquetrolunate extrinsic ligaments (Fig. 7.8). The examiner's
ligament injury. thumb exerts a radially directed force on the
triquetrum. A radial shift of the proximal
prox imal carpal
Masquelet's Ballottement Test row relative to the distal radius may be
appreciated in the setting of radiocarpal
Examiner uses both hands to apply shear force
instability. Crepitus may be felt in the setting of
across articulation. Examiner's index finger
articular pathology of the radiocarpal joint.
placed on the pisiform bone volarside, which lies
on the surface of the triquetrum, the other hand
holding the lunate with the thumb on the Midcarpal Instability
dorsum, triquetrolunate joint is stressed
Midcarpal Shift Test of Lichtman
anteroposteriorly. The shear test is assessed for
abnormal mobility and pain, and compared with Normally as the wrist moves from radial to ulnar
the normal side. This indicates triquetrolunate deviation, the proximal carpal row rotates
instability. The landmark for the triquetrum is smoothly from flexion to extension while the
the pisiform bone, which is the most prominent distal row translates from palmar to dorsal. With
bony landmark on volar and ulnar
ulnar aspect of the midcarpal instability, the proximal row remains
wrist (Fig. 7.7). flexed and the distal row remains volarly
translated longer than normal during ulnar ulnar deviated. The test is positive if a painful
deviation. As ulnar deviation progresses, the soft- catch-up clunk occurs with ulnar deviation that
tissue and bony restraints cause a sudden "catch- reproduces the patient's symptoms. The
up" of the proximal row into extension and the presences of palmar translation or a clunk alone
distal row into dorsal translation, which is often without the reproduced symptoms are not
an audible or palpable "clunk". With the wrist in considered positive, because they can occur in
neutral ulnoradial deviation the examiner normal asymptomatic patients (Figs 7.9A and B).
stabilizes the forearm in pronation with one
hand, and with the other hand applies a palmarly ASSESSMENT OF RADIA L WRIST PAIN
directed pressure at the level of the distal capitate,
Pain can be due to scaphoid fracture, non union,
noting the ease and extent of palmar translation.
styloid fracture, SLAC (scapholunate advanced
The wrist is then axially loaded and passively
collapse) lesion, scapholunate instability,
radiocarpal arthritis, scapho-trapezio-trapezoid
arthritis (Triscaphe), trapeziometacarpal arthritis,
tendonitis—de Quervain's tenosynovitis and flexor
carpi radialis tendonitis. Superficial branch radial
neuritis—Wartenberg's
neuritis—Wartenbe rg's chieralgia characterized by
pain and tenderness 1 to 2 cm proximal to the radial
styloid, and radicular pain distally along the course
of the superficial radial nerve elicited by percussion.
Pain in this structure is much more likely related
to a traumatic neuroma, peritendinitis crepitans
(intersection syndrome).
Palpate the distal palmar tuberosity of the
scaphoid. Curl one's fingers about the radial aspect
to the dorsum of the patient's wrist
wris t while the thumb
Fig. 7.8: Radiocarpal glide test is palmar and points distally (Fig. 7.10). This is
(For color version, see Plate 2) located immediately proximal to the thenar
A B
Figs 7.9A
7.9A and B: Midcarpal shift test (For color version, see Plate 3)
eminence and immediately radial to the flexor carpi Immediately radial to this point and distal to
radialis tendon. Use the opposite hand to move
m ove the the scaphoid tuberosity is the scaphotrapezial
patient's hand/wrist unit into flexion-extension and (ST) joint. At this location, place your thumb nail
radioulnar deviation. If one is palpating the distal transversely and at 90° to the long axis of the
pole of the scaphoid, this small bony lump will forearm. Ask the patient to move his thumb.
move, demonstrating that it is part of the carpus There will be an appreciation of movement
and not the radius. More importantly, the distal distally while the scaphoid tuberosity remains
pole will become prominent palmarly with wrist still. This will be useful for localizing pain related
flexion and with radial deviation as the scaphoid to ST arthritis, a common cause of radial palmar
rotates into flexion. wrist pain, and to localize the entry point for an
Adjacent and immediately ulnar to the injection into that joint.
scaphoid tuberosity is the tendon of the flexor
carpi radialis (FCR). This can often be visualized Finkelstein' s Test Test
proximally, and if' not, it can be palpated. Follow
De Quervain's tenosynovitis is assessed by thumb
it proximally by laying three fingers on it while
in palm and ulnar deviation of the wrist. This causes
palmar and dorsiflexing a clenched fist. FCR
pain over the radial styloid region and along the
tendonitis can manifest as tenderness upon
tendon sheath. The first dorsal compartment, which
palpation distally near the fibro-osseous tunnel
has abductor pollicis longus and extensor pollicis
in the trapezium as it dives to insert into the base
brevis gets
brevis gets infl
inflame
amedd (Fig. 7.11).
of the second metacarpal. There is usually
Intersection syndrome, also known as
localized pain with hyperextension of the wrist
peritendonitis crepitans, is an overuse condition
caused by tendon stretch and with resisted wrist
resulting in inflammation in the area where the
flexion and radial deviation.
muscle bellies of the APL and EPB cross the
underlying extensor carpi radialis longus (ECRL)
and brevis (ECRB) tendons. The underlying
pathologic abnormalities include stenosing
tenosynovitis of the tendon sheath of ECRL and
ECRB tendons or APL bursitis. It presents as pain,
swelling, tenderness, and crepitus in the
radiodorsal forearm about 4 cm proximal to the
Fig. 7.10: Palpation of distal tuberosity of scaphoid

(For color version, see Plate 3) Fig. 7.11: Finkelstein test
tip of the radial styloid, corresponding to the The dorsal border is formed by the combined
intersection of the first and second extensor second and third compartments. The proximal
compartments. Finklestein's test is often painful border is the distal radius and the distal border
with APL bursitis, although the pain is usually the base of the first and second metacarpals.
more proximal in the radiodorsal forearm. Spend a moment and find these limits. The
snuffbox contains fat, the radial artery traversing
Grindi ng Test obliquely, and the wrist joint capsule. Through
this capsule the waist of the scaphoid can be
Axial loading of the first metacarpal and twisting
readily felt when the wrist is ulnarly deviated.
around causes severe pain and crepitus in
The junctional point along the radial border of
trapeziometacarpal arthritis (Fig. 7.12). Usually
the scaphoid, where the proximal articular
this is accompanied by palpable crepitus and a
surface changes to nonarticular surface, is
painful sensation. If the subluxation is more than
referred to as the scaphoid articular-nonarticular
2 or 3 mm, the outline of the thumb will form a
(ANA) junction. With the wrist in ulnar
slight step, called the "shoulder sign".
deviation, the ANA junction can be palpated with
the examiner's index finger placed just distal to
Scaphoid Pathology
the radial styloid. Whereas mild tenderness is
Tenderness in anatomical snuffbox and axial present there in normal wrists, scaphoid instability
loading of first metacarpal can cause pain at or synovitis is said to result in more severe pain.
dorsoradial aspect of wrist. Examiner's index Asymmetry on bilateral examination is important.
finger palpating just distal to radial styloid with Move to the dorsal border of the snuffbox and
wrist moved passively from radial to ulnar realize that this border consists of both superficial
deviation can palpate articular/non-articular and deep components. The extensor pollicis longus
junction of scaphoid. It is painful in scaphoid (EPL) forms the superficial border and heads
nonunion, periscaphoid synovitis, scaphoid toward the thumb. Deep to this is the ECRL tendon.
instability or SLAC changes at styloid. Extend the interphalangeal (IP) joint of the thumb
and feel the EPL. Dorsiflex the wrist and feel the
The Snuffbox ECRL. Follow the ECRL distally to its insertion in
bone. Make a clenched fist and put the tip of the
Distally in the snuffbox, the palmar border is
index finger into the V that forms distally between
formed by the first dorsal compartment tendons.
the ECRL and ECRB. Extend the IP joint and abduct
the thumb. The EPL should stand out visibly and
be easily palpable through its course to the mid-
dorsal radius, where it courses about the ulnar
aspect of Lister's tubercle. Feel this definite short
oblong bump with the tendon moving next to it.
Feel the beginning of the radiocarpal joint just 2 to
3 mm distal to this tubercle. Move the wrist into
dorsi and palmar flexion and be certain that the
"lump" remains stationary.
Next, hold the hand and apply thumb pressure
in the interval between the two arms of the V made
by the ECRL and ECRB. Flex and extend the wrist.
In flexion, appreciate a smooth firm bump becoming
Fig. 7.12: Grinding test prominent in this interval. This is the dorsal proximal
pole of the scaphoid covered by capsule. It should

be firm and not painful to press on. Scaphoid
impaction is a condition in which repetitive
hyperextension of the wrist causes impingement of
the scaphoid onto the dorsal lip of the radius. A
tender dorsal osteophyte or spur on the dorsal radial
lip or dorsal scaphoid rim may be palpable, and
extension of the wrist may be limited or painful.
STT (scapho-trapezio-trapezoid) joint pathology: This
joint is felt by following the course of 2nd
metacarpal proximally with examiner's thumb until
it falls into a recess. It is painful in STT synovitis, Fig. 7.13: TFCC test
degenerative disease or other scaphoid pathology.
of wrist (Fig. 7.13). This "grind test" will be positive
Scapholunate joint pathology: Follow the course of
in ulnocarpal impaction or TFCC tear.
3rd metacarpal proximally until the examiner's
With the forearm pronated, palpate ulnar and
thumb falls into a recess over capitate.
distal to the ulnar head. Deviate the wrist radial
Scapholunate joint is just proximal between
and ulnar, and feel the tendon of the extensor
extensor carpi radialis brevis and 4th dorsal
carpi ulnaris (ECU) become prominent on ulnar
compartment. It is tender in Keinbock's disease
deviation. Trace this tendon distally to its
and scapholunate dissociation.
insertion into the dorsoulnar base of the fifth
metacarpal. Tenderness along the tendon sheath
ASSESSMENT OF ULNA R WRIST PAIN
indicates tendonitis.
The conditions that may cause ulnar wrist pain The ulnar styloid (US) is best felt when the
are triangular fibrocartilage complex injuries forearm is pronated. It is distal to the ulnar head
(TFCC) more common in radial fracture and palmar to the ECU. It is slightly obscured by
malunion, tendonitis, ulna-carpal abutment the ECU when the forearm is supinated. It should
syndrome or impaction syndrome, pisotriquetral not be tender to palpate unless there has been a
arthritis, triquetrolunate instability (VISI), recent fracture or ulnar styloid-triquetral
hamate fracture, extensor carpi ulnaris impaction (USTI) is present. To search for clinical
subluxation and caput-ulna in rheumatoid support for this diagnosis, a USTI provocative test
arthritis. is performed. This USTI test is based on the fact
Triangular fibrocartilage complex (TFCC) that the US is ulnar in pronation, and is more
consists of articular disk, meniscus homologue, central and dorsal in supination. Thus it is evident
ulnar carpal ligament, dorsal and volar radioulnar that to approximate the US to the triquetrum, one
ligaments, and extensor carpi ulnaris sheath. It needs to bring the US closer to the carpus by
is important in loading and stabilizing the supinating the forearm, and bring the carpus
distal radioulnar joint. It can get torn due to closer the wrist dorsiflexed and the forearm
degeneration or trauma. This is assessed by elbow pronated, and simply add one motion, supination,
resting on the table, holding the hand in 'shake- while maintaining dorsiflexion (Fig. 7.14). To
hand position', the other hand supporting the support the diagnosis the US should also be tender
forearm apply axial load in ulnar deviation of the exactly over its tip. This is tested in pronation and
hand and do supination-pronation movement. neutral wrist flexion. The patient may indicate
This produces extreme pain on the ulnar aspect from the history that this test produces pain. The
Fig. 7.14: USTI provocative test (For color version, see Plate 3)
pain with the hand in the back pocket, repetitive Fourth and Fifth Extensor Compartment
page turning, or the distal supinated hand on the
The extensor digitorum communis (EDC) tendons
ice hockey stick may be historical evidence of a
(fourth compartment) and their tenosynovium is
positive USTI provocative test.
easily appreciated by flexing and extending the
The lunotriquetral (LT) joint can be localized,
fingers at the MCP joints. This can be done as a
it is a depression just distal to the radial side of
unit, but is better appreciated if done in rhythmical
the ulnar styloid, because the head of the ulna
consecutive fashion. Similarly, place the fingers
articulates with one half of the lunate and one
in a "piccolo" fashion longitudinally between the
half of the triquetrum. Direct palpation of the LT
EDC and head of ulna, and flex and extend the
joint may be tender when LT pathology is
little digit. The tendon of the extensor digiti minimi
present.
(EDM) can be felt moving. Tenosynovitis is a
common source of pain, swelling, and tenderness
ASSESSMENT OF DORSAL WRIST PAIN
in the dorsuin of the wrist. Ganglion cysts and
Scapholunate Interval vestigial wrist extensor muscles (extensor
digitorum brevis minus) are less common but may
Move ulnarly and place your thumb just distal to the have a similar presentation.
dorsal lip of radius in line with the long metacarpal.
Flex and extend the wrist and feel a poorly defined Carpometacarpal Joints
hard lump becoming prominent in flexion. This is
the dorsal pole of lunate. It is covered by capsule, Sprains of the second through fifth CMC joints
extensor digitorum longus, tenosynovium, and can be associated with localized tenderness and
retinaculum, and is not felt very distinctly-but it is swelling. Stressing the joint by flexion, extension,
felt. Pressure on this area is generally not painful and rotational forces may add additional
unless a fracture or Kienbock's disease is present. information. A bony prominence at the base of
Appreciate the hard fullness felt with palmar flexion, second or third metacarpal, often involving the
and move back and forth between the dorsal pole of CMC joints, is called a carpal boss. The cause and
the lunate and proximal pole of the scaphoid. Palpate significance of this prominence is unknown, and
the intervening SL area. Appreciate the slight valley caution is suggested when considering any
that exists. This area should not be painful unless there surgical treatment.
is a recent SL ligament tear or a chronic occult Ganglion: It is a cystic, well-localized swelling with
ganglion. This is usually the area where the dorsal positive transillumination test. Dorsal ganglion
ganglion becomes obvious. results from cystic myxomatous degeneration
within the dorsal scapholunate ligament and may Palpate the flexor carpi ulnaris (FCU)
be related to scapholunate instability. proximally from the pisiform. It is most prominent
by having the patient make a clenched fist during
Keinbock's disease: It is avascular necrosis of the
mild wrist flexion. Tenderness along the tendon
lunate and is associated with ulna minus variant.
sheath or pain and weakness with resisted wrist
Clinically patient will have tenderness on mid-
flexion and ulnar deviation suggest tendonitis.
dorsum over the lunate bone.
With the tip of the thumb on the radial palmar
side of the pisiform, add deep pressure. The
ASSESSMENT OF PAL MAR WRIST PAIN
uncomfortable sensation is related to pressure on
In the palmar ulnar aspect hold the pisiform the ulnar nerve. Although one cannot objectively feel
between the index finger and thumb. Flex and this nerve, this means of localization will be of value
extend the wrist and move the pisiform medially for assessing symptoms or injecting local anesthetic.
and laterally while applying dorsally directed The palmaris longus (PL) tendon is central
pressure, compressing the pisiform on the and superficial in the palmar distal forearm. It
triquetrum, to search for articular cartilage stands out with a flexed grip, and can be
crepitus or pain associated with pisotriquetral visualized and palpated. It may be absent. At the
degenerative joint disease. This is referred to as wrist crease between the PL and FCR, an astute
the pisotriquetral grind test (Fig. 7.15). examiner can often palpate it fine snapping of
Palpate the hook of the hamate just distal and the palmar cutaneous branch of the median
radial from the pisiform. It is localized by placing nerve. This subtle finding is aided by tensioning
the IP joint of the examiner's thumb over the more the nerve with dorsiflexion of the wrist and then
superficial pisiform, with the tip of the thumb drawing the tip of the examining digit across the
directed toward the metacarpal head of the long interval with slight deep pressure. Finally,
finger. Deep palpation with the tip of the circumferential wrist compression with the
examiner's thumb reveals the hook of the hamate. thumb and index will produce pain when a
This can be tender in the setting of fracture or synovitis and effusion is present.
nonunion of the hook of the hamate. Remember Palmar wrist pain can be from palmar ganglion
that this is the area of the ulnar nerve, and deep that arises from scaphotrapezial ligament or a
palpation onto this nerve is usually painful. compound palmar ganglion from radial bursitis
in rheumatoid or tuberculous synovitis (presence
of cross-fluctuation proximal and distal to flexor
retinaculum). Rarely it can be referred pain.
ASSESSMENT OF DISTAL RADIOULNAR

JOINT (DRUJ)
Tenderness over distal radioulnar joint with

subluxation of the ulnar head dorsally indicates
DRUJ pathology.
Shear Test or Distal Ulna Ballottement Test

(Fig. 7.16)
Holding the distal end of radius and ulna with
Fig. 7.15: Pisotriquetral grind test thumb and fingers of each hand individually
(For color version, see Plate 4) elicit shearing movement, this causes pain in
Fig. 7.16: DRUJ test Fig. 7.17: Carpal compression test
degenerative changes, chondromalacia or diagnostic which elicits pain and

osteochondral injuries. paresthesia along the median nerve
distribution. This test is more sensitive than
Ulnar Compressi on Test Phalen's test (Fig. 7.17).
It can also be confirmed by pressing ulnar head 3. Phalen's test keeping the wrist flexed for 30
against the sigmoid notch by spring test of distal seconds elicits pain and paresthesia along the
radius and ulna or test supination/pronation median nerve distribution (Fig. 7.18).
with DRUJ squeezed together. 4. Wasting of thenar muscles and hypoesthesia
on radial three and half fingers of the hand
Piano K ey Test can be present in long-standing cases.
5. Strength of abductor pollicis brevis is assessed
The examiner depresses the ulnar head palmarly by keeping the hand flat with the palm facing
while the pisiform is stabilized with a dorsally up and asking the patient to touch the tip of
directed force. A positive piano key sign is when the examiner's finger with the thumb in the
the ulnar head springs back into position like a plane of abduction and feel for muscle.
piano key when the forces are released. Pressing 6. Opponens pollicis is tested by making the
the dorsum of the ulna with one finger elicits pain thumb tip opposed to little finger and assessing
at DRUJ. the ability to keep opposed against resistance.
7. The sensation over thenar eminence will be
Differential Lig nocaine Injectio n Test
normal as it is supplied by palmar cutaneous
Differential Lignocaine Injections can be branch of median nerve.
Incorporated into the Physical Examination to
Help Localize the Source of Pain Colles' Fracture
SPECIFIC CONDITIONS Fracture of the distal radius at corticocancellous

ju ncti on (2 cm from th e arti cula r surface)
Carpal Tunnel Syndrom e characterized by dorsal displacement, dorsal tilt,
1. Tinel's sign may be elicited over median nerve. lateral displacement, lateral tilt, impaction and
2. Direct carpal compression test is most supination of distal fragment.
Clinically it manifests with pain, swelling, Tendonitis

bruise, limitation of movements and dinner-fork In tendonitis or tenosynovitis there is oblong or
deformity. It is a common fracture in the elderly longitudinal swelling along the course of the
population from fall on outstretched hand due tendon, stretching the tendon passively can be
to osteoporosis. Complications include Sudeck's painful and soft crepitus can be elicited on flexion
atrophy, extensor pollicis longus rupture, and extension movements, e.g. extensor carpi
malunion, nonunion and post-traumatic stiffness. ulnaris or flexor carpi ulnaris tendonitis.
Smith Fracture
Gamekeeper's Thum b or Skier's Thumb
Fracture of distal radius at metaphysis with volar (Fig. 7.20)
displacement or tilt of the fragment. Ulnar collateral ligament injury of thumb that
usually tears at its distal attachment to the proximal
Barton's Fracture
Intra-articular fracture of the distal radius with
displacement of the carpus along with the distal
intra-articular fragment. It can be of volar or
dorsal displacement.
Malunited distal radius (Fig. 7.19): Malunited distal
radius manifests with deformity and thickening
of the radius. The levels of styloid of the radius
and ulna are assessed. Both styloids are at same
level or radial styloid is more proximal than ulna
due to shortening of radius. Distal radioulnar joint
is assessed as described earlier. Movements are
limited depending on the tilt of the distal fragment
and intra-articular extension. For example, a
dorsally tilted articular surface of the distal radius Fig. 7.19: Malunited Colles’ fracture with X-ray showing
limits palmar flexion and may have excessive gross radius shortening, radial deviation and flexion
dorsiflexion as the arc of movement has changed. deformity of the wrist
Fig. 7.18: Phalen's test Fig. 7.20: Gamekeeper's thumb

phalanx. The ligament can become displaced Radial Club Hand

outside of the adductor aponeurosis (Stener's Radial agenesis may be total or partial
lesion) and cannot heal without operative longitudinal deficiency. Radial deviation of wrist
intervention. Avulsion fracture is treated according due to absent or partially developed radius and
to the displacement. Clinically this injury can be hand with absence of radial carpus or thumb ray
identified by pain, swelling and tenderness at ulnar can be present.
aspect of base of the thumb. On valgus stress test It can be associated with Holt-Oram
in 30° flexion of MCP joint the joint opens up. This syndrome, TAR (thrombocytopenia absent
leads on to chronic instability compromising pinch radius) or VATER (Vertebral anomalies, anal
grip when the thumb is stressed in abduction and anomalies, tracheoesophageal fistula, and renal
hence functional disability. Compare with opposite anomalies) syndromes. Elbow mobility decides
thumb for abnormal movement on valgus stress. the management. Good elbow movements is a
In acute painful situation infiltration of local prerequisite for centralization procedures to
anesthesia and valgus stress confirming with stress ensure hand to mouth feeding.
X-ray may be of good help.
Carpal Bos s
Madelung's Deformity
Benign bony hard swelling at the 2nd or 3rd
Manus varus and flexus deformity of the wrist due carpometacarpal joint dorsally.
to developmental abnormality of distal radius
physis. The volar and ulnar aspect of epiphyseal Ganglion
plate growth is disturbed resulting in this Myxomatous degeneration of capsule or tendon
deformity. This can be from dysplasia (develop- sheath resulting in tense globular swelling
mental), trauma, infection and metabolic causes. usually in the mid dorsum of wrist (from
The developmental type is more common in scapholunate dorsal ligament). Cystic swelling
females, usually bilateral and can be asymptomatic. with positive cross fluctuation test or Paget's test.
The patient can present with wrist pain, deformity Volar ganglion is common over radial aspect
or weak grip strength. Clinically there is dorsal from radioscaphoid joint.
bayonet like deformity of radius with shortening
and dorsal prominence of head of ulna which is Wrist Synoviti s
relatively long. Limitation of dorsiflexion and
increased flexion of the wrist can be demonstrated. Diffuse swelling and tenderness all round the
TFCC tears are common and can cause pain, and joi nt ca n be from rheu mat oi d sy no vi tis,
this can be confirmed with stress test. tuberculosis and rarely secondary osteoarthritis.
8 Examination of Hand
CHAPTER
The primary function of the hand is sensation and pinch (key pinch), tip pinch, chuck pinch, hook and fist
grasping. The dexterity and functions like grasp, side are important for day-to-day activities (Figs 1A to E).
Figs 8.1A to E: Different types of hand grips: (A) Tip pinch; (B) Side pinch; (C) Chuck pinch;
(D) Hook grasp, and (E) Power grasp (For color version, see Plate 4)
Examination of Hand 67
As in any upper limb problem the history perspire. Nail changes can be pitting from
should include: psoriasis, medical clubbing, splinter hemorrhages
a. Dominant hand indicating vasculitis and sometimes extremely
b. Occupation painful subungual glomus tumors appearing as
c. Functional impairment as seen in job, daily spot of purplish blue under the nail.
activities of eating, dressing, perineal Look for the normal attitude of the hand. Any
hygiene, fastening button, turning a tap, deviation may be due to tendon injury or rotation
using a key, holding a cup, opening jars, etc. from fractures (Fig. 8.2).
d. Involvement of other joints. Loss of skin creases can be from swelling or
Patient can complain of pain, swelling, post-traumatic sympathetic dystrophy or
stiffness, deformity, paresthesia, numbness, arthrogryposis multiplex congenita.
weakness of hand and patient's expectation must Deformities are zig-zag pattern in inflam-
be known. In acute trauma, always document the matory joint disease. They can be:
time, site, and description of the accident. Record 1. Dorsal subluxation of ulna at distal radioulnar
the type of injury as cuts, crush injuries, saw joint (Fig. 8.3).
accidents, chemical or electric burns, bite wounds 2. Palmar subluxation of the radiocarpal joint.
and closed trauma. A thorough history will 3. Radial deviation of metacarpals.
provide sufficient information for a tentative 4. Ulnar deviation of fingers (Fig. 8.4).
diagnosis. For example, altered sensation and 5. Boutonnière deformity of fingers (PIPJ flexion
weakness in the index and middle finger and DIPJ extension) (Fig. 8.5).
accompanied by night time paresthesia is typical 6. Swan neck deformity (PIPJ extension, DIPJ
of carpal tunnel syndrome. Sudden painful flexion and sometimes MCPJ flexion) (Fig. 8.5).
snapping over the metacarpal heads when flexing 7. Thumb deformities: MCPJ flexed, IPJ
and extending the finger is typical of trigger finger. extended; MCPJ extended and IPJ flexed.
Expose whole of both upper limbs. Screen the 8. Z deformity CMCJ adducted and subluxed.
neck, shoulder and elbows especially in 9. Dropped fingers: Inability to extend little or
rheumatoid arthritis. Ask the patient to do neck
ring finger (Vaughen-Jackson syndrome) due
movements, lift both hands above shoulder, flex
to extensor tendon rupture from dorsal
and extend elbows, supinate and pronate
subluxation of ulna.
forearm, and palmarflex and dorsiflex wrist. This
gives a useful quick screening of the above joints.
LOOK
From proximal to distal and in pronation and
supination of the hand. Comment on the skin
condition, color—localized hyperemia and
erythema in infection of hand, hyperpigmentation
of palmar furrows in Addison disease, shiny
atrophic skin in progressive scleroderma, attitude,
swellings, scars, muscle wasting, pulp and nail
changes, vasculitis, deformities, rheumatoid
nodules, Heberden's nodes (degenerative joint
disease of DIPJ) and Bouchard's nodes (degene-
rative joint disease of PIPJ). Dry scaly skin is a sign Fig. 8.2: Normal attitude of hand: Increasing flexion
of loss of nerve function because of inability to attitude of ulnar fingers (For color version, see Plate 5)
Fig. 8.3: Dorsal subluxation of ulna at distal

radioulnar joint (For color version, see Plate 5)
Fig. 8.5: Claw hand, boutonnière and swan neck

deformity of index finger
d. Check by passive movement, the fixed

deformity or lag. If there is a deformity, check
whether the deformity is same in all positions
Fig. 8.4: Ulnar deviation of fingers of adjacent joints.
e. Fine crepitus in synovitis and snapping sound
in trigger finger.
10. Mallet finger: DIPJ is flexed and patient is f. Grip strength and fine pinch—This can be
unable to actively extend tip of the finger, but assessed using a dynamometer or simply by
passive movement is possible. This is due to asking the patient to squeeze the examiner's
rupture of extensor tendon resulting from finger in his hand.
trauma, inflammation, degeneration or Check pinch grip by holding a key or coin.
avulsion fracture. g. Neurological examination.
FEEL MOVE
a. Tenderness—define the exact anatomical area. Check the active range of movements and pain
b. Swelling—examine in usual manner. on movements and then passive movements.
c. Synovial thickening—Pinch the skin on the At wrist check for active supination,
volar aspect of proximal phalanx, inability to pronation, palmar-flexion, dorsiflexion, radial
pinch indicates tenosynovitis (Bovier's sign). and ulnar deviation.
At fingers check for active flexion, extension,

abduction and adduction.
MCPJ moves from 0 to 90°; PIPJ from 0 to 110°;
and DIPJ from 0 to 90°.
Check individual flexor tendon and extensor
tendon function for tendon injury or nerve injury.
Differences in active and passive ranges of
motion according to the position of the joint,
narrow the differential diagnosis. For example,
equal limitations in the active and passive ranges
of motion of a joint, regardless of the position of
the joint, are a sign of shortening of capsule and
ligaments or intra-articular incongruity. An Fig. 8.6: Claw hand
extension deficit in a PIPJ that does not change
as MCPJ moves is a sign of adhesion of the flexor Intrinsic Plus or Tightness of Hand
tendon at the level of MCPJ. Adhesion of the
extensor tendon in the forearm prevents flexion The deformity is flexion of MCPJ and extension
in the wrist when the patient makes a fist; of IPJ. This results from tightness or contracture
adhesions of the flexor tendons prevent extension of the intrinsics due to ischemia or inflammation
with fingers extended. Impairment of active as in rheumatoid arthritis. Bunnel's test is done to
movement of only one finger is a sign of a tendon identify the tightness. PIPJ flexion movement is
rupture or a neurological lesion. limited with MCPJ in extension and becomes more
At thumb check for flexion, extension, with MCPJ in flexion. In rheumatoid patient,
adduction, abduction and circumduction. reduce the MCPJ subluxation and correct ulnar
Joint stability is tested by stressing the deviation before testing for intrinsic tightness.
collateral ligaments, for example in game
keeper's thumb radial deviation of thumb is done Quadrigia Effect
to assess ulnar collateral ligament of MCPJ. It presents with loss of maximum active flexion
and decreased grip strength in adjacent digits. This
SPECIFIC CONDITIONS occurs in flexor digitorum profundus (FDP)
lacerations distal to lumbrical origin resulting in
Claw Hand o r Intri nsic Minus Hand (Fig. 8.6)
tight lumbricals than extrinsics, or digital
The deformity is hyperextension of MCPJ and amputation where flexors are sutured to extensors
flexion of PIPJ. This results from intrinsic muscles or in tenodesis of FDP or poor flexor tendon
(interossei and lumbricals) paralysis in ulnar repairs. This occurs due to mass action of FDP as
nerve palsy (little and ring finger), median nerve a single unit to flex the tip of the fingers and if one
palsy (middle and index finger), Volkmann's finger FDP is affected, the other fingers cannot flex
ischemic contracture of hand and Charcot-Marie- fully. FDP tendon to ulnar 3 fingers share the same
Tooth disease. muscle belly thus any block in FDP action in one
of the ulnar 3 fingers the other two cannot flex.
Differential Diagnosis
Swan-neck Deformity
1. Post-traumatic contracture
2. Dupuytren's contracture There is hyperextension of PIPJ and flexion of
3. Camptodactyly DIPJ. It is caused by dorsal subluxation of the
lateral band following FDS dysfunction interosseous nerve palsy), subluxation of extensor
(rheumatoid hand or lacerations) or volar plate tendon over the ulnar side in rheumatoid arthritis
injury. or rupture at wrist (little or ring finger) due to
ulnar head subluxation in rheumatoid (Vaughen
Boutonnière Deformity or Butto nhole Jackson syndrome). The intactness of extensor
Deformity tendon can be confirmed either by tenodesis test,
dropped finger extends on palmar flexion of the
There is flexion of PIPJ and hyperextension of
wrist or by asking the patient to maintain
DIPJ, resulting from central slip rupture and
extension after passive correction.
volar subluxation of lateral bands. It can be due
to injury or inflammation.
Jersey Finger
Camptodactyly Rupture of FDP tendon from insertion at distal
phalanx usually involving ring finger in sports
There is flexion deformity of PIPJ, usually of the
injuries or shirt pulling injury.
little finger. It is hereditary and is painless and
progressive. In children the deformity disappears
Snapping Tendon
when the wrist is flexed but after adolescence the
deformity increases rapidly and becomes fixed On flexing the finger patient may notice snapping
by contracture of skin and ligaments. of extensor tendon over the MCPJ. It is due to
disruption of juncture tendon or saggital bands.
Clinodactyly
Giant Cell Tumor of Tendon Sheath
There is radial deviation of terminal phalanx of
5th digit. It is familial and characterized by normal Isolated solid swelling especially over volar aspect
bone structure and no periarticular swelling. of flexor tendon sheath of the base of the finger.
Trigg er Finger Ac ro meg aly

Triggering of fingers, commonly ring finger is Disproportionately large thick set, stoicky hand
due to difficulty of flexor tendon to negotiate into is suggestive of acromegaly. One must look for
A1 pulley of fibrous flexor sheath. This may be prognathism.
due to nodular thickening of the FDS tendon or
narrowing of the opening of the fibrous flexor Dupuyt ren's Cont racture (Fig. 8.7)
sheath. Patient typically develops difficulty in
It is proliferative fibrositis involving the palmar
bending and straightening the finger with
aponeurosis of hand, resulting in puckering of
sudden painful unlocking at the base of the finger
skin, nodular thickening and may progress to
on active extension after a catch.
fibrous longitudinal bands.
It can be due to repetitive strain or
History of onset, progression, previous
inflammatory disease or diabetes or congenital
surgery for same problem, anticonvulsant
as in the thumb (30% spontaneous recovery by
medication, family history and functional
the age of 1 year).
disability are important.
a. Look at both hands for presence of flexion
Dropped Finger
deformity usually of MCPJ, PIPJ and rarely
It can be due to rupture of extensor tendon due DIPJ of little and ring finger, nodular
to laceration, paralysis (radial or posterior thickening or puckering of skin in the palm.
For example, laceration at the volar aspect,

base of middle finger, (Zone II) due to holding
a knife with a clenched fist can result in injury
to skin, nerves, blood vessels, FDS, FDP, and
sometimes bone. The level of flexor tendon
laceration will differ on extension of the fingers.
The FDP laceration is more distal to FDS
laceration; this can be easily missed if we do not
know the position of the hand at the time of
injury.
Skin
Assess the extent of the damage, presence of skin
Fig. 8.7: Dupuytren’s contracture little finger loss and soft tissue damage and need for any local
flaps.
b. Look at dorsum of hand for knuckle pads,
which is usually on one PIPJ. Vascularity
c. Dupuytren's diathesis-familial predisposition This is assessed as discussed by Allen's test, both
of some patients with multiple areas of at wrist and fingers.
involvement and early onset of the disease.
Look for Peyronie's disease (chordee), plantar Tendons
fibromatosis and knuckle pads. Test the anatomical sites for tendons that are
d. Feel for tenderness (usually painless). liable for injury at that spot. Visible laceration in
e. Active and passive movements of fingers. the tendon, more than 30-40 percent of the
f. Distal neurovascular examination. substance needs exploration. Division of both
g. Heuston's tabletop test is used to decide when flexor tendons to a digit result in pointing sign.
to operate. The patient is asked to keep the
palm flat on the table and if the patient's palm Nerves
cannot touch the flat surface of the table i. Sensory examination: Check for touch using a
evenly because of the flexion deformity of the cotton swab or the tip of your finger and
finger, it indicates the severity of flexion pinprick sensations for any nerve damage.
contracture and the need for surgery. Running the ballpoint pen barrel across the
digit can make out lack of sweating distal to
EXAMINATION OF THE HAND WITH
the site of injury. In a normal finger it will
LACERATIONS
adhere and drags, in denervated digit the pen
Mechanism of the Injury runs smoothly. Fingertip should be examined
for two-point discrimination, less than 6 mm
The injury and anatomical structures at the site is normal but it varies with age.
of lacerations must be thoroughly examined. ii. Motor examination for muscles supplied by the
Palmar lesions involve flexor tendons and nerve.
neurovascular structures; dorsal lesions usually
involve extensor tendons, bones and joints. Axial Skeletal System
and rotational defects provide information about
fractures and dislocations. It is important to Examine for fractures, open joint injuries and
evaluate the degree of contamination. dislocations.
In examining a major crush injury of the hand TRAUMATIC AMPUTATIONS AND

it is better to give regional anesthesia to make MICROSURGERY
the patient comfortable for assessing the extent Assessment and patient selection is important by
of the damage and for debridement, but always clinical judgment for replantation. Patients
check for nerve injuries and distal vascularity should be referred to appropriate microsurgery
before hand. center if they satisfy the criteria.
In treating major injuries, the order of
importance is: Nature of Injur y
1. Circulation, reduction of dislocation or
realigning the twisted finger. Sharp amputation is better than crush or avulsion
2. To provide skin cover. injuries. Multiple level cuts are unsuitable for
3. Adequately align bones and joints. replantation.
4. Tendon and nerve function.
Level of Injury
Partial transection of the vessel can result in
life-threatening bleeding; no blind clamping Better results are with distal forearm to hand
should be done as it may injure the nerves. amputations. Amputation at proximal phalanx
High-pressure injection injuries (industrial level leads to poor flexor tendon function.
accidents, lead paint) may present with very
small punctured wound, but this needs Ag e
aggressive treatment with extensive debridement Children do better. Very elderly with not much
and wound should be left open. demand, need not have replantation.
Late presentation with healed laceration, one
should examine for damage of tendons, nerves, Indications
vessels, bones and adjacent joint stiffness.
Multiple digit injury, thumb amputation proximal
Reflex Sympathetic Dystrophy or Complex to IP joint, amputations in children, clean
Regional Pain Syndrome (Types I and II) amputations at hand, wrist or distal forearm.
Reflex sympathetic dystrophy is a neurological
dysfunction characterized by burning pain, Ab so lu te Co nt rai nd ic ati on s
swelling, stiffness and discoloration due to Severe injuries or associated medical problems,
vasomotor disturbance. The pain can be out of multiple level injury of the amputated part,
proportion to the nature of injury. It goes through refusal to abstain from smoking for at least 3
three phases. months postoperation, and psychotic patients.
Stage-i Acute phase (0 to 3 months) characterized The amputated part should be transported in
by swelling, pain, warmth and stiffness. X-ray a cool pack with no direct contact with the ice.
can be normal, triple phase bone scan shows
increased uptake in early and late phases. HAND INFECTIONS
Paronychia
Stage-ii Dystrophy (3 to 6 months) characterized
by glossy skin, change in pain, cool, It is the infection of the nail bed. Usually inside the
contractures. nail fold, characterized by pain, swelling, and redness.
Stage-iii Atrophic (6 to 9 months) characterized
Felon
by tight skin, contractures and diffuse punctate
osteopenia on X-ray. Subcutaneous abscess of distal pulp.
Suppurative Flexor Tenosynovitis Midpalmar Infectio n

Suppurative flexor tenosynovitis is the infection Results in loss of midline contour, pain on
of the flexor tendon sheath. It presents with movement of middle, ring and little finger.
Kanavel's four cardinal signs—pain on passive
extension, finger in flexed position, severe Web Space Infection
tenderness along the tendon sheath and sausage
digit. The infection can spread into the deep Web space infection can result in web space
spaces—small finger infection can spread to ulna inflammation, with widening and collar stud
bursa, index and thumb infection can spread to abscess.
the thenar space, middle, ring and small finger
infection can spread to the midpalmar space. Human Bite
This results in serious soft tissue and bone
Thenar Space Infection infection, more common after punching injuries
Patient will have pain, swelling over the thenar over knuckles, especially III and IV MCPJ. The
eminence with painful flexion of the thumb and wound may be deceptive, and should be
the index finger. explored in the theater and debrided.
9 Examination of Peripheral
CHAPTER Nerves and Brachial Plexus
The presentation of peripheral nerve problem can Troph ic Changes

be of deformity, loss of function, neurological
Pulp atrophy, loss of hair, loss of sweating,
symptoms and sometimes neuralgic pain. The
trophic ulcers.
onset, nature of any injury, progression and other
relevant histories must be documented as
discussed before. Patient’s expectation must be
known. Neurological examination is done by
testing individual components of motor, sensory
(sympathetic and cutaneous sensation) and reflex
changes to identify the level of lesion.
Cut injury wounds or other injuries causing
nerve damage should be examined for associated
tendon or muscle damage, vascular damage and
bony involvement in addition to contamination.
Expose the patient fully rather than exposing
only the involved region.
For example, a nerve palsy of hand could be
due to cut injury or surgery in the neck. Patient Fig. 9.1: Erb’s palsy
should be undressed to expose the whole of upper
arm and the neck to look for any scars or wounds.
LOOK
At ti tu de o f t he L im b
Example: Erb’s palsy patient may keep the arm
in “Waiter’s tip position” (Fig. 9.1).
Deformity
Example: Clawing in ulnar nerve and median nerve
palsy or isolated ulnar nerve palsy. Wrist drop or
fingers drop in radial nerve palsy
(Fig. 9.2). Foot drop in lateral popliteal nerve palsy. Fig. 9.2: Wrist drop
Examination of Peripheral Nerves and Brachial Plexus 75
Muscle Wastin g most tender area. The trigger spot causing

burning or sharp pain distally due to nerve
Profound wasting of denervated muscles in
irritation can be identified. Tenderness along the
chronic condition.
course of the nerve should be sought.
Condition of Skin and Soft Tissues
Swelling
Healed scars, cuts or punctured wounds along
course of nerve, hypopigmentation (Hansen’s), Nerve swelling or thickening should be felt for in
café-au-lait spots and multiple swellings— any neurological symptoms. The nerve swelling
neurofibromatosis. (neurofibroma) is usually oblong, soft to firm in
consistency, can be multiple, moves perpendicular
As so ci ated Bo ny Inj ur y to the long axis of the nerve and has little
movement along the long axis of the nerve.
Example: Middle third humerus fracture can Neuritis (Hansen’s–lepra reaction) results in
cause radial nerve palsy, supracondylar humerus diffuse swelling along the course of the nerve with
fracture can cause radial, median or ulnar nerve evidence of inflammation. Palpable cutaneous
palsy, proximal tibial or fibular neck fracture can nerves are ulnar nerve at elbow behind the medial
cause common peroneal nerve palsy, knee or hip epicondyle, and common peroneal nerve at the
dislocation can cause damage to sciatic nerve. fibular neck. These nerves can be thickened in
Hansen’s disease and hypertrophic neuropathy.
Dysmorphism Proximal neuroma and distal glioma can be felt at
Local gigantism (neurofibroma); limb hypo- the site of untreated long-standing nerve injury.
plasia—neurofibromatosis causing pseudo-
arthrosis tibia (look for neurocutaneous markers); Provoc ative Test
Hansen’s disease causing resorption of digits,
a. Tinel’s sign: Percussing the nerve along its
dysmorphic face, deformities due to involvement
course from distal to proximal can identify any
of peripheral nerves; Neuropathic joints (foot or
bare nerve ends (without myelination). It is a
ankle) causing disfigurement and distortion of
helpful sign to assess the progression of nerve
joints and foot ulcers.
regeneration. On percussion, a sharp shooting
or tingling pain occurs along the distribution
FEEL
of the nerve due to nerve irritation or it can be
Ask for tender spot before palpation and always a localized electric shock like sensation at the
look at patient’s face while palpating for site of percussion due to a neuroma.
tenderness. b. Direct compression of the nerve: To reproduce
the nerve symptoms by direct pressure on the
Warmth nerve in different conditions like direct carpal
The paralytic limb is susceptible to the compression test in carpal tunnel syndrome
environmental temperature changes. Periphery and direct tarsal compression test in tarsal
of the paralytic limb may feel less warm than the tunnel syndrome.
other side.
MOVE
Tenderness
Active movements of the joints should be tested
The most tender spot should be palpated last. first. Patients with full range of active movements
Assess for soft tissue or bony tenderness and the need not be tested for passive movements.
If there is restriction then it could be due to discrimination at fingertips, vibration and joint
pain, fixed deformity, loss of muscle power or position sense are assessed.
mechanical block. This warrants testing for Autonomic functions tested are sweating (pen
passive movements to identify the range of tip or starch–iodine test) and pilomotor erection.
movement and the probable cause. Assessment
of free movements of the joint is mandatory Reflexes
before considering tendon transfer. Stability of
Superficial reflex ‘polysynaptic reflex arc’.
the joints must be assessed.
Abdominal reflex—upper or lower quadrant,
Trick movements should be identified.
cremastric reflex, bulbocavernosus reflex, anal
Example: For active abduction of shoulder in
wink reflex, plantar reflex.
supraspinatus paralysis, patient may sway the
Deep reflex ‘monosynaptic reflex arc’.
body to the same side to get initial abduction and
Biceps, triceps, supinator, knee, ankle jerk.
then with the help of deltoid can carry out rest of
abduction.
EXAMINATION OF INDIVIDUAL NERVES
Example: In radial nerve palsy the finger
extension at IPJ may mimic extension at MCPJ MEDIAN NERVE
(interossei is responsible for IPJ extension,
supplied by ulnar nerve while MCPJ extension is Median nerve (C 5,6,7,8,T 1) is formed by the union
of medial root of medial cord and lateral root of
by long finger extensors, supplied by radial nerve).
Subluxation of the nerve especially ulnar lateral cord. It supplies the flexor muscles of the
nerve at elbow should be felt for on flexion/ forearm (except flexor carpi ulnaris and ulnar half
extension movements. of profundus), thenar muscles – abductor pollicis
brevis, opponens pollicis, superficial head of flexor
pollicis brevis; first and second lumbricals. The
NEUROLOGICAL EXAMINATION
anterior interosseous nerve is a branch of median
Motor Examination nerve and it supplies the deep flexor compartment,
flexor pollicis longus, flexor digitorum profundus
a. Bulk radial half and pronator quadratus. This branch
b. Tone ends by supplying the front of wrist and distal
c. Power—Assessed by MRC grading radioulnar joint. The median nerve is responsible
M0– No active contraction. for sensation over the volar aspect of lateral three
M1– A flicker of contraction seen or found and half digits.
by palpation.
M2– A weak contraction which can Motor Examination
produce movement with gravity
eliminated by positioning of the limb. To test muscle power it is easy to keep the patient
M3– Movement against gravitational in the position of muscle action and ask the
resistance. patient to hold in that position. The examiner
M4– Movement against gravity and some should resist this position by opposite
resistance. movement. This tests the power of the muscle.
M5– Normal power. The other way is the patient should perform
the action of the muscle against resistance of
examiner’s hand. This is sometimes too
Sensory Examination
cumbersome if the patient does not understand the
Fine touch and pinprick assessed in autonomous direction of action of the testing muscle. (Please note
zones of the nerve distribution. Two-point when a patient does the movement against resistance it
is in the direction of primary action of the muscle, when “O” shape is formed (Fig. 9.5). In patients with
an examiner tests against resistance opposite force is anterior interosseous nerve palsy (Kiloh Nevin
applied to the function of testing muscle). syndrome) FPL and FDP to index finger is
Long flexors: Flexor digitorum superficialis (FDS) affected causing inability to do “OK”, as the index
and profundus (FDP). FDS is tested by holding the finger tip and the tip of the thumb are
fingers in extension, the finger to be assessed is hyperextended at IP joints.
asked to bend (Fig. 9.3). Flexion occurs at PIP joint
Sensory Examination
due to the action of FDS. This test can be deceptive
in little finger, because of normal variant. It supplies the volar aspect of the radial three and
FDP is tested individually by asking the half digits. The sensory supply of the median nerve
patient to bend the tip of the finger at DIP joint may be confusing, but usually the volar surface of
while stabilizing the middle phalanx. thumb, index and middle fingers and the dorsal
Flexor carpi radialis (FCR): It is tested by resisted surfaces of the distal phalanges of the index and
radial flexion at wrist and feeling for the tendon. middle fingers are supplied by median nerve. The
smallest autonomous zone of the median nerve is
Flexor pollicis longus (FPL): It is tested for active the tip of index and middle fingers.
resisted flexion at IP joint of the thumb (Fig. 9.4).
Pronator teres and quadratus Patient is tested for
resisted supination by the examiner in a pronated
and extended elbow for pronator teres. Pronator
quadratus is tested in a flexed elbow.
Abductor pollicis brevis (APB): The APB is tested
by “Pen test”, ask the patient to keep the palm
facing up on a table. Hold the pen such a way
that the thumb abducts 90° to touch the tip, that
is perpendicular to the plane of the palm. Feel
for the contracting muscle.
Opponens pollicis: This is tested by asking the
patient to touch the base of little finger with the
Fig. 9.4: Testing FPL
tip of the thumb, feel for the strength against
resistance.
Bunnell’s “OK” sign: Normally on opposing the
tip of thumb, to the tip of index finger, silhouette
Fig. 9.3: Testing FDS Fig. 9.5: OK sign

Specif ic Sign s in Median Nerve Palsy ULNAR NERVE

1. Wasting of forearm muscles and thenar muscles. Ulnar nerve (C8,T1) is a branch of the medial cord
2. Pointing index sign: In high median nerve of brachial plexus. It gives motor branches to
palsy due to affection of FDS and FDP to the flexor carpi ulnaris (FCU), ulnar half of flexor
index finger, the index finger cannot be flexed. digitorum profundus (FDP), hypothenar
The other fingers can due to the action of ulnar muscles—abductor digiti minimi, opponens
half of FDP supplied by ulnar nerve (Fig. 9.6). digiti minimi, flexor digiti minimi, interossei, 3rd
3. Ape-thumb deformity: Due to inefficiency of and 4th lumbricals, adductor pollicis and
the abductor and opponens pollicis, the 1st sometimes deep head of flexor pollicis brevis.
metacarpal drops to the same plane as the Sensory distribution is over ulnar 1 ½ fingers
other metacarpals resulting in “Simian hand.” and ulnar aspect of hand.
4. Pen test (abductor pollicis brevis): The patient
places the affected hand flat upon a table with Motor Examination
palm uppermost, a pen is held above the thumb
1. Flexor carpi ulnaris test: This is tested by flexion
and the patient is told to touch the pen with the
and ulnar deviation of the wrist against
edge of his thumb by abducting (Fig. 9.7).
resistance and feel the contracting tendon at
the wrist and assess its power.
2. Card test: Palmar interossei are adductors
(Pad), tested by asking the patient to hold a
card between the extended fingers and assess
resistance against pulling (Fig. 9.8).
3. First dorsal interosseous: Place the hand flat on
the table with the palm down, ask the patient
to actively abduct index finger against
resistance, feel for the muscle contraction in
1st web space (Fig. 9.9). Wasting of the muscle
may be obvious in 1st web space.
4. Froment’s sign/book test: To test adductor
Fig. 9.6: Pointing index pollicis ask the patient to grasp a book or card
between extended thumb and index finger.
Fig. 9.7: Pen test Fig. 9.8: Card test

Fig. 9.9: 1st dorsal interosseous test Fig. 9.10: Book test
In ulnar nerve palsy patient tries to grasp the Ulnar Paradox

book by flexing the IPJ of thumb (using FPL
In low ulnar nerve lesion clawing of little and
supplied by median nerve), as the patient is
ring finger is very obvious whereas in high ulnar
unable to adduct the thumb (Fig. 9.10).
nerve lesion clawing is less and this is due to the
5. Wartenberg sign: It is the abduction attitude
paralysis of ulnar half of FDP.
of little finger due to the unopposed action of
extensor digiti minimi (radial nerve) in
paralysis of palmar interossei. This attitude RADIAL NERVE
becomes more evident on extending the Radial nerve (C 5,6,7,8 and T1) is a branch of the
finger and is seen with clawing. posterior cord of brachial plexus. It supplies the
6. Ulnar claw hand (little and ring finger): Clawing extensors of the elbow, wrist, fingers and thumb
is hyperextension deformity of the MCPJ with and long abductors of the thumb. Muscles
flexion of the IPJ. This is due to imbalance supplied in the arm are triceps, anconeus,
between flexors and extensors at the MCPJ. brachioradialis, ECRL and ECRB. The radial
The lumbricals and interossei are the prime nerve divides into superficial radial and deep
flexors of MCPJ. Paralysis of these muscles posterior interosseous nerve at the level of lateral
results in hyperextension by long extensors. epicondyle. Superficial radial nerve passes under
7. Muscle wasting: Wasting of hypothenar brachioradialis and becomes subcutaneous few
muscles, lumbricals and interossei (guttering). centimeters above the wrist to supply the dorsum
of 1st web space. The posterior interosseous
Sensory Examination
nerve supplies extensor carpi ulnaris, extensor
Tested from distal to proximal, especially in the digiti minimi, extensor digitorum longus,
autonomous zone. Altered or decreased extensor indicis, abductor pollicis longus,
sensation in little and ulnar half of ring finger. extensor pollicis longus and brevis, and ends as
Loss of sensation over the dorsum and ulnar a pseudoganglion supplying the wrist.
aspect of hand indicates high lesion as the dorsal In proximal third extensor aspect cut wound
sensory branch of ulnar nerve arises 7 cm of forearm there can be inability to straighten the
proximal to the wrist. fingers or thumb that may be due to posterior
interosseous nerve cut injury or muscle

laceration. As abductor pollicis longus and
extensor indicis has more distal origin in forearm,
if these muscles are functioning it indicates
muscle laceration rather than posterior
interosseous nerve injury (Rex sign) at that level
(Fig. 9.11).
Motor and Sensory Examination

High radial nerve palsy will cause:
a. Triceps weakness: This is tested by resisted
active extension of the elbow and feeling for
the muscle contraction.
b. Brachioradialis: Tested by resisted active Fig. 9.12: Testing extensor digitorum longus by active
flexion of the elbow with forearm in extension of MCPJ (For color version, see Plate 5)
midprone position and feeling for the muscle
contraction. In posterior interosseous nerve palsy:
c. Wrist drop: This is due to paralysis of wrist a. Dorsiflexion of the wrist results in radial
extensors. deviation due to paralysis of extensor carpi
d. Finger drop: This is due to paralysis of long ulnaris and intact ECRL and ECRB.
finger extensors causing inability to extend b. Finger and thumb drop but no wrist drop.
fingers at MCPJ (beware of trick movements, c. No sensory deficit.
as IPJ can be extended by the intrinsic
muscles) (Fig. 9.12). COMPRESSION NEUROPATHY
e. Thumb drop: This is due to paralysis of
extensor pollicis longus and abductor Ulnar Nerve
pollicis longus.
f. Sensory loss over the autonomous zone, Cubital Tunnel
dorsum of 1st web space. At the elbow the ulnar nerve can be entrapped
behind the medial epicondyle due to anatomical
or pathological cause.
Anatomical cause—shallow groove, subluxation
of the nerve, thick deep (Osborne’s) fascia and
between the two heads of FCU.
Pathological cause—fracture medial epicondyle,
Hansen’s neuritis, tardy-ulnar nerve palsy in
cubitus valgus.
Findings include Tinel’s sign and repro-
duction of symptoms with full elbow flexion and
holding for a minute.
Fig. 9.11: Lacerated wound extensor aspect in Guyon’s Canal

proximal third forearm with medial three fingers drop
indicates superficial extensor muscle injury without The ulnar nerve can be entrapped as it passes
involvement of posterior interosseous nerve between the pisiform and pisohamate ligament
medially, hook of hamate and insertion of Median Nerve

transverse carpal ligament laterally and volar
Pronator Syndrome
carpal ligament forming the roof.
Causes: Ganglion, ulnar artery aneurysm or Pain in the volar aspect of forearm increases with
thrombosis, fracture hook of hamate, tumors, activity. It can be due to compression of median
anomalous muscle, hypothenar hammer nerve by ligament of Struther (3rd head of
syndrome, palmaris brevis hypertrophy. coracobrachialis), lacertus fibrosis, pronator teres
If the entrapment is more distal in the canal it muscle or proximal arch of FDS. Patient may
involves only the motor branches and sensation have positive Tinel’s sign at pronator area, pain
to ulnar one and half fingers are spared. on resistance to pronation (in pronator
Sensation over dorsum and ulnar aspect of hand involvement) or pain in the forearm on resistance
will be normal. to isolated flexion of the PIPJ of middle and ring
Physical findings include hypoesthesia in finger (FDS arcade). Nerve conduction test is
ulnar one and half fingers, intrinsic muscle confirmatory.
weakness and lack of filling of ulnar artery in
ulnar artery pathology (Allen’s test). Anterior Interosseous Syndrome
Allen’s Test
This is usually due to entrapment of anterior
interosseous nerve in deep head of pronator
Feel both the radial and ulnar artery at the wrist teres, which supplies FPL, radial half of FDP and
with hand elevated, ask the patient to squeeze pronator quadratus. This causes forearm pain
the fingers and make a fist. Obstruct the blood and inability to make “OK” due to loss of IPJ
flow through the arteries by local pressure. Open flexion of thumb and DIPJ flexion of index
the hand and see it looks pale and white, release finger.
the pressure on one artery to see the flare. This
Differential diagnosis Mannerfelt syndrome due to
indicates adequacy of blood supply through that
rupture of FPL in rheumatoid arthritis.
artery. Repeat the same procedure for the other
artery (Figs 9.13A and B).
Carpal Tunnel Syndrome
Similar test can be done in the fingers to assess
the digital artery flow (Finger Allen’s test). Discussed in Chapter 7.
A B
Figs 9.13A and B: Allen’s test

Radial Nerve interval in distal forearm causing sensory

disturbance.
Crutch Palsy
Due to inappropriate length of axillary crutches. Thoracic Outlet Syndrome
Middle aged or young females typically present
Saturday Night Palsy
with neck pain, paresthesia in ulnar nerve
Direct pressure of the nerve in the upper arm due distribution with motor weakness due to
to abnormal posture for prolonged time. entrapment of brachial plexus at scalene triangle.
Vascular symptoms like Raynaud’s
Humerus Shaft Fracture phenomenon —intermittent attacks of pallor or
(Holstein Lewis Fracture) cyanosis of fingers and embolic episodes to
fingers with gangrene formation can occur. This
Radial nerve is entrapped as it crosses the lateral
can be due to cervical rib, anterior scalene muscle
intermuscular septum in middle third- lower
contraction or abnormal fibrous band.
third junction fracture of humerus.
Ad so n’s Test
Posterior Interosseous Nerve Syndrome
First feel the radial pulse of a seated patient in
There is weakness of fingers and wrist due to an externally rotated, slightly abducted arm, and
entrapment of the nerve in proximal supinator then ask him to turn his head as far as possible
(arcade of Frohse), tumors, ganglion, lipoma, towards the affected side and take a deep breath.
radial head fracture or surgery. It manifests with The test is positive if the pulse becomes feeble or
loss of finger extension and dorsiflexion of wrist is not felt (Fig. 9.14).
resulting in radial deviation due to paralysis of
ECU. Dorsal wrist pain can occur due to Ar m El evat io n Test (Roo s Test)
termination of nerve as pseudoganglion at wrist.
There is no sensory deficit. Both arms elevated, abducted to 90° and
externally rotated with elbows flexed to 90°, now
Radial Tunnel Syndrome fingers are flexed and extended rapidly for 3
minutes. This causes claudication pain in the
This is a syndrome of pain. Radial tunnel is forearm and wrist in vascular compromise
bordered by brachioradialis and brachialis and (Fig. 9.15) and inability to complete the test.
extends distally to distal border of supinator.
Fibrous bands can entrap radial nerve before it
reaches supinator, radial recurrent vessels (leash
of Henry), arcade of Frohse or by origin of ECRB.
This usually presents with pain localized 5 cm distal
to lateral epicondyle and aggravated by resisted
extension of middle finger (ECRB inserts at the base
of 3rd MC) with no motor or sensory deficit.
Differential diagnosis: Tennis elbow.
Cheralgia Paresthetica (Wartenberg Syndrome)

Superficial radial nerve becomes compressed as
it comes superficial at brachioradialis and ECRB Fig. 9.14: Adson’s test
Branches from the Trunks

1. Suprascapular nerve—Supplies supra-
spinatus and infraspinatus.
2. Nerve to subclavius muscle.
Branches from the Cord
Medial Cord (Money Makes Many Men

Unhappy—MMMMU)
1. Medial cutaneous nerve of arm.
Fig. 9.15: Arm elevation test 2. Medial cutaneous nerve of forearm.
3. Medial pectoral nerve.
4. Medial root of median nerve.
SUPRASCAPULAR NERVE ENTRAPMENT 5. Ulnar nerve.
Deep diffuse pain in the scapular area and
atrophy of supraspinatus and infraspinatus can Lateral Cord (MLL—Major between
be the presenting feature. Symptoms can become Two Ladies)
worse with arm abduction and palpation of 1. Musculocutaneous nerve—Supplies biceps,
suprascapular notch. It can be due to trauma or brachialis and coracobrachialis.
space-occupying lesion. 2. Lateral root of median nerve.
3. Lateral pectoral nerve.
BRACHIAL PLEXUS INJURY (FIG. 9.16)
Brachial plexus is formed by the anterior rami of
C5,6,7,8 and T1 roots. These roots leave the
intervertebral foramen and form the plexus. C5 and
C6 roots join to form the upper trunk, C7 continues
as the middle trunk and C8 and T1 join to form the
lower trunk behind the scalene muscles.
The three trunks then proceed behind the
clavicle and each divides into anterior and
posterior divisions. The three posterior divisions
unite to form the posterior cord, the anterior
divisions of the upper and middle trunks unite
to form the lateral cord and the anterior division
of the lower trunk continues as the medial cord.
Branches from the Roots

1. Long thoracic nerve (C5,6,7) —Nerve to
serratus anterior.
2. A twig to phrenic nerve (C3,4,5)—Supplies
the diaphragm.
3. Dorsal scapular nerve (C5)—Supplies rhomboids
major and minor and levator scapulae. Fig. 9.16: Brachial plexus
Posterior Cord (ULNAR) consists of ptosis, miosis, anhydrosis and

enophthalmos.
1. Upper subscapular nerve.
2. Lower subscapular nerve.
Deformity
3. Nerve to latissimus dorsi.
4. Axillary nerve. There is loss of normal contour with prominent
5. Radial nerve. anterior aspect of shoulder, from hooking of
acromion and coracoid process. Other
EXAMINATION OF THE BRACHIAL PLEXUS deformities at the elbow, forearm, wrist and hand
should be noted.
Patient is stripped to the waist to allow
visualization of both upper limbs and the dorsal Arm Length Discrepancy
musculature.
Childhood brachial plexus injury (Obstetric palsy)
can result in hypoplasia of the limb. In adults it
Look
can be due to associated fracture or dislocation.
Attitude of the Limb
In upper plexus injury (Erb’s palsy , C5,6 Feel
involvement) the limb is typically adducted and Ask for the most tender spot and be gentle in
internally rotated at shoulder, extended at elbow, palpation. Start from the cervical spine; feel for
pronated at forearm and flexed at the wrist— any step, tenderness or deformity of spine.
Waiter’s tip posture (see Fig. 9.1). Palpate the clavicle, scapula, interscapular area,
In lower plexus injury (Klumpke’s paralysis, supraclavicular area and then the shoulder joint
C8,T1 involvement) the hand functions are for posterior subluxation, elbow and forearm.
primarily affected with paralysis of wrist and Feel the distal pulses.
finger flexors.
In complete brachial plexus injury the arm is
Move
totally flail with no function.
Examine the active movements of the shoulder,
Muscle Wasting elbow, forearm, wrist and hand. The passive
movements are tested to assess fixed deformities
Look for proximal muscle wasting in Erb’s palsy,
or loss of muscle power.
wasting of intrinsic muscles of hand in
Klumpke’s paralysis and total arm wasting in
Tinel’s Sign
complete plexus injury. Muscle wasting in the
back (lat is simu s do rs i and trape zius ), th e Start from distal to proximal, tapping along the
scapular region (rhomboids medially, supra- and course of the radial, median and ulnar nerves,
infraspinatus over shoulder blade) and anteriorly any tingling sensation or shock like sensation
pectoralis major is noted. along the nerve is noted and marked.
Measurements are taken at regular intervals to
Scars assess the motor march. Presence of Tinel’s sign
indicates infraganglionic lesion.
Horner’s Syndrome
Systematic neurological examination is done
This occurs in lower plexus injury due to damage to localize the site of injury —supraclavicular,
of T1 root, which receives sympathetic component infraclavicular, supraganglionic or infra-
from its own ganglion. Horner’s syndrome ganglionic injury. In preganglionic lesion —
avulsion of the nerve roots can be associated with 4. Internal rotators/External rotators : Ask the
spinal cord injury and lower limb involvement, patient to keep the arm by the side of the body
Tinel’s sign can be negative and EMG can with the elbow flexed 90°, apply resistance
demonstrate the denervation of paraspinal to the palm while pushing inwards. This tests
muscles. The lower root injury can have Horner’s the subscapularis and pectoralis major
syndrome. (internal rotators).
Postganglionic lesions can be supraclavicular Repeat the test asking the patient to resist
or infraclavicular. Tinel’s sign will be positive. outward movement. This tests the infraspinatus
Infraclavicular lesion involves branches from the and teres minor (external rotators).
trunk and below. 5. Subscapularis: Ask the patient to hold the
dorsum of the hand over the buttocks and
Axon reflex test: Presence of triple response to lift off the hand (Gerber’s lift off test) and
indicates intact axon reflex and preganglionic to push the hand backwards against the
lesion. In postganglionic lesion there is a examiner’s hand. This tests the power of
sequential response of vasodilatation and wheal subscapularis.
formation but flare response is absent. 6. Supraspinatus (Empty can sign): With the arm
in 30° forward flexion and abduction, with
Motor Examination full internal rotation and thumb pointing
The examiner stands behind the patient to test down ask the patient to hold the arm in that
trapezius, serratus anterior, rhomboids, supra- position. Push the hand down against
and infraspinatus, deltoid and latissimus dorsi. resistance and feel for the supraspinatus
The examiner stands in front of the patient to test muscle, sometimes difficult to feel because of
pectoralis major and other upper limb muscles. the overlying trapezius.
1. Diaphragm : Weakness of diaphragm 7. Deltoid: It is tested by keeping the arm in
manifests with breathing difficulty. These abduction and pressing down against resis-
patients may have high cervical cord lesion tance while feeling the muscle contraction.
and impaired chest movements and are 8. Biceps: The long head of biceps is tested by
dependent on abdominal breathing. resisted flexion of the elbow and feeling the
2. Serratus anterior: Asking the patient to push muscle contraction in arm.
against the wall tests this muscle. Winging of
scapula manifests weakness (Fig. 9.17).
As patients with brachial plexus injury have
difficulty to raise the arm to perform this test
one can perform the scapular protraction (anterior
movement of scapula on thorax) by flexing the
arm to 90°and elbow fully flexed, the examiner
holds the elbow and the other hand of examiner
stabilizes the spine, ask the patient to push the
bent elbow forward. If the serratus anterior is
weak there is winging of scapula.
3. Rhomboids: Ask the patient to place the hand
on the hip and to resist the elbow that is being
pushed backwards by the patient. Feel for the Fig. 9.17: Test for serratus anterior showing
muscle contraction medial to the scapula. winging of right scapula
9. Brachioradialis: It is tested by resisted flexion buttocks, gun shot injury, posterior dislocation
of the elbow in midprone position and feeling of the hip or during hip surgery. Most of the
the muscle contraction in forearm. sciatic nerve injuries affect the peroneal
10. Triceps : It is tested by resisted extension component more frequently than complete
movement of the elbow and feeling the nerve palsy.
muscle contraction. Motor involvement in complete sciatic nerve
11. Latissimus dorsi: Feel the posterior fold of palsy includes:
axilla and ask the patient to cough or hold Weakness of hamstrings, gastroc soleus.
the upper arm in forward flexion of 90° with Tibial nerve component —tibialis posterior,
external rotation and elbow in flexion and long flexors of toes and small muscles of
resist the extension of arm by holding the sole.
elbow (Climber’s muscle). Peroneal nerve component—tibialis anterior,
The distal muscles are tested as described in long extensors of toes, peroneus tertius, peroneus
peripheral nerve injuries. longus and brevis.
Sensory examination is also helpful to localize Sensory deficit may be present over the lateral
the lesion. aspect of the leg, dorsal and plantar aspect of the
C4 root – sensation above the clavicle foot.
C5 root – innervates the lateral arm
C6 root – lateral aspect of forearm and thumb Common Peroneal Nerve Palsy
C7 root – middle finger
Common peroneal nerve palsy can be a part
C8 root – the little finger and ulnar aspect of hand
of sciatic nerve palsy or occurs per se in
T1 root – medial aspect of forearm
entrapment or fracture of fibular neck from
LOWER LIMB NERVE INJURY trauma and presents with foot drop (anterior
and peroneal compartment component muscles
Sciati c Nerve (L4,5 S1,2,3)
involvement) and absent sensation over the
This is formed by the ventral rami of L4,5 anterolateral aspect of lower leg and dorsum of
S1,2,3. This nerve is injured in stab injury to foot.
10 Examination of Spine
CHAPTER
Normal adult spine has four balanced sagittal Back pain and sciatica have affected man
plane curves. Thoracic and sacral curves are throughout recorded history. The oldest surviving
kyphotic and rigid. These are primary curves surgical text, the Edwin Smith papyrus from 1500
present at birth. The cervical and lumbar spines BC, includes a case of back sprain. Today the
are lordotic and are secondary or compensatory symptom of back pain is the most common
curves. At birth the spine is entirely kyphotic. As musculoskeletal symptom encountered. The vast
infant gains head control and begins to crawl majority of sufferers have a minor lumbar sprain
cervical kyphosis changes to anatomic lordosis. or strain, perhaps related to ageing changes in the
As child begins to ambulate, lumbar kyphosis spine, poor posture (Figs 10.1A to F) and lack of
changes to lordosis. Neutral sagittal balance is physical fitness. The exact pain source is usually
maintained when a line dropped perpendicular difficult to ascertain and exhaustive investigation
to the horizontal from C 7 vertebra passes through often is counterproductive, doing no more than
the posterior aspect of the first sacral vertebra. reinforcing the sufferers view that there is
Figs 10.1A to F: Various types of posture: (A) Physiologic, (B) Thoracic hyperkyphosis, (C) Lumbar
hyperlordosis, (D) Thoracic hyperkyphosis and lumbar hyperlordosis, (E) Total kyphosis, (F) Flat back
something seriously wrong with their back. Early Pain

assessment, advice and physical therapy with or
The history of the pain is the most important single
without manipulation and the judicious use of
part of the assessment. Time must be spent with
analgesics and anti-inflammatory agents will lead
the patient establishing exactly the date and mode
to an early resolution of this benign, self-limiting
of onset, the exact site and any radiating symptoms
condition in most cases. Chronic cases are more
as well as the quality (type of pain, e.g. aching,
difficult to manage but probably arise more from
stabbing, electric shock like, burning). Aggravating
inappropriate primary management or adverse
and relieving factors are of importance.
psychosocial factors than any spinal pathology.
Mechanical low back pain with radiation is
The key challenge to the interested practitioner is
usually posture and activity related, and relieved
to identify the more serious cases early and for
by rest. This is likely to be due to soft tissue strain
this, the concept of Red Flags is useful.
or disk degeneration.
CLINICAL RED FLAGS IN BACK PAIN
Local Pain
• Age of onset <20 or >55 years
• Violent trauma, e.g. fall from a height, road Predominant axial pain in the cervical, thoracic
traffic accidents or lumbar region involving anatomic structures.
• Constant, progressive, non-mechanical pain, In spine the structures innervated to cause pain
night pain and rest pain are muscular, ligamentous structures, fascia, the
• Thoracic pain—interscapular pain annulus of disk, bone, the facet joints, dura mater
• Past medical history of malignancy, steroid or vascular structures.
use or drug abuse
Referred or Overflow Pain
• Systemically unwell or weight loss
• Neurological deficit like cauda equina injury, All structures of common embryologic segmental
progressive radiculopathy or myelopathy origin tend to refer pain in very similar patterns,
• Structural deformity and the pattern of pain is really determined by
• Persisting severe restriction of lumbar flexion. the nerve supply to the structure. The end result
– Symptoms suggestive of infection is that there is substantial overlap between the
– Pain persisting more than 8 weeks. referral patterns for anatomic structures of the
same level such as disk or zygoapophyseal joint
Ag e pathology as well as the sclerotomal or myotomal
Back pain in children and the elderly arising for referral patterns at many spinal levels. The
the first time should arouse a high index of cervical zygoapophyseal joint pain and its
suspicion and be investigated to rule out infection characteristic referral areas were mapped for the
or tumor. site of pain distribution clinically. Pain in the
lower limb is less intense than pain in the back.
Occupation This pain, which is worse in the lumbar area, can
be referred to the thighs but not below the knee.
Those in desk bound or driving jobs appear to This pain is referred along the tissues developed
suffer more from mechanical back pain, as those from same sclerotome or myotome with
in very heavy, physically demanding jobs. segmental innervations, e.g. discogenic pain from
minor disk bulge with no thecal sac or root
Smoking
compression; due to irritation of posterior
Smokers have a higher incidence of back pain than annulus, posterior longitudinal ligament, facet
non-smokers and poor results with treatment. capsule.
Examination of Spine 89
Radiating Pain Localized pain in the back, which is tender

on superficial palpation in the paraspinal area,
Radiating pain indicates involvement of the
and sometimes with nodularity, can be due to
neurologic structures. Pain along the
myofacial strain or fibrositis.
dermatomal distribution with paresthesia,
Pain from instability can present with
burning, hyperalgesia or loss of sensation and
extension catch. Flexion of the back is normal but
weakness. This may be due to disk herniation,
getting up from bent position can produce a catch
degenerative process, neural foraminal stenosis,
and excruciating pain.
space occupying lesion in spinal canal, intrinsic
disease of the spinal cord or nerve root (herpes
Onset and Duration
zoster, neurofibroma). In the lower limbs often
associated with paresthesia is most likely due How did pain start in the first place? Sudden
to neural compression. This root pain, which shooting pain in the back while lifting heavy
radiates to lower limb below the knee along the weight or straightening the back from bent posture
dermatomal distribution, is called sciatica. can be from disk prolapse or myofascial strain.
Associated weakness of the involved root can Elderly patient presenting with sudden onset
be present. pain after lifting heavy weight can be from
compression fracture of osteoporotic spine.
Claudication Pain Injuries at work are very likely subjected to
personal injury claim and treatment of any kind
Pain in the buttocks, thigh or calf on walking.
will hardly improve the symptoms if there is any
This can be of neurogenic or vascular in
pending litigation.
origin.
a. Vascular claudication produces pain,
Nature of Pain
which is relieved on standing for few
minutes unlike neurogenic claudication Electric shock like sensation down the leg starting
where bending forward relieves pain. from the back or well-localized pain radiating
b. The pain is relieved quickly in vascular from the back is radicular pain due to nerve
claudication than neurogenic claudication. irritation. Dull pain of poor localisation in the back
c. Cycle test: Patient with vascular claudication and thigh area is usually referred pain. Burning
gets pain on cycling but not in neurogenic pain in the leg again signifies neurogenic origin.
claudication. The spinal canal space
increases on bending forwards, for the Exacerbating and Relieving Factors
same reason walking up hill does not
In relation to activities of daily living, rest and
cause pain in neurogenic claudication.
night pain, prolonged sitting, bending
d. Palpating the distal pulse may again help
movements and lifting weight. Coughing and
to differentiate vascular from neurogenic
sneezing can produce increased pain in disk
cause.
prolapse sometimes shooting down the leg below
e. The claudication distance is fixed in
the knee. Simple mechanical back pain is activity
vascular but variable in neurogenic
related and mostly relieved with rest or lying
claudication.
down posture.
f. Cramps and numbness is more common
in neurogenic claudication.
Night Pain
Pain at rest, relieved by activity especially
bending forwards and pain on extension can be Severe pain can signify infective or tumorous or
due to facet joint arthrosis. inflammatory condition of the spine.
Neurologic al Symptoms as the patient rises from the chair and observe
how much difficulty he or she has undressing.
The presence or absence of a neurological pain
The examination then continues with the patient
symptom (e.g. radicular, claudicant) will by now
in underclothes in four positions. These are
have been established. Similar detail is required
standing upright, lying supine (the main part of
with regard to the symptoms of paresthesia (pins
the neurological examination is performed in the
and needles), numbness, deadness, weakness,
supine position), lying prone, and finally with
gait disturbance, bladder or bowel symptoms
the patient on the side.
and any other neurological symptoms.
Standin g Upright (Fig. 10.2)
Stiffness
Early morning stiffness of the back and sacroiliac Observe walking, undressing, abnormalities of
joints can be due to inflammatory spondy- posture—alteration of normal curvature. Scoliosis:
loarthropathy. Chest expansion should be lateral bending of spine, Kyphosis: increased
checked for in suspected cases of ankylosing forward bending of spine, round back, and
spondylitis in young adults. Chest expansion of kyphoscoliosis. Kyphosis may occur in elderly due
less than 5 cm signifies restriction due to to osteoporosis, in ankylosing spondylitis in young
costovertebral inflammatory arthritis. adults and Scheuermann's adolescent kyphosis.
Stiffness again can manifest by inability to Gibbus: knuckle like localized deformity in spine
bend forwards or lean backwards or walking due to sharp posterior angulation from wedging
with a "lateral list" (swaying the body to one side of one or more vertebrae. This occurs in congenital
on standing and walking). The lateral or sciatic defect, fracture or spinal tuberculosis. Excessive or
list typically occurs in a posterolateral disk diminished lumbar lordosis, furrow sign—deep
prolapse with root compression where the
patient sways his shoulder to the opposite side
to relieve pressure on the nerve root.
Miscellaneous
Constitutional symptoms in infection of spine, loss
of appetite and weight (malignancy and infection
like tuberculosis) and other joint involvement.
Social background, psychological aspect,
significant past medical history, family history,
menstrual history (in scoliosis to know the age
of menarche for assessment of further growth
and progression), and treatment history must be
recorded.
• What is patient's expectation?
• General examination
• Local examination
THORACOLUMBA R EXAMINATION
Prior to the physical examination you will have
noted the patient's gait and posture. Now watch Fig. 10.2: Surface marking of spine
groove between the chest wall and iliac crest appearance rib hump. The lateral bending
because of severe spondylolisthesis causing towards the side of convexity can also correct a
narrowing of distance between lower ribs and iliac non-structural scoliosis.
crest, any local abnormalities, paraspinal abscess,
neurocutaneous markers like tuft of hair, lipomas, Check Movements
dimple, nevus, café-au-lait spots indicating spina
Flexion: Ask the patient to bend forwards, without
bifida, and scars. Look for the plumb line from base
bending the knee to touch the ground. The distance
of cervical spine to midline of sacrum. Ask the
between the ground and the tip of the hand can be
patient to bend forwards and look for scoliosis and
taken as the measurement. Patient with stiff back
rib hump tangentially (Adam's forward flexion
has limitation. The back muscles may go for spasm.
test). Postural scoliosis disappears on flexion. Short
Hip flexion can misguide this movement.
leg causing scoliosis disappears when patient sits.
Schober's test is done to identify the flexion at
Sciatic scoliosis is painful and disappears on
lumbar spine. A point is marked 10 cm above a
treating the underlying cause.
line connecting the dimple of Venus. The patient
In case of scoliosis look for shoulder
bends forwards fully and measurement is taken
asymmetry, tilting of the head, level of scapula,
again. Lumbar spine excursion should be at least
level of pelvis, shortening of leg, neurocutaneous
5 cm; less than 3 cm suggests substantial
markers, wasted leg, cavus feet and claw toes.
pathology, usually ankylosing spondylitis
Describe the extent of the curve, the apex and
(Figs 10.3A and B).
the side of convexity; check if the curve is
balanced by dropping a plumb line from head to Extension catch: Patient getting up from fully bent
natal cleft. Ask the patient to bend forwards and position experiences catching pain on extension,
look for the correctability of the scoliosis and the which may be due to instability or disc problem.
A B
Figs 10.3A and B: Schober's test

Extension: Ask the patient to lean backwards or

look at the ceiling by bending backwards. It is
difficult to grade.
Lateral flexion: Ask the patient to slide the palm
down the thigh and note the distance the hand
could reach on the leg on each side (Fig. 10.4).
Extension and lateral bending to side can
cause pain in facet joint pathology.
Rotation: Predominantly it happens in the
thoracic spine, fix the pelvis and ask the patient
to spread the arms out and twist the upper trunk
and note the rotations on each side (Fig. 10.5). Fig. 10.5: Testing rotation of spine
Chest expansion: This should be checked in case
of suspicion of ankylosing spondylitis; the Standing on tiptoes and heel, it is a quick
normal chest expansion is 5 cm or more on deep and easy test to assess power in the lower limb,
inspiration. S1 root for plantar flexion and L 4, 5 roots for
Feel for localized tenderness in the midline dorsiflexion.
on spinous process, paraspinal area and deep
tenderness over loin for kidney pathology. The Lying Supine
scoliosis is better appreciated (Figs 10.6A to C). Observe the patient getting onto the couch. Does
Simple percussion with the examiner's fist can he overreact with grunting/groaning?
elicit the deep tenderness on the spine. Observe for any gross deformities, swelling,
muscle wasting and then feel the abdomen and
the pelvis.
Dural Tension Signs or Stretch Tests
Straight Leg Raising (SLR) Test (Fig. 10.7)

The patient is asked to actively raise the leg
without bending the knee and assess for pain
radiating from the back to the foot and then
repeat passively to confirm. The site of radiation
is especially asked for. Pain that radiates from
back to below the knee on SLR is only considered
positive and not just the back pain or thigh pain.
The test is considered positive if pain occurs
between 30 and 70 degrees of elevation, because
there is no true change in tension on nerve roots
outside this range. Beware tight hamstrings can
cause stretch pain but this does not radiate down
the knee. There is normal excursion of sciatic
nerve on SLR. If there is a disk prolapse or lateral
Fig. 10.4: Testing lateral flexion canal stenosis, this normal excursion is impeded
A B C
Figs 10.6A to C: Scoliosis
causing nerve root tension and sciatic pain. knee. The test is positive if the patient has
Normal L5, S1 root excursion is 4 to 5 cm and posterior thigh pain radiating down the leg on
less in the upper roots. extension of the knee.
If SLR test is positive the leg is lowered down
by 10º from the point of sciatic pain and foot Bowstring Test
dorsiflexed to reproduce the same pain. This First do the SLRT, then the level at which patient
stretch test is called Bragaard's test. develops pain bend the knee slightly and apply
firm pressure with the hand in the popliteal fossa
Lasegue's Test to stretch the nerve. Positive test should produce
Patient in supine position flex the hip and knee radiating pain and paresthesia in the leg
to 90°, then keeping the hip flexed, extend the (Fig. 10.8).
Fig. 10.7: Straight leg raising test Fig. 10.8: Bowstring test
Well Leg Raise Test or Crossed SLR Test Motor Examination

This is a more definitive test for disk disease causing Bulk, tone and power of the muscles are assessed.
sciatica. On performing SLR test on the normal leg, A test for each motor root is highlighted by
the cross over sciatic pain is experienced in the testing the key muscles.
affected leg, usually an axillary disk.
Lower Limbs
Neurological Examination L 1,2,3 - Iliopsoas—flexion of the hip
Done to assess motor, sensory system and L 4,5 - Gluteus maximus and hamstrings,
reflexes in upper and lower limbs (Fig. 10.9). extension of the hip
Fig. 10.9: Structural and neurological scheme of vertebral column and spinal cord with neurological implications
L5 - Gluteus medius—abduction of hip results in weakness of the

L 3,4 - Quadriceps—extension of the knee musculature in the dermatome
L5, S1 - Hamstrings—flexion of the knee innervated by the root causing
L 4,5 - T ib ia li s a nt er io r a nd th e l on g umbilicus to deviate towards the
extensors of hallux and toes— strong uninvolved side. This
dorsiflexion of the ankle deviation is called Beevor's sign.
S 1,2 - Gastrosoleus—plantar flexion of
the ankle Sensory Examination (Figs 10.10A and B)
L4 - Tibialis posterior—inversion of the
Lower Limbs
foot
L1 - over groin
L5, S1 - Peronei, eversion of the foot
L2 - over lateral aspect of upper thigh
L5 - Extensor hallucis longus—
L3 - over lateral aspect of lower thigh
dorsiflexion of big toe
and front of knee
S1 - Flexor hallucis longus and gastro-
L4 - over lateral aspect of leg and front
soleus—plantar flexion of toes and
of ankle
ankle
L5 - over 1st web space
Upper Limbs S1 - outer border of foot
C5 - Deltoid and supraspinatus— S2 - strip in middle of calf upto sacrum
shoulder abduction S3 - perianal region
C 6,7 - Pe ct or ali s m aj or —s ho ul de r
Upper Limbs
adduction
C4 - supraclavicular area
C 5,6 - Biceps—elbow flexion
C5 - upper and outer aspect of arm
C 7,8 - Triceps—elbow extension
C6 - radial aspect of forearm, index
C6 - Pronation and supination
finger and thumb
C 6,7 - Wrist dorsiflexion and palmar
C7 - the middle finger tip
flexion
C8 - ulnar aspect of forearm, little and
C 7,8 - Finger flexion and extension
ring finger
T1 - Intrinsic muscles of hand—
T1 - inner aspect of arm and elbow
abduction and adduction of fingers
T2 - inner aspect of upper arm
Trunk
T 8,9 is upper abdomen, T 10 is
Lower thoracic nerve roots motor
umbilicus and T 11,12 is lower
function is analysed by Beevor's
abdomen (Fig. 10.11).
sign. This is a gross test of muscular
Test for light touch and pin prick sensation
innervation from the thoracic
at the autonomous zone. To find out the level of
spine. Patient is asked to do a half
normal sensation in spinal cord pathology run
situp with knees flexed and the
the finger from below upwards for light touch
arms behind the head. In normal
and pin prick sensation and ask the patient when
person because of symmetric
he or she could feel.
contraction of abdominal muscle,
umbilicus remains in midline
Superficial Reflex
during this maneuver. Root
compression or tumor or spinal a. Abdominal reflex: Stroking the four quadrants
dysraphism or poliomyelitis of the abdomen in a radial manner beginning
A Fig. 10.11: Sensory level surface marking
at the umbilicus to check for contraction of

abdominal muscles in each quadrant by
movement of umbilicus in the direction of
stroke. Absence indicates the level of lesion
and spinal cord pathology in scoliosis. D 8,9
is upper abdomen, and D 11,12 is lower
abdomen.
b. Anal reflex: Stroking or scratching the skin
around the anus will cause contraction of the
anal sphincter. S 3 and 4 segments are
involved.
c. Bulbocavernosus reflex: Elicited by squeezing
the glans penis or tugging on Foley's catheter
and noting the anal sphincter constriction. S3
and 4 segments are involved.
d. Cremastric reflex: In males stroking the inner
side of thigh causes contraction of detrusor
muscle of scrotum. This is absent in L 1 lesion.
e. Plantar reflex: Stroking the outer aspect of sole
B causes plantar flexion of big toe in a normal
awake patient. Up-going big toe is called
positive Babinski's sign. This is seen in upper
Figs 10.10A and B: (A) Dermatome distribution, motor neuron lesion, unconscious patients,
(B) Sensory dermatome distribution of anterior leg and child below 1 year and cannot be elicited
if sensation over sole is not normal. L5 and

S1 segments are involved.
Deep Reflex
Upper Limbs
a. Biceps reflex (C 5,6) (Fig. 11.12): With the elbow
flexed and relaxed and a finger over the
tendinous insertion gentle tap is given with a
patellar hammer. Sudden reflex flexion of
elbow due to biceps contraction indicates
intact reflex arc. Fig. 10.12: Biceps reflex
b. Triceps reflex (C 7) (Fig. 11.13): Tapping over the
triceps insertion of a flexed and relaxed elbow
produces extension of the elbow due to triceps
contraction. This indicates intact C 7 root.
c. Supinator jerk (C 5,6) (Fig. 11.14) : With the
elbow flexed and forearm in mid-prone
position, gentle tap over the radial styloid
process causes supination and flexion of
forearm due to contraction of brachioradialis.
d. Hoffmann's sign: This indicates hyperreflexia
in upper limbs. This is demonstrated by
flexing the distal phalanx of middle finger and
then abruptly releasing it. Positive sign is
when the thumb and fingers flex and adduct.
Lower Limbs Fig. 10.13: Triceps reflex
a. Knee jerk (L 2,3,4) (Fig. 11.15): Patient relaxed
and keeping the knee bent, tapping on the
patellar tendon produces a jerk with
extension of the knee. It is exaggerated in
upper motor neuron lesion and absent in
lower motor neuron lesion or with atrophy
of quadriceps muscle.
b. Ankle jerk (L5, S1) (Fig. 11.16) : In supine
position this can be elicited by bending the
knee, externally rotating the leg, keeping the
ankle in slight dorsiflexion and tapping on
the tendo-Achilles tendon. This produces
reflex contraction of gastrosoleus with
plantarflexion of foot and ankle.
c. Ankle clonus: Occurs in upper motor lesion
and is pathological if more than 5 beats occur
continuously. This is elicited by sudden
dorsiflexion of the foot. Fig. 10.14: Brachioradialis reflex
d. Patellar clonus: Occurs in upper motor lesion and Lying on Side

is elicited by sudden downward movement of
An important part of the neurological
patella in a relaxed knee to produce beats.
examination is to test for skin sensation in the
Vascular Examination "saddle area" (S3,4) and for the anal reflex (S4,5).
Rectal examination can also be performed to test
Test for dorsalis pedis and posterior tibial pulse, anal sphincter tone. These examinations are
as vascular claudication can mimic neurogenic mandatory in spinal injury and possible cauda
claudication. equina syndrome cases. Sacral and coccygeal
tenderness (e.g. in coccydynia) is also best
Lying Prone
assessed in this position.
The presence of gluteal or other muscle wasting
may be more obvious now. Feel along the
spinous processes for any bump or step. Note
tenderness in the midline and three
fingerbreadths from the midline in the line of the
facet joints. Fibrofatty nodules are common over
sacroiliac area, which may be normal if no
tenderness is present, and if it is tender to feel,
reproducing the same pain, it can be fibrositis.
The femoral stretch test is then conducted to
test tension or irritability in the femoral nerve roots
(L2,3,4 roots). With the hip extended the femoral
nerve is stretched by passively flexing the knee.
In a positive test the patient complains of pain in
the front of the thigh. Pain can be further increased
by hyperextending the hip (Fig. 10.17). The prone
position is used to test gluteal (active buttocks
squeeze) and hamstring muscle (patient flexes
knee against resistance) power. Finally the ankle
jerks are best elicited with the patient prone. Fig. 10.16: Ankle jerk
Fig. 10.15: Patellar reflex Fig. 10.17: Femoral stretch test

Testing the sacroiliac joints and both hips SPECIFIC CONDITIONS

completes back examination. Lumb ar Disc Disease
Examination after exercise may demonstrate
Lumbar disc degeneration is thought to be
altered neurology in neurogenic claudication due
capable of causing mechanical back pain. This
to lumbar spinal canal stenosis.
may be secondary to overloading of facet joints,
muscular or ligamentous strain at the involved
Waddell's Symptoms and Signs
segment due to disc failure or inflammation or
Symptoms: Pain in the tip of tailbone, complete annular tear of the disc itself. Pain can radiate to
leg pain, numbness in whole leg and giving way the buttocks and lower limbs but this pain should
of the leg. not be confused with the neurological pain of
Inappropriate signs: Include the physical signs for radiculopathy caused by disc prolapse
non-organic lesion, which helps to identify those (protrusion), extrusion (nuclear material breaks
patients who have psychological or socio- through the annulus) or sequestration (nuclear
economic basis for their pain. material fragment lies in the spinal canal separate
1. Non-organic tenderness: Superficial tenderness from the rest of the disc). These latter conditions
to light touch or widespread tenderness in may benefit from surgical discectomy if leg pain
non-anatomical distribution. persists despite conservative treatment or when
2. Simulation test: Low back pain produced by neurological deficit progresses (Table 10.1).
axial compression or rotation of the shoulders Pain is increased on forward bending, lifting
and pelvis. weight, on prolonged sitting or on coughing and
3. Distraction test: Patient's attention is distracted sneezing. Stretch test and neurological
to reproduce positive physical findings. examination are helpful to identify and localize
Positive SLR test in supine position can be the disease. Most common is the posterolateral
counterchecked by lifting the leg straight with disk prolapse at L5,S1 resulting in S1
knee extended in sitting position to see radiculopathy (the transiting root S1 rather than
whether it reproduces the same sciatic pain. the exiting root L5) or L4 to L5 disk prolapse
4. Regional disturbance: Like giving way, resulting in L5 radiculopathy. Acute central disk
weakness and sensory loss in a stocking prolapse with cauda equina syndrome—
distribution. bilateral buttock and leg pain, bladder and
5. Over-reaction. bowel disturbance, saddle anesthesia
Table 10.1: Findin gs in lumbar di sk di sease
Level Nerve root Sensory loss Motor loss Reflex loss

L1-L3 L2, L3 Anterior thigh Hip flexors None
L3-L4 L4 Medial calf Quadriceps, Knee jerk
tibialis anterior
L4-L5 L5 Lateral calf, EDL, EHL None
dorsal foot
L5-S1 S1 Posterior calf, Gastrocnemius/soleus Ankle jerk
plantar foot
S2-S4 S2, S3, S4 Perianal Bowel/bladder Anal wink
(Fig. 10.18) lower motor neuron lesion of lower

limb below the level of lesion and absent ankle
jerk is a surgical emergency. Far lateral disk
prolapse is uncommon and affects the exiting
root (Fig. 10.19).
Meralgia Paresthetic a
This condition should not be thought of as a
lumbar spine condition. Pain or paresthesia is felt
in the anterolateral aspect of the thigh in the
distribution of the lateral cutaneous nerve of the
thigh. The nerve is entrapped or irritated usually
at the level of the inguinal ligament.
Marfan's Syndrome
Tall stature with arachnodactyly, arm span more
than the height, high arch palate, heart disease,
dislocation of lens, scoliosis and pectus carinatum
or excavatum.
NEUROFIBROMATOSIS (VON RECKLING- Fig. 10.18: Saddle anesthesia with loss of sensation
HAUSEN'S DISEASE) in dermatomes S3 to S5
Presents with five or more café-au-lait spots

greater than 15 mm in diameter, multiple
neurofibromata, local gigantism, axillary
freckling, and leg length discrepancy.
Scoliosis
It is lateral bending with rotation of the spine.
Scoliosis society has accepted >10 degrees of
Cobb's angle as scoliosis. Spinal balance is
assessed by plumbline from C7 to know whether
it bifurcates the sacrum (natal cleft). List is a pure
planar shift to one side in the coronal plane. It
may be caused by pain, muscle spasm and more
common in lumbar disk prolapse.
Salient Points to be asked are:
• Birth history (cerebral palsy), any congenital
problems or other significant past history
• Family history of spinal deformity
• Breathing problem Fig. 10.19: Relationship of exiting
• Neurological symptoms and transiting roots
• Deformity—when was it noticed, who the concavity of the curve

noticed it, is it static or progressive balanced identified by parallel disk
or unbalanced, major (primary) and minor space.
(secondary or compensatory curves) Neutral vertebra - Vertebra without any rotation
Treatment taken previously. Stable vertebra - Bifurcation line from mid
Aim of examining scoliosis: sacrum cutting the vertebra
1. To know the extent on the curve equally into two
2. Cause: Idiopathic (Infantile 0 to 3 yr, halves. Fusion should be up
juvenile 4 to 9 yr, adolescent 10 to 18 yr), to this level.
congenital, neurological, myopathic,
Scanogram of chest wall.
tumors, metabolic, degenerative
MRI-scan for spinal dysraphism, syrinx, Arnold-
3. Structural or non-structural curve
Chiari malformation.
4. Progressive or static; balanced or not
Pulmonary function test and spirometry are
5. Abnormal neurology
done and not to operate if vital capacity is below
6. Pulmonary function
40 percent in Duchenne's muscular dystrophy.
Short, sharp curves with penciling of ribs,
scalloping of vertebra and enlarged neural Kyphosis
foramen due to dumbbell tumors are
characteristic of scoliosis due to neuro- Forward bending of spine is called kyphosis.
fibromatosis. Normally dorsal spine has 30 to 40 degrees
Large "C" shaped curve, more severe, can be kyphosis. Hyperkyphosis is forward bending
of neurogenic or myogenic origin. more than the normality. In thoracic spine >55
degrees is pathological (Fig. 10.20), flexibility can
Investigation
be tested by kneeling test (Fig. 10.21). If the
kyphosis is one or two levels then it is called
Long plain X-ray to include both iliac crests for angular kyphosis (Gibbus). If it extends on all
Risser's sign. Scoliosis is most apparent by spine then it is called rounded kyphosis. It can
looking from back, front and sides (see Fig. 10.6A be con ge ni ta l, de ve lo pm en ta l (a do le sce nt
to C) . The forward bending Adam's test Scheurmann's kyphosis—osteochondritis of
differentiates the structural from nonstructural spine), infection (tuberculosis or nonspecific
scoliosis where the scoliosis persists on bending, infection), traumatic, degenerative (osteoporotic
with rotation of spine causing rib hump in dorsal compression fracture) and tumors.
spine scoliosis. Lateral bending is to assess the
flexibility of the curve (correctability). In a smaller Spinal Infection
child vertical suspension test can be used to assess
the correctability. Spinal infection can be specific infection like
tuberculosis or nonspecific pyogenic infection.
Lateral bending film. Pott's spine or caries spine due to Mycobacterium
Cobb's angle - Angle subtented by drawing tuberculi can occur at any age and usually affects
perpendiculars from a line the dorsal spine and can be of multisegment
along the superior surface involvement. Commonly, infection will involve
and inferior surface of the the end-plates of two adjacent vertebrae across a
end vertebrae. disk space. History of exposure to tuberculosis,
Apical vertebra - Most rotated vertebra at the back pain, night pain, loss of weight and appetite,
apex of the curve evening fever, localized tenderness over spine,
End vertebra - Most tilted vertebra towards stiffness and rarely cold abscess formation at
Malign ant Spinal Disease

Metastatic disease accounts for the majority of
malignant lesions of spine. Elderly patient with
sudden onset, back pain without any cause
should raise the clinical suspicion of metastasis.
There is progressive pain that is unresponsive to
rest and normal conservative measures. Previous
history of malignancy treatment, loss of weight,
appetite, and symptoms and signs of metastasis
to lungs and liver must be enquired. The
common primary malignancies that metastasize
to bones are breast cancer, prostrate cancer, lung
cancer, lymphoma, renal and thyroid cancer.
Isotope bone scan is helpful to know the extent
of metastasis.
Multiple myeloma is the most common
primary bone malignancy.
Fig. 10.20: Method of measuring various parameters of Cauda Equina Syndro me
sagittal spinal alignment. The sagittal vertical axis (SVA)
is positive in kyphotic deformities, because the C7 plumb As the spinal cord ends at lower border of L1
line anterior to the sacrum. δ = the Cobb angle between vertebra, any lesion below this level inside the
two vertebrae. β = the angle of sacral inclination spinal canal can affect only filum terminale
(bunch of roots). This is characterized by saddle
anesthesia over the genitalia, perineum and
buttocks, with retention of urine, disturbance of
defecation and lower motor neuron paralysis of
lower limbs with absent ankle jerk. A massive
central disk prolapse of lower lumbar spine can
cause this syndrome and should be treated as a
Fig. 10.21: Kneeling test for evaluating the flexibility surgical emergency to prevent permanent deficit.
of kyphotic deformity
Spondylolisthesis
different sites may be present. Paraparesis may Forward slipping of one vertebra over another.
be a late presentation. It is common in lower lumbar spine and can
Pyogenic vertebral osteomyelitis occurs most present with back pain or neurogenic
commonly in lumbar spine and occurs due to claudication pain due to canal stenosis or root
hematogenous seedling from genitourinary tract, pain from lateral canal stenosis and clinically
skin or respiratory tract. The initial focus of hamstring tightness (limitation of forward
infection is the vertebral end-plate. Common flexion), step on palpation of spinous process, flat
presentation is back pain, unrelieved by rest and back and narrowing of loin space (foreshortened
local spinal tenderness. Constitutional symptoms trunk) may be noted. Antalgic gait with flexion
may be present. Neurologic deficit can occur. of knee and prominent buttock can be present in
extreme slips with a "spondylo crisis". Most

common is the isthmic type where there is a
defect in pars interarticularis, which is
developmental and present at young age. The
other types are congenital, traumatic,
degenerative and pathological in origin.
Inflammatory Spondyliti s
(Ankylosing Spondylit is)
Pain starts before the age of 40 especially in male
of upper back pain with more than 3 months
history, insidious onset, and worse in early
morning with associated sacroiliitis features
alleviated by exercise. Increasing dorsal kyphosis
with stiffness with restrictive lung disease
limiting chest expansion and severe disease can
cause hip arthritis and hip fusion. This results in
hunch back deformity (Fig. 10.22), chin to chest
deformity (Fig. 10.23), flexion deformity of the Fig. 10.22: Stooped posture in a young man due to
hip with fusion of spine obvious in X-ray as ankylosing spondylitis (For color version, see Plate 5)
bamboo spine.
Scheuermann's Kyphosis
This is a developmental condition of ring
epiphyseal osteochondritis of vertebrae
occurring in adolescence with increased thoracic
kyphosis more common in males presenting with
back pain. Radiographic criteria for diagnosis are
3 contiguous vertebral bodies with greater than
5 degrees of anterior wedging, abnormal disk
space narrowing, endplate irregularities and
Schmorl's nodes, defined as disk herniation into
vertebral bodies.
Failed Back Syndrome

Often the result of poor patient selection but other
causes include recurrent herniation, herniation
at another level, discitis (3 to 6 wk postop with
rapid onset of severe back pain), Unrecognized
lateral stenosis and vertebral instability. Epidural Fig. 10.23: Measurement of the distance between the
fibrosis and focal arachnoiditis and nerve external occipital protuberance and the wall with the
damage may due to iatrogenic surgical injury are patient standing erect heels touching the wall in cervical
other causes including wrong level surgery. kyphosis especially in ankylosing spondylitis
EXAMINATION OF THE CERVICAL SPINE Dizziness

Neck pain is second only to back pain as a Sudden neck movements can cause vertebro-
common complaint. basilar insufficiency in cervical spondylosis
History taking in patients with neck problems leading to dizziness.
must establish details of the following symptoms.
Miscellaneous
Pain
Other symptoms are often volunteered
The mode of onset (spontaneous, sudden, particularly after injuries such as whiplash. These
gradually shortly after an injury, etc.) must be include headache, tinnitus, dysphagia and
established in detail. The site of pain with any blurred vision.
radiation, aggravating or relieving factors are
important. Neck pain can be in the midline of Other History
the neck or in the paraspinal area or can be
referred to suprascapular area across the Involvement of other joints, constitutional
shoulder, and it may radiate to upper limb or symptoms, dysphagia, neck swellings, relevant
the occiput. Patients with severe radicular pain past history, family history, social history and
in the upper limb due to cervical disk prolapse treatment history must be recorded.
may feel better with the arm supported or
keeping it raised than letting the arm down to What is Patient' s Expectation?
hang by the side of the body. Very localized pain Following history-taking, a differential diagnosis
in the supra- or interscapular area can be due to should be formed in the examiner's mind. Often
nodular fibrositis in muscle. the findings on physical examination will make
the diagnosis clear without recourse to any
Stiffness special tests. Diagnostic categories include:
This often accompanies pain and may be variable Traumatic— w hiplash injury, fracture or
and subjective (often worse in the morning) or dislocation with or without neurological
constant with objective loss of movements. involvement.
Neurologic al Symptoms Degenerative— c ervical spondylosis, disk

prolapse, canal stenosis, central cord syndrome.
Brachialgia, weakness, numbness, paresthesia (pins
and needles sensation) in the upper limbs. Weakness Infective— spinal tuberculosis or other bacterial
in the lower limbs suggests spinal cord damage. infection.
Neoplastic— i n particular metastatic spinal
Deformity
disease.
Can be marked cervical flexion deformity from
Congenital— Klippel Feil syndrome, sprengel
degenerative disease, inflammatory disease or
shoulder, syringomyelia, cervical rib.
instability; chin to chest deformity in ankylosing
spondylitis; wryneck or torticollis (lateral Inflammatory— rheumatoid, ankylosing spondy-
bending) due to various causes. litis.
Local Examination Move

As in most orthopedic examinations the look, Active range of movements are assessed by
feel, move system is useful. asking the patient to move and then helping the
Neck examination begins with the patient patient to move to his maximum range without
standing (if he can) and continues with the hurting him (assisted active movement). Flexion
patient lying supine when the neurological is by asking the patient to do chin on chest;
examination is carried out. extension by looking at roof; lateral bending by
ear to touch shoulder without shrugging the
Look shoulder and lateral rotation by turning to left
and right to look at each shoulder.
The patient should be undressed to allow
Spurling test: This is tested by slight
exposure at least from the waist up.
extension, lateral flexion and rotation of the neck
You must be able to look from the front, side
to reproduce the same pain in the neck and arm.
and back of the patient. Some information can
This manoeuvre causes narrowing of
be obtained by noting the patient's posture
intervertebral foramen causing root irritation in
during history taking, observing how much head
lateral canal stenosis (Fig. 10.24).
movement occurs during conversation and
whether he has difficulty undressing.
Lhermitte's Sign
When he is undressed look for asymmetry,
muscle wasting—trapezius, deltoid, spinati, Presence of electric shock like sensation radiating
pectoral muscles, small muscles of hand; down into the limbs on flexion of spine either
abnormal posture, scars (which may be very neck or trunk indicates spinal cord lesion.
inevident) and swellings.
Feel
The cervical spine is palpated from the back with

patient sitting and examiner looking at patient's
face for any tenderness. Feel the midline of spine
for tenderness and deformity, then paraspinal
tenderness and then the front of the neck. The
anterior aspect of spine can be felt by palpating
the spine along the medial aspect of
sternomastoid in the upper half from the back of
the patient, and carotid pulse can also be felt. Feel
only one side at a time to prevent vasovagal
shock. Then feel for muscle tenderness or nodular
swelling over suprascapular area. Neck swellings
are examined as discussed in Chapter 1.
In some patients with muscle spasm,
examination of the posterior aspect of the
neck may be more easily and reliably done
with the patient prone and head resting over
a pillow. Fig. 10.24: Spurling test
Neurological Examination (root compression), and myelopathy (cord

Assessment of tone and power in all major compression). In root compression the exiting
muscle groups in all four limbs is required. root is involved, for example, C5, C6 disk disease
Reflexes are elicited and sensation is tested (this affects C6 root (remember C1 root exits above
can be limited to light touch and pinprick in C1 vertebra and the other roots are numbered
certain circumstances). Of course specific accordingly, C8 root exits between C7 and T1
pathologies will lead to specific neurological vertebra) (Table 10.2) . Myelopathy is
deficits and the examiner will when experienced characterised by weakness of upper and lower
enough, be able to quickly identify and limbs, sensory disturbance, spasticity, upper
demonstrate to any observer the key findings motor signs in lower limb, radicular signs in
which suggest a specific diagnosis. upper limb with weak intrinsics and ataxic broad
Examples are: Cervical disk prolapse leading ba se d sh uf fl in g ga it . Fu ni cu la r pai n is
to radiculopathy. Commonly the C6 or the C7 or characterized by central burning and stinging
the C8 root are involved with a lower motor with radiating lightning like sensation down the
neurone (LMN) pattern of deficit (weakness, back with neck flexion (Lhermitte's sign) may be
wasting, diminished or absent tendon jerk present. Inability to open and close the hand
specific to that root). rapidly, little finger abducts from the fingers on
Rheumatoid neck, canal stenosis or other asking the patient to keep the finger extended
pathology such as ununited odontoid fracture are tests for cervical spinal stenosis. Hoffman's
can lead to cord myelopathy with more test may be positive where one flicks the terminal
widespread weakness, LMN signs phalanx of middle finger into extension
predominating in upper limbs with suddenly, the index finger and thumb flex.
hypertonicity, brisk reflexes, and upgoing Positive inverted brachioradialis reflex where
plantar responses (upper motor neuron signs) in finger flexion is seen with brachioradialis reflex.
lower limbs.
Fibromyalgia
SPECIFIC CONDITIONS A clinical syndrome of diffuse pain, present at
rest and exacerbated by activity, fatigue and sleep
Cervical Spondylosis/Cervical Stenosis
disturbance. History of diffuse pain, patient
Degenerative disk disease with facet arthropathy complaining pain all over with tender points on
of cervical spine can present with discogenic palpation. Pain and tender points can be at
neck pain (mechanical pain), radiculopathy insertion of cervical paraspinal muscles on
Table 10.2: Finding s in n erve root com pression
Level Root Muscles affected Sensory loss Reflex

C3-C4 C4 Scapular Lateral neck, shoulder None
C4-C5 C5 Deltoid, biceps Lateral arm Biceps
C5-C6a C6 Wrist extensors, biceps, Radial forearm Brachioradialis
triceps (supination)
C6-C7 C7 Triceps, wrist flexors Middle finger Triceps
(pronation)
C7-C8 C8 Finger flexors, interossei Ulnar hand None
C8-T1 T1 Interossei Ulnar forearm None
occipital condyles, sternocleidomastoid muscle profound weakness at the level of injury and
over lateral transverse processes of C5 to 7, belly upper motor neuron lesion in the lower limb with
of trapezius, supraspinatus, over rhomboids, variable sensory disturbance. This syndrome has
lateral epicondyle, 2nd rib pectoralis insertion, good prognosis for recovery.
upper outer buttocks and greater trochanter.
Some patients have palpable tender knots Anterior cord syndrome: This is due to damage of
representing local muscle spasm. anterior two-third of the cord, sparing the
posterior columns. These patients have profound
Spinal Cord Inju ries
weakness of lower limb than upper limb. The
prognosis is worst.
Spinal cord injury (SCI) assessment should not
be left to the inexperienced doctor. The first Brown-Sequard syndrome or lateral cord syndrome:
neurological examination in such patients is of This is due to damage of one-half of the cord.
vital importance and must be very thorough. This is characterized by lower motor neuron
Cord injuries may be complete or incomplete and lesion at the level of cord injury, ipsilateral loss of
although the former are tragically not rare it is posterior column sensation-position and
very difficult to be sure that an injury is truly proprioception, ipsilateral upper motor neuron
complete on initial assessment. Truly complete lesion, and contralateral loss of pain and
cervical cord lesions rarely recover. Incomplete temperature sensation (due to crossing of lateral
lesions may recover fully. Any sign of cord spinothalamic tract at each level of entry into spine).
function below the level of injury means the This has the best prognosis.
lesion is incomplete. The poorly understood
phenomenon of spinal shock that can last a few Sprengel Deformity (Fig. 10.25)
days makes a full assessment difficult even for Congenital elevation of scapula usually
the experienced. unilateral, producing shoulder asymmetry and
Apart from classifying lesions as complete or small scapula. It can be associated with scoliosis,
incomplete the cervical cord lesions of an Klippel Feil syndrome (congenital cervical spine
incomplete nature can usefully be grouped into fusion, low hair line and restricted neck
anterior, lateral (Brown-sequard), posterior (rare) movements), fused ribs and other anomalies.
and central cord syndromes and in any case Patient usually presents for cosmetic deformity
mixed patterns of injury do regularly occur. and rarely for restriction of shoulder movements,
They may be initially in a state of spinal shock particularly abduction. Bony omovertebral bar
that usually lasts 24 to 48 hr and recovery from may be present between the superomedial aspect
spinal shock is noted by reappearance of of scapula to lower cervical spine (Fig. 10.26).
bulbocavernous reflex. On return of
bulbocavernous reflex if evidence of complete Back Pain in Childr en and Adol escents
spinal cord injury is still present, then the patient
has a grave prognosis for return of power. In children younger than 5 years the likely
diagnosis is tumor or discitis; 5 to 10 years it is
Central cord syndrome: This syndrome is most Langerhans cell histiocytosis, discitis (tuberculosis
common in elderly due to hyperextension injury or pyogenic) or infective spondylitis, or tumor/
causing damage to central gray matter and leukemia; 10 to 18 years it is Scheuermann's
surrounding white matter. This is characterized kyphosis, herniated disk, apophyseal ring
by lower motor neuron lesion in the upper limb fracture, spondylolysis or listhesis, ankylosing
due to damage of anterior horn cells causing spondylitis, osteoid osteoma/osteoblastoma in
Fig. 10.25: Sprengel shoulder Fig. 10.26: Bony omovertebral bar on the right side
with high riding scapula
posterior element of spine, aneurysmal bone of vertebra. Painful left thoracic scoliosis can be
cyst—expansile lytic bubbly appearance of spine associated with spinal dysraphysm—tethered
body and tumors like Ewing's and osteosarcoma cord or syringomyelia.
11 Examination of Hip
CHAPTER
The hip joint is the largest ball and socket joint sport, etc. Each should be quantified to assess the
with extreme degrees of movement in all disability and to plan treatment.
directions. Its versatile movements are important
for standing, walking, running, jumping, sitting Stiffness
cross-legged, sexual activities and childbirth. The Patients explain this in their own terms like
examination should be in a systematic fashion. inability to bend forwards, inability to reach
Introduce yourself and ask the name, age, and toenails to trim, difficulty in putting socks or
occupation. shoes, inability to squat on Indian toilet and tricks
patients employ to get dressed and do activities.
PRESENTING HISTORY
Patient may also mention about morning stiffness
Pain in arthritic conditions.
Ask for onset, duration, nature of pain, Limp, Shortening or Deformity

aggravating and relieving factors—pain on
activity or at rest, pain when first setting off to Shortening and fixed deformities can lead to tilt
walk, pain that stops patient walking, i.e. start of the pelvis and limp, which can be a presenting
up pain may be different from stopping pain, i.e. feature. Limping can also be due to pain or
loose femoral stem in failed THR or differential weakness of abductor mechanism.
pain from spinal and vascular claudication; and
Others
radiation. Night pain indicates the severity of
pain in arthritic conditions either due to History of multiple joint problems especially
osteoarthritis (OA), rheumatoid arthritis or other hip involvement (avascular necrosis,
infective arthritis (TB). Hip pain is mostly over dysplasia of hip), constitutional symptoms, loss
the groin, buttocks area and sometimes radiates of weight and appetite (tuberculosis, secondaries
to the inner aspect of thigh up to the knee. Kids in subtrochanteric area) and any history of
with hip problem present with referred pain in trauma must be recorded.
the knee, which is through the innervation of
obturator nerve. Ask about numbness and pins Past History
and needles to identify neurological problem or
spine pathology. Hip problems, significant medical problems like
tuberculosis, diabetes, hypertension, childhood
Level of Activ ity
problems in hip-sepsis, obstetric history, if
known, that is breech presentation, milestones
This includes the walking distance, day-to-day and congenital anomalies; hip operations, steroid
activities, performance of job, hobbies including intake, occupational exposure (Caison's disease),
etc. Abdominal, urological and gynecological a. Short limb gait: Here the patient walks either
symptoms with referral to hip joint must be kept with equinus of the ankle on the affected side
in mind and asked for. to compensate for the short limb or one can
notice drooping of the shoulder and pelvis
Person al and Social Histor y towards the same side. When the patient stands
he or she can compensate for the shortening by
Married or unmarried, smoking, alcohol
keeping the unaffected leg bent (Fig. 11.1).
(avascular necrosis), hobbies, the type of house
b. Trendelenburg gait: On weightbearing on the
(stairs) and toilet facilities.
affected side, the weak abductors fail to raise
the pelvis on the opposite side. So the center
Family History
of gravity fails to shift towards the weight
Any similar problems. bearing leg. To achieve balance the upper
trunk sways towards the weight bearing leg
Treatment Histo ry to move the center of gravity closer to weight
bearing leg. If the Trendelenburg gait is
Allergies, all types of treatment patient has had
present bilaterally it produces typical
(tablets, local injections, physiotherapy, surgery)
waddling gait (duck walking).
and the response to it.
c. Antalgic gait: Patient has a short stance phase
(less time of weightbearing on the affected
What is Patient's Expectation?
leg) and short stride walk (small steps).
Treatment is dictated by the needs of the patient, d. Stiff hip gait: Very little movement of the hip
employment, that is, type of job being done now characteristically produces swinging of the
and possibilities in future, specific activities pelvis with circumduction of the leg to clear
needing unusual or prolonged hip activity- the ground.
religious activities. Walking aid and footwear assessment done.
GENERAL EXAMINATION
Local Examination
The sequence of examination in walking,
standing, sitting and then lying down posture is
ideal. It is cumbersome to ask the patient to
change the examination position every time for
our convenience. The economy of movements
and smooth flow of examination gains
confidence of the patient. It is better to go through
look, feel and move at each step before you
change the position of the patient.
Gait
Walking with and without walking aids.
This is analyzed with brisk walking on bare
foot. Fig. 11.1: Short left leg
Examination of Hip 111
PATIENT STANDING I prefer to do Trendelenburg's test by

combining the ways described above. Kneeling
Examination
Examination f rom Front in front of the patient, feel the anterosuperior iliac
Assess the attitude and deformity in hip, knee and spines and place the patient's hands on either side
foot. Note any scars, skin changes, swelling, contours
contou rs of examiner's shoulder. Now ask the patient
and muscle wasting especially quadriceps. to stand on the affected leg. Positive
Assess shortening of leg by block test: With Trendelenburg's test is indicated by downward
appropriate size blocks under the foot assess the pressure exerted by the patient on the examiners
shortening by achieving both anterosuperior iliac shoulder with the opposite hand and also the
spines at same level. sagging of the opposite anterosuperior iliac
spine. This method confirms both by tactile
Trendelenburg's test (Fig. 11.2): There are many perception and traditional way of assessment.
ways to do this test and you must be comfortable The single leg stance should be maintained
with the way you do. From front feel for the for at least 30 seconds as delayed Trendelenburg's
anterosuperior
anterosuper ior iliac spine (ASIS) with your thumb test could be positive. False-positive test can
and position yourself by kneeling down to the occur with fixed abduction contracture, painful
level of pelvis. The first bony prominence felt abduction, in poor balance due to generalized
while palpating the groin from below and medial weakness especially in elderly people. The test
is anterosuperior iliac spine. Ask the patient to can be positive with any disorder affecting the
stand on sound leg lifting the other
ot her leg by flexing fulcrum (hip), the lever arm (neck) and the power
the knee but not the hip. The opposite side pelvis (abductor muscles).
tilts up due to the abductor muscle function on
the sound leg. Standing on the affected leg (single Examination
Examination fr om Side
leg stance) causes drooping of the opposite side
pelvis due to inefficiency of abductor mechanism. Assess for flexion deformity at hip, knee and
This can be well-appreciated by feeling the exaggerated lumbar lordosis.
anterosuperior iliac spine. The positive test is
when the opposite side anterosuperior iliac spine Examination
Examination fr om Back
drops (sound side sags). This test was originally Look for scars, wasting of gluteal muscles,
described by looking at the back of the patient Trendelenberg test noting the buttock-fold raise
exposing the buttocks and asking the patient to or drop.
do single leg stance. The drop in the buttock fold
(gluteal fold) must be appreciated on the non-
weightbearing side by standing on the affected
leg in a positive test.
Apley's method: Place one hand on shoulder
of test side. Use the other hand to support the hand
of opposite side. This hand is to assess the
downward pressure. Now ask the patient to stand
on test side. The other leg, which is lifted off the
ground, should only be bent at the knee. The
positive test is indicated by downward pressure
exerted on supporting hand. This is a more elegant
test and can be done without stripping the patient
in the outpatient clinic (Figs 11.2 and 11.3A and B). Fig. 11.2: Trendelenburg's test
Figs 11.3A
11.3A and B : Trendelenburg's test-alternate method
SUPINE ON COUCH iliacus and psoas muscle and accessory muscles

of help are rectus femoris, sartorius, tensor fascia
Look lata, pectineus, and adductors. Strength of
Reconfirm all the inspection findings like iliopsoas is tested by placing the patient in sitting
exaggerated lumbar lordosis, attitude of the leg, posture to fix the pelvis and actively ask the
deformity, wasting, leg length discrepancy, etc. patient to elevate the flexed knee against
resistance. To assess fixed flexion deformity
Feel (FFD) Thomas test is done. Place hand behind
the back to assess lumbar lordosis. The examiner
Ask the patient for tender spot and feel this last. flexes the patient's normal hip and knee until the
Always look at the patient's face. Feel for lumbar lordosis is obliterated. Now the affected
tenderness along greater trochanter (trochanteric hip reveals the fixed flexion deformity if any.
an y. Ask
bursitis),
bursitis), anter
anterior
ior joint line, that is along the groin
groin,, the patient to clutch the unaffected bent knee to
and feel for lymphadenopathy. Feel for any the chest and flex the affected hip from the
abnormal bony mass. Femoral pulse can be feeble position of fixed flexion deformity to full further
furth er
in developmental dislocation of hip (Vascular flexion to assess the range of movement (e.g. FFD:
sign of Narath). 30°; ROM: 30°-110°) (Figs 11.4A and B).
If both hips are affected flex both hips to
Move eliminate lumbar lordosis and then gently extend
one hip passively. Stop when the lumbar lordosis
Flexion (Normal 0-120°)
begins
beg ins to rea
reappe
ppear.
ar. Thi
Thiss is the fix
fixed
ed fle
flexio
xion
n
Ask the patient to actively flex to have an idea of deformity of that hip. Similarly repeat the test
pain-free movements. The primary flexors are for the other hip.
Figs 11.4A
11.4A and B: Thomas test
In special cases where there is fixed flexion

deformity of knee, place the patient so that the
knee is at the edge of the couch to eliminate the
effect of FFD at knee.
In patients with deformed femoral head or
any rotational deformity, on bending the hip an
'axis deviation' can be appreciated.
Example: Normally on flexing the hip the knee
approaches the same shoulder, but in slipped
capital femoral epiphysis with fixed external
rotation deformity there is axis deviation on
flexing, with knee pointing out on extreme flexion.
Rotation in Extension
In extended knee rotate the leg by holding the foot
with one hand and the other hand over the th e lower
thigh and turn the foot in and out for internal and
external rotation, respectively (Fig. 11.5).
Fig. 11.5: Testing internal rotation of
Rotation in Flexion hip with knee extended
Hip flexed to 90°, knee flexed to 90° use leg as a

lever arm to do internal rotation (Normal 0 to The prime internal rotators are gluteus minimus
45°) by turning the foot out and external rotation and tensor fascia lata. Accessory muscles that
(Normal 0 to 45°) by turning the foot in. This test help in internal rotation are gluteus medius,
can be done in prone position especially in semitendinosus and semimembranosus. The
children for more accuracy. Differential range of prime external rotators are obturator externus
rotational movements in flexion and extension and internus, piriformis, superior and inferior
positions of the hip indicates deformed femoral gemelli, gluteus maximus and sartorius (Figs 11.6
head (Perthes' disease, avascular necrosis of hip). and 11.7).
Fig. 11.6: Testing internal rotation of Fig. 11.7: Testing external rotation of
hip with knee flexed hip with knee flexed
Abduction/Adduction in Extension flexion is easy because of the flexion attitude of

the limbs in young kids. Normally the thigh
Try active movements first. Active adduction is
should touch the couch on abduction.
done by adductor magnus, brevis, longus,
pectineus and gracilis. Active abduction is Telescoping test: Fix the pelvis with one hand,
primarily done by gluteus medius and accessory thumb feeling the ASIS and forefinger on greater
muscles of help are gluteus minimus, tensor trochanter, flexing the hip and knee 90°. Hold
fascia latae, upper fibers of gluteus maximus. the leg with other hand and give axial force along
Keep the hip and knee extended, fix the pelvis the thigh and feel for superior displacement of
after squaring the pelvis as mentioned below. The trochanter in relation to ASIS (Fig. 11.10).
pelvis can be fixed in children by palpating both Patrick's 'faber' test (flexion, abduction and external
anterior superior iliac spines (ASIS) with one rotation test): This produces click and pain in osteo-
hand span. In adults the pelvis can be fixed with arthritis or in acetabular labral tear (Fig. 11.11).
forearm and the other hand used to move the
leg. Now assess the range of movements of Measurement
abduction (Normal 0 to 40°) and adduction
Apparent leg length discrepancy can be measured
(Normal 0 to 25°) (Figs 11.8 and 11.9).
from xiphisternum to medial malleolus keeping the
body and legs parallel to the couch and not making
Abduction in Flexion
any attempt to square the pelvis. This gives the
In neonates and young children it is easy to functional leg length discrepancy (Fig. 11.12).
appreciate the limitation of abduction with hips Feel for anterior superior iliac spine and make
and knees flexed, and performing pelvis square (line joining both ASIS is
simultaneously on both sides. Abduction in perpendicular to the couch). Attempt to make
Fig. 11.8: Testing abduction of hip with knee extended
Fig. 11.9: Testing adduction of hip with knee extended

Fig. 11.10: Telescoping test
Fig. 11.12: Apparent measurement
Fig. 11.11: Faber test Fig. 11.13: True measurement
legs parallel to the couch with pelvis squared. makes the pelvis square indicates the degree of
Now measure the leg length from ASIS to medial abduction contracture from the neutral position.
malleolus. This is the true length measurement. Further free abduction is assessed from this point
Make sure the legs are in identical position and (e.g. fixed abduction deformity 20 degrees; free
attitude (Fig. 11.13). abduction 20 to 40 degrees).
In abduction contracture the ASIS will be at a In adduction contracture the ASIS will be at a
lower level on the affected side when the legs higher level on the affected side when the legs are
are parallel and to square the pelvis the leg needs parallel. Adducting the affected leg further until
to be abducted. The point when the abduction both ASIS are perpendicular to the table can square
the pelvis. The degree of adduction necessary to Galleazi's or Allis's Sign

square the pelvis is the fixed adduction deformity.
Flex knees to 90° with hips and ankles at 45°.
Further free adduction is assessed from this point
Keep both malleoli at same level. Note the level
(e.g. fixed adduction deformity 20 degrees; free
of knees and parallelism of femora and tibia. If
adduction 20 to 40 degrees).
knees are at different levels, and tibia are parallel,
In both adduction and abduction contracture
the discrepancy is in tibia. If femora are parallel
true leg length measurement can be done only
the discrepancy is in femur (Fig. 11.15).
after squaring the pelvis and measuring each leg
in the same identical position (Fig. 11.14). Please
Bryant's Triangle
note, the adducted leg crosses over the other leg
and is measured from ASIS to medial malleolus. Identify ASIS with thumb and tip of greater
The other leg needs to be crossed in the same trochanter with forefingers. Assess the
way, maintaining the same degree of adduction perpendicular distance between the two points.
before measuring from ASIS to medial malleolus. This gives an idea on supratrochanteric
Flexion, varus or valgus deformity of the knee shortening. Supratrochanteric shortening can be
will affect the measurement of the legs. In such due to fracture neck of femur, traumatic
cases it is better to measure thigh and leg segments dislocation of hip, developmental dislocation of
separately. ASIS to knee joint line or tibial hip, avascular necrosis with collapse, arthritis
tuberosity, and from there to medial malleolus. hip—rheumatoid, infective and coxa vara.
Roser-Nelaton's line: If both hips are affected
construct Roser-Nelaton's line. This is a line
joining ASIS to ischial tuberosity. The tip of the
greater trochanter should touch this line
normally (Fig. 11.16). If it lies above this line
supratrochanteric shortening is confirmed.
Chiene's lines: The lines joining the two ASIS and
two greater trochanter are normally parallel to
each other. This is disturbed if trochanter is
shifted up (Fig. 11.17).
Schoemaker's line: The lines joining the greater
trochanter and ASIS when extended above from
both sides may cross above the umbilicus in the
midline normally. In supratrochanteric shortening
on one side the lines may cross above the
umbilicus away from the midline. In bilateral
supratrochanteric shortening these lines may cross
in the midline below the umbilicus (Fig. 11.17).
Morris bitrochanteric line: The distance from pubic
Fig. 11.14: Measurement from anterosuperior iliac
symphysis to greater trochanter is measured.
spine to medial malleolus varies in different positions This again indicates supratrochanteric
of adduction and abduction but measurement taken shortening (Fig. 11.17).
from the hip joint (fulcrum) to medial malleolus remains Infratrochanteric shortening is accounted by
constant actual measurements of individual components
Fig. 11.15: Galleazi's sign
Fig. 11.17: Showing the construction of A:

Schoemaker's line, B: Chiene's line, C: Morris
Fig. 11.16: Bryant's triangle and Nelaton's line bitrochanteric line
of femur and tibia. This can be from femoral shaft PRONE EXAMINATION
or tibia or calcaneum malunited fracture or from
Examine the spine, buttocks for any scars,
growth disturbance.
wasting of muscles, extension (Normal 0 to
15°), internal and external rotation of hip (Figs
LATERAL ON COUCH
11.18 to 11.20). Gluteus maximus is the prime
Test active abduction and also palpate the mover of extension of hip with the accessory
abductors for power against resistance. Draw muscles of help are semimembranosus,
Roser-Nelaton's line if necessary. semitendinosus and biceps femoris. Feel for
Fig. 11.18: Testing extension of hip
Fig. 11.20: Testing external rotation of hip with k nee

flexed in prone position
bend both hips to obliterate the lumbar lordosis,

that is, the lumbar spine is flat and parallel to the
couch. Extend one hip at a time and check when
the lordosis begins to reappear. This indicates the
Fig. 11.19: Testing internal rotation of hip with k nee
FFD of that hip. Repeat the same in the other hip.
flexed in prone position
The examiner may need an assistant to hold the
legs that hangs free from the couch.
Examination is completed by sacroiliac stress
any abnormal mass (dislocated femoral head
test, opposite hip examination, examination of
or myositis ossificans).
ipsilateral knee and foot. Spine should be
Prone examination is useful to assess the
examined including neurological assessment to
version (anteversion or retroversion) of femur as
rule out any radiating pain.
discussed in the assessment of rotational
General abdominal examination—femoral
malalignment of the leg (Chapter 14).
hernia, urological problem and other pathology
Prone on couch is avoided if patient cannot lie
giving hip pain vascular supply (saddle thrombus—
because of pain or severe fixed flexion deformity
buttock and leg pain) must be considered.
of the hip or obesity or other medical problems.
In children with bilateral fixed flexion CONDITIONS AFFECTING HIP
deformity, flexion deformity of each hip can be
revealed in prone examination. Bring the Developmental Dysp lasia of Hip (DDH)
patient's pelvis to the edge of the couch so that History: Birth history—breech presentation, first
the thighs hang down and can be flexed. Now born female child, developmental milestone,
family history of DDH. Mother may notice anterosuperior iliac crest. Test is positive in free
difficulty in abduction while putting nappy or proximal and distal movement of greater
can present late at the age of walking with limp trochanter in DDH, old unreduced posterior hip
or short leg. dislocation, dislocated total hip replacement,
fracture neck of femur or loss of head/neck.
Clinical Signs
Trendelenburg's test: This test is done in an older
The clinical signs to be assessed are: child who can understand and cooperate. This
test is done as described earlier.
Barlow's test: The baby must be relaxed and it is
helpful to examine the baby shortly after a feed. Galleazi's sign or Allis's sign: Shortening of the
Hold both the lower extremities in such a way limb from pelvis to knee is observed by flexing
that the knees are flexed to 90 degrees and the the knees and the hips as described before.
upper thigh is held with the thumb along the
medial aspect and the middle or ring finger Asymmetrical Skin Crease
behind the greater trochanter.
Restricted abduction Foot anomalies, torticollis,
The hip is adducted while pressing down gently
plagiocephaly and associated congenital
on the knee with the palm and inside of the thumb.
anomalies.
An unstable hip may dislocate with a soft cluck.
X-ray finding is illustrated in Figure 11.22.
This is a test for dislocatable hip (Fig. 11.21).
Ortolani's test: The child is held as above; the hip Osteoarthritis (OA)
is then flexed to 90° and gently abducted while
It is a degenerative wear and tear process of hip
lifting the greater trochanter upwards with the
joint of primary or secondary etiology. Primary
fingers. A dislocated hip may reduce with a
OA is common in elderly population while
clunk. This is a test for dislocated hip.
secondary OA can occur at any age.
Telescoping test: The pelvis is fixed, the thigh is Predisposing factors are obesity, trauma-
grasped above the knee and the hip is flexed to fracture or dislocation, AVN, dysplasia, post-
90°. The thigh is pushed and pulled along the infective sequelae, etc.
axis of the femur while the other hand feels the
relationship between the greater trochanter and
Fig. 11.22: Pelvis lines-horizontal Hilgenreiner's line is

through triradiate cartilage and vertical Perkin's line is
through the outer rim of acetabulum. Normally the capital
Fig. 11.21: Testing for DDH, Barlow's test femoral epiphysis is in inner and lower quadrant
Patient presents with pain over the groin or sis, irradiation, etc. Young patient presenting with
buttocks area, morning stiffness, inability to trim hip pain and limitation of movements especially
toe nails or tie shoe lace, difficulty to squat, limp, internal rotation must raise suspicion of AVN.
decreased walking distance and restricted X-ray may be normal in the initial stage, later
movements. Clinical examination reveals antalgic on subchondral fracture, deformation of head,
gait, limitation of movements especially internal sclerosis, cyst formation and secondary OA changes
rotation, fixed deformities and rarely shortening may occur. MRI scan is diagnostic at early stage.
of leg (shortening is common in secondary OA).
Radiologically OA of hip can be medial, Legg-Calve-Perthes Disease
lateral or global arthritis.
Idiopathic necrosis of capital femoral epiphysis
Findings are:
can cause collapse, fragmentation and deformity
a. Narrowing of joint space
of the femoral head. It affects boys four times more
b. Marginal osteophytes
commonly than girls. It usually affects only one
c. Subchondral sclerosis (overweight
bearing part of acetabulam) hip and bilateral involvement is 10 to 15 percent.
d. Subchondral cyst formation (acetabular or Typically presents between the ages of 4 to 8 years,
femoral head side) short stature and delayed milestones (small for
e. Signs of causes of secondary OA. age) has been associated with the disease.
Patient may present with insidious onset groin
Inflammatory Arthriti s or anterior thigh pain or knee pain and limp. The
limb is held in flexion, adduction and external
This is of two types-rheumatoid and non- rotation attitude. Limitation of abduction and
rheumatoid. internal rotation are early signs of hip irritation.
Patient presents with pain, stiffness,
deformity and limitation of activities of daily Differential diagnosis
living associated with other joint problems. • Unilateral—septic arthritis, transient
Non-rheumatoid arthropathy commonly synovitis of hip and epiphyseal dysplasia.
affects hips (ankylosing spondylitis, psoriatic • Bilateral—multiple epiphyseal dysplasia,
arthritis, etc.) usually results in progressive hypothyroidism.
stiffness and sometimes ankylosis of joint.
Rheumatoid arthritis commonly affects small Slipped Upper Femoral Epiphy sis (SUFE)
joints but can affect hips to produce laxity of the It is a cause for pain in boys of 12 to 14 years and
joint with destruction of femoral head and girls of 10 to 12 years age group. Commonly
sometimes protrusio acetabuli. The other hip unilateral and bilateral in 30 percent of cases.
involvement is common. Obesity, rapid growth spurt and endocrinopathy
like hypothyroidism and renal rickets can
Avasc ul ar Necr os is (AVN)
predispose to slip. This condition is a
It is a rare condition affecting the hip joint in the consequence of an imbalance between the forces
age group 20 to 50 years. Fifty percent is bilateral that stabilize the epiphysis and the normal
and in steroid induced AVN it is up to 80 percent mechanical forces that may tend to displace it.
bilateral. The presentation can be acute slip (<3 weeks),
Mostly idiopathic; secondary causes include- acute pain presenting after trauma or in chronic slip
trauma (fracture or dislocation), drugs (steroids, insidious onset of chronic pain in the groin or anterior
antiepileptics, chemotherapy, indomethacin), thigh or medial aspect of the knee. Acute on chronic
alcohol, Gaucher's disease, dysbaric osteonecro- slip can also be a presentation. Patient can have FFD
due to muscle spasm (paradoxical to extension Transient Synovitis of Hip

deformity at the site of slip) and external rotation
It is a common self-limiting condition of unknown
deformity of the leg. Limitation of abduction due to
etiology where there is nonspecific inflammation
varus deformity can also be demonstrated.
of the joint in children less than 8 years old. It can
Shortening of leg may be seen in severe slip.
be a post-viral reaction. The child usually presents
X-ray anteroposterior and frog leg lateral is
with sudden onset limp and pain with no history
recommended.
of injury. It must be differentiated from septic
Widening of physis may be the subtle early
arthritis by normal well-being of the child (not
sign on comparison with opposite normal hip,
irritable, no septic focus and no fever) and normal
with decrease in the height of epiphysis.
blood tests (full blood count and ESR).
Metaphyseal blanch sign, a dense area seen
in proximal metaphysis, which may be due to
Ac ut e Sept ic Ar th ri ti s Hi p
healing process or superimposition of posteriorly
rotated head on metaphysis. Common in neonates and children with classical
Capener's sign—A line (Kliene's line) drawn presentation of pseudoparalysis of the lower limb
along the superior border of the femoral neck due to pain. Child is very reluctant to move the
passes through the superior corner of the leg and will not put weight on that leg. Spasm
epiphysis normally but will not do so after a slip. and pain with gross restriction of hip movements
Lateral view shows the slip clearly. are the features. Child will be sick, irritable and
Chondrolysis and avascular necrosis are feverish with classical attitude of position of ease,
recognized complications of SUFE. of flexion, abduction and external rotation. Blood
test, Ultrasound scan and aspiration/culture, and
Tuberculosis of Hip MRI scan can confirm the diagnosis.
It is the second most common bony site of Trochanteric Bur sitis
tuberculous infection after the spine. The
Patients present with localized pain, tenderness
infection starts in the acetabulam or the head of
and swelling over the greater trochanter area. It
femur (Babcock's triangle).
is due to irritation of overlying soft tissue
Limp is the earliest complaint, initially after
(iliotibial band) due to constant friction in flexion-
walking and later even after rest. Patient may
extension movement. It is common in sports
have pain referred to the thigh or knee and night
person, following lateral hip surgery,
cry. Muscle wasting is present. Thomas' test will
trochanteric internal fixations and rarely
reveal the fixed flexion deformity of hip and
infection, but most of the time it is idiopathic in
rotations will be restricted.
origin. Pain is aggravated in flexion adduction
Deformities are seen depending on the stage
movement or on sitting cross-legged.
of hip involvement.
Stage 1 (Stage of synovitis)—effusion causes
Femoro acetabul ar Imping ement
flexion, abduction and external rotation of hip
with apparent lengthening of the limb. It is a recognized cause of pain and early arthrosis
Stage 2 (Stage of arthritis)—muscle spasm in young adult hip. Ganz described two types:
causes flexion, adduction and internal rotation CAM type presenting more commonly in young
of hip with apparent shortening of the limb. males and pincer type more commonly in women
Stage 3 (Stage of erosion)—destruction of the of late 30s or early 40s. Cam type impingement
joint and dislocation of the femoral head causes is defined as insufficient offset or concavity of
true shortening of the limb. femoral head neck junction causing shearing
damage to the labral-chondral junction and neck against acetabular rim, pinching the labrum
acetabular articular cartilage. In pincer-type between the femoral neck and the bony rim. It
impingement the primary deformity is on also typically causes a thin rim of acetabular
acetabular side in the form of overcoverage articular damage. Young people present with
(protrusion, coxa profunda or acetabular insidious onset of hip pain related to activity and
retroversion) leading to abutment of femoral in certain cases related to specific injury. Pain is
typically in midgroin or referred to buttock area
often localized by the patient by grasping the hip
between thumb and index finger, the so-called
‘C’ sign. Exacerbation of pain after long periods
of sitting or sporting activity with periods of rest
from their activity providing some relief and
physical examination reveals limitation of
internal rotation in flexion. Flexion, adduction
and internal rotation can reproduce their pain
with positive impingement test.
SACROILIAC JOINT (SIJ) STRESS TEST

Sacroiliac joint becomes diseased in inflammatory
conditions (seronegative inflammatory arthro-
pathy), infections and fracture-dislocation.
Special stress tests and other diagnostic tools
can identify the pathology. Turning on bed
especially in early morning hours and getting
up from bed is very painful. Sometimes there
can be pain on weightbearing with hamstring
Fig. 11.23: Pump handle test spasm.
A B
Figs 11.24A and B: (A) Lateral and (B) anterior to posterior compression is applied to provoke pain in the
supine patient with pelvic fracture
Genslen's test: The hip and knee of the affected The test is positive if pain is experienced in the
side are flexed to fix the pelvis and the hip on SIJ (Fig. 11.23).
the unaffected side is hyperextended over the
edge of the examination table. This will exert Faber test: The lower limb is forced into flexion, abduction
rotational strain on the SIJ. and external rotation at the hip. This causes pain at SIJ.
Pump-handle test: Patient supine, grasp the limb Compression and distraction stress test: Forceful
just below the knee and steady the trunk by compression over both iliac crests inwards or
grasping the shoulder on the same side. Fully forceful distraction of pelvis over both ASIS
flex the hip and knee joints and direct the flexed outwards can cause pain in sacroiliac disruptions
knee steadily towards the opposite shoulder. or in pelvic fractures (Figs 11.24A and B) .
12 Examination of Knee
CHAPTER
Knee joint is the largest joint of the body with rotates on tibia to lock the knee) and the
poor inherent bony stability and depends on the quadriceps are at rest with no exertion. Constant
ligaments and muscles for static and dynamic pain and night pain may indicate infection or
stability. A systematic examination can help the tumors or severe arthritis.
examiner to identify and accurately diagnose a
knee problem. Introduce yourself to the patient; Swelling
ask his/her name, age and occupation.
Onset, duration, site of first appearance, change
in size and shape, appearance in different
PRESENTING COMPLAINT
positions of knee and associated pain must be
Pain recorded. A horseshoe shaped swelling around
the patella and suprapatellar area is usually joint
Onset, duration, location of pain and point of effusion. Time of appearance after injury is
maximum pain should be asked for. Knee pain important. If it appears within an hour or two
can be a referred pain from hip pathology after injury it is most likely a hemarthrosis
especially in children. Pain limiting the level of (anterior cruciate ligament [ACL] or posterior
activities should be assessed by the walking cruciate ligament [PCL] injury, intra-articular or
distance, work and hobbies. Pain on climbing osteochondral fractures, peripheral meniscus tear
stairs or coming down stairs indicates quadriceps or tear in deep portion of joint capsule). Swelling
or patellar mechanical problem. Catching pain on which appears after 6 hours or next day is a
turning movements indicates some mechanical sympathetic reactionary effusion. A localized
pain due to chondrosis or meniscal injury or swelling along the joint line can be due to
patellar malalignment or loose body. Clicking meniscal cyst, ganglia or bursa.
associated with pain in the front of the knee is
mostly from patellofemoral malalignment. Tense Stiffness
effusion in the knee causes more pain. In severe
injury with fracture there is less hemarthrosis due This can be morning stiffness or inability to bend
to capsular disruption and extravasations of blood, or straighten the knee fully.
causing less pain. Patients with fixed flexion
deformity of the knee can present with thigh pain. Mechanism of Injury
This is due to muscle fatigue from constant action It gives a clue to the diagnosis. A twisting injury
of quadriceps in standing and walking posture. with the foot resting on the ground can give rise
Normally on standing the knee joint gets locked to collateral ligament injury, meniscus tear and
in full extension by screw home movement cruciate ligament rupture. Sudden deceleration
(during terminal extension, femur internally can result in anterior cruciate ligament rupture.
In sports injury it is important to know whether leg in some position. The loose body felt by the
the patient was able to walk or complete the game patient in different sites must be noted—"joint
after the injury. A dashboard injury to the front mouse" (Fig. 12.1).
of the knee can produce posterior cruciate
ligament injury. Clicks
Most common in young adults due to
Giving Way patellofemoral disorders. Bilateral clicks near
Sudden giving way of the knee can be due to terminal extension can be due to discoid meniscus
quadriceps wasting or quadriceps inhibition (meniscus is like a full disk covering the tibial
from pain or swelling, or it can be due to ACL condyle instead of a normal 'C'-shaped structure).
injury or combined ligamentous injury.
Miscellaneous
Sometimes patellofemoral malalignment
resulting in subluxation or dislocation can Other joint involvement, history of urethritis,
present with giving way of the knee. Patient conjunctivitis, bowel disturbances (inflammatory
walking in a straight line has no problem but diseases, crystal arthropathy) and constitutional
sudden turning or twisting of the body leads to symptoms must be recorded.
buckling with collapse and pain in the knee. This Other relevant history must be asked for as
true giving way symptom is common in ACL tear discussed in Chapter 1.
or patellar instability. This flexion rotation injury What is Patient's Expectation?
is common in sports like foot ball and one should General Examination
always enquire about whether the player was
able to complete the game or discontinued. LOCAL EXAMINATION
Examine the patient—walking, standing, supine
Locking
on couch and prone on couch.
Patient walking in a straight line has no problem Explain to the patient at each step what you
but sudden turning or twisting of the body leads are doing.
to buckling with collapse and pain in the knee.
This knee buckling is common in patients with
anterior knee pain with true giving way
symptoms in ACL rupture and patella
dislocation or subluxation. True mechanical
locking results from meniscal injury where the
patient is not able to straighten the leg from a
fixed angle of flexion or there is sudden loss of
terminal extension.
Pseudo-locking is what patient describes as
a transient sensation of tightness and not being
able to straighten or bend the knee. This can be
from loose bodies or chondral flap tears or
patellar subluxation. Pseudo-locking due to loose
body happens at different degrees of knee flexion
at different times. Patient sometimes describes Fig. 12.1: Loose bodies in knee due to synovial
that the locking corrects by maneuvering the osteochondromatosis (For color version, see Plate 6)
Examination of Knee 127
Look Localized swelling around the knee can be due

to ganglion, meniscal cyst or tumors.
Gait
Ask the patient to take off the footwear and to Looking from Side
walk briskly to and fro. Comment on any Ask the patient to push the knee back and assess
walking aid or external appliances used. flexion deformity or recurvatum of the knee. By
Types of gait: Antalgic, lateral thrust, stiff looking from front and side triple deformity of
knee, quadriceps gait (hand to knee gait in the knee- flexion, posterior subluxation and
poliomyelitis patients with weak quadriceps external rotation of tibia can be made out
where the hand is used to push the thigh back to (rheumatoid arthritis, tuberculosis). Look for any
lock the knee, or can internally rotate the leg to lateral swellings.
use iliotibial band as the extensor of knee).
Looking from Behind
Patient Standin g
Looking from Front Inspect the popliteal area for any obvious swelling
(Baker's cyst, gastrocnemius-semimembranosus
Assess the knee alignment for deformity, varus bursa, popliteal artery aneurysm, lymphadeno-
(bow leg) or valgus (knock knee) deformity (Figs pathy, soft tissue tumours), wasting of hamstrings
12.2A to C), patellar rotation (squinting patella and calf muscles.
to one side, usually laterally), foot rotation, any
scars (note for tiny arthroscopic scars), wasting Supine on Couch
of quadriceps, swelling around the knee—diffuse
horse-shoe shaped swelling around the patella Confirm the inspection findings.
due to fullness of suprapatellar pouch with
obliteration of hollowness on either sides of Feel
ligamentum patella indicates effusion of the joint. Feel for the quadriceps bulk and tone.
Figs 12.2A to C: Varus/valgus knee/windswept deformity

Warmth from the top. Now press medial to the patellar

This is felt using the dorsum of the hand and tendon and look for ripple of fluid appearing on
compared to the other side. Inflammatory the lateral aspect of the tendon.
conditions and infections produce increased
warmth. Moderate Effusion
This can be assessed easily by cross fluctuation
Tenderness in two planes, above-downwards and
Ask the patient for tender spot and always look mediolateral fluctuation.
at the patient's face. Soft tissue and bony
tenderness must be assessed individually. Moderate to Severe Effusion
In supine position with knee extended start Patellar tap—Squeezing the suprapatellar pouch
from suprapatellar pouch, patella- retropatellar and giving a sharp tap on the patella with
area (medial and lateral facet palpation by gliding fingertips elicit patellar tap. The patella touches
the patella, to one side in extended knee and the trochlea with a knock and bounces back. This
feeling the undersurface) and parapatellar area, can be felt in moderate to severe effusion. It may
patellar tendon, tibial tuberosity, condyles of be difficult to elicit in very tense effusion (Fig. 12.6).
femur and tibia especially the attachment of Tense effusion must be aspirated to relieve
collateral ligaments. pain, to prevent quadriceps inhibition and for a
Bend the knee to 90° and feel for tenderness diagnosis. Hemarthrosis can be due to anterior
along the medial and lateral joint line or cruciate ligament injury, osteochondral fracture
thickening of bone due to osteophytes. Deep (usually in patellar subluxation or dislocation)
tenderness at medial femoral condyle just medial or any intraarticular fracture, peripheral tear of
to patellar tendon in extreme flexion can be meniscus, or capsuloligamentous complex injury,
elicited in osteochondritis dissecans of medial hemophilia, pigmented villonodular synovitis,
femoral condyle. The localization of pain gives a etc. Presence of marrow fat (oil droplets) in
clue to the probable pathology (Figs 12.3 to 12.5). hemarthrosis indicates intra-articular fracture.
Swelling Defects or Gaps

Localized or diffuse swelling should be examined Feel for any defect in the quadriceps mechanism
in the way as described in Chapter 1. The due to rupture. Similarly a patient with lateral
generalized synovial hypertrophy is best felt over joint problem should be palpated for intact
the anteromedial aspect of the suprapatellar fibular collateral ligament by keeping the leg bent
pouch as it is immediately below the vastus to 90° and externally rotating the hip. A tight
medialis muscle and this muscle atrophies first band could be felt spanning across the lateral
in any knee pathology. The hypertrophied femoral epicondyle to the head of fibula.
synovium can be rolled under the palpating
fingers, has a doughy feeling and is tender. The Distal Pulsation
fluid collection in the joint (effusion) can be Check for dorsalis pedis and posterior tibial
assessed by the following manner. artery pulsations.
Mild Effusion Move

Wipe or Bulge test: Small effusion is assessed by The normal movement is flexion and extension
emptying the suprapatellar pouch by squeezing of the knee but a jog of adduction or abduction
Fig. 12.3: Feeling the joint line Fig. 12.5: Feeling for tenderness at femoral
attachment of MCL
Fig. 12.4: Feeling for tenderness in fat-pad lesion Fig. 12.6: Eliciting patellar tap
and some amount of internal and external Passive extension is assessed by lifting both heels
rotation is possible (Normal range, Flexion—0 to know fixed flexion deformity or recurvatum of
to 130° and Extension—0°). the knee. The popliteal angle is the angle subtended
by the long axis of thigh and lower leg segment, and
Straight leg raise: Active extension is assessed by this
gives the measure of fixed flexion deformity. Passive
test to verify the integrity of extensor mechanism.
flexion with one hand on the knee is used to assess
This may not be possible in quadriceps rupture,
for crepitus or any loose body movement.
patella fracture and patellar tendon rupture. Lack
of terminal extension can be due to fixed flexion
Measure
deformity or extension lag. The quadriceps lag is
assessed by the ability to passively extend fully The girth of the thigh muscles from a fixed point
(Figs 12.7A and B). Active flexion is assessed by above the knee is measured to know the amount
patient bending both knees fully and looking for of wasting. The thigh and leg segment can be
heel to buttock distance (Fig. 12.8). measured to analyse leg length discrepancy.
Figs 12.7A and B: (A) Extension lag-knee; (B) Passive correction to full extension
Varus or Valgus Stress Test in 30° Flexion

(Figs 12.9 and 12.10)
Varus or valgus stress test in 30° flexion is used
to assess isolated collateral ligament injury. This
position relaxes the posterior capsule and
cruciate ligaments. In heavy patients it is difficult
to keep the knee flexed at 30° with one hand, so
either we can place a pillow or bring the leg out
by the side of the couch and bend the knee to 30°
and perform the test. The minimal opening of
the joint with pain on stressing indicates partial
tear. Less pain and swelling with gross opening
indicates complete tear of the ligament. Feel for
Fig. 12.8: Full knee flexion-heel to buttocks the end point.
Grading of MCL injury with valgus stress
testing:
SPECIAL TESTS TO ASSESS
Grade 1: 1 to 4 mm opening
JOINT STABILITY
Grade 2: 5 to 9 mm opening
Examine the normal side first and compare with Grade 3: 10 to 15 mm opening
affected side.
Lachman's Test (Fig. 12.11)
Varus/Valgus Stress Test With knee in 15 to 20 degrees flexion, examiner's
In full extension assess for opening of the joint by one hand fixing the lower thigh and with the
holding the knee with one hand and the ankle with other hand thumb over the anterior joint line with
the other hand to apply varus (adduction)/valgus all the fingers around the back of upper tibia
(abduction) stress. Abnormal opening of the joint perform a forward movement of the tibia on the
indicates collateral ligament injury, posterior capsular femur and assess for the anterior glide and the
tear and cruciate ligament tear. This also helps to end point. A mushy end point with forward
know the correction of mediolateral deformity. movement of tibia on femur in excess of the
Fig. 12.9: Varus stress test Fig. 12.10: Valgus stress test
normal side indicates anterior cruciate ligament displacement and the end point in comparison
rupture. to the normal knee. This indicates ruptured
Grade 1+ (0-5 mm displacement) anterior cruciate ligament.
Grade 2+ (5-10 mm displacement) The test is done in neutral position of the foot,
Grade 3+ (> 10 mm displacement) in internal rotation and external rotation position
Both the above tests can be easily performed of the foot.
in an acutely injured knee without bending and Positive anterior drawer test in internally rotated
causing pain. foot indicates anterolateral instability (anterior
cruciate ligament, lateral collateral ligament and
Posterior Sag arcuate ligament complex insufficiency).
Positive anterior drawer test in externally
Bend both knees to 90 degrees and look
rotated foot indicates anteromedial instability
tangentially from side for posterior sag of upper
(anterior cruciate ligament, medial collateral
tibia. This indicates posterior cruciate ligament
ligament, medial capsule and posterior oblique
rupture. From this position bring the tibia to
ligament insufficiency).
neutral to perform drawer tests (Fig. 12.12).
Posterior Drawer Test
Quadriceps Act ive Test
This is performed in similar way but giving a
In the presence of posterior sagging of tibia in posterior force on upper tibia to assess abnormal
the above mentioned position, ask the patient to backward movement. Positive test indicates
extend the knee against resistance by fixing the posterior cruciate ligament rupture.
foot to the floor. This produces visible shift of
the sagging tibia forwards. Macint osh' s Pivot Shift Test
An ter io r Draw er Test (Fig . 12.13)

Patient supine with one hand holding the upper
tibia and other hand on the heel, with knee in full
Sit on the foot of the patient with both the thumbs extension, internally rotate and apply valgus force.
over the anterior joint line and fingers over the It will sublux the tibia in anterolateral instability.
ba ck of the up pe r tibi a, fe el fo r rel ax ed From extension maintaining the valgus—internal
hamstrings and do forward movement of tibia rotation force flex the knee. At about 30° flexion,
on femur and assess the amount of forward the tibia reduces back with a clunk. This is due to
Fig. 12.11: Lachman's test Fig. 12.13: Anterior drawer test
deformity and external rotation in posterolateral

instability (Fig. 12.15).
Reverse Pivot Shift Test of Jakob

Patient supine, keep the knee flexed and leg
externally rotated to sublux the tibia posterolaterally,
and now extend the knee with slight axial load in
valgus stress. The subluxation reduces with a jerk.
This indicates posterolateral instability.
Dial Test
Fig. 12.12: Posterior sag in PCL insufficiency This test is for posterolateral instability. Passive
external rotation of tibia with knee in 30° and 90° of
flexion. Best performed with patient in prone position
the action of iliotibial band, which lies to the front
where posterior subluxation more at 30 degrees and
of the knee axis in extension and on bending it
less at 90° indicates isolated posterolateral corner
falls behind the knee axis pulling the tibia to
injury. Marked subluxation with external rotation at
reduced position (Figs 12.14A and B).
both 30° and 90° indicates both PCL and
Jerk Test of Hughs ton and Lo see posterolateral corner injury. Posterolateral instability
is also confirmed by posterior drawer at 20° and
Patient supine with one hand holding the foot of varus stress test being positive.
the patient and the other hand over the proximal
tibia starting from flexed position of the knee, McMurray's Test
extend the leg with valgus stress and internal
This rotatory test was described to assess medial
rotation. The tibia subluxes with a jerk at 30° flexion.
meniscus tear but also can be used for lateral
meniscus. Flex the knee fully, externally rotate,
External Rotation Recurv atum Test apply valgus stress and extend the knee, any pain
Holding both legs with big toe and lifting the legs over the medial joint line or a click indicates
up can produce sagging of the knee with varus probable medial meniscus tear.
Figs 12.14A and B: Pivot shift test
Fig. 12.15: External rotation-recurvatum test
By maneuvering this way we are producing

a suction force to displace an unstable medial
meniscal tear which gets caught between the
articular surfaces and causes pain.
Similarly for testing lateral meniscus apply
varus force, internally rotate the tibia and extend Fig. 12.16: McMurray's test
the knee from full flexion. The pain starting in
full flexion indicates posterior horn pathology Apley's Grinding Test
and pain in more extension indicates middle or
Place the patient prone with knee joint flexed
anterior horn pathology.
90°, give axial compression and lateral rotation
Because of poor sensitivity a negative test
to the leg from the foot, if the patient complains
does not rule out meniscal tear (Fig. 12.16).
of pain there may be tear of medial meniscus.
With axial compression and internal rotation if
Prone on Couch
pain appears, there may be lateral meniscus tear.
Look, feel and assess the popliteal area for The same test if done in distraction of the joint
tenderness, swelling and pulsation. may detect collateral ligament tear, lateral
rotation for medial ligament pathology and evidence of patella alta (high riding patella) or
medial rotation for lateral ligament pathology. baja (low riding patella) by measuring the height
of the patella and the length of patellar tendon
PATELLOFEMORAL JOINT PROBLEMS in 30° flexion of the knee. Normally these are of
same length.
Usually a problem of young adults who give
history of anterior knee pain, difficulty in getting Osmond-Clarke's Test (Fig. 12.19)
up from prolonged sitting posture due to pain, With gentle pressure in superior pole, ask the
difficulty in climbing stairs, inability to squat in patient to lift the leg up straight without bending
the toilet, difficulty in kneeling or sitting cross the knee. This produces contraction of quadriceps
legged on the floor. and shear at patellofemoral joint. This is a painful
Salient features to be noted are: test similar to patellar grind where the patella is
Patellar Rotation in Standing Position
compressed on to trochlea.
Comment on squinting, tilt, foot rotation, wasting Patellar Tilt Test

of quadriceps (VMO) and any lateral scars.
With the patient supine with knees extended
With Patient Lying compare transepicondylar axis to patellar tilt.
With patient lying assess patellar tracking on Now elevate the lateral edge of patella and
bending movement. Persistent lateral movement depress the medial edge. Normal is 0 to 20° tilt.
in knee flexion is called J sign (normally Abnormal is not able to tilt beyond 0°(horizontal)
because of lateral retinacular tightness. This may
inferomedial).
be helped with lateral release (Fig. 12.20).
Generalized Ligament Laxity Assessment
(Figs 12.17A to C) Patellar Glide Test (Sage Test)
• Thumb touches the volar aspect of forearm. With the knee flexed to 30° by crossing over the
• Little finger hyperextends parallel to forearm. leg, the ability to translate patella medially and
• Elbow hyperextends more than 15°. laterally is assessed. By dividing the patellar
• Knee hyperextends more than 15°. width into 4 quadrants, it is graded in number
• Palm to touch the floor by bending forward of quarter widths the patella glides. Normal
with the knee extended lateral glide is upto 2.5 quadrants, more than 3
• Presence of 4 or more signs indicates quadrants indicates abnormal medial restraint.
generalized ligament laxity. Normal medial glide is 1 to 2.5 quadrants, less
than 1 quadrant glide indicates tight lateral
Q Angle (Quadriceps Angle) restraint. More than 3 quadrants is hypermobile
patella.
Knee in 20° flexion, either legs crossed or over a
pillow, an imaginary line is drawn from ASIS to
Apprehension Test
center of patella and from there to tibial tuberosity.
Angle formed by these two lines is the Q angle. This is done in 30° flexion of the knee with
Normal range is 8 to 10° in males and 12 to 15° in patient relaxed and patella pushed laterally.
females. Abnormal if more than 15° in males and The test is positive if the patient is
more than 20° in females (Fig. 12.18). apprehensive and uncomfortable. This will be
Now feel for the size of the patella, tenderness positive in recurrent dislocation or subluxation
in the parapatellar and retropatellar surface, of patella (Fig. 12.21).
Figs 12.17A to C: Ligament laxity tests
Assessment of Rotational Profile subtended by the anatomical longitudinal axis

of thigh and the leg segment measured with
As discussed in Chapter 14 assess for increased goniometer gives the valgus angle. This can be
femoral anteversion and external tibial torsion. accurately measured in standing radiograph.
To know whether the deformity is in femoral
SPECIAL NOTE or tibial component assess the deformity in full
Genu Valgum (Knock Knees) (Fig. 12.22) flexion and full extension. Most of the times it is
due to abnormal lateral femoral condyle. So the
Trauma, infection (pyogenic, tuberculosis, deformity is obvious in extension and disappears
postpolio), inflammation and metabolic or in flexion. This is due to different surface of
developmental disorders can cause this femoral condyle articulates with the same surface
deformity. The intermalleolar distance is used to of the tibia. In tibial defects the valgus deformity
assess the progress of the deformity. The angle persists in all degrees.
Fig 12.20: Patellar tilt
Fig. 12.18: Q angle
Fig. 12.21: Apprehension test
increase beyond the normal (6° to 8°) and then

reduces to normal value at the age of 5 to 7 years.
Unilateral deformity or severe varus deformity
can be pathological. Always examine the patient
Fig. 12.19: Osmond-Clarke's test standing to know the severity and standing X-ray
is preferable. The distance between the knee joint
or the angle between the thigh and leg segment
This condition should also be assessed for
can be used to assess the progress. Radiological
common peroneal nerve palsy. The patient may have
measurement of varus angle is more accurate.
patellofemoral malalignment due to lateral position
In kids with genu varum the differential
of tibial tuberosity and hyperpronated flat feet.
diagnosis includes rickets, metaphyseal
dysostosis, hypophosphatasia, Blount's disease
Genu Varum (Bow Legs)
and other dysplasias, trauma and infection. In
Newborn baby is born with physiological varus, elderly the most common cause is medial
which tends to correct by 15 to 18 months and then compartment osteoarthritis (Figs 12.23A and B)
approaches to more valgus. The valgus may and rarely Paget's disease (Fig. 12.24).
Genu Recurv atum Medial and lateral swellings can be due to

It is hyperextension of the knee or posterior pes anserinus bursa, meniscal cysts, ganglion
bowing of the knee. This can result from damage from superior tibio-fibular joint, and soft tissue
to anterior portion of distal femoral or proximal or bony tumors.
tibial epiphysis due to trauma, infection or Swelling in the back of the knee can be
dysplasia; muscle weakness as in polio, cerebral gastrocnemius-semimembranosus bursa—Baker's
palsy or arthrogryposis; congenital joint laxity cyst. Baker's cyst is an outpouching due to
and Charcot's disease. In young girls the growth collection of fluid from knee joint pathology
of the proximal tibial epiphysis may be retarded (osteoarthritis or rheumatoid arthritis). It has to
from ballet dancing. This condition can cause
patellofemoral malalignment. Look from the side
with the patient standing to assess the degree of
hyperextension at the knee. In fixed equinus of
the ankle there may be associated recurvatum at
the knee (Figs 12.25A and B).
Swellings around the Knee

Prepatellar (housemaid's knee) and infrapatellar
(Clergyman's knee) bursitis—cystic swelling
with inflammation that appears in front of patella
or below the patella respectively.
Figs 12.23A and B: Severe osteoarthritis of knee

Fig. 12.22: Genu valgum: right leg resulting in bow leg (For color version, Fig. 12.23A,see
(For color version, see Plate 6) Plate 6)
Fig. 12.24: Genu varum due to tibia varum from

Paget's disease of right leg and fracture shaft of femur
left leg (For color version, see Plate 6)
be differ enti ated fr om popl iteal ar tery

aneurysm—pulsatile nature and absence of
transillumination. This can burst and the fluid can
extravasate into calf to cause severe pain.
Differential diagnosis for sudden onset severe pain
in calf includes deep vein thrombosis, calf muscle
rupture and stress fracture.
Osteoarthritis Knee
Figs 12.25A and B: Genu recurvatum due to
It is a degenerative wear and tear process of the
congenital anterior knee dislocation (For color version,
knee joint. Primary osteoarthritis is common in
Fig. 12.25A, see Plate 7)
elderly population and secondary osteoarthritis
(trauma, infection, etc) can occur at any age. In
the early stages it is usually the medial complains of thigh pain due to constant action
compartment (anteromedial) and later it becomes of quadriceps on standing resulting in muscle
tricompartmental (lateral compartment and fatigue. Clinically joint line tenderness with bony
patellofemoral joint). Patient present with pain, thickening from osteophytes and limitation of
swelling, deformity (varus deformity, flexion movements can be appreciated. Weightbearing
deformity), morning stiffness, limitation of X-ray will show narrowing of joint space,
movements and decrease in walking distance. A subchondral sclerosis, marginal osteophyte
patient with fixed flexion deformity of knee often formation, cyst formation and deformity.
Inflammatory Arthriti s the load on patellofemoral joint and any lesion or

malalignment can cause discomfort or pain). These
This can affect knee joint producing swelling,
patients find difficult to squat or get up from
pain, and limitation of movements. It can be
squatting position or to kneel or to sit cross-legged.
rheumatoid or non-rheumatoid arthritis.
Sitting on a chair for long time and getting up can
Inflammatory arthritis of knee produces synovial
cause anterior knee pain ' Cinema sign'. Difficulty
hypertrophy and thickening with loss of joint
in getting up and coming down stairs is again a
space in X-ray and periarticular osteoporosis. It
problem. Clicking sensation with or without pain
normally produces valgus deformity of the knee.
is common in patellofemoral malalignment.
Rheumatoid is diagnosed by polyarticular
Reactionary effusion may be present in acute
symmetrical involvement of small joints of
situation. Feeling of giving way due to subluxing
fingers and by the criteria designed by American
or dislocating patella can be one of the
Rheumatoid Association. Non-rheumatoid
presentation. Tenderness may be elicited at
arthritis can be of reactive arthritis (gonococcal
parapatellar area, retropatellar—medial and lateral
or non-gonococcal urethritis), psoriatic
facets, and over the patellar tendon (patellar
arthropathy or other seronegative arthropathy.
tendinitis in runners). Other signs must be assessed
Crystal Arthropathy in case of malalignment as discussed before.
Calcium hydroxyapatite crystal arthritis or Meniscal Injury
calcium pyrophosphate arthritis (Pseudogout) or
Ochronosis (Alkaptunuria) are some of the This occurs in two groups; young adult and
conditions that cause sudden onset pain and middle age group. Mechanism of injury is due
inflammation. It is most common in elderly to twisting of the knee in flexed position. This
population with acute flare of pain. X-ray may happens often in sports person. In middle age
show calcification of meniscus and articular adults degenerative tear of meniscus is common
cartilage. Aspirate can demonstrate the type of with trivial injury of the knee. Patient present
crystal causing inflammation of the joint. with sharp localized pain over the joint line
especially on twisting or turning movements,
Osteonecrosis locking in bucket handle tear, inability to extend
fully in displaced bucket handle tear and
This condition again affects mostly elderly
sometimes getting relieved of pain on slight
population with sudden onset severe pain in the
manoeuvering of the joint.
knee (similar to myocardial infarction), with
Localized joint line tenderness along the
localized tenderness over the condyles and effusion
meniscus, reactionary effusion, and positive
of the joint. Patient may be unable to weight bear
McMurray's test are pathognomonic of meniscal
during this crisis period with rest pain. Cause is
injury. A negative McMurray test does not rule
unknown. This must be differentiated from stress
out meniscal tear.
fracture of tibia (upper tibia) from severe varus
deformity in osteoarthritis knee which is again Cruciate Ligament Injury
sudden onset pain with inability weight bear and
walk. Here pain is characteristically present on Anterior Cruciate Ligament Injury
movement like any fracture. A noncontact pivoting injury in sports or domestic
accidents are commonly associated with a "pop"
Patellofemoral Conditions (Anterior Knee sound or feeling, with immediate swelling
Pain) (Table 12.1) (haemarthrosis). It happens in flexion rotation
Patellofemoral pathology causes pain especially on mechanism of knee or in hyperextension or in frank
bending activities (bending more than 30° increases dislocation. In chronic insufficiency patient describes
Table 12.1: Classifi cation of patellofemoral dis orders (Anterior knee pain)
I. Trauma
A. Acute trauma
1. Contusion
2. Fracture
a. Patella
b. Femoral trochlea
c. Proximal tibial epiphysis (tubercle)
3. Dislocation
4. Rupture
a. Quadriceps tendon
b. Patellar tendon
B. Repetitive trauma (Overuse syndromes)
1. Patellar tendonitis (jumper's knee)
2. Quadriceps tendonitis
3. Peripatellar tendonitis (e.g. anterior knee pain of the adolescent due to hamstring contracture)
4. Prepatellar bursitis (housemaid's knee)
5. Apophysitis
a. Osgood-Schlatter disease
b. Sinding-Larsen-Johansson disease
C. Late effects of trauma
1. Post-traumatic chondromalacia patellae
2. Post-traumatic patellofemoral arthritis
3. Anterior fat pad syndrome (post-traumatic fibrosis)
4. Traumatic neuralgia of cutaneous nerves
5. Reflex sympathetic dystrophy of the patella
6. Patellar osseous dystrophy
7. Acquired patella infera
8. Acquired quadriceps fibrosis
II. Patellofemoral dysplasia—patellofemoral malalignment
A. Lateral patellar compression syndrome (LPCS)
1. Secondary chondromalacia patellae
2. Secondary patellofemoral arthritis
B. Chronic subluxation of the patella (CSP)
C. Recurrent dislocation of the patella (RDP)
1. Associated fracture
a. Osteochondral (intra-articular)
b. Avulsion (extra-articular)
D. Chronic dislocation of the patella
1. Congenital
2. Acquired
III. Idiopathic chondromalacia patellae
IV. Osteochondritis dissecans
a. Patella
b. Femoral trochlea
V. Synovial plicae (anatomic variant made symptomatic by acute or repetitive trauma)
a. Medial patellar (shelf)
b. Suprapatellar
c. Lateral patellar
a giving way feeling or abnormal movement of thigh instability, swelling, infection and stiffness. A
bone over leg bone and an insecure feeling. systematic approach to the evaluation of the
Lachman's test is most sensitive and easily patient requiring revision total knee arthroplasty
done in acute swollen knee as there is no need to can help identify the correct diagnosis and guide
be nd the kne e mor e th an 20 °. In ch ron ic surgical intervention.
insufficiency Lachman's test, anterior drawer test The causes of dysfunction and pain are
and pivot shift test may be positive. Associated considered in two broad categories: extrinsic
meniscal injury is common. (extra-articular) and intrinsic (intra-articular).
Extrinsic sources of pain include the ipsilateral
Posterior Cruciate Ligament Injury hip, lumbar spine (stenosis or radiculopathy),
This most commonly results from a direct bow soft tissue inflammation (pes anserinus bursitis
to the upper tibia in a flexed knee-dashboard or iliotibial, patellar or quadriceps tendinitis),
injury or hyperflexion without a blow or in frank complex regional pain syndrome, neuroma,
dislocation. Loss of confidence in the knee and vascular claudication, stress fracture and rarely
giving way feeling may be present. Positive intrapelvic lesion compressing femoral
posterior sagging, posterior drawer test, external cutaneous nerve. Intrinsic sources include
rotation recurvatum test and posterolateral aseptic loosening, polyethylene wear, osteolysis,
instability tests may be present. malalignment, instability (mediolateral, flexion
or global), infection, implant fracture,
Osteochondrit is Dissecans arthrofibrosis, soft tissue impingement,
Osteochondral lesion of bone and overlying component overhang, and dysfunction of
cartilage resulting in separation and loss of blood extensor mechanism like instability, fracture,
supply usually involves the lateral aspect of maltracking, lateral patellar facet impingement,
medial femoral condyle and is common in excessive component construct thickness,
teenagers and young adults. It can affect lateral patella baja, and patellar or quadriceps tendon
femoral condyle and patella. The lesion is thought rupture.
to be due to occult trauma, ischemia or abnormal Pain that was present before surgery
epiphyseal ossification. Patients present with pain, persisted without change indicates extrinsic
swelling or mechanical symptoms. Localized etiology. Pain that began within the first year
tenderness in fully flexed knee over the femoral after surgery suggests infection, malrotation,
condyle area may be present. Tunnel or notch or soft tissue impingement. Pain after a year
view X-ray is valuable for identification. Children suggests wear, osteolysis, loosening or
have the best prognosis. infection (acute hematogenous or late
chronic). Comorbid conditions should be
Osgood-Schlatter Disease noted. Visual inspection and careful palpation
for swelling and point tenderness are noted.
Osteochondritis of tibial tubercle apophysis due Stability testing in extension, mid flexion and
to stress from extensor mechanism in a growing 90° flexion and evaluation of patellofemoral
child. There is localized pain and tenderness over stability were done. Note the gait and
tibial tuberosity with prominent tubercle. X-ray alignment on walking, measure active and
may show fragmentation of apophysis. passive ranges of motion, evaluate patellar
tracking, patellar clunk, neurovascular
Failed Total Knee Replacement
examination including the power of
There is increasing number of patients who had quadriceps and examine adjacent joints and
total knee replacement coming back with pain, opposite limb for completion.
13 Examination of Ankle
CHAPTER and Foot
The bipedal stance of human being makes our Swelling

foot a unique structure to take the weight of the Site, duration, onset—sudden or insidious, trau-
whole body. Any slight change in the matic or postsurgical, localized or generalized,
biomechanics alters the weightbearing pattern associated with inflammation or other swellings.
and results in pain and deformity. Enquire about medical conditions, which may
This chapter offers an introduction to the cause bilateral foot swelling: Renal or cardiac
clinical assessment of the foot and ankle. The first problems, anemia, hypoproteinemia, pregnancy,
section contains general instruction. There are liver disease, lymphoedema, etc. In unilateral
then separate sections on the ankle and regions foot swelling other than local pathology think of
of the foot. any pelvic pathology causing venous stasis like
gynecological problems and gather more
PRESENTING COMPLAINT information.
If there is an injury, ask about the mechanism
Define exactly what the patient is complaining
of injury. This may indicate likely injuries. Fall
of, how the problem first started, how long has
from height and landing on heel may result in
it been going on and about the footwear.
calcaneal fracture; twisting injury to feet can cause
fracture base of 5th metatarsal and twisting injury
Pain to ankle can cause ligament sprain or fracture.
Ask about duration, site, aggravating and Giving Way
relieving factors. Pain during the night, early
morning or on walking after prolonged rest or Can be due to ankle instability, anterolateral
sitting as in plantar fascitis, walking on uneven impingement syndrome, neurological problems
surface and climbing up or down stairs should or osteochondritis of dome of talus.
be recorded. Neurological Symptoms
Weakness, numbness, and pins and needles.
Morning Stiffness
Other Joint Involvement
In inflammatory conditions like rheumatoid or
seronegative arthritis. Rheumatoid arthritis, seronegative-arthropathy
and gout. It is a good habit to look at hands for
Deformity joint involvement.
Onset, progress, problem with wearing footwear, Miscellaneous Symptoms

cosmetic, associated callosities and pressure Ulcer, gangrene—dry or wet, painful corns or
sores. callosities, web space skin problems—Athelete's
Examination of Ankle and Foot 143
foot, ingrowing toenail with nail fold infection produce problems in the foot. The foot is a
and pain. common presenting site of rheumatoid arthritis,
for example. The general examination also allows
Limitation of Activities assessment of a person's overall fitness. It will
be tailored to the problems suggested by the
Effects on gait and mobility. How is the problem
history: for instance, examination of other joints
affecting the patient's life: Work, sport and
in suspected arthritis, full neurological
hobbies, social activities.
examination in a patient with suspected
neuropathy, assessment of joint mobility in a
PAST HISTORY
child with flat feet, looking for features of a
Does the patient have any other relevant medical syndrome in a child with club feet.
or psychological conditions, e.g. diabetes,
Spine: Not only overt neurological disease but
rheumatism, gout, tuberculosis, trauma or
also features such as pes cavus, dysmorphic feet
allergy? Is he or she on any regular medication?
or toes, or marked foot asymmetry, should lead
to a full examination of the spine and lower limb
FAMILY HISTORY
neurology. Look for scoliosis, evidence of spinal
Do they have a family history of present problem dysraphism such as sacral sinus, lipoma or hairy
or related conditions? If anything significant like patch. Do a full neurological examination of the
rheumatism, idiopathic flat feet, generalized lower limbs, including evaluation of pressure,
ligament laxity. vibration and two-point perception-
abnormalities in these may be the only features
PERSONAL HISTORY of diabetic neuropathy or tarsal tunnel syndrome.
Occupation, hobbies, smoking, alcoholism. Limb alignment and length: Look for pelvic
obliquity, limb length discrepancy (and its level),
TREATMENT HISTORY valgus/varus deformities, usually at the knee,
and rotational alignment. The differential
What treatment has been tried and with what
amounts of internal and external rotation at the
result. Ask about surgery, local injections,
hip can be used to measure femoral rotation and
physiotherapy, splints and orthoses.
the thigh-foot test with neutral hindfoot to
All patients with foot and ankle problems
measure tibial torsion. The overall foot position
should be asked about:
completes rotational alignment. Check for
1. Diabetes
contractures of the hips and knees, especially in
2. Inflammatory arthropathy
patients with neurological disease or arthritis.
3. Neurological disease
4. Vascular disease Gait: Familiarize yourself with the gait cycle and
5. Trauma. get used to analyzing people's gait. Normal gait
has stance phase (weight bearing) and swing
What Sort of Treatment d o th ey Expect and phase (non-weight bearing). Stance phase
Want? consists of initial contact (normally heel strike),
loading response, midstance, terminal stance and
EXAMINATION preswing (toe off). Swing phase consists of initial
swing, midswing and terminal swing. At initial
General Points
contact (Fig. 13.1) the body is about to begin
Avoid the habit of examining patients only from deceleration. The ground reaction force is
the ankle down. Many generalized diseases posterior to the ankle at or just in front of the
Fig. 13.1: Gait
knee and anterior to the hip joint. This produces cruciates at the knee). Hence, by eccentric
a plantar flexion moment at the ankle, zero to contraction of the soleus in second rocker the
slight extension moment at the knee and a flexion sagittal plane position of the ground reaction force
moment at the hip. These moments would be is controlled, thus allowing one muscle to stabilize
resisted by eccentric contraction of ankle three joints. Initial swing has begun on the
dorsiflexors, posterior knee capsule and hip contralateral side. The body is in single support and
extensors. This is the first rocker at ankle. its center of the mass has reached its highpoint.
The next illustration is at the end of loading Terminal stance: Begins as the body's mass
response. Body weight has been decelerated by moves in front of the base of support such that it
controlled knee flexion and ankle plantar flexion. is literally falling anteriorly and towards the
The ground reaction force imposing a zero unsupported side. Gastrocnemius (fast twitch)
moment at the ankle as first rocker has been has joined soleus (slow twitch) with sufficient
completed and second rocker is about to begin. power to stop further dorsiflexion of the ankle.
Hence, anterior tibial muscle action ceases and Hence the heel leaves the ground and the triceps
triceps surae, tibialis posterior and peroneal surae are now contracting concentrically as third
action begins. There is a large flexion moment at rocker begins. Acceleration and forward
the knee requiring quadriceps (vasti) contraction. propulsion are produced by the combination of
Hip extensors are ceasing activity as the ground triceps action and forward fall of the trunk. By
reaction force has moved anteriorly and is now the end of terminal stance, the opposite limb is
passing through the hip. in terminal swing.
In midstance, the ground reaction force passes Initial contact of the opposite limb marks the
anterior to the knee and posterior to the hip. Thus beginning of double support and of preswing.
no muscle action is necessary at either joint since Iliopsoas is now firing concentrically as an
both can be stabilized by ligaments (iliofemoral accelerator (flexor) of the thigh. As the ground
ligament at the hip and posterior capsule and reaction force moves behind the knee and weight
is unloaded onto the opposite limb, the ankle overpronated position in stance and may be
plantar flexes and the knee is driven into flexion. even more so on walking. Distinguish
With normal cadence (number of steps per between flexible and rigid flat feet by asking
minute), no muscle action is necessary at the knee. the patient to stand on tiptoe to see if the arch
However during fast cadence, the rectus femoris re-appears and the heel goes into varus. Then
comes into action to provide an additional flexion do a single foot tiptoe test to look for tibialis
force at the hip and to eccentrically decelerate knee posterior insufficiency. The "too many toes
flexion, i.e. prevent excessive heel rise. At normal sign" demonstrates forefoot abduction.
cadence, ankle plantar flexion is approximately Manipulate the subtalar joint to identify a
27°, knee flexion 45° and hip flexion 10° at the time rigid hindfoot suggesting arthritis or a tarsal
of toe-off. This sequence of events gets changed coalition. Exclude a neurological cause by
in abnormal gait. appropriate examination.
Ask the patient to walk up and down while 3. Cavus foot—Typically with a plantar flexed
you concentrate on each phase of the cycle in first ray, high arch and forefoot pronation. In
turn—first contact, shock absorption, mid-stance many cases the hindfoot is in varus and this
and so on. You can do a lot of gait analysis with may be fixed or mobile. Pes cavus may be
the naked eye and patience! Learn the common associated with spinal anomalies (especially
abnormal gaits and their clinical significance. if asymmetrical) or with hereditary
sensorimotor neuropathies such as Charcot-
Shoes: All patients are asked to bring a well-worn Marie-Tooth disease. Use the Coleman block
pair of shoes or slippers to clinic. Examination of test to tell the difference between fixed and
these is like a summary of gait over time. They mobile hindfoot varus. The cavus foot
show the areas under pressure in gait and from typically has a plantar flexed first metatarsal,
deformity, and the areas that take no pressure at producing a pronation deformity of the foot.
all. They also show what forces have been exerted To make the foot flat on the floor the hind
on the foot in the recent past. Sometimes foot inverts. In this special test a wooden
changing a patient's ideas about shoe wear is the block is kept under the heel and lateral rays
most important service we can offer them. so that the 1st ray is allowed to drop freely.
This results in reproduction of forefoot
Skin: Look for inflammation, infection, varicose
pronation with the hind foot in neutral
veins, tophi, discoloration, gangrene, scars or
position. If the hind foot varus does not
contracture, ulcers, calluses, corns, trophic
correct with this test, then it indicates fixed
changes, the cool dry hairless foot of vascular
deformity of subtalar joint due to long-
disease, the warm dry neuropathic foot.
standing deformity.
Overall foot shape: Assess the size of both feet: 4. Skewfoot—Hindfoot valgus and forefoot
Normal, small as in clubfoot or long and thin in adduction. Do the same tests for hindfoot
Marfan's syndrome. correction as in flatfoot. Manipulate the forefoot
Examine the overall foot shape with the to determine correctability of adduction.
patient standing. The hindfoot component of foot 5. Metatarsus adductus—Neutral hindfoot and
shape is best appreciated from behind. adduction of the metatarsus (some patients
Recognize common foot shapes: have some forefoot supination too).
1. Neutral or rectus foot—No overall deformity. Commonly seen in pre-school children when
2. Flat foot—Heel valgus, low arch, commonly it is usually correctable, but also in adults
forefoot abduction and supination. The when it is often relatively fixed but usually
subtalar joint is commonly in the in itself asymptomatic.
Neurological Examination
Neurological examination including strength
testing, usually recorded in MRC grades, light
touch, pinprick and pressure testing with
Semmes-Weinstein filaments. Palpate and
A B C
perform the Tinel test for neuromas over all major
nerves, especially those which might explain the
patient's symptoms (such as the tibial nerve in a
patient complaining of pain and paraesthesia on
the sole of the foot). The Romberg test—failure
to keep the body balance upright on closing the
eyes-indicates posterior column lesion and
favours the diagnosis of Friedreich's ataxia.
Vascular Examination
D E
Vascular examination includes, if necessary,
ankle pressure measurements with the Doppler Figs 13.2A to E: Foot deformities: (A) Normal foot;
probe, and calculation of the ankle-brachial (B) Equinus; (C) Calcaneus; (D) Varus, and
systolic index. (E) Valgus deformity
LOCAL EXAMINATION Foot size: Normal, small as in clubfoot or long and

Explain to the patient at each step what you are thin as in Marfan's syndrome.
doing and follow a systematic approach. Skin condition: Inflammation, infection, varicose
veins, discoloration, gangrene, scars or
Look contracture, ulcers, trophic changes.
It is always better to start the examination with Nail condition: In-growing toenail, nail fold
the footwear, which can give a clue to the problem. infection—paronychia or fungal, pitting and
scaling in psoriasis, trophic changes.
Footwear
Swelling: Ganglion, exostosis, fractures/dislocation
Look for irregular wear of the sole, the insole and
Hair: Changes and distribution
appropriate fit.
Deformities Toes-splaying, over-riding,
Standing clawing (hyperextension at MTPJ),
mallet toes (flexion at DIPJ) or
Expose up to both knees to assess deformities.
hammer toes (flexion at PIPJ)
Start from front; look at sides and then the back
Big toe-hallux valgus (outward
of the feet.
deviation), hallux flexus (bent
down), hallux varus (medial
From Front
deviation) or bunion (prominence
Posture: Is the foot plantigrade or equinus or over Ist MTPJ)
calcaneus? In-toeing, inversion or eversion of foot Forefoot—adduction, abduction
must be noted (Figs 13.2A to E). Midfoot—supination, pronation
Muscle wasting Extensor digitorum brevis, a small

bulky muscle seen in front of the
anterolateral aspect of the ankle.
From Side
• Assess the arch of the foot for flat foot or cavus.
• Tibialis posterior tendonitis—swelling and
inflammation from the navicular tuberosity
along the posterior aspect of medial malleolus
and above.
• Look for peroneal tendon standing out in spasm. Fig. 13.3: Standing on tip toes shows heel inversion
• Venous ulcer or pigmentation.
4. Antalgic—patients with ankle or subtalar
From Back
joint pain walk with foot externally rotated
• Look for calf muscle wasting. with short stance phase.
• Look for attitude of the heel—varus or valgus.
• Too many toes sign-more than two toes Lying Down
visible laterally due to planovalgus feet.
Look at the sole for callosities, corns, ulcers, and
• Widening of heel in calcaneal fractures.
web-space infections—fungal infection.
• Swelling posterior aspect of heel—insertional
or noninsertional Achilles tendonitis,
Feel
retrocalcaneal bursitis, rheumatoid nodules,
lipoma, etc. Temperature, pulse, skeletal structure, joints,
• Gap in heel cord in complete tendo-Achilles tear. ligament and tendon course and insertions
Ask the patient for any tender spot and examine
Standin g on Tip Toes that part at the end. Always look at the patient when
Implies good strength of tendo—Achilles and also you palpate. Feel for warmth and then bony or soft
inverts the heel due to the action of tibialis tissue tenderness starting from ankle (Fig. 13.4) to
posterior (invertor). Tibialis posterior insufficiency toes including metatarsal heads (metatarsalgia) and
results in failure of inversion or inability to do intermetatarsal space (Morton's neuroma).
single leg stance on tiptoes (Fig. 13.3). Swelling is examined as described in Chapter
1. In ankle effusion there may be fullness along
Standin g o n Heel the anterior joint line and on either sides of tendo-
Achilles with cross fluctuation.
To assess the power of dorsiflexors. Deformity is assessed for flexibility, rigidity
Leg length discrepancy can be commented. or for partial correctability. Heel is held square
(in neutral) to assess the forefoot deformity
Walking (supination-pronation).
Assess for gait patterns. Gentle percussion over the peroneal tendon
1. Stiff ankle—peg-like gait can elicit spasm of peroneal muscles.
2. Foot drop—forefoot drops in swing and
Move
patient has high stepping to clear the ground
and doesn't have heel strike on stance phase Starting from ankle, move onto subtalar joint
3. Fixed equinus (talocalcaneal), midtarsal joints (talonavicular
and calcaneocuboid), metatarsophalangeal joints Active toe movements are next looked into.
and interphalangeal joint movements. Start with Passive movements at ankle are tested by
active movements in both feet and then test for holding the heel in one hand and neck of talus
passive movements. with the other hand to check plantar flexion and
Active and passive range of movements, stability, dorsiflexion (Figs 13.5 and 13.6). Limitation of
flexibility, and contractures of joints are identified. dorsiflexion movement should always be
Ankle dorsiflexion (normal range: 0 to 20°) checked with knee joint in flexion to rule out
can be assessed by asking patient to actively pull gastrocnemius tightness.
up the feet. Ask the patient to move foot down Subtalar movement is assessed by holding the
to assess plantarflexion (normal range: 0 to 60°) heel by cupping with the hand, foot supported
and in same way the inversion (normal range: in neutral position with the examiner's forearm,
0 to 20°) and eversion (normal range: 0 to 10°) of test inversion and eversion (Figs 13.7 and 13.8).
subtalar joint is tested by actively moving the foot
inwards and outwards respectively (or by asking
the patient to touch the examiner's fingertip, held
inside and outside, with their forefoot without
moving at hips or knees).
Fig. 13.6: Testing dorsiflexion of foot
Fig. 13.4: Surface marking on anterior aspect of ankle
Fig. 13.5: Testing plantar flexion of foot Fig. 13.7: Testing inversion of foot
Subtalar movement can also be tested by a. Tip of lateral malleolus to heel tip.
holding the neck of talus with the thumb and b. Lateral malleolus to 5th metatarsal head.
four fingers of one hand while the other hand
holds the heel, keeping the foot in neutral Neurologic al Assessment
position and doing inversion and eversion
i. Motor system: Assess ankle dorsiflexors,
movements (Fig. 13.9).
plantarflexors, subtalar joint invertors and
[General belief of dorsiflexing the foot to lock
evertors by MRC grading. Always feel the
the talus to test subtalar movements is not needed
muscle to confirm the contraction. Assess the
as this restricts the normal subtalar movements
strength of the toe flexors and extensors.
because of tight medial tendinous (posterior
ii. Sensory system: Examination of sensation is very
compartment muscles) and lateral tendinous
important in neuropathic foot-diabetic foot,
(peroneal compartment muscles) structures
neurotrophic ulcers, spina bifida (Fig. 13.10).
embracing the calcaneum. Moreover there is no
iii. Reflexes.
inversion or eversion movement at the ankle
hence there is no necessity to lock the talus].
Vascular As sessment
Mid tarsal movements are tested by holding the
talus with one hand and the other hand holding Feel for dorsalis pedis and posterior tibial pulses,
the forefoot to do supination and pronation. if feeble or absent feel the popliteal and femoral
Toe movements are individually tested from pulses. Absent pulse warrants further
MTP to IP joints for dorsiflexion and plantar flexion. investigations before any foot surgery to prevent
wound problems.
Measure Look for changes due to ischaemia or gangrene.
Leg length discrepancy should be assessed. Check for varicose veins in the leg, venous
Size of the foot: ulcer or deep vein thrombosis.
On the medial side: Examine knee For any deformities, which may
a. Tip of medial malleolus to heel tip. cause secondary deformity in the foot.
b. Medial malleolus to 1st metatarsal head. Examine spine Neurocutaneous markers for spina
On the lateral side: bifida, deformity, etc.
Salient features in history and examination
of each region of the foot and ankle are elaborated
in detail as follows.
Fig. 13.8: Testing eversion of foot Fig. 13.9: Alternative method of testing inversion/eversion
Fig. 13.10: Sensation in the foot
ANK LE Range of movement: First get the patient to move

History: As well as asking patients with ankle the ankle through their active range of movement
problems about pain, stiffness, swelling and all and compare with the other side, then repeat
the usual things, ask: passively. Check particularly for loss of
a. Does the ankle give way-how often, in what dorsiflexion as this is more disabling and may
circumstances? be related to other problems in the foot. Loss of
b. Does the ankle lock? ankle dorsiflexion is commonly seen after an
c. Does it feel as if something jumps or comes injury but may also accompany Achilles tendon
out of place in the ankle? problems, arthritis or flatfoot. The actual block
to dorsiflexion may be a tight Achilles tendon,
Inspection: Look at the ankle for swelling, redness, anterior ankle impingement and incongruity or
deformity, sinuses, scars. arthrofibrosis of the ankle. If the patient has
Palpation: Feel the temperature of the joint and anterior or posterior ankle pain, also check for
compare it with the other side. Feel for tender impingement in the dorsiflexed (especially with
areas, systematically checking: the foot everted) or plantarflexed position. Local
a. Anterior joint line (see Fig. 13.4) anesthetic injection may clarify this further.
b. Lateral gutter and lateral ligaments Stability: Test for ankle stability using the anterior
c. Syndesmosis drawer and tilt tests. In the acute trauma situation
d. Posterior joint line pain makes these difficult. Sometimes local
e. Medial ligament complex anaesthetic injection into damaged ligaments or
f. Medial gutter the lateral popliteal nerve makes stress testing
Feel for an effusion, synovitis, deformity, easier. The anterior drawer test should be done
bony prominence and loose bodies. with the ankle plantarflexed 20°. Push posteriorly
with one hand on the tibial shaft and draw the generalized joint laxity; a stiff joint should
calcaneum forwards. Look for a sulcus forming suggest inflammatory, post-traumatic or
in the anterolateral joint line as a vacuum is degenerative arthritis, post-traumatic
created in the joint by the subluxing talus. Drawer arthrofibrosis or tarsal coalition. Pain in the sinus
test is positive if there is more than 4 mm tarsi area maximal on varus tilt is usually due to
translation. The tilt test can be done with the talocalcaneal ligament injury; pain maximal on
ankle in neutral. In many people it is possible to valgus stress is usually due to impingement in
hold the talus and tilt it directly while holding the calcaneofibular recess after calcaneal fracture,
the tibia. This allows you to be confident that any or in the sinus tarsi due to hindfoot valgus with
tilt is occurring in the ankle. In other patients it or without inflammatory joint disease.
is necessary to tilt the heel while holding the tibia Stability: The anterior draw or tilt tests holding
(inversion/eversion stress test). A finger on the the talar neck and manipulating the heel may
talar neck will then give an impression of talar occasionally give a feeling of subtalar laxity, but
movement. Instability of the syndesmosis may instability is difficult to demonstrate
be palpable, usually on A-P translation of the convincingly even on stress views or
distal fibula or valgus stress of the ankle. arthroscopy.
Abducting the talus or squeezing the tibia and
fibula together (the squeeze test) may produceIrritability: When you move the joint, does it
pain from an injured syndesmosis. reproduce the patient's symptoms? This is a
useful guide to whether the symptoms are
Irritability: When you move the joint, does it coming from the subtalar joint. The injection of
reproduce the patient's symptoms? This is a local anaesthetic into the joint can also be helpful
useful guide to know whether the symptoms are if it relieves the symptoms.
coming from the ankle. If you suspect the
symptoms are coming from the syndesmosis the Sinus tarsi (Fig. 13.11): Remember to examine the
squeeze test can be useful. sinus tarsi carefully. The "sinus tarsi syndrome"
of sinus tarsi pain and tenderness relieved by
SUBTALAR JOINT local anesthetic injection with subjective hindfoot
Observe: The shape of the hindfoot and its
flexibility as described under general
examination. Look for swelling, especially
synovitis in the sinus tarsi and the broadening
of the hindfoot that occurs after a calcaneal
fracture. Look for scars and sinuses.
Palpation: Compare the warmth of the lateral
hindfoot with the opposite side. Palpate over
each facet for tenderness, bony prominence and
synovitis. Palpate the sinus tarsi.
Range of movement: Hold the talar neck and ask
the patient to move the heel from side to side.
This should give you a rough idea of how much
active motion occurs in the free position. Repeat
using a hand on the heel to move the joint. A
hypermobile joint is often associated with Fig.13.11: Palpation of tarsal sinus
instability is usually caused by injury to the TARSOMETATARSAL JOINTS

interosseous talocalcaneal ligament (which may
Observation: Look for midfoot deformity,
be to rn, im pi ng in g in the sub tala r jo in t,
swelling and osteophytes from the joint.
chronically inflamed or fibrosed) or the subtalar
joint arthritis. Palpation: Compare the warmth of the
tarsometatarsal region with the opposite side.
Ankl e: Remember that many patients with
Palpate over the tarsometatarsal joints for
subtalar problems, especially after trauma, have
tenderness, bony prominence and synovitis.
problems with the ankle too, most commonly
Osteophytes dorsal to the first TMTJ are usually
instability or anterolateral synovitis, so examine
innocuous but may indicate instability or arthritis.
the ankle as well.
Range of movement: Active movement at the
MIDTARSAL JOINT TMTJs is almost always zero. Hold the midfoot
and manipulate each metatarsal up and down to
Observation: Look for midfoot deformity,
estimate passive range of movement. Also
swelling and osteophytes from the joint.
manipulate the first metatarsal in a valgus-varus
Palpation: Compare the warmth of the midfoot plane. When manipulating the first metatarsal,
with the opposite side. Palpate over the be sure to hold the medial cuneiform in the other
talonavicular and calcaneocuboid joints for hand—the first ray is quite mobile in some people
tenderness, bony prominence and synovitis. but often most of this movement is in the
talonavicular or, usually, the naviculocuneiform
Range of movement: Hold the heel and ask the
joint.
patient to move the foot from side to side and up
and down (it varies from patient to patient). Stability: Stressing the TMTJs may give an
Repeat the process holding the heel and moving impression of instability but this is rare.
the midfoot to estimate range of midtarsal
Irritability: When you move the joint, does it
movement. Adduction is 20° and abduction is 10°.
reproduce the patient's symptoms? This is a
Stability: The talonavicular joint may be unstable useful guide to whether the symptoms are
in the flat foot but this is multi-directional and not coming from the TMTJ. The injection of local
generally palpable. The navicular drop test gives anaesthetic into the joint can also be helpful if it
an estimate of talonavicular instability. Vertical relieves the symptoms.
calcaneocuboid instability is occasionally seen,
Other structures: If midfoot pain does not appear
usually with post-traumatic lateral foot pain.
to be coming from the tarsometatarsal joints,
Irritability: When you move the joint, does it carefully examine the subtalar and midtarsal
reproduce the patient's symptoms? This is a joints, the tibialis anterior and posterior and
useful guide to whether the symptoms are peroneus longus tendons and the plantar fascia.
coming from the subtalar joint. The injection of The planovalgus foot may have some laxity at
local anaesthetic into the joint can also be helpful the tarsometatarsal level and a vague midfoot
if it relieves the symptoms. ache, which is not reproduced by TMTJ
manipulation or blocked by local injection.
Other structures: If midfoot pain does not appear
to be coming from the midtarsal joint, carefully
ACHILLES TENDON
examine the ankle, subtalar and tarsometatarsal
joints, the tibialis posterior and peroneus longus History: As well as the general questionnaire,
tendons and the plantar fascia. establish in detail the patient's level of sporting
activity and whether anything has changed Integrity: Some ruptured tendons have an
recently—distance, running surface, shoes. obvious gap. The best test for integrity of the
Always ask not only about trauma but non- tendon is the Thompson (or Simmond's) test:
traumatic acute pain in the tendon. Acute pain squeezing the calf produces plantar flexion of the
during sport or other vigorous activity followed foot equal to that on the normal side. Do not be
by swelling and a limp suggests a torn Achilles misled by the ability to stand on tiptoe—it does
tendon. not exclude an Achilles tendon rupture.
Observation: Lack of push-off in the propulsive Strength: Compare active and resisted plantar
stage of gait suggests Achilles weakness or flexion with the opposite side but remember this
rupture. A tendency to walk with the foot in does not only test the triceps surae. If weak, check
valgus may be due to a tight Achilles tendon. that the Achilles tendon is intact and examine
Inability or difficulty with walking on the heels the S1 root sensory supply.
also suggests a tight tendon.
Contracture: Assess the range of passive ankle
Palpation: Feel the gastrocnemius and soleus dorsiflexion with the heel in the neutral
bellies and the whole length of the tendon, feeling position (this is particularly important in
for gaps, tenderness, swelling, or paratendonitis. planovalgus feet in which the heel tends to go
Distinguish between paratendonitis, in which into valgus when the ankle is dorsiflexed
there is generalised tenderness and puffiness giving a spurious impression of no Achilles
with a slightly crinkly feeling, insertional contracture). If restriction of dorsiflexion is
tendonitis in which the pain and swelling is at the greater with the knee extended than flexed the
insertion of the tendon (Fig. 13.12) and there is contracture is principally in the gastrocnemius,
often a Haglund's prominence, and non- whereas restriction, which is equal in all knee
insertional tendonitis in which the swelling is in positions, is due to the soleus. Remember that
the substance of the tendon about 3 to 6 cm above there are other causes of restricted ankle
the insertion. Also identify the posterolateral dorsiflexion: Capsular contracture or
(Haglund's) prominence of the calcaneum and arthrofibrosis of the ankle after trauma,
palpate the retro-Achilles bursa. anterior ankle impingement, ankle arthritis and
other soft tissue contractures.
TIBIAL IS POSTERIOR
Hi st ory : The classic complaints in tibialis
posterior problems are posteromedial ankle pain
and swelling and gradual (occasionally sudden)
arch collapse. Many people with tibialis posterior
insufficiency have a pre-existing flat foot.
Observation: There may be swelling along the
course of the tendon, especially behind and
below the medial malleolus. The foot may be flat.
Examination from behind may show a valgus
heel, prominent talar head and the "too many toes
sign" indicating an abducted forefoot. The shoes
Fig. 13.12: Palpation of Achilles tendonitis and will show pressure and buckling if there is a
retrocalcaneal bursitis significant flat foot.
Palpation: Palpate the entire muscle and tendon, or neuropathy, requiring a thorough examination
looking for swelling, gaps, tenderness and and often further investigation.
synovitis.
Observation: The gait of foot drop is the classical
Integrity: From behind, ask the patient to do a high step and flop. Tendonitis of the dorsiflexors
single foot tiptoe test on both sides. Most people causes pain and affects gait in the early contact
cannot get the affected heel off the ground at all; phase, especially when going uphill. The
a few develop an acute midfoot breach. Another dorsiflexors are often weak in pes cavus, but are
useful test is to get the patient to contract the rarely the cause of complaint in this condition.
tibialis posterior in the plantar-flexed/inverted
Palpation: Palpate the entire muscles and tendons,
position (Fig. 13.13). The tendon may be weak,
looking for swelling, gaps, tenderness and
impalpable or palpably thin. The plantar flexed
synovitis. Feel for synovium protruding between
position prevents recruitment of the tibialis
the limbs of the inferior extensor retinaculum.
anterior. Always examine for an Achilles
contracture, which is present in most people with Integrity: Resisted dorsiflexion with palpation of
tibialis posterior insufficiency. the tendons should assess tendon integrity.
Strength: Strength can be tested both actively and Strength (Figs 13.14A to D): Active and resisted
against resistance in the plantar-flexed/inverted dorsiflexion will allow estimation of strength.
position. Always test the strength of the other Weakness should lead to evaluation of the CNS,
muscles too. L5 spinal level and the sciatic, common and deep
peroneal nerves.
Contracture: A fixed tibialis posterior contracture
presents with a fixed equinovarus foot. After a Contracture: Dorsiflexor contracture is rare,
stroke tightness or inappropriate firing of the except where the toe metatarsophalangeal joints
muscle may present with a dynamic equinovarus are pulled into dorsiflexion by muscle imbalance
that may only be clear on formal gait analysis. and loss of passive toe control.
The Achilles tendon is usually tight too.
PERONEALS
DORSIFLEXORS
History: Peroneal tendon problems present with
Hi st ory : Tendonitis of the dorsiflexors is lateral hindfoot pain or pain under the midfoot.
uncommon and usually presents in athletes. Foot It may be precisely located to the point where
drop may present after stroke, spinal injury, the peroneus longus curves under the foot
stenosis or disc prolapse, peripheral nerve injury (sometimes known inaccurately as POPS—
painful os peroneum syndrome). Another
presentation is with pain, swelling and
sometimes popping or obvious dislocation of the
tendons behind the lateral malleolus. Patients
with peroneal instability may complain that the
ankle gives way.
Observation: The gait, if affected, tends to be
antalgic. There may be swelling over the lateral
hindfoot. Occasionally the peroneal tendons are
Fig. 13.13: To test tibialis posterior have the patient obviously dislocated from behind the malleolus
to supinate and invert the foot from a lateral position or can be made to do so by the patient.
A B
C D
Figs 13.14A to D: (A) Tibialis anterior is tested by stabilizing the calf above the ankle with one hand while
exerting pressure in plantar flexion and eversion on the dorsum of the foot with the other hand against resistance;
(B) Extensor hallucis longus is tested by immobiling the tarsus with one hand and apply dorsal pressure to the
distal phalanx of great toe with t he examiner’s other hand against resistance; (C) Extensor digitorum longus is
tested by immobilizing the tarsus and applying dorsolateral pressure to the distal small toes; (D) Extensor
digitorum brevis is tested by immobilizing the tarsus and applying dorsolateral pressure to the proximal phalanges
of small toes
Palpation: Palpate the entire muscles and tendons, rupture but is difficult to test and FHL can
looking for swelling, gaps, tenderness and compensate. Test the integrity of the peroneal
synovitis. Post-malleolar tendonitis may produce retinaculum by attempting to dislocate the
a "popping" or grating sensation on compression. tendons with the ankle dorsiflexed and the foot
It may be possible to dislocate the peroneal in eversion.
tendons, especially with the foot in dorsiflexion/
eversion. Carefully palpate around the peroneal Strength (Fig. 13.15): Testing of eversion, both
trochlea and the peroneus longus where it goes active and resisted, gives an estimate of peroneal
under the foot as these are also common sites of strength.
tendon problems. Contracture: Peroneal contracture is not often seen
Integrity: Testing of eversion, both active and but produces fixed hindfoot eversion and first
resisted, gives an estimate of peroneal integrity, ray plantarflexion. "Peroneal spasm" is said to
but major tendon defects may be present without be a feature of tarsal coalition but the muscles
palpable weakness. Inability to plantar flex the are usually contracted secondary to the hindfoot
first metatarsal is typical of peroneus longus valgus rather than truly in spasm.
Fig. 13.15: Peroneus longus and brevis is tested by

keeping the leg internally rotated, immobilizing the calf
slightly proximally to the ankle with one hand while
pressing the lateral margin of the foot into adduction
and inversion with the other hand against resistance
HEEL
History: Heel pain is usually due to plantar
fascitis but several other conditions can produce Fig. 13.16: Palpation of heel spur
this complaint. Ask particularly about trauma,
diabetes, spinal problems, arthritis and other
features of inflammatory disease, symptoms patients have tried homemade or proprietary
suggestive of nerve entrapment such as heel pads, which are often of little benefit.
numbness, burning and electric shock sensations. Palpation: Palpate all round the heel, checking the
Clarify exactly where the pain is felt: many medial calcaneal tubercle, the rest of the
patients with plantar fascitis point directly to the undersurface, the medial hindfoot (especially the
medial calcaneal tubercle (Fig. 13.16), whereas nerves in the tarsal tunnel and the medial side of
in heel pad atrophy the whole heel pad is sore, the calcaneum and the nerve to abductor digit
and other patients will indicate the medial, lateral quinti where it passes under the heel), the
or posterior aspect of the heel, not the underside, Achilles tendon insertion, the peroneal and
as the source of pain. Ask about the diurnal tibialis posterior tendons and the ankle and
rhythm of the pain: plantar fascitis is typically subtalar joints, manipulating the latter to see if
worse on getting out of bed and then gets worse they are unduly stiff or irritable. Always examine
towards evening, while heel pad atrophy tends for an Achilles tendon contracture, which is often
to be simply activity related. Ask about present in patients with plantar fascitis.
occupation: heel pain is more common in those
who are on their feet a lot, especially if they work THE GREAT TOE
on a hard surface in hard shoewear, and
History: Decide exactly what the patient is
obviously this may affect the ability to return to
complaining of: Cosmetic dissatisfaction, medial
work.
eminence pain, dorsal MTPJ pain, joint pain, stiffness,
Observation: The early part of the stance phase of shoe problems, other pressure problems such as
gait is shortened as the patient unloads the kissing corns between the great and second toes.
painful heel. Obesity is common in patients with Make a realistic assessment of the patient's attitude
plantar heel pain. Look for other evidence of to shoes and their willingness to look for shoes that
inflammatory arthritis: joint deformity, psoriasis, fit the foot. Always ask about lesser toe problems,
rheumatoid nodules. Look in the shoes: often lesser metatarsalgia and generalized arthropathies.
Observation: With a stiff or severely valgus great rigidus, measure how much movement remains,
toe the propulsive phase of gait may be weak or in both plantar and dorsiflexion. Manipulate the
even absent. The shoes will show deformation hallux MTP joint for irritability in both the
by a substantial bunion or dorsal exostosis. neutral (arthritic pain) and dorsiflexed (dorsal
Assess the severity of the hallux and any lesser impingement pain) positions. Hallux valgus
toe deformities in the standing position. Look for interphalangeus is usually most apparent with
skin breakdown or sinuses over bony the IP joint flexed, although with practice it can
prominences. Distinguish between a medial usually be diagnosed with the toe straight.
prominence (hallux valgus) and a dorsal Assess the range of movement of the proximal
exostosis (hallux rigidus). Look for sub- first ray in both sagittal and transverse planes.
metatarsal calluses. Interspace fullness can be Test the lesser MTP joints, especially the second,
due to synovial pathology, neuroma or bursitis. for instability. All toes are tested for strength
(Figs 13.18A to C).
Palpation: Palpate for tenderness, swelling,
synovitis and joint instability. Especially localize
GREAT TOENAIL AND NAIL B ED
tenderness around the hallux (Fig. 13.17). Medial
PROBLEMS
pain can be due to exostosis, dorsomedial
cutaneous nerve irritation or bursitis/synovitis History: Which part of the nail is the patient
especially in gout. Sesamoid arthrosis can cause complaining of? If the problem is recurrent, is
pain in the plantar aspect. Feel for tenderness there an obvious reason, such as diabetes or
under the lesser metatarsal heads. systemic steroid use? What has been done in the
past? Take a careful history of lesions under the
Movement: Assess the range of movement in the
nails - remember some of them are tumors. If the
hallux MTP and IP joints, the lesser toes and
nails are dystrophic, a general medical history
the rest of the foot, both passively and actively.
should be taken to look for the cause.
If there is hallux valgus, test the MTP joint in
the corrected position if possible. Assess how Observation: Look for nail deformity and
correctable the hallux valgus is. If there is hallux dystrophy. Are one or both nail folds inflamed?
Is there any spreading cellulitis or abscess
formation? Look for lesions under the nail.
Remember that melanomas are not always
pigmented.
Palpation: If there is active infection or a
subungual lesion palpate the regional lymph
nodes.
METATARSAL REGION
History : Patients generally complain of pain,
which we usually call "metatarsalgia."
Sometimes this term is used more specifically
of pain under the metatarsal heads. There are
many possible causes, not all in the foot. Always
remember to think about:
a. Obesity
Fig. 13.17: Palpation of flexor hallucis longus tendon b. Diabetes
f. Neurological problems such as interdigital

neuralgia or, more rarely, tarsal tunnel
syndrome.
Other people complain only of calluses under
the forefoot (usually pressure-related) or tingling,
numbness or other neurological symptoms,
A
which are usually due to interdigital neuralgia.
Observation: The gait may be antalgic or there
may be a poor propulsive phase. Examination of
the spine, proximal limb, leg lengths or other
joints may be necessary and a more or less full
neurological examination is often needed. Carry
out a full examination of the proximal foot as
detailed in previous sections, particularly looking
at the overall shape of the foot and for evidence
of arthritis, trauma and previous surgery.
B Look at the forefoot, again looking for
deformities of the overall forefoot and toes,
arthritis/synovitis, scars, swellings, malalignments.
Assess toe deformities with the patient standing.
Look carefully for corns and other skin lesions
between the toes. Look carefully for calluses
under the metatarsal heads— Do they
correspond with the patient's complaints?
Palpation: Again, palpate the proximal foot as
detailed in the sections above. Palpate the
forefoot, feeling for tenderness, swelling, and
malalignment. Differentiate between tenderness
C
in the MTP joints, under the metatarsal heads and
between the metatarsal heads. Test for a Mulder's
Figs 13.18A to C: (A) Flexor hallucis longus is tested
click. Examine the pulses, using the Doppler if
by applying pressure to the distal phalanx of the
necessary, and examine the foot neurologically
reat toe as shown against resistance; (B) Flexor
hallucis brevis is tested by applying pressure to the
including pressure testing with Semmes-
proximal phalanx of the great toe as shown against Weinstein hairs if diabetes is present or
resistance; (C) Flexor digitorum longus is tested by suspected.
applying pressure to distal phalanges of small toes as Movement and stability of joints: Assess active and
shown
passive range of movement of MTP and
interphalangeal joints. Evaluate the stability of
all the MTP joints and the reducibility of lesser
c. Generalized arthropathy such as rheumatoid
toe deformities in plantar flexion. How stable
disease
overall is the first ray?
d. Biomechanical problems such as a tight Achilles
tendon, short or dysfunctioned first ray Injections: Diagnostic injections of local anesthetic
e. Lesser toe deformities can be very useful in locating the source of
forefoot pain. Usually inject joints first before Movement and stability of joints: Assess active and
testing nerves. passive range of movement of MTP and
interphalangeal joints. Evaluate the stability of
LESSER TOES all the MTP joints and the reducibility of lesser
History: Complaints usually relate to toes, which toe deformities and estabilised contractures.
rub on the shoes (usually over a PIP joint or at
the tip) or on each other (usually with a bony SPECIFIC CONDITIONS
prominence on a condyle underneath). Some
people are unhappy with the appearance of their Pes Cavus
toes. Some lesser toe problems present with Clinically cavus can be made out by high medial
metatarsalgia. Multiple toe problems, especially arch and lateral aspect of foot not touching the
if the toes look odd or there is pes cavus or muscle ground that can be tested by passing a coin.
wasting, may be associated with a generalized
neurological disorder or a spinal malformation. Coleman's Block Test (Figs 13.19A and B)
Interdigital neuralgia sometimes presents with
symptoms mainly in the toes. To understand this test, it is essential to know
the mechanism of pes cavus. Usually it starts due
Observation: Sometimes the gait is antalgic or to muscle imbalance resulting in dropping of 1st
there is a poor propulsive phase. Look at the metatarsal, this creates a pronation deformity of
entire lower limbs for muscle wasting or other the foot. To make the foot flat on the floor the
deformities, which may suggest a neurological hind foot inverts. In this special test a wooden
or malformation syndrome. Look at overall block is kept under the heel and lateral rays so
foot shape, especially pes cavus or a severely that the 1st ray is allowed to drop freely. This
overpronated foot. Look for evidence of results in reproduction of forefoot pronation with
generalized arthropathy or vascular the hind foot in neutral position. If the hind foot
insufficiency. Assess the shape of the toes with varus does not correct with this test, then it
the patient standing. Look for calluses under the indicates fixed deformity of subtalar joint due to
metatarsal heads, over the PIP joints and at the long-standing deformity. This test essentially
tips of the toes, and soft interdigital corns and differentiates flexible from rigid hind foot varus
other skin lesions. deformity.
Palpation: Palpate the proximal foot as detailed Look for clawing of hands, which may
in the sections above. Palpate the forefoot, feeling indicate the diagnosis of Charcot-Marie-Tooth
for tenderness, swelling, malalignment. Palpate disease.
the toes for tenderness, swellings and synovitis. Assess spine for tethered cord syndrome or
Feel for any soft corns carefully underlying bony any other spinal disorders.
prominences. If there are symptoms suggestive Check for Romberg sign, which is failure to
of interdigital neuralgia, feel for a Mulder's click keep the body balance upright on closing the
with two fingers of one hand gently palpating eyes. This indicates posterior column lesion and
the interdigital space while the other hand favors the diagnosis of Friedreich's ataxia.
compresses the metatarsal heads together. Diseases causing pes cavus includes:
Examine the pulses, using the Doppler if i. Neuromuscular cause Friedreich's ataxia,
necessary, and examine the foot neurologically Charcot-Marie-Tooth disease, cerebral palsy,
including pressure testing with Semmes- poliomyelitis, spinal dysraphism
Weinstein hairs if diabetes is present or ii. Post-traumatic malunited fractures, compart-
suspected. ment syndrome, crush injury foot.
Figs 13.19A and B: Coleman's block test
iii. Inflammatory condition rheumatoid arthritis Tibialis Posterior Insufficiency Test

iv. Congenital residual club foot, arthrogryposis,
This can be tested by 'single leg stance' on
idiopathic.
tiptoes, which produces inversion of hind foot
due to intact tibialis posterior. Patient with
Flat-foot
rupture will not be able to stand on one leg on
Look for too many toes sign from the back in tiptoes. The muscle can also be assessed for
standing posture (Fig. 13.20). contraction by bending the knee, with foot in
equinus and performing resistant inversion.
Flexible or Rigid Flat Feet Always feel for taut tendon 2 cm behind and
above the medial malleolus. Plantarflexing the
In flexible flat feet the medial arch is present on
foot eliminates the action of tibialis anterior as
non-weightbearing and disappears on weight
invertor.
be ari ng. On sta nd in g on tip to es th e arch
reappears in flexible flatfeet. This can also be Tight Tendo-Achilles
checked by Jack test in which dorsiflexion of big
toe reproduces the medial longitudinal arch. This should be tested by bringing the valgus heel
into neutral position and dorsiflexing the foot to
reveal tightness. It is a cause for flexible flatfoot
due to ligamentous laxity.
Conditions causing flatfeet include:
Congenital: Flexible—tight heel cord
Rigid—tarsal coalition, vertical talus,
arthrogryposis
Acquired: Tibialis posterior insufficiency
Rheumatoid arthritis
Diabetes
Degenerative joint disease of tarsometatarsal
joint
Traumatic-calcaneal fractures
Neuromuscular—polio, cerebral palsy, nerve
Fig. 13.20: Too many toes sign injuries
Club Foot (Congeni tal Talipes (Fig. 13.22) which is a nonprogressive disorder
Equino Varus with multiple congenital rigid joints due to
It is a congenital deformity of the foot disorder of myopathic, neuropathic (decreased in
characterized by stork-like legs, equinus of ankle, anterior horn cell) or mixed affection. They have
inversion at subtalar joint and adduction of normal intelligence, absence of shoulder muscles,
forefoot. It is bilateral in 50 percent and 90 percent thin tubular limbs, elbow extended, clasp thumb,
is idiopathic in origin (Fig. 13.21). wrist flexed, no flexion creases, teratologic hip
Size of the foot and leg is always comparatively dislocations, knee contractures, resistant club feet
smaller, with deep medial crease, convex lateral and vertical talus.
border and raised posterior heel. Postural club foot
is differentiated from true club foot by dorsiflexing Plantar Fascit is
the foot and in which case the dorsum can touch Heel pain with tenderness in plantar medial
the shin of tibia. Presence of very short 1st ray and aspect of calcaneum. This can be due to
absent posterior skin crease over calcaneum with inflammatory diseases, sudden increase in
small heel indicates rigidity of the foot. It can be weight, plantar flexed 1st ray on forefoot valgus.
differentiated from neurogenic clubfoot by This condition is treated by anti-inflammatory
stroking the sole, which should normally cause drugs, modified footwear, local heat treatment
dorsiflexion of the foot. Examine the ipsilateral hip and sometimes night splint in dorsiflexion.
for developmental dislocation of hip and spine for Presence of calcaneal spur rarely causes pain.
any obvious neurocutaneous markers. A child Differential diagnosis includes neurologic
with a congenital anomaly should be screened causes—lumbar disk prolapse, tarsal tunnel
completely for other associated anomalies. It is syndrome, and entrapment of posterior tibial
important to know the prenatal, perinatal and nerve branches; stress fracture of calcaneus and
postnatal history, nature of birth, any family heel pad atrophy.
history of similar problems and delayed
milestones. Child needs opinion from a
pediatrician and the family needs genetic
counseling. It can be associated with multiple
congenital contractures of the joint, otherwise
called arthrogryposis multiplex congenita
Fig. 13.22: Arthrogryposis multiplex congenita

Fig. 13.21: Bilateral club foot (For color version, see Plate 7)
Posterior Heel Pain Osteochondri tis of Navicular (Avascular

Necrosis of Navicular Bone)
It can be from insertional Achilles tendonitis,
retrocalcaneal bursitis, and Haglund's disease. It is also called Kohler's disease. It is common in
children who present with midfoot pain and is a
Tendo-Achilles Rupture self-limiting condition.
This condition presents with sudden giving way An kl e Instabil it y
and pain at the heel cord region, sometimes with
Anterior Drawer Test (Figs 13.24A and B)
a feeling of being tripped by somebody from back
(in attrition rupture). Patient feels the leg is weak It can be done by sitting on the foot and
with loss of push off and is unable to stand on pushing the shin of the tibia back or holding
tiptoes on involved side. There may be swelling the talus in equinus in one hand and the other
or ecchymosis in the heel cord area. A gap may hand to stabilize the lower leg, perform
be felt in complete rupture (commonly about 2 anterior drawer test. This implies injury to
inches above its insertion) with abnormal range lateral ligament complex.
of dorsiflexion. This is confirmed by Simmond-
Thomson's test.
Simmond-Thomson's Test (Fig. 13.23)

The calf is squeezed while the patient lies prone
with the foot projecting beyond the edge of the
couch or by kneeling on the chair. Plantarflexion
of foot is seen if the tendo-Achilles tendon is
intact or incompletely ruptured. In complete
rupture of tendon there will be no plantar flexion
of the foot.
Osteochondritis of Talus (Osteochondral

Dome Fractur e or Partial Talar Necrosis )
Patient presents with pain, giving way of ankle,
and occasional swelling.
Fig. 13.23: Thomson's test Figs 13.24A and B: Anterior drawer test
Inversion-Eversion Stress Test and infections are some of the causes of
metatarsalgia. This can be investigated by pedo-
This can be assessed clinically and radiologically
barography to assess the areas of weightbearing.
by talar tilt. Isolated anterior talofibular ligament
Appropriate insoles by distributing the weight
injury is tested by inversion of the foot in equinus
evenly under the foot can solve this problem.
position. Inverting the hind foot in neutral
position tests calcaneo-fibular ligament and any
Morton's Neuroma
opening in neutral position indicates ankle
instability and subtalar joint instability. Talar Usually it is a neuroma of the 3rd digital branch
tilting of more than 5° in comparison to opposite of medial plantar nerve, manifests with
side can be pathological. metatarsalgia and sometimes numbness and
tingling between 3rd and 4th toes. Patients
Osteoarthritis Ank le present with pain on walking, well-localized and
patients wearing shoes note that taking the shoes
It can be primary or secondary and patients
off relieves the pain. Some patients feel sitting
present with pain on walking and stiffness.
crosslegged causing pain. Mulder's click may be
Swelling of the ankle can be due to bony
present (Fig. 13.25). This is clicking sensation on
outgrowth-osteophytes, soft tissue synovial
squeezing the forefoot like a spring test.
thickening or effusion of the joint. As the ankle
Tenderness in the intermetatarsal space (Fig.
joint gets stiffer it lacks the normal rocking of
13.26) and sometimes a palpable nodule can be
the gait cycle. Patients try to externally rotate the
found. Examine the toes for neurological deficit.
foot to shorten the lever arm of the dorsiflexion
In doubtful cases either a trial injection can be
and plantarflexion movement.
done or a MRI scan to confirm the diagnosis.
Subtalar Arth ritis
Metatarsus Adductus
It can be of infective, post-traumatic or
Characterized by adduction of forefoot and
inflammatory cause. Patients present with
commonly associated with developmental
difficulty in walking on uneven surface and
dysplasia of hip. Bleck described a grading
morning stiffness. Some patients can have
peroneal spasm. Inversion and eversion
movements may be restricted.
Metatarsalgia
Foot and toes deformities should be assessed.
Plantar callosities should be identified and felt
for tender spot both on metatarsal heads and
intermetatarsal space. Spine should be examined
if the foot has pes cavus with clawing of toes.
Any previous surgery should be noted especially
hallux valgus correction by 1st metatarsal
osteotomy that results in shortening of the ray
and transfer metatarsalgia to lesser rays.
Inflammatory conditions, Freiberg's infraction
(osteochondritis of 2nd MT head), tibial tunnel
syndrome, viral warts, stress fractures, tumours Fig. 13.25: Mulder's click
system based on heel bisector line, which

normally passes through second and third toe
interspace (Fig. 13.27).
Hallux Valgus (Fig. 13.28)

Outward deviation of big toe at Ist
metatarsophalangeal joint. Assess the length of
the 1st ray in comparison to 2nd ray, presence
of medial bunion, plantar callosities to know the
weightbearing part in the sole, and range of
movement of the joint. Pain on movement
indicates inflammation or arthritis. Attempt to
passively correct the deformity; this gives an
indication on soft tissue tightness. Extreme Fig. 13.26: Intermatatarsal tenderness
hallux valgus can result in hammer 2nd toe.
Hallux inter-phalangeus can also result in hallux
valgus. Metatarsus primus varus should be
identified clinically and radiologically, as it
needs basal osteotomy for correction. Also
examine the 1st tarsometatarsal joint for
hypermobility.
Hallux Rigidus
More common in young and middle-age and and
is unilateral disease. Presents sometime with Fig. 13.27: Heel bisector line
dorsal bunion and inability to stand on tip toes. I
st MTP joint movement is very much restricted
with pain. Weightbearing foot X-ray AP and
lateral is essential.
Gout (Figs 13.29A and B)

It presents with signs of acute inflammation
of 1st MTP joint. In chronic gout there may
be go ut y to ph i over th e pi nn a of ea r and
fingertips. It is related to alcohol and food intake.
This crystal arthropathy is due to deposition of
monosodium urate crystals. Serum uric acid
may be elevated.
Tarsal Tunnel Syndrome

Tibial nerve is constricted beneath the flexor
retinaculum in the tunnel formed by septae from Fig. 13.28: Bilateral hallux valgus
this fibrous roof to calcaneum. Unexplained (For color version, see Plate 7)
paresthesia in the plantar aspect of foot and toes swollen joint with radiographs showing
aggravated at night or by exertion. This can be advanced destructive changes of both sides of
due to talar or calcaneal fractures, tenosynovitis, joint, chunks of bone all around with distortion
ganglia, rheumatoid synovitis, varicosities etc. of the joint. Because of warmth and destruction
This can be confirmed by EMG and nerve and new bone formation it is confused with
conduction test. osteomyelitis but patient will not be in acute pain
and etiology may be obvious. Commonest cause
Neuropathic J oint (Charcot Arthr opathy) is diabetes involving foot, syringomyelia
involving shoulder and elbow, Hansen's disease
Chronic progressive, destructive process involving upper or lower limb joints, spinal cord
affecting the joint alignment due to lack of injury or spinal dysraphism, nerve injuries,
proprioception. Extreme form of arthritis congenital insensitivity to pain ant tabes dorsalis
typically characterized by unstable, painless, are other causes (Figs 13.30 and 13.31).
A B
Fig 13.29A and B: (A) First metatarsophalangeal joint acute inflammation from gout; (B) Pathology in gout
Fig. 13.30: Neuropathic tropic ulcer of foot with Lisfranc fracture dislocation from trivial trauma
Figs 13.31A and B: Neuropathic knee joint (For color version, Fig. 13.31A, see Plate 8)
Neuropathi c Foot have pain, lot of swelling, increased warmth,

This may start with a trivial fracture or injury to deformity, trophic ulcer and bony thickening.
foot in a patient with sensory disturbance. The There is total disorganization of the tarsal joints
most common cause is diabetes, but can also occur with new bone formation. The proportion of pain
in tabes dorsalis, spina bifida, leprosy, congenital is less for the damage that has occurred and in
indifference to pain and nerve injuries. Patient can some patients it may be totally pain free.
14 Examination of Rotational
CHAPTER Deformities in Lower Limb
Clinical evaluation of rotational deformities of Examination on Standing

lower extremity in children is important.
Assess the normal limb alignment in sagittal plane.
Rotational deformities in children manifest with
The normal plumb line (mechanical axis) is from
toeing in or toeing out. The deformity can be in
midinguinal point (midpoint between antero-
the femur, tibia or foot. The usual presentation
superior iliac spine and pubic symphysis) through
is for cosmetic reasons or sometimes with gait
midline of knee joint and passes through second
disturbance, patellofemoral disease and arthritis.
toe. In-turning of patella due to excessive femoral
Version refers to normal rotational alignment
torsion may be associated with toeing in or out
of tibia and femur; torsion is when the deformity
depending upon tibial rotation. In early stages of
is abnormal. In common practice version is used
excessive femoral anterior torsion, in toeing is
for describing femoral rotational alignment and
present, but in late stages normal toeing out is
torsion for tibia.
present because of compensatory lateral tibial
rotation following growth (Table 14.1).
HISTORY
Presentation Examination on Sitting
The family may complain of: (i) clumsiness, (ii) Sitting with legs hanging down, axis of thigh to
difficulty in running, (iii) frequent falls and (iv) intermalleolar axis gives an indication of tibial
cosmetic appearance. torsion. Normally the tip of lateral malleolus is 1
cm behind and below the medial malleolus. Child
Prenatal Histor y with significant anteversion often sits in "W"
position that is "both hips fully internally rotated
Birth history and milestones must be asked. and legs out."
Always check the hip for dysplasias, spine
Family History for any abnormalities, knee for patellofemoral
Some of the deformities may run in the family malalignment and increased "Q" angle, and foot
and this must be asked for. for deformities.
Knowing patient's or parents' expectation As ses sm ent of Rotati on al Pr of il e
EXAMINATION Staheli's Rotational Profile Tests
Gait can be in-toeing or can have other Staheli's rotational profile tests are used to
abnormalities. identify the site of rotational deformity (Fig. 14.1).
Table 14.1: Imaging princ iples
Modality Source Result Radiation Vocabulary Indication

X-ray X-rays 2-D Yes Opacity—White Fractures
Shadow Lucency—Black Dislocations
Foreign bodies
Bone infection
Bone tumors
Computed X-rays 2-D Yes X 100 Attenuation— 3D-Reconstruction
Tomography Slices High (Pelvic fracture, Pilon
(CT scan) Low fracture,
Tibial Plateau fracture,
Acetabular fracture)
Stress fracture
Spine fracture
Osteoid osteoma
Bone tumors
Tarsal coalition
CT-guided biopsy
Ultrasound Sound Waves Sector No Echogenicity— DDH
(US scan) Hypo/Hyper Abscess—Psoas
Fracture healing—
Ilizarov
+/- Acoustic Cysts—Baker's cyst
Enhancement/ Bursitis
Shadow Muscle tear
Tendon rupture
Joint effusion
Foreign bodies
DVT (Doppler US)
Magnetic Rf-Radio- Any slice No Signal Intensity Tumours staging
Resonance Frequency Any plane Hypo (Low-black) Infection
Imaging - Pulse on Hyper (High-white) Spine-pathology
(MRI scan) tissues in T1 and T2 Soft tissue injury-
Magnetic Images (Rotator cuff tear,
Field Labral lesion,
T1-fat is bright Menisci /cruciates)
T2-water is bright DDH
Osteonecrosis
Tarsal coalition
Bone Scan - Radioactive 2-D A/P Yes Increased Bony Metastasis
Radionuclide Tracer View of Activity— Stress fracture
Scan Technetium 99 entire Hot scan or Bone infection
Gallium 67 skeleton Cold scan Tumors
Indium 111 AVN
RSD
Bone X-rays Density Yes Bone mineral Osteopenia
Densitometry Pattern content and density Osteoporosis
Examination of Rotational Deformities in Lower Limb 169
Fig. 14.2: Thigh foot angle and hindfoot forefoot angle
and neck axis to the horizontal and is

represented by the angle between the leg and
vertical axis. Clinically the head and neck axis
is made horizontal to the couch by rotating
the leg and holding it when the trochanter is
Fig. 14.1: Staheli's tests most prominent. The normal anteversion is
about 40º at birth and 15º in adults.
3. Thigh foot angle: This determines the tibial
1. Foot progression angle (FPA): It is the angle torsion and is between the longitudinal axis
between the longitudinal axis of foot and of the thigh and foot when observed from
direction of gait progression. The average FPA above with patient in prone position and knee
is +4.2° with a normal range of -8º to +8º. It flexed to 90º (Normal 0 to 30º). Transmalleolar
gives a measure of degree of toeing in or out angle can also be used for tibial torsion; with
due to contributions from foot, tibia and femur. patient in same position the angle between
2. Medial and lateral rotation of hip: This is best axis of thigh and line perpendicular to
assessed in prone position with knees flexed transmalleolar axis (line connecting mid point
to 90º. Patient with excessive femoral of medial and lateral malleoli) measures the
anteversion will have more internal rotation tibial torsion. This can be used when there is
movement with corresponding limitation of a foot deformity (Fig. 14.2).
external rotation. Internal rotation of hip 4. The foot deformity is assessed by noting the
greater than 70º indicates excessive femoral position of forefoot in relationship to hind foot
anteversion. The version is estimated by the by the heel bisector line as described in the
degree of hip rotation required to bring head foot chapter.
Index
Page numbers followed by f refer to figures and t refer to tables
A Ankle 25, 150, 152 Auscultation 5

clonus 97 Avascular necrosis 121
Abdominal reflex 76, 95 instability 162 Axillary nerve 84
Abduction jerk 76, 97 Axon reflex test 85
contracture 24 Ankylosing spondylitis 103
extension 114 Antalgic gait 110 B
in flexion 114 Anterior
Abductor cord syndrome 107 Babinski’s sign 23
paradox 35 cruciate ligament injury 139 Back pain in children and
pollicis brevis 77 dislocation of shoulder 43f adolescents 107
Abnormal drawer test 131, 132f , 162, 164f Barlow’s test 120, 120f
mobility 18 interosseous syndrome 81 Barton’s fracture 64
neurology 101 knee pain 139 Biceps 85
Achilles tendon 152 slide test 42 brachii 36
Acromioclavicular superior iliac spines 114 load test 42
joint translocation test 39f reflex 97
separation 28 Apical vertebra 101 tests 29, 37
stress test 38f Apley’s Bicipital tendinitis 41
tests 29, 38 grinding test 133 Bilateral
Active compression test 42 method 111 club foot 161f
Acute Apprehension test 39, 40f , 134. 137f hallux valgus 166f
osteomyelitis 6 Apprehensive sign 49 Blood test 122
septic arthritis hip 122 Arcade of Frohse 82 Book test 78, 79f
Adduction Arm Boutonnière deformity of fingers 67
contracture 24 elevation test 82, 83f Bow legs 136
in extension 114 length discrepancy 84
Bowstring test 93, 93f
Adductor tightness 24 Arnold-Chiari malformation 101
Brachial plexus 26
Adhesive capsulitis 44 Arthritis of acromioclavicular joint 28
injury 83
Adson’s test 82, 82f Arthrogryposis multiplex
palsy 26
Adult respiratory distress congenita 162f
Brachioradialis 80, 86
syndrome 20 Assessment of
Advanced trauma life suppo rt 8, 17 Breathing 8, 9
activities of daily living 22
Aggressiveness 5 Brown-Séquard’s syndrome 107
distal radioulnar joint 62
Airway Bryant’s triangle 117, 118f
dorsal wrist pain 61
obstruction 14 instability 53 Bulbocavernosus reflex 96
with cervical spine control 8 palmar wrist pain 62 Bunnell’s OK sign 77
Allen’s radial wrist pain 57
test 81, 81f rotational profile 135, 167 C
sign 117, 120 ulnar wrist pain 60
Alternative method of testing Associated bony injury 75 Caison’s disease 109
inversion 149f Asthma 1 Calcific tendinitis 28, 41
American Rheumatoid Asymmetrical skin crease 120 Calf muscle hypertrophy 24
Association 139 Atraumatic instability 28 Camptodactyly 69, 70
Anal reflex 96 Attitude of limb 18, 74, 84 Capener’s sign 122
Card test 78, 78f Crepitus 18 E

Cardiac tamponade 14, 16 Crossed SLR test 94
Carpal Cruciate ligament injury 139 Elbow
boss 65 extension 95
Crutch palsy 82
flexion 95
compression test 63f Crystal arthropathy 139
Eliciting patellar tap 128f
tunnel syndrome 63, 81 Cubital tunnel 80
Empty can sign 33
Carpometacarpal joints 61 Cubitus varus 45f
End vertebra 101
Cauda equina syndrome 102 Curved acromion 41
Erb Duchenne palsy 26
Cavus foot 145
Erb’s palsy 74, 74f
Central cord syndrome 107
D Esophageal trauma 15
Cerebral palsy 26, 100
Evaluating collateral ligaments 49f
Cervical De Quervain’s tenosynovitis 57, 58 Eversion of foot 95
spondylosis 106 Decreased systolic pressure 16 Ewing’s sarcoma from pelvis 5f
stenosis 106 Deep Examination of
Charcot arthropathy 165 reflex 76, 97 adjacent joints 19
Check movements 91 vein thrombosis and pulmonary ankle and foot 142
Cheralgia paresthetica 82 embolism 20 bone and
Chest Deformity 18, 19, 29, 52, 74, 84, joint infection 6
expansion 92 101, 104, 142 soft tissue tumors 5
injuries 14 Developmental dysplasia of hip 119 brachial plexus 84
tube intercostal drainage 15 Diabetes 1, 143 cervical spine 103
Chiene’s lines 117 Dial test 132 elbow 45
Chronic osteomyelitis 6 Diaphragm 85 hand 66
Circulation with hemorrhage Different types of hand grips 66f with lacerations 71
control 8, 9 Differential lignocaine injection test 63 hip 109
Claudication pain 89 Direct individual nerves 76
Clavicular fracture 28 carpal compression test 63 injured patient 8
Claw hand 69, 69f compression of nerve 75 knee 125
Cleidocranial dysostosis 28 Disability 8, 10 overlying skin and soft tissue 18
Dislocation of sternoclavicular peripheral nerves 74
Clinodactyly 70
joint 28 rotational deformities 167
Club foot 161
Distal shoulder 27
Cobb’s angle 100, 101
neurovascular spine 87
Coleman’s block test 159, 160f
examination 19 swelling 3
Colles’ fracture 63
symptoms 18 ulcer 4
Common peroneal nerve palsy 86
pulsation 128 wrist 52
Compartment syndrome 13, 19
ulna ballottement test 62 Exposure 8, 10
Complete tear of rotator cuff 28
Distant site problems 5 Extension 92
Compression Distraction test 99 catch 91
and distraction stress test 124 Dizziness 104 lag-knee 130f
neuropathy 80 Dominant hand 67 of middle finger 82
Condition Dorsal Extensor
affecting hip 119 scapular nerve 83 carpi radialis longus 58
of skin and soft tissues 75 subluxation of ulna 67, 68f digiti minimi 61
Congenital Dorsiflexors 154 digitorum communis 61
radioulnar synostosis 51 Drop arm test 34, 35f hallucis longus 95
talipes equinovarus 161 Dropped finger 67, 70 pollicis longus 59
Coracobrachialis 36 Duncan Ely’s prone rectus test 25 External
Coracoid impingement sign 37 Dupuytren’s contracture 69, 70 rotation recurvatum
Cozen’s test 47, 47f Dural tension signs 92 test 132, 133f
Cremastric reflex 96 Dysmorphism 75 rotator strength test 34
Index 173
F G Inflammatory
arthritis 121, 139
Faber test 116f , 124 Galleazi’s sign 117, 118f , 120 arthropathy 143
Failed Gamekeeper’s thumb 64, 64f spondylitis 103
back syndrome 103 Ganglion 61, 65 Instability 28
total knee replacement 141 Gastrosoleus 95 tests 29, 38
Feeling joint line 129f Generalized ligament laxity Intersection syndrome 57
Felon 72 assessment 134 Intrinsic
Femoroacetabular impingement 122 Genslen’s test 124 minus hand 69
Fibromyalgia 106 Genu muscles of hand 95
Findings in recurvatum 137, 139f Inversion-eversion stress test 163
lumbar disk disease 98t valgum 135, 137f Irritability 151, 152
nerve root compression 107t varum 136, 138f
Finger Gerber’s lift off test 33, 34f
J
Allen’s test 81 Giant cell tumor of tendon sheath 70
drop 80 Glasgow coma scale 10, 11t Jerk test of Hughston and Losee 132
flexion and extension 95 Gluteus Jersey finger 70
Finkelstein’s test 58, 58f maximus 94 Jobe’s
First dorsal interosseous 78 medius 95 relocation test 40f
Fixed flexion deformity 112 Gower’s sign 25 test 33
Fixity 4 Great toe 156 Joint sepsis 6
Grinding test 59, 59f
Flail chest 14, 16
Guyon’s canal 80 K
Flat
acromion 41
H Keinbock’s disease 62
foot 145, 160
Kirk Watson’s test 54, 55f
Flexed hip with normal knee gait 24f
Hallux Kliene’s line 122
Flexible flat feet 160
rigidus 164 Klippel-Feil syndrome 28
Flexion 91, 112
valgus 164 Klumpke’s
adduction test 38
Hamstring tightness 24 palsy 26
Flexor
Hand infections 72 paralysis 84
carpi Hansen’s disease 75 Knee 25
radialis 58, 77 Hawkin’s test 35, 35f flexion deformity 25
ulnaris test 78 Heel bisector line 165f jerk 97
digitorum Hereditary diseases 2 Knock knees 135
profundus 69 Heterotopic ossification 50f Kyphosis 101
superficialis 77 Hoffmann’s sign 97
hallucis longus 95 Holstein Lewis fracture 82
pollicis longus 77 L
Holt-Oram syndrome 65
Fluctuation 4 Hooked acromion 41 Lachman’s test 130, 132f
Foot Horner’s syndrome 26, 84, 85 Lasegue’s test 93
deformities foot 146f Housemaid’s knee 137 Lateral
progression angle 169 Human bite 73 cord syndrome 107
Fourth and fifth extensor Humeroulnar joint 45 flexion 92
compartment 61 Humerus shaft fracture 82 pectoral nerve 83
Fracture of Hypertension 1 pivot shift test 49f
neck of femur 18f root of median nerve 83
proximal humerus 28 Latissimus dorsi 36, 84, 86
I
Froment’s sign 78 Legg-Calve-Perthes disease 121
Frozen shoulder 44 Iliotibial-band tightness 24 Lesser toes 159
Full knee flexion-heel to buttocks 130f Impingement tests 29, 35 Levator scapulae 36
Level of Metatarsalgia 163 Open

activity 109 Metatarsus adductus 145, 163 fracture 17
injury 72 Midcarpal pneumothorax 14
Lhermitte’s sign 105 instability 56 Opponens pollicis 63, 77
Ligament laxity tests 135f shift test 57f Origin of tumors 6f
Limb of Lichtman 56 Ortolani’s test 120
alignment and length 143 Midpalmar infection 73 Osgood-Schlatter disease 141
length discrepancy 18, 19 Midtarsal joint 152 Osmond-Clarke’s test 134f , 137f
Lippman test 38 Mild effusion 128 Osteoarthritis 120
Local Monosynaptic reflex arc 76 ankle 163
bony tenderness 18 Morning stiffness 142 knee 138
pain 88 Morris bitrochanteric line 117 shoulder 42
Long Morton’s neuroma 163 Osteochondritis
flexors 77 Muffled heart sounds 16 dissecans 141
thoracic nerve 83 Mulder’s click 164f of navicular 162
Lower Muscle of talus 162
limb 23, 94, 95, 97 spasm 18 Osteomyelitis 28
nerve injury 86 testing chart 36t Osteonecrosis 139
motor neuron 23 wasting 24, 75, 79, 84 Overall foot shape 145
subscapular nerve 84 Musculocutaneous nerve 83
LT compression test 55 Myocardial contusion 15 P
Lumbar disc disease 99 Myositis ossificans 50
Lunotriquetral instability 55 Paget’s test 4f
Pain 5, 27, 52, 88, 104, 109, 125, 142
N
Palmar subluxation of radiocarpal
M
Nature of joint 67
MacIntosh’s pivot shift test 131 injury 72 Palm-up test 37
Madelung’s deformity 65 pain 2, 89 Palpable structures in elbow
Malignant spinal disease 102 Necrotizing fascitis 4f region 46f
Mallet finger 68 Neer’s Palpating annular ligament 47f
Malunited distal radius 64 impingement sign 35, 37f Palpation 3, 11, 13, 14, 152
Marfan’s syndrome 100 injection test 37 of radial and ulnar styloid 53f
Marginal osteophytes 121 Nelaton’s line 118f Paronychia 72
Masquelet’s ballottement test 56 Nerves 14, 71 Partial tear of rotator cuff 28
Massive hemothorax 14, 15 Neurofibromatosis 100 Patellar
McMurray’s test 132, 133f Neurologic level in upper limb 37t clonus 98
Neurological disease 143 glide test 134
Mechanism of injury 17, 71, 125
Neuropathic rotation in standing position 134
Medial
foot 166 tilt 137f
and lateral rotation of hip 169
joint 165 test 134
cutaneous nerve of
Neurovascular status 3 Patellofemoral
arm 83
Neutral vertebra 101 conditions 139
forearm 83
Night pain 89 joint problem 38, 134
hamstring tightness 24
Non-organic tenderness 99 Pathological fracture 5
pectoral nerve 83
Patrick’s Faber’ test 114
root of median nerve 83
O Pectoralis
Median nerve 76, 81
major 36, 95
Meniscal injury 139 O’Brien’s test 42 minor 36
Meralgia paresthetica 100 Ober’s test 25f Pelvic injuries 16
Meryon’s sign 26 Obstetric palsy 26, 84 Pen test 78f
Metaphyseal blanch sign 122 OK sign 77f Pes cavus 159
Metatarsal region 157 Olecranon bursitis 50, 50f Phalen’s test 63, 64f
Index 175
Phannelstein’s incision 16 fracture malunion 60 Schober’s test 91, 91f

Phelp’s gracilis test 24 nerve 79, 82, 84 Schoemaker’s line 117
Piano key test 63 tunnel syndrome 82 Sciatic nerve 86
Pisotriquetral grind test 62 Radiating pain 89 Scoliosis 93f , 100
Pivot shift test 133f Radiation 2 Septic arthritis 28
Plane of swelling 4 Radiocarpal Serratus anterior 85
Plantar glide test 57f Severity of pain 2
fascitis 161 instability 56 Shear test 55, 62
reflex 96 Range of movement 150-152 Short
Pointing index 78f Raynaud’s phenomenon 82 left leg 110f
Polysynaptic reflex arc 76 Reagan’s shear test 56 limb gait 110
Popliteal angle 26f Rectus femoris tightness 25 Shoulder
Posterior Referred or overflow pain 88 crepitus 44
cord 84 Reflex sympathetic dystrophy 72 dystocia 26
cruciate ligament injury 141 Rheumatoid instability 43
dislocation of elbow 49 arthritis 43, 160 sign 59
drawer test 131 nodules 51 Signs of causes of secondary OA 121
heel pain 162 Rhomboids 85 Silfverskiold’s test 25
interosseous nerve syndrome 82 Rigid flat feet 160 Simmond-Thomson’s test 162
load and shift test 40 Romberg’s sign 26 Simple compartment pressure 13
stress test 41f ROOS test 82 Simulation test 99
Post-traumatic contracture 69 Roser-Nelaton’s line 117 Sinus tarsi 151
Progression of Rotation 92 Skeletal system 71
lump 3 in extension 113 Skier’s thumb 64
pain 2 in flexion 113 Skin 12, 71
Pronator of hip, torsion of tibia 25 Skip lesions 5
syndrome 81 Rotator cuff Slide test 42f
teres and quadratus 77 disease 41 Slipped upper femoral epiphysis 121
Prone rectus test 25f strength Smith fracture 64
Provocative test 75 assessment 33 Snapping tendon 70
Proximal radioulnar joint 45 tests 29 Snuffbox 59
Pseudostability test 53, 55f Specific signs in median nerve
Pulled elbow 49 S palsy 78
Pulmonary Speed’s test 37
contusion 15 Sacroiliac joint stress test 123
Sage test 134 Spinal
function 101 cord injuries 107
Pulsatility 4 Saturday night palsy 82
Scanogram of chest wall 101 deformity 100
Pump handle test 123f , 124 dysraphism 24
Scaphoid
articular-nonarticular junction 59 infection 101
Q Spondylolisthesis 102
pathology 59
shift test 54 Spreading cellulitis of thigh 3f
Quadriceps 95
Scapholunate Sprengel deformity 28, 107
active test 131
ballottement test 56f Stability 150, 152
angle 134, 137f
dorsal ligament 65 tests 48
tightness 25
instability 54 Stable vertebra 101
Quadrigia effect 69
interval 61 Staheli’s
joint pathology 60 rotational profile tests 167
R tests 169f
test 55
Radial Scapho-trapezio-trapezoid joint Stiff hip gait 110
club hand 65 pathology 60 Stiffness 28, 52, 90, 104, 109, 125
deviation of metacarpals 67 Scheuermann’s kyphosis 103 Straight leg raising test 92, 93f

Clinical Assessment and Examination in Orthopedics

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Clinical Assessment and Examination in Orthopedics

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Clinical Assessment and

Chief Surgeon and Head

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Jaypee Brothers Medical Publishers (P) Ltd.

Clinical Ass essment and Examination in Orthopedics

First Edition: 2002

I would like to acknowledge my teachers, fellow colleagues, my team of Orthopedic Junior

1. Hist ory Taking and Clin ical Examinatio n .............................................................. 1

2. Exam in ation of Inj ured Patient ............................................................................... 8

3. Examinatio n of Patient wit h Bone and Joi nt Injur ies ......................................... 17

4. Examination of Neurom uscular Disease ............................................................. 22

5. Examination of Shou lder ...................................................................................... 27

6. Examin ation o f Elb ow ........................................................................................... 45

7. Examin ation of Wris t ............................................................................................. 52

8. Examin ation of Hand ............................................................................................. 66

9. Examin ation of Peri pheral Nerves and Br achi al Plexus .................................... 74

10. Ex amination of Spi ne ............................................................................................ 87

• Neurofibromatosis (von Recklinghausen's Disease) 100

11. Examin ation of Hip .............................................................................................. 109

12. Examin ation of Kn ee ........................................................................................... 125

13. Examination of Ankle and Foot .......................................................................... 142

14. Examinatio n o f Rotation al Deformi ties in Low er Li mb .................................... 167

Index ...................................................................... ........................................................... 171

Treatment Histo ry symptom which gives a clue to the diagnosis, it

b. Symptoms associated with lump: Pain, pressure • Measurements

Everted edge—In squamous cell Occupational History

Fig. 1.5: Origin of tumors in various parts of bone

EXAMINATION OF BONE the lower limb, pathological fracture or exuberant

Chronic Osteomyeliti s (Figs 1.6A and B) Feel

Figs 1.6A and B : Diaphyseal sequestrum in chronic osteomyelitis of humerus

percussion of the bone causes deep severe pain, Move

INTRODUCTION treating then re-evaluating life-threatening

Disability are removed and the patient is covered and

exclude associated injuries (e.g. axillary nerve • Where

Type III A : Adequate

Tension Pneumothorax (Fig. 2.2)

Massive Hemothorax (Fig. 2.3)

Examination should begin as discussed in the In case of recurrent dislocation of shoulder

In anterior tibial compartment syndrome, Ad ul t Res pi rat or y Di st res s Sy nd ro me

Ag e, Occ upati on and Dom in ant Hand

Deformity deformities— winging of scapula, and

Table 5.1: Typical shoul der disor ders in vario us age-group s

Newborn/infant Adolescent/young adult Older adult

The rhythm disturbance is well noted on clavicle, acromioclavicular joint, subacromial

Passive abduction is done in case of restricted

down, fully pronated. Patient should hold the

Fig. 5.9: Fixing the scapula while testing

Rotator Cuff Strength Assessment

External Rotator Strength Test Drop Ar m Test

Neer's Imping ement Sign

Fig. 5.15: Drop arm test Fig. 5.16: Hawkin's test

Table 5.2: Musc le testing chart

Muscle Innervation Myotomes Technique for testing

Trapezius Spinal accessory C2-C4 Patient shrugs shoulders against resistance

Table 5.3: Neurologi c l evel In upper lim b

Dermatomes in the upper limb:

Neer's Injection Test

Coracoid Impingement Sign

Yergason's Test Flexion Adduction Test

Terminal Painful Arc Sulcus Sign