Examination Of Extremities
Transcript of Examination Of Extremities
DR. Müge BıçakçıgilYÜH. Romatoloji BD.
The patient should be undressed and gowned as needed for this examination.
The examination may not be appropriate (e.g. performing ROM on a fractured leg).
The musculoskeletal exam is all about anatomy.
Think of the underlying anatomy as you obtain the history and examine the patient.
General ConsiderationsWhen taking a history for an acute
problem ;always inquire about ; mechanism of injury, loss of function, onset of swelling (< 24 hours), and initial treatment.
General ConsiderationsWhen taking a history for a chronic
problem always inquire about ;past injuries, past treatments, effect on function, and current symptoms.
General ConsiderationsThe cardinal signs of musculoskeletal
disease are: pain, redness (erythema), swelling, increased warmth, deformity, and loss of function.
Always begin with ;inspection, palpation and range of motion,
regardless of the region you are examining.
General ConsiderationsSpecialized tests are often omitted unless
a specific abnormality is suspected.
A complete evaluation will include a focused neurologic exam of the effected area.
Check the radial pulses on both sides. If the radial pulse is absent or weak, check the brachial pulses.
Check the posterior tibial and dorsalis pedis pulses on both sides. If these pulses are absent or weak, check the popliteal and femoral pulses.
Press down firmly on the patient's finger or toe nail so it blanches.
Release the pressure and observe how long it takes the nail bed to "pink" up.
Capillary refill times greater than 2 to 3 seconds suggest peripheral vascular disease, arterial blockage, heart failure, or shock.
Edema, Cyanosis, and Clubbing
Check for the presence of edema (swelling) of the feet and lower legs.
Check for the presence of cyanosis (blue color) of the feet or hands.
Check for the presence of clubbing of the fingers.
Check for the presence of axillary lymph nodes.
Check for the presence of inguinal lymph nodes.
Look for scars, rashes, or other lesions.
Look for asymmetry, deformity, discoloration, or atrophy.
Always compare with the other side.
Varus - distal extremity deviates medially from the joint (bow-legged)
Valgus - distal extremity deviates laterally from the joint
Often in a fracture or disclocation there is an obvious deformity about the joint or bone.
Swelling - suspect if normal landmarks about the joint are not apparent, or the normal contour of the extremity is altered.
Wasting - muscle wasting can result from neurologic or muscular disease or injury. Bony landmarks often more prominent.
Discoloration:• Erythema, or redness, is a sign of
inflammation. • Ecchymosis, or bruising, can be secondary to
superficial bruising, or may indicate damage to the underlying muscle, ligament, or bony structure.
The examination of the patient begins when tha patient first enters the room. How is the patient's posture? Does the patient appear uncomfortable? Are there any obvious joint deformities? How is the patient's gait?
PalpationExamine each major joint and muscle
group in turn. Identify any areas of tenderness.
Identify any areas of deformity.
Always compare with the other side.
During palpation, changes in temperature, palpable deformities, crepitus and tenderness.
Temperature Use the back of your hand
Deformities Palpate using your finger pads. Is there a palpable deformity? Any dislocation. An irregular enlargement- due to
arthritis, deposition of inflammatory material, an old injury, or more rarely a tumor.
Crepitus Grinding or rubbing sensation or sound. Due to bony or cartilaginous structures
moving across each other, or due to tendons moving across each other.
Tenderness Pain with palpation is usually an indicator of
injury or inflammation. The severity of the pain is usually a marker of
the severity of the underlying condition.
Fractures, dislocations and complete tears of ligaments or tendons are usually very painful.
Acute inflammatory arthritis due to gout or infection is also exquisitely painful.
Mild sprains or contusions tend to be less painful.
Pain from chronic conditions such as rheumatoid arthritis or osteoarthritis, while sometimes severe, is usually less painful
Range of Motion
Start by asking the patient to move through an active range of motion (joints moved by patient).
Proceed to passive range of motion (joints moved by examiner) if active range of motion is abnormal.
Ask the patient to move each joint through a full range of motion.
Note the degree and type (pain, weakness, etc.) of any limitations.
Note any increased range of motion or instability.
Always compare with the other side. Proceed to passive range of motion if
abnormalities are found. If there is injury or pain, begin with
normal side first. Assess one joint at a time. Observe the patient for pain, smoothness
of motion, and any unusual movements.
Passive ROMAsk the patient to relax and allow you to
support the extremity to be examined.Gently move each joint through its full
range of motion. Note the degree and type (pain or
mechanical) of any limitation. If increased range of motion is detected,
perform special tests for instability as appropriate.
Always compare with the other side.
Palpation during passive (or active) ROM
may reveal crepitus. Be sure to have the patient tell you if the
ROM becomes painful. Discrepancies between active and passive
ROM may be due to weakness, pain or joint disorder.
If pain or injury, begin with normal side. Isolate the joint about which you are testing
strength. Compare one side to other.
SPECIAL MANEUVERS Clinicians perform special maneuvers when
they are hypothesis testing, i.e., they are concerned about a specific condition or injury.
Some common special maneuvers for the upper extremity include:
Shoulder Impingement test Drop test
Hand and wrist Tinel and phalen's (for carpal tunnel) Finkelstein's maneuver (for deQuervain's
It has an incredibly wide range of motion, due to the complex structures of the shoulder girdle.
PALPATION : Palpate the acriomoclavicular joint, the
acromion, the scapular spine, and the bicipital groove.
Palpate the muscles about the shoulder.
STRENGTH TESTING Routinely test flexion, extension and
abduction. If indicated (pain, other complaints), check
internal and external rotation, and adduction.
ACTIVE AND PASSIVE RANGE OF MOTIONObserve the patient abducting, flexing and
extending their shoulder. Evaluate external rotation by having the
patient place their hand behind the head. Evaluate internal rotation by asking the
person to touch his fingers at the back.
Range of MotionAbduction (150 degrees) Forward flexion (180 degrees) Extension (45 degrees) External Rotation (90 degrees), elbow at
90 degrees With arm comfortably at side With arm at 90 degrees abduction
Internal rotation (90)
SPECIAL MANEUVERSThe Neer
impingement sign: This maneuver
narrows the space between the acromion and the humeral head. If a patient has impingement of a rotator cuff tendon (or a tear), they will usually have increased pain with this test.
The drop test: Gently abduct the arm above ninety degrees,
if pain allows. Ask the patient to maintain the arm in the this position, warn the patient and then drop the arm. In a patient with a rotator cuff tear, they will often not be able to maintain the arm's position and it will fall.
A - Olecranon B - Lateral
INSPECTIONInspect the elbows with the arm in a neutral,
anatomic position PALPATION Be able to palpate the lateral and medial
epicondyles, and the olecranon process.
RANGE OF MOTION Flex and extend, and supinate and pronate. Normal elbow range of motion Extension: 0 degrees Flexion: 150 degrees Pronation: 70 degrees Supination: 90 degrees
HAND AND WRIST
A - Distal wrist crease
B - Thenar eminence
C - Hypothenar eminence
Dorsal Hand A - Carpometacarpal
joint B -
C - Proximal interphalangeal joints
D - Distal interphalangeal joints
E - Interphalangeal joint of thumb
INSPECTION At rest, the fingers will be slightly flexed and
almost in parallel. Inspect the dorsum of the hand and wrist for
swelling. Inspect the palmar expect for thenar or
hypthenar wasting. Inspect each joint for swelling, discoloration
PALPATION Palpate the radial and ulnar styloid, and the
radiocarpal and radioulnar joints. Palpate the CMC joint, and the lateral and
medial aspects of each MCP, PIP and DIP joint. The joints of the wrist and hand are commonly
affected in osteoarthritis and rheumatoid arthritis. Other common conditions affecting the hand and wrist are ganglion cysts and Dupuytren's contractures
In osteoarthritis palpation will reveal tenderness and bony growths (osteophytes) that enlarge the joints - particularly the DIP and PIP joints. These are called Heberden's nodes and Bouchard's nodes, respectively
In rheumatoid arthritis the synovium of the joint is inflamed, leading to tenderness and bogginess about the joint, in addition to warmth and redness.
Later in the course of the disease, the bony and ligamentous structures supporting the joint are damaged, and joint deformity results.
Ganglion cysts are common, and arise from the synovium. There are frequently found on the dorsum of the wrist, but can arise from the MCP and other joints as well. They only require treatment if they are painful.
Dupuytren's contracture is a localized thickening of the palmar fascia, most frequently affecting the fascia overlying the 4 th and 5 th metacarpals. It can lead to hand contracture, deformity and decreased function.
RANGE OF MOTION Assess pronation and supination of the forearm Assess flexion, extension, abduction and
adduction of the wrist. Assess flexion of the MCP joints with the PIP
joints extended, and have the patient make a fist to assess flexion of the PIP and DIP joints, and spread the hand out to assess extension of the PIP, DIP and MCP joints.
Have the patient oppose the thumb to the small finger
Normal wrist range of motion • Extension - 70 degrees • Flexion- 90 degrees • Radial deviation (abduction) - 20 degrees • Ulnar deviation (adduction) - 55 degrees
Normal hand range of motion • MCP hyperextension - 30 degrees • MCP flexion - 90 degrees • PIP and DIP extension - 0 degrees • PIP and DIP flexion - 90 degrees • Oppostion - thumb should touch the 5 th
MCP. Passive ROM of the hand is frequently not
STRENGTH TESTING Test wrist flexion and extension Grip strength Opposition - have the patient touch thumb to
small finger, and try to pull your finger through. (median nerve)
Key grip strength - have patient grip a thin object (piece of paper) between his thumb and the proximal phalanx of index finger, and resist you as you try to pull the object from his grasp. (median nerve, collateral ligament)
Finger abduction - have patient spread fingers out against resistance.(ulnar nerve)
Special Tests-Snuffbox Tenderness
(Scaphoid)Identify the "anatomic snuffbox"
between the extensor pollicis longus and brevis (extending the thumb makes these structures more prominent).
Press firmly straight down with your index finger or thumb.
Any tenderness in this area is highly suggestive of scaphoid fracture.
Flexor Digitorum Superficialis Test
Hold the fingers in extension except the finger being tested.
Ask the patient to flex the finger at the proximal interphalangeal joint.
If the patient cannot flex the finger, the flexor digitorum superficialis tendon is cut or non-functional.
Flexor Digitorum Profundus Test
Hold the metacarpophalangeal and proximal interphalangeal joints of the finger being tested in extension.
Ask the patient to flex the finger at the distal interphalangeal joint.
If the patient cannot flex the finger, the flexor digitorum profundus tendon is cut or non-functional.
Neurologic TestsPhalen's Test (Median
Nerve)Ask the patient to press the
backs of the hands together with the wrists fully flexed (backward praying).
Have the patient hold this position for 60 seconds and then comment on how the hands feel.
Pain, tingling, or other abnormal sensations in the thumb, index, or middle fingers strongly suggest carpal tunnel syndrome.
Tinel's Sign (Median Nerve)Use your middle finger or a reflex hammer to
tap over the carpal tunnel. Pain, tingling, or electric sensations strongly
suggest carpal tunnel syndrome.
EXAMINATION OF SPINE
Landmarks helpful in identifying spinal levels include:
• C7 and T1 - prominent spinous processes
• T7 to T8 - inferior angle of scapula typically located at this level
• L4 - an imaginary line across the tops of the iliac crests crosses L4
PHYSICAL EXAMINATION Examination of the spine includes inspection,
palpation and range of motion. Strength testing of the spine is not a part of the typical physical examination.
Observe the patient from the back, with the back exposed. The patient could either be wearing only undergarments, or a gown that is not tied in the back. Normal Findings
Shoulders (left and right should be equal height) Scapulae (left and right should be equal height) Iliac crests (left and right should be equal height) Hands at equal height.
Unequal heights of any of these structures might indicate scoliosis (congenital or acquired), leg-length discrepancy or spinal pathology.
Observe the patient from the side, identifying the normal cervical and lumbar concave curves, and the convex curves of the thoracic and sacral spine.
Scoliosis - curvature of spine - congenital, developmental, acquired Note the slight curvature to this patient's spine, and note that the right
scapula is raised relative to the left. The curvature is seen more clearly on the X-ray:
Lordosis - increased or "swayback" curve in lumbar area Pregnancy, muscle imbalance, obesity
Kyphosis - increased or "humback" curve in thoracic area Osteoporosis, posture, congenital
Palpation: Palpate the spinous processes and the
paraspinous musculature, assessing for tenderness, swelling, warmth, and muscle tone.
Range of motion The examiner asks the patient to flex, extend,
laterally bend and rotate (or turn) the cervical spine and the "back" (primarily the lumbar, thoracic and sacral spine). Begin from the neutral position, with the patient standing up straight (can assess range of motion of the cervical spine with the patient seated).
Cervical spine range of motion: Flexion - 45° "Touch chin to chest" Extension - 55° "Tilt your head back as far
as you can" Lateral bending (right and left) - 40° "Try to
touch your ear to your shoulder without moving your shoulder"
Rotation (right and left) - 70° "Turn your head towards your shoulder"
Back range of motion: Flexion - 90° "Try to touch your toes without
bending your knees" Extension - 30° "Lean back as far as you
can" Lateral bending (right and left) - 35° "Lean to
your side" Rotation (right and and left) - 30° "Twist to
your side" Examiner may need to stabilize patients
pelvis to prevent rotation at the pelvis.
Special Maneuvers: Straight leg raise (SLR)
Purpose: Used to evaluate back pain that radiates into leg (sciatica). Places tension on sciatic nerve and inflamed nerve root
Technique: Patient supine, legs straight. Hold heel, and passively lift affected leg with knee straight. Talk with patient to be sure their leg muscles remain relaxed. Repeat with other leg.
Findings: Positive test is reproduction of sciatic-type pain when hip is flexed between 30° and 70°. Dorsiflexion of foot may aggravate pain. If SLR of leg opposite the affected leg causes pain in the affected leg, patient is very likely to have a ruptured disc
HIPCan assess entire lower extremity,
observing the hips, knees, ankles and feet. Observe for symmetry, deformity and
discoloration. Can assess hip strength by watching
patient rise from a chair. Individuals needing to use their arms to push
up from the chair, or who have to "rock" themselves out of the chair have muscle weakness of the proximal hip musculature.
Palpation: Palpate the iliac crest and greater
trochanter. In the patient with hip pain, palpate the gluteal
musculature as well as the hip and thigh musculature.
In the patient with pelvic pain, palpate the symphysis pubis, ischial tuberosities, the posterior superior iliac crest.
Range of motion: Either active or passive. In patient with
pain, active should precede passive ROM. Flexion (with knee bent) - 120° Flexion (with leg straight) - 90° Extension - with patient lying on side, lying
prone or standing - 15° Abduction - 45° Adduction - 30° Rotation - with knee flexed to 90°
Internal 40° External 45°
KNEEInspection: Evaluate for swelling, discoloration,
deformity. Identify the landmarks about the knee.
Inspect the quadriceps muscle for atrophy. Atrophy is common in chronic knee conditions.
Palpation: Evaluate for warmth, tenderness, crepitus
and fluid. Identify the tibial and femoral condyles in
order to palpate the tibiofemoral joint space medially and laterally.
Palpate the patella Palpate the popliteal space (swelling may
indicate Baker's cyst )
Range of motion: Passive or active. If patient has pain,
active should proceed passive. Expected ROM:
Flexion - 130° Extension - 0° (neutral) to 15° (hyperextension)
Special Manuevers: The knee is a commonly injured joint, due to
its lack of inherent bony stability, reliance on ligamentous structures for structural stability, and extreme forces it is subject to. There are a number of tests used to evaluate specific cartilaginous and ligamentous structures.
Presence of fluid: Ballotement: With knee extended, apply
downward pressure on the suprapatellar pouch with one hand, and with the other hand push the patella firmly down against the femur. A tapping or clicking will be felt if an effusion is present, and as you slowly release pressure, you will feel the patella "floating" upwards
Bulge sign: With knee extended, "milk" the medial aspect of the knee upward several times, then tap the lateral side of the knee, between the patella and the femoral condyle. Watch for a bulge on the medial knee as fluid returns to this region.
Mediolateral instability Purpose: evaluate the medial and collateral
Medial collateral ligament: with the knee flexed at 30° (or in neutral position), apply a valgus stress to the knee.
Lateral collateral ligament: with the knee flexed at 30° (or in neutral position), apply a varus stress to the knee.
Compare injured to normal side.
Positive finding - pain, with evidence of joint space widening in comparison to normal side. Pain alone suggests possible strain of ligament, without disruption of the fibers.
FOOT and ANKLE Inspection: Evaluate for symmetry, deformity,
discoloration. In patients with diabetes, assess for ulcers,
which can often lead to osteomyelitis (bone infection).
It is often helpful to observe the foot and ankle during weight-bearing
Palpation: Evaluate for warmth, tenderness and
crepitus. Palpate the achilles tendon, medial and lateral malleoli
The anterior tibiofibular ligament, along with the posterior tibiofibular ligament and the transverse tibiofibular ligamen are the structures injured in high ankle sprains
Range of Motion: Expected ROM - neutral position of foot
and ankle is with foot at 90° to leg. Dorsiflexion - 20° "Point your toes towards
nose" Ankle joint: Plantarflexion - 45 "Point toes
towards floor." Inversion (sole points "in") - 30° Eversion (sole points "out") - 20° Flex and extend toes.
Strength:Dorsiflexion - patient flexes up against your
hand. Plantarflexion - patient flexes down against
FABER Test (Hips/Sacroiliac Joints)FABER stands for Flexion, ABduction, and
External Rotation of the hip. This test is used to distinguish hip or sacroiliac
joint pathology from spine problems. Ask the patient to lie supine on the exam table. Place the foot of the effected side on the
opposite knee (this flexes, abducts, and externally rotates the hip).
Pain in the groin area indicates a problem with the hip and not the spine.
Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest.
Pain in the sacroiliac area indicates a problem with the sacroiliac joints.
FADIR TEST(Hips/Sacroiliac Joints)
FADIR stands for Flexion, ADduction, and Internal Rotation of the hip.
10 cm 15 cm