Clinical Orthopedic

Edited by: Dr.Soran Mohamad Gharib

2008

Principles of Fracture treatment -:

1

The fundamental principles of fracture are ( Reduction ,Immobilization and Rehabilitation(

І- Reduction: it is done if (Necessary) ba st there is no need to it, so do it in good (acceptable) alignment i.e out any shortening or overlap or angulation after reduction, so get

acceptable alignment and prevent Malunion .Reduction is necessary only in (displaced or angulated fractures)

-Methods of Reductions: by (manipulation, mechanical traction, open reduction, closed under image intensifier-screen).

1(Manipulation: Manipulation is done in reverse direction i.e if there is internal rotation of fracture do external rotation and if abduction do adduction and it is better to reduced under general anesthesia, by simply grasping in fragment through soft tissue, to disimpact them if necessary, and then to adjust them as nearly as possible to their correct position Occasionally, however reduction is not achieved because of soft tissue interposition or because it is impossible to obtain a sufficient hold on one or other fragments so do open reduction.

2 (Mechanical traction: This is used mainly in fracture of femur shaft, because of bulky m. that exerts a strong displacing force. By this we put a traction at tibia or lower end of femur and put wts, and pulley to pull on limb, try to

tilt bed, lift foot of bed “so body wt acts as counter traction. ”

There are 2 types of mechanical tractiona)Skin Traction: put elastoplast on limb end in cord and we pass a cord on a pulley, and then pull traction by wt. depend on thigh m. skin can not tolerate move than 5 kg.wts.

b)Skeletal traction: because in skin traction we can not use >5kg so if we need more wt, then we insert an instrument “steinmanpin” is inserted (1) inch distal and (1) inch behind tibial tubercle and this is attached to a loop called (sterup) tight loop on a cord is attached at end of cord. If we fail to reduce fracture by these methods then we try 3rd type which is

3 (Open (operative) Reduction: In this method surgeon exposes bone-ends and realigns them. This obviously

2

converts a simple (closed) fracture to a compound (opened) fracture is danger of infection and nonunion.

-Indications of open reduction:1 (Soft tissue interposition between two fragments.2 (Failure of conservative method especially spiral

fracture .3 (If fracture is inside joint or a piece of bone has been

trapped inside Joint.Once we reduce fracture, we’ve to hold this reduction by immobilization.

П – Immobilization :- Indicated when necessary and indications are:

1 (prevention of displacement or angulation.2 (Prevention of movement

3 (Relief of pain

*Methods of Immobiliazation: A) External Fixation: it includes

1) POP ( Plaster of Paris): This is Standard

method for most fracture. It is hemi hydrated Ca Sulfate. It reacts with water to form hydrated Ca Sulfate and Liberating heat ( Exothermic reaction).

2) Immobilization by Continuous traction with Splintage: In some POP it is impossible to hold fragments in proper position by pop especially if fracture is oblique or spiral because elastic pull of m. tend to drown distal fragments upwards. So it overlaps proximal fragments. In Such cases pull of m. must be balanced by continuous traction on distal fragment.

3 (External fixation –When there is compound comminuted .

B) Internal Fixation: The methods are:

1 (Metal plate held by screws as in long bone.2 (Bone graft held by screws: Screws to hold small

fragments in place or to hold against redisplacement when overall immobilization is achieved by a plaster Caste

3 (Intramedually rods and nails used for fracture of long bones.

3

4 (Oblique Transfixation screws.5 (Suture by wire as in small fracture in epicondyle.6 (Circumferenial wire or band and suture through

soft tissue.7 (Closed Femoral nailing and tibial nailing .

8 (k wire fixation-post reduction per cutaneous wire.

Indication of external fixation:

1) If fracture is as severe soft tissue damage.2) If fracture as arterial injury.3) Severe comminuted fracture.4) Infected fracture in internal fixation is contra

Indic.5) Severe multiple injuries to reduce risk of

complication.

Complications : 1) Loosing of pins (Fixation)2) Pin tracted infection .3) Destruct of fracture.

Indications of internal fixation :

1) When closed method impossible as in case of spiral fracture.

2) Poor. bl. Supply as in sub capital fracture of a neck pf femur.

3) Multiple injuries ( as in upper and lower limbs fractures).

4) Pathological fracture ( in order to make life easier and mobilize it ) e.g female breast ca, have metastases to humerus, so by metal bone and cement we do in fixation.

5) When accurate reduction is necessary ( in fracture involving articular surfaces).

6) When early mobilization is needed, especially in old patient-to prevent bed sore, DVT, pull embolism, chest infection.

7) To avoid un-union ( as in sub capital fracture of femur or fracture of scaphoid bone so reduce it and fixed it to avoid non-union.

4

Complication of internal fixation

1 (Infection as wound infection and pull embolism2 (Non-union as a result if poor fixation or poor inetal

use.

RehabilitationImportant factor to all patient

- Resp- Bowel- Urinary- Limbs

Advantage to:1) reduce oedema2) Preserve joint movement3) Restore muscles power4) Guid the patient to normal activity

Causes of delayed union:l/infection 2/abnormal or in adequate support 3/0vertraction 4/early mobilization of the Joint 5/inadequate bl. supply. 6/intact follow bone (e.g. fractt. of ^ tibia while the fibula is intact, s.t in this condition we excise a segment from the fibula to promote union) Causes of non-union:1/too large gape( excess. traction or b. loss) 2/soft tis.interposit. 3/infection 4/lose of apposition 5/solution of fract. hematoma (synovail fluid washes ^ hematoma preventing union as in fract. Of fem. neck) 6/usage of bad quality metal of int. fix. 7/destruction of b. by turn.

Complications of fracture They are either general or local complications.

local complication of fractures 1 – Early local complication of fractures

a) bone complications :(infection)

5

b) * skin complications fract. Blisters)c) M. complications ( tearing) d) * Hawmarthrosis :(bl. In ^ j.)e) Vascular complications : ( complete or partial)f) N. complications : (cut or pressure)g) *Visceral damage : (e.g. bladder inj. In pelvic

fract.)2 – late local complication of fractures :( in bone)

i) Avascular Necrosis : ( Xray appearance) ii) Delay union : ( causes)iii) Non- union : (2 types & Rx)iv) Mal – union v) Shortening ( growth disturb. & physeal inj.)

(In soft tis *) i) bed soreii) myositis ossificansiii) tendonitis : ( friction synovitis)iv) tendon rupturev) n. compression

(in joints)i) J. instability ii) J. stiffness (3 causes ) & 3 conditions:

1 – sudeck’s atrophy 2 – osteoarthrosis3 – myositis ossificans

General complications of fracture: I-shock:as a result of ^ fract.shock may occure & it is either:

)a (Neurogenic shock: due to pain. Rx by immobilization either by splintage or tie ^ limb to ^ other one or to ^ chest or truck to avoid mov., also give analgesics (morphine,pethidine )

)b (Hypovolemic shock:^b.is vascular,so damage bleeding

into ^ soft tis. Shock will be ^ result of loss of blood . ( eg.

Closed fract.Of ^ femur IL of blood will be lost inside ^ tis./ more bleeding in pelvic fract. / also even more in

6

Compound fract(.

II-Crush Syndrome:occurs esp.in comp.fract.& as a result of massive

Damage to ^ m. The acid myohematin is released to bl.Circulation, thisEither causes*blockage to^ renal tubules acute ren.Failure OR causes

*spasm of ^ renal vess. With anoxia of ^ ren. Tis. acute tubular necrosis.

Crush synd. Occurs also if we leave ^ tourniquet for a long time>)

6hr.). If this happens we should amputate ^ limb before releasing

tourniquet to avoid passage of myohematin into ^ circulation ( so you should state ^ time of placing ^ tourniq(.

In this synd. We should deal with ^ ren. Failure by decreasing prot.

Intake,increase CHO intake,& do electrolyte balance, high caloric food

&renal dialysis .

III-Venous Thrombosis & Pulmonary Embolism: about 5% of pat. withDVT will develop pul. Thromboemb., esp in pelvic fract. The .

IV- Infection: occurs esp. in comp. fract. That may cause osteitis by

Staph.,pseoudomonus, E.coil.This can be Rx by proper AB. Tetanus: dead tis. Is a good media for growth of Clostridia

tetani . So we need good wound excision & cleaning, & give a

booster

7

Dose of tet. Toxoid. Management :

Prophylaxis with active imm. Of poplution & use of booster

Dose after injury. Active? Imm. By giving anti - toxin serum of

Human type (horse type not use bec. Of anaphylaxis ) In established tet. Give i.v. fluid balance,& assist

ventilation.

Gas gangrene :Clostridia welchii (anaerobic m.o).In this case we

Excise all ^ dead tis.+ debris, so if we receive a wound after 6hr.

Of inj. Or a contaminated wound those should kept open . Give proper AB C is crystalline penicillin.

If we see dust color,swollen wound with special odour&

Crepitus under ^ skin. We should open ^ wound if it is sutured,

Excise dead tis., give AB,& s.t. hyperbaric O2 is effective. &if severe infection we have to sacrifice ^ limb by

amputation .

V-Fracture Fever: increase in temp.by 0.50 C as a result of absorption of

Fract. Haematoma .

VI- Fat Embolism: takes place during ^ 1st 3 days. As a result of Liberation of small fatty molecules in ^ circulation, as chyomicrones CMay be > 10um in diameter pass into ^ general circulation & aggregateInto cap. & might go to ^ alveoli & pul. Cap. Anoxia.

8

Clinical orthopedic examination 1.The BackA) With the patient upright• Stand Face to face• Stand behind the patient.•MovementsB) With the patient prone (remove the pillow)C) With the patient supine2.The HipWith the patient:( upright, sitting, lying down, In supine position)3.The KneeWith the patient: upright, Sitting, supine, proneNerve examination[Supply , Inspection , Power .Sensation)I.Radial Nerve (more motor) 2.Ulnar Nerve3.Median nerve4.Femoral nerve (2 cm, has 12 branches) 5.Sciatie nerve (L4,5 & S1, 2,3)Cervical spine examination• Inspection, skin, S.C tissue (swelling, scar)• Feel:• Movement: (Flexion, Extension , lat. Rotation, lat. Flexion)• Neurological exam: supply of the upper limb (C5,6,7,8&T1) Examine roots of the nerves by : power, reflex , sensation

The back : A- with the pateint uprighta- stand face to face1. Physique and posture.2. Symmetrical tow sides or not,3. Scars on the chest or abdomen.4. Wasting of thigh b) Stand behind the patient, 1 General Posture and shape.2. Stand upright or lean to one side.

9

3. Pelvis level4. One leg shorter?5. Hyper kyphosis?6. Hyper lordosis?7- scoliosis8. Scar, hair, lump (spina bifida occulta)9. Stand on his toes.10. Stand on his heals.(to assess balance & M.power)

Movements *1-Extension(hands on trunk & knee straight) - :2. Flexion (look at arc & measure lumbar excursion); decreased in Ankylosing spondylitis 3 - Lateral flexion.(slid,his hand dawn) j 4-Rotation,(anchor the pelvis of the pat. In neutral position & ask the pat. To twist to one side then to another side)B)With the patient prone (remove thepillow)1. Look for glutei wasting. 2 Feel spinous processes..

(Kyphus=TB of spine or Step= spondylolithesis .)3 .Then 3 fingers from midline(artic!ar process& facet J.)

4. Femoral stretch test (pain in ant. thigh).

femoral stretch test :

This is a test for irritation of higher nerve roots - L4 and above.

The patient is positioned lying face downwards, and with the knee flexed, the hip is lifted into extension. Lumbar root irritation tension may cause pain to be felt in the front of the thigh and the back. 5- hamstring power.(feel the M.)6. Gluteus maximus power. (feel it)7. Saddle area sensation.(S3&4)8. Anal reflex. (S4&5),9. Popliteal & tibial pulses.c- with the patient supine:1-Look for muscle wasting. ,

10

2. Examine the hip.3. FABER Test (Hips/Sacroiliac Joints)FABER stand for Flexion, Abduction, and external Rotation of the hip (and finally press). This test is used to distinguish hip or sacroiliac joint pathology from spine problems.1. Ask the patient to lie supine on the exam table,2. Place the foot of the effected side on the opposite knee (this flexes, abducts, and externally rotates the hip).3. Pain in the groin area indicates a problem with the hip and not the spine,4. Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest 5. Pain in the sacroiliac area indicates a problem with the sacroiliac joints.

FABER test

This is a test for evidence of hip arthritis. In this manoeuvre:

the patient's pelvis is stabilized by placing a hand on the iliac crest (the side furthest from the examiner).

the patient flexes his hip joint (the hip joint nearest to the examiner)

the patient's flexed hip is slowly abducted

If there is early hip osteoarthritis then the abduction of the flexed hip will be restricted and painful. An alternative manoeuvre is to internally rotate the hip with both hip and knee flexed to 90 degrees - internal rotation of the hip joint is the first restriction of movement to occur in hip disease.^ "•""••••••••*P-IW"" ' "**» ' '•: *#v»>i»*:»'"aea lir""nT1"*"li|««W'»i "•.•««•*••«» |»"1 ""f4 straight leg Raising (L5/S1 nerve Roots)*Ask the patient to lie supine on the exam table with the knees straight *Grasp the leg near the heel and raise the leg slowly towards the ceiling.

11

*Pain in an L5 or SI distribution suggests nerve root compression or tension (radicular pain, which may be due to disc prolapse).• Dorsiflex the foot while maintaining the raised position of the leg • Increased pain strengthens the likelihood of a nerve root problem.

*Repeat the process with the opposite leg.* Increased pain on the opposite side indicates that a nerve root problem is almost certain.

Or straight leg raising (SLR) test :

This is a test for lumbosacral nerve root irritation for example, due to disc prolapse.

With the patient laid on their back:

raise one leg - knee absolutely straight - until pain is experienced in the thigh, buttock and calf

record angle at which pain occurs - a normal value would be 80-90 degrees - higher in people with ligament laxity

perform sciatic stretch test - dorsiflex foot at this point of discomfort - test is positive if additional pain results

flexing the knee will relieve the buttock pain - but this is restored by pressing on the lateral popliteal nerve

Severe root irritation is indicated when straight raising of the leg on the unaffected side produces pain on the affected side. A central disc prolapse is likely with risk to the cauda equina and consequently, of bladder dysfunction.

Pain upon straight leg raising before the leg is raised 30 degrees cannot be due to disc prolapse as the nerve root is not stretched within this range. Another explanation of nerve root irritation must then be sought.

12

Lasègue's sign is said to be positive if the angle to which the leg can be raised (upon straight leg raising) before eliciting pain is >45°

Bowstring Test

This is carried out in asimilar manner to a traight leg raising test , once the patient exprences symptoms the knee is flexed by approximately 20 degree this leads to pain relief in the patient with nerve root irritation , thumb or finger pressure is then applied to the popliteal area , if this recreates the patients radicular symptoms , it is indicative of nerve root tension

5. Neurological exam,- Knee extension (L3,L4).- Big toe dorsiflexion (L5).-Planter flexion(S1)-Foot inversion (L5).-Foot eversion (S1)-Knee reflex( L3.L4)-Ankle reflex (S1)-Sensation.(foucH&pinprick)The HipExpose from groin to toesA- with the patient upright( face to face)1.posture 2. Symmetrical lower limbs

13

3. One limb shorter or thinner.4. Pelvis level. 5. Scar. 6. Swelling. 7. Trendelenburg test

Trendelenburg's sign :

A Trendelenburg's sign is a gait adopted by someone with an absent or weakened hip abductor mechanism.

During the step, instead of the pelvis being raised on the side of the lifted foot, it drops. Thus it is seen as the patient's pelvis tilting towards the lifted foot, with much flexion needed at the knee on the affected side in order for the foot to clear the ground.

Note that the lesion is on the contralateral side to the sagging hip.

A positive Trendelenburg sign is found in:

subluxation or dislocation of the hip abductor weakness shortening of the femoral neck any painful hip disorder

A weak abductor mechanism may also be demonstrated by Trendelenburg's test8. Gait.(phases of gait= heel strike, stance phase, swing phase) *•-. • ''.-•"'• -'"-'•B) With the patient s itting iliopsoas function (flex hip against resistance)c- with the patient lying down in supine position1- the pelvis should be horizontal i.e both ASIS at the same level

2. Shortening. 3. Scars & sinuses.4. Swelling or wasting 5. Limb rotate?

14

6.Measure the apparent length7. Measure real length,.8- feel for landmarks (ASIS , greater trochanter , iliac crest09- movement 1- flexionThomas test: to detect fixed flexion deformity, place your left hand in the hollow of lumbar spine, flex the hip & knee of the unaffected side until lumbar spine straighten , if hip of affected side lifts up from the bed so it is fixed flexion deformity of affected hip) .then flex the hip & knee of affected side to see range of flexion of affected hip

Or Thomas test:

A test for hip flexion contracture. The uninvolved flexed leg is held against the chest of the supine patient to flatten the lumbar lordosis. If a hip flexion contracture is present in the opposite leg it will not remain flush with the examination table. The angle formed between the involved leg and the examination table equals the number of degrees of flexion contracture present

Thomas test (positive)

15

Thomas test (negative)

iii) Abduction, normally the range is 45 degree ( fix pelvis and draw angle between the longitudinal axis of both lower limbs)iv) Adduction, normally the range is 30° (fix pelvis & draw angle between the longitudinal "axis of both lower limbs)v) Lateral & medial rotation vi) Extension (in prone position)

the knee: expose from groin to toes

- A- with the patient upright

1. General shape & posture of Lower Limb. 2 Scars. 3. Swollen knee.(traumatic , pain , weakness) or non-traumat/c(inflam.ldegeneration) 4. Quadriceps wasting.

5. Normal feet or deformity = bilateral valgus(RA), bilateral varus (OA)6. Gait.7. Ask her to squat.B-with the patient sitting With the knee over the edge of the couch. 1. Look at patellae.(for; squint patella)2- ask to extend the knee.( observe movement of patella) c-with the patient supine

16

1. Redness of skin. 2. Scars. 3. Knee swelling. 4. Muscle wasting5. Measurements of the girth. 6. Valgus or varus.7. Flexion deformity. '8. Ask to press against the couch, 9. Feel for skin temperature. 10. Synovea! thickening. (Solomon'stest by the name of orthopedician). (Grasp the patella by thumb and middle finger& lift it away from femur)11. feeling for fluid: i) Patellar tap.(moderate amount of fluid) ii) Cross fluctuation. iii) Bulge test.(small amount of fluid) iv) The hollow test. 12) Tenderness 13) MovementsI) Flexion. ( ii) Rotation (with knee slightly flexed)

bulge test for fluid in the knee joint :

The bulge test is used to determine the presence of fluid in the knee joint. It is useful when only a little fluid is present in the joint.

The suprapatellar bursa is first emptied of fluid by squeezing distally from about 15 cm above the patella. The medial compartment of the knee join is emptied by pressing on the side of the joint with the free hand. The hand is then lifted away and then the lateral side is sharply compressed.

If the test is positive, a ripple is seen on the flattened, medial surface.

The test is negative if the effusion is tense - up to 120 ml.

17

patellar tap

The patellar tap is a test for fluid in the knee joint. This test is likely to be positive with moderate amounts of fluid.

Excess fluid is squeezed out of the suprapatellar pouch with the index finger and the thumb. These are advanced distally from a level about 15 cm above the knee to the level of the upper border of the patella.

Then, using the tips of the fingers of the free hand, the patella is hit squarely and with force downwards.

If the test is positive then the patella can be felt striking the femur with a click and bouncing off again.

If the effusion is small or tense then the tap test will be negative.

The patellar apprehension test: reveals recurrent dislocation of the patella where the patient shows apprehension because he or she knows that the movement, which simulates that of dislocation, is going to be painful.

The knee is extended and the patella is pushed laterally. To reproduce the mechanics of dislocation, the knee is then slowly flexed. In recurrent dislocation of the patella, even slight movement can induce resistance and anxiety to further movement.

The apprehension can manifest in a variety of manners, from tension in the muscles to a shout of alarm.

(a)Looking for an effusion: The examiner's hands are placed on either side of the patella, with the thumb and middle to little fingers stroking the synovial fluid

18

towards the patella, while the index finger is used to elicit the patellar tap: The patella is at first pressed down and submerged under the synovial fluid, and will strike the trochlea, producing a tap. As the pressure is relieved, the patella will bob up like an ice cube in a drink

(b)Looking for a fixed flexion deformity: The patient is positioned supine and made to relax. The examiner grasps both the patient's heels and supports them at a height of 10 cm above the examination couch. This is the best position for screening for a flexion deformity, which is a major feature of knee pathology. This sensitive and straightforward method is ideal for screening purposes. It does not, however, lend itself to a quantification (in degrees) of the deformity. Also, since the patient's feet are braced against the examiner's abdomen, the examiner may seek to reduce the flexion deformity by pressing down on the patient's knees

19

Patellar tests;'- Apprehension sign

The patient is positioned supine, with the knee flexed between 0° and 30°. The examiner firmly pushes the patella in a lateral direction. The patient, who knows and apprehends the dislocation that will be produced by this manoeuvre, will stop the examiner. Results are recorded as + or 0.

-Pathophysiology: Between 0° and 30° of flexion, the patella is at its highest point in the trochlea. Pressure from the medial side will push the patella in a lateral direction, causing it to dislocate from the trochlear groove. This will cause not only pain, but apprehension on the part of the patient

This sign may be elicited in recurrent dislocation; it is highly suggestive, and particularly useful in patella alta. As Henri Dejour puts it, "You can't get near their kneecaps."

20

- Patellar grind testThe examiner's hand is placed on the front of the knee. The patient performs flexion-extension. The examiner will feel a crepitus, and may even notice the patella catching. The crepitus is difficult to interpret. If there is nothing more than a positive grind test, a diagnosis of OA or of cartilage damage cannot be made.- McMurray's test: Forced flexion and external

rotation with compression of the medial joint line will elicit pain in the medial meniscus. The hand pressed over the joint line will feel a click. The test may be reversed, to examine the lateral meniscus. Or

- McMurray's test :

This is a rotation test for demonstrating a torn meniscus. The tear may cause a pedunculated tag of meniscus which may become jammed between the joint surfaces.

Held by one hand which is placed along the joint line, the knee is flexed to 90ø while the foot is held by the sole with the other hand. The ankle is internally rotated and the knee extended. The manoeuvre is repeated with external rotation of the ankle and at varying degrees of knee flexion.

A tag, caused by a tear will cause a palpable or even audible click on extension of the knee.

The 'normal' leg must be checked for completeness: clicks can arise from normal tendon movement.iii) McMurray's Test (meniscal injury):

21

For medial minisci, lat rotate & abduct knee then do flexion & extension of the joint and vice versa for lateral menisci

Apley's grinding test: For this test, the patient is positioned prone, with his or her knee flexed. Compression and external or internal rotation may be painful, showing that the medial or the lateral meniscus are torn. This test is always checked, by performing rotation without compression. This manoeuvre should not cause discomfort, unless the collateral ligaments are affected

.. iv) Vulgus stress (medial collateral L.)knee should be slightly flexed.

(a) Medial instability in extension

The examiner grasps the patient's heel (not the ankle or the leg) with one hand, while the other hand is placed against the lateral aspect of the patient's knee. A brisk valgus stress is imparted and immediately released. Medial instability is demonstrated if the medial joint line opens up (Fig. 25). Sometimes the most characteristic phenomenon is a little click as the knee reduces after the stress test. Sometimes, it is difficult to decide whether there is instability.

22

v) Varus stress (lateral collateral L.) knee should be slightly ftexed.

valgus and varus stress tests:

These tests attempt to reveal instability to medial or lateral displacement within the knee.

The valgus test involves placing the leg into extension, with one hand placed as a pivot on the knee. With the other hand placed upon the foot applying an abducting force, an attempt is then made to force the leg at the knee into valgus. If the knee is seen to open up on the medial side, this is indicative of medial ligament and / or cruciate ligament damage.

The varus test involves applying forces to the knee in the opposite direction. Widening of the joint on the lateral side is indicative of lateral ligament and / or posterior cruciate ligament deficiencies.

Variations of these tests involve placing the knee in varying amounts of flexion and rotation

b) Lateral instability in extension

The examiner grasps the patient's heel with one hand, while exerting pressure against the inside of the knee with the other hand. The varus stress applied will cause lateral gaping in the laterally unstable knee. Lateral joint gaping

23

is physiological. It is the asymmetry of the gaping that constitutes the abnormal finding.

(c)Anterior drawer in 90° flexion, or direct anterior drawerThe examiner sits on the patient's foot, which has been placed in neutral position. The knee is in 90° flexion. The index fingers are used to check that the hamstrings are relaxed, while the other fingers encircle the upper end of the tibia and push the tibia forwards

If a direct anterior drawer is obtained, the ACL will be torn. However, for this sign to be elicited, peripheral structures such as the medial meniscus or the meniscotibial ligament must also be damaged. This ligament forms a wedge, in 90° flexion, preventing anterior tibial translation. The finding of an anterior drawer is conclusive evidence of an ACL tear. However, not every ACL tear will be associated with a positive anterior drawer test

The posterior drawer test: is used to test the posterior cruciate ligaments.

The knee is flexed to 80 degrees and the examiner sits upon the end of the foot to steady it. An attempt is then made to jerk the tibia backwards. Maximum displacement of more than 1cm may indicate rupture of the posterior cruciate tendon. This might have been predicted if there was observation of the tibia subluxing upon the femur.

24

vi) Cruciate ligaments: knee flexed, look at tibia. => Drawerf test {Antenor/Posterior Drawer Test) (Cruciate L) ; Ask the patent to lie supine on the exam table with knees flexed to 90 degrees and feel flat on the table, f

1. Sit on or otherwise stabilize the foot of the leg being examined. 2. Grasp the leg just below the knee with both hands and pull forward3. If the tibia moves out from under the femur, the anterior cruciate ligament may be torn. 4. without changing the position of your hand, push the leg backward.• •'- - " • - - .-' -." -.. • • • , " ^^a^•fcjfc**^.^ " . . - . _,5. If the tibia moves back under the femur, the posterior cruciate ligament may be torn

=> Lachman Test (Cruciate L.) (move tibia backward & foreword): ;' 1 Ask the patient to lie supine on the exam table.; 2 Grasp the thigh with one hand and the upper tibia with the other hand , hold the knee in about 15 degree of flexion 3 Ask the patient to relax and gently pull forward on the tibia.1 ".;•"• --•= -''."'". ' • I ; * '"-.•' ~:' " - ;4 The normal knee has distinct end point. If the tibia moves out from under the femur, the anterior cruciate ligament may be torn. i5 -Repeat the test using posterior stress. i:,6 The normal knee has a distinct end point. If the tibia moves back under the femur, the posterior cruciate ligament may be torn.

25

• Note:The Lachman Test is used by athletic trainers on the field to check for cruciate ligament injury. It is very accurate and can be done on an acutely injured knee (when the patient cannot tolerate bending the knee for a drawer test). - 14) Feel posterior surface of patella.15) Patello-femoral tenderness test. D) With the patient prone1) Scar or Swelling2) Grinding Tesf (for meniscal tear)3) Distraction Test,(for collateral & cruciate ligament tear)

Nerve examination :

Radial Nerve (More motor)

1. Triceps2. Supinator

3.brachioradialis4. Abductor policis longus5. All extensors of forearmExamination:I) A) Inspection •1. Wrist drop2. Wasting of triceps3. Wasting of forearm extensors B.) Power ; 1. Extension of the wrist2. Extension of M.C.P.joint3. Supination against resistance (in extension)4. flexion of Brachioradialis (in mid prone position)!5. Triceps (extension of elbow)

Note:- Do the movement on your self in front of the pat. -Let the pat. imitate you .-Do it against the resistance on the pat. Ill) C)sentsation

26

1st cleft dorsally

Ulnar nerve:Supplyflexor carpi ulnaris 1/2 of flex. Dig. Prof.Hypothenar mminterossei.2 medial lumbricalsAdd policis Sensory for medial 1/3 of palm & 1 1/2 of fingers.(ant.ly& post ly)

Examination:A- InspectionHypothenar wasting Claw hand Interossei wasting (spl.y in the 1st dorsal interosseus)Medial forearm wastingTrophic ulcer B- power: Paper between little & ring fingers (do it bilaterally) Abduct index against resistance (1st dorsal interosseous) Abduct Little finger against resistance (abd. Digiti minimi) Froment's test (adductor pollicis) , do it bilaterally.c- sensation :Medial 1/3 of hand (palmar & dorsal) Media 1 1/2 of fingers (palmar & dorsal)

Median nerve:Supply:1-All forearm flexors except that by ulnar nerve. 2.Pronator teres. 3-.Pronator quadratus, 4-Thenar M. 5.lateral 2 lumbricals. 6.Sensation:lat. 2/3 of palm & 3 1/2 of fingers till nail beds. •Exam, : A) inspection j 1-Lat. Forearm wasting 2. Thenar wasting,

27

3. Index extension|(benediction attitude due to loss of flexion of . inlerph.j. of index) 4-trophicchanges B )Power. 1-Abductor pollicis brevis (palpatr-Bulk- tone of thenar M.)2. Flex. Poll. Long, (distal) 3. Flex. Dig. Profundus (reach^dislaj IP.J.) 4. Pronation against resistance (in extension) C) Sensation: lat. 2/3 of palm &3 1/2 of lingers till nail beds. Some special tests of median n

Phalens Test (Median Nerve) 1. Ask the patient to press the backs of the hands together with the wrists fully flexed (backward praying). ,2. Have the patient hold this position for 60 seconds and then comment on how the hands feel. • 3. Pain, tingling, or other abnormal sensations In the thumb, Index, or middle fingers strongly suggest carpal tunnel syndrome.

j .Tinel's Sign (Median Nerve)1. Use your middle finger or a reflex hammer to tap over the carpal tunnel. 2. Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome.

Femoral nerve: (2cm , has 12 branches)Supply:

1. Quadriceps (fastidious M.) 2. iliopsoas 3. Sensation • Front of thigh

28

• Medial aspect of leg (skin of the shin) • Medial aspect of foot.

Exam - Quadriceps wasthg - Extension of knee against resistance( feel the muscle)- iliopsoas against resistance (should be in siting position) -Sensation (mentioned) ,: ;

Sciatic nerve:((L4, 5&S1,2,3)Supply:-Hamstrings (3M. biceps femoris,semitendinosis, semimembrinosis) -all muscles below knee - iSensation: below knee.

Examination:inspection:

- Wasting of hamstrings - Wasting of leg muscles - Foot drop - Trophic ulceration

Power: -o flexion of knee (Hamstrings & gastrocnemus)o flexion of ankle o extension of ankle Sensation: below knee specially the lat. Half of the leg & foot.

cervical spine examination(all chest & upper limb)

inspection:(look)skin,S.C tissue (swelling, scar) Feel Tenderness of spinous process &Tenderness of the facet J. (1 finger lat. To the cervical spines)

29

Movement:( assisted active) ]1. Flexion: ask the pat,;To touch the chine to the chest. 2. Extension: tell the pat To look to the roof of room. 3. lat. Rotations &lat Flexion: compare both sides > Neurological exam: supply of upper iimb (C 5, 6,7, 8 & T1). Examine roots of the nerves by power, reflex , sensation. -

Power:

1. C5 = abduction of the shoulders (against resistance)2. C6 = extension of the wrist3. C7 = flexion of the wrist4. C7 = extension of the fingers5. C8 = flexion of fie fingers (close the hand)6. T1 = abductidn of the fingers

-reflex - biceps reflex =C5;-brachioradialis (it doesn't cross the wrist J.)=C6-Triceps-C7 -Sensation: Do sensory screen with light touch & pinprick &. vibration &joint position sense. Dermatomes in the upper limb:1. Shoulders (C4) ';2. Forearms :lnner aspect (T1) .outer aspect(C6)3 Hand Thumbs (C6),and little fingers (C8) & (C7) in between of them

Edited by:

Dr.Soran Mohamad Gharib

30

2008

Sources: 1-Lectures by dr baxtyar rasul , collected by

sarteep izzat 2-hamilton baileys physical signs

3 -outline of fracture 4-norman browse

5 -short practice of surgery 6 -internet

31