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Medical Students and Doctors in Libya

Examination Of Locomoter System

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1- General examination:

  • General look.
  • Gaite.
  • Scalp.
  • Eyes.
  • Mouth.
  • Neck.
  • Skin.
  • Hands.
  • Legs.
  • Vital signs.

2-Examination of locomotor system:

 

GOALS:1)Learn general techniques for examining any joint

              2) Review exam techniques for some specific joints

 

Examination Principles

 

Inspection

 

Observe patient as they move

Adequate exposure is important

Joint:

Findings:

 Asymmetry (compare to unaffected side)

Deformity or misalignment

                                                Varus- distal extremity deviates medially

Valgus- distal extremity deviates laterally

Overlying tissues:

Findings:

 Discoloration

Erythema (redness)

Ecchymosis (bruising)

Edema

Palpation-

 includes range of motion (ROM) and muscle strength

Technique:

Palpate bones, joints, surrounding muscles

If injury or pain is present, start with normal side first

Gives you an idea of uninjured baseline

Prepares the patient for exam on the affected side

Findings:

Warmth

Compare to unaffected side

Use back of hand

Switching hands back and forth may bring out

subtle difference

Tenderness

Crepitus (KREPP-it-uss)-grating feel and sound

CLINICAL SITUATION: signs of fracture

Bony point tenderness

Swelling

Ecchymosis

Deformity or crepitus

Be aware of possible neurovascular complications of injury (For example, radial artery in humeral fracture or axillary n. in shoulder dislocation)

Range of motion (ROM):

If injury or pain is present, start with normal side first

Test active ROM first

Then passive ROM

Discrepancy may be due to weakness, joint disorder, or 

pain 

Strength: (usually reported as part of neurologic exam)

Compare with contralateral side

Grade resistance against gravity and against you

Grade Muscle Function Level

0 No contractility

1 Slight contractility, no movement

2 Full passive ROM with gravity eliminated

3 Full ROM against gravity

4 Full ROM against some resistance

5 Full ROM against full resistance

Examination of Specific Joints

Temporomandibular Joint (TMJ)

Inspection: Usually nothing obvious

Palpation:

Technique: 1 or 2 fingertips anterior to tragus

Little finger in ear canal

Findings: Tenderness, crepitus, popping

ROM:

Open and close Normal: 50mm between upper and lower

teeth

Lateral movement Normal: 12mm in either direction

Cervical spine

Inspection: Symmetry, alignment

Palpation: Cervical spine and paravertebral, trapezius, SCM muscles

ROM: Flex/extend

Lateral bending (ear towards shoulder)

Rotation (chin towards shoulder)

Shoulders

Inspection:

Contours of shoulders and clavicles

Symmetry, deformity, discoloration

Palpation:

Sternoclavicular joint

Acromioclavicular (AC) joint

Clavicles

Scapulae

Greater tubercle of humerus

Bicipital groove

Surrounding muscles

ROM:

Flex/extend

Adduct/abduct

Pain from impingement during abduction is a common

problem“Total elevation” refers to combination of

flexion/abduction

Internal rotation (hand behind opposite scapula)

External rotation (hand behind head- elbow out)

Elbows

Inspection:

Symmetry, deformity, discoloration

Contour- look for subcutaneous nodules (rheumatoid

arthritis) or olecranon bursitis

“Carrying angle” between humerus and radius

Palpation:

Olecranon and epicondyles

Lateral epicondylitis- “tennis elbow”

Medial epicondylitis- “little league elbow”

ROM:

Flex/extend

Pronate/supinate

Hands and Wrists

Inspection: dorsal and palmar aspects of the hands and fingers

Symmetry, deformity, discoloration

Findings

Atrophy of thenar/hypothenar eminence or

interphalangeal muscles

Dupuytren’s contracture

Evidence of osteoarthritis

Heberden’s nodes at distal interphalangeal (DIP) joints

Evidence of rheumatoid arthritis

Ulnar deviation and subluxation (partial dislocation) of

metacarpophalangeal (MCP) joints

Swan neck, Boutonniere deformities

Ganglion cyst- round swelling on dorsal surface, more

prominent in flexion. Benign, common.

Palpation: Finger joints and wrists

Findings

Nodules, tenderness, bogginess

ROM:

Fingers, thumb, wrists

Strength:

Hand grip

Finger abduction- ulnar nerve

Wrist extension- radial nerve

Thumb/finger opposition- median nerve

 

Thoracic/Lumbar Spine

Inspection:

Landmarks

Head directly over gluteal cleft

Shoulders _

Scapulae _   }        left and right     

Iliac crests_ should be equalheight

(Iliac crests cross L4- landmark

for lumbar puncture)

Lateral inspection

Lordosis- “swayback” curve in

lumbar area

{Pregnancy, muscle

imbalance,obesity}

Kyphosis- “humpback” curve in

thoracic area

{Osteoporosis}

Palpation:

Spinous processes

Paraspinal muscles

ROM:

Flex/extend (touch toes, lean back)

You can examine for scoliosis as patient straightens from flexion

Lateral bending

Rotation

Special test:

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

Passively lift affected lower extremity with knee straight

Findings:

Positive test is reproduction of sciatic-type pain when hip is flexed between 30 and 70 degrees

Dorsiflexion of foot may aggravate pain

Hips

Inspection: Can assess entire lower extremity here-hips, knees, ankles

Symmetry, deformity, discoloration

Hips: Symmetry of iliac crest height,

glutealfolds

Can assess hip strength by watching

patient rise from chair

Palpation:

Can include iliac crest and greater

trochanter

Palpate for stability in trauma patients

ROM:

Flexion with knee bent

Extension (prone, on side, or standing)

Adduction/abduction

Rotation with knee flexed to 90 degrees

Internal rotation (note: to test this, foot goes externally- think about it!)

External rotation (likewise, foot rotates medially for this)

Knees

Inspection: Symmetry, deformity, discoloration

Alignment, landmarks

Palpation:

Popliteal space (swelling may indicate

 Baker’s cyst)

Tibiofemoral joint space-lateral and

medial

Patella

ROM and strength:

Flexion/extension

Ankle/Foot

Inspection: symmetry, deformity, discoloration

often helpful to observe during weight-

bearing

Palpation: Achilles tendon, medial and lateral

                malleoli,forefoot

ROM:

Dorsiflexion/plantarflexion

Inversion/eversion (inversion when sole

points “in”)

Abduction/adduction

 

 

 

by: Dr Younis Ejwalli

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