Orthopedic Examination

7/26/2019 Orthopedic Examination

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Copyrighted Material


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I

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ATLS OF

r h I C i (

Exaian f teCricral Js

Many students learn the details of skeeta anatomy bt ten nd it dicult to reate

that knowledge to rea uman bengs when they present for clinica examnaton

and assessment. Ths atas aims to the nfomation gap between descrptive

and papato anatomy and to elp the stdent make the nk between the two.

It addresses the cnca appeaance of noma tissues and thei function, andprovides gudance on how to examne and assess nomal joints.

Key features

ntroduces te basics of cncal emnation

Provdes step-bystep gudance to te cnca assessment of the periphea

jon and ter associated tssues and stuctues

Details the examnation of te mao oints of the body one by one:

Souder/Ebow/Wist/Hip/Knee/Foot and descbes the nomal ndings

n heathy ndviduas

Emphaszes the mportance of performing dagnostc movements corectly

Addresses te common mistakes in examnaton techniques and expains

where peope go wrong

Profusey ustrated with hgh quali photogaphs and diagams

Text desgn ensures that the ustatons appear close to the elevant text

Ths o Ohopdic xminon o h Piphl/oin wl provide an

nvaluable souce of efeence fo medca students and membes of all heat

care pofessons concerned wth the anagement of oopedic problems

W. B SAUNDERS9 780702 021244



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l Ex l J



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I1stratio by: Kei Ma

F W. 8 Sa"nd

Editial Diet, Heath Science Ma awHad f Prje Mngement wa Ha

et Devepment Mage Dah hoSei Deige Juh W



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Atlas of Orhopedic

Examination of thePeiphea Joints

Ludwig Ombregt MDMedical Practitoner n Orthopedic Medcne. Kanegem Begu;Intenatona Lecre n Ohopedc Medce

Pierre Bisschopysoteapst speciaizing n Orthopedic Medicine, Knesseae Begnteationa ectue in Oopedc Medcne

W. B AUNDEREdnbugh ondon New Yok Phiadephia ouis Sydney Toono



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w. B SAUNDERSAn imprint of Harcourt Bace and Company imited

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NoteMedica nowledge i conany changing newnfomaon becme avaiabe, ang in reatmen,p qpm and h of rug omeneceay e autho and e pubiher have, a fa a it poble aen care o enue tat the infomaton given in

thi text accurate and up-to-date However, reader arerongy adved o conf a e nfoation, epeiallywth regard to drg uage, ompe wth the latetlegiation and tandard of patice

Pned i n Chna



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Contents

Pa ii

Ioduo ix

1. Sod 1

2 Eow

3. Ws

4 Hp 6

5 K 81

6 A ad oo

d 11



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Preface

s ausp was dvlopd as a aual o

da ad psoap suds s puposs o l sg oao ad aggap w dspv aao ad paolog o ppal jos

Dug ou ouss oopd dw a alos dal ood posgaduasuds (o psoapss ad doos)wo do o av paal kowldg opogap,sua ad uoa aao Dsp a a a lal sklls sa w a ud

sadg o oal sd o lalappaa o oa ssus ad avou dug aual aao ss o agossl gld aa o dal duao

s ook ssal addsss lalappaa o oa ssus ad uo,ad povds guda o aao adassss o oa jos W od ousvs o a dsusso o os poa ssusd oopd d a lavlspl o po ad av a ga s

al s ss (av,passv ad ssdovs) a apd oopd d, psoap ad aua ap as as ss o a good lal valuao o j uso s ook ouss o pa uo o ovs Mu oou g w av o olud a poolodud ss o gv o oaoad o lad o aua dagoss Wlv a ou ag p a o

ga lp o ad ad o w av

lsd os suds os ul ak

so o 'oo saksA sall so o oo paologal

suaos olows a dsusso o aluo o s, ad dgs oalsujs s so oud ousg a dsd s s o a o dagos podu o d odo Alal dag dos o l o ouo oo sgl s u s ad o paoo a lal pa ( od ouo o a

s o la ss) pao o paologal dgs ad udg up o lapas s o w sop o s ook sd ad s d o ou lal ook Sysm of Oopc Mcpulsd Sauds 1995 I s wok, apaologal odos ad osvavas a dsussd oougl

ckowledgemens

W would lk o ak ollagus wo aas o Oopad Md aoa(MI) ad wo povdd sga lp Wa paulal gau o E Baa,

a Maual ap a Uvo Busss, wo ad as a ll advs,povdg o ps ad osuvs

ollowg gus av ak o

Og,Bssop P, V H Va d Vld



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v REFCE

1995 A system of orhopaedc medcne W BSuders odo: 18-116, 118-134; 21 23,24 28-212, 214-216 219-221 224-235 33,34 36, 310, 31 315, 316 318, 323 324,327-360; 45,411,43,414,41642042232

435436; 56-51,5.14,518 521543, 54555065 612616 6.18, 620 62443

KegemTel1999 Ldwg OmbregPerre Bsschop



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Inroducion

The pupose o eamaon and / o esng po

cedues ohopedc medcne s o eamne hec/o o he dee ssues o he movgpas The echques ae ased o he pncpleo 'elecve eso'

Each ssue o he ody has s pacuaucon I acs ehe as a solaed sucueo as pa o a goup o sucues Fucodes,depedg on whehe a ssue s u omake ohe ssues move (musculoedoussucues), o cool ange o movemen

capsuogamenous sucues), o aclaemoveme (usae) o o acvae movemeneve sucues)

The musculoendnous un has he heecapaly o coac s a 'coace ssue'wheeas a he ohe sucues do o possesshs capaly hey ae 'e' Conacesuces can e esed (= pu unde eso)y povong a mamal somec coaconIe sucues ae esed y pung hem udemama sech.

ctve movemets

A acve moveme s peomed as a as may go I does o ollow he pcple oesng y selecve eson: a lo o sucuesae pu ude sess The eamne o oy gesa dea o he ple age o moo n hejon omal, med o ecessve), he s alsonomed aou he egy o he musculo

endous appaaus

Passve movemets

A passve movemen ngs a jon o he ed ohe nomal age The omal amplude desom he heoecal ange o moo Aculasuaces aow a cea amou o movemen,u he moveme s usualy sopped as a esuo eso n he capsulogameous sucesThe moveme heeoe no oly noms heeamne aou he noma ange, u also aouhe sucues ha sop he moveme omgog uhe Ths happe y assessng he

endeel o a moveme whch ca e eheelasc capsula), had (ony o gamenous) oso (ssue appomaon)

Passve movemens ae good ess o eamehe ne sucues ad gve an aswe o heollowg quesos:

a Does he ne suce uncon nomaly? Ino, pa may e elced and / o he agemay have dmnshed

oes allow a omal ange o moo Ino, he edee wll have chaged

Fom he echnca pon o vew he eameshould poson hm o hese n such a way hahe moveme can e eecued ove he eneple age o moo and ca e ougho he end o he age n ode o es he endeel I may e ecessay o ae he sujecsody o pa o he suec's lm n ode oavod paasay movemens ha would gve se

o an coec answe



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x NRODUCO

Resisted movemens

A essed moveme s me o es hemusu ssue o I sould e eeued some w hee hodg e o

e eul poso: s pus s o heoe ssue u eves he e suuesueded The es ves e musleso musle goups ( dee musles w hesme uo) I oms he eme oue om segh o e oo

Ressed movemes es he ole suue: he whole o he musle ell e musuloedous juo he od o e edo de seo oo e oe Whe leso oe o hese ps s pese he oo wll

esu p wh o whou wekess Dmuo o segh s e esul o ehe upue oo poem wh e evou ssem vge musle

The eme should poso hm o hesel suh w he o she s soge h hesuje he ol w o eeue he movemes

some w The jo s oug ohe eul poso lowg e e ssueso el d he suje s sked o peom oo wh mm seg The emeesss e moveme hee o lowg

u moveme ll He o se heeoepus hs o he hds suh w h oe hdees pessue whle he ohe gves ouepessue

Te oeess o he eh eeuo o heess guees he oeess o he swe

Futher eading

Diel igh 99 Mcle eg ueLd

pji I 7 pyigy f he j v hl Lvge Ebgh

Ombeg L Bh P, Vee H V de Vede 15 Ayem f hpe meie ue L

ety } Mre A P 998 Nemuelelemi eme: hdb f heh Lvge Edbgh



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CAPTER CONNTS

Sua and palpatoy anaomy 1Bny lndm Pltn fsf t 3

Funciona examinaon of he shouer 8Atv tt

Atv lvtn Pv tt Pv lvtn Psv xl ttn Psv xl ttn wt th dr n

dtn Pssv ntrn ttn Pv lnrl dctn

Imt cntcn Rtd ddtn Rtd dtn Rtd x rttn Rtd ntrnl rttn Rtd x th lw 5

Rtd xtnn f t lw S tt Pv ntl ddtn Ahnn tt n xt tn Ahnn tt n nt ttn Ant dwr tt 9Ptr dwr tt 9

Shoulder

SURFACE AND PAPATORYANAOMY

e shuder is inextricl und up with theshulder girdle, nteril vi the clvicle ndt the psterir spect vi the scpu. hese twn structures re esil detectle ndmrkst strt the plptn f the shuder structures

Bony landmarks

Anterolatea (Figs 1 nd he clvicle A is the mst prminent nend is esil detectle ecuse t lies sucutneusl. Its medil prt is cnvex nd te lterthird is cncve Its medil end sternl end isubus nd rticultes with te sternum

e terl end is fttened nd rticultes wth

Fg. 1 Antr vw th hl (n vv



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ATLAS OF ORTHOPEDI EXAAIO

g eio view o he shoule (skeeo)

the scpul's crmin (B whic cn be recgni s flt bn vring h sulr jintPlpte he nterir spect f the cvice ncntinu furtr ltr unti h crmi nC is flt Just trl it smll inentinis ppble befre e cler nerir brer f

the crmin is reche his inentin is hentrir n f he crmiclviculr jin. Bmving th ppting fngr n p f th shulrth crmil n f t clvicl cn b f lieslightl iger tn te crmin When thefingr is in cnct with h tw bns thecvicle n he crmn it ies n the crmicvicur jint f whic h uppr pr f hcpsul is rinfrc wih t suprir crmicvicur igment

n e infrclviculr fss jus belw hecncve erl prt f te clvic bn prmi

nnc cn b ft his is th scpuls crciprcess (D, f which nl t tip n te melsurfce re plpbl frm he pints frigin fr th shrt h f h bicps brchiimuscle n fr th crcbrchiis musclrspctivl

Plc t fingr n he crci prcss n g1 cm wn Nw mve th finger lter unti shrp bn strucure is reche his is te esserubersit f he he f the umerus Ppehis bn n fl fr its ltrl brr hmi lip f th interubrcur sulcus

Just lerl t tis brer lis t bicipitgrv tht cntins he ng he f te bicepshis inerubercur sulcus is plpbe wih he

thumb plce flt n it n uring rtr mvmns f h umerus efin t bicipitgrv, use he subjec's frrm s lever nrte the umerus er unt he mei ipf the sulcus its h thumb hen rt th rmmi unti h tr ip ctcs h humb

At he lterl spect f t sulcus greertubrc cn b plp his is h grrubersit ( When mving th pping fingerupwrs eprssin cn be flt bfr th

lrl brr f t crmin is rch

Posolaal (Figs 3 n 4)

h scpul (A is th ms imprtn bn th psrir si f he thrx It hs vprminent spine (B h is es t ppte el

D

g .3 Vew o he sholder fom above



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Fg. oeroaeral vew o e oler elo

r th pstrr margin th spin and llwthis urthr latray whr it cms mrprminnt h spn can t t mak a 90rwards turn th acrmia ang C - r itrms th acrmin (D) gthr wth th acrmial n th clavicl and th cracacrmaligamnt it rms th cracacrmal r

h spin divids th scapua int a supraspinus ssa E) and an inraspinus ssa (,in which li, rspctvy th supraspinatus andth nraspinatus musc llis

Pac th suct sitting with th arm in 90aductin and papat in th supraspnus ssain a latra dirctin h spin th scapula ist t mt th clavicl At this pint lis thpstrir aspct th acrmclavicular jnt (G)

(Fg. 15. Plac th thum at this pnt and papat smultanusy r th antrir indntatn

SHOULDER

g .5 Papaio of e upapou foa (ode nabduco

twn th clavicl and acrmin h acrmiclavicular jint li jins ths tw pints

Palpatio of soft ssue

Palpaion of he delod muscle

h dltid musc is asy t rcgni trms th mst imprtant muscuar mass thshudr and is rspnsl r its rund k(Fg 16 h antrir prtin (A) vrlis thantrir rdr th acrmin and th lssrrsity h midd prtn (B lis vr thlatral rdr th acrmn and th gratrtursity and th pstrir prtin (C uildsth pstrir aspct th shuldr and cvrsth atra part th spin th scapula

c

g. aeral vew of e oler n vvo



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4 ATAS OF OOPIC XAMINAON

Flg. 1. Vew o e deoid musce coaco)

Ask th subct to abdct th arm agaistrsistac A groov (D) (Fig 17) ca b palpatdbtw th atrior ad middl portios of thdltoid This ovrlis th bicipital groov

Plpion of he suprspius muscle

Musl by an musulonnous junon Thsubct sits with th arm i full abdctio adrstd o th couch Th lbow ow is o thsam lv as th shouldr Th xamir stadsbhid th sbjct h trapzius muscl is wllrlaxd ad palpatio ca b prformd throughthat muscl Palpat for th spi of th scapulaTh muscl by yig just abov th spi of thscapula is th spraspiatus muscl It fills up thsupraspious fossa Mov th papatig figrmor latraly uti it rachs th corr formdbtw th clavicl ad th spi of th scapulaTh figr ow s o th muscuotdious

uctio of th supraspiatus which ca b flt tocotiu latrally udr th acromio Fig. .8)

Inson on h rar urosy Now positioth subjct with th forarm bhid th back. Tharm is ow i ful itral rotatio alpat forth latral bordr of th acromio follow it i thatrior dirctio util th corr is ft btwth latra ad atrior bordr ad idtify thlattr Also look for th acromioclavicuar joitad kp th papatig figr atra to it Movth figr forwards so that it coms to o th

Fg. 18 Palaio of he msuoedios jtio o espaspatus

gratr tubrosi of th humrus but is sti icotact with th acromio as wll Exrt a prssr vrtically dowwards agaist th humrsTh figr ow is o th supraspiatus tdoof which th mdia bordr ca b ft quitclary (Fig 19)

Papaton of h nfraspaus mus Fig 1.1Th sbjct is i pro lyig ad rsts o th

bows Th uppr arm should b kpt vrticaad i slight adductio. Th subjct thrforlas towards th shouldr to b palpatd Withth had h grasps th dg of th couch Thisrsts i som xtral rotatio of th shouldras wl Th xamir looks for th spi of thscapula ad papats blow it i th ifraspiousfossa Th thumb ow lis o th ifraspiausmuscl blly Plac th thumb just udr thspi of scapula ad palpat mor ad morlatrally A tdo will b flt that rus parallto this spi. This is th ifraspiats tdo.



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Fg 1.9 alatio o e eoeoseal ucio o esuraspiatus

I ca b wd uil h aachm hga ubiy i fud Th b ca b flhugh h diu ma alpa m laaly uil h humb li h ga ubiyTh diu ucu ca b f ay m.Cm back pviu pi wh bb ad d a f Ti i h

apaon of he subscapuas endon

h ubcapula mucl blly ca ly bachd by bgig h had i bw h

SHOULDER

g .10 alpatio of e eoeiosea uco o tifaspatus

capula ad a I ca aly bpalpad Th diu ii h lubiy wv ca aiy b palpad

Th ubjc i i a half lyig pii a

cuch h upp am alg h bdy ad hlbw fld 90 h xami gap h



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6 TS O OROD XIO

g 11 ushi the teds f the sh head bcesad f rarahals ediay

subjt's had ad bigs th should ito afw dgs tal otatio Pla th thumbof th oth had o th lss tubosiy of thhumrus. t ow is o th istio of thsubsapulais tdo Th otat is ot ditbaus th istio is paty ovd by o tho had th tdos of th shot had of th

bips ad of th oaobahialis both uigtowads th oaod poss ad o th othhad th atio potio of th dltoid muslruig th dtio of th aromio Tuth thumb so that ts tip lis i th dtio ofth xiphid poss of th stum (Fig. 1.1).

Push th musula mass fowads l ththumb ad om bak towads th ss ubosiy h two tdos a b lt sappig away.Thy ow li mdially to th thumb At th sam

tim dltoid fibs hav b daw idwaysad li latay to th thumb whih ow is idit otat with th subsapulais istio(Fgs 11 ad 1.13)

Papaton of e ong ead of bicep (Fg 1.14)

a th fig i th goov btw th atio ad middl potios of th dtoid musl.Mov th fig atioly ad distaly It owis o th biipta goov whih is stuatd

mo latally tha is usually supposd

g 1 alpati f the subscauas (upper pat)

2

3

Fg. 13 tei vew f he shde: 1t lei ise the bces; 2 a , iceps e; se f thesscauais sce

dtify th itubula sulus by plaigth thumb flat o it ad by utig smallotatoy movmts of th humrus Th latalad mdial lips a b flt athig agaist ththumb I this goov is th tdo of th loghad of bips It is diffiult to palpat as it isovd with a tasvs ligamt. Mov ththumb upwads utl th upp pat of th goov

is ahd ust bow th aomio Ask fo



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114 alpaio o e o ead o bces i e sus

n civ fxin f h lbw d ri hmvmn Tighig f h d c b fl

apaon o he peoas majo muse(Fig 1)

h lrl pc f h pcrli mjr muclfrm h nrir brdr f h xill whri infrir brdr c b ppd vry wlpciy during rid dduci f h rm

h nd ir h cr f h grrbry ju blw h lrl brdr f hbicipl c

apaon o he assmus dos muse(Fig 16)

Th r pc f h im dr muclbd h prir brdr f h xi I fl crc during rid ddcin f h rm

inrin i rrly h cr f hr briy

SHOULDER 7

F 1.15 apaio of he muscle be o e ecoralsmajor

F. 16 alpaio o e aar pa o he aissis os.



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8 TS O OTHOPDI XNTION

g 17 eror vew of e aia

Palpaion o e axilla

Bring the subjets arm into 90 abdution. Askhim to press the arm downwards and resist thismoement During palpation in the anteroposterior diretion the following strutures anbe identified (Fig 117): petoralis major (A),forming the anterior border of the ailla, thetendon of the short head of bieps (B), the orao

brahiais musle C and the atissimus dorsiD), orming the posterior border

FUNCTONAL EXAMINATION OF THESHOUDER

Inroucion/general remarks

Shouder lesions gie rise to pain felt mostly inthe proimal part of the upper imb The shoulder

eamination is therefore ommonly used inth dignosis o pp m pain Howe theeaminer shoud realize that symptoms in theregion of the shouder an also originate fromthe eria spine, the upper thorai spneand the shouder grdle The eamination of theshouder is to be onsidered as an element in thediagnosti proedures for lesions of the upperquadrant

ACTVE TEST

Acive eevaion

POSo he subjet stands wth the armshangng aongside the body he eaminer standsbehind.

Prour. Ask the subet to bring up both armsideways as high as possible (ig 118)

Commo msaks:

The moement s not performed to the eryend of the possible range

The arms are brought up in a sagitta pane The arms are kept in internal rotation, whih

makes fu moement impibe.

Nomal foal aaomy

/ 180 Ss d Many strutures are

ommitted The moement is started by thesupraspinatus musle and ontinued by the

118 tive eevao of he am



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mile prti te elti a by the lgea biceps Rtati the scapla s emay by the serrats aterir mscle,spprte by te trapezs mscle, especially

twars the e rage The memet alsstretces a/ r sqeezes seera strctressc as the capsle the glehmera jitthe sbet brsa a the sterclaicara acrmcaicar gamets

M Ths a ery speciic test wichs almst always istrbe whe a sher rher girle pathlgy is preset It as gies

a iea te patiet's wiigess t cperatePai at mirage may iicate a strctre

betee the hmeral hea a the cracacraarc eiter e the tes spraspiats,raspiats, sbscaplaris, g hea bceps,

r the sbacrmial brsa r ierir acrmiaicar gamet - beig pay pche

Te patet te ais pa mpgemet byag a aterr cmpet er part thememet

Lmtati wit r wtht pai ccrs iser artritis r arthrsis certai extra

apsar esis a sm ergical cis casig weakess the shler eeatrs

PASSI TSTS

Passve eevaon

POSo The sbct stas wth the armshagig agsie te by The examer

tas beh the sbect a taes l thebw at the ista part the pper arm

Poc Tae te arm p seways therta pae as ar as pssibe Allw sme exera rtat abt 90 abct. Reachighe e rage ge cterpressre wit the

ter a at the sbject's ppste slerFig 9)

Common msts

Whe the arm is graspe stally t tesbject elbw, elbw memet preets

assessmet eee The arm s t awe t extealy rtate

g19 asse eea e am

HULE 9

The memet s stppe bere the e

te pssble rage is reace At the e rage te arm is tae

backwars i a sagitta plae sicet cterpressre reslts i te

sbject ielexig the by.

Norml nco tomy:

Ralge: 80 Ede elastic Limitilg structurs:

- the axillary part the jit capsle- stretchig the acrmiaiar asterclaclar igamets

- the actrs a iteral rtatrs tesler

- ctact betwee the lesser tbersty thehmers a the pper part the gleilabrm

Common ptholocl sutons he eet c be pai i sbet

brsis i rtatr c teiitis, as welas i acrmaclar lesis



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1 AAS O OROPDC XAMATIO

Lmtion ours n rthrtis nd thosis ofthe shouder nd in serious etrpsuonditions

Passive exernal otaonPostonn he subet stnds with the perm ongside the od nd the eow fleed to ght ngle he emner stnds leve with thesubets rm nd stbiizes the elbow with histunk One hnd is pled on the ontrltershoulde to stbilize the shouder gde ndtrunk; the other tkes hold of the dist forerm.

Por Rotte the rm outwrds menwhe

ssuring the vertl position of the hmeusuntil the movement omes to n elsti sto(g 1

Common msts

he shouder gidle is not well enough fiedso tht tunk movement is llowed to hpen

he elbow s not we stbiized so thtshoulde bduton or etension ors

he movement is not eformed to the end ofthe ossibe nge.

g 0 asse eera roao e o eeomera joi

ormlunton ntomy

o Rag Edleei: esti LmHg c:

the nteio portion of the oint sule- the intern ottor muses of the shoude- ontt eween te gete tuerosit o

the humeus nd the posterio pt of theglenod rum

Common ptolol stuons

Pin on u ssve eternl rottion is one ofthe first signs of shoude rthtis Etenrottion lso stethes the romioviulligments nd the subspris tendon nd

sueezes the subdeltoid urs solted iton os n ontre of te

nterior sue nd n soroid ursits he movement is mred mited s rt of

sulr ttern of limittion of movementn moderte or moe dvned rthtisepending on the ondton being eitherute o honi the endfeel will be either ofmuse spsm or hd

Eessive rnge m indite shoudeinstbilit.

Passive exernal rotaion wh teshouder n 90 abduction

Postonn he subet stnds with the mhnging longsde the bod nd the eow eedto . he eminer stnds leve wth the subet's rm he ontrtel hnd tes hold ofthe eow nd bings the rm into 9 of bdution. he other hnd gss the dist foerm

Pod Put the shoulder into ete rottion menwhile stzng the ebow Fg 2)

Common mstks. f the movement is too nfuthe ptient will move the od bkwrds

Norm fnonl nomy

Rg: d-J elsti

mng rr: the nterior prt of the ont psule



22/144

g. .2 Pive oriot eterl otto

he ddutrs nd inern rttrs f the

shuder

Common atologa statons

he mement is mited in rhris ndrhrsis f the shulder nd s in isledntrture f the nterir r f the jintsule.

Eesse memen my resent inshude instty

Passve nernal oaonPostog he suje stnds wth the uerrm ngside he bdy nd the ew lexed t righ ngle he exminer stnds leel withthe sujets rm nd stiizes the ew withhis trunk One hnd is led n the siteshuder t sze the shulder girdle ndrunk he ther tkes hld f the disl frerm

Pror Bring the sujes frerm ehind her

k nd me her hnd wy frm her dy sfr s ssile (ig. .

HL

g. .22 ive tel rotto tet for teleohue oit

Commo mstaks

The shulder is hed n muh dun he ew is uled kwrds whih rees

n extensin f the shuder insted finern rtn

he hnd is med uwrds insted fkwrds

ormal ntonal anatomy

g 9 d: esti Lmng r

- he serir r f the jint sule

- the exernl rttr musles f the shuder- ntt between the esser uersity f he

humerus nd he nterr rt f heglenid lrum f he su.

Commo pathoogal statons

Pin t the end f rnge my ur in lesinsf the nfrsntus nd sursntustendns, nd ls f the rmiliulrligments

n t mdrnge my ur in rtr uffendinis r n surmil ursis



23/144

ATLA F THPEIC EXAIATI

Mr r l itati i u a pat acapuar patr ita t irat an r arthi

ci rag ay iicat hulritaility

Passive genomeral abdcion

Posonn Th ujct ta with th upprar algi th y Th air ta with a hi th ujc ar Oha tak hl th lw jut a th jit.Th thu th thr ha i plac agait thatral apct th lwr agl th capula

Procur.Auct th ar lwly awhilprtig th capula r ig ig .23.

E rag i rach wh th capua ca lgr taiiz a tart t lip urth thu

Common msaks

Th capua t tailiz uficity- Attiv chiqu Wh th lwr agl

th capula catb tailiz, thlatra arg ay u. Th capula

ca al tailiz y placig haup th acr

g3 assie samea abd es f e

emea jit

Mt i t prr t th thpil rag

Nomal nconal anaomy

g 90

Eldf ligatu Limitig scts:

th aillary part th jit capul ctact w t gratr turity a

th uppr part th gli aru.

Common paholocal saons

h t i liit i hulr artriti It ay al c rtrict i acut

uti uriti

ISOMERIC CONTRACTIONS

Resised addcon

Posonn Th ujct ta with th arhagig a lghtly auct Th airta ll with th ujct ar plac ha agat th ipatral hip a th thrha agait th ir apct th lw

Procur Rit th ujct attpt t auct

hr ar ig. 24)

Fg 24 Resised addi e shude,



24/144

Commo mses

T lbow is allow to lx Momt is allow at t soulr

Aoml sres ese

Muscle function:

Ipotat actos toalis mao Latssimus orsi Trs major Trs mior

Lss i/potat aos Log a o trps braii Sort a o bips braii

Claiular pat o ltoi Spial part o to.

Neura funcon

Msce

Peas a

asss ds

ees aj

ees nr

ces ba

Bs acDed

sa a

aca a

Peea

Pea

Tadsa

Sscaa

Axay

Iea

Rada

MscaesAxay

Axay

Pea

Commo pool sos

Nee o

C5-C

C6) C c)

C5-CCSC6C). C7 C)

C5,C6CSC6CSC6C5C

ai suggsts a lsio i o o t automusls or i t toai wal

Wass ours i sr C7 r root palsy aiu wass is pri i rib raturs

a mor ray i a ruptur o t ptoalismajor musl

Resisted abdion

Poso. T subjt stas wit t armagig a sligtly abut. T amirstas l wit t subjts arm H plaso a agaist t opposit ip a t otra agaist t outr aspt o t lbow.

Proeue Rsist t subjts ampt to abut arm Fig 125)

SHOULDE

Fig 5 ssd abd sudr

Commo mskes. Momt is aow at tsoul

Aoml srues ese

Musce functon

Impotant abctos ltoi Supraspiatus

Lss potat abtos Log a o bips braii

Neural funcon

Msce

Ded

Sasas

Bs bac

Inea

Peea

Axay

Sascaa

Mscaes

Commo polo sos

ee

CS (CCS CsC6

ai is usuay t rsult o a supraspiaustiits, mor rarly o a lsio o tltoi but may also our i subtoi

burstis Wass ours i total ruptur o t



25/144

4 ATAS OF OTOPIC XAMINATON

supaspinaus tndn r in nurlgicalcnditins, such as lsins th axarynr, th suprascapular nr th C5nr rt.

Painul waknss is indicati a rcnt

parta rupur th supraspinatus tndn

esisted extern rottion

Poson. h suct stands with th uppram aganst th dy and th lw lxd t arght ang h rarm is hd in th sagittalplan s kping th shudr in a nutral psitn. h xaminr stands ll with th sujctsarm H pacs n hand n th ppst shudr

and th th hand against th ut and distalaspct th arm which h supprts

Poceure Ask th suct t kp th waganst th trunk and rsist th attmpt t puhth hand latrally ig. 1.26.

ommon msaes h suct tnds t xcutth tst wrngly ithr y nging th shuldr

g 26 essed eel otio of he shouler

int aductin r y xtnding th lw spially whn waknss is prsnt

Aaomcal srucures ese

Mcle fncn

mprtant xtra rtatr aspnatus rs mnr

ss mprtat xtO rtatrs Spinal part dtid

Nea fncn

sc

Inasnaus

Ts mno

Od

Pa

Suascaa

Axa

Axa

Iaon

ommon paolocal suaos

oo

e5.(eG)

e5. (eGIe5. (eG)

Pain ccurs n inraspinatus tndntis utmay as psnt n sudtd urstis

Waknss indicats a tta ruptur thinraspnaus tndn r a nurlgcalcndtn g C5 nr rt palsy supra

scapular nr pasy, nuragic amytrphyBilatral waknss is suggsti mypathy Painu waknss is th sut a patia

ruptur th nraspinatus tndn.

esisted intern rottion

Poso h sujct stands with th upparm aganst th dy and th lw lxd t aright ang h rarm is hd in th sagittal

pan, s kping th shuldr in a nutra psitin h xaminr stands with th sujcts arm H pacs n hand n th ppsitshuld and th th hand against th innand distal aspct th rarm

Proceure Rsist th sujct's attmpt t pu hhand twads hr (ig 127)

ommon msakes:

h shuldr is awd t aduct Mmnt is awd at th shuldr



26/144

Fg. 12 esste te oao of he se

Anaomical scts tstd

Muscle uncon

mpot "te otos- Sucapuari Pecrali majr Lamu dri- ere majr

s pott ten ottos Ln head f cep rach Claicuar par delid

Neral uncon:

Muscle Inevato

Subsapas

ecorahs majo

LatssmusdTees majo

Bps ai

Detod

cavca pa

Pepea

SubscapuaPecoa

TrclSubscapua

Musutaeos

ectoa

Neve t

CC8CC8(C6, C7(C8)C8CSC6

CC8

SHOUDE 5

Common ahooical siaions Pain i he reul f a ein f he

ucapuai pecrai majr r aimudi endn r mucle and mre rarely f

he ere majr Iaed weakne ccur n al rupure fhe ucapulari endn.

ss flxion of t lbow

Posiionn The ec and wih he armalnde he dy he elw en a rihane and he frearm in ul upinain Theeaminer and lee wih he ujec' hand

One hand i n p f he hulder and he hern he dia apec f he frearm

Procdr Rei he ujec' aemp fle heew Fi .

g. 28 Resiste fe te ebw



27/144

1 ATLAS O OTOPEDIC EXAMINATION

Commo msas The ubje hrug up he houlde i he

hope of exerig ore regh Movee i lowed he elbow I rog ubje flexio o uffiiely

b reied if he reie i o gieperpediulr o he ubje' forer

Anaomal srutus ts

Muce fuco:

mpoa xos- Brhili Biep brhii

ss impotat o Brhiordili

Neua uco

Me

epe

et

Bc

Bcep cf

BcH

Mcte ()

Mcte

R

Commo patoloal stuaons

ee rt

CC6C5C6C56

Pi i he regio of he houlder ourwhe leio i pree i eiher he loghed or he hor hed of biep.

Weke i he reul of eiher C5 or C6ere roo leio

Resisted exension o e elow

Poston. The ube d wih he rlogide he body d he elbow be o righ

gle wih he forer i upiio Theeier d leel wih he ubje' forerOe hd i o op of he houlder, he oher ohe di pe of he forer

Pour. Rei he ubje' ep o exedhe elbow (ig 9)

Common msas

eo i lowed he houlder Movee llowed he ebow

Fg 1.9 Resste eteson of the eo

Aaomal sruurs tstd

Muce uco

Most mpot1Jt xtso Triep brhii

ss mportat tso: Aoeu.

Neua fuco:

Mce

epea

Tcep c R

Aces R

Ie

Common paoloal stuatos

ee r

C7-C8C7C8

i eliied i he houder regio i hereu of he hueru beig pulled upwrdgi he roil rh d pihig ifled ubroi ruure Thi hppei ubdeloid burii or edii o oe ofhe edo of he roor uff



28/144

P o eeso moe aey idicaesiceps edis

Weakess is say e est o a 7 eeoot palsy

SPECIFIC TESTS

assve orizona addcon

gnfan This tes stesses te acomioclaila ad steoclaca jois ad ligamets aso sqeezes te sbcoacoid bsa ad the

ppe pa o he isetio o te sbscaplaisedo to te lesse tubeosty o the hmes

PStonng The sbject sads with the amshagg aogide the body The eamie sadsee wi the sbjects am Oe had gasps theelbow at the distal pat o he ppe am Te othehad is placed a the back o te oe solde

Pro Take the am io abdctio is adhe bg t oiotally i ot o te body,

pessig e elbow towads te cotalatealolde ig 130

Fg. 130 ss hozo duto of he shouder

SOLE 17

Common mstaks Te sbects sode gidles ot wel stabilied so ha she may twist awayom the pesse

Appeension es n exernaroaion

gnfan The tes s peomed o detececet ateio dslocaio o the sholde.Te es is positie whe he paiet gets heeelig that te solde moes o o place soecogiig e sympoms

Postonng Te sbject lies spie wh te

am alogide the body ad the ebow leedto 90 Te eamie sits leel with the sbectssholde. Oe had is o te sbjects shodewith the iges aeioly ad the hmb posteioly agaist the hmeal head. The othe hadaes old o the oeam

Prou Bg te sbects am ito etea oaio, meawhe eetig a ateio pesse o he mes with the thmbig 131 Repeat ths tes i dieet degees o

abdctio

Appreension es in inernal roaion

gnfan Te test is peoed o deec ecet poseio dislocatio o he soldeThe est is positie whe e patiet gets heeelg ha the sholde moes ot o place soecogizig he symptoms.

PStonng Te sbjec sits o a chai te ami sigt abdctio ad te oeam behid theback The eamie sits leel with he sbjectshode Oe ad is o the sbject soldewit the hmb ateioly ad the gesposteioly agaist the hmea head. The othead gasps the oeam

Po Bg he sbjects am io sigtabdctio ad ft eal otatio ad eet

a poseio pesse o the hmes with hetmb ig 13



29/144

18 ATS OF OTOPC XAMINAON

11 pprhs s r rr r sl

. 2 pprs s r rurr ps s



30/144

Aneor rawer tes

ia his es is ea ee aerirhypeiliy i he glehuera i

Poson he sue es supe he uhwih he a ey he ege he exaiersas lee wih he shuler He sailies hesapla wh he raaera ha, he hu fwhh is plae he rai pess a hefigers he ari he a is ugh iau 20 f a a i sligh exi

F 1 T teror rwer tes

SOLE

he frea is seee ewee he exaiersr a he psilaeal a he ha f whihgasps he heus i he axila ig 33

Po he hera hea is firs rgh iis era psii i he gle fssa (ae')a he glie i he aeir irei.

Poserior rawer est

nfa hs es is ea ee psehypeiy i he gehueral ji



31/144

0 AA O ORODC AMNAON

g 134 he posterio dwe tes

Positoning. Te ubect lie upine on te cocwi e arm beyond e edge Te examiner

tand level wit te oulder e abie tecapula wt e cotralaeal and, te tumb ofwic placed on e coracoid proce and tefinger on te acromon Te am i brougt inoabo 20 of abducton and into gt flexione oream i queeed beween te examer'

runk and e pilaeral arm, te a of wicgrap te umeru in e axilla Fig 1.34)

Procedure Te mera ead i firt brug o neutra poition in e glenoid foa 'loadedand ten gded in te poterior direction andigly lateally.



32/144

CHAPTER CONTNTS

uace and papatory aatomy Anor

Bon nd pon o o

Bon nd pon o o

oor Bon nd pon o o 8T ub nn 8

Md 9Bon nd 9pon o o u 9

uctoa exmaton of he ebow 3

on non ponon

upnon

Io onon d on d non d ponon d upnon 5d non of w d fon of h w

Elbow

SURFACE AND PALPATORY

ANATOMY

ANTERIOR

Bony landmarks

hr ar no ra bony landarks rogniablat th antrior aspt of th bow Idntify thbital fossa Just bow it and deeply throughth ss of th antrior and ppr part of thorar, palpat latrally for th radial had (

and day for t oronoid pross o t ulna(2 (ig. 2 s bony parts an b idntifidor asily whn onsidring th latra anddial aspts of t lbow (s blow

Papation of soft issue

Palpation of the bceps muscle and the

neurovascula structures in the cubtal fossa

Kp th subt's bow slighty fld. Ask for

an ati flion and papat anwil in thbital ossa with a pinhing grip for thbiipital tndon (ig. 22 A as an outstandingtat stutur. It runs distaly to attah to th radiatubosity Mda to th tndon ts aponurosis( an b ft, and atra to th tndon th bllyo th brahioradiais usl (C rXially tbips broadns and its usotndinos junton D an b privd, and vn or proially its usl belly (ig 23 and ig 22 E)

Mdial to th biipital tndon, deep undrth aponurosis li th brahial arty and th



33/144

AS O OOD XAMIAO

ig. 1 Ane vew 0 he elw selet

F. Ane vew he elw vv

Fi. 3 alan f the es sle ey

di rv T rr i plg, te tter rd strd

apan f e racais musce

Ak bjc crc t bicep lce tb d gr te idt bsde e bicpil ted (e lr ddil bicipit grv d w k r ietrc ei dr te figer d bd bicp ted e ctrci tebrcili cl (F c be flt rg rei ts scl, it bely, wic r rrdisy te cle bely e bicep, cbe pped wi pcg grp e brciir t r tbrty

apa f e prar eres musce

e sbect ld i lbw i 0 fle d erer i e r psiti betwe prti d pti Ak e bject prte

te rr d ri t oveet ptewt e tr d i tic clr s



34/144

. 4 aaton o te onato tees se

ust dista t the cubital fssa (Fi 24 A rund

nd strn muscle can be felt runnin frmhe medial epicndyle t midradius. his is thernatr teres muscle (G).

LATERAL

Boy admaks (F 25)

he subject hlds his ebw n 0 f flexn andhe frearm supinated The ateral epicndye (Aan be palpated as the mst prminent bne

rm its anterir aspect riinates the extensrarpi radias brevis muscle The epicndylarrder cntinues prximally in the ateral suprandylar ride B evel wth it and frm thenterir surface f the humerus riinate therachiradiais and just belw it the extensrarpi radialis lnus musces

alpate distal t the epicndyle fr a depresin - the radihumeral jint ine (C ts prximampnent the ateral ede f the humeral capi

ulum 0 can be felt as a spherical structure.

ELBO

5 atea vew o te elbow (skeeto

The dista cmpnent - the head f the radius ()- is we perceivable when small rtaty mve

ments f the frearm are perfrmed The jintline becmes a bit wider and thus even betterpalpable when the elbw is bruht twardsmre extensin Feel fr the lwer brder fthe head f the radius and place the finer justdistally t it. It nw lies n the radial neck (F

Palpatio of soft issu

alpan f the brachradials muscle

(Fi 26The subject's elbw is held in 0 flexin and thefrearm in the neutra psitin between prnatin and supinatin Ask the subect t flex theelbw and resist the mvement. The cntractinf the brachiradialis muscle (A is wel palpableand visble and the structure can by palpatin inthe psterir drectin easily be fwed furtherprximaUy n its curse until its insertin atthe anterir aspect f the humerus level with the

atera supracndyar ride



35/144

4 ATAS O OTHOPEDIC EXAMINATION

i 6 Vew o te raoradas use

lpin f he ril exensrs he ws

(Fi 27

The muscles are nw relaxed Brin the subjectsfrearm nt supiai and ask him t d acmbined active memet f extensin andradial deviati f the wrist Just dista t therin the brachiradialis muscle (A betwee this muscle and the ateral epicndyle -the cntracti f the extensr carpi radiais

lnus 8 can be een By pressn the psterir directi ts riin can be palpated aainat the anterir aspect f the humerus (Fi 28

G mre distaly and papate nw the ateriraspect f the lateral epicndyle (E) A flat tedinus structue is recnized which is the riinf the extensr carp radialis brevs muscle(Fi 2 and Fi 2, C

Brn the subject elbw int mre extensin30-35 and int prnati Over the head f

the radius (F the teds wrist and finer extensrs (Fi 20 ad F 7, D can be palpated

aea vew of he elbow n vvo

8 aaon o the extensor ar raals onssle



36/144

9 Palpan f h n cap ada bv muc

.1

F0 alpatn h wt n

bl

ELBO 5

I



37/144

26 A TAS O OTOPEIC EXAMATIO

low and foea ae again ougt into 0fleion and supination. U a pining gip andstat palpaton leve wit te ne of te adius(ig 2.11) Ove a distane of 3 downwads

g 211 po o u b o o pd onu nd b

g. 1 Eno of h w 1, o of o pdl o 2 on of no p d b

do o o p d b;4.

by o op d b

te ellies of aoadialis (supefiia) andetensos api adialis longus and evis (deep)(Fig 212) an e fet, te atte espeally wente suet atively etends is wist

apaon o he exenso ai ulnas muse(Fig 213)

e eow and foea ae st eld in te saestatng position (0 fleion, supination) Plaete palpatng finge elow te latea epiondyle(A) As te suet to pefo ulna deviationof te wist ension an b felt in te tendonof te etenso api unais (ig. 2.14 andFig 213, A), wi uns towads te oleanon

lg.213 Vw o no n u

g24 h o p l u



38/144

alpaon o he supnaor muse F 2.15)

Plae the subets ebw n 313 extensnand n pnatn denty th adus m theada head dwnwads Identy the ulna mhe leann dwnwads. he spnat mseF. 26) s knwn t le n the ntspae bween adus and ulna between the elbw and

F 15 Papan f pna ml

i 16 h pa ml

ELBO 27

mdam Ask th subet t supna andesst ths attmpt Cntatn an b e.

POSTERORBony landmarks Fs 217 and 218)

hee bny pmnenes an be dented On anxtendd lbw tey e n ne ln aally sstuated the lateal pndyle A and mdallyth meda epndyle B) In bewen s tleann C) ss and pmnent. unlexn th elbw the leann mves dwnwads whh makes ts apx asly papabl Ina bent ebw the thee bnes m an sselestanl. Btwen the leann and te mdalepndyle les the sulus the ulna neve 0)

g.21 v f (k)



39/144

8 S O OHOPEDC EXMNON

Papation of soft tissueFigs 2.18 and 29

Over he oecraon es he olecrao bursa,which is oly really palpable when i becoes

inflaed and swoeKeep he subecs elbow flexed Palpae for he

upper border apex of he olecranon Fl uslaera o his apex for he isertion o he endo

8 sr w bw (n

F 1 9 apan f h s ndn

of he riceps uscle Move he figersupwards: a broad ad fla endon is el and edsn he sculoendnous uncio F, shaped asan invered U Fig 22

Disally ad sghly laera o he oecraohe ancoeus usce (G) ca be fe durig aaep o acively overeend he ebow

Palpaon o a fleed elbow bewee heolecrao ad he edia epicondye dscloseshe scs i whch he nar erve - a sof andrond srucure - can be fod is covered byhe poserior par o he unar collaeral gae The nerve courses nder he edia headof he riceps use, he behind he ediaepicondyle and he furher disally n bewee

he wo heads o he lexor carpi naris sclewhich or a aponeuroic arch

The cubita tunne

The cubial nnel Fig 221 s b fro heedial epicondyle, he oecranon, he ularcollaera gae and he aponeurotc arch.



40/144

F 0 T p mu: 1, lndnnn; 2 dy f h ndn npa n

F 1 ubal unn

J

ELBO

MEDIA

ony landmarks Fi 222

The medi epiondyle i reonized s very

promnen bone whih lie ju ubuneouly

Palpation of soft tissFi 223 nd 4

Keep he sbje ebow mos ompeelyexended d n ful upinion. Move he finerrom he med pe of he medil epiondyeA bou 115 m owd he nerior pePpe for ouh round ruure. Th i heommon endon of he flexor Fi 2.25 nd

Fi 223 B

. da vw lw (kn



41/144

3 ATLAS O OTHOPEDC EAMATIO

i 3 a vw h w n vv

05 r diay, ju w th infrirrdr f th picndy and with th wighty fxd a thck and rnd ucuar ai papa th ucutndinu juntin fthi xr grup (C cniting f, r dia

i 5 h cmmn r nn 1, na 2munnu

t ara th fxr carp Lnari, thp lm ri

ng, h fxr arpi radiai and th pron tetr

atra th cn fxr tndn th darv i papa a a ud u t ruur

i 4 apan f h cmmn ndn f f



42/144

UNCTONAL EXAMNATON OF THELBOW

ASSVE TESTSassive fexin

sitonng. h u and wih h ahd. h xain nd v wih u a H pla n hand aain ak h huld and ap h diaa wh h hand

ocedure Bin h hand wad huldy ailizin h a uni h vn

a p (Fi. 226).

mmon mistakes nadqua aiizain alw hud v akwad

mal fuctoal anatomy:R'ge au 16-ee n wll uld u a f p y

. 6 n

ELBO 3

iu appxiain h ul f ha in in na wih h ulf h upp a

n ply uld u a ah had

p f n nain wih n iitig tte:

- in wll uld u: h uulaa f h upp a and fain in na wih ah h

- in ply uld u ny nawn 1) h nid fa f hhuu and nid p f h ulnaand (2 h had f h adiu and adiafa f h huu

nin in h pi pa f h in

apu.

Commo pathoogica stuatios Painful liiain u in aii (a pa f

h apula yp f liiain whn a dy i pn in h ani pa fh in

Painl liiain i pn nunpiad ahi.

Passive extensin

Posoig h u and wih h ahd h xan and v wi hu lw On hand aiiz h wand h h and ap h dial fa

Pocee an v hand in ppi

din - dial and dwnwad and

pxial hand upwad Fi. 227) ndfl in h u lw

in lih flxn and v hand auplyu nly in ppi din wadxnin

Common mistakes lw i n n plupnain.



43/144

3 ATAS O OOEDIC EXAMAION

g Pav n

Nomal fcioa aaomy Rnge: geneay 0 in he male; in emale

be and in hypemobile peonoeexenon of a fe degees may beposibe

Er-fel: had op of bone engaging hbone

Limitiug srtres:- bony ona beeen he oeanon poes

and oeraon fosa enion in he aneio pa of he join

aple.

Commo ahological siaos A painfl limiaion ous in ahi of he

elbo jon and alo hen a looe body ipeen in he poeio pa o he jon

A painle limiaion i peen innompiaed ahois

Passve ponaon

Posiioig The bje and ih he amhanging and he elbo ben o a igh anglehe examine sand n on of he bje Bohhand enile he dia oeam in h a ayha he heel of he onalaeal hand i paed

again he ola pa of he na and he fingeof he ohe hand again he doal aspe of headi.

Pocede. Bing he be foeam ino fuponaion by a imlaneo moemen o bohhands in opposie dieion (Fig 228)

Commo msaes The bje sholde bogh ino

abdion Too mh loal pese on he adi/na

may pooke endene

omal fcioa aaomy

Ra: abo 85 Ed-eel: eai imiig srcfres: ehing o he

neoeo membane and qeezing of heneon of he bipial endon beeen headial beosiy and he na

Commo aological saios The moemeni painfl in leon of he poximal adiolnaoin in biipioadial bi and n endiniiof he bep bah a he ineion ono headia ubeoiy

g. 8 Pav pnan



44/144

ave upinaton

Positonng Th ubect tand with th armhanging and the bow bnt to a right anglThe examiner tand in front of the ubect. Bothhand encircl th dital forearm in uch a wayhat th heel of the ipiatera hand placed

againt th doral part of th lna and the fingrof the other hand againt th olar apct of theadi

Pocede. Bring the ubect fora into uupinaon by a imultaneou moement of both

hand in oppoite direction Fig 229)

Coon istaes. Too much local prure onhe radiu ulna may prooke tendern

Nora fncoa anatoy Rg abot 9 -ee elatic Uitg trctre

tenion in th introeou mmbran theobique cord and the antrior igament ofthe dital radioulnar oint

tenion i the extenor carpi unari tndonwhen th potrior apct o th nar

Fg. ass supnan

EBO 33

notch of the radi impact againt thetylid proce of the una

Coon paologcal stations. Th moemen

i pain when th proximal radiolnar oint iaffected

ISOMETRIC CONTRACTIONS

Reed flexion

Postioning. Th ubect tand with the armhanging th ebow flxd to a right angle andthe forearm upinatd The examinr tand lelwith the elbow One hand i on th dital part

of the forearm and th othr hand on top of theholder

Procedre Rit th bct' attmpt to lx thebw (Fg 23

Coon saes In trong ubect fxion cannot fficiently

be reited if the reitance i not ginprpndiclar to the bect' forearm.

Moement i alowed at th lbow Th bct perform hodr eleatio

Fg 30 ssd n



45/144

S O OHOEDIC EXMNON

Anatomial stutes tested

Muscle function:

Ipor exor Bchili

- Bicp bchii e ipor exor Bhidii

Ex cpi dii lgu- P

Neural functon

Msc Ivai

BacasBicps bachiiBacadiais

pa N

Musccuas C6Musccuas C6adia C6

Exs capi dias s adia C C7C C7a s Mdia

Common patologia situations Pi idct i ith th bip

bchii h bh uc Pil w u i th C

C6 t

Piful w i uggti fu f th di tuby

Reted exenion

Postioning. h ubjct td with th mgid th bdy, h bw fxd t 90 dh fm upi h xmi td with h bw. O hd uppt th ditl

pt f th fm d h h hd i tp th hud

Poede. Rit th ubjt ttmp xdh bw Fig 231)

Common mistakes: tg bt, fxi c

ufitly b d th itc it gi ppdiu h ubjt

fm Mmt wd t th lbw

g. 31 d xnon

Anatomia sttues tested

Muscle function

Mos ipor exeor:- cp bh

e por1 exe1or:

- Au

Neua unctn

Musc

Tcps baccs

pa

adiaadia

Iva

Common patologia sitations:

N

C7-C8

C78

h tt i piful wh li f t tipi pt.

W cu li ih h dil h C7 t.

Piul w my idict ptil rupf th icp u f th lc

Reited pronaton

Positionng. h ubjt d wh h m

lgd th bdy, h lbw bt ighg d h fm i l piti h



46/144

amr sads i ro o h subj hpsara had arris h orarm h hargais h palmar ad disa asp o h radiusd h igrs agais h dorsal asp o h

la. h ohr had riors: har o uad igrs o radius

oede. Rsis h subs amp o proah orarm Fig 22

ommo mitakeh subj adus h shouldroo mh oa prssur o h radius/ulama proo drssMom is allod a h bo

atomial tte teted

Musce fucti

Proaor rsProaor quadraus

Neura functn

sc

a sa qadas

pa

MdiaMdia

g 2.32 Ressted pronao

Iai

N

I7CT1

ELBOW 35

Commo pathologal itato Pai ors golrs bo a so o h ommo lordo or a soad sio o h proaorrs musl

Resisted supnatn

Poitoig h subj sads ih h armaogsid h ody h bo b o 90 ad horarm ra poso h amir sads ro o h suj h ipsaral had arrish orarm h har agains h disa ad palmarasp o h ua. h har o h ohr had isplad agais h dorsal asp o h radius

Poedue Ris h subs amp o spah orarm (Fg 2)

Commo mitake h sub ds h lbo Mom is allod a h bo oo muh loa prsur o h radu/ ua

ma prook drss

Aatomial ttue teted:

Musce functin Ms ipa p Supaor Bps brahi

Fg 233 Ressed supao



47/144

ATAS O OTHOPEDIC EXAIATION

Lss importaNt sup;alor:- Brachiradialis

Neua uio

Musle Inneaion

Peripheral Nere oo

SunatoBes bacBraoradials

RadaMuslouaeosRada

C5CSC8

Commo pahologcal siaios Pain is th rsutof a sin f h bicps or, mo ay a lsin fth supinatr muscl

Resisted extension of he wrisPosioig Th subct stands with th amhanging th lbw xtndd and h wrist nnura positin btwn pronain and supnaton and btwn flxion and xnsin Thxamin stands l wih h subt's lbowTh nraatral am lifts and carris h lbowand ps it xndd. h hand stabis thforarm Th h hand is pacd a th drsumof h sub's hand

Pocere. Rsis th subcts attmp t xndh wrist ig. 234

F. 234 Ressted exenso of the ws

Commo misakes Th sub s allwd t lift am up h bow is allwd t flx This can b

prnd by th xaminrs arm png thsub's lbw w raid

h wst s n hld i nura psin wchpus srss n nnnrac suurs

Aaomical srces ese

Muse futio

Ipora1t wrist extenorsExtnsr digitum cmmnisExtnsr carp radialis longus

Extnsr arp radiais bis- Extnso carp unaris

Le portt wrist extenor Extnsr indis prprius- Extns plliis ngus- Extns digii minimi

Neura utio

usle nervaion

Exensor digioum ommusExensor ap radais longusExen arp radais bevisExensor arpi unaisExen ds oisExensor Us losExensor di minm

Peperal

Rada

AadialRadiaAadialRadalRadalRadal

Commo pahologica siaos

erve oo

C&C8C&C7C7C7C8C&C8C8CC8

Whn lbw pai is id, tns lbow - alsin in th radia xnsrs f th wris ss pbabl Ohr pssbs a a sinf th xnsr arp ulnas r f h xnsrdigitum

Wanss may rsu fm a adia nrlsin fm ithr h C r C8 nr rBilara wanss suggss ith ladpsng, r brnchus arinma a mrgnra nurlgial disas.

Resisted fexion of he ws

Posioig. Th subct sands wih th amhanging h lbw xtndd and h wis n



48/144

ura posio (w proao ad supaio ad w io ad so hamr sads v wih h sucs ow

h coraara arm lifs ad carris h ow

d kps i dd h had sailzs horarm h ohr had is pacd a h pam ofh sucs had.

roee Rss h su's amp o l hwris (ig 23

Commo make h suc s aowd o push h arm dow

F 235 Reed fleon of he w

BOW 37

I his happs i is h rs o aduaiao

h wris s o hld ra posio whhps sss o ocorc srucurs

Anaoma rue eed

Muscle funtion:

/po wit xo- or digorum suprficiais- For oru proudus lor carpi ularis- lor carpi radialis

mott i o: Aducor pollicis ogus

- Palmars ogus.

Nral funon:

Muscle Inneation

Fexo dgom specasFexo dgom pofndsFexo cap nasFexo ca adasAbdco pocs ons

Pamas ons

Pephera Nee oo

Medan C7-T1Medan C7-TUna C7-C8Medan C7-T1Rada C7-C8Medan C7-T

Commo paooga iao Pai a h ow occurs gor's ow a

so i h commo or do Wakss suggss a C7 or C rv roo

so



49/144

HAPER ONTENTS

n pp ny 3Radal 3

Bony andmak 3Palation of o t 4

oa 4Bony landmar 4

Palaton of ot t 42Ulna 43Bony landar 43Palation o ot t 43

Pama Bony landar h aa nn 4h tnnl of Guyon Palpaton of oft tu 46

nn n Pav t o dtal adionar ont 4

Pav ponaon 48Paiv pnation 4

Pav t o t r on 4Pav fon Pav non Pav adal dvaon 5Pav unar dvao 5

Paiv fo h tapzum- maaaljont 5

Bckad movmn drn ton 5Ioc contacon 2

Mcl conrolln h rt 2Mucl nrolln th tumb Mucl conrolln h fin 7ntnc uc of h and

Siic t 6

Phan' t 6n tt Gnd tt fo h tzuf macaal

oin 62Fnktn 62

Wrist

SURFACE AND PALPATORY

ANATOMY

RADIAL

Bony landmaks g 3 3 ad 33)

the dtal ed f the radu the tyd prce) ca be palpaed. lghly re prxally the radu a all grve ca be fud.Jut dtally t the tyld prce the caphdavcular) be ( papabe. t ca be ade

re pre by ag he ubjec t executeular deva f the wrt. Whe the palpatgger he avcular be e a depre bewee w ed, caed he 'aatal uffbx' t the da ed f the uffbxthe jt e ca be palpated betwee thecaphd be ad the trapezu epecally

Fg. 3 Rada v of t t (to

3



50/144

ATLAS O ORHOPEI EMNION

3 ony landaks at te radal side o he st nvvo)

F 33 oy strutes at the ada sde the st

whe the ubect ve the thub 7 e dty ther jt e plpble - thee betwee the trpezu be d the frtetcrpl be h t le well plpbledurg veet f the frt etcrpl befee f the hft f the ft etcrp bewth e fger d ve prxlly twrdthe be f the be C he jt le c befet ut prxlly t the pxl bder f the

be, epecly whle the ther hd ve theft etcrp t d fr

Palpation of soft tissue

Pce the plptg fger jut dty t thetyld pce d feel fr the tghteg f therd cter lget dug ur devt

It ttche t the cphd be (Fg 3Mve the fger lghty twrd the plpect k the ubect t exted the thub(Fg. 35) w trg ted c be ecgzed(Fg. 36) frt the exter pllc brev ()whch ee t ru twrd the be f theprxl phlx t fr the rd brde fthe 'tc uffbx' Next t t the bduct

. 3. he ada olateal liaent

F 35 e o the etensos ad aduto o th thub



51/144

. 36 ends a e ada aspec e wrs

olls logs () s elt, sertg at the base h rs aarpa oe

DORSAL

Bony andmars (Fgs 3 ad 38

adus ad ula ar asl palpabe The stodroess o th rads dsds a bt urthrsta ha he stod proess o he ula.The dsta radoular jot a b rogzd

graspg the dstal ed o he radus wthe had ad the dstal ed o the ula wth thther, ad ovg both hads opposterosThe dstal border o th radus s sharp ad

a be el as beg he proa bordr o th

3 rs vew he ws (seen)

WRIST 4

. 3.8 Bn adas a he dsa sde he ws (n.

radoarpa jot, whh has a wde o e.Oe grwdth or proa, o th dorsaaspt o th radus, a odular bo a b lThs s he dorsal tuerl (A) o th radswhh ors a portat adark. A hular sd th thk had o h ula s palpatd

The arpa bos oss o wo rows I thproxal row th saphod, luat, trquetraad psor bos

Dsta o th eror order o the radus, twooes a be papatd. Th ost radal o s harad deeed saphod bo It s el orelarl durg ular devato o he wrs Theost ular bo s th uate boe () whhs palpale o a leed wrst ar to th uaad arulag wth he ua les he trqutralbo. It s to ov whe the had s agabrought o rada dvato

The dsa row oas h trapzu, rapezod, aptate ad haate boes.

Dsa ad a bt or rada to the saphodles th trapezu w h uate ad hebase o the hrd aarpal o a dprsso(C) s el whh he aptat bo s palpabTh apae arulates wth the base o thhrd etaarpal bo (D). Th bo btwe thapae ad the rapzu s th trapod bo,whh s or dul o papae

To the ular sd o the apat ad sowhator dstal ad rada tha the trqutral, th

haat oe s elt artulas a wththe ourth etaarpal bo



52/144

42 ATAS OF ORTOPIC AMINATON

Palpation o sot tissue

Place oe ger jus radall o he dorsal uberceo he radus (A (Fg. 39 Ask e subjec oae a rs ad o squeeze ad usueeze

Durg hs aco edous gheg ca bee These are he edos o he exesor carpradas logus ad exesor carp radals brevs(Fg. 30 We he subjec coues hese uscular coracos he edos ca be ollowedapproxae c ore dsal, u he powere e separae B) The os rada edo

F 39 Vew te exesrs te wst ( vv

Fig. 310 he extens c ds nus () nd revs2

(logus (C) s e o ser a e rada aspeco he base o he secod eacarpa boe ade ore ular edo brevs D sers a herada aspec o he base o e rd eacarpa

boe Fg 3.Pace oe ger jus ular o he dorsauberce o e radus. Ask he subjec o exede hub Feel or e exesor pollcs logus(Fg 3 A edo, whch s he uar bordero e aaocal subox I ca be palpaedul s sero oo he dsa palax o he

F 311 Pt the extens crp dls ns

i312 Vew te extesr ps s vv



53/144

Vew e exess he es (i vv)

humb: he endon tus 45 arond the dorsalbecle of the radiu croe over he extensoarpi adiali ongus and bevis and goesowards he humb

Papate he doal apec of the wri whilehe ubject exends the ingers Movement can beelt o the endon of he extenor digorum com

mns an o the extenso indicis propiu. Whenne finger i extended at a ime the diffeenndons can be palpated one by one

Plce one inge ut adiay to the head of thena Ak he ubject to extend the ittle nger andee or he extenso digiti minimi Thi tendonvere he dia aionar join

Plce one inge a the infeio and ulnaroer o the head of the ulna ig 34 A) Askh ubec to perorm an ulnar deviation ungxenion. The stong and hick endon o he

1 View the extens cap unas (i vv)

WRS

F he extens cai ars

Fi 16 Papatin e extensr carp nais

extensor carpi nari B) i fet igs 35 and3 It can be ollowed to i inerion a the baseo he ifh metacapal bone

ULNAR

Bony landmaks ig 37

A the dital end o the una the ma tyoid pocess A is palpabe Ju dita o i the riquera bone 8 becomes prominent when the ubjectmove the hand in radial deviaton When thepapating inge move even more distally andthe hand is brought back to the neral positionthe bae o the fith meacapal bone C) encountered

Palpation o sot tissue

Pace the finger jus dista to he tyloid processand move the subjecS hand in radia deviation



54/144

ALA O ORTHOPEDC EXAMNAON

A C

g. 3.7 Bo amarks at te a se o the wst (vvo)

Tghg c b fl of h ulr cor

PALMAR

Bony landmars Fg 3 d 3.0)

Rdu d ul c b dfd A h dd ul d of h ul bo pomcc b fl: h pform bo A. Pu h rphgl o of h humb oo h pformd drc h humb owd h b of hdx fgr of h ubc lx h humb dfl p ouch h hook of hm hrough hmucl of h hpohr.

gm Fg 3 whch go owrd h Arurl bo Ak h ubc o mo hhd owrd h ul d d o xdh wr Ugh Aog h dl p of hul h do of h xor crp ur plpbl

g. 38 he la olatea amet

g39 o admaks at te almar se o the wst( vvo

Fg. 32 almar view o te wist (skeeto



55/144

t he dia end of he radiu the promnentberle of apoid 8 i well palpable Pute interpaangea on of he hmb onto heapoid' uberle and diret te thumb towarde bae of te thumb lex he thumb and feel iip ou he trapezim bone. Laterall and ditalo it lie e bae of he firt metaarpa (C)

When te finger moe from he aphod ine dreon of he index finger the bae of heeond meaarpal bone an be palpated troughe mle of the thenar

e capa tunne (ig 3 3 and 33

Te arpal tnne e beween on the nar ide

te piform bone () and te ook of tehamae bone 8 and on he radial de - theubere of he aphoid bone C) and he rapeim bone (0)

I an be loalized on the heel of he and andomewhat oward te unar de It i oered

b the tranere ligamen.he ontent of e arpa tunnel i:

te median nere e flexor poll i longu he flexor arpi radiali he flexor digitorm uperfiai and

profund

g. 321 bundae f he aal une n vv)

WRIS 45

F 322 Vew e caa nel (ecme)

1-

2

g 323 he bundae f e aalune ri ha

ama vew cahd; 2, aeum 3, sfm hamae



56/144

ATLA O ORTHOPDC XAMNATION

F 324 The la ee asses thr he nel Gyn

he tunnel o Guyon ig 324)

pe fo he inespce beeen he pisifomnd he oo o me his is uons unne conins he un neve nd n end is coveed b he psohme ligmen

Palpation o sot tissueigs 325 nd 326)

eel fo e pisifom bone nd plce he p

ping finge gins is poxim spec Ashe subjec o cvel bduc he lile finge heighening of he flexo cpi ulnis A cn befe igs 327 nd 328) he endon cn no befooed disl o he pisifom unil is inseonon he bse of he fifh mecpl bone. hepisfom is sesmod bone in he endon of heflexo cpi ulnis.

ce he humb dil o he pevious endon he disl p of he foem I no ies on heendons of e fexo digioum speficilis B)

g 325 View te lexs o wst and nes vv.

0

g 32 Radial vew o the wrist vvo)

F. 327 he leor ai ars



57/144

g 328 aaon o he exor ai uars

o whh the moemet e elt dig tveleo d eteio o the iger ig. 9

I deepr lyer he preee o he leodigitorm pod e imged

Move the iger i more towrd the rdide d k the jet to oppoe he thmd litle ige d o imeoly le the

wri he th tedo o he plmi log C

g 329 aatio o e exo ioum seas

WRT 47

eome pomiet t iert o he plmpoeoi o the hd t h o e rememeed tht th mle iott

Appomely m diy to the pmri

log he rog d hik tedo o the leorrpi di (0) i ppe ig. 0) epeiywhe he et lee d dilly detehe wit It er he e o the eodmetpl oe ig 1

Fg 33 The exo a raiais

ig 331 aaton o te lexor ai aialis



58/144

ALA O OHOEDIC EXAMINAION

In bwn h plmris longus nd h florrpi rdilis in dpr lr th tndon o thflor pollis longus n b fl o mo duringion d tnsion momns of th humbigs 2 nd )

Fg 332 e feor ollcis ons ee o the fismeaara; 2 eve of the arus

Fg. 3.33 Paaton o the feo os ons (a the ws)

Btwn th flor rp rdlis nd thbdutor poliis ongus th pulstions of hrdil rtr ) n b

FUNCIONAL EXAMINATION OF THEWRIST

Introductio/geeral remarks

Emnon of h wris shoud inlud ll struturs tht n b rsponsbl for pin ft in hrgion lld 'wrist b th pit

This ompriss th dis rdioulnr join hwris join h rpzium-firs mrpl join

d lso th tndons th ontro h wris, humbd fingrs d th inrins muss o h hnd

PASSIVE TESTS OF THE DISTALRADIOULNAR JOINT

Passive ponation

Poonng Th subt stnds with h rmhgng nd th lbow bn to 90 Th minrsnds i front of h subjt Both hnds nirh dis pr of th forrm n suh w hh h of h otrlrl hnd is pd on hplmr sp of h un nd h ingrs o hohr hnd li t th dors sp o h rdus

Podu Brng h subjs orrm ino fupronton b smunous tion of boh hndsin opposit dirions ig 4)

Common mak:

Th subt is owd o bdut h shoudr Too muh prssur on h rdius or ul m

proo o ndrnss

Nomal unonal anaomy:

Rg bout 5 E-: lsti itig stcs imption of th rdius

ginst th uln ogthr with srhing oth inrossous mmbrn

Common pahooga uaon Pn full



59/144

g 3.34 ave onaton

rge suggests trts or rtross of te dstlrdoulr jot

Passive supination

oiioning e subjet stds wt te rmgg d te elbow bet to 0 e exmestds rot of te subjet ot ds erlee dstl prt of te orerm su wy tte eel of te psterl d s ped o te

dors spet o te ul d te ges o teoter d t te pmr spet of te rdus

Podu rg te subjets forerm to fusupto by smuteous moemet of botds opposte dretos Fg 33

Common m oo u pessue o dusor u my pooe loal tedeess

om unon nom

Rg: bout 0 Ed-fel: elst Liing scs:

- teso te terosseous membe te

obue od d te teo lgmet ofte dstl rdoulr jot

WRT 49

g 3.3 Pave uiao

teso te extesor rp us tedowe te posteror spet of te urot of te rdus mpts gst testyod poess o te ul

Common pthoog iuon:

P t fu ge ous rtts orrtross o te dst rdour jot dso tedts of te extesor rp ulrsleel wt te dst ed of te u

Lmtto dtes muted Colles'frture

PAIVE E O HE WRI

JOINRemark

e wst ot s proxm prt - te rdorp ot - d dstl oe - te terrpjot e tests desbed ts pter testte wrst jot s wole d do ot test tsstruures seprtely

A moemets re exeuted wt te wrsted te eutrl posto:

lfwy betwee flexo d exteso lfwy beee rdl d ulr deto.



60/144

50 ATLA OF ORTHOPDIC XAMIATION

The oiionng fo ive e of he woin i he me.

Poiioning fo ing h mobiity o th wt

The uje nd wih he m hnging he

eow fleed o igh ngle nd he foemoned The emine nd ne o he uec The onle hnd ie he ue'foem whih i ke eween he eminem nd unk The ohe hnd g heuje' hnd dily on he mel

Passive flexon

Podu Bng he uje' wi ino mimlfleion Fig 6)

Common mitak None

oma unional anaomy Rag: 85 l-f li Lng scs: ehing of he do

gmen of he u, of he inelgmen nd he ule of he dffeeninel oin

Common pahoogia uaion in he dol e ou in a leion of

he do gmen o he eeno endonof he wi

in he m e my ou ineioii, moly of he hod one

F . assve fex f the wst

inful imiion my ndie hiiinle miion hoi.

Passive extenson

Podu Bing he ue' w ino mmeenion Fg .7)

Common miak None

oma funtona anaomy Rang 8 l-f: he hd g scts

- ehing of he lm ligmen of he

u nd of he ne igmen ndue- on of he oim ow of l one

gn he diu

Common pathoogia ituaion

Pin full nge nd fe he do emy ugge eioii of he dieihy of he du o dol gnglionm in my e ovoked in leion ofhe m igmen of he wi o of one ofhe feo endon

nfu miion i een in hii, luluon uully of he ie onend ei neoi uully of he neone

nle imiion i yil fo hoi

Fg. 7 assve extes he wst



61/144

Fg. ave adia deviat f te wt

Passive adal deviation

Podu Push h sbjes ws o he dide il h ed of g is hed (g 338)

oon ita Noe

oal untona anatoy

Rge: bo 15 -f/ he hd

Ltg sructL sehg of he ulollel gm d of he eeso pils

oon pahoogia uaion

i h ul side is yp fo lsio ofh ul oll gm o h eesopi ulis.

Pi h di sid my be povoked i deQuevs dses s h sul o gidg ohe edos of bdo pollis logus dso pois bvis h ifmdsheh.

Passive una deviaton

odu Pll he sbjes wis o h ulde il h d of ge is ehed (ig 339)

oon a he humb is uded i hmovem should b lef f o vod s

ive shig of he dos o he eesosd log bduo

Fg. .9 Pave ua deva f he w

Noal untiona anaoy Rag bo 5 E-f he hd

W 5

fgm di o gm

oon pahologial tuaion

P h di sde fll ge is pesei spi o he dil oe gme os h es of gdg of dos i ifmd shh i ovgiis of bduo

poiis logs d eeso pollis bevis(d Quevis disese)

P h sd b liid by lesio of he igu fboilgousomp

PAVE E O EAPEZIUM-I MEACAPALJON

Bacwads movement dungextenson

Potoning Th subje sds wih he mhgig d h ebow be o 9 d supio he m es h sub O hdgsps he hd d sbzes

Podu h ohe hd movs h humb iosio fis d h bkwds ig 3

oon ita he humb is hypeeeddi he mpophge oi so h mos



62/144

52 AA O ORTOPDIC XAMNATION

F. 0 assve vee the hb

stress s on tis oint nd not on te trpeziuirst etrp one

Noma unciona anatomy:

Rlg: until te oveent stops E-f lsti L/g scs streting o te

nterolterl prt o te oint psue o tetrpeziu-irst etrpl oint

Common athoogica ituaion

Pin indites rtritis or rtrosisrzrtrosis genery o te oint betweente trpeziu nd te irst etrpl bonesMore exeptiony it is te oint betweentrpeziu nd spoid bones

Exessive rnge o otion ours terrupture o te ulnr spet o teetrpopngel oint psule

OMERC CONRACION

Muscles controlng the wrist

Remarks

s ost uses tke teir origin t t elbownd overrun it te subets ebow sould wysbe ed n extenson to put xi stress ontese strutures

ll oveents re exeuted wit te wristeld in te neutr postion:

lwy between lexion nd extenson lwy betwen rd nd ulnr devition

Te positioning s te se or te our tests

Poioning o eing e eied movement

o te i Te subet stnds wit te rnging te elbow extended nd te orerin neutr position Te exiner stnds levewit te subets ebow Te ontrlterl rlits nd rries te ebow nd kps it extendede nd stbilizes te orer Te oter ndgrsps te subets nd disty on te etrps to pply resistne

Ressted exon

ocedue Resist te subets ttept to lex tewrist Fig 34

Common miake:

Te subet is llowed to pus te r down ts ppens t is te resut o indeuteixtion

e ebow s not ed in extension

Anaomical tuctue eed:

Muscle funco:

Ipon wi xo Flexor digitoru superilis

F. . essed lexn he ws



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Feo digitorum proundusFeo arpi unarisFeo arpi radialis

Less i1lportat wrst fexors:

dutor poliis ongus Pamaris ongus

Neural (uti

Muscle Inneation

Peiphera Neve rt

eo dgiom supeas edan C7-T

exo digiom pofundus edian C7-T1

exo car unas Una C78

exo cari adas edian C7-T

duo iis ongs Rada C78

amais ongs edian C7T

Commo polog iuio

Pain at the wrist ours in tendinitis o theleo arpi radialis eor arpi unais andeo digitorum profundusWeakness is found n C7 and C8 neve rootesions

Ressted eteso

odu esist the sujets attempt to etendhe wrst Fig 342.

g .2 esised exensi te wist

WRT 3

Commo mik

The subjet is allowed to push the armupwards If this happens it is the resut ofnadequate fiaton

The elbow is not held in etenson.

Aomil uu d

Musle (u

ImportHt wrst etensorstensor digitoum ommunstensor arp radialis longustensor arp radialis bevistensor arp ulnas

ess mpotut wrst etesors

tenor indiis propustensor poiis longustensor digiti minm

Neual futi

Musce Innevaon

Extenso digitom commnis

Extenso capi adias ongs

Extenso capi adias beVS

Extenso capi unas

Extenso ndicis ois

Extenso pocis ongus

Extenso digiti mnim

eipea

Rada

Rada

Rada

Rada

Rada

Rada

Rada

Commo polog uo

ee t

CHB

CH7

C7

C7C8

CHB

C7C8

CHB

Pain at the wist is indiatve of tendinitiso etenso arpi adialis longus and/orrevis etenso api ulnaris etensondiis popius or etensor digitoumommunis

niatea weaness is aused eithe by anerve root lesion espeially C and C8 or ya eson of the radia nerve

Bilatera weakness suggests eithe leadpoisoning o bonhus arinoma o a moregenera neurologal disease

Vaao: ressted eteso of the wst wth thefges held actvey feed

Sigii Ths test an e used to differenateetween wrist etensos and inge etensors



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4 AA O OROPDC XAMINAO

Acv conrcion o ingr lxor inib ingr xnor Abnc o pin indic wn on i prn i in on o ngr xnor

Poioning ubjc i nding nd old xndd r orwrd H quz bningr ino p o i nd xinrnd vl wi ubjc r nd biz orr wi on nd or nd ipcd dor o ubjc' ndg. 33

Podu R ubjc p o xnd wr

Common ma: n r i id up bow i no d n xnon

Ressted radial devat

Pod Ri ubc' p o ov nd rdly (ig 3

Common miak: ub i no l r ru o wic

i ub xnor nd bducorbco dircy involvd

lbow no p xndd

. 3.3 Ressted exeso o te wst w eexed

3. essted ada deato o te wst

Anaomia uu d

Mucle unction

xnor crpi rdili long Abdcor pollici ongu Exnor pollici longu xor crpi rd lxor pollic longu Brachoradas

Neurl unction

se o

Extnso cpi dis ogs

Aduo poicis ongus

Exnso poiis ongus

exo pi diis

exo oIcs ogs

hiodiis

Peiphe

d

di

d

di

d

di

Common ahoogial iao:

ee ot

n i o coony prn n ndino r xnor crp rdi ongund /or brvi or lxor crp rdli

y o b pnul in d Qurvn'novgni - on o bducorpollici longu nd xnor poici brv inr coon ndon

Resisted ular deati

Pod bjc p o p nd ovr o ulnr id ig. 3



65/144

Fl35 ss la dai rs

Common mk bw t xtdd

Anom uu d

Mscle cio

Iotat l1 vats: Extr crp ur Flxr crp ulr

ss tat na vats: Extr dtrum cmmu Extr dt mm.

e fco

Ms

xtsor c as api narsxtsr dtm mmsxtsr dti mm

Pa

adaaadaada

Common polog uon

vat

v roo

C7C

C78

C&8

C&8

P t rult f tdt t f txtr crp ulr r f t flxr crpul.

Wk dct uuy CB rv rt

Muscles controling te tumb

Rmaks

pt f t ubjct t m f tur tt. S t pt f t mr

RIST 55

ox 3. Diis

Aci mb ms m a pama pssally ji pla f macarpas

Aci T mb ms a plmar dicaay rm pa f macaas

xsi A camacapal macappalaal a irpalaal jis r is amm raial rc y

xi

a pla para pla f macaas

A capmacaa, macappalaal a irpalaal js r s amm i ar irci rly ia pa parall pa0 rmcarpas

xcpt tt fr fx d xt Bx 3f dt) tc v t t dtlp d f bduct d dduct t tdt prt d f t frt mtcrp b

Poonng ubjct td wt t rm, t lbw bt t rt l tfm d d t utr pt d

t tumb pt upwrd. mr fct ubjct ctrtrl d cr tubjct wt tr d t tumb

Rsstd xon

Podu Rt t ubjct ttmpt t fx ttumb F 36

F 36 Rsis fl m



66/144

56 ALAS O OHOEDC EXAMNAON

Common mtak thumb allwd thypxtnd at th mtacapphaanal nt

Aatomica tuctu ttd

Mu unon

Imprtt thmb frs:- Fx pllc nu- Fx pllc v

s mprt hmb f Adduct p

Nura unon

Muscle Inevation

Fexor pocs ongsFe)or pocs bevs

supefca headeep ea

Aduco pocs

Pephera

Medan

MedanUnaUna

Common patoogical ituation

Nee roo

S

lBS

Pan nt n a tnynvt f th lx lnu

Wa utv f a ln a ancf t mdan nv - th ant

ntu nv - and m ay f tulna nv

Rssd xs

Pocdu Rt th ct' attmt t xtndt thumb F 47)

g 37 esste eeso o the thm

Common mitak Hypxtnn f th ftmtacaphalanal nt tak pac

Aatomical tuctu ttd

Mu unon

xtn pc lnu Extn pc v Abduct pc; nu

Nura unon

Msce Inevaon

Exenso pocs osExensor pocs es

bdcor pocs os

erphea

RadaRada

Rada

Common patoogica ituaton:

Nee oo

S

Pan ccu n tndnu n thabdct c nu and xtn cbv d Quvan da) and xtnpc n cptatn tnynvt)

Wan pby th ult f a uptu fth xtn pll lnu t may andcat a ncal cndtn t f th

ada nv f t 8 v t

Rssd bduc

Pocdu Rt t ct attmpt t abductth thumb F 48)

g 38 esste ato of the thm



67/144

ommon miae Ric i gin on il pnx.

naomical uctue eted

Mue funon

Abdco poici longAbdco poici bixnor polli bri(Flxor pollici bri)

Neura unon

sce Ievt

bt cS s

bct cs esxtes cs esex cs es, ee e

Pee

Me

ommon pahoogical iuaton

Nee t

6B)

Pn i o do o o bdco poici log nd xno pollicbi g d Qri' di ocping oynoiiWk occ n nr on g

porio oo nr or din n

aco

ocedue R bjc' p o ddc b (Fg 349

ommon mitake Ric gin il px

. .9 ssd addto o t

Anatomical tucue eed:

Mue unon

Impott thm ddcto Addcor pollici

pott thm ddto

RST 5

- Fxo pollici bri prficil d- Opponn poici

Neua funtion

Msce Iet

Act csex cs bes

sec e

Oes cs

Pee

Me

Me

Common pahoogca iuaon

eve r

Pin occr n on of ddcopollici lly i obliq porion

W occ i lio o i nn or C8 nr roo

Muscles contolling te inges

xo of ach fgr paraloiionng and pocedue T bjc prni d p downwd xi biliz wi wi o d W o ppli ric o di plx o cfing rpciy Fig 30

Fg. .50 Rsstd eenson of one ne



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LS O OROEDIC EMION

ommon mtak e

Aaoma uu d

Msce fncon

Exei f e idex figer Exer idii prpr Tedo o e dex fger f e exeor

digiorm omm me Exeio of e mdde figer

- Tedo e middle fger of e exeordigiorm ommi me

Exeio of e rig figer- Ted o e rig figer f e exeor

digiorm ommi me Exei f e ie figer

- Exer igiti ni Tedo o e e figer of e exeor

digorm omm mce

Nea fncton

M nnan

Prphra Nr r

ns ds ppsns m mmsns mnm

RaaRaaRaa

ommo athooga uato

C&8C&8C&8

Pa ediiti f e exerid prpri r f e f e ed fe exeor digirm omm

Weake ma or i a leio f e radiaerve

Resisted exn f ech nge septey

Potong ad odu Te be presei ad palm dowward. Te examier abiize e wri w oe ad. Wi e oerad e applie reiae o e dial paaxof ea figer repeivel ig 3

ommon mak Noe

Anaoma utu ttd

Msce fncton:

lexor digiorm perfiali lexor digorm profd

Fg 3.51 R x n

Nera fnction

Msc Ira

l dgm scas digrm pds

pha

MdanMan

ommon aologa uaon

N

7-7

We reed moveme of oe peififiger i paif, e e io, if pree,m lie i e edo goig o afiger

Pai i all e rel of a leio of oe ofe edo of e fexor dgiorm profdeier a e wri or more dia

Intinsic musces of the and

RemkWe ris mscle f e ad are affeted,i i all a leio i e dora ierei. Teemle mai abd e figer awa frm emiddle fger ig. 35 ef)

Tere are for doral eroei ad ree palmar oe e laer add e figer owarde middle figer ig. 352, rig).

Tee mle a be eed b preadig efiger agai reiae followed b qeeig

e examier figer Te ombaio of poive awer idiae wi me affeed.



69/144

- f

I

\H!I

I

f 1/g 352 () Aduo, o oa neoe )to, t paa noe

he postonng s the same for a s testsWhen spreadng the examner appes resstane

t the dstal phalanges Durng squeeng thexamne plaes hs fnger beween he promalnerphalangea jonts

here are no ommon mstakes

Speading 1-11

odu Resst he subjet's atempt to speadhe nde and mddle fngers Fg 353)

Anaomal uu d

Muscle uncon:

Inteosseus dorsals IInerosseus dorsals m

Spreadng I-I

odu Resst the subet's attemp to spreadhe mddle and rng fngers Fg. 3.5

Anaomia uu d

Muscle funcon

Interosseus dorsals 11 Interosseus dorsals lV

WRST 5

g. 353 Rt eaao o he ners IIIII

g.3.54 Rt paao o g lIV.



70/144

60 AAS O ORHOEDIC EAMINAON

Fg.55 ee eparao o te fie: V-V

Sredng VV

Podu Rit t ubjt attmpt to pradt ring and littl fingr ig. 355).

Anoi uu d:

Muse utio ntrou pamari IV Abdutor digiti minimi.

Squeezing 111

Podu Rit t ubct attmpt to uzyour fingr bwn indx and middl fingrig. 3.56.

Fg. 56 Squee he e: I-II

Fg .57 Sqeez e e: -IV

Anoil uu d:

Mue uo:

ntrou palmari II Introu dorai II

Squeezing II-IV

Podu Rit t ubjt' attmpt to uyour fingr btwn middl nd rng fingrig 357

Aoi uu d:

Musle uto:

Introu dora II Introu pamar IV

Squeeng IVV

Podu Rit t ubjt' attmpt to uzyour fngr bwn ring and itt fingr ig 3.58)

l 5 Squee te e: VV



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Anaomal uu d:

Musce fucti

Itereu dra IV Itereu palmar V

Neura cti

sce

Da neePama eeAbdct dgit ini

Peea

aaa

nevi

Neve

CTCC

Common pahoogia uaion:

Pa uuall the reut a le e the dral tere The mbat ptve tet hw whh e aeted

Weae ma be e the rt g atrp atera er r vlvemet the T1 erve rt It ma adate a le the ular erve

SPECIFIC TESTS

Phalen's test= forced flexion of thewist g 3

Signiian h a mpre tet r themeda eve the arpa tuel Releae

F. 39 hles tes

WRIST

the preure aue praethe the terrtr the meda erve - 3 ger medal adpamar.

Poiioning he ubjet preet the hadhe eamer grap the dta rearm wth thetraater had Wth the ther had he taehld the ubjet' had

Podu Brg the ubjet wrt pavet u le ad keep t that ptr abut a mute he uddel reeae thempre

Tinel s test percussion of the carpaltunnel Fg. 360

Sgniian h a per tet r themeda erve the rpal tue r r the ulaerve Gu' tue It huld elt paraethea the terrtr ether the medaerve 3- ger medall d plmar r theuar erve - 1 ular ger.

Poioning he ubjet preet the had pmupward he emer grp the wrt wthe had he ther hd ue the peruhammer.

Podu Gve a lght peru the rpaltuel

Gve a lght peru Gu tuel

F. 3.60 nel's tes



72/144

62 ATLS O ORTOEDIC EAMIAO

Grind tt or th rapzium-irtmtacarpal joint Fig 361)

Significance This es is me dee repus

s smpm idiig rhrss.

Positoing The sube sds wih he rmhgig d he elbw 90 lexed. The exmiersds leve wih he subjes hd The rlerl hd grsps d sbies he wris heher hd es hld he dis pr he irsmerp be

Procedue. Exer xil pressure d irumduhe irs merpl be

F 361 Gr e

Fin kltn tt ig 3.62)

Significance. This es is me irm hepresee de Quervis disese I shuldbe mre piul h he ulr devii es s

desried pge 5

Posiioig. The subje sds wih he rmhgig he elbw lexed righ gle dhe rerm pred. The exmer sds ex he sbje The rler hd rries hererm whih is ep bewee his rm d ru.The her hd grsps he subes hd disll he merps irs merp uded.

Pocedue. Pull he sbjes wrs he lrside uil he ed rge is rehed.

F 362 keen' e



73/144

CAPER CONENS

Surface and papatory anaomy 63Anteror 6

Bon andaks 6Papation o sot tisse 6

Posteror 66Bon andaks 66

Papation o sot tisse68

Fctoa exaiation of he hp 69Pasive ests 0

Passve exon 0Passve extea oation 0Passve ea otaon Passve adon Passive addon 7Passive extenson 7

soetr onrations Resisted lexon Resisted adtion Resisted adtion

Resisted exension Resised edia roation Resisted laeal rotation 6Resisted lexon o he knee Resisted exension o he nee

Sei tests 8Biateral passive edia roaton n one

oson 8Adon in exion 9Forel pwas hrs to he ee 9Ooans test 9r te 0

Hip

SURFACE AD PAPATORY

AATOMY

ATEROR

Bony landmarks Fig 4.

Th ingunl old cn ly idntfid I covrt inguinl ligmn (A) ht cn pptd rong firou nd

Th nrior uprior c pin i octdt th rniolr] nd of h fold Th ony

prominnc orm h poin o origin of oh roriu mucl nd th nor fci

Fg. 4.1 Bon landaks n vivo

C

63



74/144

AAS O ORHOPEDIC EXAMNAION

msles The sine oninues aeraly an osalyn e ia es C.

A he meial en of e ingna fo anoherbony romnene an be alae he iuberle O Normay i lies leve wih he serior ase of he greaer rohaner oviesaahmen fo he meial en of e nguinalgamen an for e enon of he reusabominis Te enon of he auo ongusoginaes jus beow is ubee

Palpation of sot tssue

Plpn f h supicil xrs: h lrlfrl ngl Fg 4

Plae e aaing finger a few enimeresisal o he aneio suerior ilia sine an ashe aen o lif an a he ene egTwo srures an be fel an I or seen, one a

aeraemoraale

mse

Meial

ale

Gaismse

ig 2 B ladmaks

ea se of he finge foming an invee V (eaera emoal riangle) Te saoris (A) is emeial an he ensor fasae laae e aeralmsle (6) (ig 43 Noe also he bey of eeus femoris C a few enimees isa o heinvee V (ig 44.

e oigin of he ae is fel eely n heaeal femora riangle abou 5 m isa o heaneio sueior a sine As he aen oeen he nee ben he hi o 60' an asome resisane hs movemen makes he bellyof he musle beer visible Paae a bony omnene he nferior a sine from whie musle oginaes

Fig .3 atea emora trae

ig es emors he laeal emoal ane



75/144

Me femr nge (gnum f Scrp)ig 45)

he meial emal tiangle is eine seriryy the ingina igament meialy by the

tr lngs an ateally y the sartriUhe lr the triangle is me by rtins

the ilisas n the latera sie an theetines n the meia sie

Definton n vvo

To define the bey of the saorus. Stan eve withhe nee the sjet at the isilatera sien ae the hi The hi is slightly ent anightly abte Kee the knee 90 exe with

ts lateal sie resting against y hi

. .5 o w of mc: 1 innalamn looa moa ay; cn; addco on; 6 acl; ao 8 c fmo o faca aa

I 65

As the atient t erm a lexin an latealrtatin at the hi The rmer is resiste with thentalateral han the latte with the isiateralne The mse bemes even mre visile i the

sbjet is ase t a sme lexin mve

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Orthopedic Examination