ORTHOTEERS

Cerebral Palsy

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Definition

Disorder of movement and posturing
Caused by static brain lesion
Acquired during the stage of rapid brain development
Manifestations may change with growth and development

Epidemiology

Occurs in 1-5 in 1 000 live births. More common in advanced countries. Advanced perinatal care increases survival of brain-damaged children. Care only slightly reduces incidence of cerebral palsy . More common in socioeconomically disadvantaged.

Aetiology Aetiology

Prenatal (30%)
- Maternal infection - Toxoplasmosis . Rubella . Cytomegalovirus . Herpes . Syphilis
- Maternal exposure - Alcohol . Drugs
- Congenital brain malformations
Perinatal
- Birth weight <2500g>(25-40%)
- Anoxia (10-20%)
Postnatal (10%)
- Meningitis
- Head injury
- Immersion

Classification

1. Spastic
- Most common (60% of cases)
- Most amenable to surgery
- Due to upper motor neuron involvement - mild to severe motor impairment
- Characterized by increased muscle tone and hyperreflexia, with slow, restricted movements (because of co contraction of agonist and antagonists)
- Spasticity is characterized by increased muscle activity with increasingly rapid stretch (clasp knife & clonus)
- Contractures
- hemiplegia (both limbs on one side): arm usually worse than leg - all hemiplegics will walk, regardless of treatment; present with toe walking only
- diplegia : have more extensive involvement of the lower extremity than the upper extremity; most diplegics will eventually walk; IQ may be normal, strabismus is common; gait is typically characterized by a crouched gait, toe walking, and flexed knees; heel cord lengthening alone may exacerbate crouched gait;
- paraplegia (both legs): sparing of arms
- quadriplegia : look for oral, lingual, dys f(x); dysarthria;
2. Athetoid / Dyskinetic
- Writhing movements. When excited, wriggle as if tickled.
- 20% of cases
- Result from basal ganglia involvement
- Present w/ slow, writhing, involuntary movements
- may affect the extremities (athetoid), or the proximal parts of limbs and the trunk (dystonic)
- Hyperextended hips & knees with exaggerated stepping gait. Lean backwards, extending shoulder girdle & trunk.
- Abrupt, jerky distal movements (Choreiform) also may occur;
- Movements incr during with emotional tension and disappear during sleep.
- Dysarthia is present and is often severe.
- Intelligence normal (often above average)
- Most difficult to correct with surgery - results are unpredictable & plaster immobilisation hazardous due to friction from constant movements.
3. Ataxic
- 10% of cases
- Involvement of the cerebellum or its pathways
- Weakness, inco-ordination, and intention tremor produce unsteadiness, wide based gait, and difficulty with rapid or fine movements
- Poorly amenable to surgical correction;
4. Hemiballistic
- Sudden movements . As if throwing ball.
5. Hypotonic
- Usually a stage through which an infant passes.
6. Combination

Pathogenesis

1. Weakness

Upper motor neuron lesion causes

Loss of voluntary movement
Weakness
Easy fatigability

2. Spasticity

Feature of all lesions of pyramidal system . Cerebral, capsular, pontine, midbrain lesions
Related to excessive activity of disinhibited spinal neurones
Mediated via stretch reflex . Muscle spindles detect stretch and stimulate muscle to contract . Threshold regulated by descending tracts . Spasticity due to hyperactivity of stretch reflexes
Tendon reflexes hypertonic . Clonus may appear
Posture characteristic because some neurones more active than others
Attempts to change position lead to resistance which quickly yields Clasp-knife phenomenon.

3. Contracture.

Nature of muscle contracture is: Shortening of muscle-tendon unit due to failure to keep pace with growth of bones.
Muscle adds sarcomeres at musculotendinous junction in response to constant stretch
In normal children, walking and movement provide all the stretch needed. When muscles spastic, this mechanism cannot occur.

4. Deformity

From unopposed muscle contracture.
Hip dislocation. Persistent hip adduction leads to valgus of femoral neck. Persistent hip flexion leads to anteversion of femoral neck. Results in Acetabular dysplasia, Hip subluxation & Hip dislocation

Note:

Spasticity - Abnormally increased contraction of a muscle in response to a stretch. Growth of muscles is impaired.
Rigidity - Involuntary sustained contraction of a muscle not stretch-dependent. Growth of muscles is not impaired.

Clinical features

1. Spastic quadriplegia. (25%)

Initially child floppy and will not feed
Choking during feeding from pseudobulbar palsy (difficult swallowing & chewing; dribbling)
Fail to thrive
Intelligence, vision and hearing affected
Only 10-20% will walk
Begin to walk up to age 7
Usually mentally retarded
Develop hip dislocation early and scoliosis.

2. Spastic diplegia.(30%)

All developmental milestones delayed
Most walk by age 4 .

3. Spastic hemiplegia (40%)

Usually noticed at walking age
Mean age of walking is 2-3 months later than normal.
Limp and one-handedness noted
Right-sided form may have speech delay
Seizures common.
Mild learning problems
Hyperactivity

4. Monoplegia (5%)

Associated disorders

Most common with total involvement
Mental retardation
Seizures
Learning disorders
Emotional and personality derangement
Visual defects
Hearing impairments
Disorders of speech

Assessment

History

Abnormal birth history
Prematurity
Neonatal nursery
Normal Developmental milestones (brackets are 95th percentile)
- Head control -3 mths (6 mths)
- Sitting independently - 6 mths (9 mths)
- Crawling - 8 mths (never)
- Pulling to stand - 9 mths (12 mths)
- Walking -12 mths (18 mths)

Examination. (Also see CP Examination )

Walking- Arm swing . Trunk leans forward. Scissoring (d.t. Hip flexion & adduction). Windswept posture . Knee flexion . Stride length reduced . Narrow walking base. Equinus. Lordosis . Co-ordination in turning. [ Gait Analysis ]
Sitting - Legs forward or W . Upright or slouched.
Kneeling eliminates contracture effect .
Hips - Clinical signs of dislocation:
1. Limited abduction, esp. with rapid stretch (grab test)
2. Asymmetric knee height with pelvis level & knees flexed ( Galeazzi test )
3. Windswept posture - one hip adducted & other side abducted
4. Asymmetric leg length
5. Hip flexion contractures
Muscles:
- Psoas
  - FFD of hip demonstrated by Thomas test
  - Increased lumbar lordosis and prominent bottom when standing
  - Decreased sacrofemoral angle on standing lateral x-ray
  - Reduced SLR because of flexed pelvis from FFD.
- Hamstrings
  - Reduced SLR
  - Hip extension contracture
  - FFD at knee
  - Lumbar kyphosis and small bottom when standing
  - Knee flexed at beginning of stance phase
  - False equinus (flexed knee lifts heel from ground)
  - Internal femoral torsion (sitting in W position)
  - Inability to touch toes
  - Reduced popliteal angle (hip at 90o)
  - High patella (flexed knee and spastic quadriceps)
- Adductors
  - Scissored gait if bilateral
  - Apparent leg length discrepancy if unilateral
  - Trendelenberg limp
  - Decreased hip abduction
  - Eventual hip dislocation
- Quadriceps
  - Stiff-legged gait (knees never flex)
  - Inability to flex knee when hip extended means rectus is responsible
  - Ely test (child prone, flex knee, if hip flexes = rectus femoris tight).
- Triceps surae
  - Ankle equinus
  - Tiptoe gait
  - Recurvatum at knee when heel goes down
  - Silverskold's Test - equinus improves with knee flexion = soleus tighter than gastrocnemius
Neurology
- Gross. Weakness
- Clasp-knife phenomenon
- Primitive reflexes
  - Moro reflex - Hold child at 45 ^o. Allow head to drop back . Arms and legs stick out in extension . Normally disappears by 4 mths.
  - Labyrinthine reflex - Tone reduced and arms and legs flex when child prone . Tone increased and arms and legs extend when child supine . Normally disappears by 6 mths.
  - Parachute reflex - When child held head down, both hands put out protectively . Appears at 5 mths.
Upper limbs
- General.
- Look at resting position.
- Look for contractures.
- Assess joint stability
- Hand placement. Ask patient to place hand on knee and then head.
- Control.
  - Ask patient to pretend to play piano . Look for independent movement.
  - Ask patient to throw object. Look for grasp and release.
  - Stereognosis. Test ability to recognise shape in palm

Predictors of Walking (from 1 year of age):
1. Asymmetrical tonic neck reflex
2. Symmetrical tonic neck reflex
3. Neck righting reflex
4. Moro reflex
5. A pattern of extensor thrust & abduction of the legs when supported upright
6. Parachute reflex
7. Stepping reflex
- If any 2 of these 7 responses are inappropriate by 1 year of age it is highly unlikely that the child will walk independently

Birth Injuries

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OBSTETRIC BRACHIAL PLEXUS PALSIES (OBPP)

from: McGuinness & Kay. Current Orthopaedics. 13:20-26. 1999.

Anatomy

Incidence is approx 2/1,000 births
Risk Factors:
- Child
  - weight > 4000g / large for gestational age
- Maternal
  - multiparity
  - diabetes
  - sibling with shoulder dystocia or OBPP
- At Birth
  - shoulder dystocia
  - breech
  - long labour
  - forceps delivery.
Investigations:
- EMG - doesn't correlate with prognosis & can be misleading.
- MRI - fast spin echo MRI may demonstrate root avulsions.
Classification Table:

TYPE (Adler & Patterson)	TYPE (Narakas)	ROOTS	DEFICIT	PROGNOSIS
Erb-Duchenne	Group 1	C5,6	Deltoid, cuff, elbow flexors, wrist & hand dorsiflexors - 'waiters tip'	Best
	Group 2	C5-7	Above except with sightly flexed elbow	Poor
Klumpke		C8-T1	Wrist flexors, intrinsics, Horners	Poor
Total Plexus	Group 3	C5-T1	Sensory & motor, flaccid arm	Worse
(Total Plexus + Horners)	Group 4	C5-T1	Sensory & motor, flaccid arm, Horner	Worst

Natural History:
- C8-T1 injury with a Horners syndrome has the worst prognosis.
- Isolated lower root lesions have a poor prognosis, since they are usually avulsion injuries.
- The rate of recovery and the time of beginning of recovery affect the outcome.
- Toronto scoring system (Clarke) assesses the child at 3 months of age
- No biceps function at 3m indicates a poor prognosis.
- Patients who show evidence of biceps function before 6 months of age have near-normal to excellent function.
- In borderline cases exploration of the Brachial Plexus is performed.
- Early repair has the best prognosis.
- Recovery continues until 1 year old, then little further recovery thereafter.

Management:
- Early Referral to a specialist unit.
- Physiotherapy - passive range of motion exercises.
- Splinting - not popular.
- Surgery

Indications for Surgery:
- C8-T1 injury with a Horners syndrome
- C5/6 lesions with no muscle activity & breech baby.
- Toronto score <>
- Failure to progress adequately between 12-24 weeks
- EMG criteria of Smith where doubt exists.
Surgical Technique:
- Transverse incision
- Neurolysis
- Nerve grafting (Sural nerve)
- Nerve transfers (accesory to suprascapular, intercostal to musculocutaneous)

Late Deformities:
- Internal rotation & adduction contraction of the shoulder
  - modified L'Episcopo procedure - involves lengthening of pectoralis major & subscapularis tendons with transfer of teres major & insertions into posterior surface of the humerus to act as external rotators
  - osteotomy - for older children with fixed bony adaptive changes, proximal humeral external rotation osteotomy can be considered; - these patients will most often complain of internal rotation contracture
- Posterior glenohumeral subluxation: - limitation of external rotation; - in late cases, with a deficient posterior glenoid consider humeral derotational osteotomy.

TORTICOLLIS

from fibrosis of sternal head of sternocleidomastoid
can result from unilateral shortening of sternocleidomastoid, commonly associated with fibrosis of the muscle; (may also involve the platysma and scalene muscles)
Aetiology & Natural History
- birth trauma, occlusion of venous flow, or haematoma results in fibrosis of muscle & palpable mass noted within first 4 weeks of life
- mass usually resolves within the first year of life (90% resolve)
- non-tender enlargement may be palpated in body of sternocleidomastoid

Grisel's Syndrome:
- Atlantoaxial Rotary Subluxation in association with pharyngeal infection, occurs predominantly in children
- it results in severe torticollis, resistant to manual therapy
- > 5 mm of anterior displacement of arch of C-1 (Fielding type III) indicates disruption of both facet capsules as well as transverse ligament
- reduction w/ skeletal traction, followed by atlantoaxial fusion, is recommended

Rigid Torticollis:
- may also present as rigid deformity, & sternocleidomastoid is not contracted or in spasm
- torticollis most often follows an injury to the C1-C2 articulation; - frx of the odontoid in young child may not be apparent on initial x-rays

Associated Anomalies:
- congenital atlanto-occipital abnormalities
- bony anomalies of the Cervical Spine, esp involving C1 & C2
- congenital webs of skin along the side of the neck, pteygium colli
- DDH: (20%
- plagiocephaly: - w/ persistent contracture of sternocleidomastoid, deformities of face and skull result and are apparent within first year of life; - flattening of face is noted on side of contracted sternocleidomastoid and is probably caused by child's sleeping position
- metatarsus adductus
- opthalmic disorders causing the child to tilt the head.

Non Operative Treatment:
- 90% will respond to passive stretching within the first year of life
- in first yr of life, rx consists of stretching sternocleidomastoid muscle by trying to rotate the head to opposite position. - stretching exercises should include not only lateral rotation, but also side bending to the opposite shoulder

Indications for Surgery:
- failure of non operative treatment after 12 to 24 months of age, surgical intervention is needed to prevent further facial deformity

Operative Treatment:
- involves resection of portion of distal sternocleidomastoid muscle from its sternal and clavicular attachments through transverse incision in the normal skin fold of the neck
- skin incisions immediately adjacent to clavicle may result in unsightly hypertrophic scars. - transverse skin incisions in skin folds 1.5 cm proximal to clavicle result in imperceptible scars
- uncommonly, distal resection is insufficient and proximal release of sternocleidomastoid is needed;

Bibliography, Links & Recommended Reading

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The following Websites & Books were used in compiling the Orthoteer Summaries: ( Bold = Essential)

Books:

Review of Orthopaedics - Mark Miller

Campbells Operative Orthopedics - Terry Canale

Principles of Orthopaedic Practice - Dee & Hurst
Apley

Orthopaedic Knowledge Updates

Websites:

South Australian Orthopaedic Registrars' Notebook

Entrez-PubMed

University of Washington Radiology Webserver

Journals:

Current Orthopaedics

The Journal of Bone and Joint Surgery

BASIC SCIENCE

Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB Saunders, 1998.

The Developing Human - Moore & Persuad

duPont PedOrtho Education Modules

Resident Education Home Page, ALFRED I. DUPONT INSTITUTE

British Society for Children's Orthopaedic Surgery

McGloughlin & Mann.Surgery of the Foot and Ankle. 1999. Mosby.

Barton. The Upper Limb & Hand. 1999.

Electronic Textbook of Hand Surgery

eRadius - International Distal Radius Fracture Study Group

Copeland. Operative Shoulder Surgery. 1995. Churchill Livingstone.

Orthopaedic Knowledge Updates

Websites:

South Australian Orthopaedic Registrars' Notebook

Entrez-PubMed

University of Washington Radiology Webserver

Journals:

Current Orthopaedics

The Journal of Bone and Joint Surgery

BASIC SCIENCE

Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB Saunders, 1998.

The Developing Human - Moore & Persuad

duPont PedOrtho Education Modules

Resident Education Home Page, ALFRED I. DUPONT INSTITUTE

British Society for Children's Orthopaedic Surgery

McGloughlin & Mann.Surgery of the Foot and Ankle. 1999. Mosby.

Barton. The Upper Limb & Hand. 1999.

Electronic Textbook of Hand Surgery

eRadius - International Distal Radius Fracture Study Group

Copeland. Operative Shoulder Surgery. 1995. Churchill Livingstone.

Orthopaedic Knowledge Updates

Websites:

South Australian Orthopaedic Registrars' Notebook

Entrez-PubMed

University of Washington Radiology Webserver

Journals:

Current Orthopaedics

The Journal of Bone and Joint Surgery

BASIC SCIENCE

Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB Saunders, 1998.

The Developing Human - Moore & Persuad

duPont PedOrtho Education Modules

Resident Education Home Page, ALFRED I. DUPONT INSTITUTE

British Society for Children's Orthopaedic Surgery

McGloughlin & Mann.Surgery of the Foot and Ankle. 1999. Mosby.

Barton. The Upper Limb & Hand. 1999.

Electronic Textbook of Hand Surgery

eRadius - International Distal Radius Fracture Study Group

Copeland. Operative Shoulder Surgery. 1995. Churchill Livingstone.

Apley

Orthopaedic Knowledge Updates

Websites:

South Australian Orthopaedic Registrars' Notebook

Entrez-PubMed

University of Washington Radiology Webserver

Journals:

Current Orthopaedics

The Journal of Bone and Joint Surgery

BASIC SCIENCE

Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB Saunders, 1998.

The Developing Human - Moore & Persuad

duPont PedOrtho Education Modules

Resident Education Home Page, ALFRED I. DUPONT INSTITUTE

British Society for Children's Orthopaedic Surgery

McGloughlin & Mann.Surgery of the Foot and Ankle. 1999. Mosby.

Barton. The Upper Limb & Hand. 1999.

Electronic Textbook of Hand Surgery

eRadius - International Distal Radius Fracture Study Group

Copeland. Operative Shoulder Surgery. 1995. Churchill Livingstone.

Arthritis in Children

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JUVENILE CHRONIC ARTHRITIS (JCA)

Approximately 1:1000 children will develop swelling of one or more joints persisting for more than 3 months with no specific cause found. 50% of these will progress to JCA.

Aetiology - unknown

Diagnostic Criteria

Age under 16 at onset
Persistent arthritis in one or more joints for 6 weeks (minimum) to 3 months after other aetiologies have been ruled out. E.g. infection, malignancy, blood dyscrasias, Reiter's, hypogammaglobulinaemia

Classification by onset (Schaller)
1. Systemic onset (Still's disease)

Age: usually under 5years but can be any age
Sex: <5yr female =" male;">5yr female > male
Fever (high with spikes up to 40^oC daily) plus one of the following

Maculopapular rash
Iridocyclitis
RhF +ve
Cervical spine involvement
Pericarditis

Generalised lymphadenopathy
Hepatomegaly
Splenomegaly
Sites: knees, wrists, ankle, feet

2. Polyarticular onset

Age: any, even before age 1year!
Sex: female > male
5 or more joints involved in the first 3 months
Seronegative (RhFactor -ve)
Seronegative (RhFactor -ve)

Sites: knees (60%), wrists, hands

RhFactor +ve

Older children (9-10 years) with persistent activity and rapid joint destruction affecting mainly the hands and feet.

3. Pauciarticular (most common)

4 or less joints involved in the first 3 months
Type I
Type I

Younger onset <6yr,>

Type II

Older onset 9yr+, with males mainly affected. Association with HLA-B27.

Lab tests

	HB	WCC	ESR	RhF	ANA
Systemic	-	++	++	+ve	+ve
Polyarticular	+	+	+	-/+ve	30%+ve (in those with RhF+ve)
Pauciarticular	-	-	+ or -	-ve	-ve (M) +ve (F)

Radiological changes

Early features limited to periarticular osteopenia
Late features occur after 6 months and include growth disturbance, chondrolysis, joint destruction and erosions. These features are more common in the RhF +ve patients.

Prognosis

80% will eventually be able to lead normal functional lives.
Death can occasionally occur in the systemic onset group because of infection or the development of amyloidosis.
60% if seen within 1 year of onset will have normal function at 5 years compared with 25% of those seen after 1 year.
Functional outcome is related to joint contractures and destruction.

Poor prognostic factors

Onset <>
IgM (RhF) +ve
Eye involvement
Hip involvement leads to a greater functional deficit

Medical Management

Aim: to suppress activity and therefore prevent joint deformity
Multidisciplinary approach with rheumatologist, PT, OT, child psychologist etc
PT to help prevent joint contractures and keep healthy muscles working. Hydrotherapy affective.
OT for splints and orthoses

Drug treatment

NSAID's
- Ibuprofen, voltarol, naproxen etc.
- Aspirin used to be the drug of choice but dangerous with children under the age of 5 years because of the risk of Reye's syndrome.
Disease modifying drugs
- Methotrexate: shown to be effective in polyarticular disease
- Gold, penicillamine, azathioprine etc.
Corticosteroids
- Systemic: the use of steroids does not affect the ultimate prognosis and there are many complications related to their use, in particular growth disturbance, adrenal suppression etc.
- Intra-articular/tendon sheath: can be effective in controlling flare ups

Surgical treatment

Hip
- Soft tissue releases for contractures
- Total joint replacement
Knee
- Soft tissue releases for contractures
- Synovectomy
- Epiphyseal stapling
- Supra-condylar osteotomy
- Total joint replacement (rarely needed)
Foot and ankle
- Orthoses
- Triple fusion

Summary

Type	%	Joints	Features	Progression (%)
Systemic (Still's)	25	many	Fever, rash, organomegaly	25
Polyarticular: RhF -ve	15	many	Mild fever	30
Polyarticular: RhF+ve	15	many	Severe joint destruction	25
Pauciarticular I (F)	30	large	Iridocyclitis	15
Pauciarticular II (M)	15	large	Spondylitis, HLA-B27	15

Other arthritides

Juvenile psoriatic arthropathy
Ankylosing spondylitis
Reiter's disease
Acute rheumatic fever

Wrist Examination

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LOOK

Dorsum, side, palmar- palmar flex wrist to exacerbate dorsal swellings

Deformity e.g. radial deviation after colles, prominent ulna

Swellings e.g. ganglion

Scars, muscle wasting

FEEL

Start radial side & move in a circle around wrist;

Palpate for tenderness of :

- APL, EPL- de Quervain's

- Anatomical snuffbox- scaphoid

- Distal Radioulnar joint

- lunate- locate by dorsiflexing wrist

- ulnar styloid

- Hook of hamate

- Pisiform- pisiform triquetral degen

- Guyons canal

- Over median nerve

MOVE

Dorsiflexion- palms together, lift up elbows. Normal 75 degrees

Palmar flexion- Dorsum of hands in contact, drop elbows. Normal 75 degrees

Radial deviation- in neutral pron-sup. Normal 20 degrees

Ulnar deviation- Normal 35 degrees

Pronation-supination-elbows by sides ask patient to hold pen, measure angle between vertical and pen

-pronation 75 degrees

-supination 80 degrees

SPECIAL TESTS

Pseudostability test-

Hold patients hand in right hand and forearm with left, normal wrist clunks on palmar displacement of hand on forearm. Nonspecific test

DRUJ

1. Piano key sign- for instability = balottment of ulnar head, (prominence of ulna)

2. squeeze and turn test- the examiner stabilises the patient's forearm with one hand while with the other hand, he grasps the patient's hand as if for a vigorous handshake. When the patient resists forced passive rotation, or when there is active rotation against resistance, pain usually is elicited. If the pain is caused by compressing the ulna against the radius, it is mostly suggestive of chondromalacia.

Ulnar impingement test

For TFCC - shake hands with patient; ulnar deviate wrist whilst rotating the forearm. Pain = positive.

CARPAL INSTABILITY TESTS

Matrise Orthopaedics - Physical Examination of Wrist Instabilities

A. Scapholunate instability

1.scapholunate ballotment - using both index fingers and both thumbs, stabilise the lunate between thumb and index finger of one hand and the scaphoid between the thumb and index finger of the other; the scaphoid pushed in a volar to dorsal direction; discomfort in this area suggests the possibility of injury to the Scapholunate Ligament (SLL).

Scapholunate Ballotment Test

2.Kirk Watson's scaphoid shift test- examiner opposite patient, both elbows on table as if arm wrestling ipsilateral arms. Examiners thumb on scaphoid tubercle, index finger on scapholunate ligament to palpate clunk. SLL initiates scaphoid flexion on radial deviation of wrist. Completion of flexion of scaphoid caused by pressure from surrounding bones.

Normal- can feel scaphoid flexing in radial deviation, thumb pushed away

SLL injury- pressure of examiner's thumb prevents initiation of flexion of scaphoid , then Clunk occurs on sudden pressure from bones. Patient may withdraw hand with pain 'apprehension test'

Must compare to opposite wrist.

N.B. 20 % of normal people have positive test

[Watson HK, Ashmead D4, Makhlouf MV : Examination of the scaphoid. J Hand Surg Am. 1988; 13: 657-660.]

Kirk-Watson Test

Original Description by Watson:

'The patient is approached by the examiner as if to engage in arm wrestling, face to face across a table with diagonally opposed hands raised (right to right or left to left) and elbows resting on the surface in between. With the patient's forearm slightly pronated, the examiner grasps the wrist from the radial side, placing his thumb on the scaphoid tuberosity (as if pushing a button to open a car door) and wrapping his fingers around the distal radius. The examiner's other hand grasps at the metacarpal level, controlling the wrist position. Starting in ulnar deviation and slight extension, the wrist is moved radially and slightly flexed with constant thumb pressure on the scaphoid. This radial deviation causes the scaphoid to flex. The examiners thumb pressure opposes this normal rotation, causing the scaphoid to shift in relation to the other bones of the carpus. This scaphoid shift may be subtle or dramatic. A truly positive test requires both pain on the back of the wrist (not just where you are pressing on the scaphoid tuberosity), and comparison with the opposite wrist is essential.'

B. Lunotriquetral instability [Back To Top]

1. Reagan test (Lunotriquetral ballotment test) - stabilise the lunate between thumb and index finger of one hand and the triquetrum between the thumb and index finger of the other;the pisiform and triquetrum are pushed in a volar to dorsal direction; discomfort in this area suggests the possibility of injury to lunotriquetral interosseous ligament

[Reagan D.S., Linscheid R.L., Dobyns J.H. Lunotriquetral sprains: J Hand Surg Am 1984; 9:502-514.]

Reagan Test

2. Kleinman shear test (shuck test)- Examiner opposite patient, contralateral thumb over dorsum of lunate, index finger over pisiform. Attempt to squeeze thumb and index finger together. Pushing the pisiform dorsal arouses pain in the lunotriquetral joint.

Kleinman Shear Test

(Examiner's thumbs used in this illustration instead of index finger & thumb)

3. Linscheid's test (ulnar snuff box compression test) - This test may be the least specific according to Kleinman (Figure 25). The thumb placed on the ulnar side of the triquetrum exerts an axial pressure directed toward the lunate, which arouses pain.

[Linscheid RL : Scapholunate ligamentous instabilities. Annales de Chirurgie de la Main. 1984; 3: 323-330]

Tests to distinguish causes of radial pain (to be done early if tenderness on radial side of wrist)

De Quervain's tenosynovitis- Finkelstein's test- ulnar deviation,thumb in palm

Thumb CMC joint- Press over CMC joint and circumduct thumb with axial pressure

STT joint- Resisted pronation causes pain

Wartenburg's (superficial radial nerve irritation) Tinel's test

Phalen's, Tinel tests and Median nerve compression test

Spine Examination

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Added by Feroz Dinah , May 2004

Suitably undressed, usually down to underwear. Start with the patient standing, then lying prone and finally lying supine.

1. STANDING

Look

Scars: previous surgery
Lumps: abscess, tumour (e.g. sacral lipoma), prominent paravertebral muscle spasm
Sinuses: deep infection
Cafe au lait spots / nodules: Neurofibromatosis
Hairy patch (spinal dysraphism)
Mongolian blue spot (more common in Asians: no clinical significance)
Low hairline due to short neck: Klippel-Feil syndeome: fusion or absence of cervical vertebrae; may be associated with Sprengel shoulder (undescended scapula)
Down / Morquio syndromes: Atlanto-axial instability
Asymmetry of shoulder height / trunk balance / loin crease: scoliosis (lateral curvature with rotational deformity of vertebral bodies)
Leg length discrepancy (check level of iliac crests)
If patient consistently stands with one knee bent in spite of equal leg lengths, this may indicate nerve root tension, as knee flexion relieves the pull on the nerve root(s)
Lateral deviation of spine (known as 'list' or 'tilt'): may be a sign of prolapsed intervertebral disc causing nerve root ompression
Associated anomalies of hands/feet, e.g. syndactyly, pes cavus: may be part of a syndrome
Kyphosis and lordosis (best assessed from side): may be exaggerated or reduced
Round backing / hunched shoulders: Schuermanns disease/kyphosis
Gibbus (aka kyphos): acute angular deformity with bony prominence, e.g. tuberculous vertebral collapse
Observe gait

Feel

Tenderness: may be bony, intervertebral or paravertebral
Bony prominence or steps

Move

Flexion: Ensure spinal rather than hip flexion, by marking two spots about 10cm apart on the patient lumbar spine: these should separate by a further 5cm on flexion.
Forward bend test: Flexion should accentuate any scoliosis by causing a rib prominence (aka rib hump) on the convexity of the curve and a loin crease on its concavity.
If the scoliosis disappears on forward bending, it is postural.o If the scoliosis disappears on sitting, it may be due to leg shortening.
Scoliosis may be secondary to nerve root compression and will therefore disappear after resolution (spontaneous or surgical), i.e. sciatic scoliosis
Extension: Ask patient to arch backwards, but beware of cheating by trick movement of bending knees.
The wall test will unmask even small fixed flexion deformities: Ask patient to stand with his/her back against a wall. Observe if heels, buttocks, shoulders and occiput all touch the wall.
Lateral flexion: Ask patient to run hand down ipsilateral thigh on one side, and then the other. Asymmetry in range of movement is clinically more significant than actual range of movement
Rotation: Again, of little clinical significance, but as most rotation occurs in the thoracic spine, this should not be reduced in lumbo-sacral disease. Stabilise the patients pelvis with both hands, and ask the patient to twist/turn to either side, looking for asymmetry of range of movement.
Rib cage excursion: This should be about 7cm between full inspiration and full expiration.

CERVICAL SPINE
The books are full of normal ranges of neck movements in degrees, but you have to ask the patient to put something in his/her mouth to act as a goniometer. It may be more useful to use (less precise) anatomical landmarks to gauge range of movement. Also, CHANGES in ranges of movement are often more useful.

Flexion: Most people can get their chin on their suprasternal notch.
Extension: should allow nose or forehead to be parallel to ceiling.
Rotation: cheek parallel to shoulder.
Lateral flexion: very variable, and first movement to be restricted in arthritis.

NOTES
1. Rotation occurs throughout C-spine, but mainly at atlantoaxial joint (C1/C2).
2. Flexion / extension occurs throughout the C-spine (C0 to C7).
3. No flexion in thoracic spine, because splinted by ribcage.
4. No rotation in lumbar spine, because facet joints are vertical.

LYING PRONE

Look

Watch the patient climb on the examination couch.

Feel

Focal spinal tenderness
[Assess sensation on back of whole leg; if worried about cauda equina syndrome, perianal sensation may also be assessed here.]
Check popliteal and posterior tibial pulses

Move

Femoral nerve stretch: Either acutely flex the knee with the thigh resting on the couch, or extend the hip with the knee in moderate flexion. If pain is elicited, there is a positive nerve stretch test.
[Assess hip rotation and ankle reflexes with the knee at 90o of flexion.]

LYING SUPINE

Look

Watch the patient turn over onto his/her back.

Feel

Sensation can be tested here [or at the end, in the neurological examination]

Move

Assess hip/knee mobility if you haven't already.
Straight leg raise (SLR): keep the knee extended and passively flex the hip by lifting the heel off the examination couch and estimate the angle of elevation (normally 80 - 90o). If restricted by pain radiating from back to BELOW the knee (i.e. back, buttock, thigh and calf), there is evidence of sciatic nerve root irritation. Tension on the sciatic nerve can be increased by dorsiflexion of the ankle, causing increase in pain.
Lasegue's test: Tension is then removed by flexing the knee, often allowing the hip to be fully flexed. If when the knee is extended from this flexed hip/knee position, the pain is reproduced, Lasegue's test is positive.
Bowstringing's test: With hip flexed to 90o, extend the knee as far as the patient tolerates. Pressure applied to the hamstrings (possibly pulling on the peroneal nerve) with the thumb will immediately cause pain if there is nerve root irritation.

NOTE: If the pain on SLR is felt in the contralateral limb (cross-leg pain or cross-sciatic tension), there may be a central disc prolapse, with risk of cauda equina syndrome.
Signs of nerve root compression
Standard full neurological examination of both lower limbs, i.e. tone, power (MRC grading), sensation (light touch, pinprick and proprioception if indicated) and reflexes. Usually deficit(s) will follow an anatomical distribution, i.e. dermatome(s) or myotome(s). Whole limb pain, weakness, or anaesthesia suggest supratentorial overlay.

Non-organic signs (Waddell G. et al. Non-organic physical signs in low back pain. Spine 1980; 5: 117)

1. Superficial / non-anatomical tenderness: Lightly pinch the skin on a wide area of lumbar skin (pinch test). If this causes pain, test is positive.
2. Axial loading: Using the flat of his/her hands, the examiner vertically loads the patient's skull. If this causes pain, the test is positive. Similarly, simultaneous ipsilateral rotation of shoulders and pelvis (i.e. log-roll) in the same plane should NOT cause pain.
3. Distraction: If the examiner elicits severe pain on SLR, but the patient is able to comfortably sit forward with legs extended on examination couch, the test is positive. (aka 'flip' test in USA)
4. Regional disturbances: Test is positive in presence of non-anatomical motor or sensory deficits (e.g. normal heel-toe walk, but cog-wheel foot weakness).
5. Over-reaction: Test is positive if muscle spasm, tremor or collapse occur during examination

Shoulder Instability Tests

2007-10-07T23:06:00.001-07:00

From University of Washington

Laxity Tests

These tests examine the amount of translation allowed by the shoulder starting from positions where the ligaments are normally loose.
These are tests of laxity, not tests for instability : Many normally stable shoulders, such as those of gymnasts, will demonstrate substantial translation on these laxity tests even though they are asymptomatic.
The amount of translation on laxity testing is determined by the length of the capsule and ligaments as well as by the starting position (i.e. more anterior laxity will be noted if the arm is examined in internal rotation - which relaxes the anterior structures, than if it is examined in external rotation - which tightens the anterior structures).
Use the contralateral shoulder as an example of what is 'normal' for the patient.

1. Drawer Test

The patient is seated with the forearm resting on the lap and the shoulder relaxed. The examiner stands behind the patient. One of the examiner's hands stabilizes the shoulder girdle (scapula and clavicle) while the other grasps the proximal humerus. These tests are performed with (1) a minimal compressive load (just enough to center the head in the glenoid) and (2) with a substantial compressive load (to gain a feeling for the effectiveness of the glenoid concavity). Starting from the centered position with a minimal compressive load, the humerus is first pushed forward to determine the amount of anterior displacement relative to the scapula. The anterior translation of a normal shoulder reaches a firm end-point with no clunking, no pain and no apprehension. A clunk or snap on anterior subluxation or reduction may suggest a labral tear or Bankart lesion. The test is then repeated with a substantial compressive load applied before translation is attempted to gain an appreciation of the competency of the anterior glenoid lip. The humerus is returned to the neutral position and the posterior drawer test is performed, with light and again with substantial compressive loads to judge the amount of translation and the effectiveness of the posterior glenoid lip, respectively.(Silliman and Hawkins, 1993)

2. Sulcus Test

The patient sits with the arm relaxed at the side. The examiner centers the head with a mild compressive load and then pulls the arm downward. Inferior laxity is demonstrated if a sulcus or hollow appears inferior to the acromion. Competency of the inferior glenoid lip is demonstrated by pressing the humeral head into the glenoid while inferior traction is applied.

3. Push-Pull Test

The patient lies supine with the shoulder off the edge of the table. The arm is in 90 degrees of abduction and 30 degrees of flexion. Standing next to the patient's hip, the examiner pulls up on the wrist with one hand while pushing down on the proximal humerus with the other. The shoulders of normal, relaxed patients often will allow 50 per cent posterior translation on this test.

Stability Tests

These tests examine the ability of the shoulder to resist challenges to stability in positions where the ligaments are normally under tension.

1. Fulcrum Test

The patient lies supine at the edge of the examination table with the arm abducted to 90 degrees. The examiner places one hand on the table under the glenohumeral joint to act as a fulcrum. The arm is gently and progressively extended and externally rotated over this fulcrum. Maintaining gentle passive external rotation for a minute fatigues the subscapularis, challenging the capsular contribution to the anterior stability of the shoulder. The patient with anterior instability will usually become apprehensive as this maneuver is carried out (watch the eyebrows for a clue that the shoulder is getting ready to dislocate). In this test, normally no translation occurs because it is performed in a position where the anterior ligaments are placed under tension.

2. Crank or Apprehension Test

The patient sits with the back toward the examiner. The arm is held in 90 degrees of abduction and external rotation. The examiner pulls back on the patient's wrist with one hand while stabilizing the back of the shoulder with the other. The patient with anterior instability usually will become apprehensive with this maneuver. As for the fulcrum test, no translation is expected in the normal shoulder because this test is performed in a position where the anterior ligaments are placed under tension.

3. Jerk Test

The patient sits with the arm internally rotated and flexed forward to 90 degrees. The examiner grasps the elbow and axially loads the humerus in a proximal direction. While axial loading of the humerus is maintained, the arm is moved horizontally across the body. A positive test is indicated by a sudden jerk as the humeral head slides off the back of the glenoid. When the arm is returned to the original position of 90-degree abduction, a second jerk may be observed, that of the humeral head returning to the glenoid.

Strength Tests

The strength of abduction and rotation are tested to gauge the power of the muscles contributing to stability through concavity compression. The strength of the scapular protractors and elevators are also tested to determine their ability to position the scapula securely.

Shoulder Examination

2007-10-07T23:05:00.000-07:00

Look

From the front, side and above

Asymmetry, scars, deltoid wasting, SCJ or ACJ deformity, swelling of the joint

From behind

Look and feel for rotator cuff wasting, scapula shape and situation e.g. winging, Sprengel shoulder etc

Feel

SCJ to the ACJ and acromion
Greater and lesser tuberosity, feel for rotator cuff defects
Glenohumeral joint: anterior and posterior aspects
Biceps tendon/bicipital groove
Spine of scapula

Move

ALWAYS EXAMINE THE CERVICAL SPINE FIRST

Move both arms at the same time. Active then passive ROM.
Quick screening test: "Arms above the head and behind the back "
Flexion : 0-180 ^o
Abduction : 0-180 ^ocheck for painful arc and watch the scapulothoracic rhythm
If restricted then repeat with the scapula fixed to check for the amount of glenohumeral movement
Internal rotation: T4
External rotation : 70 ^o

Feel for crepitation during motion

Special tests

1. Impingement

Neer's sign: Hold scapula down, pronate forearm and flexion will cause pain
Hawkin's test: Flexion to 90 ^ointernal rotation will cause pain
Neer's test: Pain caused by Neer's test eliminated by local anaesthetic injection
Scarf test: forced cross body adduction in 90 ^oflexion, pain at the extreme of motion indicative of ACJ pathology

2. Rotator cuff Integrity

Supraspinatus/anterosuperior cuff:

Resisted abduction with arms by side
Jobe's test: arm abducted to 20, in the plane of the scapula, thumb pointing down

Infraspinatus+teres minor/posterior cuff:

Resisted ER with the arms by side
Drop test : with arms fully ER by side (= massive infraspinatus tear)
Patte's test: 90 ^oflexion, flexed elbow and resisted external rotation
Hornblower's sign (Emery): similar to Patte's test inability to ER & Abduct from hand in front of mouth (against gravity)
Hornblower's sign (JBJS, 1998) / Drop test: with arm in 90 ^oabduction & ER, elbow 90 ^o(+ve = massive tear of both infraspinatus and teres minor and operative repair will result in 50% failure)
Pointing elbow test: place hand on opposite shoulder and ask pt to hold shoulder flexed to 90 ^o

Subscapularis/anteroinferior cuff:

Gerber's lift off test: push examiner's hand away from 'hand behind back position' (eliminates pectoralis major)
Internal rotation lag sign: inability to hold hand away from back
Napoleon test: if pt cannot fully internally rotate, push on their belly, elbow will drop backwards if +ve

Biceps

Check for long head of biceps rupture
Speed's test: supinated arm flexed forwards against resistance pain felt in the bicipital groove indicates biceps tendon pathology
Yergason's test: feel for subluxation of the biceps tendon out of the bicipital groove when the arm is gently internally and externally rotated in adduction
AERS test: Abduction External Rotation Supination test. Pt feels pain on resisted supination in this position. Test with elbow abducted & ER to 90 ^o.

Deltoid: resisted abduction at 90 ^o

Serratus anterior : "Winging" test

3. Instability testing

Patient supine

Anterior and posterior draw "Lachmann of the shoulder"(Gerber and Ganz)

Patient seated

Inferior draw "sulcus sign"

Anterior subluxation test: abduction and external rotation "apprehension test" with thumb posteriorly and fingers anteriorly over humeral head
Posterior subluxation test: internal rotation, adduction, flexion and push posteriorly

More Detail on Instability Tests
Imaging

XR: AP, Lateral/axial/trans-scapular/Wallace, sub-acromial view

CT: good for glenoid fractures

MR: Good for labral tears anteriorly-inferiorly-posteriorly. Not superiorly

OK for rotator cuff pathology

USS: Now thought to be superior to MR for rotator cuff pathology but operator dependent

Short Case Examination Tips / Approach

2007-10-07T23:03:00.000-07:00

Look at the:

Patient

Problem

Props (aids, testing devices etc.)

Ask:

about tender areas

Feel

Move

Active

Passive

Special Tests

Neurological Problem

Test sensation before motor

Patient
Problem
Props (aids, testing devices etc.)

Ask:

about tender areas

Feel

Move

Active
Passive

Special Tests

Neurological Problem

Test sensation before motor

RUPTURE OF THE CENTRAL SLIP OF THE EXTENSOR HOOD OF THE FINGER. A TEST FOR EARLY DIAGNOSIS

2007-10-07T23:00:00.000-07:00

By Elson, R. A.

JBJS - VOL. 68-B, NO. 2, MARCH 1986, pp. 229-231

From the Northern General Hospital, Sheffield

ABSTRACT: Closed rupture of the middle slip of the extensor hood of a finger is easily missed until the late appearance of a buttonhole deformity. Early diagnosis gives the best chance of satisfactory treatment, but Boyes' test becomes positive only at a late stage. A new test is described in which, from a 90 degrees flexed position over the edge of a table, the patient tries to extend the proximal interphalangeal joint of the involved finger against resistance. The absence of extension force at the proximal joint and fixed extension at the distal joint are immediate signs of complete rupture of the central slip. The theoretical basis and the method of performing the test are discussed. END OF ABSTRACT

Closed rupture of the central slip of the extensor tendon hood of the finger can easily be missed at an initial examination, even when it is suspected. Later, a classic buttonhole deformity will develop, but by then correction is difficult. Early diagnosis is essential for successful treatment. Boyes (1970) described a test for the integrity of the central slip. If the proximal interphalangeal joint is held passively extended, it is then possible for the normal individual to flex the terminal interphalangeal joint in isolation. However, if the central slip has been ruptured, there is increasing difficulty in performing this action. Unfortunately this test only becomes positive when the proximal part of the ruptured central slip has retracted and become adherent to the surrounding tissues. The test which is described below becomes positive immediately after complete rupture of the central slip.

Anatomy

The extensor mechanism of the human finger is complex, but its basic pattern is of three relatively uncompliant bands: one central slip and two lateral bands. These arise from the extensor communis tendon (Fig. 1). During flexion of a finger at both interphalangeal joints, the extensor hood mechanism moves distally, but the lateral bands must travel further than the central slip because they cross two joints. In addition, the finger lengthens during flexion because of the shape of the condyles of the middle and proximal phalanges, a point emphasised by Stack (1962). Harris and Rutledge (1972) demonstrated that, during flexion, the lateral bands sublux in a volar direction on either side of the head of the proximal phalanx, a movement facilitated by the conical shape of the bone. They also showed that during extension, the lateral bands recover their position on the dorsum of the finger and that this is not due to any elastic recoil from the triangular ligament. This could be divided; the lateral bands still returned to their dorsal position on extension provided that the central slip was intact (Fig. 2). Few individuals can flex the interphalangeal joints independently; this is because both flexor profundus and flexor superficialis act on the check-rein afforded by the extensor hood with its three uncompliant components. Action by the profundus tendon alone must take up the slack in the extensor hood as a whole and result in simultaneous flexion of both interphalangeal joints. Flexor superficialis acting alone must draw the hood distally, relaxing the lateral bands and allowing weak flexion of the distal joint by the normal tone of the flexor profundus. The well-known manoeuvre first described by Apley in 1956 demonstrates the integrity of flexor superficialis to one finger by neutralising the action of its profundus tendon and thus allowing the proximal interphalangeal joint to move in isolation.

Independent flexion of the distal interphalangeal joint can be achieved by holding the proximal joint in full extension. The action of flexor superficialis is blocked and flexor profundus can act on the distal joint alone (Fig. 3). When it does so, the lateral bands tighten, drag the extensor hood distally, and relax the central slip (which relates to the mechanism of Boyes' test). Some individuals with hypermobile proximal interphalangeal joints, can hyperextend and lock the joint in this position by the action of the central slip. They are then able to contract the profundus tendons to all the fingers and produce the unusual posture shown in Figure 4.

Theoretically, the oblique retinacular ligaments of Landsmeer (1949) should preclude flexion at the distal interphalangeal joint while the proximal joint is fully extended, but in practice, as shown above, this is not the case. Only later may contracture of the retinacular ligaments contribute to holding the lateral bands in subluxation; they play no effective part in the findings in acute injury. This was recognised by Harris and Rutledge (1972) and by Bendz (1985). The retinacular ligaments may therefore be neglected in describing the new test.

When the proximal interphalangeal joint is held at 90 degrees flexion the central slip is drawn distally and the lateral bands therefore become slack unless the distal joint is also flexed; this is easily demonstrated (Fig. 5), and it is in this posture that the new test is effective.

Test for integrity of the central slip.

The finger to be examined is flexed comfortably at a right angle at the proximal interphalangeal joint, over the edge of a table and firmly held in this position by the examiner (Fig. 6). The patient is then asked to attempt gently to extend the proximal interphalangeal joint. Any pressure felt by the examiner through extension of the middle phalanx in the posture described can only be exerted by an intact central slip. Final proof is that the distal interphalangeal joint remains flail during this effort, since the competent central sip prevents the lateral bands from acting distally.

In the presence of complete rupture of the central slip, any extension effort perceived by the examiner will be accompanied by rigidity at the distal interphalangeal joint with a tendency to extension (Figs 7 and 8). This is produced by the extensor action of the lateral bands alone. This test will not demonstrate partial rupture of the central slip, and its performance may be impeded by pain or by lack of co-operation from the patient. Pain can be relieved, if necessary, by proximal infiltration of the dorsal nerves of the finger.

Boyes' test for rupture of the central slip uses a different mechanism. It depends upon retraction of the proximal end of the ruptured central slip and its adhesion to surrounding tissues, and will, therefore, not become positive until these adhesions have developed. Irrespective of the chosen method of treatment, it is clear that early diagnosis of complete rupture of the central slip is essential; this can be achieved by the test which has been described.

Article Figure Legends

FIGURE 1: Diagrams to show the central slip and one of the lateral bands arising from point X. Distal pull on the central slip relaxes the lateral band, while a distal pull on the lateral band relaxes the central slip. These effects can readily be demonstrated in a fresh dissection.

FIGURE 2: Diagram of the distal end of a proximal phalanx, to show the conical shape which facilitates volar displacement of the lateral bands during flexion of the proximal interphalangeal joint. During extension they move in the direction indicated by the arrows provided that the central slip is intact (modified from Harris and Rutledge 1972).

FIGURE 3: If the proximal joint is held extended by an examiner, isolated flexion of a normal distal interphalangeal joint is possible. This is not possible once adhesions have developed after a rupture of the central slip (Boyes' test).

FIGURE 4: In some individuals, hypermobility of the proximal interphalangeal joints allows them to lock into hyper-extension. The flexor profundus can then act in isolation on the distal joints. Locking is maintained by the bowstring tension induced in the lateral bands; in this position the central slip is relaxed because the lateral bands have pulled the extensor hood distally.

FIGURES 5 and 6: Diagram and photograph showing a normal proximal interphalangeal joint flexed passively to 90 degrees. The origin of the lateral bands is drawn distally by the intact central slip, which allows the distal joint to remain flail. Attempted active extension affects the middle phalanx but leaves the distal joint flail.

FIGURES 7 and 8: Diagram and photograph to show the effect of division of the central slip. This allows proximal movement of the origin of the lateral bands; they hold the distal joint in extension.

References

Apley AG. Test for the power of flexor digitorum sublimis. Br Med J 1956;i:25-6.

Bendz P. The functional significance of the oblique retinacular ligament of Landsmeer: a review and new proposals. J Hand Surg 1985;10-B:25-9.

Boyes J, reviser. Bunnell's surgery of the hand. 5th ed. Philadelphia: JP Lippincott, 1970:440-1.

Harris C Jr, Rutledge GL Jr. The functional anatomy of the extensor mechanism of the finger. J Bone Joint Surg [Am] 1972;54-A:713-26.

Landsmeer JMF. The anatomy of the dorsal aponeurosis of the human finger and its functional significance. Anat Rec 1949;104:31-44.

Stack HG. Muscle function in the fingers. J Bone Joint Surg [Br] 1962;44-B:899-909.

Posterolateral Instability of the Knee & Knee Dislocations

2007-10-07T22:56:00.000-07:00

POSTEROLATERAL INSTABILITY

= when stress testing the lateral tibial plateau rotates posteriorly in relation to the femur with lateral opening of joint

associated with knee dislocation (see below)

Posterolateral injury components

popliteus tendon
arcuate ligament
LCL and lateral capsular ligaments

Tests:

See Knee Examination
Check common peroneal nerve function

Management:

Surgery always required

Preop planning:

X-Rays:
- Segond fracture - avulsion fracture of lateral capsule off tibia - indicative of an associated ACL injury - seen on AP view.
MRI
- allows assessement of posterolateral corner injury as well as ACL & PCL
- assess which structures of the posterolateral corner are injured and whether the injuries are mid-substance or whether they have been avulsed from the fibula or femur

Arthroscopic findings:

"drive through sign" = >1cm of lateral opening and exceptional posterior visualization of the lateral meniscus

Procedure:

Exposure: Identify the IT band, hamstrings, fibular head, peroneal nerve, and femoral attachment of the LCL
Incision: - straight lateral incision centered over the lateral joint line; - proximally the subcutaneous flaps are mobilized to allow identification of the anterior and posterior borders of the IT band; - the anterior and posterior attachments of this band are freed to allow anterior and posteiror mobilization; - peroneal nerve is identified posterior to the biceps and is followed distally around the fibular neck (look for evidence of nerve injury
Sequential assessment of injury: - look for avulsion of IT band off of Gerdy's tubercle, peroneal nerve injury, biceps avulsion off of the fibular head, LCL injury (proximal or distal), and popliteus avulsion
Repair will procede from the deepest structures to the most superficial structures
1. lateral meniscus repair
2. Capsular repair
3. Reattach popliteus to its femoral attachment (bone anchor) and to its fibular head attachment (pull thru sutures)
4. Arcuate ligament: - reconstruction/repair of this structure is necessary to avoid excessive tibial rotation, especially as the knee moves from extension to flexion; - remember that the biceps tendon, LCL, and arcuate complex all insert on the fibular styloid, and that if there is a fibular styloid avulsion, osseous reattachement will restore all three structures; Achilles tendon allograft may be indicated; - main goal is to create a checkrein to external rotation;
5. LCL repair / advancement on its femoral attachment
6. Biceps Tendon
7. IT Band: - note that the posterior 1/3 of the IT band attaches to the femoral epicondyle; - if this attachement is deficient, it should be repaired to help restore lateral stability

KNEE DISLOCATIONS

Clinical Findings:

Popliteal artery & vein injury is common
- note that knee dislocations that have spontaneously reduced may look benign but may lead to thrombosis of the popliteal artery
- popliteal artery is usually tethered proximally at adductor hiatus & distally by arch of soleus
- injury to the popliteal artery may initially manifest as an intimal tear or intraluminal thrombus.
Peroneal nerve injury:
- in 20% to 40% (half of these palsies are permanent)
- w/ peroneal nerve injury, be highly suspect for vascular injury; - even if pulse returns following reduction, consider need for arteriogram, since incidence of intimal injury is high w/ concomitant nerve injury
Both cruciates and least one collateral ligament are usually disrupted

Classification:

Anterior (31%)
- hyperextension of knee (may need > 30 deg of hyperextension to produce this injury)
- often PCL & ACL torn
- either the MCL or LCL or both will usually be injured
- alternatively, hyper-extension injuries may cause disruption of the ACL and posterior capsule while the PCL is spared
- Popliteal artery injury
Posterior (25%)
- disruption of both cruciate ligaments
- possible extensor mechanism disruption
- avulsion of or complete disruption of popliteal artery
Lateral (13%)
Medial ( 3%)
Rotatory ( 4% - usually posterolateral)

Investigations:

1. X-Rays:

Associated radiographic findings:
1. Tibial plateau fracture
2. Proximal fibula fracture
3. Avulsion fracture of Gerdy's Tubercle
4. Intercondylar spine fracture
5. Avulsion of Fibular Head

2. Arteriogram - indications unclear

3. MRI - see above

Management:

Reduction
- may be complicated by interposed soft tissue
- External fixation - it is important that the external fixator pin sites will not interfere with the ACL/PCL tunnel sites (during future ligament reconstruction)
Vascular Inuries
- the worst error to make is to underestimate the need to promptly treat these injuries
Nerve injury:
- the location of the nerve injury may be well above the knee joint
Assessment of ligament injuries:
- EUA
Surgical Treatment of Ligament Injuries:
- if vascular injury has been previously repair, get clearance from the vascular surgeon to utilize a tourniquet
- Deep to superficial (as above)

Neurological Examination

2007-10-07T22:52:00.000-07:00

SUMMARY

Equipment Needed

Reflex Hammer
128 and 512 (or 1024) Hz Tuning Forks
Wooden Handled Cotton Swabs
Paper Clips

General Considerations

Always consider left to right symmetry
Consider central vs. peripheral deficits
Organize your thinking into seven categories:

Mental Status
Cranial Nerves
Motor
Coordination and Gait
Reflexes
Sensory
Special Tests

Motor

Observation

Involuntary Movements
Muscle Symmetry
- Left to Right
- Proximal vs. Distal
Atrophy
- Pay particular attention to the hands, shoulders, and thighs.
Gait

Muscle Tone

Ask the patient to relax.
Flex and extend the patient's fingers, wrist, and elbow.
Flex and extend patient's ankle and knee.
There is normally a small, continuous resistance to passive movement.
Observe for decreased (flaccid) or increased (rigid/spastic) tone.

Muscle Strength

Test strength by having the patient move against your resistance.
Always compare one side to the other.
Grade strength on a scale from 0 to 5 "out of five":


Grading Motor Strength
Grade	Description
0/5	No muscle movement
1/5	Visible muscle movement, but no movement at the joint
2/5	Movement at the joint, but not against gravity
3/5	Movement against gravity, but not against added resistance
4/5	Movement against resistance, but less than normal
5/5	Normal strength
Grade	Description
0/5	No muscle movement
1/5	Visible muscle movement, but no movement at the joint
2/5	Movement at the joint, but not against gravity
3/5	Movement against gravity, but not against added resistance
4/5	Movement against resistance, but less than normal
5/5	Normal strength

Test the following:

Flexion at the elbow (C5, C6, biceps)
Extension at the elbow (C6, C7, C8, triceps)
Extension at the wrist (C6, C7, C8, radial nerve)
Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1)
Finger abduction (C8, T1, ulnar nerve)
Oppostion of the thumb (C8, T1, median nerve)
Flexion at the hip (L2, L3, L4, iliopsoas)
Adduction at the hips (L2, L3, L4, adductors)
Abduction at the hips (L4, L5, S1, gluteus medius and minimus)
Extension at the hips (S1, gluteus maximus)
Extension at the knee (L2, L3, L4, quadriceps)
Flexion at the knee (L4, L5, S1, S2, hamstrings)
Dorsiflexion at the ankle (L4, L5)
Plantar flexion (S1)

Pronator Drift

Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed.
Instruct the patient to keep the arms still while you tap them briskly downward.
The patient will not be able to maintain extension and supination (and "drift into pronation) with upper motor neuron disease.

Coordination and Gait

Rapid Alternating Movements

Ask the patient to strike one hand on the thigh, raise the hand, turn it over, and then strike it back down as fast as possible.
Ask the patient to tap the distal joint of the thumb with the tip of the index finger as fast as possible.
Ask the patient to tap your hand with the ball of each foot as fast as possible.

Point-to-Point Movements

Ask the patient to touch your index finger and their nose alternately several times. Move your finger about as the patient performs this task. [p519]
Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patient to move their arm and return to your finger with their eyes closed.
Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the patient's eyes closed.

Romberg

Be prepared to catch the patient if they are unstable.
Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without support.
The test is said to be positive if the patient becomes unstable (indicating a vestibular or proprioceptive problem).

Gait

Ask the patient to:

Walk across the room, turn and come back
Walk heel-to-toe in a straight line
Walk on their toes in a straight line
Walk on their heels in a straight line
Hop in place on each foot
Do a shallow knee bend
Rise from a sitting position

Reflexes

Deep Tendon Reflexes

The patient must be relaxed and positioned properly before starting.
Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response.
Reflexes can be reinforced by having the patient perform isometric contraction of other muscles (clenched teeth).
Reflexes should be graded on a 0 to 4 "plus" scale:


Tendon Reflex Grading Scale
Grade	Description
0	Absent
1+ or +	Hypoactive
2+ or ++	"Normal"
3+ or +++	Hyperactive without clonus
4+ or ++++	Hyperactive with clonus
Grade	Description
0	Absent
1+ or +	Hypoactive
2+ or ++	"Normal"
3+ or +++	Hyperactive without clonus
4+ or ++++	Hyperactive with clonus

Biceps (C5, C6)

The patient's arm should be partially flexed at the elbow with the palm down.
Place your thumb or finger firmly on the biceps tendon.
Strike your finger with the reflex hammer.
You should feel the response even if you can't see it.

Triceps (C6, C7)

Support the upper arm and let the patient's forearm hang free.
Strike the triceps tendon above the elbow with the broad side of the hammer.
If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close to the chest.

Brachioradialis (C5, C6)

Have the patient rest the forearm on the abdomen or lap.
Strike the radius about 1-2 inches above the wrist.
Watch for flexion and supination of the forearm.

Abdominal (T8, T9, T10, T11, T12)

Use a blunt object such as a key or tongue blade.
Stroke the abdomen lightly on each side in an inward and downward direction above (T8, T9, T10) and below the umbilicus (T10, T11, T12).
Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus.

Knee (L2, L3, L4)

Have the patient sit or lie down with the knee flexed.
Strike the patellar tendon just below the patella.
Note contraction of the quadraceps and extension of the knee.

Ankle (S1, S2)

Dorsiflex the foot at the ankle.
Strike the Achilles tendon.
Watch and feel for plantar flexion at the ankle.

Clonus

If the reflexes seem hyperactive, test for ankle clonus:

Support the knee in a partly flexed position.
With the patient relaxed, quickly dorsiflex the foot.
Observe for rhythmic oscillations.

Plantar Response (Babinski)

Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key.
Note movement of the toes, normally flexion (withdrawal).
Extension of the big toe with fanning of the other toes is abnormal. This is referred to as a positive Babinski.

Sensory

General

Explain each test before you do it.
Unless otherwise specified, the patient's eyes should be closed during the actual testing.
Compare symmetrical areas on the two sides of the body.
Also compare distal and proximal areas of the extremities.
When you detect an area of sensory loss map out its boundaries in detail.

Vibration

Use a low pitched tuning fork (128Hz).
Test with a non-vibrating tuning fork first to ensure that the patient is responding to the correct stimulus.

Place the stem of the fork over the distal interphalangeal joint of the patient's index fingers and big toes.
Ask the patient to tell you if they feel the vibration.

If vibration sense is impaired proceed proximally:

Wrists
Elbows
Medial malleoli
Patellas
Anterior superior iliac spines
Spinous processes
Clavicles

Position Sense

Grasp the patient's big toe and hold it away from the other toes to avoid friction.
Show the patient "up" and "down."
With the patient's eyes closed ask the patient to identify the direction you move the toe.
If position sense is impaired move proximally to test the ankle joint.
Test the fingers in a similar fashion.
If indicated move proximally to the metacarpophalangeal joints, wrists, and elbows.

Subjective Light Touch

Use your fingers to touch the skin lightly on both sides simultaneously.
Test several areas on both the upper and lower extremities.
Ask the patient to tell you if there is difference from side to side or other "strange" sensations.

Dermatomal Testing

If vibration, position sense, and subjective light touch are normal in the fingers and toes you may assume the rest of this exam will be normal.

Pain

Use a suitable sharp object to test "sharp" or "dull" sensation.
Test the following areas:

Shoulders (C4)
Inner and outer aspects of the forearms (C6 and T1)
Thumbs and little fingers (C6 and C8)
Front of both thighs (L2)
Medial and lateral aspect of both calves (L4 and L5)
Little toes (S1)

Temperature

Often omitted if pain sensation is normal.
Use a tuning fork heated or cooled by water and ask the patient to identify "hot" or "cold."
Test the following areas:

Shoulders (C4)
Inner and outer aspects of the forearms (C6 and T1)
Thumbs and little fingers (C6 and C8)
Front of both thighs (L2)
Medial and lateral aspect of both calves (L4 and L5)
Little toes (S1)

Light Touch

Use a fine whisp of cotton or your fingers to touch the skin lightly.
Ask the patient to respond whenever a touch is felt.
Test the following areas:

Shoulders (C4)
Inner and outer aspects of the forearms (C6 and T1)
Thumbs and little fingers (C6 and C8)
Front of both thighs (L2)
Medial and lateral aspect of both calves (L4 and L5)
Little toes (S1)

Discrimination

Since these tests are dependent on touch and position sense, they cannot be performed when the tests above are clearly abnormal.

Graphesthesia

With the blunt end of a pen or pencil, draw a large number in the patient's palm.
Ask the patient to identify the number.

Stereognosis

Use as an alternative to graphesthesia.
Place a familiar object in the patient's hand (coin, paper clip, pencil, etc.).
Ask the patient to tell you what it is.

Two Point Discrimination

Use in situations where more quantitative data are needed, such as following the progression of a cortical lesion.
Use an opened paper clip to touch the patient's finger pads in two places simultaneously.
Alternate irregularly with one point touch.
Ask the patient to identify "one" or "two."
Find the minimal distance at which the patient can discriminate.

Knee - Pivot Shift Test

2007-10-07T22:48:00.002-07:00

Jules Froment

2007-10-07T22:48:00.001-07:00

1878-1946

Jules Froment was Professor of Medicine at Lyons, and devoted his life to neurology, combining diligent observation, a philosophical approach and debating skill.

Graduating in 1906 with a thesis on disease of the heart in thyrotoxicosis, he remained at Lyons until the Great War. After a year at the front, he joined a nerve injuries unit at Rennes, and later was at Paris with Babinski. During this time he evolved a series of tests for nerve dysfunction, the best known being his sign of ulnar nerve weakness; another was loss of the hollow of the anatomical snuff box in radial nerve injury.

After the war he ran a Red Cross Hospital in Lyons, and the encephalitis epidemic of 1918-1922 provided another intellectual challenge. In 1926 he nearly died as a result of being severely injured by one of his patients.

Froment pointed out the difference between a pinch grip and grasping, both of which are impaired by a low ulnar nerve palsy due to weakness of adductor pollicis. He introduced the following test to show this. Today it is used to assess flexor pollicis brevis.

Froment's Signe du Pouce: 1915

In order to demonstrate the disorder of the grip it is sufficient for the patient to take hold of any object between the thumb and other fingers. Two features may be observed: first, the weakness of the grip, and secondly the abnormal position of the thumb, although, while at rest, nothing would lead one to suspect it.

It is when a thin object is gripped that the faulty position of the thumb is most clearly evident. In practice, we hold out a folded newspaper to the patient; he is asked to pull it hard with the strong band and then with the affected hand, while we pull it fairly firmly away. This is what is observed: on the healthy side the thumb is in contact with the object gripped all the way along-the distal phalanx is extended or only slightly flexed. On the paralysed side the thumb resembles a flying buttress, the distal phalanx is markedly flexed and no matter what force is used it only holds the object by the very tip of the pulp. Very often there is a gap between the thumb and the newspaper, or, to be more exact, between the thumb and the side of the palm. (It is necessary to pull bard: the grip with the fixed thumb is only pathological when the grip is forcible).

This asymmetric attitude between the thumbs appears very dearly when the patient, taking the newspaper in both hands, pulls with different strength at both ends. This can clearly be seen in the photograph.

Hip Examination

2007-10-07T22:47:00.001-07:00

Updated by Ahmed Dinah, May 2004

Patient must be suitably undressed (down to underwear)

First examine patient standing and then lying down.

Look, feel, move and special tests.

1. PATIENT STANDING

Look

Front and back of pelvis/hips and legs: any ischaemic or trophic changes
Swelling (e.g. lipoma) Scars (previous surgery)
Sinuses (infection/neuropathic ulcers)
Wasting (old polio, Carcot-Marie-Tooth) or hypertrophy (e.g. calf pseudo-hypertrophy in muscular dystrophy)
Deformity (leg length inequality, pes cavus, scoliosis)

Feel (Not a lot!)

Assess any swellings
Assess pelvic tilt by palpating iliac crests

Move

Gait:
- Trendelenburg (pelvic sway/tilt, aka waddling gait if bilateral)
- Broad-based (ataxia)
- High-stepping (loss of proprioception/drop foot)
- Antalgic (mention "Ã¢€Å"with reduced stance phase on left/right side)
- Smooth progression of phases of gait cycle: stance, toe-off, swing and heel-strike
- In-toeing (persistent femoral anteversion: most PFA is not clinically significant as both Monica Selles and Andre Agassi manage quite well with theirs!)
- Appropriate stride length
- Sufficient flexion/extension at hip/knee ankle and foot: Any fixed contractures?
- Observe arm-swing and balance on turning around

Trendelenburg test/sign:
- Make sure pelvis is horizontal by palpating iliac crests/ASIS.
- Ask patient to stand on one leg and then on the other.
- Assess any pelvic tilt by keeping an index finger on each ASIS.
- Normal (Trendelenburg negative): In the one-legged stance, the unsupported side of the pelvis remains at the same level as the side the patient is standing on. In fact, the unsupported side may even rise a little, because of powerful contraction of hip abductors on the stance leg.
- Abnormal (Trendelenburg positive): In the one-legged stance, the unsupported side of the pelvis drops below the level as the side the patient is standing on. This is because of (abnormal) weakness of hip abductors on the stance leg. The latter hip joint may therefore be abnormal. In addition, the patient may try to compensate for this pelvic tilt by swinging his/her torso away from the unsupported side, i.e. towards the abnormal hip.

If balance is a problem, face the patient and ask them to place their hands on yours to support him/her as he/she does alternate one-legged stance. Increased asymmetrical pressure on one hand indicates a positive Trendelenburg test, on the side of the abnormal hip.

A 'delayed' Trendelemburg has also been described, where the pelvic tilt appears after a minute or so: this indicates abnormal fatiguability of the hip abductors.

Romberg's test (for sake of completeness!)

This assesses proprioception/balance (dorsal columns of spinal cord/spino-cerebellar pathways).

Ask the patient to stand with heels together and hands by the side (Remember: heels together). Ask the patient to close his/her eyes and observe for swaying for about 10 seconds. Most people sway a bit but then quickly decrease the amplitude of swaying. If however, the swaying is not corrected, or the patient opens the eyes or takes a step to regain balance, Romberg's test is positive. When doing this test, stand facing the patient with your arms outstretched and hands are at the level of the patient's shoulders to catch or stabilise him/her in case of a positive Romberg's test. DO NOT LET THE PATIENT FALL!

2. PATIENT LYING DOWN

Look

Observe the patient climb onto the examination couch, assessing hip/knee/ankle flexion and extension.
Assess attitude of joints for any fixed flexion deformity.

Feel

Assess any swellings.
Palpate the groin, and greater trochanter area for tenderness.
Measurement can be done here or at the end.
Measure true and apparent leg lengths (ASIS to medial malleolus, and then umbilicus or xiphisternum to medial malleolus). This is inherently inaccurate, especially if you can't find the ASIS or medial malleolus because of generous adipose tissue. Also, many people have asymptomatic leg length inequality of up to 1cm.
If there is a true leg length discrepancy, determine which bone/segment of the lower limb is short.
- It may be below or above the knee (See Galeazzi test below).
- If above the knee, it may be above or below the greater trochanter. Drop a perpendicular from the side of the ASIS and measure distance from greater trochanter to this line.
- If above the trochanter, it may be the femoral neck (varus/valgus neck) or head (DDH): Don't forget to ask yourself "Is the hip in joint?" as a dislocated hip will cause a positive Trendelenburg and leg length inequality. It is difficult to do Ortolani or Barlow's test in older children and well nigh impossible in adults! However, inability to feel a femoral pulse on one side may indicate that the femoral head is out of the (true) acetabulum.

Move

1. Galeazzi test (If leg length discrepancy has been detected on measurement)

Ask the patient to flex hips to about 45 ^oand knees to about 90 ^o. Make sure the heels are together on the couch, with medial malleoli touching. Look at the knees from the side to see if they are at the same level. If one is proximal to the other, there is femoral shortening; if one is distal to the other there is tibial shortening.

2. Range of movements: Patients can appear to have good range of movements in spite of stiff hips, by tilting the pelvis. To detect this 'trick' movement, place a finger on the ASIS contralateral to the hip being examined: true hip movement ends when the pelvis begins to move (similar to differentiating true gleno-humeral from scapular movements in the shoulder)

Flexion can be assessed with the patient supine, but extension is best assessed with the patient in the lateral position.

Can the patient flex hip in a straight line or does the leg roll into external rotation with flexion? This may be a retroverted femoral neck or a slipped proximal femoral epiphysis.

Internal and external rotation can be assessed with the hip in extension (watch patella, not foot) or in flexion (flex knee and use tibia as goniometer).

Rotation is often the first movement to be limited by pain in degenerative/inflammatory conditions

Femoral neck anteversion presents with limited external rotation (can't sit cross-legged) and increased internal rotation (television position), allowing patellae to 'kiss' (hip extended) or allowing flexed knees to touch couch. Internal and external rotation can be done with the patient prone, but beware not to confuse internal and external rotation. In the prone position, thigh-foot angle (tibial torsion) can also be assessed.

Abduction/Adduction

Remember to distinguish true hip movements from pelvic tilt.

Thomas test: To detect fixed flexion deformity of the hip

FFD of the hip means that the patient cannot lay the back of the thigh on the couch when resting supine, but this can also be due to a FFD on the knee. If the knee has no FFD, the patient can lay the leg flat on the couch by a trick movement of 'extension' of the pelvis, resulting from increased lumbar lordosis. Abolishing this lumbar lordosis will therefore unmask this FFD, and this is the basis of the Thomas test.

Place your hand behind the small of the patient's back, between it and the couch. There is normally a small gap here due to normal lumbar lordosis. Abolish the lumbar lordosis by asking the patient to flex the hip ("Ã¢€Å"Bring you knee up to your chest and hold it there with your hands, please), and feel the lumbar spine flatten out onto your hand. When you are happy that the lumbar spine is flat, see if the patient's other knee is flat on the couch. If not, measure the angle of (fixed) hip flexion. Then repeat the test asking the patient to clasp his/her other knee up against his/her chest and observe for FFD in the previously flexed hip. (NOTE: Tight trousers will give a false impression of FFD, so make sure the patient is undressed to underwear!)

Finally, it is often worth examining the back in patients with any lower leg problem.

Trendelenburg Test from: Hardcastle & Nade. JBJS(B): 67-B(5):741-6

Thomas Test

Hand Examination

2007-10-07T22:44:00.000-07:00

LOOK

Expose the whole forearm & hand.

Look at the:

Dorsum, Palm,
Muscles - Thenar, Hypothenar, first dorsal interosseus, ADM, FCU (in forearm)
Congenital abnormalities
Open & close hand to quickly assess mass movement of the hand

FEEL

- ask for & feel the tender area
- muscles
- swellings
Palmar fascia & 1st web space (for nodules)

MOVE

Make a fist (active mass motion)
Thumb:
- Opposition to all fingers in turn
- Adduction, Abduction, Flexion
- EPL = tested by asking patient to lift thumb up off a table whilst hand held palm down on table
EDC - extend fingers at MCPJ's
Interossei - Ask patient to abduct fingers (dorsal interossei); ask patient to adduct fingers (palmar interossei)
FDS - individually tested by holding other fingers in hyperextension
FDP - tested by fixing the PIPJ & thus isolating the DIPJ
Quadriga phenomenon ( a Quadriga = an ancient Greek four horse chariot )
- when testing for FDS the FDP is defunctioned because the FDP tendons are combined, while the FDS muscles are separate in the forearm.
- Following repair or reconstruction of an FDP tendon the tension must be identical to the other FDPs, since the excursion of the combined tendons is equal to the shortest tendon.

NEUROLOGICAL TESTS

Sensory:

1. Autogenous zones:
- Median nerve = volar index finger
- Ulna nerve = volar little finger
- Radial nerve = over 1st dorsal interosseous muscle
2. Superficial branch of median nerve - over thenar eminence. Discriminates between a high or low median nerve lesion.
3. Dermatomes - C6 = thumb & index finger; C7 = middle finger; C8 = ring & little fingers.

Motor:

Median nerve - test APB with examiners hand over the thenar muscles from the first web space (like shaking hands)

Ulna nerve -

1. ADM & 1st dorsal interosseous muscle together, by opening fingers against resistance.
2. Testing ADM alone
3. Wartenburg's sign - little finger lies abducted due to the unopposed action of EDM.
4. Froment's test (Froment described this after watching a train commuter reading his newspaper with on thumb flexed & the other straight)
Ulna Paradox = less clawing of the fingers than a low lesion, because FDP is involved in high lesions thus flexing MCPJ & relaxing IPJs.

Anterior Interosseous nerve - loss of precise pinch (unable to make 'OK' sign, instead make a square) due to loss of FPL & FDP to index finger.

Posterior Interosseous nerve - Wrist dorsiflexion results in radial deviation (since ECU supplied by PIN, but brachioradialis & ECRL are supplied by the Radial nerve)

Superficial Branch of Radial Nerve:

Wartenburg's Neuritis (compression at the insertion of Brachioradialis)
Dellon's sign = active forceful pronation of the forearm & ulnar deviation of the wrist with the elbow extended by the side.
Tinel's test at the insertion of Brachioradialis

FUNCTIONAL TESTS

Power grip / Grasp
Precision Pinch (AIN)
Key Grip Pinch
Strength - tested on Dynamometer or Sphygmanometer

PULSES

Allens test - Ask patient to clench fist; compress both the radial & ulna arteries together with thumbs; Patient relaxes hand; Release one artery & observe capillary refill

INTRINSIC TESTING

1. Differentiate Intrinsic contracture from forearm flexor contracture

Flexing the wrist relaxes the FDS & FDP (long flexor) tendons; if patient can then flex the IPJ's with the wrist flexed there is intrinsic tightness, if they cannot it is a Volkmann's contracture.

2. Bunnel-Littler Test

For intrinsic tightness.

1) With the MCPJ in extension the intrinsics are put on a stretch. Try to flex the PIPJ with MCPJ in extension.

If it doesn't flex = tight intrinsics or joint capsule contracture.

2) With MCPJ in flexion the intrinsics are relaxed. Thus if unable to flex PIPJ= tight capsule.

NB- prior to test check that passive motion of PIPJ is possible (i.e. normal PIPJ)

Tight intrinsics occur in: 'Intrinsic Plus' hands due to ischaemia or fibrosis of intrinsics or RA.

3. Differentiate a Lumbrical Plus Finger from an Intrinsic Plus Finger:

Lumbrical Plus Finger is manifested by intrinsic plus attitude in involved finger on attempted flexion: ( with MCPJ flexion there will be IP extension ); FDP becomes an extensor of the PIP joint; when FDP relaxes FDS can work with less antagonism and PIP can flex; treatment may involve division of the lumbrical; Causes: (lumbrical tighter than FDP) - FDP laceration or rupture distal to the Lumbrical Origin from FDP (the proximal end of the lacerated FDP tendon will retract proximally, drawing the attached lumbrical proximally as well. The effect is increased tension on the radial lateral band, which causes the PIP joint to extend); 2) Amputation of the Distal Phalanx (distal to central slip insertion); 3) Excessively Long Tendon Graft.

Bouvier's Test

To determine if PIPJ capsule & ext. mech. are working normally.
If PIPJ capsule & ext. mech are functioning normally then blocking MCPJ hyperextension allows IPJ extension.
Positive test occurs as a result of: attenuation of central slip, adherent central slip at PIPJ or volar subluxation of lateral bands.

Tests for Traumatic Bouttoniere Deformity

Elson's Test = Put finger over edge of table, with PIPJ flexed to 90deg. & ask Pt to extend against resistance. Weakness of resisted extension of PIPJ & hyperextension of DIPJ occurs if the central slip is ruptured. More Detail - Original Article

Passive test = flex wrist & MCPJs. Poor passive resistance to pushing over middle phalanx indicates weak extensor mechanism.

Boye's Test (1970) - If the PIPJ is held passively extended, it is then possible for the normal individual to flex the terminal interphalangeal joint in isolation. However, if the central slip has been ruptured, there is increasing difficulty in performing this action. Unfortunately this test only becomes positive when the proximal part of the ruptured central slip has retracted and become adherent to the surrounding tissues.

How to measure fixed contractures in the MCPJs and PIPJs in dupuytrens etc.

Pronate the hand so that the dorsum faces you.
Then keep a goniometer on the dorsum of the MCPJ.
For assessing the PIPJ flex the MCPJ as much as possible - this reduces the possible chance for a fixed contracture of the MCPJ to contribute to a contracture of the PIPJ

EXTENSOR COMPARTMENTS:

Compartment	Contents	Pathologic Conditions
1	APL & EPB	DeQuervain's Disease
2	ECRL & ECRB	Tennis elbow
3	EPL	Rupture at Lister's tubercle
4	EDC & EIP	Extensor Tenosynovitis
5	EDM	Rupture (rheumatoid)
6	ECU	Snapping at ulnar styloid

Foot & Ankle Examination

2007-10-07T22:39:00.000-07:00

LOOK

Expose the whole lower leg and foot.

Examine the soles of the patient's shoes for signs of asymmetrical wear

Look for side to side asymmetry or abnormal contact w/ the ground

Walking Gait - look for a high stepping gait (foot drop, equinovarus), antalgic gait (ankle, hindfoot or midfoot pain) and short propulsive phase (forefoot pain)

Look at the patient standing (and then sitting).

Limb alignment (especially genu valgus with flat feet)
Look at the foot shapes and positions.
Medial arch - obliterated in pes planus, exaggerated in pes cavus (NB - look at lower back for signs of spina bifida or neurofibromatosis)
Hindfoot (from behind) - varus (pes cavus) or valgus (pes planus). Ask patient to stand on tiptoes and see if deformity corrects (= mobile subtalar joint).
'Too many toes' sign = looking from behind more toes are seen on the lateral side of the leg. This occurs in pes planus, splayed forefoot.

The patient should sit on the examination couch with both lower legs hanging over the side. The examiner should sit on a chair at a lower level than the couch.

Overall Foot Shape:

neutral or rectus foot - no overall deformity
flat foot - heel valgus, low arch, commonly forefoot abduction and supination. The subtalar joint is commonly in the overpronated position in stance and may be even more so on walking. Distinguish between flexible and rigid flat feet by asking the patient to stand on tiptoe to see if the arch re-appears and the heel goes into varus. Then do a single foot tiptoe test to look for tibialis posterior insufficiency. The "too many toes sign" demonstrates forefoot abduction. Manipulate the subtalar joint to identify a rigid hindfoot suggesting arthritis or a tarsal coalition. Exclude a neurological cause by appropriate examination.
cavus foot - typically with a plantar flexed first ray, high arch and forefoot pronation. In many cases the hindfoot is in varus and this may be fixed or mobile. Use the Coleman block test to tell the difference. Pes cavus may be associated with spinal anomalies (especially if asymmetrical) or with hereditary sensorimotor neuropathies such as Charcot-Marie-Tooth disease.
skewfoot - hindfoot valgus and forefoot adduction. Do the same tests for hindfoot correction as in flatfoot. Manipulate the forefoot to determine correctability of adduction.
metatarsus adductus - neutral hindfoot and adduction of the metatarsus (some patients have some forefoot supination too). Commonly seen in pre-school children when it is usually correctable, but also in adults when it is often relatively fixed but usually in itself asymptomatic.

Look at the:

Skin on the Dorsum and Plantar surfaces
Muscle wasting
Nail condition and hygiene
Bony prominences or exostoses
Check Dorsalis Pedis & Posterior Tibial Pulses

FEEL

- Ask for & feel the tender area

ANKLE

Feel for tender areas, systematically checking:

the anterior joint line
the lateral gutter and lateral ligaments
the syndesmosis
the posterior joint line
the medial ligament complex
the medial gutter

Feel for an effusion, synovitis, deformity, bony prominence and loose bodies.

HINDFOOT & MIDFOOT

Palpate the following structures from Lateral to Dorsum to Medial surfaces:

Lateral (from distal to proximal) [Figure 1] :

Styloid process of fifth metatarsal
Groove in the cuboid for Peroneus Longus tendon (just posterior to 1)
The peroneal tubercle (a small lateral extension of the calcaneus, separating the peroneus longus & brevis tendons)
Sinus Tarsi - soft tissue depression just anterior to the lateral malleolus. (Sinus Tarsi is filled with EDB & fat pad)

Dome of Talus (made prominent by plantarflexing ankle)

Medial (from proximal to distal) [Figure Below]:

First Metatarso-cuneiform joint.
Navicular Tubercle - most obvious bony prominence in front of medial malleolus. (insertion of Tibialis Posterior tendon)
Head of Talus - felt just behind the navicular, by everting & inverting the midfoot.
Sustentaculum Tali - one fingerbreadth below medial malleolus. (serves as an attachment for the spring ligament & supports the talus)
Medial Malleolus.

FOREFOOT

Palpate the all bones and joints in a circle, paying particular attention to:

First Metatarsal head
First MTPJ
Metatarsal heads
Web spaces

MOVE

PAED	P ronation = A bduction, E version & D orsiflexion
SAPI	S upination = A dduction, P lantarflexion & I nversion

Compare both sides

ANKLE

Active Combined - ask the patient to lift foot up (dorsiflex) and down (plantarflex)

Passive -

Dorsiflexion = Put one hand on the heel with the same forearm supporting the foot. The other hand supports the tibia. Dorsiflex the ankle by lifting the forearm under the foot. [Figure Below] (Normal = 55 degrees)

Plantarflexion = As in [Figure Below] below: (Normal = 15 degrees)

SUBTALAR

Hold the calcaneus with one hand and the talar head/neck with the thumb & index finger of the other hand. Apply varus and valgus stress with the hand on the calcaneus feeling for movement of the talus (at extremes of subtalar motion) with the other hand. Holding talus rather than the tibia isolates subtalar from ankle motion. (Normal = 5 degrees in each direction)

The subtalar joint can also be examined with the patient prone & the foot off the end of the couch.

MIDTARSAL (Talo-navicular & Calcaneo-cuboid joints)

Hold the calcaneus with one hand and move the forefoot medially & laterally with the other hand = adduction (20 degrees) & abduction (10 degrees). This movement cannot be seen, but can be felt.

TARSOMETATARSAL

Active motion is zero, but test the joints for stability (by pushing each joint up & down)

FIRST METATARSOPHALANGEAL JOINT

Normal ROM = 70-90 degrees DF; 45 degrees PF. Normal toe-off requires 35-40 degrees DF.

MUSCLE TESTS

TIBIALIS POSTERIOR MUSCLE & TENDON

From behind, ask the patient to do a single foot tiptoe test on both sides. Most people cannot get the affected heel off the ground at all; a few develop an acute midfoot breach. Another useful test is to get the patient to contract the tibialis posterior in the plantar-flexed/inverted position. The tendon may be weak, impalpable or palpably thin. Always examine for an Achilles contracture which is present in most people with tibialis posterior insufficiency and may only be apparent with the heel held in neutral or varus.

TIBIALIS ANTERIOR MUSCLE & TENDON (L4,5)

Ask the patient to walk on his heels with his feet inverted. The tibialis tendon can be seen prominent.

Manual test = the patient should sit on the edge of the examination table. Support his lower leg, and place your thumb near the dorsum of his foot in such a position that he must dorsiflex and invert his foot to reach it. Test resisted eversion from this position. Palpate the tibialis anterior muscle as you perform the test.

PERONEALS

Ask the patient to walk on the medial border of his feet.

Manual test = Secure the ankle by stabilising the calcaneus and with the other hand feel the peroneal tendons while testing resisted eversion. (Reverse of the Tibialis Anterior test)

Peroneal Snapping = DF & PF the ankle with the foot everted and palpate for 'snapping' of the peroneal tendons over the lateral malleolus

STABILITY TESTS

ANKLE

Test for ankle stability using the anterior draw and tilt tests. In the acute trauma situation pain makes these difficult. Sometimes local anaesthetic injection into damaged ligaments or the lateral popliteal nerve makes stress testing easier. When doing the tilt test, hold the talus at the neck, rather than the heel, as then you can be sure that any tilt is in the ankle not the subtalar joint. Instability of the syndesmosis may be palpable, usually on A-P translation of the distal fibula or valgus stress of the ankle.

OTHER TESTS

DISTAL TIBIO-FIBULAR JOINT / SYNDOSMOSIS

FIBULAR DRAW TEST

When attempting to displace the fibula anteriorly in an uninjured ankle, the examiner cannot elicit movement; - in a normal ankle the examiner frequently can feel movement when he attempts to displace the fibula posteriorly; - rarely can he initiate an increase in anterior displacement of the fibula in pts who have sustained injures to the ligamenotuos structures supporting the syndesmosis; - w/ sprain, the examiner can initiate increase in posterior displacement which usually reproduces pain;

CORONAL DRAWER TEST

talar motion in the coronal plane is another indication of syndesmotic widening.

SQUEEZE TEST

clinical test for syndesmotic instability; - w/ positive test, compression of the proximal calf causes pain at the distal syndesmosis; - anatomically, squeezing the proximal calf will cause separation of the distal fibula and specifically will cause separation of the anterior tibiofibular ligament

BLOCK TEST for Pes Cavus

Note the position of the heel when standing on a 2cm block. Then get the patient to stand with the forefoot over the medial edge. If a varus remains then the subtalar joint is fixed. If it corrects to valgus then the joint is mobile.

ACHILLES TENDON TEST (Simmonds / Thompson)

Lie the patient prone and squeeze the calf to elicit movement at the ankle = intact TA.

Elbow Examination

2007-10-07T22:36:00.001-07:00

Matrise Orthopaedics - Elbow Exam 1

Matrise Orthopaedics - Elbow Exam 2

Look

Swelling, effusion, deformity, scars, muscle wasting, carrying angle

Feel

Tenderness over epicondyles, joint line, olecranon

Move

Flexion/extension 0-140 ^o
Pronation/supination 80 ^oeach way

Special tests

Instability

Overhead position (resembling a leg), and the elbow resembling a knee.

Both valgus and varus testing are performed with the elbow in full extension and several degrees of flexion to about 30 degrees to unlock the olecranon from the olecranon fossa.

Valgus testing is performed with the elbow fully pronated so that posterolateral rotatory instability is not mistaken for valgus instability, which occurs because the ulna and radius as a unit rotate away from the humerus in response to valgus stress when the LCL is disrupted. Forced pronation prevents this from happening by using the intact medial soft tissues as a hinge or fulcrum, just as the periosteum is used for this purpose during the reduction of a supracondylar fracture in a child.
Varus testing is easiest to perform with the shoulder fully internally rotated.
Posterolateral rotatory instability is diagnosed by the lateral pivot-shift test of the elbow.
With the patient in the supine position and the affected extremity overhead, the wrist and elbow are grasped as the ankle and knee are held when examining the leg.
The elbow is supinated with a mild force at the wrist and a valgus moment is applied to the elbow during flexion.
This action results in a typical apprehension response with reproduction of the patient's symptoms and a sense that the elbow is about to dislocate.
Reproducing the actual subluxation and the clunk that occurs with reduction can usually only be accomplished with the patient under GA, or after injecting local anesthetic into the elbow joint.
The lateral pivot-shift test performed in that manner results in subluxation of the radius and ulna from the humerus, which causes a prominence posterolaterally over the radial head and a dimple between the radial head and the capitellum. As the elbow is flexed to approximately 40 degrees or more, reduction of the ulna and radius together on the humerus occurs suddenly with a palpable, visible clunk. It is the reduction that is apparent.

Lateral Pivot Shift Test for posterolateral instability

Epicondylitis

Tennis elbow: pain on resisted dorsiflexion of the wrist
Golfer's elbow: pain on resisted palmarflexion of the wrist

Neurological problems

Ulnar tunnel neuropathy: fully flex elbow for 5mins and check for ulnar nerve symptoms
Radial tunnel syndrome: pain on palpation around the supinator muscle (arcade of FrÃƒ ¶hse). Pain eliminated by LA injection indicative of radia tunnel syndrome

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Elbow Examination

2007-10-07T22:36:00.000-07:00

Matrise Orthopaedics - Elbow Exam 1

Matrise Orthopaedics - Elbow Exam 2

Look

Swelling, effusion, deformity, scars, muscle wasting, carrying angle

Feel

Tenderness over epicondyles, joint line, olecranon

Move

Flexion/extension 0-140 ^o
Pronation/supination 80 ^oeach way

Special tests

Instability

Overhead position (resembling a leg), and the elbow resembling a knee.

Both valgus and varus testing are performed with the elbow in full extension and several degrees of flexion to about 30 degrees to unlock the olecranon from the olecranon fossa.

Valgus testing is performed with the elbow fully pronated so that posterolateral rotatory instability is not mistaken for valgus instability, which occurs because the ulna and radius as a unit rotate away from the humerus in response to valgus stress when the LCL is disrupted. Forced pronation prevents this from happening by using the intact medial soft tissues as a hinge or fulcrum, just as the periosteum is used for this purpose during the reduction of a supracondylar fracture in a child.
Varus testing is easiest to perform with the shoulder fully internally rotated.
Posterolateral rotatory instability is diagnosed by the lateral pivot-shift test of the elbow.
With the patient in the supine position and the affected extremity overhead, the wrist and elbow are grasped as the ankle and knee are held when examining the leg.
The elbow is supinated with a mild force at the wrist and a valgus moment is applied to the elbow during flexion.
This action results in a typical apprehension response with reproduction of the patient's symptoms and a sense that the elbow is about to dislocate.
Reproducing the actual subluxation and the clunk that occurs with reduction can usually only be accomplished with the patient under GA, or after injecting local anesthetic into the elbow joint.
The lateral pivot-shift test performed in that manner results in subluxation of the radius and ulna from the humerus, which causes a prominence posterolaterally over the radial head and a dimple between the radial head and the capitellum. As the elbow is flexed to approximately 40 degrees or more, reduction of the ulna and radius together on the humerus occurs suddenly with a palpable, visible clunk. It is the reduction that is apparent.

Lateral Pivot Shift Test for posterolateral instability

Epicondylitis

Tennis elbow: pain on resisted dorsiflexion of the wrist
Golfer's elbow: pain on resisted palmarflexion of the wrist

Neurological problems

Ulnar tunnel neuropathy: fully flex elbow for 5mins and check for ulnar nerve symptoms
Radial tunnel syndrome: pain on palpation around the supinator muscle (arcade of FrÃƒ ¶hse). Pain eliminated by LA injection indicative of radia tunnel syndrome

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Cerebral Palsy examination

2007-10-07T22:30:00.000-07:00

Also see Cerebral Palsy

LOOK STANDING

Spine
Pelvic obliquity
Hip - Trendelenburg
Knee
Feet - Jack's Test, Tip toe

WALK

Sagittal - hip, knee, ankle, rockers
Coronal - hip, knee, ankle, rockers
Transverse - thigh, shin, foot (pronation posture of foot)

SIT

Spine
Pelvic obliquity

SUPINE

Knees down to end of couch with lower legs off end
Active ROM - hip, knee, foot & ankle
Hip
- FFD (Thomas test)
- Abduction
- Rotation (hips extended & knees flexed off end of couch)
Knee
- FFD
- Hamstring tightness
- Popliteal angle - flex hip to 90deg. & extend knee (angle in front of knee, not in popliteal fossa)
Ankle
- Silverskold's Test - equinus improves with knee flexion, indicating gastrocnemius is tighter than soleus.

PRONE

Hip
- Tibial rotation (malleolar plane)
- Thigh-foot angle (3rd toe to mid heel & thigh)
- Duncan-Ely Test for rectus femoris tightness
- IR & ER - lay forearm on post. pelvis & palpate greater trochanter (idea of amount of anteversion or retroversion of neck)
- Staheli test - for flexion posture of hip (hips flexed over end of couch, support pelvis posteriorly & passively extend hip)

LATERAL

Ober's Test - for TFL tightness - knee flexed & hip in neutral, extend knee & observe hip - positive if hip abducts
Abductor power

NOTES:

Total Flexor Pattern -> eliminates clonus pattern
Clasp-knife phenomenon (correlates with cospastisity in swing)

Clinical Signs & Tests

2007-10-07T22:26:00.002-07:00


Region:	Test / Sign:	Description
	commemorative sign:	any sign of a previous disease.
	antecedent sign:	any precursory indication of a malady.
	cogwheel phenomenon:	jerky motions produced on testing a muscle's strength; the jerks are neither rhythmic nor equal and represent malingering or protection from pain; cogwheel s.
	somatic sign:	any sign presented by trunk or limbs rather than sensory apparatus.
	Dupuytren sign:	for determining sarcomatous bone; a crackling sensation on compression of that area is noted.
	Gower sign:	for progressive muscular dystrophy and tabes dorsalis; abrupt intermittent oscillation of iris under light is the indication of ongoing process.
	Hueter sign:	for indication of fracture; absence of the transmission of osseous vibration in fractures as heard by a stethoscope, where the fibrous material is interposed between the fragments.
	Langer line:	the normal tension lines of skin commonly used to define direction of scar, as to how the scar runs with or across those lines.
	objective sign:	one that can be seen, heard, measured, or felt by the diagnostician to confirm or deny an ongoing symptom; physical s.
	quadriceps test:	for hyperthyroidism or debilitating condition; while standing, the patient is asked to hold leg up and straight out; a disease is present if patient cannot maintain this position for 1 minute.
	Raynaud phenomenon:	pallor or blueness of fingers, toes, or nose brought about by exposure to cold and less commonly by other stresses.
	cafe-an-lait spots:	for neurofibromatosis; hyperpigmented areas of skin indicate this ongoing problem; von Recklinghausen disease.
Back	Soto-Hall sign:	for lesions in back abnormalities; with the patient supine, flexion of the spine beginning at the neck and going downward will elicit pain in the area of the lesion.
Back	Mennell sign:	for spinal problems; examiner's thumb is taken over the posterosuperior spine of sacrum outward and inward for noting tenderness, which may be caused by sensitive deposits in gluteal aspect of posterosuperior spine; ligamentous strain and sensitivity.
Back	Minor sign:	for sciatica; patient rises from sitting position, supporting himself on healthy side, placing hand on back, and bending affected leg, revealing pain.
Back	Naffziger sign:	for sciatica or herniated nucleus pulposus; nerve root irritation is produced by external jugular venous compression by examiner.
Back	Patrick test:	for pain in lumbosacral area or hip; see Fabere s. and fadire t.
Back	postural fixation:	a sign noted on range of motion of the back; any postural deformity (stiffness) noted does not reverse with range of motion.
Back	spine sign:	for poliomyelitis; the patient is unable to flex the spine anteriorly because of pain.
Back	sponge test:	for detecting lesions of the spine; the examiner passes a hot sponge up and down the spine, and the patient feels pain over the lesion.
Back	Lasegue straight leg raising (SLR) test:	for determining nerve root irritation; the supine patient elevates his leg straight until there is back or ipsilateral extremity pain or until the pain is increased with dorsiflexion of the foot; Lasegue s.
Back	Turyn sign:	for sciatica; when examiner bends the patient's great toe dorsally, pain is felt in the gluteal region.
Back	Lorenz sign:	for ankylosing spondylitis (Marie-Strumpell disease); ankylotic rigidity of the spinal column, esp. thoracic & lumbar segments.
Back	Vanzetti sign:	for sciatica; the pelvis is horizontal in the presence of scoliosis. In other scoliotic conditions the pelvis is inclined.
Back	fadire test:	forced position of the hip causing pain; the letters stand for flexion adduction internal rotation in extension; Patrick t., fadir s.
Back	Valsalva maneuver:	for determining nerve root irritability within the spinal canal. This maneuver is also used for many other unrelated reasons. The patient takes a deep breath and then on bearing down, such as one does when lifting a heavy object, notes pain.
Back	Babinski sign:	for testing sciatic nerve pain; also for loss or lessening of the Achilles tendon reflex in sciatica, distinguishing it from hysteric sciatica.
Back	Abbott method:	for scoliosis of the spine; traction is applied to produce overcorrection, followed by casting.
Back	Goldthwaite sign:	for distinguishing lumbosacral from sacroiliac pain; with the patient supine, his leg is raised with one hand, while the examiner's other hand is placed under the patient's lower back; leverage is then applied to the side of the pelvis. If pain is felt by the patient before the lumbar spine is moved, the lesion is a sprain of the SI joint; if pain is not felt until after the the lumbar spine is moved, the lesion is in the SI or lumbosacral articulation.
Back	Anghelescu sign:	for testing tuberculosis of the vertebrae or other destructive processes of the spine; in the supine position the patient places weight on his head and heels while lifting his body upward; inability to bend the spine indicates an ongoing disease process.
Back	Bekhterev test:	for nerve root irritability in sciatica; while sitting up in bed, the patient is asked to stretch out both legs; with sciatica he cannot sit up in bed this way, he can only stretch out each leg in turn.
Back	Bragard sign:	for nerve or muscular involvement; with the knee stiff, the lower extremity is flexed at the hip until the patient experiences pain; the foot is then dorsiflexed. Increase in pain points to nerve involvement; no increase in pain indicates muscular involvement.contralateral straight leg raising test: for sciatica; when the leg is flexed, the hip can also be flexed, but not when the leg is held straight. Flexing the sound thigh with the leg held straight causes pain on the affected side; Fajersztajn crossed sciatic s.
Back	Coopernail sign:	for fracture of pelvis; ecchymosis of the perineum, scrotum, or labia indicates a pelvic fracture.
Back	Dejerine sign:	for symptoms of a herniated nucleus pulposus (HNP); a Valsalva maneuver produces aggravation of symptoms of radiculitis by coughing, sneezing, and straining at stool.
Back	Demianoff sign:	for differentiation of pain originating in the lumbosacral muscle from lumbar pain of any other origin; the pain is caused by stretching of the lumbosacral muscle.
Back	Erichsen sign:	for sacroiliac disease; when the iliac bones are sharply pressed toward each other, pain is felt in the sacroiliac area.
Back	FABER sign:	for testing lower back or sacroiliac joint disorder by using a forced position of the hip; the letters stand for flexion abduction external rotation in extension; Patrick t., faber t., figure of 4 t.
Back	Gaenslen sign:	for lumbosacral disease; pressure on hyperextended thigh with the hip held in flexion elicits pain, indicating a lumbosacral problem.
Back	Amoss sign:	for painful flexure of the spine; pain is produced when the patient places his hands far behind him in bed and tries rising from supine position to sitting position.
Feet	Helbing sign:	for flatfoot; medialward curving of the Achilles tendon as viewed from behind.
Feet	Keen sign:	for Pott fracture of the fibula; if fracture exists, there is increased diameter around the malleoli area of the ankle.
Feet	Marie-Foix sign:	for central nervous system disorder; withdrawal of the lower leg on transverse pressure of the tarsus or forced flexion of toes, even when the leg is incapable of voluntary movement.
Feet	Morton test:	for metatarsalgia or neuroma; transverse pressure across heads of the metatarsals causes sharp pain in the forefoot.
Feet	Mulder's clunk	for Morton neuroma - palbable 'clunk' when compressing the metatarsal heads in the transverse direction & applying pressure to the affected web space
Feet	Nelson's toe spread sign:	for Morton neuroma; disproportional spreading of the toes, comparing one foot with the other.
Hand	prehension:	the ability to grasp with the fingers and thumb.
Hand	Finkelstein sign:	for synovitis; bending the thumb into the palm to determine synovitis of the abductor pollicis longus tendon to wrist.
Hand	pulp pinch:	the strength in the position one would use to pick up a piece of paper.
Hand	circumduction maneuver:	a maneuver for the thumb; any general test or motion involving a rotation action of a group of joints; a range of motion examination.
Hand	Allen test:	for occlusion of radial or ulnar artery; if compression of one vessel stops blood supply to the hand, the opposite vessel is occluded.
Hand	Froment paper sign:	for ulnar nerve loss; flexion of the distal phalanx of the thumb-with a sheet of paper held between the thumb and index finger, the thumb flexes on the side of the index finger.
Hand	Wartenberg sign:	for ulnar palsy; a sign noting the position of abduction assumed by the little finger. In describing the functional capacity of the hand, certain motions are peculiar to that anatomy. key pinch: the strength in the ability to grasp, as in holding a key; lateral pinch.
Hand	bracelet test:	for early rheumatoid arthritis involving the distal radioulnar joint; compression of the lower ends of the ulna and radius elicits moderate lateral pain.
Hand	Fowler maneuver:	a maneuver for testing rheumatoid arthritis; tight intrinsic muscles in ulnar deviation of the digits and a heavy, taut, ulnar band are demonstrated when the digit is held in its normal axial relationship.
Hand	Kanavel sign:	for infection of a tendon sheath; there is a point of maximum tenderness in the palm 1 inch proximal to the base of the little finger.
Hand	Phalen test and maneuver:	for carpal tunnel syndrome; impingement on the median nerve is determined by holding the wrist flexed or extended for 30 to 60 seconds.
Hand	Maisonneuve sign:	for Colles fracture; there is marked hyperextensibility of the hand.
Hip	Ortolani sign:	for congenital dislocated hip; an audible click is heard when the hip goes into the socket; noted in infancy; if the sign is elicited; the dislocation should be corrected at that time to avoid hip dysfunction later.
Hip	Galeazzi sign:	for congenital dislocation of the hip; the dislocated side is shorter when both thighs are flexed to 90 degrees, as demonstrated in infants; in an older patient a curvature of the spine is produced by shortened leg.
Hip	Jansen test:	for osteoarthritis deformans of the hip; the patient is asked to cross the legs with a point just above the ankle resting on the opposite knee. If significant disease exists, this test and motion are impossible.
Hip	Langoria sign:	for symptoms of intracapsular fracture of the femur; relaxation of the extensor muscles of the thigh is present.
Hip	Leadbetter maneuver:	for slipped capital femoral epiphysis; a maneuver to get the epiphysis in place.
Hip	Allis sign:	for femoral neck fracture; relaxation of the fascia between the crest of the ilium and the greater trochanter.
Hip	Trendelenburg test:	for muscular weakness in poliomyelitis, ununited fracture of the femoral neck, rheumatoid arthritis, coxa vara, and congenital dislocations. With the patient standing, weight is removed from one extremity. If gluteal fold drops on that side, it signifies muscular weakness of the opposite weight-bearing hip and weakness of the abductor of the weight-bearing hip. Also called Trendelenburg sign.
Hip	Nelaton line:	(x-ray and physical examinations): for detecting dislocation of the hip; a line from the anterosuperior iliac spine to the ischial tuberosity, which normally passes through the greater trochanter.
Hip	Ely test:	for determining tightness of the rectus femoris or contracture of the lateral fascia of the thigh; with patient in prone position, flexion of the leg on the thigh causes buttocks to arch away and leg to abduct at the hip joint.
Hip	anvil test:	for early hip joint disease or diseased vertebrae; a closed fist striking a blow to the sole of the foot with leg extended produces pain in the hip or vertebrae.
Hip	Thomas sign:	for hip joint flexion contracture; when the patient is walking, the fixed flexion of the hip can be compensated by lumbar lordosis. With the patient supine and flexing the opposite hip, the affected thigh raises off the table; Striimpell sign., Thomas test.
Hip	Chiene test:	for determining fracture of the neck of the femur by use of a tape measure.
Hip	piston sign:	for congenital dislocation of the head of the femur; if positive, there is up-and-down movement of the head of the femur; Dupuytren s.
Hip	Desault sign:	for intracapsular fracture of the hip; alternation of the arc described by rotation of the greater trochanter, which normally describes the segment of a circle but in this fracture rotates only as the apex of the femur rotates about its own axis.
Hip	Ludloff sign:	for traumatic separation of the epiphysis of the lesser trochanter; swelling and ecchymosis are present at the base of Scarpa triangle, together with inability to raise the thigh when in sitting position.
Knee	Apley test:	for differentiating ligamentous from meniscal injury; tibial rotation on femur with traction or compression with the patient prone and knee flexed; Apley s.
Knee	McMurray circumduction maneuver:	for noting joint menisci tears or tags; there is cartilage clicking medially or laterally on manipulation of the knee; McMurray s.
Knee	bayonet sign:	lateral placement of infrapatellar tendon with a valgus knee produces a bayonet appearance in the quadriceps patellar tendon complex.
Knee	British test:	for knee pain and/or injury; compression of patella during active quadriceps contraction as knee is extended elicits pain.
Knee	camelback sign:	an unusually prominent infrapatellar fat pad of the knee and hypertrophy of the vastus lateralis.
Knee	double camelback sign:	prominence of a high-riding patella and infrapatellar fat pad, producing the appearance of a camel back.
Knee	drawer sign:	for ligamentous instability or niptured cruciate ligaments; with the patient supine and knee flexed to 90 degrees, the sign is positive if knee is not displaced abnormally in a posterior direction with knee pulled forward. Also called an anterior drawer sign, meaning the anterior cruciate is lax or ruptured.
Knee	Lachman test:	with the patient supine and the knee flexed to 20 degrees, the tibia is pulled anteriorly. A "give" reaction or mushy end point indicates a torn anterior cruciate ligament.
Knee	patellar retraction test:	for synovitis; compression of patella causes pain when the patient attempts to set the quadriceps muscles with the knee in full extension.
Knee	pivot shift sign:	usually sports related; when the knee is brought to full extension, there is a sudden forward shift of the lateral side of knee.
Knee	Slocum test:	for rotatory instability of the knee; the examiner pulls on the upper calf of a supine patient with the knees flexed 90 degrees.
Knee	thumbnail test:	for patellar fracture; fracture is felt as a sharp crevice when the examiner's thumbnail is passed over the subcutaneous surface of the patella.
Knee	grimace test:	for knee pain or crepitus; if compression of the patella elicits pain or crepitus is noted, the patient will grimace.
Lower Limb	tourniquet test:	for phlebitis of the leg; toumique is applied to the thigh and pressure gradwincreased until the patient complains of pain ir the calf; result is compared with the effect on the Opposite leg.
Lower Limb	anterior tibial sign:	for spastic paraplegia; involuntary extension of the tibialis anterior muscle when thigh is forcibly flexed on the abdomen.
Lower Limb	Cleeman sign:	for distal fracture of femur with overriding of the fragments; shows creasing of the skin just above the patella
Lower Limb	Homans sign:	lower calf examination for thrombophlebitis; discomfort in the body of the calf on forced passive dorsiflexion of the foot indicates thrombosis in the leg.
Lower Limb	Ober test:	for tensor fascia femoris contracture (tightness); if fascia lata mechanism is tight, knee cannot extend fully when thigh is abducted.
Lower Limb	Payr sign:	early sign of impending postoperative thrombosis, indicated by tenderness when pressure is placed over the inner side of the foot.
Lower Limb	Schlesinger sign:	for extensor spasm at the kne joint; with patient's leg held at the knee joint an flexed strongly at the hip joint, there will follo~ an extensor spasm at the knee joint with extr~ supination of the foot.
Lower Limb	Addis test:	for determination of leg length discrepancy; with patient in prone position, flexing the knees to 90 degrees reveals the potential discrepancies of both tibial and femoral lengths.
Metabolic	Tensilon test:	for myasthenia gravis; a chemical test for denoting muscle strength or weakness; injection of edrophonium chloride (Tensilon) will reverse the symptoms in patients whose muscle weakness is caused by myasthenia gravis.
Metabolic	Chvostek sign:	for determining low serum calcium leading to tetany; tapping of cheek near the facial nerves causes the muscles to twitch or gointo spasm; Chvostek t., Chvostek-Weiss s., Weiss s., Schultze-Chvostek s.
Metabolic	lead line:	a blue line seen in the gums of a patient with lead poisoning; Burton s.
Neck	Rust sign:	for caries or malignant disease of the cervical vertebrae; the patient supports his head with his hands while moving his body.
Neck	anvil test:	for vertebral disorders; a closed fist striking blow on top of the head elicits pain in the vertebra(e).
Neck	Allen maneuver	for same diagnosis as Adson in., except the forearm is flexed at right angle with the arm extended horizontally and rotated externally at the shoulder, with the head rotated to the contralateral shoulder.
Neck	Adson maneuver	for scalenus anticus syndrome, noted on obliteration of radial pulse; upper limb to be tested is held in dependent position while head is rotated to the ipsilateral shoulder.
Neck	Spurling test:	for cervical spine and foraminal nerve encroachment; compression on the head with extension of the neck causes radicular pain into the upper extremities.
Neurologic	Moro reflex:	for testing normal early neurologic development or the failure to progress neurologically; the infant is placed on a table, then the table is forcibly struck from either side, causing the infant's arms to be thrown out as in an embrace; should disappear as infancy progresses.
Neurologic	pronation sign:	for central nervous disorders; there is a strong tendency for the forearm to pronate; Strumpell s.
Neurologic	Leichtenstern sign:	for cerebrospinal meningitis; tapping lightly on any bone of the extremities causes patient to wince suddenly.
Neurologic	Len sign:	for hemiplegia; passive flexion of the hand and wrist of the affected side shows no normal flexion at the elbow.
Neurologic	Lhermitte sign:	for cervical cord injuries or cord degeneration; transient dysesthesia and weakness are noted in all four limbs when the patient flexes the head forward.
Neurologic	long tract sign:	any sign that one would see in affection of either sensory or motor tracts in the spinal cord; Babinski reflex, Romberg t.
Neurologic	Mendel-Bekhterev reflex:	for organic hemiplegia; using a percussion hammer, the examiner notes flexion of the small toes if the dorsal surface of the cuboid bone is struck.
Neurologic	Morquio sign:	for epidemic poliomyelitis; the supine patient resists attempts to raise trunk to a sitting position until the legs are passively flexed.
Neurologic	Piotrowski sign:	for organic disease of the central nervous system; percussion of tibialis muscle produces dorsiflex ion and supination; anticus sign or reflex.
Neurologic	pseudo-Babinski sign:	in poliomyelitis the Babinski reflex is modified so only the big toe is extended, because all foot muscles except dorsiflexors of the big toe are paralyzed.
Neurologic	Queckenstedt sign:	for detecting a block in the vertebral canal; compression of veins in the neck on one or both sides produces rapid rise in pressure of cerebral spinal fluid of a healthy person and quickly disappears. But in a patient with blockage in vertebral canal, pressure of cerebrospinal fluid is little or not at all affected by this sign.
Neurologic	radialis sign:	for nerve impairment; inability to close the fist without marked dorsal extension of the wrist; Strumpell s.
Neurologic	Raimiste sign:	for paretic condition; patient's hand and arm are held upright by examiner; a sound hand remains upright on being released, but a paretic hand flexes abruptly at the wrist.
Neurologic	Romberg test:	for differentiation between peripheral and cerebellar ataxia; increase in clumsiness in movements and in width and uncertainty of gait when patient's eyes are closed indicate peripheral ataxia; no change indicates cerebellar type. (NOTE: Romberg sign is similar in testing but used for noting tabes dorsalis.)
Neurologic	Sarhb sign:	for locomotor ataxia; analgesia of peroneal nerve is noted.
Neurologic	Schreiber maneuver:	for patellar reflex testing; rubbing the inner side of the upper part of thigh enhances the reflex.
Neurologic	stairs sign:	in locomotor ataxia there is difficulty or failure of ability to descend stairs.
Neurologic	station test:	for coordination disturbance; feet are planted firmly together; if the body sways, lack of coordination is indicated.
Neurologic	tendon reflexes:	for testing continuity of normal muscle to spinal cord to muscle reflex arc. Any tendon may be so tested, but the most common are the deep tendon reflexes (DTRs):
Neurologic	Oppenheim sign:	for pyramidal tract disease; dorsal extension of the big toe is present when the medial side of the tibia is stroked in a downward direction.
Neurologic	Huntington sign:	for lesions of the pyramidal tract; patient is supine, with legs hanging over the examining table, and is asked to cough; if coughing produces fiexion of the thigh and extension of the leg in the paralyzed limb, a lesion is indicated.
Neurologic	contralateral sign:	see Brudzinski s.
Neurologic	doll's eyes sign:	for testing normal or abnormal brain function; the normal coordinated eye motions seen when passively turning the head of an unconscious patient; Cantelli s.
Neurologic	Ely test:	for L-3 and L-4 nerve root irritation; flexing thigh with patient prone causes back and/or thigh pain; femoral nerve stretch t., Ely s.
Neurologic	fan sign:	for central nerve problems; stroking the sole of the foot with a needle causes toes to spread; part of Babinski reflex examination.
Neurologic	finger to nose test:	for cerebellar disease; when the patient attempts to put a finger on his nose and then to the examiner's finger, back and forth rapidly, any incoordination indicates test to be positive.
Neurologic	Fournier test:	for determining ataxic gait; it is noted with the patient moving about abruptly in walking, starting, and stopping.
Neurologic	Frankel sign:	for tabes dorsalis; noted by diminished tonicity of muscles about the hip joint.
Neurologic	Guilland sign:	for meningeal irritation; when the contralateral quadriceps muscle group is pinched, there is brisk flexion at the hip and knee joint.
Neurologic	tibialis sign:	for spastic paralysis of the lower limb; there is dorsiflex ion of the foot when the thigh is drawn toward the body; tibial phenomenon.
Neurologic	Hoffmann sign:	for testing digital reflex; nipping of three fingernails (index, middle, ring) produces flexion of terminal phalanx of thumb and second and third phalanx of some other finger; digital reflex. Indicative of a cervical myelopathy
Neurologic	Babinski reflex:	for loss of brain control to lower extremities; scraping the soles causes toes to pull up; Babinski s.
Neurologic	Jendrassik maneuver:	to enhance a patellar reflex; the reflex is tested when the patient hooks hands together with flexed fingers and pulls apart as hard as possible.
Neurologic	Kernig sign:	for meningitis; in dorsal decubitus, the patient can easily and completely extend the leg; in sitting or lying down with thigh flexed upon the abdomen the leg cannot be completely extended.
Neurologic	Kerr sign:	for spinal cord lesions; alteration of the texture of the skin below the somatic level in eliciting location of lesions.
Neurologic	Brudzinski sign:	for meningitis; flexion of the neck forward results in flexion of the hip and knee; when passive flexion of the lower limb on one side is made, a similar movement will be seen in the opposite limb; neck s., contralateral s.
Neurologic	Thomas sign:	for cord lesions; pinching of the trapezius muscle causes goose bumps above the level of the cord lesion.
Neurologic	Beevor sign:	for functional paralysis; excursion of the umbilicus occurs when the patient attempts to sit up.
Neurologic	Tinel sign:	for noting a partial lesion or beginning regeneration of a nerve; tingling sensation of the distal end of a limb when percussion is made over the site of divided nerve as in carpal tunnel impingement on the median nerve of the hand; formication s., distal tingling on percussion (DTP) s
Neurologic	Chaddock sign:	for upper motor neuron loss (brain); the big toe extends when irritating the skin in the external malleolar region; indicates lesions of the corticospinal paths; external malleolus s., Chaddock reflex.
Neurologic	Hirschberg sign:	for pyramidal tract disease; internal rotation and adduction of foot on rubbing inner lateral side.
Shoulder	Callaway test:	for dislocation of the humerus; the circumference of the affected shoulder measured over the acromion and through the axilla is greater than that on the opposite, unaffected side.
Shoulder	Codman sign:	for rupture of the supraspinatus tendon; the arm can be passively abducted without pain, but when support of the arm is removed and the deltoid muscle contracts suddenly, pain occurs again.
Shoulder	Comolli sign:	for scapular fracture; shortly a injury, there is triangular swelling, reproduci the shape of the body of the scapula.
Shoulder	Dawbarn sign:	for acute subacromial bursiti with arm hanging by side, palpation over t. bursa causes pain; when the arm is pain disappears.
Shoulder	Dugas test:	for dislocation of the shoulder; placing hand of affected side on opposite shoulder bringing elbow to side of chest, a dislocation may be present if the patient's elbow will touch side of his chest; Dugas s.
Shoulder	Hamilton test:	for luxated shoulder; a rod applied to the humerus can be made to touch the lateral epicondyle and acromion at the same time to determine a dislocation.
Shoulder	Kocher maneuver:	for reducing anterior dislocations of the shoulder; done by abducting arm, externally rotating, adduction, and then internally rotating.
Shoulder	Bryant sign:	for dislocation of the shoulder with lowering of the axillary folds, as noted on visual examination.
Upper Limb	Laugier sign:	for a displaced distal radial fracture; condition in which the styloid process of radius and ulna are on same level.
Upper Limb	Mills test:	for tennis elbow; with wrist and fingers fully flexed and the forearm pronated, complete extension of the elbow is painful.

Cauda Equina Syndrome

2007-10-07T22:26:00.001-07:00

Secondary to Lumbar Disc Herniation

A Meta Analysis of Surgical Outcomes

Spine Vol 25 No. 12 pp1523-1532

Introduction

Definition of CES as a severe neurological deficit with clinical features of low back pain, sciatica, saddle anaesthesia, motor weakness, sensory deficit, urinary incontinence.
CES is the primary absolute indication for the acute surgical treatment of lumbar disc herniation
There have been small studies recommending early rather than late decompression but others saying that late surgery can give satisfactory outcomes
Purpose of this study was to increase the statistical power of previous studies in the English literature of CES caused by herniated lumbar disc.
The aims were to
Find specific preoperative variables which are significantly associated with good or bad post op outcomes
Determine whether there is a correlation between the time of surgery after onset of CES and outcomes of surgery

Materials and Methods

MEDLINE search from Jan 1966 to May 1999
Eligible studies (42 papers out of 104)
A collection of patients was only included if the following preop and post op variables were known

Preop variables	Post op variables
Age	Resolution of pain
Gender	Resolution of sensory deficit
Occupation	Resolution of motor deficit
History of previous spinal surgery	Resolution of urinary incontinence
History of chronic low back pain	Resolution of sexual dysfunction
Duration of chronic back pain prior to CES	Resolution of rectal dysfunction
History of trauma with onset of CES
Sudden onset of CES
Presence of sciatica with CES
Preop weakness of legs
Preop sensory deficit
Preop loss of reflexes
Preop rectal dysfunction
Length of time to surgery from onset of CES

Univariate logistic regression analysis was used to compare each post op outcome with preop variables
Analysis of time to surgery was performed separately
5 groups were constructed
1. <24>
2. 24-48 hrs
3. 2-10 days
4. 11 days to 1 month
5. More than 1 month
Time of onset of CES defined as time of onset of sphincter disturbance
Resolution of sensory and motor deficits defined as complete recovery.
Partial recovery of deficits recorded as a failure to resolve

Results

322 patients
69% sudden onset
82 % chronic low back pain
Trauma in 62% of cases
Significant associations
- Worse prognosis for urinary incontinence if patient had preop chronic lower back pain. (11 x the risk) or preop rectal dysfunction
- Prognosis for rectal function worse with a history of preop chronic low back pain (25 x the risk)
- Prognosis for return of sensory deficit worse if preop rectal dysfunction present (1.15x the risk)
- Older patients had a worse prognosis for sexual dysfunction (by 2.6x if older by 10yrs)
Times to decompression
- Better outcome in those decompressed before 48 hrs than those after 48 hours
- No significant difference in outcome between those decompressed at <>
- No significant difference in outcome between all three groups decompressed at > 48 hrs

Discussion

Comparison of the above results with smaller studies are consistent although the smaller studies do not show statistical significance
Acknowledgement that the follow ups in the papers included did vary, and recovery from cauda equina can occur up to 5 years after surgery
Acknowledgement that different operative procedures were used
Acknowledgement of the problems of metaanalysis- different studies report results in different ways, some more objectively than others, some were prospective, some retrospective

A Standard Trendelenburg Test

2007-10-07T22:24:00.000-07:00

from: Hardcastle & Nade. JBJS(B): 67-B(5):741-6

As a result of our observations, we have formulated a standard method of performing the Trendelenburg test; if this is used the response can be interpreted in a clinically meaningful way. To perform the test properly does take time, and its accurate assessment demands the full understanding and co-operation of the patient.

How to do the test

1. The examiner stands behind the patient and observes the angle between the pelvis (the line joining the iliac crests) and the ground (Fig. 7).

2. The patient is asked to raise from the ground the foot of the side not being tested, holding the hip joint at between neutral and 30 of flexion. The knee should be flexed enough to allow the foot to be clear of the ground in order to nullify the effect of the rectus femoris muscle. The position of the pelvis is again noted (Fig 8) A supporting stick can be used in the hand only on the side of the weight-bearing hip; alternatively, both shoulders can be supported by the examiner so as to maintain balance without a stick (Fig. 12).

3. Once balanced, the patient is then asked to raise the non stance side of the pelvis as high as possible (Fig 9). The examiner may support the patient by holding the arm on the stance side (Fig 10; compare with Fig. 11)

4. If the patient leans too far over to the side of the weight-bearing hip, the examiner corrects this by gentle pressure on the shoulders to bring the vertebra prominens approximately over the centre of the hip joint and the weight-bearing foot (Fig. 12).

Interpretation

(a) The response is NORMAL (i.e. the test is "-negative") if the pelvis on the non-stance side can be elevated as high as hip abduction on the stance side will allow, and providing this posture can be maintained for 30 seconds with the vertebra prominens centred over the hip and foot.

(b) The response is ABNORMAL (i.e. the test is "positiveâ€) it' this cannot be done. This includes responses where the pelvis is elevated on the non-stance side above the stance side, but where this elevation is not maximal.

(c) The response is also ABNORMAL if the pelvis can be lifted on command, hut can not be maintained in that position for 30 seconds. The time taken before the pelvis starts to fall is recorded. By introducing a time ele-ment, the Trendelenburg test can be objectively recorded for comparison purposes. Obviously the response described in (b) constitutes a zero time Trendelenburg test.

Non-valid responses. In the presence of back or leg pain or of deformity, or if the patient is uncooperative because of age or mental status, inappropriate responses may arise (Table II). An abnormal response (positive test) in these circumstances can be misleading. However, if the test is negative that is significant-it means that the subject does not have abnormal hip mechanics

Significance

Neurological disorders. MRC Grade 5 abductor muscle strength was required to produce a normal response. All subjects whose hip abductor power was Grade 4 or less had abnormal responses at times between 0 and 25 seconds. Some patients in this group were able to elevate the pelvis, but not to the full extent. We considered this to be a positive Trendelcnburg test at 0 seconds.

One subject who had Grade 5 strength on clinical testing had a delayed (or timed) positive Trendelenburg test at 15 seconds. Only one subject with Grade 3 hip abductors had an initial negative response which became positive at 5 seconds (a delayed positive test). He had a good rectus femoris muscle which probably helped. The two subjects with isolated nerve root entrapment of L5 or SI had negative responses.

Mechanical disorders.

Congenital dislocation of the hip. The Trendelenburg test was always positive in subjects with congenital dislocation of the hip. One patient who had been treated by bilateral replacement arthroplasty had a normal response when examined three years after surgery.

S ubl uxating hips. Mitchell (1973) has described the importance of the delayed (timed) Trendelenhurg test in assessing clinical deterioration in adolescents with acetabular dysplasia. Our two patients with subluxating hips both had positive (timed) Trendelenburg tests, one at 15 and one at 20 seconds.

Coxa vara. The test may be positive or negative depend-ing on the femoral neck angle and the presence of degenerative changes. With femoral neck angles of up to 100 degrees the response can be normal. One child with an angle of 90 after a varus osteotomy had a positive test at 20 seconds.

Slipped femoral capital epiphysis. The Trendelenburg test was not altered by the rotation of the femoral head in relation to the femoral neck and the subjects examined all had negative responses if they were pain free.

Perthes disease. The Trendelenburg test was not altered by the size of the femoral head. However, if there is incongruity or hinge abduction the test can become posi-tive, and a delayed positive response was seen in one subject.

Arthritis of the hip. Variable responses were observed but the type of response did not vary in the same individual when studied at different times. Obviously pain or progression of the disease would be expected to alter the response, particularly in respect to reduction of time of the normal response.

Leg length inequality after hip arthroplasty. Two patients with up to 2cm of shortening above the intertrochanteric line after hip replacement had negative Trendelenburg tests (i.e. normal responses).

Avulsion of the greater trochanter after hip arthroplasty. In the absence of pain, the Trendelenburg test was particularly valuable some time after operation. Where the osteotomy gap was greater than 2 cm the Trendelenburg test was positive either immediately (zero time) or with a delayed positive response.

Fractured neck of femur. Patients who had unstable fixation with Ender or Zickel nails had a positive response until the fracture was united radiologically. These people were tested initially 8 to 10 weeks after operation and had no pain at the time of their initial Trendelenburg response, which was positive. Two malunited fractures also had positive responses.

Avascular necrosis of the f e moral head. Hip pain made proper assessment of these cases difficult. However, one of our four patients had only mild symptoms; his test was positive at 20 seconds on the first examination, and at 25 seconds on the next day. In the other patients pain pre-vented adequate assessment.

Spinal disorders :

St i ffness. Totally stiff spines, as in ankylosing spondylitis, did not affect the test unless there was also abnormality of the hip or gross spinal deformity.

Deformity. Kyphosis did not affect the outcome. Severe scoliosis, however, may lead to impingement between the lower costal margin and the iliac crest and give a false-positive test.

Pain. Nerve root irritation can lead to false-positive results, but back pain itself did not lead to abnormal responses.

DISCUSSION

When asked to stand on one leg, and follow a standard routine to ensure hip abductor muscle contraction on the same side, patients may respond to the standardised Trendelenburg test in one of three ways. Only one response is normal; the other two are abnormal. An ability to assume the normal response must be absolute, and if the pelvis drops on the non-stance side within 30 seconds the Trendelenburg test is positive. The use of a timer is an essential part of the Trendelenburg test, and, indeed, makes it an objective measure of severity of altered hip mechanics.

However, the presence of pain, poor balance and either lack of co-operation or understanding by the patient can lead to false-positive tests, because the test cannot he properly performed. The reason for false-negative tests is that the subject uses muscles above the pelvis to elevate the non-weight-bearing side of the pelvis, or shifts the torso well over the weight-bearing side; these can be called "trick movementsâ€. Variable responses were noted in some patients less than seven years of age, and the test is of no value in children under four. Nevertheless, if the Trendelenburg test is carefully performed, it is an accurate clinical sign with prognostic implications.

Inman (1947) measured the torque strength about the hip with the pelvis in different postures with respect to the ground. Our electromyographic results confirm his findings that little abductor muscle strength/activity is necessary to maintain a balanced posture with the pelvis dropped (as in Response 3) on the non-weight-bearing side. As the pelvis rises on this side there is increase of abductor muscle activity provided that the torso is centred over the hip.

Functional assessment of a joint is important in the clinical assessment of patients. Observation of gait is probably performed less often than is desirable because of limitation of space. The Trendelenburg test allows for functional assessment in a confined space, and is a more valuable clinical sign than many static tests. It can also be easily recorded on film or videotape.

It is our belief that a patient who has an abnormal response to the Trendelenburg test as described in this paper has an inefficient gait, and therefore becomes easily fatigued. With a little practice, the test is not difficult to perform and interpret. Timing is an essential part of the test; it provides an objective measure of improvement or deterioration in the neuromuscular or mechanical function of the hip.

Trendelenburg's original observations were precise and clear, and his interpretations accurate. We support the need for meticulous clinical examination in order to provide correct diagnosis and we recommend the use of the standardised timed Trendelenhurg test in the assessment of function and malfunction of the hip.

Conclusions

1. The Trendelenburg test is a useful part of clinical examination if performed and interpreted correctly. We have described a standard method for performing the test.

2. False-positive and false-negative responses may occur, but their interpretation can be clarified if the test is properly performed.

3. The use of a timer when performing the test is essen-tial, and allows measurement of a "delayed abnor-mal" response.

REFERENCES

Inman VI. Functional aspects of the abductor muscles of the hip. J Bone Joint Surg~BrJ 1947;29:607-19.
Mitchell GP. The delayed Trendelenburg hip test. I nt Con gr Ser 1973; 291:1113.
Rang M. Anthology of orthopaedics. Edinburgh. E&S Livingstone, 1966; 139-43.

Amputations & prosthetics of the upper limb

2007-10-07T02:06:00.000-07:00

Forequarter Amputation

is the removal of the upper limb in the interval between the scapula and the chest wall
Mainly for malignancy
Anterior (Berger) vs posterior (Littlewood)
Difficult skin flaps
ref: Littlewood " Amputations at the shoulder and the hip" Br Med J 1: 381, 1922

Shoulder disarticulation

Racquet incision from tip of coracoid, along ant deltoid ,over deltoid insertion laterally, along post deltoid to post axillary fold, then back across the axilla to the ant side
Ligate cephalic vein
Reflect pectoralis major off its insertion
Locate neurovascular structures in interval between coracobrachialis and pectoralis minor
Ligate axillary artery and divide nerves under gentle tension allowing them to retract
Reflect deltoid off its insertion and divide latisimus dorsi and teres major near the bicipital groove
Divide biceps and triceps tendons 2cm distal to the level of bony resection (at origin of disarticulation)

For proximal amputation
- Resect bone at desired level
- then suture the LHT, LHB + SHB, and coracobrachialis over the end of the humerus and swing pec major laterally and suture to the end of the bone
For disarticulation
1. divide capsule and rotator cuff
2. then reflect the cut ends of all the muscles over the glenoid and suture them there - and secure muscle ends over the glenoid cavity
3. then bring the deltoid flap inferiorly and suture just inferior to the glenoid
4. Trim coracoid if too prominent
Close skin over drains

Above Elbow Amputations

Use equal anterior and posterior flaps.
Divide flexors 1.3cm below the level of bony resection, and the triceps 4cm below the bony resection.
Suture triceps to anterior fascia.

Elbow disarticulation

Use equal anterior and posterior flaps with the apices at the level of the humeral condyles and flap extending 2.5cm distal to the olecranon posteriorly and to level of insertion of biceps tendon anteriorly.
Free muscle attachments to medial and lateral condyles
Ligate nerves under tension
Leave the articular surface intact and suture triceps tendon to brachialis, and remnant of flexors to extensors.
Close flaps over drains

Below Elbow Amputations

Preserve Length
Fish mouth equal anterior and posterior flaps about 1/2 the diameter of the arm at the level of the amputation.
Myoplastic closure suturing FDS to the extensor group.

Transradial Amputation

High functional level
Rotation proportional to residual length
Good for myoelectric implants

Krukenberg procedure

Separate radial and ulna rays distally -> radial and ulna pincers capable of strong prehension and excellent manipulative ability.
Especially useful for blind patients with bilateral BEA's but may be of some use in other amputees as well.

Wrist disarticulation

Preserves forearm rotation
Flare of distal radius improves prosthetic suspension
Difficult prosthetic fitting due to length
Fish mouth starts 1.3cm proximal to radial styloid
Resect radial and ulna styloids' without damage to distal radio-ulna joint and triangular fibro- cartilage.
Tendons are divided and allowed to retract.

Transcarpal

Results in limited pronation and supination, flexion and extension preserved.
Use a long palmar and short dorsal fish mouth flap (2:1)
Suture tendons over the ends of the carpus

Hand Amputations

Preserve length, function, sensation
Salvage procedure
Primary amputation for irreversible loss of blood supply and tumours.
Consider:
- Ultimate function
- Other fingers involved
- Delaying (use of parts)
Salvage thumb

Fingertip

2' intention
VY Atasoy/Kutler
Skin graft
Thenar flap

Finger Amputation

Index

Distal to PIPJ
Proximal to base Mc
Avoid damage to digital nerve
Reinsert 1st dorsal interosseous into prox phalanx of long finger

Ring/Middle Finger Amputation

Preserve proximal phalanx
Close gap
- Suture transverse ligaments
- Consider metacarpal transfer

Thumb Amputation

Preserve:
- Length
- Stability
- Sensation
- Mobility
- Cosmesis
Closure:
- 2' intention
- Graft
- Reconstruction
- Toe transfer
- Pollicization

Upper Limb Prosthetics (also see Prosthetics Summary)

Position hand in space
Limb length and joint salvage are directly related to functional outcome
Sensation important for function (cf lower limb)
Early fitting (85% if in 30 days, 50% with late fitting)
Shoulder Amputations
- Proximal humeral amputations behave like a shoulder disarticulation, but better cosmesis and suspension
- Prostheses provide a post, and cosmesis
Elbow/ Humeral Amputation
- Better suspension with elbow disarticulation but poor cosmesis
- Better function with distal humeral amputation (3.5 cm proximal to elbow)

Amputation Principles

2007-10-07T02:04:00.001-07:00

Indications for Amputation:

Peripheral vascular disease
Trauma
1. Insensate limb distally
2. Facilities
3. MESS score
Infection
Tumours
Nerve injury (trophic ulceration)
Congenital anomalies

Aims:

Return Patient to maximum level of independent function
Ablation of diseased tissue
Reduce morbidity & mortality
Considered first part of a Reconstruction to produce a physiological end organ
Requires a Multidisciplinary approach

Pre-operative Evaluation

Tissue
1. Clinical - feel pulses, skin temperature, level of dependent rubor
2. Doppler - Ankle/ Brachial index more than .45 = 90% healing; inaccurate with calcified vessels
3. Toe systolic BP - 55 mm Hg min for distal healing
4. Transcutaneous PO ₂min 35 for assured healing
5. Arteriogram
6. Other:
  1. Skin blood flow (Xe 133 clearance)
  2. thermography
  3. thallium scanning
Immune Competence
1. serum albumin at least 3g/dl
2. WCC more than 1500/ mL
Systemic
1. control diabetes
2. evaluate cardiac, renal + cerebral circulation
3. Preop TPN in malnourished pt
Psychological
1. early plan for return to function
2. preop counselling
3. amputee support groups
Preop Pain Control
1. Pain clinic review
2. Spinal anaesthesia

Surgical Principles

Level [ Diagram below ]

Amputation Levels (for prosthesis fitting):	Optimum	Shortest	Longest
Transradial (forearm)	junction prox 2/3 & distal 1/3	3cm below biceps insertion	5cm above wrist joint
Transhumeral	middle third	4cm below axillary fold	10cm above olecranon
Transfemoral	middle third	8cm below pubic ramus	15cm above medial joint line of knee
Transtibial	8cm for every metre of height	7.5cm below medial joint line of knee	level at which myoplasty can be done

Skin flaps
- Use defined flaps electively with the apex of the fish mouth at the level of the bony resection
- Use any available flaps in trauma to preserve length
- Tailor flaps at least as long as the diameter of the stump
Muscles
- Divide ~5 cm distal to level of bone resection
- Bevelling or contouring may be required for good stump shape
- Stabilisation of muscle mass
- provides stump padding
- prevents atrophy
- counterbalances deforming forces
- improves function
- prevents bursa formation
- Myoplasty = involves suture of flexors to the extensors over bony stump
- Myodesis = direct suture of muscle to bone - most useful in AK, AE and disarticulations
Nerves
- Divide cleanly under gentle tension proximal to bone ends - allow to retract
- Large nerves eg sciatic - ligate due to large contained vessels
Blood vessels
- Large arteries & veins should be doubly ligated and haemostasis achieved prior to closure
Bone
- Avoid excessive periosteal stripping (prevent spur formation)
- Bevel & smooth bone
Closure
- Do not close under tension
- Interrupted sutures preferably
Drains
- are necessary
metabolic costs
- higher with more proximal amputations (incr. O ₂consumption)

Children

Usually for congenital limb deficiencies
Try to retain limb if possible
Preserve length
Disarticulate if possible to preserve growth potential rather than trans-diaphyseal amputation (-> bony overgrowth)

Aftercare

Rigid vs soft dressing
Compression -Avoid proximal compression
PAM Aid
Prevent contracture
Early prosthetic fitting

Complications

Haematoma
Infection
Necrosis
Contractures
Neuroma
Phantom pain
Terminal overgrowth (children)

Prosthetics

2007-10-07T01:57:00.001-07:00

Prosthesis - replaces a missing limb or body segment (Orthotic supports a body segment)

Amputations should be considered constructive procedure rather than destructive.

Amputation Levels (for prosthesis fitting):	Optimum	Shortest	Longest
Transradial (forearm)	junction prox 2/3 & distal 1/3	3cm below biceps insertion	5cm above wrist joint
Transhumeral	middle third	4cm below axillary fold	10cm above olecranon
Transfemoral	middle third	8cm below pubic ramus	15cm above medial joint line of knee
Transtibial	8cm for every metre of height	7.5cm below medial joint line of knee	level at which myoplasty can be done

Disarticulations

Advantages:

retention of WBing surface
bulbous stump assists prosthetic suspension

Disadvantages:

compromise the choice & siting of joint
bulky appearing prosthesis

Ideal Stump:

Healed, mobile scar
Sensate
Cylindrical or conical shape
Myoplastic procedure
Nerves sectioned under tension
Bone ends bevelled

Elements of a Prosthesis:

1. Socket

transmits forces between the stump & the prosthesis in all planes
may be proximal, distal or total bearing

2. Means of Suspension

suction socket
suspension belts
neoprene sleeve
elastic stocking
silicone sleeve

3. Joint mechanism (knee)

Stance phase control
- Simple:
  - aligns the prosthesis so the ground reaction force passes in front of the knee
  - locks in hyperextension; 2 drums lock at 0-15deg.
  - for elderly
- Mechanical stabilisers
  - braking mechanism activated by the WBing load or hydraulics
Swing phase control
1. Pneumatic cylinder
2. Hydraulic cylinder
3. Intelligent prosthesis - computer adjusts rate of swing to cadence (steps/min)

4. Terminal device (hand / foot)

Foot
1. non-articulated
2. solid ankle cushoin heel (SACH)
3. articulated (uniaxial / multi-axial)
4. energy storing

Orthoses

2007-10-07T01:55:00.000-07:00

An externally applied device used to control motion & function of body segments

Compensate for a disorder & reduce handicap for biomechanical (& psychological) reasons.

Orthoses rely on 3 point fixation, moment arms & pressure distribution.

Named according to the joints over which they pass (eg. KAFO = Knee Ankle Foot Orthosis)

Descriptive Terms:

Conventional (leather, metal) vs. Contemporary (plastics)
Static, dynamic (store energy) or a combination
Corrective vs. Accommodative

Materials used:

Thermosetting plastics - mix liquid + catalysts to form model
Thermoforming plastics - soften when reheated & rigid when cooled
Lightweight foam plastics

Common Orthoses:

Insoles

Simple insoles - off the shelf or fabricated without casting
Total contact or Moulded insoles - taking a cast with the patient partially or fully WBing
Functional or Biomechanical orthosis - cast taken in corrected position of subtalar joint neutral & mid-tarsal full pronation

Gait

2007-10-07T01:23:00.000-07:00

DEFINITIONS

(see Walking Cycle Picture )

Step = The advancement of a single foot

Stride = The advancement of both feet (one step by each side of your body.)

Step length = longitudinal distance between 2 feet

Stride length = distance covered during 1 cycle = 2 step lengths

Velocity = stride length/cycle time (m/s)

Cadence = steps /minute

Double support = both feet on ground

Float phase = neither foot is on the ground

PHASES OF GAIT CYCLE

Gait has been divided into eight descriptive stages for the purpose of assessment, this is obviously an artificial division as these are all points within a moving continuum, however it is a useful way of providing reference points for comparisons to be made

Normal Gait

Cycle begins when foot strikes the ground and ends when it strikes the ground again

Stance phase:

Heel strike to toe off
60% gait cycle
2 periods of double stance 10% each -at these times the body's centre of gravity is at its lowest
Divided into 5 phases:
1. Initial contact
  - at initial contact, the knee is extended and the ankle is neutral (or slightly plantarflexed)
  - Normally, the heel contacts the ground first (in patients with pathological gait patterns, the entire foot or the toes contact the ground initially)
2. Loading response
  - Loading response corresponds to the gait cycle's first period of double limb support & ends with contralateral toe off , when the opposite extremity leaves the ground.
  - during loading, knee flexes 15 deg while ankle plantarflexes 15 degrees, which is an energy-conserving mechanism
  - throughout first phase of stance, hamstrings and ankle dorsiflexors remain active
  - quadriceps and gluteal muscles act during loading and throughout early midstance to maintain hip and knee stability
3. Midstance
  - begins with contralateral toe off and ends when the center of gravity is directly over the reference foot
  - by midstance the knee is extended & ankle is neutral again
  - the triceps surae acts to control tibial advancement (preventing the tendency for the tendency for the ankle to dorsiflex due to body wt and inertia)
4. Terminal stance
  - begins when the center of gravity is over the supporting foot and ends when the contralateral foot contacts the ground
  - Terminal stance & midstance are the only phases when the centre of gravity truly lies over the base of support.
5. Pre-swing
  - begins at contralateral initial contact and ends at toe off
  - preswing corresponds to the gait cycle's second period of double limb support
  - at preswing, knee flexes 35 degrees & ankle plantarflexes 20 degrees
  - in these last phases of stance, the toes, which have been neutral, dorsiflex at the metatarsophalangeal joints;

Swing phase:

40% gait cycle
during swing, the ankle dorsiflexes by the concentric contraction of anterior tibialis muscle; all other muscles are silent
sub-talar joint assumes near neutral position, & toes dorsiflex slightly as foot prepares for next period of stance

Initial swing
- begins at toe off and continues until maximum knee flexion (60 degrees) occurs
- contraction of the quadriceps, initiated before toe off, serves two purposes
  1. it prevents heel from rising too high in a posterior direction
  2. it helps to initiate the forward swing of the leg
Mid-swing
- from maximum knee flexion until the tibia is vertical or perpendicular to the ground
Terminal swing
- begins where the tibia is vertical and ends at initial contact.
- hamstrings muscles become active to decelerate forward swing of the leg and thereby control the position of the foot at heel strike

Distance & Time Dimensions of Walking Cylcle (Picture)

Running:

the two periods of double support are replaced by periods of double float
Stance time less than swing time

COMPONENTS OF GAIT

1. Stability of Stance

compromised in cerebral palsy by- Abnormal foot position in stance, poor balance d.t. loss of trunk/ lower limb motor control

2. Foot clearance in swing

compromised in CP by decr. knee motion, ankle DF

3. Step length

compromised in CP by knee extensors, unstable foot in stance, weak PF at push off

4. Pre-positioning for initial contact

compromised in CP by foot position in stance

5. Energy conservation

Ground Reaction Force

Newton's third law states that every action must have an equal and opposite reaction, therefore the downward force passing through the foot when it bears weight must be matched by an equal and opposite upward force. This force may pass in front or behind the hip and knee and so act as either a flexor or extensor force, the direction of its action in relation to the joints being dependent on the joint positions and normally varies through the gait cycle. If the joint positions or the cadence of the gait are altered from normal then the effect of this force may be changed.

In normal gait the ground reaction force (GRF) passes anterior to the hip and knee until just before toe off. This therefore produces an extensor force reducing which acts to reduce the work required from quadriceps during the stance phase. During terminal stance and preswing the force passes behind the hip and knee and acts as a flexor so reducing the work requirement for hip and knee flexion.

It anything prevents this normal progression it will therefore increase the energy expenditure required. This effect can be illustrated by considering the effect of excessive heel cord lengthening, weakening plantar flexion thus causing the foot to be dorsiflexed when weight bearing. In this scenario the GRF passes posterior to the knee and anterior to the hip for almost the whole gait cycle, tending to produce a crouch posture that can only be resisted by muscle action. Once this is established the further the crouch deepens the greater the force tending to produce it becomes; as cerebral palsy often causes weakness as well as spasticity this may be sufficient to prevent walking.

Energy Storage

Normal gait is very energy efficient, in addition to the way that ground reaction force acts to reduce work, accurate control of muscles allows energy to be stored in them by the use of eccentric contracture. This effect can be illustrated with regard to the ankle. Perry described ankle movement in terms of three stages or rockers, the second being that time from the foot being placed flat on the ground until heel lift off. During the forward progression of the tibia triceps surae undergoes eccentric contracture storing energy within the muscle. This effect also occurs at other muscles, Gage attributing this particularly to the biarticular muscles, reduction in control of these, in particular spasticity, reduces this effect, increasing work requirement.

Much of kinetic energy for swinging limb is provided by inertia, which is augmented by the plantarflexors (85%) and hip flexors (15%). Energy is conserved by minimizing movements of center of gravity of body, by controlling momentum, and by transfer of energy between body segments.

Force Vectors

Loss of normal limb positioning may again act to disadvantage muscle action. This effect can be illustrated by the effect of external rotation at the foot. As the movement at the ankle can be considered to be around a fulcrum sited at the talar dome, the force produced by tricips surae can be resolved into extension and valgus components. Normally as the axis of the foot is close to the line of progression of the body the valgus component is small, however as the foot externally rotates and this increases, there is a concomitant decrease in the extensor moment. This means that for a given power of toe for an increased workload is required.

Also See :

Foot & Ankle Mechanics
Gait Abnormalities

Foot & Ankle Mechanics
Gait Abnormalities

Foot & Ankle Mechanics
Gait Abnormalities

Foot & Ankle Mechanics
Gait Abnormalities