Shoulder Examination

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 ^o check 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 ^o internal 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 ^o flexion, 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 ^o flexion, 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 ^o abduction & 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

Look at the:

• Patient

• Problem

• Props (aids, testing devices etc.)

Ask:

• about tender areas

Feel

Move

• Active

• Passive

Special Tests

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Neurological Problem

• Test sensation before motor

• Patient

• Problem

• Props (aids, testing devices etc.)

Ask:

• about tender areas

Feel

Move

• Active

• Passive

Special Tests

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Neurological Problem

• Test sensation before motor

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

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

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

1. popliteus tendon

2. arcuate ligament

3. 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

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KNEE DISLOCATIONS

Clinical Findings:

1. 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.

2. 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

3. 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

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:

1. Mental Status
2. Cranial Nerves
3. Motor
4. Coordination and Gait
5. Reflexes
6. Sensory
7. 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

1. Ask the patient to relax.
2. Flex and extend the patient's fingers, wrist, and elbow.
3. Flex and extend patient's ankle and knee.
4. There is normally a small, continuous resistance to passive movement.
5. 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:

1. Flexion at the elbow (C5, C6, biceps)
2. Extension at the elbow (C6, C7, C8, triceps)
3. Extension at the wrist (C6, C7, C8, radial nerve)
4. Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1)
5. Finger abduction (C8, T1, ulnar nerve)
6. Oppostion of the thumb (C8, T1, median nerve)
7. Flexion at the hip (L2, L3, L4, iliopsoas)
8. Adduction at the hips (L2, L3, L4, adductors)
9. Abduction at the hips (L4, L5, S1, gluteus medius and minimus)
10. Extension at the hips (S1, gluteus maximus)
11. Extension at the knee (L2, L3, L4, quadriceps)
12. Flexion at the knee (L4, L5, S1, S2, hamstrings)
13. Dorsiflexion at the ankle (L4, L5)
14. Plantar flexion (S1)

Pronator Drift

1. Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed.
2. Instruct the patient to keep the arms still while you tap them briskly downward.
3. 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

1. 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.
2. Ask the patient to tap the distal joint of the thumb with the tip of the index finger as fast as possible.
3. Ask the patient to tap your hand with the ball of each foot as fast as possible.

Point-to-Point Movements

1. 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]
2. 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.
3. 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

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

Gait

Ask the patient to:

1. Walk across the room, turn and come back
2. Walk heel-to-toe in a straight line
3. Walk on their toes in a straight line
4. Walk on their heels in a straight line
5. Hop in place on each foot
6. Do a shallow knee bend
7. 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)

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

• Triceps (C6, C7)

1. Support the upper arm and let the patient's forearm hang free.
2. Strike the triceps tendon above the elbow with the broad side of the hammer.
3. 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)

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

• Abdominal (T8, T9, T10, T11, T12)

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

• Knee (L2, L3, L4)

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

• Ankle (S1, S2)

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

Clonus

If the reflexes seem hyperactive, test for ankle clonus:

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

Plantar Response (Babinski)

1. Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key.
2. Note movement of the toes, normally flexion (withdrawal).
3. 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.

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

• If vibration sense is impaired proceed proximally:

1. Wrists
2. Elbows
3. Medial malleoli
4. Patellas
5. Anterior superior iliac spines
6. Spinous processes
7. Clavicles

Position Sense

1. Grasp the patient's big toe and hold it away from the other toes to avoid friction.
2. Show the patient "up" and "down."
3. With the patient's eyes closed ask the patient to identify the direction you move the toe.
4. If position sense is impaired move proximally to test the ankle joint.
5. Test the fingers in a similar fashion.
6. 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:

1. Shoulders (C4)
2. Inner and outer aspects of the forearms (C6 and T1)
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2)
5. Medial and lateral aspect of both calves (L4 and L5)
6. 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:

1. Shoulders (C4)
2. Inner and outer aspects of the forearms (C6 and T1)
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2)
5. Medial and lateral aspect of both calves (L4 and L5)
6. 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:

1. Shoulders (C4)
2. Inner and outer aspects of the forearms (C6 and T1)
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2)
5. Medial and lateral aspect of both calves (L4 and L5)
6. 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

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

• Stereognosis

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

• Two Point Discrimination

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

Knee - Pivot Shift Test

Jules Froment

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.