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OBJECTIVES: • Identify the gross anatomy of the upper extremities, spine, and lower extremities. • Perform a thorough and accurate orthopaedic ORTHOPAEDIC EXAMINATION examination of the upper extremities, spine, and lower extremities. • Review the presentation of common spine and Angela Pearce, MS, APRN, FNP-C, ONP-C extremity diagnoses. Robert Metzger, DNP, APRN, FNP - BC • Determine appropriate diagnostic tests for common upper extremity, spine, and lower extremity problems
REMEMBER THE BASIC PRINCIPLES OF MUSCULOSKELETAL EXAMINATION
Comprehensive History Comprehensive Physical Exam THE PRESENTERS • Chief Complaint • Inspection • HPI OLDCART • Palpation HAVE NO CONFLICTS OF INTEREST • PMH • Range of Motion TO REPORT • PSH • Basic principles use a goniometer to assess joint ROM until you can • PFSH safely eyeball it • ROS • Muscle grading • Physical exam one finger point • Sensation to maximum pain • Unusual findings winging and atrophy
SPINAL COLUMN SPINAL CORD / NERVES • Spinal cord • Begins at Foramen Magnum and • Consists of the Cervical, Thoracic, continues w/ terminus at Conus Medullaris near L1 and Lumbar regions. • Cauda Equina • Collection of nerves which run from • Specific curves to the spinal column terminus to end of Filum Terminale • Lordosis: Cervical and Lumbar • Nerve Roots • Kyphosis: Thoracic and Sacral • Canal is broader in cervical/ lumbar regions due to large number of nerve roots • Vertebrae are the same throughout, • Branch off the spinal cord higher except for C1 & C2, therefore same than actual exit through the nomenclature is applicable to all intervertebral foramen areas of the spine. • 1st root exits between C0/C1; 8th cervical root between C7/T1 • 1st thoracic and so on exit below the vertebral body
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DERMATOMES LIGAMENTS (BRIEF OVERVIEW) • Areas of skin innervated by sensory fibers from a single spinal nerve • Anterior Longitudinal Ligament • Posterior Longitudinal Ligament • Ligamentum Flavum (noncontinuous, yellow color) • Interspinous Ligament (connects the SPs) • Supraspinous Ligament (connects the tips of the SPs) • Intertransverse Ligament (connects the TPs)
INTERVERTEBRAL DISCS INTERVERTEBRAL DISCS • 2 Components • Discs are located between the endplates of the vertebral • Annulus Fibrosus bodies • Outer part of the disc • Collagen fibers w/ water and • Most important and unique articulating system in the spine, proteoglycans allowing for multiplanar motion • Layered in concentric layers called Lamellae which are • Make up ¼ of the total length of the spine column, run from thicker and more numerous in C2/3 to L5/S1 the anterior portion of disc • Nucleus Pulposus • Largest avascular structure in the human body • Interior substance of the disc • Cartiliginous joint of the motion segment (gelatinous) • Increased water and • Shock absorbers of the spine which are so strong that w/ proteogylcan content (85% compression, the vertebral bodies will fail before the discs Water content)
CERVICAL SPINE • C3 – C7: Similar in structure • Cervical Spine consists of • Foramen 7 vertebrae • Vertebral: triangular • C1 (Atlas) shaped • Supports the weight of the skull • Intervertebral: Exiting nerve root occupies about • Ring shaped vertebrae 75% of space • C2 (Axis) • Uncovertebral Joints • Provides a pivot point for the Atlas • Spinal Processes • Projection into the C1 • C2-6: Bifid processes body, called the Odontoid (Dens) • C7: Vertebrae prominens
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DIAGNOSTICS X-rays SPECIAL DIAGNOSTICS: CT MYELOGRAM • Provides basic evaluation of bone and disc spacing allowing visualization of degeneration, • Needle is introduced into the subarachnoid space and contrast is fractures, and instability of the spine injected Magnetic Resonance Imaging (MRI SCANS – non-radiation) • Magnet causes Hydrogen atoms in the tissue to line up, then radio waves bounce off the H+ • Patient is then tilted on the table so the dye will go to the specific atoms to provide a picture region we are testing • Adept at evaluation of soft tissue pathology (i.e. nerves, spinal cord, and discs) • AP/Lat views of spine are taken • Order w/ contrast if prior surgery has been done to r/o scar tissue involvement or tumor • Can be performed unless pt has pacemaker/defib implant, aneurysm clips, other motor run • Contrast appears white w/ neural structures dark implants, spinal cord stimulators, or bullet close to the spine • Compression or displacement of neural elements may be Computed Tomography (CT SCANS – high radiation) visualized • Thin beams of xrays pass through the pt. to a detector which transmits images to a computer • Particularly good for detecting bony tissue pathology • Painful procedure • May consider CT if patient had prior hardware and there’s concern for artifact on MRI
DIAGNOSTICS FOR CERVICAL EVALUATION: TYPICAL DIAGNOSES OF THE CERVICAL SPINE: • X-RAYS • AP / Lateral 1. Cervical Disc Degeneration (spondylosis) • Flexion / Extension – evaluation for instability or movement of spine • Odontoid Views – Evaluation of the C1 & C2 bodies (especially fractures) 2. Cervical Disc Protrusions • MRI SCANS 3. Cervical Radiculopathy • Evaluation for radiculopathy / disc protrusions / stenosis • Typically, pt should have neurological involvement 4. Cervical Stenosis • CT SCANS 5. Cervical Myelopathy • Performed if pt is unable to undergo MRI imaging or if major concern is bone 6. Cervical Fractures • Myelogram • Performed if pt is unable to undergo MRI imaging and concern for possible 7. Combination of Above stenosis
DISC HERNIATION • Most frequent surgically treated pathologies of the spine • Commonly occurs at C4/5, C5/6, C6/7 & L4/5, L5/S1 (regions w/ great ROM and axial loading) • Internal disruption to the disc is permanent due to the disc being avascular • Four degrees of herniation 1. Fissure / Bulging 2. Protrusion
3. Extrusion 4. Fragmented / Segmented
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DEGENERATIVE DISC DISEASE (DDD) • Loss of normal tissue structure and • Symptoms function due to the aging process. • Asymptomatic • Usually is a gradual process, however • Neck pain / Low back acute trauma will accelerate the process pain • Changes within the intervertebral disc • Radiculopathy into upper • Water and proteoglycan decrease in extremities / lower the nucleus first, then the annulus extremities • Fibers of the annulus become • Cauda Equina Syndrome distorted, tears may occur in the lamellae decreasing the strength of • Foot Drop the disc • Loss of • Most common levels are C5/6 and L4/5 Bowel/Bladder • By age of 50, 95% of people will have Function evidence of DDD
• Effects the entire motion SPINAL STENOSIS segment • Stenosis is “narrowing of a tube” • Facet joints override and • Spinal stenosis refers to narrowing of the spinal canal wear at the hyaline cartilage and/or lateral foramen
• Disc shrinks and the disc • Developmental or Acquired (most common) space narrows • Degenerative stenosis • Loads are transferred from disc to the endplates • Found in older population • Osteophytes may develop • L3/4, L4/5 are most involved lumbar segments and encroach on neurological structures • C5/6, C6/7 are most involved cervical segments • Occasionally associated with spondylolithesis • Occurs most often in lower cervical / lower lumbar spine.
SPINAL STENOSIS • Symptoms SPINAL STENOSIS • Associated with LBP, • Cervical stenosis occasionally will have buttock, leg pain (bilat) • Presents more with history of neck trauma • Neurogenic claudication • Most patients present with radiculopathy of C5, C6, or C7 nerve • Most important sx roots • Worse w/ standing/ walking upright • Important to watch for MYELOPATHY • Alleviated with bending forward (flexing) • Symptoms of myelopathy are altered gait, diminished fine • Differentiate between vascular motor coordination, sensory changes, muscle weakness, and claudication in late cases, bowel / bladder incontinence
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SPINAL FRACTURES COMPRESSION FX ODONTOID FX • Most common fractures seen in an outpatient setting: • Compression / Burst • Associated with falls from greater than 6 feet or any fall in a patient with osteoporosis • Transverse Process / Spinous Process • Odontoid (Dens) & Facet fractures are more common in emergent settings • Trauma to spine implies injury to any or all anatomical structures: bony elements, soft tissues, and neurological structures
NEUROLOGICAL EXAMINATION KEYPOINTS SPINAL FRACTURES C5 M Shoulder Abduction (Deltoids), Elbow Flexion (Biceps) R Biceps Reflex S Lateral portion of Deltoid and Upper Arm to Elbow
• Instability - loss of normal relationship between C6 M Wrist Extension R Brachioradialis Reflex anatomic structures with alteration in natural function S Lateral Forearm (below elbow) including Thumb, Index Finger, and ½ of Middle Finger • Dislocation – misalignment of normal structure of the C7 M Elbow Extension (Triceps), Wrist Flexion, Finger Extension anatomic components R Triceps Reflex S Middle Finger
• Fracture / dislocations may occur in any region of C8 M Finger Flexion R NONE the spine and are associated with high degree of S Medial Forearm (up to elbow), Ring Finger, and Pinky Finger
neurologic injury. T1 M Finger Abduction and Adduction R NONE S Medial Forearm and Medial Upper Arm
SPECIAL TESTS (CERVICAL): SPECIAL TESTS (CERVICAL) – CONT.: • Llhermitte’s – • Myelopathy Signs / Tests • Look up – Look down (Touch your chin to your chest) : Causes electrical shocks • Finger Escape Test – Have pt close all fingers together while flexed. Positive – down the spine, and occasionally into the legs, if positive pinky will continue to move away from the remaining fingers • Suggestive of Cervical HNP • Intrinsic Pad (Adductor pollicis) Wasting – Wasting of the muscle pad on the • Some practitioners suggest applying compression simoultaneously to increase the hand sensitivity of the test • Special Reminders • Spurling’s (Foraminal Compression) – • Throwing a Basketball – helps recall of motor function innervated by cervical • Pt bends or side flexes the head to the unaffected side first, followed by the affected spine side. Each time the examiner presses straight down on the head. • Perform if history includes nerve root symptoms • Gait Testing –
• Tandem Gait – checks for any possible cord impingement or brain involvement (instability)
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LONG TRACT SIGNS (PATHOLOGIC REFLEXES) [SUGGESTIVE OF UPPER MOTOR NEURON LESIONS] SHOULDER ANATOMY
• DTR’s • Bones: Scapula, Humerus, Clavicle, • 3+ unilaterally or 4+ Acromion • Hoffman’s Sign • Muscles: • Flicking of the 3rd DIP • st nd Deltoid, • Positive if the 1 & 2 DIPs flex • Rotator Cuff- x4 (SITS) • Ankle Clonus • Quick dorsiflexion of the relaxed • Supraspinatus ankle joint. • Infraspinatus • Positive will cause repetitive (4+) twitching/pulsing of the foot • Teres minor • Babinski’s • Subscapularis • Stroking of lateral aspect of sole of • Scapular rotators include rhomboids, foot from the heel to the toes • Positive with extension of great toe trapezius, serratus anterior and and fanning of four small toes levator scapulae
SHOULDER PAIN DIAGRAM
• Describe point of intensity • Any clicking or subluxing/dislocation of the joint? • Can the patient sleep on the shoulder? • Is it pain or weakness /loss of function? • Was the injury traumatic?
SHOULDER HISTORY: ACUTE VS. CHRONIC SHOULDER EXAMINATION
• Age of patient • RANGE OF MOTION: • Palpate AC joint and • Comorbidities/ look for deformities diabetes/thyroid -Forward Flexion adhesive capsulitis • Palpate biceps tendon -Abduction to 90 • Fractures • Look for painful arc degrees • Neck & shoulder of motion ?radiculopathy -External Rotation • Brachial plexopathy • Muscle strength -Internal Rotation • Thoracic outlet • Sensation and pulses syndrome • Arthritis AC vs GH
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TESTS SPECIFIC TESTS FOR SHOULDER • Neer’s • Neer’s Impingement Sign • Hawkin’s Impingement sign • Hawkin’s • Cross body or Horizontal Adduction Test • Apprehension sign • Jerk test for posterior instability • Empty can test/ Drop arm test • Crossed body • Subscapularis lift off test • Wall push up for scapular winging • Speeds test for biceps tendinitis
TESTS DIAGNOSTICS • Apprehension • Radiographs: AP, Lateral and Axillary • MRI • Sulcus Sign • EMG/NCS • CT with 3D reconstruction • Consider other causes such as tumors
• Jerk Test
ELBOW ANATOMY ELBOW PAIN DIAGRAM
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ELBOW EXAM: ELBOW EXAM: LATERAL & MEDIAL EPICONDYLITIS
• Flexion • Three most common • Lateral • Extension complaints: -Tennis elbow (Extensor supinator group) • Supination - Epicondylitis • Medial • Pronation - Fracture/dislocation -Golfers elbow (Flexor pronator group) • Valgus - Bursitis • Cozen’s sign • Varus Stress -Pt pushes hand up in extension against resistance with pain at lateral epicondyle • Palpation of Epicondyles -Pt pushes hand down in flexion against resistance with pain at medial epicondyle
TEST FOR EPICONDYLITIS ELBOW DISLOCATION • Cozen’s Test Medial Lateral o Pain o Loss of normal contour and relationships o Loss of motion o Attitude of extremity
OLECRANON BURSITIS OLECRANON BURSITIS • Fluid filled cavity at patient’s olecranon • Often after trauma to elbow • Can be drained and injected with corticosteroid but will often reoccur • Best treated with compression Ace wrap • May become infected so always reassess and give warnings
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HAND AND WRIST ANATOMY DIAGNOSTICS
• Radiographs: AP, Lateral and oblique • MRI • EMG/NCS • CT with 3D reconstruction • Consider other causes such as tumors
DISORDERS OF THE UPPER Hand and Wrist Pain EXTREMITIES Diagram • CMC arthritis Typical complaints • Dequervains Tenosynovitis and their regions • Flexotenosynovitis SURGICAL EMERGENCY • Ganglion • Trigger fingers • Dupuytrens contracture • Carpal Tunnel Syndrome • Cubital Tunnel syndrome • Tinel’s and Phalens tests
TESTS DIAGNOSTICS • Tinel’s • Radiographs: AP, Lateral and oblique • EMG/NCS • Phalen’s • Consider other causes such as tumors
• Finkelstein’s
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LUMBAR SPINE • Vertebrae • Kidney shaped bodies TIME • ML > AP dimensions - Smaller Transverse Process TO - Spinal Processes are large, PRACTICE square, and horizontal - Foramen - Vertebral: wider and triangular - Intervertebral: 33% occupied by nerve
DIAGNOSTICS FOR LUMBAR EVALUATION: TYPICAL DIAGNOSES OF THE LUMBAR SPINE: • XRAYS • AP / Lateral 1. Lumbar Disc Degeneration (spondylosis) • Flexion / Extension – evaluation for instability or movement of spine • Oblique Views – Evaluation of spondylolysis (Pars defect) – “Scotty Dog” 2. Lumbar Disc Protrusions • MRI SCANS 3. Lumbar Radiculopathy • Evaluation for radiculopathy / disc protrusions / stenosis 4. Lumbar Stenosis • Typically, pt should have neurological involvement • CT SCANS 5. Spondylolysis & Spondylolisthesis • Performed if pt is unable to undergo MRI imaging or if major concern is bone 6. Lumbar Fractures • Myelogram 6. Combination of Above • Performed if pt is unable to undergo MRI imaging and concern for possible stenosis 7. Cauda Equina Syndrome
SPONDYLOLITHESIS
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SPONDYLOLITHESIS SPONDYLOLITHESIS • Slippage of one vertebrae in relation to the adjacent vertebrae • Confusing Terms: • Spondylosis – degenerative changes in vertebrae at the disc and facet joints • Incidence is approximately 3-4% of all populations • Spondylolysis – defect in the vertebrae in area of pars interarticularis
• Strong hereditary factor • Descriptive Terms: • Noticed more in gymnasts, football linemen, and weightlifters • Anteriolithesis – anterior / forward • Most slips are related to a deficit in the pars interarticularis • Retrolithesis – posterior/ backward • Disc degeneration is associated with almost all forms of • Lateral – sideways movement spondylolithesis • Symptoms • Most common complaint is LBP • Radiation into the buttocks and occasionally posterior thighs
EXAMPLES OF SPONDYLOLYSIS SCOLIOSIS • Defined as a lateral curvature of the spine • Adult scoliosis: Idiopathic / Degenerative • Idiopathic • Continued progression from adolescent • Degenerative • Onset of scoliosis in previous straight spine • Result of asymmetric deterioration of spinal components, caused by spondylosis
NEUROLOGICAL EXAMINATION KEYPOINTS
T12 – L3 M Hip Flexion (Knee Raising - Iliopsoas) – L2, Quadriceps (Knee Extension) – L3, Hip SPECIAL TESTS (LUMBAR): Adduction • Gait Testing – R NONE • Normal Gait Pattern ( no evidence of foot drop) S L1 – Proximal third of Anterior Thigh • Heel Walking – If difficult, can indicate L4/5 involvement L2 – Middle third of Anterior Thigh • Tip Toe Walking – If difficult, can indicate S1 involvement L3 – Distal third of Anterior Thigh (to knee) • Straight Leg Raise (AKA Laseque’s test) – L4 M Foot Inversion (Tibialis Anterior), Ankle Dorsiflexion R Patellar Tendon reflex • Pt lays supine or sits upright while provider passively raises each leg individually with knee extended until the patient complains of pain down the back of the leg. Once pain is S Medial Leg (Tibial Crest – Medially), Medial Foot, and Medial Great Toe elicited, drop the leg slowly until they feel no pain, then dorsiflex the foot. L5 M Hip Abduction (Gluteus Medius), Great Toe Extension (EHL), 2nd-5th Toe Extension (EDL) • Positive if pain is elicited within the leg between 35-70 degrees of elevation. Dorsiflexion R NONE should increase this pain (if not, likely hamstring tightness). Hamstring pain involves only the posterior thigh. Back pain alone is not a positive SLR. S Lateral Leg (Tibial Crest – Laterally), Dorsum of Foot • Perform if history includes nerve root symptoms S1 M Foot Eversion, Calf Raises (Gastrocnemius), Hip Extension (Gluteus Maximus) • FABER (AKA Patrick’s Manuever & LaFebere test) R Achilles Tendon Reflex S Lateral Foot, Portion of Plantar Surface • Flex the knee and place ankle above contralateral knee. Apply downward force onto the flexted knee to stress the lower back, SI joint, & hip. S2-S4 M Intrinsic Muscles of Foot, Bladder motor supply, Knee flexion – S2 • Positive – pt will elicit pain that should point to the source of pathology R Superficial Anal Reflex (Sphincter Wink) S Concentric Rings – S2 – Outermost Ring, S3 – Middle Ring, & S4/S5 – Innermost Ring
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SPECIAL TESTS (LUMBAR) – CONT.: HIP ANATOMY
• Femoral Nerve Stretch • Opposite of SLR and tests L3 (femoral nerve)
• Conducted in standing or prone position with back straight, examiner grasps the limb flexing the knee while slightly hyperextending the hip • Positive – produces L2-4 radicular symptoms to the anterior knee • Special Reminders
• German Octoberfest Dancer – Remember the dermatomes of the lower extremity • Umbilicus – Level of L3/4 • Line across iliac crests – Level of L4/5
HIP PAIN DIAGRAM HIP EXAMINATION
• RANGE OF MOTION: • Palpate bony anatomy -Flexion • Palpate trochanteric bursa -Extension • Muscle strength -Abduction • Sensation and pulses -Adduction
TESTS COMMON CAUSES OF HIP PAIN
• Thomas Test • Osteoarthritis
• Femoral Acetabular Impingement
*REMEMBER HIP pain is most typical in the groin. • Ober’s Test BACK pain is in the BUTTOCK.
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OSTEOARTHRITIS FEMORAL ACETABULAR IMPINGEMENT • 3 Types • CAM lesion bump on femoral head causing irritation to hip articular cartilage and pain • PINCER lesion osteophytic outgrowth of acetabulum causing irritation to the articular cartilage • COMBINED lesions
FEMORAL ACETABULAR IMPINGEMENT
• Symptoms include pain in groin area or lateral hip pain with sharp stabbing pain when turning ,twisting or squatting
• Check for hip impingement by flexing knee and internal rotation
KNEE ANATOMY DIAGNOSTICS
• Hip X-rays AP & Dunn view • MR arthrogram of hip for labral tears
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KNEE ANATOMY KNEE PAIN DIAGRAM
MECHANISM OF INJURY HISTORY – KNEE INJURY • Unusual sounds/sensations • Clicking/locking: meniscus injury • “Pop”: cruciate ligament injury, patellar dislocation
• History of previous injury/surgery
KNEE EXAMINATION INSPECTION/OBSERVATION • Inspection/Palpation • ALWAYS compare bilaterally • Obvious deformity • genu valgum (“knock knees”) • genu varum (“bow legged”) • genu recurvatum (“hyperextension”) • Bleeding • Discoloration/ecchymosis • Swelling • Immediate vs. gradual, amount • Scars
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PALPATION SPECIAL TESTS • ROM o Patella o MCL • Active: patient/athlete moves joint o Femoral condyles o LCL • Passive: clinician moves joint, evaluates end feel o Tibial plateaus o Infrapatellar • tendon Resistive: proximal stabilization and distal o Tibial tuberosity application of resistance (“break” test vs. o Quadriceps resistance through ROM) o Fibular head • o Hamstrings Neurovascular o Joint line (menisci) o Gastrocs
ROM NEUROVASCULAR o Knee extension o Neurological evaluation n Primary movers are quadriceps n Nerve root level and peripheral nerve sensory and motor distributions o Vascular evaluation o Knee flexion n Skin temperature/color n Primary movers are hamstrings n Capillary refill n Popliteal pulse n Secondary movers are gastrocs (cross knee joint posteriorly) n Dorsalis pedal pulse n Posterior tibial pulse
SPECIAL TESTS ANTERIOR DRAWER TEST • Anterior drawer/Lachman tests – ACL
• Posterior drawer/posterior sag tests – PCL
• Valgus stress tests – MCL
• Varus stress tests – LCL
• Apprehension test – patellar instability
• McMurray’s/ Apley’s /Thessaly tests – menisci
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LACHMAN’S VALGUS STRESS TEST
VARUS STRESS TEST MCMURRAY’S TEST
COMMON KNEE PROBLEMS DIAGNOSTICS
Osteoarthritis • X-rays AP/lateral and Merchant View Sprains • MRI Meniscal injuries • EMG/NCS ACL tear • Always consider tumor Patellofemoral pain
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ANKLE ANATOMY ANKLE LIGAMENTS LATERAL
ANKLE LIGAMENTS MEDIAL ANKLE PAIN DIAGRAM
Ankle Injuries SPECIAL TESTS FOR ANKLE Anterior Drawer test Sprained (twisted) ankle is the most common type of ankle injury. A sprain is the stretching or tearing of ligaments Talar Tilt
Mechanism: Inversion or turning of the foot inwards
Eversion or turning Thompson’s Test of the foot outwards
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DIAGNOSTICS
• X-rays AP/lateral and oblique, weight-bearing if possible TIME • MRI TO • EMG/NCS • Always consider tumor PRACTICE
REFERENCES: • Bono, C. & Garfin, S. (2004). Spine. Philadelphia, PA: Lippincot, Williams, & Wilkins THANK YOU FOR YOUR • Hawkins, R. (1995). An organized approach to musculoskeletal examination and history taking. St. Louis, MO: Mosby ATTENDANCE!! • Hoppenfeld, S. (1976). Physical examination of the spine and extremities. East Norwalk, CT: Appleton-Century-Crofts • Hoppenfeld, S. (1997). Orthopaedic neurology: A diagnostic guide to neurologic levels. Philadelphia, PA: Lippincott, Williams, & Wilkins Please fill out your • Magee, D. (2002). Orthopedic physical assessment. (4th edition). Philadelphia, PA: Saunders • Sarwark, J. (2010). Essentials of musculoskeletal care. (4th edition). Rosemont, IL: evaluation form American Academy of Orthopaedic Surgeons • Thompson, J. (2002). Netter’s concise atlas of orthopaedic anatomy. Philadelphia, PA: Saunders and turn it in as you leave!!
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