Appendix A Physical Exam Overview Danica Vance and Maggie Wright Distal Extremity Exam.................................................................................... 518 Spine Exam....................................................................................................... 519 Shoulder Exam................................................................................................. 526 Elbow Exam...................................................................................................... 528 Wrist Exam....................................................................................................... 531 Hand Exam....................................................................................................... 536 Hip Exam.......................................................................................................... 542 Knee Exam........................................................................................................ 544 Foot and Ankle Exam...................................................................................... 549 References......................................................................................................... 554 © Springer International Publishing Switzerland 2017 517 M.C. Makhni et al. (eds.), Orthopedic Emergencies, DOI 10.1007/978-3-319-31524-9 518 Appendix A Physical Exam Overview Initial evaluation guided by Advanced Traumatic Life Support protocol (ATLS) • A: Airway • B: Breathing • C: Circulation • D: Deficits • E: Exposure/Environment Physical exam of all affected systems See Chap. “Initial Trauma Evaluation” for more details Distal Extremity Exam Upper Extremity Motor Radial nerve: MCP extension, thumb abduction/extension. Median nerve: finger flexion, thumb flexion/opposition. Ulnar: interosseous muscles. Sensory Radial nerve: dorsal web space between thumb and index finger. Median nerve: radial border of tip of index finger. Ulnar nerve: palmar side of tip of little finger. Lower Extremity Motor Deep peroneal nerve. Tibialis anterior—foot inversion/dorsiflexion. EHL—great toe dorsiflexion. Superficial peroneal: peroneal muscles → foot eversion. Tibial: Gastrocnemius—plantarflexion. Sensory Deep peroneal nerve: 1st dorsal webspace. Superficial peroneal nerve: dorsal foot. Tibial nerve: plantar foot. Saphenous nerve: medial foot. Sural nerve: lateral foot. Appendix A Physical Exam Overview 519 Spine Exam Inspection • Scars: location, surgical or traumatic, healing. • Skin abnormalities (cafe-au-lait spots, dimple/hair over spine). • Muscle atrophy. • Spinal deformity. Gait • Wide-based, unsteady gait (myelopathy). • Foot drop (weakness of TA or EHL, nerve root compression L4–L5). • Flatfoot/loss of push off (weakness in gastrocnemius–soleus, nerve root com- pression S1–S2). • Abductor lurch (possible weakness of gluteus medius, nerve root compression of L5). Palpation • Useful landmarks: °° T4: Level of the nipples. °° T7: Xiphoid process/inferior sternum. °° T10: Level of umbilicus. • Bony palpation. °° Starting at occiput, palpate spinous processes from C2 down to sacrum, checking for any tenderness or step off deformity consistent with a spondylo- listhesis/fracture. • Soft tissue/paraspinal muscles. Range of Motion Cervical Spine • Flexion: 75°—“chin to chest.” • Extension: 60°—“look up at ceiling.” • Lateral flexion: 20°–45°—“ear to shoulder.” • Rotation: 70–90°—“chin to shoulder, with shoulder stabilization.” 520 Appendix A Physical Exam Overview Thoracic Spine Limited range of motion due to rib stabilization. Lumbar Spine: • Flexion: 45–60°—“toe touch with straight legs.” • Extension: 20–30°. • Lateral flexion: 10–20—“bend to each side.” • Rotation: 5–15°—stabilize the hip. Neurovascular • Motor testing: Assessed using a 0–5 grading scale • Sensory: Dermatomal. • Reflexes: Assessed using a 0–4+ grading scale. • Motor/Sensory/Reflexes °° Cervical ■■ C5: Deltoid and biceps/upper lateral arm and elbow/biceps ■■ C6: Biceps, wrist extension/lateral forearm, thumb and index finger/ brachioradialis ■■ C7: Triceps, wrist flexors, long finger extension/middle fingers/triceps ■■ C8: Digital flexors/little and ring finger/none ■■ T1: Interossei muscles/medial arm/none °° Lumbar ■■ L3: Iliopsoas/anterior and medial thigh/none ■■ L4: Quadriceps/medial leg and ankle/patellar tendon. ■■ L5: Gluteus medius, Tibialis anterior and Extensor hallucis longus/dorsal foot and 1st web space/none. ■■ S1: Gastrocnemius-soleus/lateral and plantar foot/Achilles tendon. ■■ S2–4: Anal sphincter/perianal sensation/bulbocavernosus. Additional Tests: • Rectal exam °° Rectal tone. °° Presence of normal “anal wink.” • Bulbocavernosus reflex. °° Anal sphincter contraction in response to squeezing glans penis or tugging Foley. °° If reflex absent (acute injury), cannot determine if neurologic injury permanent. °° Return of reflex marks end of spinal shock. Appendix A Physical Exam Overview 521 • Cervical °° Babinski sign: Run stick/pointed object along plantar foot; upgoing big toe (patient above 1 year of age) indicative of upper motor neuron injury/myelop- athy (Fig. A.1). °° Brudzinski: With patient supine and neck flexed, flex the hip; reduction of symptoms with hip flexed indicative of meningitis (Fig. A.2). °° Distraction test: With patient supine and neck stabilized, apply a distraction force; relief of symptoms indicative of foraminal compression of nerve root. °° Hoffman’s sign: Flicking the distal phalanx of the middle finger into flexion of the DIPJ; pathologic if thumb IPJ flexes indicating myelopathy (Fig. A.3). °° Kernig’s sign: With patient supine, flex neck; radiating pain with neck flex- ion indicative of meningitis (Fig. A.4). Fig. A.1 Babinski sign Fig. A.2 Brudzinski sign 522 Appendix A Physical Exam Overview Fig. A.3 Hoffman’s sign Fig. A.4 Kernig’s sign Appendix A Physical Exam Overview 523 Fig. A.5 Lhermitte’s sign Fig. A.6 Spurling’s maneuver °° Lhermitte’s sign: With neck flexed apply axial load to cervical spine; elec- tric/shock like sensation down trunk/extremities indicative of possible cervi- cal disc disease/herniated disc/cervical spondylosis/MS (Fig. A.5). °° Spurlings maneuver: With neck flexed and rotated toward affected side, apply axial load; radiating pain down affected side indicative of nerve root compression; can help differentiate between neck and shoulder related pain (Fig. A.6). °° Arm abduction relief sign: In seated position, have patient place arms on top of their head; reduction of symptoms (Fig. A.7). 524 Appendix A Physical Exam Overview Fig. A.7 Arm abduction relief sign Fig. A.8 Finger escape sign °° Finger escape sign: The patient holds their fingers extended and adducted; the two ulnar digits will be flexed and abducted usually in less than 1 min in patients with cervical myelopathy (Fig. A.8). • Lumbar °° Bowstring: With patient supine, perform an SLR until pain is felt; once pain is felt have patient flex the knee slightly to relieve the pain and then apply pressure to popliteal fossa; radiating pain with popliteal pressure indicative of sciatic nerve pathology. Appendix A Physical Exam Overview 525 Fig. A.9 FABER sign Fig. A.10 Femoral nerve stretch test °° FABER: (Flexion, ABduction, External Rotation) With patient supine, place leg in figure four position; anterior hip pain/groin pain indicative of hip conditions; lower back pain/posterior pelvic pain indicative of sacroiliac joint conditions (Fig. A.9). °° Femoral nerve stretch test: With patient prone and knee flex, passively hyperextend the hip; anterior thigh pain indicative of L2–L4 nerve root com- pressions (Fig. A.10). °° Straight-leg raise test (SLR): With patient supine, flex hip; radiating lower extremity pain between 30° and 70° indicative of radiculopathy (Fig. A.11). ■■ Lasegue’s Sign: While performing straight-leg raise, dorsiflex foot; worsening/aggravated pain with ankle dorsiflexion indicative of radiculopathy. 526 Appendix A Physical Exam Overview Fig. A.11 Straight leg raise °° Sustained ankle clonus: rapidly flex and extend ankle. Multiple beats of clo- nus indicative of upper motor neuron injury. °° Waddell’s signs: Presence of >3 signs indicate possible non-organic causes of pain that may cause patient to respond poorly to treatment. Shoulder Exam Inspection • Deformity, swelling/ecchymosis, skin integrity, resting position of arm, muscle tone. °° Skin tenting → clavicle fracture, AC separation. °° Flattened shoulder in flexion/IR → dislocation. Palpation • Bony palpation °° Clavicle, AC joint → tenderness or crepitus indicating fracture or separation. °° Humeral head (greater/lesser tuberosity) → fracture vs rotator cuff. • Soft tissue palpation °° Biceps tendon → tendonitis vs. tear (hook test for tear distally). Appendix A Physical Exam Overview 527 Range of Motion • Decreased due to fracture/pain, osteoarthritis, rotator cuff tear. • Normal values: °° Forward flexion 0–180. °° Abduction 0–180. °° Internal rotation—note level reached on back, mid thoracic normal. °° External rotation—0–60. Neurovascular • Axillary nerve—Important to test in proximal humerus fractures and shoulder dislocations. °° Motor—deltoid, can have patient fire posterior fibers and push elbow back if too painful/unable to abduct. °° Sensory—over lateral shoulder. • Radial nerve—Important to test in humeral shaft fractures, especially middle third fractures. °° Motor—triceps extension may be painful, can do wrist/finger extension distally. °° Sensory—dorsal aspect of hand and forearm. • Median/ulnar nerves—test distally if suspicion for brachial