Musculoskeletal Examination Vivek Pandey, Hitesh Shah
INDEX
Page numbers followed by ‘b’ refer to box; ‘f’ refer to figure; ‘fc’ refer to flowchart; and ‘t’ refer to table, respectively.
A
Abdominal muscles 77
Abdominal organs 38
Abducted thigh 25f
Abduction 4, 17, 88b, 89, 89f, 379
and external rotation, loss of 476f
deformity 17, 218
measurement of hip 220f
shoulder pain 79
Abductor digiti minimi 160t, 443, 444, 444f, 445, 445t
test for 446f
Abductor mechanism 242
normal and abnormal responses of 243f
Abductor pollicis brevis 160, 437f, 438, 442
Pen test for 441f
Abductor pollicis longus 155, 155f, 162, 434f
Above-knee stump 515
Abrasion 32
Acetabular labrum 201, 202f
Acetabulum 201
Achondroplasia 51f, 378
Acromioclavicular arthritis 74
Acromioclavicular joint 71, 84
arthritis 80, 106, 112
tests for 106
stability 73
tenderness 106
Acromion 85
undersurface of 107
Adam's forward bend test 367, 367f
Adamkiewicz, artery of 351
Adduction deformity 218, 221f, 240
Adductor longus 202
brevis and magnus 202t
Adductor magnus tendon 254f
Adductor pollicis 445
Adductor tubercle 254f
Adhesive capsulitis 111
Adson's test 380, 381f
Advanced trauma life support 26
care 29fc
Aird's test 383
Airway 28
Akimbo sign 432
Alcoholism, chronic 410
Allen's test 182
Allis sign 228
Alpine hunter cap patella 259
American Spinal Injury Association Sensorimotor Impairment Scale 393b
Amputation
and disarticulation 518f
atraumatic 512
common level of 518
complications of 517
indications for 512
principles of 516
right upper limb 35f
stump
clinical evaluation of 511
examination of 520
level of 518
patient with 512
special Chopart's amputation 519
special external hemipelvectomy 519
special hindquarter amputation 519
special Lisfranc's amputation 519
special Pirogoff amputation 519
special Syme's amputation 519
types of 517
definitive end-bearing 517
definitive non-end-bearing amputation 517
provisional amputation 517
Analgesia 41
Anconeus triangle 129
palpation of 131
surface landmarks for 129f
Aneurysmal bone cyst 502, 508, 533
Anhidrosis 473
Ankle 325
and foot 330f
major ligaments of 310
parts of 327f
dorsiflexion 383f
equinus deformity, evaluation of 489fc
examination 340
foot, position of 334f
joint 24f, 310, 331
bony ankylosis of 19f
line 328, 328f
plantar flexion 331f
space 19f
ligament complex, medial 311f
medial ligament of 311
neutral position of 331f
plantar flexion 338f, 454f
plantar flexion range of movement 24f
posterior aspect of 329f
sprain 344
stability, tests for 335
Ankylosing spondylitis 57, 64, 362, 405
Ankylosis, true 19
Annular ligament 120f
Anomalies, congenital 197
Antebrachial cutaneous, medial 466f
Anterior cord syndrome 408, 408f
Anterior interosseous syndrome 461
Antituberculosis, treatment drugs 152
Aperta 212
Apley's test 294f
compression test 294
distraction test 294
grinding test 292, 294
Apprehension test 91, 91f, 295f
Arm and forearm, posterior cutaneous nerve of 434f
Arm
length measurement 90f
span 377
wasting of 136
Arnold-Chiari malformation 116
Arterial blood gas 29
Arterial circulation 156
Arterial Doppler 39
Arthritis
classification of 54fc
mutilans 65
stage of 61
tender in 84
Arthrodesis 63
Arthropathy
reactive 65
resection 63
Arthroscopic, appearance of
mucoid ACL 304f
normal ACL 302f
Arthroscopic capsular release 112
Arthroscopic synovectomy 63
Arthroscopic view of 309f
cartilage fibrillation in chondromalacia 306f
discoid lateral meniscus 300f
normal lateral meniscus 300f
normal patella cartilage 306f
OCD of right medial femoral condyle 307f
Articular facet, superior and inferior 354f
Asynchronous scapula movement 107
Ataxic cerebral palsy 485
Athetoid (dystonic) cerebral palsy 485
Atonic bladder 409
Auscultation 37, 538
Autoimmune diseases 415
Automatic bladder 409
Autonomic examination 419
Autonomic nervous system 348, 351
examination 421
outflow 351f
Autonomic symptoms 414
Autonomous zone 421
Autosomal recessive 198
Axilla 142
Axillary nerve 420
C5, 6 430
muscles supplied 431t
paralysis, features of 431
Axis deviation, normal hip 226f
Axon reflex test 422
B
Babinski sign 394
Baker's cyst 58, 271f, 530, 535
in right popliteal fossa 59f
Ballottement test 185, 273, 339, 339f
Bancroft's sign 339, 339f
Barber chair phenomena 387
Barlow test 234, 234f
Bear weight, difficulty to 44
Bear-Hug test 103
Bearing weight 5
Bechterew's disease 64
Beevor's sign 384
Beighton and Horan joint mobility index 86
Beighton hypermobility score 86
Beighton score 87f
components of 87t
Belly-off test 103, 103f
Belly press test 102
Below-knee amputation stump 514f, 517f
Below-knee prosthesis 514f
Below-knee stump 515
Benediction sign 443
Benett lesion 111
Benign chondrogenic tumors 199
Benign tumor 494t
Biceps bulk, loss of 128
Biceps femoris tendon 259, 305, 450
Biceps groove tenderness 105
Biceps tendon 72f
distal 127, 133
pathology, tests for 105
Bicipital groove 85
Bicipital tendinitis 105
Bigelow, ligament of 201
Birth brachial plexus palsy 479
Blackberry thumb 165
Bladder and bowel status 395, 492
Blount's disease 263, 264, 301
Body
dermatomes of 388f
myotomes of 392f
Bone 271
and joints, acute injury of 26
cement 505f
cyst
aneurysmal 313, 496, 502, 505, 507, 508f
simple 496, 507, 508f
unicameral 313, 507
disease 43b
fixity 543
forming arch 312
grafting of GCT cavity 505f
length of 535, 538
sarcomas, spread 499
shortening of 535
tumors 265, 504
clinical classification of 494fc
clinical evaluation of 494
during history assessment 495b
history taking in 495
Bony and soft tissue landmarks 271b, 132b
Bony crepitus 36, 47
Bony deformity 500
Bony irregularities 59, 173, 538
Bony mass, abnormal 133
Bony swellings 537
Bony tenderness 36
Bony thickening 47
Book test 445, 447f
Bouchard and Heberden's nodule 172f
Bouchard node 57
Boutonnière deformity 172
Bowstring test 383
Brachial cutaneous, medial 466f
Brachial plexus 75, 83, 89, 90, 414, 465f, 466f, 467t, 477b
common conditions affecting 471b
injury 30, 74, 76, 79, 80, 101, 470t, 475t
anatomical classification of 469t
clinical evaluation of 465
etiology and classifications of 468
examination 482
lower 470
post-traumatic 468, 483
suspicion of 475f
lower trunk of 380
nerves of 467t
palsy 9, 12, 74, 100, 474
roots of 468f
surgical anatomy of 465
tension 379
Brachioradialis 435
test for 436f
Bragard's test 383
Brain 6f
Brain's sensory cortex 349
Breathing 28
Brevis 202
Brittle bone disease 51
Broadened heel 324
Brodie's abscess 49, 50
Broken levers 76, 242
Brown-Sequard syndrome 406
Brucella spondylodiscitis 362
Bryant's triangle 244
measurement of 228, 228f
Bucket handle tears 9
Bulk 390
Bunionette 321
Bunnel's ‘OK sign’ 443
Bunnell-Littler test 180, 182
Burning sensation 513
C
Cadaveric knee 253f
Cadaveric view of lateral side of knee 256f
Café-au-lait spots 369, 369f
Calcaneofibular ligament 310
Calcaneovalgus 314
Calcaneum 325, 328
fracture, malunited 324f
Calcaneus deformity 324
Calcium pyrophosphate dihydrate crystal deposition 122
Calf muscle 229
wasting 213
Calf musculature 325
Callosities 326
Campylobacter 66
Capitate 174, 175
Capitellum 118
Caplan's syndrome 63
Capsule 71
posteromedial 255
Capsule-muscle-tendon, contracture of 125
Card test 445, 448
Cardiac disease 75
Cardiac origin pain 78
Carpal bones 174b
Carpal instability 195
tests for 184
Carpal tunnel syndrome 22, 63, 162, 165, 167, 180, 197
signs of 181f
tests for 180
Carpometacarpal 162
Carpometacarpal joint arthritis, tests for 181
Carpometacarpal joint of fingers 159
Carpometacarpal osteoarthrosis 57
Cartilage damage 7
Cauda equina 348f
Cauda equina syndrome 363, 408, 408t
Central cord syndrome 406, 406f
Central slip injury 166
Cerebellar artery, posterior-inferior 351
Cerebellar ataxia gait 529
Cerebral palsy 171, 208, 484, 487t
examination 493
mixed 485
spastic 485
geographic classification of 485
Cervical facetal disease 404
Cervical intervertebral disc prolapse 362
Cervical myelopathy 404
tests for 387
Cervical region 357
Cervical rib 400f
Cervical spine 108, 143, 353
anteroposterior X-ray 400f
flexion 373f
lateral rotation 373f
movement 372
assessment of 373f
pathology 106, 142
right lateral flexion 373f
Cervical spondylitis 142, 362, 371, 371b
myelopathy 362
Chair push-up test 140f, 140
Charcot's arthropathy 68f, 116, 135, 315
deformed foot in 347f
Charcot's foot 320, 326
medial arch collapse in 326f
Charcot's joint 67, 346
Charcot's shoulder 74, 117, 117f
Charcot-Marie-Tooth disease 322, 342, 412, 415, 416, 522
Cheiralgia paresthetica 190, 462
Chest
expansion 377
pain 78
Chiene's parallelogram 230, 231f
Child with cerebral palsy
clinical evaluation of 484
symptoms in 484
Chlamydia 66
Chondromalacia patella 265, 305
Chopart joint 313
Chordoma 502
Ciliospinal reflex, loss of 473
Clarke test 275, 275f
Clavicular head, test for 430f
Clavicular osteolysis, distal 80
Claw hand 171, 417, 444, 459
assisted and contracture angle in 187
Claw toe 63, 321
Cleidocranial dysostosis 52, 74
Clonus 394
Clubbing 499
Clubfoot 341
Coccydynia 363
Coccygeal root 348
Codfish vertebra 51
Cold abscess 369, 370f
Coleman block test 337, 337f
reverse 337
Collar stud infection 200
Collateral ligament 157
medial 138, 143, 200, 254f, 260, 309
Colles' fracture 170, 193
malunited 163, 193
Compartment syndrome 39, 194
Complex regional pain syndrome 166, 169f, 193
Compound palmar ganglion 191, 191f
Compressibility 537
Compression rotation test 104
Compression test 37, 294f
Compressive neuropathies 122
Condyloid joint 159
Connective tissue disorders 415
Contralateral flexion 379
Contralateral limb 37
measurement and examination of 538
Conus medullaris 348, 348f
Conus medullaris syndrome 408, 408t
Coracoacromial ligament 107
Coracoid process 85
Coronal plane deformity, assessment of 219fc
Coronoid fracture 123
Corticospinal tract 350, 407f, 408f
anterior 349f, 350
lateral 349f, 350, 406f
Coudane-Walch test 87
Coughing, impulse on 538
Coxa vara
adolescent 247
developmental 208, 245
right hip 245f
Cozen's test 137, 137f
reverse 137, 138f
Craig's test 227, 244
Cranial nerves 388
Crank test 104, 104f
Crepitus 10, 278
types of 278
fixed crepitus 278
mobile crepitus 279
Cross-chest adduction test 106, 106f
Crossed radial reflex 387
Cruciate ligament
anterior 252, 253, 253f, 256, 260, 262, 309
posterior 253, 253f, 256f, 260, 309
Crutch palsy 459
Crutch, axillary 206
Crystal arthropathy 66
Cubital fossa 130, 133
Cubital tunnel syndrome 122, 123, 167, 462
anatomy of 462f
Cubitus recurvatum 129f
Cubitus valgus 125, 147
of right elbow 128f
Cubitus varus 125, 128, 135, 147
Cytomegalovirus 415
D
Daily living, disruption in activities of 165
De Quervain's tenosynovitis 162, 164, 166, 180, 190
tests for 181
Dead arm syndrome 76
Debris and sclerosis 68f
Deep fascia 20
Deep penetrator sign 205
Deep peroneal nerve 333, 333f, 420, 448fc, 450f, 451, 453
Deep space infections 200
Deep tendon 421
Deep tendon reflex 394
grading 394b
Deep vein thrombosis 48, 339
Deformities 8, 15, 16, 32, 44, 56, 125, 163, 169, 171, 205, 267, 360, 472, 488, 497
angular 532
assessment, principle of 16, 268
congenital 197
correctable 331
in sagittal plane 216
of hip 215b
of knee joint 16f
progression of 314
rotational 223
assessment of 223
spasmodic 8
sprengel 74
stage of 61
structural 8
test for unilateral flexion 216
triple 58
Degenerative osteoarthritis, primary 60
Degloving injury 34
Delayed union 49
Deltoid 73, 431
ligament 329
wasting 82f
De Quervain's tenosynovitis 106, 181f
Detrusor-sphincter dyssynergia 409
Diabetes and thyroid dysfunction 78
Diabetes mellitus 68, 165
Diadochokinesia 393
Dial test 290
for posterolateral corner injury 291f
Diplegic cerebral palsy 485
Disability 28
Disarticulation 519, 519b
Disc disease, degenerative 366
Disc herniation, stages of 402f
Discoid meniscus 300
Disease, severity of 69
Disease-modifying antirheumatic drugs 148
Dislocation
primary or recurrent 76
tests for 183
Dislocation of knee, congenital 300, 301f
Dislocation patella, recurrent 309
Dislocation shoulder, recurrent 79
Distal femur and proximal tibia, fracture of 34f
Distal femur lateral condyle 505f
Distal interphalangeal 160, 172, 179, 200
Distraction test 294f
Diurnal variation 123, 205
Dizziness 360
Dorsal column tract homunculus 349f
Dorsal intercalated segment instability 184, 192
Dorsal intercarpal 153f
Dorsal interossei 445
Dorsal ramus 410
Dorsal root 410
Dorsal scapular nerve 424
Dorsal spine 355
curvature 82
left lateral rotation of 375f
movement 374
right lateral rotation of 375f
Dorsiflexion 177f, 489
Dorsolumbar spine, scoliosis of 366f
Dorsum skin condition 321
Double crush syndrome 22, 122, 142, 164, 188
Double hemiplegic cerebral palsy 485
Dowager's hump 365
Down syndrome 209
Drawer test
anterior 93, 93f, 281, 283f, 335f
false-negative 282
for anterior stability 335
anteroposterior 186, 187
posterior 95f, 95, 287f, 287
posterolateral 140, 292, 292f
Drop arm test for supraspinatus tendon tear 99
Drop sign 100
Drug-induced peripheral neuropathy 416
Duncan-Ely test 490f
Dupuytren's contracture 167, 171
Dupuytren's test 231
Dupuytren's contracture 20, 165, 171f, 190
of left hand 191f
Durkan's median nerve compression test 180
Durkan's test 180
Dyskinetic scapula 84
Dysplasia of hip
developmental 1, 207, 245
test for developmental 234
Dysplastic spondylolisthesis 355
Dystonia 492
E
Ecchymosis 32
Edema 499
Eichhoff test 181, 181f
Elbow
and radioulnar joint 134b
and superior radioulnar joint, bony anatomy of 118f
clinical diagnostic snippets 126t
common conditions affecting 122b
cubital tunnel syndrome 150
examination 143
flexion movement 18
instability 137, 144
tests for 138
joint
clinical evaluation of 118
line, palpation of 132
ligaments of 120f
location of anterior and posterior joint lines of 133f
movements, extension, flexion 134f
myositis ossificans of 147f
pain
anterior 123
causes of 123t
lateral 123
medial 123
posterior 123
pathology, case of 122
range of motion 135b
stabilizing structures 119
terrible triad of 146
varus buttress of 118
with goniometer, flexion range of movement 24f
Electrolyte imbalance 523
Elson test for central slip of extensor tendon rupture 187
Ely's test 234, 234f, 240, 379
Empty can test 99
Enchondroma 199
Enchondromatosis, multiple 199
Endoneurium 410, 456
Enophthalmos 473
Enteropathic arthropathy 66
Entrapment neuropathy 63
Eosinophilic granuloma 502
Epicondyle
lateral 120f, 256f
medial 120f, 137, 150, 253f, 254f, 272f, 274, 307f
Epileptics 78
Epineurium 410
Epiphyseal lesion 505f
Erb's palsy 481f
Erb's point 466
Erector spinae 77
Essex-Lopresti
fracture-dislocation 146
injury 192
lesion 142, 196
Eunuchoid habitus 377, 378
Eversion talar tilt test 335
Ewing's sarcoma 1, 507
of left humerus 507f
Exostoses, multiple 499
Extensor capri radialis longus and brevis 155f
Extensor carpi radialis brevis 155, 156, 434f
Extensor carpi radialis longus 155, 156, 435
test for 436f
Extensor carpi ulnaris 155, 155f, 156, 162, 175, 434f, 435
test for 436f
Extensor digiti minimi 155, 155f, 434f
Extensor digitorum communis 434f, 435
test for 436f
Extensor digitorum longus 313, 334f, 453
test for 453f
Extensor expansion 157
Extensor hallucis longus 313, 334f, 448, 448fc, 453
test for 453f
Extensor indices 155, 155f, 434f
Extensor lag 277, 277b
in knee 18
Extensor lateral and medial band 157f
Extensor pollicis brevis 155, 162
Extensor pollicis longus 155, 155f, 175, 434f, 435
Extensor retinaculum 155, 155f
compartments of 155t
Extensor tendon injuries 196
Extensor tendon zones 158
External rotation lag test 100
External rotation recurvatum test 290, 291f
External rotation test 336
External urethral sphincter 352, 354f
F
Faber test 237f
Facet joint 352, 353
Facet joint arthropathy 404
Facetal arthropathy 363
Fairbank's apprehension test 295
False ankylosis 20
Fascial contractures 8
Fasciculus cuneatus 349f, 350f, 407f
Fasciculus gracilis 349f, 350f, 407f
Felon 162, 168, 199
Felty's syndrome 63
Femoral acetabular impingement 208
Femoral condyle, lateral 253f, 256f
Femoral condyles 252
Femoral head 225, 227
blood supply of 202f
vascularity of 201
Femoral nerve 420, 421, 449
motor assessment 449
stretch 384
stretch test 384f
Femoral osteosarcoma 506f
Femoral steochondroma 504f
Femoral triangle 213
Femoroacetabular impingement 249
Femoroacetabular lesion, types of 250f
Femur component, measurement of 228f
Festinant gait 527
Fexor hallucis longus 334f
Fibrocartilage complex, triangular 154f
Fibrocartilage, triangular 187
Fibromyalgia 409
Fibrous ankylosis 19
Fibrous dysplasia 509
Fibula, neck of 276
Fibular neck 272
Figure-of-four test 385, 385f
Finger escape sign 387
Finger sign 112
Finger under normal MLA 322f
Finger-nose test 393
Finkelstein test 181
Finochietto-Bunnell test 182
Fixed abduction deformity 218
Fixed deformity 216
Fixed flexion deformity 276
Flail limb 472f
Flatfoot 314
Flatfoot, congenital 341
Flexion deformity 16, 125, 277, 240
of left knee 269f
Flexor and extensor zones of hand 158t
Flexor carpi radialis 156, 437f, 438
test for 440f
Flexor carpi ulnaris 156, 162, 175, 200, 445t
test for 446f
Flexor digitorum longus 313, 334f, 455
Flexor digitorum profundus 155, 438
test 440
Flexor digitorum superficialis 155, 438
Flexor digitorum superficialis and profundus 160, 437f
testing for 441f
Flexor digitorum superficialis test 440, 441f
Flexor hallucis longus 313, 455
Flexor pollicis brevis 160, 437f
Flexor pollicis longus 160, 437f, 438
test for 440f
Flexor retinaculum 154
anatomy of 154f
Flexor tendon
injuries 197
of fingers, pulleys over 157f
pulleys of 157
zones, injury area 158
Flexor tenosynovitis 200
Flip test 383, 384f
Fluid discharges, type of
purulent discharge 543
sanguineous 543
seropurulent 543
serosanguinous 543
serous 543
Fluid thrill 537
Foot
arches of 311, 311f
bones of 310b
ligaments of 311
sensory innervation of 333f
size of 333
types of arches of 312t
Foot and ankle 313b
clinical diagnostic snippets 317t
joint, clinical evaluation of 310
locations of 315t
muscles of 313t
surgical anatomy of 310
Foot arch, type of 320f
Foot concavity, loss of 326f
Foot drop 417, 459
Foot progression angle 237
measurement 238f
Foramen magnum 348
Forearm length 90
measurement 90f
Forearm mid-prone 81
Forearm muscles 136, 179
Forearm supinated, biceps assessment with 433f
Forefoot 321
dorsum, palpation of 330
plantarflexion reclassifies 238
pronation 337
Foreign body, presence of 543
Fovea 175
Fovea sign 183
Foveal tenderness 184f
Foveal test 187
Fracture
blisters 32, 32f
bones 242
malunited 476
neck femur 230, 242
pathological 50
Frank dislocation 77
Frankel sensorimotor classification 393b
Fredrich's ataxia 322
Frieberg disease 346
Froment's sign 445, 447f, 448
Frozen shoulder 78, 80, 111
Fulcrum issues 242
Full Can test 98
Fustilo-Anderson classification 36t
G
Gaenslen's test 386, 386f
Gagey's hyperabduction test 92
Gagey's test 93f
Gait 57, 210, 266, 320, 364, 486, 521
analysis 523
antalgic 524
ataxic 529
cautious 266, 266b
circumduction 529
coxalgic 524
Crouch 486f, 527
cycle 521f
disturbance
assessment of 523
etiology of 522
equinus 526
hand-to-knee 528f
in severe OA knee 528f
in spastic cerebral palsy 527f
knock knee 527, 528f
patterns of, 521, 524
abnormal 45
phases of 521
scissoring 486f, 526, 526f
short limb 525
spatial parameters of 522
stiff hip 526
stomping 529
true equinus 526
types of 210b
antalgic gait 210
bell clapper gait 210
gluteus maximus gait 210
high-stepping gait 210
in-toeing (pigeon gait) 210
out-toeing (Charlie Chaplin) gait 210
short-limb gait 210
stiff-hip gait 210
Trendelenburg gait 210
Galeazzi sign 244
Galeazzi test 228, 229f
Gamekeeper's thumb 182
Ganglion 190, 303f
dorsum of wrist 170f
over dorsum of left wrist 190f
over dorsum of wrist 533f
Ganglionic cyst 115
Ganglions 533
Gap, palpation of 36
Gas in soft tissue 37
Gastrocnemius 259, 454
lateral head of 256f
medial head of 254f
muscle, test for 455f
tubercle 254f
with knee, test for 454f
Gastrocsoleus 488
testing 334f
Gemellus superior and inferior 203
Genu recurvatum 16, 16f, 263, 269f
Genu valgum 58, 263, 268f 268, 280
Genu valgus 63
Genu varum 15, 58, 263, 267, 268, 280
in rickets, bilateral 52f
Gerber's lift-off test 102, 102f
Gerdy's tubercle 256f
Ghost sign 303
Giant cell tumor 1, 265, 504, 533
of distal femur 497f
of tendon sheath 167, 199
Glasgow Come Scale 28t
Glenohumeral arthritis 74, 80
Glenohumeral internal rotation deficit 74, 77, 89, 110, 110f
Glenohumeral joint 71, 73
anatomy of 71
arthritis 113
Glenohumeral ligament
anterior inferior 72f
posterior inferior 72f
Glenohumeral osteoarthritis, left 114f
Glenoid and head of humerus 73
Glenoid bony avulsion 76
Glenoid cavity 71
Global brachial plexus injury 470
Global brachial plexus palsy 474f
Global pain 123
Globular mass 240
Glomus tumor 168, 199, 199f
Gluteal muscle wasting 212
Gluteal region 215
Glutei 77
Gluteus maximus 202
Gluteus maximus contracture 208
Gluteus maximus gait 526, 526f
Gluteus medius 202
Gluteus minimus 202
Godfrey's sag sign 287, 287f
Golfer's elbow 122, 123, 126, 137, 150
test for 137
Goniometer 225, 280f
static limb of 226f
technique of using 24
using 24
Gonococcal arthritis 61
Gout 66
Gouty arthritis 344
Gracilis 202
Grazed abrasions 33, 33f
Greater trochanter 230f
level of 211, 213, 214
palpation of 214
Greater tuberosity 85
Grind test 181, 183
Gross motor function classification system 485, 486f
Growth disturbance 532
Guillain-Barré syndrome 415
Guyon's canal 174, 443
anatomy of 463f
boundaries of 463
compression 463
Guyon's canal syndrome 167
H
Habitual patella dislocation 302
Haglund's bump 318, 325, 325f, 329f
Haglund's deformity 343
Hallux rigidus 321
Hallux valgus 63, 314, 343
bilateral 321f
Hallux varus 63, 314
Hamate 174
Hammer toes 314, 321, 345
Hamstrings 260, 452
medial test for 452, 452f
Hand comprises metacarpals and phalanges 156
Hand
dominance 15, 77
dorsal aspect of 170
extensor zones of 158f
flexor zones of 158f
function, assessment of 178
infections 199
ligaments of 157
tumors 199
wrist-forearm alignment 169f
zones of 158
Hansen's disease 68, 272, 415, 463
Hawkins and Bokor, grading system, modified 93, 94t
Hawkin's sign 98f
Hawkins-Kennedy test 97
Head of
femur 201
humerus, vascularity of 73
talus 329
Head sternal 430f
Heberdon's node 57
Heel broadening 333
Heel valgus, bilateral 324f
Heel varus, left heel 324f
Heel-rise test 323f, 324, 324f, 337
Heggar's hand 481f
Hemangioma 502
Hematogenous osteomyelitis, case of 50
Hematoma, subungual 172
Hemiplegia 522
Hemiplegic cerebral palsy 485
Hemiplegic gait 529
Hemiresection interposition arthroplasty 193
Hemochromatosis 67
Hemophilia, genetics and type of 69
Hemophilic
arthropathy of right knee 69f
cysts 69
joint 69
Hemorrhages in
joint 69
muscle 69
nerves 69
Hepatorenal recess 38
Hereditary diseases 415
Herpes zoster 415
Hildreth test 199
Hill-Sachs lesion 76
Hindfoot alignment 323
Hindfoot and calf 323
Hindfoot valgus deformity 324
Hindfoot varus 323
flexibility 337
Hinge joints 135
recording in 19
Hip
abduction range of movement 25f
abductor, mechanism of 242f
and knee, attitude of 213
anteversion angle 227
arthritis, primary or recurrent 208
avascular necrosis of 248
clinical diagnostic 207t
condition, diagnosis of 203b
diseases, use of cane in 243
disorders, case of 209t
examination 244
extension 224
flexion 224
deformity assessment 490
strength assessment 449
test for 449f
impingement, tests for 235, 236f
joint
articulating bones 202f
clinical evaluation of 201
common conditions affecting 203b
ligaments of 202f
line, anterior 214f
muscles around 201, 202t
pathology, differential diagnosis of 204b
movement
abduction and adduction 226f
flexion 225f
pathologies affecting pediatric population 240t
rotations 224
with knee extended 225
stability, test for 231
subluxation 208
transient synovitis of 208, 246
Hoffmann's test 387
Holt-Oram syndrome 198
Homan's sign 339, 339f
Homogentisic acid oxidase enzyme, lack of 70
Hook grip 159
Hook test 133
for distal biceps tendon rupture 133f
Horn cell, anterior 6f, 349f
Horn, anteror
lateral meniscus 253f, 256f
medial meniscus 256f
Horn
lateral 349f
posterior 349f
Hornblower's sign 100, 432
Hornblower's test positive on right side 101f
Horner's sign 473f
Horner's syndrome 473b
Horse-shoe shape swelling 58
Huckstep triad 371b
Humeral
osteophytes 114f
tuberosity 72f
Humeroradial articulation 118
Humerus, chondrosarcoma of 534f
Hump-bump deformity 343
Hyaluronic acid 61
Hydroxychloroquine 63
Hyperextension 277
Hypermobility, presence of 86
Hyperparathyroidism 67
Hypertrophic scar 541t
Hypertrophied synovium 274
Hyperuricemia 318
Hypotension, causes of 352
Hypothenar eminence 160
Hypothenar hammer syndrome 172, 192
Hypotonic cerebral palsy 485
I
Idiopathic and degenerative 111
Idiopathic scoliosis, adolescent 362
Igawa sign 445, 448
Iliac spine
posterior superior 396
superior, anterior 211
Iliopsoas 202
Impingement in shoulder 107
Impingement test 97, 108
anterior 235, 236, 236f
anterolateral 236
posterior 236
Index finger 439f
Infections 116, 152, 199, 246, 400
Infections
acute 261
around nailbed 172
of nerve 415
Infective synovitis 265
Inflammation
acute 3
chronic 3
Inflammatory arthritis 167
Inflammatory conditions 148
Inflammatory diseases 62, 361, 410
Inflammatory seronegative spondyloarthropathy 167, 405
Inflammatory tenosynovitis 162
Infraganglionic spinal nerve 469
Infraspinatus 73
Infraspinatus tear 99
Infraspinatus tendon, tests for 101f
Injury
mechanism of 124
scene of 41
severity score 27b
type of 28
Instability 57, 125, 262
and weakness in grip 164
catch sign (active flexion test) 385
feeling of 45
lateral side 125
medial side 125
of joint 8
posterolateral rotatory 123, 139, 144146
recurrent 301, 315
Intact abductor mechanism 242
Intercarpal joints 153
Intermeniscal ligament 253f, 256f
Internal rotation lag sign 102
Internal rotation lag test 102f
Internal urethral sphincter 352, 354f
Interosseous
lateral and medial band 157f
nerve injury, posterior 459
nerve, anterior 437f, 461f
nerve, posterior 149, 156, 462f
tendon and hood 157f
Interosseous, card test for 446f
Interphalangeal 179
Interphalangeal joint 159, 176, 313
distal 163
Intersection syndrome 190
Interstitial cystitis 409
Interstyloid distance, measurement of 179f
Intertrochanteric femur fracture 242
Intertrochanteric fracture, malunion of 208, 248
Intervertebral disc 352
calcification of 70
prolapse 75, 355, 396
prolapse of cervical region 401
prolapse of lumbar region 402
Intra-articular
hip pathology 237
spread of tumor 502
swelling 5
Intramuscular swelling 537
Intrinsic and extrinsic muscles of hand 160t
Intrinsic minus 171
Intrinsic plus hand 171, 179b
Inversion talar tilt test 335
Inverted radial reflex 387
Inververtebral disc calcification in ochronosis 70f
Ipsilateral anterior horn cells 350
Iridocyclitis, signs of 364
Irritable bowel syndrome 409
Ischial tuberosity 230f
Isthmic spondylolisthesis 363
J
Jack's test 336, 336f
Javelin thrower 111, 151
Jaw pain 409
Jendrassik maneuver 394
Jerk test 94, 95f
Jersey's finger 166, 195
Jobe's supraspinatus test 99
Joint above 15, 22, 38, 48
examination of 106, 188
Joint below 15, 22, 38, 48
examination of 106
Joint capsule 7
anterior 121
Joint, crepitus 59
Joint, hyperlaxity of 86
Joint in ankle and foot, type of 312
Joint involvement, symptoms of 497
Joint line tenderness 272
Joint, misplaced 76
Joint, movement 18
normal component for 7
Joint of upper and lower limb, examination of 395
Joint of wrist, type of 156
Joint, stability of 262b
Joint, stiffness of 45
Joint, tuberculosis 57
Joint, type of 73, 121, 159, 201, 258
Juvenile kyphosis 398
K
Kapandji score for thumb opposition 178f
Keinbock's disease 165
Keloid 541t
multiple 541f
Keratoconjunctivitis sicca 63
Kienbock's disease 200
Kirk-Watson test 184, 184f, 187
Kleinman shear test 185, 185f, 187
Klippel-Feil deformity 355, 367, 399
Klippel-Feil syndrome 74, 368f
Klumpke's palsy 472
Knee
dislocation 259
effusion in standing 273
examination 299
extensors (quadriceps), test for 449f
flexion deformity of 278f
flexion movement 18
hyperextension 268
ligaments of 258t
pathology of 261b
snippets of 264t
Knee joint 9, 251, 260b
clinical evaluation of 251
function of 251
in coronal, anatomy of 251f
minimal fluid in 273b, 274f
muscles around 260t
normal hyaline cartilage of 304f
Kneeling method 233
Kothari's method 219, 222f
Kothari's parallelogram method 222
Kyphosis 397
angular 365f
deformities 365
round-back 365f
L
Labral tear
posterior 109
posterosuperior 79
Labrum 71
Lacerated wound over
cubital fossa 33f
forefoot 33f
Laceration 33
Lachman test 283
modified 284, 284f
Lasegue test 383, 383f
reverse 384
Lateral collateral ligament 143, 255, 256f, 260, 309
complex 119
stability 139
Lateral cord syndrome 406, 407f
Lateral hamstrings, test for 452, 452f
Lateral meniscus, posterior horn of 256f
Latissimus dorsi 73
test for 429f
Leflunomide 63
Left knee, horseshoe-shaped swelling of 270f
Leg and foot, long axis of 24f
Leg hanging down testing tibialis 334f
anterior 334f
posterior 334f
Leg, lateral compartment of 453
Legg-Calve-Perthes disease 247
Lelli's test 258, 281, 285, 285f
Leprosy 68
Lesser tuberosity 85
Levator scapulae 425, 424f
Lever sign 285
Lhermitte's sign 387
Lichtman test 186f, 187
for midcarpal instability 185
Ligament, anatomy 259
Ligament, anterolateral 256f
Ligament laxity 276, 331
grade of 281b
Ligamentous injury 264
Ligamentum flavum 354f
Ligamentum teres 202f
artery of 201
Limb and deformity, alignment of 46
Limb, circumference of 538
Limb, distal part of 48
Limb injuries 42
Limb length 20, 37, 58, 90
apparent discrepancy 20
discrepancy 6, 15, 16, 21, 21b, 32, 45, 46, 128, 136, 206, 263, 270, 213, 367, 370, 377
measurement 20, 108, 143, 189, 227
true discrepancy 20, 227
upper measurement 90f, 136f
Limb, major vascular injury of 40
Limb salvage surgery 506f
Limb, traumatic amputation of 40
Limb, vascular examination of 395
Limp 6, 206
Ling test 237
Lipoma 537
Lisfranc joint 313
Lisfranc's amputation stump 519f
Lister's tubercle 173, 174
Little league elbow 152
Liu's test 104
Load and shift test 94, 94f
Lobstien syndrome 51
Locking 262
Locking specific, cause for 56
Locking, true 9
Long bone
affections 49
and joints diseases, clinical evaluation of 43
common tumor in 500f
disease 43
Long extensor tendon 157, 157f
Long thoracic nerve palsy 427, 428f
Long thoracic nerve, muscles supplied 428t
Longitudinal arch, medial 330
Longitudinal ligament, anterior and posterior 354f
Love's pin test 199
Low radial nerve palsy 459
Low ulnar nerve palsy 446
Lower limb 213, 225, 227
attitude 210f
measure true length of
measurement technique of 279f
muscles, major nerves supplying 448fc
myotomes of 392f
nerves, examination of 448
normal alignment of 268
normal rational right alignment of 213f
rational deformity of 213
segmental length of measurement technique of 279f
true length of 228f
Lower motor neuron lesions 391, 391t
Lower subscapular nerve 466f
Lower trunks, typical mechanism of injury 469f
Lumbar canal stenosis 359, 403
Lumbar facetal disease 404
Lumbar intervertebral disc prolapse, type of 368f
Lumbar lordosis 213, 213f, 215, 240
Lumbar region 357
Lumbar sciatic scoliosis, acute 367
Lumbar spinal canal stenosis 363
Lumbar spine 355, 376f
extension 375
flexion and extension of 377
flexion, assessment of 375
instability, special test for 385
lateral flexion of 376
movement 375
assessment 376f
painful/limited 377b
Lumbar spondylolisthesis 369f
Lumbosacral coccygeal nerve roots 348
Lumbosacral junction 369f
Lumbosacral nerve root compression 382
Lumbosacral spine, section of 348f
Lumbrical plus finger 200
Lunate 174, 175
Lunotriquetral 184
Lunotriquetral shuck test 185, 187
Lyme's disease 415
Lymph node 60, 48, 539
enlargement 499
examination 22, 106, 108, 143, 188, 239, 244, 298, 299, 395, 423
M
Madelung deformity 163, 198, 198f
Maffucci syndrome 199
Magnus 202
Malignancies 507
Malignant bone tumor 494t
Malleolus
lateral 544f
medial 544
Mallet finger 166, 195
Mallet little finger 195f
Mallet toe 63, 321
Maneuvers, internal rotation 97
Mangled extremity 34
severity score 34, 35t
Mangled lower limb 35f
Manus valgus deformity 163, 193
right wrist 170f
Marfan's syndrome 53, 378
Marie-Strumpell disease 64
Marjolin's ulcer 545f, 545
Martel sign 67, 67f
Maudsley's test 149
McMurray for
lateral meniscus 293
medial meniscus 293, 294
McMurray's test 293, 293f
Median nerve 122, 180, 420, 437
muscles supplied 438t
Median nerve palsy, features of 439
Medical Research Council grading for muscle power 391b
Medulla oblongata 348
Megaprosthesis 506f
Meningomyelocele 68
Meniscal cyst 303f
lateral 270f
Meniscal root tear, posterior 303
Meniscal tear 9, 303
location of 293b
Meniscal tests 281, 292
Menisci 257
function of 257
Meniscofemoral ligaments 254
Meniscus
lateral 256f
medial 256f, 282b
medial posterior root tear 264
Meniscus test 299
Menstrual irregularities 207
Meralgia paraesthetica 409, 463
Metabolic arthropathy 69
Metacarpophalangeal joint 55, 87, 159, 176, 177, 178b, 179b, 435, 474f, 476, 482, 516
Metastatic tumor, secondary 532
Metatarsal heads 326f
Metatarsophalangeal 313
Metatarsus adductus 238
assessment 239f
Methotrexate 63
Midfoot 322
Midfoot Charcot's arthropathy 319
Midfoot dorsum, palpation of 330
Midfoot instability, chronic 339f
Mid-tarsal joint movement 332
Milking maneuver 138, 139f, 143, 146
Milwaukee shoulder 74, 116, 117f
Milwaukee shoulder syndrome 77, 117
Miosis 473
Mobile arm 24 24f, 25
Mobility, abnormal 36
Monoarticular exacerbation 63
Mononeuritis multiplex 63
Mononeuropathy 410
Monoplegic cerebral palsy 485
Morant-Baker cyst 265
Morel-Lavallée lesion 34, 34f
Morning stiffness 205
Morrant Baker's cyst 305
Morris bitrochanteric line 227, 230, 231f, 244
Morton's neuroma 314, 318, 346
Moses’ sign 339, 339f
Motion, restriction of 360
Motor assessment 333
Motor examination 390, 419, 421, 477, 491
Motor march phenomena 423
Motor power examination, method of 421b
Motor symptoms 413
Movements 17, 37, 48, 59, 87, 223, 331, 419, 538, 501
and stability of neighboring joints 515
difficulty in 75, 262
elbow and radioulnar joint 134
glenohumeral joint 73
hip joint 201
involuntary 393
loss of 56
painful 89
range of 24, 87, 90, 176, 177, 179, 200, 309
spasm in 18
wrist 176
Moving valgus test 138, 139f
Mulder's click 330
Muscle 121
around elbow joint 121t, 259
contractures 489
tests for 234
girth, measurement of 48
hypertrophy 128
power of 421, 492
strength around elbow 143
tendon complex 20
test of
biceps (forearm supinated) 142f
brachialis (forearm pronated) 142f
brachioradialis 142f
tone of 391, 421
wasting 15, 16, 46, 58, 82, 128, 171, 269, 475, 535
Muscular torticollis, congenital 397
Musculocutaneous nerve 421, 433
Musculocutaneous nerve, major muscles supplied 433t
Musculoskeletal integrity, lower limbs 523
Myeloma, multiple 502
Myelomeres 349f
Myelopathy hand 387
Myositis ossificans 49, 127, 130, 147
N
Nail and pulp changes 172
Nail changes 418
National Pressure Ulcer Advisory Panel grading 395b
Neck 82
Neck and scapula 367
Neck and shoulder 82f
Neck pain 78
radiation, pattern of 358f
Neck webbing 209
Neer's impingement sign 97
Neer's sign 97f, 108
Nelaton's line 230, 230f
Neoplasia 3
Nerve compression 532
Nerve conduction velocity 151, 200
Nerve entrapment 115, 150, 197
Nerve injury 326, 459
axillary 76
classification of 412
specific 413t
type of 412t
Nerve palsy, typical deformities 417b
Nerve paralysis 76
Nerve recovery, clinical signs of 422
Nerve roots 6f, 348
Nerve, structure of 411f
Nervous system, components of 352t
Neurilemma 456
Neurilemmal sheath 410
Neurofibroma 483
Neurofibromatosis 531f
Neurogenic claudication 359f, 359
Neurological condition, distal 22
Neurological diseases 522
Neurological examination 387, 419, 477, 491
Neurological status of limb 547
Neuromuscular junction 411f
Neuromusculoskeletal pathway 6f
Neuropathic arthropathy 54, 67
Neuropathic joint 346
Neuropathic ulcer 546
Neurovascular bundle 39
Neurovascular compression 539
Neurovascular examination 15, 22, 38, 48, 60, 143, 231, 244, 299, 333, 502
lower limbs 281
upper limb 90, 137, 180
Neutropenia 63
Nonunion 49
Nonunion neck femur 208, 248
Nucleus pulposus 353
Numbness 125, 315
Nutritional deficiency 415
rickets, typical 52
O
O'Brien test 104, 104f
Ober's test 234, 235f, 244
Oblique ligament, posterior 254f, 255
Oblique retinacular ligament 157f
Obturator externus and internus 203
Obturator nerve 420, 450
motor assessment 450
test for 450f
Occulta 212
Ochronosis 70
Ochsner's clasping sign 442, 442f
O'Donhogue triad 285
OK sign 137, 180, 437, 439, 440, 443, 443f, 461
Olecranon bursitis 122, 123, 127, 150, 150f
Olecranon, position of 129
Olecranon process, tip of 131
Olecranon stress fracture 123, 152
Olecranon, tip of 129, 130f
Ollier's, achondroplasia 198
Ollier's disease 199
Omovertebral bar 398f
Open degloving with skin loss 34f
Open fracture 36, 36t, 39
case of 31b
Opponens pollicis 437f, 438
Orthopedic case presentation 1
Orthopedics
basics of history taking and examination in 1
etiopathology 12b
Ortolani test 234, 234f
Os naviculare 343
Os trigonum 316, 342
Osborne-Cotterill’ lesion 144
Osgood-Schlatter disease 265, 307, 307f
Osteitis deformans 53
Osteoarthritis 309
of knee 58
Osteoarthrosis
degenerative 54
of hip, primary 249
primary 60
Osteoblastoma 502
Osteochondral loose bodies 9
Osteochondritis dessicans 9, 70, 70f, 264, 306
of capitellum 122, 123
of elbow 152
Osteochondroma 496, 502, 504
Osteochondroma femur
exposure for excision 504f
X-ray of 504f
Osteoclastoma 502, 504
Osteogenesis imperfecta 51, 51f
Osteoid osteoma 509, 510f
of spine 362
Osteomalacia 49, 53, 405
Osteomyelitis 74
chronic 7, 50
sinus 543
Osteophytes, lack of 63f
Osteoporosis 53, 355, 405
Osteoporosis, severe 70
Osteoporotic vertebral body fractures 362
Osteosarcoma 1, 505
of distal femur 506f
Overload syndrome conditions 151
Overuse syndromes 122, 123
P
Pacinian corpuscles 483
Paget's disease 53, 263, 365
Pain 3, 44, 55, 75, 123, 161, 163, 261, 356, 472, 497, 542
activities causing 44
character of 44, 205
dull aching 531
during bending backward 358
from neighboring areas mimicking shoulder 77
nature of 162, 357
of neurological origin 4
onset of 3, 44, 162, 205, 356
progression of 3
quality of 3
radiation of 3, 205, 357
referred 205
severity of 4, 205
site of 3, 123, 356
timing of 4, 75, 356
Painful arc syndrome 114
Painful catch sign 385
Painful extension 377
Painful forward flexion 377
Palmar 170
aponeurosis 156
fascia, contractures of 171
flexion 177f
interossei 445
Palpate for thuds and clicks 279
Palpate popliteal fossa 276
Palpate serratus anterior insertion, method to 478f
Palpate spine 215
Palpate tibial nerve 329
Palpating medial and lateral hamstrings 452f
Palpation technique of
anterior joint line 85f
posterior joint line 86f
Pancoast tumor 483
Paralysed muscles 9
Paralysis 480
delayed onset 414
of femoral nerve 449
of obturator nerve 450
pattern of 470t, 479t
Paraolecranon fossa 130f
for swelling 129
Paraspinal abscess 370f
Paraspinal spasm 369, 371
Parasympathetic nervous system 354f
Paronychia 168, 200
Pars interarticularis 403f
Parsonage-Turner syndrome 483
Partial rotator cuff tear 74, 80
Patella 252, 254f
facet of 272
maltracking assessment of 297, 297f
palpation of medial and lateral facets of 276f
position of 269
Patella dislocation 9
congenital 302
Patella facet tenderness 275
Patella grind 275f
Patella horizontal tilt test 296f, 296
Patella infera 269
Patella instability 264
Patella magna (large patella) 259
Patella parva (small patella) 259
Patella stability, assessment of 295
Patella stability test 281
Patella tendinosis 265
Patellar glide test 275, 296
Patellar height and geometry 259
Patellar tap 273f, 273
Patellar tracking 297
Patellofemoral joint 251
Patellofemoral ligament, medial 257
Pathological joints, clinical evaluation of 54
Pathological scarring, evidence of 540
Patte's sign 100
Patte's test 295, 295f, 100, 432
Pebble-shaped patella 259
Pectoral nerve 429
medial and lateral 430f
muscles supplied 429t
Pectoralis major 73
heads of 430f
paralysis, features of 429
test for 430f
Pediatric bone tumors 502
Pellegrini-Stieda disease 308, 308f
Pelvic floor 77
Pelvic inflammatory disease 11, 207, 361
Pelvis compression test 386
Pelvis distraction test 386
Pelvis fracture 34f
Pelvis, level of 525f
Pelvis, right hip 221f
Pelvis squared 218
Pelvis unsquared 218
Pen test 442
Periarthritis shoulder 111
Pericardial effusion 38
Perineurium 410
Peripheral nerve 6f
clinical evaluation of 410
examination 458
Peripheral nerve, surgical anatomy of 410
Peripheral nervous system 411f
Peripheral neuropathy 544
Peripheral pulses 476
Perisplenic space 38
Periungual telangiectasia 172
Perkin's method 219, 221, 222fc
Peroneal nerve injury, common 276, 459
Peroneal nerve, superficial 333f, 420, 448fc, 450f, 451, 453
Peroneal tendinitis 325, 328
Peroneus brevis 313
Peroneus longus 313
Peroneus longus and brevis 448, 448fc, 453
test for 454f
Peroneus tendon, testing 334f
Peroneus tertius 448, 448fc
Perthes’ disease 1, 207, 247
left hip 247f
Pes anserine 259, 272
Pes anserinus bursitis 271f
Pes cavus 342
common causes of 322
of left foot 322f
Pes planus 238, 341
Pes planus and pes cavus, causes of 322b
Pes planus, flat arch of left foot 322f
Petit triangle 369, 369b, 370f
Phalen's sign 180
reverse 180
Phantom limb sensation 513
Phelps test 490
Piano key sign 183f
Piano key test 183
Pigmented villonodular synovitis 309f
Piriformis syndrome 235
Piriformis tightness, test for 235
Pisiform 174
Piston test 231
Pitcher's elbow 151
Pivot shift test 284, 285f
lateral 139, 140f
reverse 292, 292f
Plano valgus 266, 314
Plano valgus foot 327
Plantar fascia contracture 322
Plantar fasciitis 318, 343
Pleural effusion 63
Pointing finger 417
Pointing index sign 442, 442f
rationale of 442b
Policeman's tip hand 417
Poliomyelitis 415
Polyneuropathy 410
Polytrauma 26, 27f, 29fc
clinical evaluation of
concepts of 26
Popeye elbow 130
Popeye sign 82, 105, 128
over right arm 82f
reverse 128
Popliteal angle
bilateral 490, 490f
unilateral 490
Popliteal artery 259
aneurysm 270
Popliteal fossa 259
examination of 270
touching couch 269f
Popliteofibular ligament 253, 255, 256f
Popliteus 256f
Popliteus tendon 255, 256f
Posterior cord syndrome 407, 407f
Posterior interosseous nerve entrapment syndrome 461
Posterolateral plica syndrome 150
Postganglionic injuries 469f
Pott's spine 355
Power, loss of 76, 163
Preacher's hand 443
Preiser's disease 200
Prepatellar bursa 270f
Primitive neuroectodermal tumor group 507
Pronator quadratus 437f
Pronator syndrome 122, 123, 151, 461, 461f
Pronators 438
test for 439f
Proprioception, position sense 349
Prosthesis
examination 516
fitting of 513
Provocative test 380
Proximal femur aneurysmal bone cyst 508f
Proximal forearm 33f
Proximal interphalangeal 160, 172, 179, 200
joints 163
Proximal tibia fracture 259
Proximal tibiofibular joint 252
Proximal ulna, coronoid process of 118
Pseudoarthrosis of tibia, congenital 51, 51f
Pseudo-coxalgia 247
Pseudogout 67
meniscal calcification in 67f
Pseudolocking 9, 262
Pseudoparalysis 20, 89
Psoriasis 172
Psoriatic arthritis 167
Psoriatic arthropathy 65
Psychological, causes 523
Ptosis 473
Pulp 172
space infection 199
Putti sign 481f
Pyogenic arthritis 60, 260
Pyogenic tenosynovitis 162
Pyramidal tract 350
Pyrazinamide 12, 66
Pyriformis syndrome 249, 409
Q
Q angle 279
Quadrant test 296f, 296
Quadratus femori 203
Quadratus lumborum 77
Quadriceps 260
active test 288, 288f
angle 259
tendinosis 265
weakness 527
Quadriplegia 406
Quadriplegic cerebral palsy 485
Quantitative pilomotor axon reflex test 422
Quervain's disease 165
R
Racial predisposition 541
Radial and ulnar artery
patency of 180
tests for patency of 182
Radial and ulnar styloid process relationship 175, 189
Radial artery 155f
Radial club hand 163, 198
Radial collateral ligament 120f
injury 182
Radial deviation 177f
of wrist 169
Radial glide test 186, 187
Radial head fracture 126
Radial head palpation 132f
Radial nerve 122, 180, 420, 421
autonomous zone of 434f
C5-8, T1 434
major muscles supply 435t
paralysis, features of 435
superficial 155f, 434f, 455f
Radial styloid process, tip of 174, 175
Radial tuberosity insertion 148
Radial tunnel syndrome 123, 126, 461
rule of nine test for 149f
Radial ulnar styloid process relationship 173
Radiation 75
area of 357
Radiocapitellar articulation 119
Radiocapitellar joint 129f, 132
Radiocarpal instability 184, 186
Radiocarpal joint 153
Radiolunate 153f
Radiolunotriquetral 153f
Radioscaphoid 153f
Radioulnar joint 135, 135f
distal 153, 162, 172, 175
superior 119
Radioulnar synostosis, congenital 144
Radius, distal end of 173
Raynaud's syndrome 382
Raynaud's phenomena 172
Reagan ballottement test 185f
Rectus femoris contracture 234
Recurvatum knee 268
Red flag sign 37
Reducibility 537
Reflex sympathetic dystrophy 193
Reflexes 393, 479, 492
deep tendon reflex 394
superficial reflex 393
Regeneration, process of 456
Regimental badge sign 432
Regional lymph node 547
cubital fossa 142
examination of 539
Reiter's arthritis 260
Reiter's syndrome 65
Relocation-release test 92, 92f
Renal phosphate wasting 52
Renal rickets 52
Resisted external rotation test 99
Retinaculum 312t
around wrist 154
Retrocalcaneal bursitis 318, 325, 325f, 329f, 343
Retrograde degeneration, primary 456
Retropatellar tenderness 275
Rheumatoid arthriti 57, 58, 60, 62, 63f, 74, 122, 123, 167, 172, 260, 265, 410
and psoriasis 172b
deformities of wrist and hand 172f
of elbow 148
severe 134
Rheumatoid nodule 533f, 533
Rhizomelic dwarfism 51, 51f
Rhomboid 424f
clinical test for 424f
palsy 425
site for palpation of 478f
Rib hump 367f, 369
Rickets 1, 52, 263
broadened wrist in 52f
Rocker bottom foot 326f
Rocking horse gait 526
Roos test 380, 381f, 381
Rotator cuff 71
arthropathy 74, 80, 113
bilateral 113f
insertion
integrity signs 108
tear 74, 76, 77, 80, 112
tendinopathy 74, 80, 112
tests for 98
Ruptured baker's cyst 48
Ryder's method 229
S
Sacroiliac joint
patohology, test for 386f
special test for 385
Sag sign 286f
modified 286, 286f
posterior 286
Salmonella 66
Saphenous nerve 420, 451
Sauve-Kapandji procedure 193
Scalene triangle 131
Scaphoid 174
Scaphoid fracture 165
Scaphoid nonunion advanced collapse arthrosis 192
Scaphoid tubercle 173f
Scapholunate 154, 184
advanced collapse arthrosis 192
instability 184, 187, 189
ligament injury 166
ligament tear 162
Scapula 83
inferior angle of 85
lateral border of 86
level of 212, 372f
medial border of 85
shape of 83
spine of 85
superomedial border of 481f
winging of 83, 417
Scapular dyskinesia 107, 109
Scapular dyskinesis 83
method to elicit 84
Scapular ligament, transverse 115
Scapular retraction test 110
Scapular winging 459
Scapulohumeral reflex 387
Scapulothoracic joint 71, 89
Scar 419, 475
and ulcer 48
clinical evaluation of 530
examination of 540
healed with
primary intention 541f
secondary intention 541f
inspection of 540
mobility of 541
palpation of 541
Scar tissue 469f, 540
Scarf test 106
Scarpa's triangle 205, 211, 213
anatomy and content of 211b
fullness in 211
Scarred limb, chronic 534f
Scheuermann's disease 360, 362, 365
Scheuermann's kyphosis 398
Schober's method, modified 375
Schober's test 376f
Schwann cells 456, 457f
Schwannoma 483
Sciatic nerve 452
injury 459
L4, L5, S1-3 450
muscles supplied 451t
Scleroderma 172
Scoliosis 51, 366, 397, 510f
functional 368f
inclination 377
Scoliosis kyphosis 16
Scoliotic spine 367f
Sectoral sign’ 224
Seddon's classification 412
Semimembranosus 254f, 259, 260, 270, 452
bursa 259, 276, 305
tendon 255
Semitendinosus 259, 452
Senile kyphosis 362
Sensitive sign, underlying shoulder pathology 75
Sensorimotor innervation 349f
Sensorimotor tracts 349f
Sensory 443
and motor disturbance in upper limb 381
supply of median nerve 437f
supply of radial nerve 434f
assessment of foot 333
ataxia gait 529
examination 388, 419, 420b, 492
innervation of
around knee 259
foot 450f
lower limb 456f
upper limb 455f
loss 439, 446
symptoms 413
Septic arthritis 74, 122, 265
acute 61, 246
of hip 208
Seronegative spondyloarthropathy 64, 358, 361, 362
Serratus anterior 73
wall push-up test for 428f
Shephard-Crook deformity 509f
Shigella 66
Shoe maker's line 230f, 230
Shoe wear pattern in various type of feet 319f
Shoulder
abduction of 114f
measurement of 25f
anterior aspect of 92
bony landmarks of 85f
clinical diagnostic snippets 79t
common conditions affecting 74b
contour 81
denotes coracoid process 85f
dislocation 1
examination proforma 108
girdle muscles, major nerves supplying 423fc
hand syndrome 74
in internal rotation 85f
instability
anterior 75
special test for 91
tests for 91
internal impingement of 111
joint 72f, 73t, 87, 142
active ROM 88f
anatomy of 72f
clinical evaluation of 71
range of movement 88b
left, calcific tendinitis of 115f
level of 82, 212
pathologies 74b
subluxation of 76
to test supraspinatus 478f
Shworth scale 491, 491b
Sickle cell anemia 207
Sign of surgical correction 540
Silfverskiöld test 489f, 489fc
for calf muscle tightness 338, 338f
Simian hand 439f
Sinus 44, 47, 543f
associated 531
clinical evaluation of 530
discharging 7
over distal tibia 47f
presence of 46
with purulent discharge 531f
Sinus tarsi syndrome 314, 316, 317, 328, 345
Sit-to-stand test 385
Skier's thumb 182
Skin
and subcutaneous tissue 20
breakdown, presence of 540
changes 10, 169f, 476
creases 325
loss 34, 34f
overlying limb 46
Slipped capital femoral epiphysis 1, 208, 247, 247f
Soft tissue 271
crepitus 37
injury 35t
palpation 476
Sole 326
palpation of 330f
Soleus muscle, test for 454f
Spasticity 491
Speed's test 105, 105f
Spina bifida 398, 341
evidence of 212
Spina bifida aperta 370
Spina ventosa 168
Spinal accessory nerve 425f
C1-C5, 6 425
injury 76
muscles supplied 426t
Spinal artery
anterior 349f, 350f, 350, 407f, 408f
posterior 349f, 350f, 407f, 408f
segmental 351
Spinal cord 6f, 348, 351
affection 389b
arterial supply of 350f
hemisection of 406
infarction 351
injury 352, 393b, 406
major ascending tracts in 349
major descending tract in 350
sensory tracts, assessment 389t
Spinal deformity 371
Spinal injury with traumatic paraplegia 363
Spinal instability 403
Spinal ligaments 352
Spinal metastasis 355
Spinal nerve 348, 410, 467t
Spinal nerve roots 352, 425
specific and single 392
Spinal osteochondrosis 362
Spinal segments 349f
Spinal tumors 322
Spinal unit, functional 354f
Spine 82f, 516
alignment of 364
and pelvis 37
clinical conditions affecting 355b
clinical diagnostic snippets of 362t
clinical evaluation of 348
common infections of 400t
curvature of 82, 353
examination proforma 396
function 353
lesions of 364
mobility 353
movement of 353, 372
normal coronal alignment of 366f
osteology of 348
pathology 356b
red flags of 360
tenderness 370
tumors 502
benign 502
malignant 502
Spinoglenoid notch cyst 116f
Spinothalamic tract
anterior 349f
lateral 349f, 406f, 407f, 408f
Spinous process 215
direct palpation of 372f
of cervical spine 372f
Spondylitis 401
Spondylolisthesis 215, 363, 402
L5 over S1 403f
types 403
Spondylolysis 355, 363, 402, 403f
degenerative 401
Sports injuries 1
Sports-related conditions 109
Sprengel deformity 398
Sprengel shoulder 74, 84, 368f, 398f
Spurling test 378, 378f
basis of 378b
Squeeze test 336
Stability test 108
elbow 137, 143
for anterior cruciate ligament 281
for posterior cruciate ligament 281, 286
for posterolateral corner 281, 289
for posteromedial corner 281, 288
lumbar spine 396
thumb 186
Staheli prone extension method 217
detecting FFD of left hip 218f
Starch-iodine test 422
Static method 84
Static valgus stress test 138f, 138
Static varus stress test 139, 139f
Sternoclavicular joint 71, 84
Sternocleidomastoid 426
test for right side 425f
Sternocleidomastoids 365
Stiff joint 7, 19
Stinchfield test 237
positive 249
Straight leg raising test 382, 382f
Stroke test 273, 274f
Stump, palpation of 515
Styloid processes 176f, 179
Subacromial bursa 107
Subacromial space 97, 107
Sublime tubercle 119
Subluxation, tests for 183
Subscapularis tear 101
Subscapularis tendon, tests for 102f, 103f
Subtalar joint 310, 332
inversion-eversion, assessment of 332f
palpation 330
Sudeck's osteodystrophy 193
Sudomotor function 422
Sulcus sign 96, 474f
grading of 97
Sulphasalazine 63
Superior labral anterior-posterior lesion 77
Superior labral anterior-posterior tear 109
Supinator crest 119
Supinator reflex 421
Supinator tunnel syndrome 122, 123
Supine method 217
Suppurative tenosynovitis, acute 168
Supraclavicular fossae 365
Supracondylar bony process 461
Supracondylar ridges 130
Supraganglionic root 469
Supramuscular swelling 537
Suprapatellar 259
Suprascapular nerve
compressive neuropathy 76
entrapment or compression 115
Supraspinatus 72f, 73
tear 98
tendon, tests for 99f
Supratrochlear 142
Sural nerve 420, 451
Sustentaculum tali 329
Swain test 289
Swallow-tail sign 432
Swan-neck deformity 172
Swelling 5, 32, 44, 46, 77, 125, 128, 163, 170, 171, 261, 270, 271, 315, 360, 369, 496, 537b, 537f
arising from nerve 537
arising from tendon 537
causes of 211
characteristics of 419
clinical evaluation of 530
diagnosis of 533t
local examination of 532
multiple 531, 531f
of distal limb 48
of right knee joint 58f
palpation of 134
plane of 536
pulsatile 536f
right ankle 328f
specific characteristics 535
submuscular 537
Syme's amputation stump 517f
Sympathetic nervous system 352, 354f
Syndactyly 198f
Syndesmosis injury, distal 336
Syndesmotic ligaments 311
Synovial chondromatosis 308, 308f
Synovial fluid 10
Synovial hypertrophy 173, 175, 261, 274
palpation of 275f
Synovial membrane 10
Synovitis, stage of 61
Syringomyelia 68
Systemic lupus erythematosus 172, 410
related arthropathy 63
T
Table-top relocation test 141
Table-top test 183
Talar dome 328
Talar osteochondral lesions 345
Talar tilt test
eversion 336f
inversion 335f
Talipes equinovarus, congenital 314, 317, 325f
Talofibular ligament, anterior 310
Tanner grading in 13
boys 14t
girls 14t
Tardieu scale 491b
Tardy ulnar nerve palsy 126, 448, 448b
Tarsal coalition 317
Tarsal collapse 326f
Tarsal tunnel syndrome 318, 329, 347, 463
Tarsometatarsal joints 68f
Tarsometatarsal junction 238
Telescopy test 231, 231f
Tenderness 47, 84, 176, 214, 271, 272, 327, 543, 547
anterior to ankle 328
around wrist 173
Tendinitis, calcific 74, 75, 80, 115
Tendo-Achilles 313, 322, 323
insertion 329
tear 318
tendinitis 318
tendon proximal 329
Tennis elbow 106, 122, 123, 126, 149
tests for 137
Tenosynovitis 165
Tensor facia lata contracture 234
Teres minor 72f, 73, 431
test for 100
Thessaly test 294, 295f
Thigh-calf circumference 244
Thigh foot angle, measurement of 239f
Thomas hip flexion test 216, 217f
rationale of 217
Thompson test 338f
Thompson-Simmond test 338
Thoracic outlet syndrome 167, 362, 399
special test for 380, 384
Thoracodorsal nerve 429f
C6-C8 428
muscles supplied 428t
Thrombocytopenia 198
Thumb 272f
abduction 442
and extension angle 177
metacarpophalangeal joint 178
movements 178f
Thyroid dysfunction 165
Tibia, pagetic bowing of 54f
Tibial bowing, anteromedial 51
Tibial component, measurement of 228f
Tibial condyles 252
Tibial nerve 420, 421
test of muscles of 454
Tibial plateau 253f
lateral 253f, 256f
medial 253, 253f, 256f
Tibial torsion 238, 239f
internal 239f
Tibial tuberosity 272
bilateral 307f
Tibialis, anterior 313, 448, 448fc, 453
test for 453f
Tibialis, posterior 313, 329, 448, 448fc, 454
insufficiency 318
tendinitis 343
test for 455f
Tibiofemoral angle 280
Tibiofemoral articulation shallow 252
Tibiofemoral joint 251
Tie beam 312
Tietze's disease 78
Tinel's sign 329, 422, 479
Tingling 125, 315, 513
Tissues, dead 546f
Toe deformities 321b
Toeing-in and toeing-out deformities 321
Toes’ sign 323f
Tom Smith arthritis 246
of hip 207
of left hip 246f
Tone 391
Torticollis 16
of right side 364f
Tourniquet inflation test 199
Trabaculae crossing joint 19f
Translucency 538
Transmitted movement, loss of 37, 47
Trans-olecranon fracture-dislocation 146
Trapezium 174
Trapezius 73, 77, 424f, 426
lower, test for 427f
middle, test for 427f
upper, test for 427f
Trapezius palsy 460
triangle sign of 460
Trapezoid 174
Trauma 3, 414
acute 261
mechanism and force of 30
related orthopedic emergencies 39
sonography in 29
triaging of 27, 28t
velocity of 30
Traumatic amputations 512
Traumatic brachial plexus injury 76
Traumatic dislocations 76
Traumatic injury
closed 414
open 414
Traumatic paraplegia 406
Trendelenburg gait 524, 525f
Trendelenburg test 232, 241
assisted 233f, 233
false-negative 232
negative 232f
positive 232f
Triangle sign 205, 460f
Triangular fibrocartilage complex 154, 162, 175, 200
functions of 154
injury 195
Triceps 435
tendinitis 122
tendinopathy 150
test for 436f
Trigger finger 166, 179, 191
Triquetrum 175
Trochanteric ‘C sign’ 204
Trochanteric region 211
Trochlear, anatomy 258
Trumpet sign 481f
Truncation sign 303
Tscherne classification 35t
Tubercular arthritis 55, 152, 305
Tubercular osteomyelitis 50
Tuberculosis 10, 45, 355
chronic infection 162
history of 57
in lung 57
of hip 21, 58, 208, 246
of infective arthritis 56
of joint 4, 44, 57, 61, 359
of knee 23, 56, 58
of musculoskeletal 55
of phalanx 161, 168
of shoulder 74, 77, 116
of spine 362, 400
of ulna 121
sicca 61
stages of 58
Tumors 199, 415
benign 49, 74
examination 503
malignant 49, 74
Turf toe 345
Turner's syndrome 209, 367, 378
Tyrosine 70
U
Ulcer 46, 544f
clinical evaluation of 530
edge, types of 546f
examination of 544
in great toe 326f
non-healing 546f
over great toe 544
over heel, non-healing 325f
over malleolus 544
over plantar aspect of foot 544
toe with gangrene 547f
types of
everted edge 546
punched out edge 546
rolled-out edge 546
sloping edge 546
undermined edge 546
Ulcus sign 96
Ulnar clawing 448
Ulnar collateral ligament
complex 120
lateral 9, 119, 120f
test 182f
Ulnar deviation 177f
forearm pronation test 183, 187
test 184f
Ulnar impaction syndrome 166, 196
Ulnar nerve 134, 180, 418f, 420
autonomous zone of 444f
C8, T1 443
muscles supplied 445t
near elbow 447
near wrist 447
neuritis 123
Ulnar nerve palsy, features of 446
Ulnar nerve signs, summary of 448
Ulnar paradox 447b
Ulnar styloid process 174
Ulnar tunnel syndrome 197
Ulnohumeral articulation 120
Ulnohumeral bony articulation 120
Ulnolunate 153f
Ulnotriquetral 153f
ULT1 test 379f
ULT1A test 379f
ULT3 test 380f
Upper brachial plexus birth palsy 481f
Upper brachial plexus injury 470, 474f
Upper limb 516
dermatomal pattern of 479f
length measurement 90f, 136f
muscles, major nerves supplying 424fc
myotomes of 392f
Upper limb tensions test 379t
Upper motor neuron 391t
bladder 409
lesions 391
Upper subscapular nerve 466f
Upper trunk brachial plexus injury 472f
Urinary bladder 352, 352t
innervation 354f
Uveitis 209
V
Vaginal discharge 207
Valgus 16, 16f
and external rotation 144f
deformity 63f, 323
extension overload syndrome 123
instability 145, 146
Valgus overload syndrome 122, 151
Valgus stress test 186, 288, 289f, 290f
Valgus thrust 266
Valgus thrust gait 527
Valsalva maneuver 387
Varicose veins 270
Varus deformity of right tibia 47f
Varus posteromedial rotatory instability 146
Varus stress test 186, 289
Varus thrust gait 266f, 527, 528f
Vascular compression 532
Vascular insufficiency changes 169
Vascular sign of Narath 233, 240
Vascular swellings 532
Vasomotor function 422
Vastus medialis obliquus 269
Veins proximal 535
Venous ulcer 547f
Ventral division 448fc
Ventral ramus 410
Vertebral compression fractures 366
Vertebral motion segment 352, 353
Vertical ground reaction force 243
Vitamin deficiency 415, 523
Volar and dorsal ligaments 153f
Volar plate injury 166
Volkmann's ischemic contracture 20, 194f
Volkmann's sign 179, 194f
Volkmann's ischemic contracture 194
Vrolik disease 51
W
Wagner-Meissner corpuscles 483
Walking stick 206
Wallerian degeneration 412, 456, 479
in proximal 457f
indirect 456
secondary 456
Wallerian regeneration 412, 456, 457f
Wartenberg's syndrome 190
Wartenburg's sign 444, 448
basis of 444
Weakness, progression of 471
Well-leg raising test 383
Wilson test for osteochondritis dissecans 299
of knee 297
Wound
boundaries 540
puncture 33, 33f
Wright's test, 380, 381f
Wrist 169
and finger drop 417, 459
and hand 161b
clinical evaluation of 153
and thumb drop 459
dorsal and volar surface of 174f
drop (left) 417
extrinsic and intrinsic ligaments of 154t
Wrist ganglion 167
Wrist hand
clinical diagnostic snippets 165t
examination proforma 189
Wrist joint 177b
clinical significance 153
line tenderness 175
surgical anatomy of 153
Wrist ligament injuries 164
Wrist osteoarthritis 192
Wrist pain, causes of 162t
Wrist ROM 177f
Wrist ulnar deviation 24f
Wrist, volar aspect of 175
X
Xiphisternum 227
Y
Yergason test 105, 105f
Yersinia 66
Z
Zancolli's sign 481f
Z-deformity of thumb 63, 172
×
Chapter Notes

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Basics of History Taking and Examination in OrthopedicsCHAPTER 1

 
FORMAT FOR ORTHOPEDIC CASE PRESENTATION WITH SIMPLE KNOW-HOW AND TIPS
The art of extracting relevant history and eliciting positive examination findings to clinch a diagnosis during orthopedic case presentations is taught with modifications from the other subjects.
The evaluation of the patient starts with basic demographic details mentioned below.
  • Name
  • Age
  • Gender
  • Occupation
  • Address
  • Hand dominance
The importance of various demographic factors is discussed below.
  1. Age: Typically, most orthopedic conditions have a predilection for a particular age group. Several examples are mentioned below:
    1. At birth: Developmental dysplasia of the hip (DDH)
    2. 6–36 months: Rickets
    3. 5–10 years: Perthes’ disease, Ewing's sarcoma
    4. 10–15 years: Slipped capital femoral epiphysis (SCFE), Osteosarcoma
    5. 18–40 years: Giant cell tumor, patella/shoulder dislocation, sports injuries
    6. 20–40 years: Inflammatory arthritis (Rheumatoid)
    7. >40 years: Various degenerative conditions such as osteoarthritis, tendinopathy, osteoporosis, and rotator cuff tear; malignancies such as multiple myeloma and secondaries.
Note that trauma-induced maladies can happen at any age.2
  1. Gender: Certain conditions have gender predilection, such as:
    1. Females: DDH, connective tissue disorders, giant cell tumor, rheumatoid arthritis, osteoporosis
    2. Males: Perthes, SCFE, and Ankylosing spondylitis
  2. Occupation: Various occupations may pose a hazard for different orthopedic conditions. For example, painters, heavy manual workers, and those who participate in overhead sports are more prone to shoulder pathologies. Pneumatic tool drillers, chain saw workers are more prone for carpal tunnel syndrome. Further, the treatment plan can be altered or tailored to accommodate quick mobilization and early return to work, e.g., a bone–patellar tendon–bone graft is more suitable for anterior cruciate reconstruction than soft tissue ones in contact athletes, whereas soft-tissue grafts (hamstrings) grafts do well in a sedentary patient or those who do not play contact sports.
  3. Address: The residence may play a significant role in the development of certain diseases in a person, especially if the person has been staying in that place for long or since birth to have enough exposure to environmental factors. For example, natives of those places where fluoride content of the water is high, are more prone to early-onset secondary osteoarthritis of joints and spinal canal stenosis. Another example, children from the south-west coast of India are more prone to Perthes' disease.
  4. Hand dominance: Considering hand dominance is an essential aspect while treating or rehabilitating a patient. For example, a minor deformity and less than optimal function after a “left side” malunited Colles’ fracture is more acceptable in a right-hand dominant person than a left-hand dominant person.
 
A. Chief Complaints (In Chronological Order)
One must always present chief complaints in chronological order. For example,
  • Pain in the right shoulder for six months
  • Difficulty in elevating and reaching overhead objects for three months
  • Swelling over the right shoulder for two weeks
  • Discoloration of skin of the hand for one week
The common chief complaints in orthopedic patients are:
  • Pain
  • Swelling
  • Inability or difficulty in bearing weight
  • Limp
  • Inability or difficulty in moving a joint
  • Discharging sinus, nonhealing wound
  • Deformity
  • Shortening or lengthening of a limb
  • Instability of the joint
  • Locking
  • Clicks, crepitus
  • Altered sensations
  • Skin changes
  • Constitutional symptoms and other systemic features3
  • Effect on activities of daily living and occupation: Routinely, it may not be part of chief complaints. However, it must be included at the end of the history of the present illness to understand the effect of the disease process on one's daily activities and occupation.
 
B. History of Present Illness (HOPI)
The fundamental idea of HOPI assessment is that each chief complaint must be evaluated and described in detail regarding onset, duration, progression, aggravating, relieving factors, and other specific points, if any. Once all the chief complaints are well described, the relevant positive and negative history is taken. The aim of detailing HOPI with positive and negative history is zero on the possible etiology and pathology of the symptoms in question.
 
Pain
Pain is one of the most common complaints in orthopedic conditions. Pain should be probed on several parameters such as site, duration, onset, progression, quality, radiation, relieving-aggravating factors, severity, and timing.
  • Site of the pain: Often, identifying the site of pain can localize the structures involved in the process of pain.
  • Onset of pain: Sudden or insidious. What triggered the pain, must be probed.
  • Progression of pain: Constant/worsened/improved/on–off
    • Trauma: Initially more (at the time of the injury) followed by a decrease in severity
    • Neoplasia: Constant or gradually worsening pain
    • Acute inflammation: Sudden increase followed by a gradual decrease
    • Chronic inflammation: Remissions and exacerbation of pain
    • New origin pain in a painless condition: Malignant change or pathological fracture
  • Quality of pain:
    • Throbbing: Abscess
    • Burning or with tingling: Neuralgic origin
    • Dull aching: Mechanical pain of degenerative conditions (osteoarthritis, spondylitis, tendinopathies)
  • Radiation of pain: Ask about the site of radiation of pain, if any. The radiation site may give a clue of pathology. For example, the cervical intervertebral disc prolapse (IVDP) pain radiates along the shoulder, arm, and forearm up to the lateral three fingers indicating the level of IVDP as C5, 6, and 7. In contrast, the cervical rib/thoracic outlet related compression of C8 and T1 root pain radiates toward the inner aspect of the hand, forearm, and arm.4
  • Aggravating and relieving factors:
    • Ask about aggravating and relieving factors with direct and indirect questions such as what happens when you move your joint, run, jump, squat, etc.
    • Its relation to food, e.g., pain due to gout increases after eating red meat, organ meat, or cabbage.
    • Whether pain relieves with analgesic or rest
  • Severity of pain: The pain could be mild, moderate, severe or excruciating.
    • Mild pain: Easily ignored
    • Moderate pain: Cannot be ignored, interferes with function, and needs time-to-time intervention/medication
    • Severe: Cannot be ignored, interferes with function, and demands constant attention and intervention
    • Excruciating: Incapacitating
  • Timing of pain: Apart from elaborating the pain on the above-mentioned factors, it is crucial to understand the timing or nature of pain, which could be “mechanical” pain, “rest” pain, or pain of “neurological origin.”
    • Mechanical pain results from loading the joint (standing, walking, turning, running, jumping, etc.). Typically, mechanical pain is due to degenerative pathologies such as osteoarthritis, spondylosis, tendinopathies, and fasciitis, and characteristically resolves upon adequate rest.
    • Rest pain happens during periods of rest even without loading the joint, and might be associated with morning stiffness. It is usually due to inflammatory, infective, or tumorous disorders such as rheumatoid arthritis, ankylosing spondylitis, tuberculosis (TB) of the joint, and malignant tumors. A thorough investigation of any rest pain lasting for more than 3–4 weeks is mandatory as “rest pain” could indicate underlying sinister pathology! Night cries are a special type of rest pain, which are described in tuberculosis of the joints, especially in children. These so-called night cries are due to decreased voluntary muscle tone during sleep, permitting the diseased joint surfaces to rub against each other more than when the child is awake when the muscle spasm does not allow gross movement.
      However, there are a few exceptions to the general rule about rest pain, e.g., shoulder and cervical spine degenerative pathologies. Most shoulder pathologies (rotator cuff tendinopathy, tear, frozen shoulder, arthritis, calcific tendinitis, etc.) are painful at night and may not hurt much during day time. Also, cervical spine IVDP with root compression often hurts at night while the patient lies on the side (due to increased root compression in lateral position as neck tilts). So, although these conditions are painful at night, they do not indicate any sinister pathology.
    • The pain of neurological origin: It is usually shooting or dragging type, often associated with tingling and numbness along the course of the nerve. Typically, it is due to nerve compression caused by varying etiologies, e.g., a prolapsed intervertebral disc compressing the nerve root can cause radiating pain along the course of the nerve, or pain on radial side of hand in carpal tunnel syndrome due to median nerve compression.5
 
Swelling
The symptom of swelling must be thoroughly probed on the following parameters: Site, onset, duration, progression, painful/painless, and number (single/multiple). The swelling could be intra-articular (effusion/synovial swelling) or arising from extra-articular structures. The swelling from an extra-articular structures should be evaluated as per the standard assessment (Refer to Chapter 17 on Swelling). While assessing the intra-articular swelling, one must question the timing of the onset of swelling (immediate or delayed), especially after trauma, as the timing of swelling onset could give a clue to the diagnosis.
  • If the intra-articular swelling appears immediately after or within a few hours of trauma, it indicates hemarthrosis. The hemarthrosis results either from intraarticular fractures or injury to any intra-articular structure which has a rich blood supply, e.g., peripheral meniscal tear, cruciate ligament tear, synovial or capsular tears.
  • If the intra-articular swelling appears 12–24 hours after the injury, it indicates excess synovial fluid production in the joint following synovial irritation. Synovial irritation could result from cartilage injury, central or inner meniscal tear, or a foreign body reaction.
  • A nontraumatic origin intra-articular swelling could be due to synovial hypertrophy, excess synovial fluid, a combination of synovial hypertrophy and fluid, or pus. It can occur in infections (TB), inflammation (rheumatoid), degenerative conditions (osteoarthritis, meniscal, or cartilage damage), synovial chondromatosis, etc.
 
Inability or Difficulty in Bearing Weight (Lower Limb)
Typically, normal weight-bearing is possible due to the normal linkage between “normally innervated painless bone–joint–ligament–muscle–tendon–capsule complexes.” Any disturbance in this linkage could lead to inability or difficulty in bearing weight. Several examples are discussed below to understand how a normal weight-bearing is affected or compensated.
  • Inability to bear weight after acute trauma indicates a significant bone or joint injury (fracture or dislocation), nerve palsy, complete ligament injury, complete muscle-tendon tear, or significant capsular disruption.
  • If the patient can bear weight immediately or soon after (within few hours or a day) the first acute injury, it “fairly well rules out” any significant bony or soft tissue injury. Nevertheless, in impacted fractures or cases of partial soft tissue injuries (muscle, tendon, and ligament), one can still bear weight, albeit with pain!
  • Chronic ligament injuries are more tolerant to weight-bearing, i.e., most patients can easily bear weight or use the limb with minimal difficulty after the first few days of the primary injury. However, with every fresh episode of twisting or instability to the limb superimposed over chronic existing ligament injury, the patient returns to weight-bearing or limb usage earlier than the previous occasion.
  • A chronic history of inability to bear weight on the lower limb with a fracture indicates a nonunion of a fracture. Many patients get gradually adjusted to chronic injuries of muscle, tendon, neglected dislocation, and nerve palsy. However, they may continue to have difficulty in weight-bearing or using a limb.6
 
Limp
Limp is frequently observed in affections of the lower limb. It could be painful (traumatic, inflammatory, and infective) or painless (DDH, coxa vara, and short limb). The various leading causes of limp are:
  • Painful conditions of the lower limb: Inflammatory (rheumatoid), infective (tubercular)
  • Weakness of the hip abductor mechanism: DDH, coxa vara
  • Limb length discrepancy
 
Inability or Difficulty in Moving a Joint
The typical sequence to move a joint is completed by a “normal neuromuscular–tendinous–ligamentous–capsular–bone and joint-soft tissue pathway.” Figure 1.1) shows the normal pathway required for joint movement, and Table 1.1 mentions various abnormal conditions, which can affect the working of the normal pathway for joint movement. A detailed history and examination would ascertain the cause of inability or difficulty in moving a joint.
zoom view
Fig. 1.1: Illustrative neuromusculoskeletal pathway required for a normal joint movement. Horizontal line in the spinal cord depicts cross-section of spinal cord. (1) Brain; (2) Spinal cord; (3) Anterior horn cell; (4) Nerve roots; (5) Peripheral nerve; (6) Neuromuscular junction; (7) Muscle; (8) Tendon; (9) Joint and bones; (10) Ligaments, capsule and other soft tissue.
TABLE 1.1   Normal pathway required for joint movement and conditions which can affect its working.
Normal Component for Joint Movement
Pathology(ies) Affecting Joint Movement
1. Normal central nervous system (CNS) where the patient can hear, comprehend, and send the motor command to the spinal cord
Hemiplegia, Parkinson's, or any other brain disorder affecting its function7
2. Normal spinal cord and nerve roots
Spinal cord injury, poliomyelitis, nerve plexus (brachial or lumbar) affection, nerve root compression, intervertebral disc prolapse
3. Normal peripheral nerve
Nerve injury, neuropathy, Hansen's disease
4. Normal neuromuscular junction
Myasthenia gravis
5. Normally functioning muscle
Muscular dystrophy, myopathies, muscle contracture (post-traumatic, infective)
6. Normal tendon to transmit the muscle power
Tendinopathy, tendon tear, contractures
7. Normal articulation of joint
Dislocation or subluxation, arthritis, osteophytes
8. Normal bone
Acute fracture, non- or malunion
9. Normal ligaments
Ligament tear, ligament contracture
10. Normal capsule and soft tissue (skin and subcutaneous tissue) to stretch while joint is moving
Post-traumatic capsular contracture, frozen shoulder, postburn scar, scleroderma, etc.
One of the major causes of difficulty in moving a joint is ‘joint stiffness, which could be due to various intra- or extra-articular causes. Box 1.1 briefly discusses the differences between the two types of stiffness.
 
Discharging Sinus
Chronic osteomyelitis is the most common condition in a orthopedic patient causing a discharging sinus. One must probe regarding the condition, which led to the onset of sinus (postsurgical or spontaneous after a swelling suggestive of hematogenous osteomyelitis), progression, number, remissions and exacerbation, and type of discharge (serous/seropurulent/purulent). Refer to Chapter 17 for further details.
However, one must remember that the mere presence of a discharging sinus in an “orthopedic case” does not confirm underlying osteomyelitis. Any dead and infected material [natural (bone) or foreign (nonabsorbable suture material, foreign body, etc.)] could result in a discharging sinus. Unless the sinus is fixed to the underlying bone, it cannot arise from a bone infection.
 
Deformity
A deformity is defined as a permanent deviation from the normal shape or contour of a bone or a joint which is not correctable by any active or passive maneuver by the patient or clinician (c.f. attitude, which is either position of ease of a limb or a temporary deviation from normal and correctable). Deformity could be structural or spasmodic. Structural deformities are passively not correctable. In contrast, spasmodic (due to pain) deformity resolves after subsidence of the pain.
  • Structural deformities could be arising from:
    • Bone: Congenital malformation (scoliosis), malunion/nonunion of fracture, and growth plate damage (traumatic, infective, metabolic, or iatrogenic)
    • Joint: Dislocated or subluxated, ankylosed
    • Muscle–tendon contractures: Volkmann's ischemic contracture, poliomyelitis
    • Fascial contractures: Dupuytren's contracture, poliomyelitis
    • Capsular or ligament contractures
    • Skin or scar contractures: Postburn contracture, scleroderma
  • Spasmodic deformities are observed in acute painful musculoskeletal conditions due to muscle spasms, e.g., paraspinal muscle spasm after acute IVDP leading to postural scoliosis or list. These deformities improve as the spasm decreases.
 
Shortening or Lengthening of a Limb
The limb of the patient may be short or long due to a congenital, traumatic, infective, or a metabolic cause.
 
Instability of a Joint
Before we understand the instability of a joint, it is essential to understand what imparts stability to a joint. A stable joint is formed by two “morphologically normal” articulating surfaces that are normally linked and stabilized by various soft tissues such as ligament, capsular, and muscle-tendon complex innervated by a nerve. Any deformation or disruption in one or more structures that form and stabilize a joint could result in an unstable joint. Several examples are discussed below.
  • Fractured or deformed articulating surfaces and adjoining bones: DDH causes unstable hip, and trochlear dysplasia contributes to recurrent dislocation of the patella. Deficient posterior acetabular wall (traumatic or congenital) could result in an unstable hip. Congenitally increased scapular retroversion predisposes to posterior shoulder instability. A malunited proximal tibia fracture with slope alteration might result in knee instability.
  • A complete tear in a ligament, capsule and muscle–tendon complex:
    • Tears in anterior or posterior cruciate ligament or medial patellofemoral ligament of the knee results in an unstable knee.
    • Injury to posterolateral corner (LCL, popliteus, popliteofibular ligament and posterolateral capsule) results in knee instability.9
    • Lateral ulnar collateral ligament injury of elbow would result in posterolateral elbow instability.
    • Anterior or posterior labral tear would result in anterior or posterior shoulder instability, respectively.
    • Massive tears in the rotator cuff could result in an unstable shoulder joint.
  • Paralysed muscles: The prerequisite for joint stability is not just anatomical continuity of the muscle-tendon complex but also a normal neurological innervation. A significant paralysis of a nerve (peripheral or central cause) renders the joint unstable, e.g., often, in a brachial plexus palsy, the shoulder is subluxated as there is complete atony in the muscles around the shoulder joint.
 
Locking
Locking implies a sudden inability to complete a particular movement. Locking of a joint is an intermittent phenomenon, which may last from several minutes to hours.
Locking is of two types: True locking and pseudolocking. True locking is a structural phenomenon, whereas pseudolocking is a spasmodic phenomenon due to pain. True locking may or may not be associated with pain, whereas pseudolocking is always associated with pain.
True locking: Typically, the joint movement is smooth without getting “stuck or fixed” in a particular position because nothing gets in between the two mobile articulating surfaces. Therefore, if something loose (structural) comes between the two articulating surfaces and gets entrapped, it prevents smooth gliding of articulating surfaces, resulting in a locked joint. Once the loose fragment moves out between the articulating surfaces, the joint gets unlocked.
Some common causes of locking are:
  • Meniscal tear in the knee joint: Bucket handle tears of the meniscus
  • Loose body in any joint: Single (osteochondral fracture fragement, osteochondritis dessicans) or multiple (synovial chondromatosis)
Pseudolocking: Pseudolocking is a non-structural spasmodic phenomenon due to severe pain leading to spasm, which prevents further joint movement. Several reasons for pseudolocking of the knee joint are mentioned below.
  • Patella maltracking
  • Patellofemoral arthritis
  • Ligament sprains causing pain and spasm
 
Clicks, Crepitus
Click is a short, often single sound, whereas crepitus is longer lasting sound, often multiple. Crepitus happens when two rough surfaces rub against each other.
Clicks often happen when a tendon/fascia slips over a bony prominence or slip in-and-out of a groove. A point to be noted that a painless click may not be of much clinical significance, while a painful click must be investigated. Crepitus is typically felt during movement of arthritic joint surfaces or one with cartilage damage (chondromalacia) or with multiple loose bodies in the joint (synovial chondromatosis).
 
Altered Sensation
Many patients complain of altered sensations (tingling, numbness, burning, less or no sensations over the skin) resulting from affections of the brain, spinal cord, or nerves. In such a complaint, one must probe the reason why neurological structure is compromised, which could be due to a traumatic, infective, compressive, or metabolic (diabetes) cause.
 
Skin Changes
The skin changes are observed in complex regional pain syndrome (mottled, bluish), nerve palsy (dry, scaly), or other skin diseases.
 
Constitutional Symptoms
Many symptoms such as fever, malaise, weight loss, or loss of appetite are part of the chief complaint. It is essential to ask about constitutional symptoms during history evaluation as it almost always indicates a sinister pathology such as infection, inflammation, or tumor, and it helps in ruling out differentials.
 
Effect on Activities of Daily Living or Activities
One of the essential parts of the complaint assessment is to evaluate the effect of the disease process on the activities of daily living and occupation such as walking, squatting, ability to clean back, tie hair, overhead activities, and sports.
The rest of the history goes archetypal. Nevertheless, one must remember that though HOPI is undoubtedly important to probe into the current complaints in ascertaining the diagnosis, the rest of the history in the form of past, personal, treatment, family, menstrual, drugs, etc. has a strong bearing in establishing the final diagnosis and prognosis. However, the rest of the history is often less explored or missed during the rush of seeing patients, especially in the out-patient department. Therefore, the clinician must give equal importance to the rest of the history too to ensure a complete evaluation of the patient. The questions asked about the rest of the history should investigate the cause of the disease and also give a perception about the prognosis.
 
C. Past History
One must confirm past history about:
  • A similar history in the past on the same or contralateral limb
  • Other orthopedic history such as underlying osteoporosis, gout, etc.
  • Medical history of diabetes, hypertension, thyroid disorder or other medical illness
  • Relevant surgical history such as hysterectomy, thyroidectomy, etc.
  • A pathological fracture of the femur in a patient currently undergoing treatment for lung cancer can be explained by the metastasis from the lung cancer.
 
D. Personal History
Smoking, alcohol intake, tobacco-chewing, sleep, diet (vegetarian, mixed), bowel–bladder habit, education, and marital status. Specific examples of the importance of personal history are: Patients who are chronic smokers and tobacco-chewers are at risk of poor wound healing, delayed or nonunion, while chronic alcoholics are at higher risk of avascular necrosis of the hip. Alcohol can also increase the level of uric acid in body, while non-vegetarians are also at higher risk of gout due to hyperuricemia.
 
E. Treatment History
One can get vital clues about diagnosis with treatment history. For example, a patient who underwent multiple debridements for chronic osteomyelitis of the tibia can have shortening of the leg, which can be explained by bone loss during multiple debridements. However, one must assess treatment separately and avoid mixing it with HOPI. An exception where treatment history is a part of HOPI is a case of trauma wherein discussing the treatment history in a sequence (open fracture → debridement, external fixator → re-debridement → intramedullary nailing → discharging sinus) is allowed to understand the evolution of the current status of the problem.
 
F. Family History
It is essential to confirm the family history of disorders such as congenital disorders (congenital talipes equinus varus, developmental dysplasia of the hip, Blount's disease), hemophilia, sickle cell anemia, rheumatoid arthritis, ankylosing spondylitis, multiple exostoses, tumors, etc.
 
G. Menstrual History
Postmenopausal women are prone to osteoporosis and resulting complications such as chronic back pain and fragility fractures. Also, chronic menstrual disorder and pelvic inflammatory diseases (PIDs) are related to chronic low back pain, exacerbating during cyclical menstruation changes or PID exacerbation.12
 
H. History of Allergies and Drug Intake
Documenting the history of drug allergies is crucial as inadvertent administration could be life-threatening and have medicolegal implications.
Eliciting the history of other drug intake is essential as many of them are implicated in disease causation or fitness for the surgery. For example,
  • Chronic steroid therapy may result in avascular necrosis of the hip.
  • Chronic phenytoin therapy is implicated in the etiology of Dupuytren's contracture. Also, long-term treatment with phenytoin and carbamazepine (antiepileptics) inhibit resorption of calcium and vitamin D from the intestine resulting in rickets/osteomalacia.
  • Long-term bisphosphonates (for osteoporosis) can result in pathological fractures in the subtrochanteric region of the femur, which are quite challenging to treat.
  • Pyrazinamide, which is an ATT, is known to cause hyperuricemia and can precipitate acute gout in a patient.
  • One needs to stop or alter the dose of blood thinners (platelet aggregator inhibitor, anticoagulants) before orthopedic surgery in consultation with the concerned physician.
 
I. Social History
Nutrition of child, work practices, travel, and constraints
 
J. Perinatal and Birth History
Important in congenital conditions (DDH) or the one which are peripartum related (cerebral palsy, obstetrics brachial plexus palsy).
 
K. Developmental Milestone History
It is essential to elicit the developmental history (gross motor, fine motor, speech and language, and social) in pediatric patients with congenital disorders.
 
L. Immunization history
Important in disorders such as poliomyelitis
At the end of the complete history assessment, the clinician must arrive at a possible conclusion about the etiopathology of the condition. The possible etiologies are mentioned in Box 1.2.
After thorough history evaluation, one must proceed towards examining the patient.
 
EXAMINATION
The examination involves general, systemic, and local examinations, which are discussed below. The crucial prerequisites for examination are mentioned in Box 1.3.
The examination always starts with a general and systemic examination, whether it is a short or long case. The general and systemic examination is mandatory as per the standard protocol. It would be improper to say that “I have not done the general and systemic examinations.”
  1. General examination: The general examination must start with assessment of consciousness, orientation to time, place and person, built, and nutrition of the patient. For example, Mr SW is conscious, cooperative, moderately built and nourished'. It is followed by assessment of vital parameters (blood pressure, pulse, respiratory rate, and temperature), pallor, icterus, clubbing, cyanosis, lymph nodes, and pedal edema. Note that one must report the relevant findings and avoid nonstandard abbreviations such as “PICCLE” in examination.
    • Other essential parameters such as height, weight, nutrition, and body mass index (BMI) should be assessed in relevant patients.
    • A general survey from head-to-toe can give a lot of clue to the underlying disease. For example,
      1. Low set ears and hairline are present in patients with Down and Turner syndrome, who can present with hip dysplasia.
      2. Black discoloration of pinna is observed in patients with ochronosis, who can have back pain due to disc calcification and osteoporosis.
      3. Neurocutaneous markers such as Cafe-au-lait spots and neurofibromatosis are associated with scoliosis and congenital pseudoarthrosis of tibia.
    • Tanner staging in pediatric patients could be important. Tables 1.2 and 1.3 briefly mention the Tanner grading in girls and boys.14
TABLE 1.2   Tanner grading in girls.
Tanner Stage
Breasts
Pubic Hair
Growth
Other
1.
Elevation of papilla only
Villus hair only
2–2.4 inches per year
Adrenarche and ovarian growth
2.
Breast bud under the areola, areola enlargement
Sparse hair along the labia
2.8–3.2 inches per year
Clitoral enlargement, labia pigmentation,
growth of uterus
3.
Breast tissue grows but has no contour or separation
Coarser hair curled pigmented covers the pubes
3.2 inches per year
Axillary hair, acne
4.
Projection of areola and papilla, secondary mound formation
Adult hair, does not spread to the thigh
2.8 inches per year
Menarche and development of menses
5.
Adult-type contour, projection of papilla only
Adult hair, spreads to the medial thigh
Cessation of linear growth
Adult genitalia
TABLE 1.3   Tanner grading in boys.
Tanner Stage
Genitalia
Pubic Hair
Growth
Other
1.
Testes <2.5 cm
Villus hair only
2.0–2.4 inches per year
Adrenarche
2.
  • Testes 2.5–3.2 cm
  • Thinning and reddening of the scrotum
Sparse hair at penis base
2.0–2.4 inches per year
Decreases in body fat
3.
  • Testes 3.3–4.0 cm
  • Increase of penis length
Thicker curly hair spreads to the pubis
2.8–3.2 inches per year
Gynecomastia, voice break, increased muscle mass
4.
  • Testes 4.1–4.5 cm
  • Penis growth darkening of scrotum
Adult hair does not spread to thighs
4.0 inches per year
Axillary hair, voice change, acne
5.
  • Testes >4.5 cm
  • Adult genitalia
Adult hair spreads to medial thigh
Deceleration, cessation
Facial hair, muscle mass increases
  1. Systemic examination: A quick and relevant examination of the central nervous system (CNS), cardiovascular system (CVS), respiratory system (RS), abdomen, and pelvis should be done.
  1. Local examination: The standard order of examination in orthopedic cases is as follows:
  • Gait: It must be evaluated in patients with lower limb or spine affections. However, it can be avoided, if the patient denies walking due to severe pain or an unstable spine condition that may potentially induce or exacerbate neurological deficit.
  • Hand dominance (in an upper extremity case), inspection of footwear, orthosis, prosthesis, if applicable
  • Attitude: It is described as the position of ease assumed by joint and bone at rest, which is comfortable to the patient.
  • Inspection (look)
  • Palpation (feel)
  • Movements (move)
  • Measurement
  • Neurovascular (NV) examination: It should be done before special tests as adequate power is required for most special tests.
  • Special tests for individual pathology/region
  • Joint above and below
  • Lymph node examination
 
Pearls and Pitfalls while Performing Local Examination
General rules while presenting the examination findings:
  • Adjectives must be avoided unless it has been standardized in the literature, e.g., “severe” tenderness. One's “severe tenderness” could be someone else's “moderate”! Tenderness is either present or absent. Further, no such grading is discussed in the literature.
  • Unless specifically asked, the methodology of examination should not be mentioned or discussed during the presentation. One must present the clinical finding and avoid its methodology during the examination.
  • Avoid discussing the etiology of the finding while presenting the finding. It must be left for discussion.
 
Inspection (Look)
The affected part must be inspected from all the sides. The position for inspection (standing/sitting/supine/prone) depends upon the region. There are many important findings to be observed on inspection such as deformity, muscle wasting, limb length discrepancy, swelling, scar, sinus, ulcer, condition of skin, etc. Assessment of many of these findings are already well known to residents due to their previous clinical experiences and is also discussed in Chapter 17. Other important findings are discussed below.
  • Deformities
  • Limb length discrepancy
  • Muscle wasting
  1. Deformities: Specific standard terms that are used to describe deformity in limbs and spine are described below.
    1. Varus: It implies “part of the body moving closer to the midline.” Genu varum means that “genu” or “knee” is the referencing point and the “part,” i.e., the leg has moved closer to the midline (Fig. 1.2A).16
      zoom view
      Figs. 1.2A to E: Images demonstrate varus (A), valgus (B), and recurvatum (C) deformities of the knee joint. (D and E) Illustrative images show the weight-bearing axis (hip-knee-ankle) passing ‘through the knee’ in a normal knee and ‘in front of the knee’ in a genu recurvatum, respectively.
    2. Valgus: It implies “part of the body moving away from the midline.” Genu valgum means that “genu” or “knee” is the referencing point, and the “part,” i.e., the leg, has moved away from the midline (Fig. 1.2B). Another example, cubitus valgus means that “cubitus,” i.e., the elbow is the referencing point, and the forearm has moved away from the midline.
    3. Recurvatum: It implies hyperextension and is observed in the elbow and knee joints. It is known as genu recurvatum in the knee. Usually, while a patient is observed from the side, the axis of the lower limb passes through the center of the hip, knee, and ankle in an erect standing patient. However, in genu recurvatum, the axis passes anterior to the knee (Figs. 1.2C to E).
    4. Flexion deformity: It implies that the affected joint cannot be brought into complete extension, passively or actively.
    5. Scoliosis, kyphosis, torticollis, and other deformities: These important deformities will be discussed in their relevant chapters.
  1. Limb length discrepancy: It could be shortening or lengthening. The shortening could be true or apparent.
  2. Muscle wasting: Any chronic disuse of the limb results in muscle wasting.
Note: Special terms for joints: Elbow-cubitus; Wrist-manus; Hip-coxa; and Knee-genu17
 
Palpation (Feel)
During palpation, one must confirm the findings observed during the inspection. Key palpatory findings include local rise in temperature, palpation of important bony-soft tissue landmarks, joint-line tenderness and other specific findings, if any, such as synovial hypertrophy, facet tenderness, paraspinal muscle spasm in spine, etc. Specific rules must be followed during palpation such as:
  • The palpation must be done with utmost gentleness using thumb or finger pulp, especially in tender areas. A hasty and jerky palpation could result in increased pain followed by guarding. Afterward, the patient may not cooperate with the rest of the examination.
  • Always start palpation with assessment of local rise in temperature using dorsum of the hand, and compare with a normal area or opposite side. Often clinicians miss assessing the rise in local temperature, which is quite crucial. A rise in local temperature suggests increased local vascularity due to underlying infection, inflammation, tumor, and trauma.
  • Before assessing local tenderness, always ask the patient to mention the exact site of tenderness with one finger as it helps localize the site of the pathology. Further, it helps the clinician to remain cautious while palpating the tender area in order to avoid hurting the patient inadvertently. It is important to note that tenderness must be elicited with “utmost gentleness.” The tenderness could be superficial or deep. Once the superficial tenderness is ruled out, the clinician should gently increase the pressure to elicit the deep tenderness.
  • In order to avoid missing crucial areas or landmarks, the palpation must follow a sequence of eliciting tenderness over important bony prominences, soft tissues, and joint lines.
 
Movement
There are specific and essential rules to be followed while assessing the movements at a joint. The type of movements vary across various joints in the body.
First and foremost principle of movement assessment is to ‘start movement assessment of contralateral normal side’ followed by assessment of index side.
  1. Always check and highlight the deformities before commenting on the range of movement (ROM). An example of how deformity is included in ROM. If a patient has 20° abduction deformity in the right hip and further abduction up to 45° is possible, then hip abduction ROM is 20–45°. Further, there are several important points to remember while discussing movement in presence of a deformity.
    1. The movement in direction opposite to the deformity is not possible. For example, a hip with 10° flexion deformity cannot have an extension, or a shoulder with 20° internal rotation contracture cannot have external rotation.
    2. In many cases, there is free movement in the direction of deformity. For example, knee flexion ROM of 15–90° implies 15° flexion deformity, and further free flexion up to 90° is possible.
  2. Always assess active ROM followed by passive ROM, and the rationale behind that is:
    • If active movement is full, then there is no need to perform passive ROM.
    • An actively moving joint indicates possibly an intact neural innervation and intact bony-musculotendinous connections. However, it may not rule out partial or recovering nerve injuries or other partial soft injuries.18
    • If the patient's active movement stops at a particular point due to pain, one must not force passive ROM beyond that point to avoid exacerbating the pain.
  3. The ROM should be measured with a goniometer (The methodology to assess the joint movement using a goniometer is discussed on Page 24).
    • While recording the movement, mention the total “ROM” with starting and an endpoint, e.g., elbow flexion is 0–160°.
    • The range of motion should have adjectives of painless or painful, e.g., the total knee flexion is 110°. The first 0–100° of flexion is painless, and the remaining 10° of flexion is painful. Another example, the total wrist dorsiflexion is 0–60° and is painless.
  4. Assess associated crepitus with passive ROM, if any: A crepitus indicates rubbing joint surfaces in arthritis of joint, loose body in the joint; an inflamed bursa, or a torn, frayed tendon-edge rubbing with another bone.
    It is essential to conclude that whether crepitus is fixed or mobile. Fixed crepitus is present in an arthritic joint with fixed rough areas over the cartilage, while mobile crepitus is observed in other conditions where one of the structures is mobile and not fixed.
  5. Associated spasm in movement: Occasionally, there can be spasm during the ROM. especially in patients with active arthritis. To elicit the spasms, a short sharp jerk is given to the joint, and the muscle may develop spasm. Note that the spasm-related limited movement can be overcome with gradual and gentle attempts to move a joint, whereas contracture-related limitation in movement cannot be overcome.
    However, eliciting spasm is a provocative maneuver and could result in sudden severe pain following which patient may not cooperate for the remaining examination. Hence, either it should be elicited at the end of all examinations or could be avoided for the fear of severe pain.
  6. Always look for extensor lag in the knee: This is a specific term used for the knee wherein the patient can actively flex his knee, but he/she cannot actively extend the knee back to the neutral or the starting point of flexion. It means that the knee “lags in extension.” However, the knee can be passively brought to the neutral or the starting point. Extensor lag occurs due to weakness in the quadriceps mechanism, which could be post-surgical (surgeries around the knee), post-traumatic (trauma around the knee), chronic infection, or inflammation of the knee.
  1. ROM description/recording in a hinge joint: Hinge joints such as elbow, knee, PIP, and DIP predominantly allow uniplanar bidirectional movement, i.e., flexion and extension. At times, these joints may have hyperextension. However, typically by convention, one must mention only unidirectional ROM (flexion), which occurs from the anatomical position of the body to the opposite direction. The extension is not mentioned unless ‘hyperextension’ exists. For example, in a patient with no hyperextension and 150° flexion at the elbow joint, the ROM can be mentioned as flexion 0–150°. Although the extension movement of 150–0° occurs in the opposite direction, conventionally, it is not mentioned. However, if the patient has hyperextension, it should be mentioned. For example, in a patient with 10° hyperextension and 120° flexion at the knee joint, the ROM can be mentioned as—10°–0–120°.
Important terminologies regarding joint movement pathologies are as follows:
  1. Stiff joint: Stiff joint implies a joint which has lost movement in one or more directions.
  2. Ankylosed joint: A joint with total or near-total loss of movements due to an underlying pathological process. Ankylosis could be either intra-articular (true ankylosis) or extra-articular (false ankylosis).
zoom view
Fig. 1.3: X-ray showing bony ankylosis of the ankle joint with trabaculae crossing the joint. Inset picture shows normal ankle joint space.
  1. True ankylosis: It is also known as intrinsic cause of joint stiffness and implies involvement of intra-articular structures such as cartilage, bone, articular surface, capsule, synovium, intra-articular adhesions, intra-articular ligaments (anterior or posterior cruciate ligaments) and intra-articular hardware. True ankylosis is of two types: Bony and fibrous.
  • Bony ankylosis: A condition wherein a complete loss of joint movement occurs due to bony fusion between the two joint surfaces. Clinically, there is absolutely no movement across the joint, and there is no pain if the clinician attempts to elicit the movement. Radiologically, the bony trabeculae are seen crossing the joint with obliteration of joint space (Fig. 1.3). Typically, bony ankylosis is seen after septic arthritis of an axial joint and between the vertebrae in the TB of the spine.
  • Fibrous ankylosis: A condition wherein there is near-total loss of movement across the joint due to thick fibrous intra-articular adhesions. Clinically, there is a jog of movement elicited, and there is pain if clinician attempts to elicit the movement. Radiologically, the joint space is preserved. However, there may be other features such as reduced irregular joint space due to arthritis, or articular incongruity. Typically, fibrous ankylosis is seen after TB of peripheral joints, rheumatoid arthritis, and gonococcal arthritis.20
  1. False ankylosis: It is also known as extrinsic cause of joint stiffness, and implies involvement of extra-articular structures such as:
  • Skin and subcutaneous tissue: Contracture following trauma, surgery, burns
  • Muscle tendon complex: Contracture of muscle tendon complex after trauma or surgery, Volkmann ischemic contracture or adherence to the fracture site.
  • Deep fascia: Dupuytren's contracture
  • Extra-articular ligaments: Collateral ligaments of the knee. For example, medial collateral ligament is contracted in OA knee with severe varus deformity.
  • Bony blocks: Bony block of myositis ossificans, callus, displaced fracture fragments, and exostosis.
Sound and unsound ankylosis: Sound ankylosis is a condition wherein a joint is ankylosed in a functional position, whereas a joint ankylosed in a nonfunctional position is unsound ankylosis, e.g., a knee ankylosed in extension is sound ankylosis, whereas a knee ankylosed in flexion is unsound.
  1. Pseudoparalysis: A condition wherein the patient cannot move a joint due to any cause (severe pain, tendon rupture) other than neurogenic. A joint which is pseudoparalysed due to pain cannot be moved actively or passively both (acute calcific tendonitis of shoulder, septic arthritis), whereas it can be passively moved to the full arc due to tendon tear (massive rotator cuff tear).
 
Measurement
During measurement, limb length, muscle girth, or other region specific measurements (three bony point relation, Bryant's triangle, etc.) are performed. The measurements are always compared with the normal side.
The objective of limb length measurement is to analyze the discrepancy in limb length, if any, and to identify the segment of discrepancy (arm and forearm/thigh and leg).
Certain guidelines must be followed during the measurement of the limb length.
  • A pre-existing deformity in the limb must be checked and corrected, such as squaring the pelvis. A pre-existing limb length discrepancy must be asked for, if any.
  • The limb measurement is performed between the two predesignated bony landmarks, marked with a skin marking pencil.
  • The two limbs must be kept in identical positions for measurement.
  • The segmental length of the limb must be measured.
  • While measuring the length of the lower limbs, there is a concept of true and apparent length.
    • A true discrepancy in the limb length is due to “the lengthening or shortening of the bone” due to traumatic (fracture/dislocation), infective, or metabolic pathology truly altering the length of the bone.
    • An apparent discrepancy in the limb length is due to a “deformity or posture,” but there is no actual deficit in the limb length when measured. It appears short or long; however, not truly long or short!
To understand this concept, we must understand the balance between the spine, pelvis, and lower limbs required for standing and walking. Typically in a standing person 21with a normal spine, pelvis, hips, and lower limb, the pelvis is horizontal to the floor, and both lower limbs are parallel to each other with feet flat on the ground, and the limbs appear equal in length. Further, to walk with a bipedal gait, the foot must touch the ground. However, if there is a deformity in the spine (scoliosis), pelvis or hip, or truly short or long lower limb bones, the foot is off the ground, which would result in difficulty in bipedal gait. To ensure a bipedal gait, body compensates by tilting the pelvis to correct the limb length discrepancy, and brings the ‘off the ground foot’ back on the ground. As a result of the non-parallel/tilted pelvis, the lower limb ‘appears long or short.’ If the limbs appear short or long due to a deformity in the spine/pelvis/hip, there is no true shortening, whereas if they appear short/long due to altered limb length, there is true shortening/lengthening. There is only one way to differentiate between apparent and true discrepancies; either half of the pelvis should be at the same level (both anterior–superior iliac spine at the same level), known as squaring of the pelvis. The squaring of the pelvis is performed in supine. For further clinical details of pelvis squaring and assessing lower limb length, refer to Chapter 7 (Hip). One example of a tuberculosis hip is mentioned below to highlight the concept of apparent and true length.
The tuberculosis of the hip undergoes three stages: Synovitis, arthritis, and deformity. The synovitis stage is characterized by flexion, abduction, and external rotation deformity of the hip, causing downward tilting of the pelvis, making the limb appear longer (Stage of apparent lengthening). However, there is no true lengthening as there is no destruction of the femoral head or neck. With further progression of the disease process, the hip undergoes arthritic changes resulting in flexion, adduction, and internal rotation deformity of the hip causing hemipelvis to move upwards (stage of apparent shortening). However, there is no true shortening. In the late stages of the tuberculosis hip, the femoral head's destruction and subluxation or dislocation resulting in flexion, adduction, and internal rotation deformity of the hip causing hemipelvis to move upwards (stage of true shortening). There is a true shortening of the limb due to the destruction of the femoral head and subluxation. A point to note is that detecting true or apparent discrepancy in the limb was done with the patient supine and squared pelvis.
  • Finally, while mentioning the limb length assessment, the student should inform the discrepancy/normalcy of limb length rather than narrating the individual bone length measurements. Box 1.4 mentions the correct way of describing the limb length discrepancy.
 
Neurovascular Examination
It should be performed as per the standard NV assessment of the limb:
  • If the NV examination of the limb/part is normal, it should be summarized as “neurovascular examination is normal.”
  • If the NV examination is abnormal, then individual pathological findings should be mentioned, e.g., if the posterior tibial pulse is feeble on the right side and neurological examination is normal, then it is appropriate to state that “neurological examination is normal. However, the posterior tibial artery is feeble on the right side.”
 
Special Tests
The key to the special tests is “explain–demonstrate–interpret–compare”.
“Explain (to the patient)–demonstrate (on normal side/on self)–interpret (finding)–compare (with normal side).”
A special test is performed to diagnose the condition in question. Multiple tests are often performed for a single condition as most individual tests carry low sensitivity and specificity. A combination of several tests increases the likelihood of the presence or absence of the condition. The clinician must be well versed with the correct technique and interpretation of each test.
 
Joint Above and Below
As per standard examination practice.
Clinical assessment of the joints above and below is essential as the disease or affection of the proximal or distal joint may affect the functioning of the index joint in various ways, e.g., radiation of pain to the knee joint in patients with hip pathology is quite frequent. Another example is bilateral flat foot could result in knee pain due to altered mechanical loading. However, the pain-perceived area may be normal on examination. Another example is double crush syndrome wherein a proximal neurological condition (cervical disc prolapse) could initiate or worsen the distal neurological condition (carpal tunnel syndrome) due to disturbed axoplasmic flow. Hence, it is vital to examine the neighboring joints.
While reporting the finding of ‘normal’ neighboring joints, it can be summarized as “joints above and below are normal.” However, if there is an abnormal finding in the neighboring joint, it should be mentioned in standard fashion.
 
Lymph Node Examination
It should always be done, especially in a suspected case of infective, inflammatory, and tumorous conditions.
  • In upper limb: Epitrochlear, axillary and supraclavicular
  • In lower limb: Popliteal and inguinal23
 
Final Diagnosis
The final diagnosis should have the following components:
  • Duration
  • Anatomical site
  • Side (right/left)
  • Pathology
  • Etiology
  • Complication, if any
Certain guidelines are to be followed while mentioning the diagnosis which are as follows:
  1. The primary diagnosis should be based upon points favoring the diagnosis from history and examination. The diagnosis must not be based upon negative points (points against primary diagnosis); the negative pointers from history and examination are for differential diagnosis.
  2. The presence of points against the primary diagnosis must stimulate the student to think about the differential diagnosis.
  3. Unless there are several pointers against primary diagnosis, giving a differential diagnosis is not always essential. For example, there will not be any differential diagnosis for fracture femur nonunion. However, tuberculosis of the knee is a possible differential diagnosis in patients with monoarticular rheumatoid arthritis of the knee.
 
Plan the Investigations Relevant to “Your Patient” and Not a Hypothetical Case
 
The Final Plan of the Treatment
It could be conservative or operative. Discuss the plan of treatment, which is relevant for the patient's diagnosis and expectation.24
 
A NOTE ON THE TECHNIQUE OF USING A GONIOMETER FOR THE RANGE OF MOVEMENT MEASUREMENT
  • Goniometer: It is an instrument that measures the range of motion joint angles of the body.
  • Technique: The joint's ROM is measured by the number of degrees from starting point of a segment to its position at the end of full ROM present at that joint.
A double-armed goniometer is used for the ROM measurement. The stationary arm of the goniometer lies parallel to the stationary segment of the limb, and the mobile arm of the goniometer is placed parallel to the axis of the mobile segment of the limb. The center of the goniometer lies over the central axis of the joint (Fig. 1.4). When all the landmarks are well-defined and goniometer arms are placed parallel to the limb, the accuracy of ROM measurement is high.
zoom view
Fig. 1.4: Flexion range of movement (ROM) measurement of the elbow with a goniometer.
 
Essential Tips while Using a Goniometer
  • The referencing segment or stationary part of the body should be stable, and the stationary arm of the goniometer should be stable and parallel to the referencing limb (Figs. 1.5 and 1.6). However, sometimes, there is no referencing segment for the goniometer in the joints connected to the torso directly, shoulder, and hip. In such cases, the referencing segment is the midline of the body, and the stationary arm of the goniometer should be placed over or parallel to the imaginary midline axis of the body (Figs. 1.7 and 1.8).
  • Look at the goniometer reading and confirm it before it is removed from the body.
zoom view
Fig. 1.5: Flexion range of movement (ROM) measurement of the knee (left image) and wrist ulnar deviation (right image) using a goniometer. The center of the goniometer is over the center of the joint.
zoom view
Fig. 1.6: Ankle plantar flexion range of movement (ROM) measurement using goniometer with the center of goniometer over the center of the ankle joint. The static and mobile arm of the goniometer is placed along the long axis of leg and the foot, respectively.
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zoom view
Fig. 1.7: Measurement of shoulder abduction range of movement (ROM) keeping stationary the arm of goniometer parallel to the imaginary midline axis of the body (black line) and mobile arm parallel to the abducted arm. The center of the goniometer is over the center of the shoulder joint.
zoom view
Fig. 1.8: Measurement of hip abduction range of movement (ROM) keeping stationary the arm of goniometer parallel to the imaginary midline axis of the body (black line) and mobile arm parallel to the long axis of the abducted thigh. The center of the goniometer is over the hip joint.
 
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