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ORTHOPAEDIC
EXAMINATION
TECHNIQUES
A Practical Guide
THIRD EDITION
EDITED BY
Faza ] Ali
and Wick Harris
Foreword by Bruce Beider
Orthopaedic Examination
Techniques
Third Edition
Orthopaedic Examination
Techniques
A Practical Guide
Third Edition
Edited by
Fazal Ali
Chesterfield Royal Hospital & Sheffield Children’s Hospital
Nick Harris
Spire Hospital, Leeds & Leeds Beckett University
https://avxhm.se/blogs/hill0
University Printing House, Cambridge CB2 8BS, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
314–321, 3rd Floor, Plot 3, Splendor Forum, Jasola District Centre,
New Delhi – 110025, India
103 Penang Road, #05–06/07, Visioncrest Commercial, Singapore 238467
www.cambridge.org
Information on this title: www.cambridge.org/9781108796705
DOI: 10.1017/9781108859295
© Cambridge University Press 2022
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2022
Third edition published 2022
Second edition first published 2014
First edition first published 2003
Printed in the United Kingdom by TJ Books Limited, Padstow Cornwall
A catalogue record for this publication is available from the British Library.
ISBN 978-1-108-79670-5 Paperback
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
................................................................................................................................
Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted
standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to
disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical standards are constantly changing through research
and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from
the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
To Gill, Reza, Sara, for your everlasting support. And my parents for
believing in me.
To Becky, Lucy, Rosie, Molly, Jack and our two Ridgebacks Atilla and
Odin, a constant source of strength.
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Contents
List of Contributors viii
Preface to 3rd edition xi
Foreword to 2nd edition xiii
Foreword to 3rd edition xv
Acknowledgements xvii
About the authors xviii
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Contributors
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Preface to 3rd edition
Since the second edition was published, we have apart from the rest of my family where I could dedi-
received numerous positive comments and reviews on cate the hundreds and hundreds of hours needed to
how this book has helped the reader. There have also completely revise this book. Conversely, social distan-
been suggestions for improvement, all of which have cing made it difficult to obtain the photographs dem-
been taken on board. This has resulted in some distinct onstrating the clinical examination techniques.
changes to the content and layout of this third edition. Fortunately, most of these were taken 3 weeks before
Despite that, it is essential that this book will continue to the first lockdown in the UK. For the remaining
teach the reader clinical examination in a systematic photos I had to use members within my own family
manner, which was the strength of the previous edition. and work ‘bubbles’.
The summary has been brought to the beginning It has been a great honour for me to have Professor
of the chapter to help the more junior reader under- Bruce Reider writing the foreword for this edition. I
stand the subject. For other readers an “Advanced used Bruce’s own book when I was training and it was
Corner” has been added at the end of the chapter. by reading his book that I was inspired to learn and
Also, wherever relevant, the anatomical basis of each perfect the art of clinical examination. It has been a
test has been described within the chapter. privilege to have since met Bruce and to be involved in
Virtually all the pictures demonstrating clinical various projects with him.
examination techniques have been changed, with an Orthopaedic Examination Techniques 3 Ed has
emphasis on diversity. More than 50 new illustrations been a labour of love, but it is the hope of myself,
have been included and 5 chapters have been added and Nick Harris, that readers continue to find this
which comprise more than 80 clinical case examples book user-friendly and informative and that it helps
showing how clinical examination will help in the them throughout their career in orthopaedics.
assessment and management of various conditions. We have both said this may be the last edition
This includes a chapter on orthopaedic conditions in before we ‘hang up our boots’. But let us see what
the developing world which we hope will be useful for the future brings. In the meanwhile, the hunt is
our international readership. on for us to pass over the baton to the next
The Covid-19 pandemic has had both a positive generation!
and negative effect on this book. For an entire year it
provided me with periods of ‘self-isolation’ and living Fazal Ali
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Foreword to 2nd edition
I am pleased to be asked to write the foreword for to which examination textbooks are compared. It is
the second edition of Examination Techniques in my pleasure to write this foreword. I think you will
Orthopaedics, coedited by Mr Nick Harris and Mr enjoy this textbook and it should stay on your shelf
Fazal Ali. The first edition of this textbook was one of until the third edition is available. I give it my strong-
the bestselling orthopaedic books in the United est endorsement and look forward to studying it
Kingdom for almost a decade. This second edition myself.
is likely to at least equal that success. So often in the
world of orthopaedic surgery we jump to advanced Mark D. Miller, MD
imaging and forget about the importance of the
examination. This is clearly a mistake and has caused S. Ward Cassells Professor of Orthopaedic Surgery
many errors in clinical judgement. Therefore, careful
Division Head, Sports Medicine
review of orthopaedic examination as presented in
this textbook is critical for all orthopaedic surgeons, Team Physician, James Madison University
young and old alike. This book provides a complete
repository of all examinations, beginning with gen- JBJS Deputy Editor for Sports Medicine
eral principle and proceeding literally from head to Director, Miller Review Course
toe, to include paediatric examination. This is truly
an excellent book and likely will be the gold standard Charlottesville, VA, USA
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Foreword to 3rd edition
Is the orthopaedic physical examination outmoded? This excellent volume, now in its third edition,
Considering the continued refinement of magnetic takes the reader through this process one step at a
resonance and other imaging techniques, an ortho- time. The first portion of the book is organized by
paedic surgeon might be tempted to assume that body part from top to bottom. Each chapter starts
diagnostic methods that require observing, palpating with an outline of the entire examination, then pro-
and manipulating the patient are no longer necessary. ceeds to a section on the important historical points
Indeed, a colleague of mine reports that many patients that will allow the examiner to narrow the diagnostic
who come to him for a second opinion are surprised possibilities before the examination begins. It then
when he examines them, because the ‘first opinion’ continues logically through the examination itself,
surgeon never did. Apparently, there is a sizable num- from inspection to palpation to active and passive
ber of practitioners who feel that a modern imaging motion. Finally, the chapter ends with advanced
study is all they need to arrive at a treatment tests that will be of particular interest to the specialist.
recommendation. Throughout, a profusion of detailed photographs sup-
On the contrary, I would propose that the advent of plements the verbal descriptions in the text.
contemporary imaging techniques makes the mun- References are provided for the reader who wants to
dane history and physical examination all the more learn more about the evidence behind the various
important. Modern imaging methods are wonderful, examination manoeuvres.
but they often uncover findings that may not be clin- The second portion of the book includes an out-
ically relevant. The orthopaedic literature is full of standing variety of clinical cases to illustrate the
studies that document a plethora of imaging abnor- pathological findings in many orthopaedic and
malities in asymptomatic individuals, especially ath- rheumatological conditions. The authors have taken
letes and older folks. In symptomatic patients, great pains to collect photographs that dramatically
multiple imaging abnormalities may be present document many common and some uncommon
when only one of them is responsible for the patient’s abnormalities that a clinician may encounter in the
complaint. An accurate history and physical examin- course of practice. The final chapter, ‘Orthopaedic
ation are vital for selecting the correct treatment. Cases in the Developing World’, is a unique contribu-
Before the actual examination begins, a clinician tion that will prove valuable to clinicians wherever
must take the time to elicit a complete history from they may practice.
the patient. Most orthopaedic problems have a char- The orthopaedic examination is vast and complex.
acteristic pattern that can be discerned by listening to A newcomer to orthopaedics should not expect to
the patient. Even when evaluating trauma, the history assimilate the contents of this comprehensive text in
is important. Patients may reveal areas of injury that one read. This is a book to be thoroughly studied and
might otherwise be overlooked, and their description then kept handy for ready reference. As experience
of the mechanism of the injury may point out the accumulates, readers will build their own memory
structures most likely to have been damaged. A good bank and begin to appreciate subtleties that recall
history is the prelude to a focused and fruitful physical cases from prior experience.
examination.
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Foreword to 3rd edition
xvi
Acknowledgements
Firstly, we would like to acknowledge the comments Ali, Sara Ali and friend Louis Govignon were also
about the second edition, both positive and negative, drafted in. We are hoping that they will all enjoy
without which the drive to construct a perfect third their new fame!
edition would not have been as crucial. We thank In this edition we added more than 50 illustrations
Nick Dunton, now retired, and Katy Nardoni from with the hope that it would enhance the text. For this
Cambridge University Press for guiding us through we thank Surita Devi (www.freelancer.com/u/surita
this process. verma) in India who expertly and patiently followed
We would like to thank Jeevan Chandrasenan, instructions via WhatsApp in order to meet our
organiser of the Chesterfield, Sheffield and Derby requirements.
Clinical Examination course and Paul Banaszkiewicz, Finally, clinical examination is an acquired skill.
organiser of the Postgraduate Orthopaedics FRCS Knowledge gained from a textbook is not complete
Revision courses, for the funds they provided to help without the guidance of the expert tutor. For this we
pay for the photography session and the illustrations. would like to thank the following consultants and
Without their generosity the production of this edi- experts in clinical examination who for years have
tion would have been difficult. shared their skills and helped refine the techniques
Thank you to Shane Nicoll, Claire Chadwick, Tony in our book. They have lectured and demonstrated
Hadfield and Kathryn Whittle for utilising their tal- these techniques on national courses and throughout
ents and being our models at the photo shoot. Philip the world. This is a great group of highly talented
Wagstaff again insisted he modelled for us in his individuals:
Brachial Plexus chapter. Philip is a legend! Shantanu Shahane, Nick Phillips, Amjid Ali, Ben
This photo shoot was expertly conducted in our frac- Gooding, Stephen Bostock, Joe Garcia, Alex Baker,
ture clinic waiting room on a Sunday just before lock- Becky Aspinall, Paul Banaszkiewicz, James Williams,
down by Jessica Findlow of Northern Star Photography. Paul Haslam, Stan Jones, Chris Blundell, John Wright,
Jess had to use all her skills to photograph ‘models’ who James Fernandes, Ashley Cole, Sanjeev Madan, Rex
were not used to being in front of a camera. Michael, Irwin Lasrado, Simon Royston, Osmond
Covid-19 and lockdown meant that because of Thomas, Mark Flowers, Steve Giles, Kevin Wembridge,
social distancing rules we were unable to use models Mick Dennison and Saeed Qaimkhani.
for those images we missed on the official photog-
raphy day. This meant that secretary Leanne Heath Fazal Ali
within our work bubble had to fill in. In addition, Reza Nick Harris
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About the authors
Fazal Ali has a special interest in soft tissue knee Nick Harris has special interest in Foot & Ankle
problems in the child and adult. He is an Honorary Surgery, Trauma and Sports Injuries. He is a Visiting
Senior Lecturer at the University of Sheffield and Professor of Sports Medicine at Leeds Beckett
Honorary Secretary of BOSTAA (British Orthopaedic University. His current research projects include
Sports Trauma and Arthroscopy Association). He is an long term function after achilles tendon rupture,
accomplished teacher of clinical examination and has novel amino acid supplements, and ankle syndesmo-
published and lectured on his examination techniques tic injuries in athletes. He has produced over 100
worldwide. He has won numerous regional and original publications and presentations. He was the
national awards for training and is a ‘Lifetime Trainer Orthopaedic Lead Designer of the mobile-bearing
of the Year’ for South Yorkshire. He is a senior exam- Rebalance Total Ankle Replacement. Approximately
iner for the UK and International FRCS Tr&Orth 3000 have been implanted globally with 90% survivor-
examinations. Fazal Ali also serves on the panel of ship on the Swedish Joint Registry. In 2019, Nick
examiners in developing countries with the view that Harris was awarded North of England Surgeon of
this would help advance the standard of orthopaedic the Year.
training and care worldwide.
xviii
Chapter
General Principles of Orthopaedic Clinical
1 Examination
Oghor Obakponovwe, Stanley Jones and Fazal Ali
— E li ucciderà?...
— No, mio padre non uccide i prigionieri e non li mangia: li tiene
schiavi.
— Ma noi li libereremo; dovremmo dare fuoco al tuo villaggio.
Il papuaso sorrise:
— Il figlio di Uri-Utanate è stato salvato da voi ed è vostro schiavo.
Quando mio padre lo saprà diverrà l’amico degli uomini bianchi e vi
farà condurre tutti alla vostra patria.
— È lontana la Durga?
— Due giornate di marcia.
— Quando credi sia avvenuto l’assalto?
— All’alba, poichè questi rami spezzati sono ancora umidi di linfa. Se
fossero stati recisi ieri sera, sarebbero ormai asciutti.
— Signor Cornelio, partiamo senza perdere un minuto, disse il
marinaio. Fra quarantotto ore noi riabbraccieremo il capitano, Hans
ed il chinese.
— In cammino, Wan-Horn. Mi sento tanto forte ora, da fare dieci
leghe senza arrestarmi.
Raccolsero il sagù disperso fra le erbe, poi si rimisero in marcia
inoltrandosi nella gran foresta che si estendeva verso l’ovest.
CAPO XXIV.
Il capo Uri-Utanate
Capo
I. — La costa australiana Pag. 5
II. — I pescatori di trepang 13
III. — La pittura di guerra del
selvaggio 23
IV. — Gli australiani 31
V. — L’assalto notturno 41
VI. — L’orgia dell’equipaggio 53
VII. — I mangiatori di carne umana 63
VIII. — Il golfo di Carpentaria 75
IX. — Il naufragio durante l’uragano 85
X. — L’uragano 95
XI. — L’isola di Corallo 109
XII. — Lo stretto di Torres 121
XIII. — I Pirati della Papuasia 131
XIV. — La Nuova Guinea 139
XV. — L’assalto dei coccodrilli 149
XVI. — La capanna aerea 161
XVII. — Fra le freccie ed il fuoco 171
XVIII. — Caccia alle testuggini 181
XIX. — Gli alberi sagu 193
XX. — I boschi della Papuasia 203
XXI. — Il Babirussa 213
XXII. — Le vendette dei Papuasi 223
XXIII. — I Prigionieri 233
XXIV. — Il capo Uri-Utanate 245
Conclusione 257
NOTE:
2. Specie di rondini che fanno dei nidi gelatinosi che si pagano assai cari
dai ghiottoni chinesi.
7. Fori aperti nei parapetti delle navi, a fior della coperta, per lo scolo
dell’acqua.
8. Nel 1879 in Italia era sorta l’idea di occupare una parte della Guinea o di
mandarvi degli emigranti, circa 3000, ma poi fu abbandonata e forse a
torto.
10. Questi uccelli sono comuni anche nell’isola di Nuova Brettagna che si
trova all’est della Nuova Guinea.
11. Il bétel è un miscuglio formato di foglie aromatiche del siri (piter betel),
di noci areca e di calce viva. Si mastica emettendo dei getti di saliva
rossa, ma col tempo annerisce i denti.
Il bétel è largamente usato da tutti gli abitanti delle isole indo-malesi e
dai papuasi.
12. Capo.
Nota del Trascrittore
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