ORTHOPAEDIC

Assessment
Wien Aryana
Orthopaedic & Traumatology Division
Surgery Department

Orthopaedic Diagnosis

History Taking
Physical Exam
Radiological Exam
Patological Exam
Laboratory
Nerve test

Principles of Examination
Obtaining data from patients story (clinical
history);
Preliminary data: name, sex, age, occupation
Chief complaint
Common musculoskeletal symptoms:
1. Pain
2. Decrease in function
3. Physical appearance

Past, Social, Economic, and Family History

Principles of Examination
While performing physical examination,
approach patient with
Kindness (cause no pain)
Precision (observe patient's face and record
findings)
Style (be cheerful and timely)

Always
Look
Feel
Move

Principles of Examination
REGIONAL EXAMINATION
Neck
Shoulder
Elbow
Wrist & Hand
Back
Hip
Knee
Ankle & Foot

General Principles of Treatment

1. First do no harm (primum non nocere)
2. Base treatment on an accurate diagnosis
and prognosis
3. Select treatment with specific aims
4. Cooperate with the law of nature
5. Be realistic and practical in your
treatment
6. Select treatment for your patient as an
individual

Examination of the Neck

1. Observe the patient
as a whole.
2. Observe the neck
and shoulders from
in front and behind.
3. Palpate the front
and back of the
neck with the
patient seated and
the examiner
behind.

Examination of the Neck

4. Assess neck flexion
by asking the patient
to touch their chest
with their chin.
5. Assess extension by
asking the patient to
look up and as far
back as possible.

4.
5.

Examination of the Neck

6. Assess lateral flexion to both sides
by asking the patient to touch their
shoulder with their ear.
7. Assess rotation by asking the
patient to look over their shoulder,
to the left and right.
8. Begin the neurological assessment
of the upper limb by examining the
motor system. This involves asking
the patient to assume a certain
position and not let you overcome
it. Begin with shoulder abduction.

9. Shoulder adduction.

10. Elbow extension.

11. Elbow flexion.

12. Wrist extension.

13. Wrist flexion.

14. Finger extension.

15. Finger flexion

16. Thumb abduction.

17. Finger abduction

18. Elicit the reflexes of the

upper limb beginning
with the biceps jerk.
19. Triceps jerk
20. Brachioradialis jerk.
21. Assess co-ordination of
the upper limb.
22. Test sensation of the
upper limb and
determine the
distribution of any loss.

Examination of the Shoulder

1. Observe the whole
patient, front and back.
2. Observe the shoulder.
3. Observe the axilla
Erythema , Ecchymosis,
Swelling
Side to side comparison

Examination of the Shoulder

4. Palpate for tenderness over
the sterno-clavicular joint,
clavicle, acromioclavicular
joint, acromion process,
supraspinatus tendon and the
tendon of the long head of
biceps.
5. Observe shoulder abduction
from in front and behind,
through the entire range of
movement. Note the
presence of difficulty in
initiation or a painful arc.

Examination of the Shoulder

6. Secure the scapula to assess
gleno-humeral movement.
7. Assess flexion and extension.
( no photos)
8. Assess external rotation with
elbows in to the sides and
flexed to 90 .
9. Assess internal rotation by
asking the patient to place
both hands behind the head.

Examination of the Shoulder

10. Assess internal rotation by asking the patient to reach

over their opposite shoulder, behind the neck and
behind the back.

Examination of the Shoulder

11. Test biceps function by asking the patient to flex the elbow against
resistance.
12. Test serratus anterior function by asking the patient to push against a
wall, looking for winging of the scapula.
13. Test for pain with palpation of subacromial Bursa - indicates
impingement of the rotator cuff.

Examination of the Shoulder

14. The apprehension test
standing. Abduct, externally
rotate and extend the patient's
shoulder while pushing on the
head of the humerus with the
opposite hand to test for
anterior subluxation or
dislocation.
15. Apprehension test lying down.
16. Assess any marked instability
in the shoulder.
Anterior - instability (moves too
far forward);
Posterior - instability (moves
too far back). (2 photos)

Examination of the Elbow

1.

Observe the whole patient, front and back, looking especially for
deformity.
Swelling , Redness , Carrying Angle

Examination of the Elbow

2. Feel for tenderness.

Examination of the Elbow

3. Accentuate the pain of tennis elbow.

4. point of
tenderness.

5. pain on resisted
extension.

6. pain on passive
stretch.

Examination of the Elbow

7. Examine extension.

(To 00)

Examination of the Elbow

8. Examine flexion.

( To 1350)

Examination of the Elbow

9. Examine supination 10. Examine pronation.

( To 900)
( To 900)

Examination of the Elbow

11. Pivot shift of elbow

(instability).

12. Provocative test for Cubital Tunnel Syndrome

(puts tension on ulnar nerve at elbow).

Examination of the Elbow

13. Palpate the ulnar nerve.

Examination of the Wrist & Hand

1. Observe the hand positioned on a
pillow or a table. Ensure you have
adequate exposure.
2. Observe the palm of the hand.
3. Observe the dorsum of the hand.
4. Review the anatomy of the hand
noting the tip of the styloid
process, the anatomical snuffbox
bordered by extensor pollicis
brevis and extensor pollicis
longus tendons, the extensor
tendons of the fingers and the
head of the ulna.

5. Feel for tenderness. (no photos)

photos)

6. Test active movements of the wrist. (no

Examination of the Wrist & Hand

7. A useful method for screening of flexion and extension of the wrists. (2

photos)
8. Test passive movements of the wrist beginning with extension. (700)
9. Flexion. ( Nearly 900)

Examination of the Wrist & Hand

10. Radial deviation.

12. Pronation.

11. Ulnar deviation.

13. Supination.

Examination of the Wrist & Hand

14. Test thumb extension.

16. Test thumb adduction.

15. Test thumb abduction.

17. Test opposition.

Examination of the Wrist & Hand

18. Observe movement of fingers from extension to flexion. (2 photos)

19. Test flexor digitorum profundus function by holding the proximal
interphalangeal joint extended and asking the patient to flex the finger.
Successful finger flexion indicates the tendon is intact.
20. Test flexor digitorum superficialis function by holding the other fingers
extended while asking the patient to flex the finger being tested. Successful
flexion indicates the tendon is intact.

Examination of the Wrist & Hand

21. Assess joint hyperextension.

22. Axial compression test.
23. Asses ulnar nerve function with Froment's test. (choice of 2 photos)
24. Asses ulnar nerve/interosseus muscle function by asking the patient to
abduct their fingers while slowly pushing the hands together until the
weaker one collapses.

Examination of the Wrist & Hand

24. Asses ulnar nerve/interosseus
muscle function by asking the
patient to abduct their fingers
while slowly pushing the hands
together until the weaker one
collapses.
25. Assess median nerve
function. (UK sign for FP Lard
FDP working)
26. Assess the function of the
hand with the fine pinch grip
(paperclip).
27. Flat pinch grip (key).
28. Tripod grip (pen).
29. Wide grip (mug).
30. Power grip.

Examination of the Wrist & Hand

PHALENS TEST
Compression of the median nerve at the wrist
The wrist flexed maximally for 60 seconds
Paresthesias in the median nerve distribution
suggest carpal tunnel syndrome

CARPAL TUNNEL PERCUSSION

Tinel sign at the wrist

Examination of the Wrist & Hand

FINKELSTEINS TEST
Painless function of the abductor P.L , Ext P.B
Flex and ulnarly deviate the wrist, then push
the thumb into flexion
Sharp pain on the radial border of the wrist
de quervains disease

Examination of the Back

1. Observe the patient
as a whole, front and
back.
2. Ask the patient to
walk on their toes.
3. Ask the patient to
walk on their heels.
4. Back extension.

Examination of the Back

5. Back flexion.
6. Bony Excursion:
measure the distance
between two bony
points when standing.
7 Ask the patient to flex
forward, the bony
points should move at
least 5 cm.
8. Lateral flexion

Examination of the Back

9. Rotation (make sure to anchor
pelvis)
10. FABER test.
Flexion Abduction External
Rotation. Press firmly on the
knee. Pain in the groin
suggests a hip problem and
pain in the back refers to the
sacroiliac joint.
11 Straight leg ranging,
dorsiflexion increases the
sciatic stretch. Watch for pain
and limitation. (2 photos)
12. Femoral stretch test: Hip
extension and passive flexion
of the knee. Watch for pain
and limitation.

Examination of the Back

A Neurological examination
including:
13. Knee extension.
14. Knee flexion
15. Knee jerk reflex
16. Ankle jerk reflex.

Examination of the Back

17. Sensation
18. Pain on compression of the head can often be
attributed to non-organic pathology.

Examination of the Hip

1. Observe the whole
patient.
2. Trendelenburg test
(normal).
3. Positive Trendelenburg
Test.
4. Ask the patient to walk
and observe their gait.
(no photo)
5. Test iliopsoas function by
asking the patient to lift
their thigh off the seat
against resistance.

Examination of the Hip

6. Ensure the Anterior Superior Iliac Spines are horizontal.

Examination of the Hip

7. Check the position of the
medial malleoli.
8. Measure from the ASIS
to the medial malleoli. (3
photos)
9. Measure the distance
from the xiphisternum to
the medial malleoli.

10. Feel for the femoral head. It is deep to the femoral pulse. (No photo)

Examination of the Hip

11. Thomas Test:

Flex both hips to eliminate the lumbar lordosis. Extend the hip you are examining
and if it is normal it should return to the bed. A fixed flexion deformity of the hip will
not allow it to extend to the neutral position. (2 photos)
12. Check the patient is not compensating with a lumbar lordosis.
13. Check the ASIS are horizontal again. Anchor leg over the edge of the bed and
abduct the other hip. (0 0 to 45 0)
14. Assess adduction. ( 200 to 300)

Examination of the Hip

14. Assess adduction.

15. Internal rotation.
(00 to 450)
16. External rotation .
( 00 to 450)

Examination of the Knee

1. Observe the patient as a
whole.
2. Observe the knee joint
front and back. Note any
genu valgum (a slight
degree of which is
normal) or genu varum.
3. Observe knee from side.
Note any genu
recurvatum
4. Ask the patient to squat

Examination of the Knee

5. Assess patellae tracking
from extension to flexion.
Note quadriceps action.
6. Patellar apprehension
test. Apply lateral
pressure to patellar as
the patient flexes the
knee. Observe facial
expressions for fear of
impending dislocation.
7. Observe the knee with
the patient lying on the
bed.

Examination of the Knee

8. Pick a bony landmark on the
knee and measure a fixed
distance from it to the
approximate centre of the
quadriceps.
9. Measure the circumference of
the of the knee and leg.
10. Feel the temperature of the
knee and leg.
11. Soloman's test. Lift the patella
away from the femur. In
synovial thickening it will be
hard to grasp.

Examination of the Knee

12. Effusion: Tap Test. Push
sharply on the patella and
with an effusion it will strike
the femur and bounce back.
13. Effusion: Feel for fluid
fluctuance.

Examination of the Knee

14. Effusion: Bulge Test.

Empty the suprapatellar pouch with pressure above the patella.
Wipe hand along the medial side to displace fluid laterally.
Compress the lateral side and watch for a bulge medially.

Examination of the Knee

15. Feel the superficial and posterior surface of the patella by pushing it
medially.
16. To test for patello-femoral tenderness press patella against the femur and
ask the patient to tighten their thigh muscles.
17. Palpate for tenderness with the knee flexed to 90. Feel along the joint line,
the ligaments and the tibial tubercle.
18. Assess extension of the knee.

Examination of the Knee

19. Flexion.
20. Internal and external
rotation of the knee is
limited.
21. Test collateral ligaments
by applying medial and
lateral pressure to the
lower leg which is tucked
away under the
examiners arm.
22. Look for posterior sag of
the femur signifying
posterior cruciate
dysfunction.

Examination of the Knee

23. Anterior drawer test. Femur should not move forward

significantly unless the anterior cruciate ligament is torn.
24. Posterior drawer test. (Posterior cruciate)
25. Lachmans test.

Examination of the Knee

26. MC test - lift leg off the bed
and if tibia drops there is
cruciate dysfunction.
27. MacMurrays test.
Place the thumb and finger on
the joint line. Watching the
patients face for pain, flex the
leg, externally rotate the foot,
abduct and extend leg to test
for medial meniscal "clicks".
Flex the leg, internally rotate
and adduct for lateral meniscal
"clicks". (2 photos)
28. Ask the patient to lie prone
and examine the back of the
knee.

Examination of the Foot & Ankle

Observe patient as a whole
from front and back.
1. From behind check hindfoot alignment and "too
many toes" sign (tib. post
dysfunction).
2. & 3. Check for inversion
(tibialis function) and
eversion (peroneal
function).
4. Single stance heel raise
test.

Examination of the Foot & Ankle

5. Windlass test.
7. Dorsi flexion.

6. Coin test.
8. Plantar flexion.

Examination of the Foot & Ankle

9. Mid foot abduction/adduction.

11. Flexion fore foot.

10. Extension fore foot.

12. Tib. anterior test.

Examination of the Foot & Ankle

13. Tib. posterior test.

14. Peroneal tendons test.
15. Ankle instability - inversion test.
16. Ankle instability - Anterior draw test.

Examination of the Foot & Ankle

17. Ankle instability Posterior draw test.
18. Simmond's test for
TA.
19. Examine the sole.
20. Check pulses,
sensation, reflexes.

Radiology

X-ray : Rule Of 2
USG
CT Scan
MRI
Bone Scan

Others
Patology
Laboratory
Nerve test

Diagnosis

Any
Questions?

THANK YOU