Upper Extremities

The radiocarpal joint (wrist) consists of the articulation of the radius and the carpal bones. Additional articulations occur between the proximal and distal rows of carpal bones. An articular disk separates the ulna and carpal bones, and the joint is protected by ligaments and a fibrous capsule. The wrist moves in two planes. There is flexion and extension movement as well as radial and ulnar (rotational) movement. The hand has articulations between the carpals and metacarpals, metacarpals and proximal phalanges, and middle and distal phalanges ( Fig. 22.3 ). The forearm joints consist of the articulations between the radius and ulna at both the proximal and distal locations. They are important for pronation and supination.

Structures of the wrist and hand joints.

The elbow consists of the articulation of the humerus, radius, and ulna. Its three contiguous surfaces are enclosed in a single synovial cavity, with the collateral ligaments of the radius and ulna securing the joint. A bursa lies between the olecranon and the skin ( Fig. 22.4 ). The elbow is a hinge joint, permitting movement of the humerus and ulna in one plane (flexion and extension).

Structures of the left elbow joint, posterior view.

The glenohumeral joint (shoulder) consists of the articulation between the humerus and the glenoid fossa of the scapula. The acromion and coracoid processes and the ligament between them form the arch surrounding and protecting the joint ( Fig. 22.5, A ). Four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) and their tendons comprise the rotator cuff, reinforcing the glenohumeral joint to stabilize the shoulder and the position of the humeral head within the joint ( Fig. 22.5, B ). The shoulder is a ball-and-socket joint that permits movement of the humerus in many axes.

Structures of the shoulder.

A, Structures of glenohumeral and acromioclavicular joints, anterior view. B, Rotator cuff muscles of shoulder, posterior view.

Two additional joints adjacent to the glenohumeral joint complete the articulation of the shoulder girdle. The acromioclavicular joint consists of the articulation between the acromion process and the clavicle, and the sternoclavicular joint consists of the articulation between the manubrium of the sternum and the clavicle.

Head and Spine

The temporomandibular joint consists of the articulation between the mandible and the temporal bone in the cranium. Each is located in the depression just anterior to the tragus of the ear. The hinge action of the joint opens and closes the mouth. The gliding action permits lateral movement, protrusion, and retraction of the mandible ( Figs. 22.6 and 22.7 ). See Chapter 11 for a description of the fused bones of the cranium.

Muscles of the face and head, left lateral view.

Structures of the temporomandibular joint.

The spine is composed of cervical, thoracic, lumbar, and sacral vertebrae. All but the sacral vertebrae are separated from each other by fibrocartilaginous disks. Each disk has a central area of fibrogelatinous material, known as the nucleus pulposus, that cushions the vertebral bodies ( Fig. 22.8 ). The vertebrae form a series of joints that glide slightly over each other’s surfaces, permitting movement in several axes. The cervical vertebrae are the most mobile. Flexion and extension occur between the skull and C1, whereas rotation occurs between C1 and C2. The sacral vertebrae are fused, and with the coccyx form the posterior portion of the pelvis.

Structures of vertebral joints.

Lower Extremities

The hip joint consists of the articulation between the acetabulum and the femur. The depth of the acetabulum in the pelvic bone—as well as the joint, which is supported by three strong ligaments—helps stabilize and protect the head of the femur in the joint capsule. Multiple bursae reduce friction in the hip. The hip is a ball-and-socket joint, permitting movement of the femur on many axes ( Fig. 22.9 ).

Structures of the hip.

(From Rothrock, 2007.)

The knee consists four bones (femur, tibia, fibula, and patella), with three separate articulating compartments: the lateral tibiofemoral, the medial tibiofemoral, and the patellofemoral. Fibrocartilaginous disks (medial and lateral menisci), which cushion the tibia and femur, are attached to the tibia and the joint capsule. Collateral ligaments give medial and lateral stability to the knee. Two cruciate ligaments cross obliquely within the knee, adding anterior and posterior stability. The anterior cruciate ligament protects the knee from hyperextension. There are four separate bursae in the anterior knee helping reduce the friction of knee movement. The knee is a hinge joint, permitting movement (flexion and extension) between the femur and tibia in one plane ( Fig. 22.10 ).

Structures of the knee, anterior view.

A, Bones and ligaments of the joint. B, Muscles attaching at the knee.

The tibiotalar joint (ankle) consists of the articulation of the tibia, fibula, and talus. It is protected by ligaments on the medial and lateral surfaces. The tibiotalar joint is a hinge joint that permits flexion and extension (dorsiflexion and plantar flexion) in one plane. Additional joints in the ankle—the talocalcaneal joint (subtalar) and transverse tarsal joint—permit it to pivot or rotate (pronation and supination). Articulations of the foot between the tarsals and metatarsals, the metatarsals and proximal phalanges, and the middle and distal phalanges allow flexion and extension ( Fig. 22.11 ) to occur.

Bones and joints of the ankle and foot.

History of Present Illness

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  Joint symptoms

  
  
  
  
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    Character: stiffness or limitation of movement, change in size or contour, swelling or redness, constant pain or pain with particular motion, unilateral or bilateral involvement, interference with daily activities, joint locking or giving way

    
    
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    Associated events: time of day, activity, specific movements, injury, strenuous activity, weather

    
    
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    Temporal factors: change in frequency or character of episodes, better or worse as day progresses, nature of onset (sudden or gradual)

    
    
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    Efforts to treat: exercise, rest, weight reduction, physical therapy, heat, ice, braces or splints

    
    
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    Medications: nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, biologic modifiers and other immunosuppressants, corticosteroids, topical analgesics; glucosamine, chondroitin, hyaluronic acid, complementary therapies

  
  
  
  
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  Muscular symptoms

  
  
  
  
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    Character: limitation of movement, weakness or fatigue, paralysis, tremor, tic, spasms, clumsiness, wasting, aching or pain

    
    
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    Precipitating factors: injury, strenuous activity, sudden movement, stress

    
    
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    Efforts to treat: heat, ice, splints, rest, massage

    
    
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    Medications: muscle relaxants, statins, NSAIDs

  
  
  
  
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  Skeletal symptoms

  
  
  
  
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    Character: difficulty with gait or limping; numbness, tingling, or pressure sensation; pain with movement, crepitus; deformity or change in skeletal contour

    
    
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    Associated event: injury, recent fractures, strenuous activity, sudden movement, stress; postmenopause

    
    
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    Efforts to treat: rest, splints, chiropractic, acupuncture

    
    
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    Medications: hormone therapy, calcium; calcitonin, bisphosphonates

  
  
  
  
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  Injury

  
  
  
  
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    Sensation at time of injury: click, pop, tearing, numbness, tingling, catching, locking, grating, snapping, warmth or coldness, ability to bear weight

    
    
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    Mechanism of injury: direct trauma, overuse, sudden change of direction, forceful contraction, overstretch

    
    
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    Pain: location, type, onset (sudden or gradual), aggravating or alleviating factors, position of comfort

    
    
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    Swelling: location, timing (with activity or injury)

    
    
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    Efforts to treat: rest, ice, heat, splints

    
    
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    Medications: analgesics, NSAIDS

  
  
  
  
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  Back pain

  
  
  
  
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    Abrupt or gradual onset, better or worse with activity

    
    
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    Character of pain and sensation: tearing, burning, or steady ache; tingling or numbness; location and distribution (unilateral or bilateral), radiation to buttocks, groin, or legs; triggered by coughing or sneezing and sudden movements

    
    
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    Associated event: trauma, lifting of heavy weights, long distance driving, sports activities, change in posture or deformity

    
    
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    Efforts to treat: rest, avoid standing or sudden movements, chiropractic, acupuncture

    
    
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    Medications: muscle relaxants, analgesics, NSAIDs

  
  

Past Medical History

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  Trauma: nerves, soft tissue, bones, joints; residual problems; bone infection

  
  
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  Surgery on joint or bone; amputation, arthroscopy

  
  
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  Chronic illness: cancer, arthritis, sickle cell disease, hemophilia, osteoporosis, renal or neurologic disorder

  
  
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  Skeletal deformities or congenital anomalies

Family History

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  Congenital abnormalities of hip or foot

  
  
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  Scoliosis or back problems

  
  
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  Arthritis: rheumatoid, osteoarthritis, ankylosing spondylitis, gout

  
  
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  Genetic disorders: osteogenesis imperfecta, skeletal dysplasia, rickets, hypophosphatemia, hypercalciuria

Personal and Social History

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  Employment: past and current, lifting and potential for unintentional injury, repetitive motions, typing/computer use, safety precautions, use of spinal support, chronic stress on joints

  
  
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  Exercise: extent, type, and frequency; weight bearing; stress on specific joints; overall conditioning; sport (level of competition, type of shoes and athletic gear); warm-up and cool-down routines with exercise

  
  
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  Functional abilities: personal care (eating, bathing, dressing, grooming, elimination); other activities (housework, walking, climbing stairs, caring for pet); use of prosthesis

  
  
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  Weight: recent gain, overweight or underweight for body frame

  
  
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  Height: maximum height achieved, any changes

  
  
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  Nutrition: amount of calcium, vitamin D, calories, and protein

  
  
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  Tobacco or alcohol use

Equipment

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  Skin-marking pencil

  
  
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  Goniometer

  
  
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  Tape measure

  
  
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  Reflex hammer

As you give specific attention to bones, joints, tendons, ligaments, and muscles, expose the body surface and view under good lighting. Position the patient to provide the greatest stability to the joints. Examine each region of the body for limb and trunk stability, muscular strength and function, and joint range of motion. Position the extremities uniformly as you examine and look for asymmetry.

Inspection

Inspect the anterior, posterior, and lateral aspects of the patient’s posture ( Fig. 22.12 ). Observe the patient’s ability to stand erect, symmetry of body parts, and alignment of the extremities. Note any lordosis, kyphosis (overcurvature of the thoracic vertebrae), or scoliosis (curved from side to side) of the spine.

Inspection of overall body posture.

Note the even contour of the shoulders, level scapulae and iliac crests, alignment of the head over the gluteal folds, and symmetry and alignment of extremities. A, Anterior view. B, Posterior view. C, Lateral view. The occiput, shoulders, buttocks, and heels should be able to touch the wall the patient stands against.

Inspect the skin and subcutaneous tissues overlying the articular structures for discoloration, swelling, and masses.

Observe the extremities for overall size, gross deformity, bony enlargement, alignment, contour, and symmetry of length and position. Expect to find bilateral symmetry in length, circumference, alignment, and the position (see Clinical Pearl, “Bilateral Symmetry ”).

Inspect the muscles for gross hypertrophy or atrophy, fasciculations, and spasms. Muscle size should approximate symmetry bilaterally. Fasciculation (muscle twitching) occurs after injury to a muscle’s motor neuron. Muscle wasting occurs after injury as a result of pain, disease of the muscle, or damage to the motor neuron.

Palpation

Palpate any bones, joints, tendons, and surrounding muscles if symptomatic. Palpate inflamed joints last. Note any heat, tenderness, swelling, crepitus, pain, and resistance to movement. No discomfort should occur when you apply pressure to bones or joints. Muscle tone should be firm, not hard or doughy. Synovial thickening can sometimes be felt in joints that are close to the skin surface when the synovium is edematous or hypertrophied because of inflammation. Crepitus (a grating sound or sensation) can be felt when two irregular bony surfaces rub together as a joint moves, when two rough edges of a broken bone rub together, or with the movement of a tendon inside the tendon sheath when tenosynovitis is present.

Range of Motion and Muscle Tone

Examine both the active and passive range of motion for each major joint and its related muscle groups. Muscle tone is often evaluated simultaneously. Allow adequate space for the patient to move each muscle group and joint through its full range. Instruct the patient to move each joint through its range of motion as detailed in specific joint and muscle sections. Pain, limitation of motion, spastic movement, joint instability, deformity, or contracture suggest a problem with the joint, related muscle group, or nerve supply.

Ask the patient to relax and allow you to passively move the same joints until the end of the range of motion is felt. Do not force the joint if there is pain or muscle spasm. Muscle tone may be assessed by feeling the resistance to passive stretch. During passive range of motion, the muscles should have slight tension. Passive range of motion often exceeds active range of motion by 5 degrees. Range of motion with active and passive maneuvers should be equal between contralateral joints. Discrepancies between active and passive range of motion may indicate true muscle weakness or a joint disorder. No crepitation or tenderness with movement should be apparent. Note the specific location of tenderness when present. Spastic muscles are harder to put through the range of motion. Measurements may vary if the muscle tested relaxes with gentle persistence.

When a joint appears to have an increase or limitation in its range of motion, a goniometer (see Chapter 3 ) is used to precisely measure the angle. Begin with the joint in the fully extended or neutral position, and then flex the joint as far as possible. Measure the angles of greatest flexion and extension, comparing these with the expected joint flexion and extension values ( Fig. 22.13 ).

Use of goniometer to measure joint range of motion.

Muscle Strength

Evaluating the strength of each muscle group is considered part of the neurologic examination. However, it is usually integrated with examination of the associated joint for range of motion. Ask the patient first to contract the muscle you indicate by extending or flexing the joint and then to resist as you apply force against that muscle contraction ( Fig. 22.14 ). Alternatively, tell the patient to push against your hand to feel the resistance. Compare the muscle strength bilaterally. Expect muscle strength to be bilaterally symmetric with full resistance to opposition. Full muscle strength requires complete active range of motion.

Evaluation of muscle strength: flexion of the elbow against opposing force.

Variations in muscle strength are graded from no voluntary contraction to full muscle strength, using the scale in Table 22.1 . When muscle strength is grade 3 or less, disability is present; activity cannot be accomplished in a gravity field, and external support is necessary to perform movements. Weakness may result from an underlying muscle disorder, pain, fatigue, or overstretching.

Specific Joints and Muscles

Hands and Wrists

Inspect the dorsal and palmar aspects of the hands, noting the contour, position, shape, number, and completeness of digits. Note the presence of palmar and phalangeal creases. The palmar surface of each hand should have a central depression with a prominent, rounded mound (thenar eminence) on the thumb side of the hand and a less prominent hypothenar eminence on the little finger side of the hand. Expect the fingers to fully extend when in close approximation to each other and to be aligned with the forearm. The lateral finger surfaces should gradually taper from the proximal to the distal aspects ( Fig. 22.15 ).

A, Bony structure of the right hand and wrist; note the alignment of the fingers with the radius. B, Features of the palmar aspect of the hand; note creases, thenar eminence and hypothenar eminence, and gradual tapering of the fingers.

Deviation of the fingers to the ulnar side and swan neck or boutonnière deformities of the fingers usually indicates rheumatoid arthritis ( Fig. 22.16 ).

Unexpected findings of the hand.

A, Ulnar deviation and subluxation of metacarpophalangeal joints. B, Swan neck deformities. C, Boutonnière deformity.

(Reprinted from the Clinical slide collection of the rheumatic diseases, 1991. Used by permission of the American College of Rheumatology.)

Palpate each joint in the hand and wrist. Palpate the interphalangeal joints with your thumb and index finger. The metacarpophalangeal joints are palpated with both thumbs. Palpate the wrist and radiocarpal groove with your thumbs on the dorsal surface and your fingers on the palmar aspect of the wrist ( Fig. 22.17 ). Joint surfaces should be smooth and without nodules, swelling, bogginess, or tenderness. A firm mass over the dorsum of the wrist may be a ganglion.

Palpation of joints of the hand and wrist.

A, Proximal interphalangeal joints. B, Metacarpophalangeal joints. C, Radiocarpal groove and wrist.

Bony overgrowths in the distal interphalangeal joints, which are felt as hard, nontender nodules usually 2 to 3 mm in diameter but sometimes encompassing the entire joint, are associated with osteoarthritis. When located along the distal interphalangeal joints, they are called Heberden nodes; those along the proximal interphalangeal joints are called Bouchard nodes. Painful swelling of the proximal interphalangeal joints causes spindle-shaped fingers, which are associated with the acute stage of rheumatoid arthritis ( Fig. 22.18 ). Cystic, round, nontender swellings along tendon sheaths or joint capsules that are more prominent with flexion may indicate ganglia.

Unexpected findings of the fingers.

A, Fusiform swelling or spindle-shaped enlargement of the proximal interphalangeal joints. B, Degenerative joint disease; Heberden nodes at the distal interphalangeal joints and Bouchard nodes at the proximal interphalangeal joints. C, Telescoping digits with hypermobile joints.

(Reprinted from the Clinical slide collection of the rheumatic diseases, 1991. Used by permission of the American College of Rheumatology.)

Examine the range of motion of the hand and wrist by asking the patient to perform these movements:

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  Bend the fingers forward at the metacarpophalangeal joint; then stretch the fingers up and back at the knuckle. Expect metacarpophalangeal flexion of 90 degrees and hyperextension up to 30 degrees ( Fig. 22.19, A ).

  
  

  
  

  
  

  

  
  

  
  

  Range of motion of the hand and wrist.

  
  

  A, Metacarpophalangeal flexion and hyperextension. B, Finger flexion: thumb to each fingertip and to the base of the little finger. C, Finger flexion: fist formation. D, Finger abduction. E, Wrist flexion and hyperextension. F, Wrist radial and ulnar movement.

  
  
  
  
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  Touch the thumb to each fingertip and to the base of the little finger; make a fist. All movements should be possible ( Fig. 22.19, B and C ).

  
  
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  Spread the fingers apart and then touch them together. Both movements should be possible ( Fig. 22.19, D ).

  
  
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  Bend the hand at the wrist up and down. Expect flexion of 90 degrees and hyperextension of 70 degrees ( Fig. 22.19, E ).

  
  
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  With the palm side down, turn each hand to the right and left. Expect radial motion of 20 degrees and ulnar motion of 55 degrees ( Fig. 22.19, F ).

Have the patient maintain wrist flexion and hyperextension while you apply opposing force to evaluate the strength of the wrist muscles. To evaluate hand strength, have the patient tightly grip two of your fingers. To avoid painful compression from an overzealous squeeze, offer your two fingers of one hand side by side in the handshake position. Finger extension, abduction, adduction, and thumb opposition may also be used to evaluate hand strength.

Elbows

Inspect the contour of the patient’s elbows in both flexed and extended positions. Subcutaneous nodules along pressure points of the ulnar surface may indicate a rheumatoid nodule ( Fig. 22.20 ) or gouty tophi.

Subcutaneous nodules on the extensor surface of the forearm near the elbow.

(From Talley and O’Conner, 2010.)

Note any deviations in the carrying angle between the humerus and radius while the arm is passively extended, palm forward. The carrying angle is usually 5 to 15 degrees laterally. Variations in carrying angle are cubitus valgus, a lateral angle exceeding 15 degrees, and cubitus varus, a medial carrying angle ( Fig. 22.21 ).

Expected carrying angle of the arm, at 5 to 15 degrees.

Flex the patient’s elbow 70 degrees and palpate the extensor surface of the ulna, the olecranon process, and the medial and lateral epicondyles of the humerus. Then palpate the groove on each side of the olecranon process for tenderness, swelling, and thickening of the synovial membrane ( Fig. 22.22 ). The olecranon bursa is a fluid filled sac that acts as a cushion between the skin and the olecranon process. Olecranon bursitis results in swelling and tenderness of the bursa. Suspect epicondylitis or tendonitis when a boggy, soft, or fluctuant swelling; point tenderness at the lateral epicondyle or along the grooves of the olecranon process and epicondyles; and increased pain with pronation and supination of the elbow are found.

Palpation of the olecranon process grooves.

Examine the elbow’s range of motion by asking the patient to perform the following movements:

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  With the elbow fully extended at 0 degrees, bend and straighten the elbow. Expect flexion of 160 degrees and extension returning to 0 degrees or 180 degrees of full extension ( Fig. 22.23, A ).

  
  

  
  

  
  

  

  
  

  
  

  Range of motion of the elbow.

  
  

  A, Flexion and extension. B, Pronation and supination.

  
  
  
  
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  With the elbow flexed at a right angle, rotate the hand from palm side down to palm side up. Expect pronation of 90 degrees and supination of 90 degrees ( Fig. 22.23, B ).

  
  
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  Have the patient maintain flexion and extension while you apply opposing force to evaluate the strength of the elbow muscles.

Shoulders

Inspect the contour of the shoulders, the shoulder girdle, the clavicles and scapulae, and the surrounding musculature. Expect symmetry of size and contour of all shoulder structures. When the shoulder contour is asymmetric and one shoulder has hollows in the rounding contour, suspect a shoulder dislocation ( Fig. 22.24, A ). Observe for a winged scapula, an outward prominence of the scapula, indicating injury to the nerve of the anterior serratus muscle ( Fig. 22.24, B ).

Contour changes of the shoulder.

A, With dislocation. B, Winging of the scapula with abduction of the arm.

(From Van Tuijl et al, 2006.)

Palpate the sternoclavicular joint, clavicle, acromioclavicular joint, scapula, coracoid process, greater tubercle of the humerus, biceps groove, and area muscles. To palpate the biceps groove, rotate the arm and forearm externally. Locate the biceps muscle near the elbow and follow the muscle and its tendon into the biceps groove along the anterior aspect of the humerus. Palpate the muscle insertions of the supraspinatus, infraspinatus, and teres minor near the greater tuberosity of the humerus by lifting the elbow posteriorly to extend the shoulder. No tenderness should be noted over the muscle insertions.

Examine the range of motion of the shoulders by asking the patient to perform the following movements:

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  Shrug the shoulders. Expect the shoulders to rise symmetrically.

  
  
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  Raise both arms forward and straight up over the head. Expect forward flexion of 180 degrees.

  
  
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  Extend and stretch both arms behind the back. Expect hyperextension of 50 degrees ( Fig. 22.25, A ).

  
  

  
  

  
  

  

  
  

  
  

  Range of motion of the shoulder.

  
  

  A, Forward flexion and hyperextension. B, Abduction and adduction. C, Internal rotation. D, External rotation. E, Shrugged shoulders.

  
  
  
  
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  Lift both arms laterally and straight up over the head. Expect shoulder abduction of 180 degrees.

  
  
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  Swing each arm across the front of the body. Expect adduction of 50 degrees ( Fig. 22.25, B ).

  
  
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  Place both arms behind the hips, elbows out. Expect internal rotation of 90 degrees ( Fig. 22.25, C ).

  
  
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  Place both arms behind the head, elbows out. Expect external rotation of 90 degrees ( Fig. 22.25, D ).

Have the patient maintain shrugged shoulders while you apply opposing force to evaluate the strength of the shoulder girdle muscles. Cranial nerve XI (the accessory nerve controlling the sternocleidomastoid and trapezius muscles) is simultaneously evaluated with this maneuver ( Fig. 22.25, E ).

Temporomandibular Joint

Locate the temporomandibular joints by placing your fingertips just anterior to the tragus of each ear. Allow your fingertips to slip into the joint space as the patient’s mouth opens, and gently palpate the joint space ( Fig. 22.26 ). An audible or palpable snapping or clicking in the temporomandibular joints is not unusual, but pain, crepitus, locking, or popping may indicate temporomandibular joint dysfunction.

Palpation of the temporomandibular joint.

Examine range of motion by asking the patient to perform the following movements:

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  Open and close the mouth. Expect a space of 3 to 6 cm between the upper and lower teeth when the jaw is open.

  
  
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  Laterally move the lower jaw to each side. The mandible should move 1 to 2 cm in each direction ( Fig. 22.27 ).

  
  

  
  

  
  

  

  
  

  
  

  Lateral range of motion in the temporomandibular joint.

  
  
  
  
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  Protrude and retract the chin. Both movements should be possible.

Strength of the temporalis and masseter muscles may be evaluated by asking the patient to clench the teeth while you palpate the contracted muscles and apply opposing force. This maneuver simultaneously tests cranial nerve V (the trigeminal nerve).

Cervical Spine

Inspect the patient’s neck from both the anterior and posterior position, observing for alignment of the head with the shoulders and symmetry of the skinfolds and muscles. Expect the cervical spine curve to be concave with the head erect and in appropriate alignment. Palpate the posterior neck, cervical spine, and paravertebral, trapezius, and sternocleidomastoid muscles. The muscles should have good tone and be symmetric in size, with no palpable tenderness or muscle spasm.

Evaluate range of motion in the cervical spine by asking the patient to perform the following movements ( Fig. 22.28 ):

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  Bend the head forward, chin to the chest. Expect flexion of 45 degrees.

  
  
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  Bend the head backward, chin toward the ceiling. Expect extension of 45 degrees.

  
  
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  Bend the head to each side, ear to each shoulder. Expect lateral bending of 40 degrees.

  
  
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  Turn the head to each side, chin to shoulder. Expect rotation of 70 degrees.

Range of motion of the cervical spine.

A, Flexion and hyperextension. B, Lateral bending. C, Rotation.

The strength of the sternocleidomastoid and trapezius muscles is evaluated with the patient maintaining each of the above positions while you apply opposing force. With rotation, cranial nerve XI is simultaneously tested ( Fig. 22.29 ).

Examining the strength of the sternocleidomastoid and trapezius muscles.

A, Flexion with palpation of the sternocleidomastoid muscle. B, Extension against resistance. C, Rotation against resistance.

Thoracic and Lumbar Spine

Major landmarks of the back include each spinal process of the vertebrae (C7 and T1 are usually most prominent), the scapulae, iliac crests, and paravertebral muscles ( Fig. 22.30 ). Expect the head to be positioned directly over the gluteal cleft and the vertebrae to be straight as indicated by symmetric shoulder, scapular, and iliac crest heights. The curve of the thoracic spine should be convex. The curve of the lumbar spine should be concave ( Fig. 22.31, A ). The knees and feet should be in alignment with the trunk, pointing directly forward.

Landmarks of the back.

Deviations in spinal column curvatures.

A, Expected spine curvatures. B, Kyphosis. C, Lordosis. D, Gibbus.

Kyphosis may be observed in aging adults ( Fig. 22.31, B ). Lordosis is common in patients who are obese or pregnant ( Fig. 22.31, C ). A sharp angular deformity, a gibbus, is associated with a collapsed vertebra from osteoporosis ( Fig. 22.31, D ).

With the patient standing erect, palpate along the spinal processes and paravertebral muscles ( Fig. 22.32 ). No muscle spasms or spinal tenderness should be noted. Percuss for spinal tenderness, first by tapping each spinal process with one finger and then by percussing each side of the spine along the paravertebral muscles with the ulnar aspect of your fist. No muscle spasm or spinal tenderness with palpation or percussion should be elicited.

Palpation of the spinal processes of the vertebrae.

Ask the patient to bend forward slowly and touch the toes while you observe from behind. Inspect the spine for unexpected curvature. The patient’s back should remain symmetrically flat as the concave curve of the lumbar spine becomes convex with forward flexion. A lateral curvature or rib hump should make you suspect scoliosis ( Fig. 22.33 ). Measure the degree of rotation with a scoliometer (see Chapter 3 ). Then have the patient rise but remain bent at the waist to fully extend the back. Reversal of the lumbar curve should be apparent.

Inspection of the spine for lateral curvature and lumbar convexity.

Evaluate range of motion by asking the patient to perform the following movements:

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  Bend forward at the waist and, without bending the knees, try to touch the toes. Expect flexion of 75 to 90 degrees ( Fig. 22.34, A ).

  
  

  
  

  
  

  

  
  

  
  

  Range of motion of the thoracic and lumbar spine.

  
  

  A, Flexion. B, Hyperextension. C, Lateral bending. D, Rotation of the upper trunk.

  
  
  
  
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  Bend back at the waist as far as possible. Expect hyperextension of 30 degrees ( Fig. 22.34, B ).

  
  
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  Bend to each side as far as possible. Expect lateral bending of 35 degrees bilaterally ( Fig. 22.34, C ).

  
  
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  Swing the upper trunk from the waist in a circular motion front to side to back to side while you stabilize the pelvis. Expect rotation of the upper trunk 30 degrees forward and backward ( Fig. 22.34, D ).

Patient Safety

Reducing the Risk for Lower Back Pain

Use appropriate techniques to lift heavy objects to reduce the risk of lower back injury. Rather than bend over to pick up a heavy object, keep the back straight and flex the knees to get closer to the object. Keep the object close to the body and lift with the knees. Avoid twisting the back during the lift.

Legs and Knees

Inspect the knees and their popliteal spaces in both flexed and extended positions, noting the major landmarks: tibial tuberosity, medial and lateral tibial condyles, medial and lateral epicondyles of the femur, adductor tubercle of the femur, and patella (see Fig. 22.10 ). Inspect the extended knee for its natural concavities on the anterior aspect, on each side, and above the patella. Loss of these concavities may suggest a knee effusion.

Observe the lower leg alignment. The angle between the femur and tibia is expected to be less than 15 degrees. Variations in lower leg alignment are genu valgum (knock-knees) and genu varum (bowlegs). Excessive hyperextension of the knee with weight bearing (genu recurvatum) may indicate weakness of the quadriceps muscles.

An effusion of the knee fills the suprapatellar pouch and the concavity below the patella medially. When this occurs, the usual indentation above and on the medial side of the patella is filled out to be convex rather than concave.

Palpate the popliteal space, noting any swelling or tenderness. Fullness in the popliteal space may indicate a popliteal (Baker) cyst. Then palpate the tibiofemoral joint space, identifying the patella, the suprapatellar pouch, and the infrapatellar fat pad. The joint should feel smooth and firm, without tenderness, swelling, bogginess, nodules, or crepitus (see Knee Assessment for additional assessment procedures).

Examine the knees’ range of motion by asking the patient to perform the following movements ( Fig. 22.36 ):

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  Bend each knee. Expect 130 degrees of flexion.

  
  
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  Straighten the leg and stretch it. Expect full extension and up to 15 degrees of hyperextension.

Range of motion of the knee: flexion and extension.

The strength of the knee muscles is evaluated with the patient maintaining flexion and extension while you apply opposing force. The patient may be sitting or standing for this assessment.

Feet and Ankles

Inspect the feet and ankles while the patient is bearing weight (i.e., standing and walking) and while sitting. Landmarks of the ankle include the medial malleolus, the lateral malleolus, and the Achilles tendon. Expect smooth and rounded malleolar prominences, prominent heels, and prominent metatarsophalangeal joints. Calluses and corns indicate chronic pressure or irritation.

Observe the contour of the feet and the position, size, and number of toes. The feet should be in alignment with the tibias. Pes varus (in-toeing) and pes valgus (out-toeing) are common alignment variations. Weight bearing should be on the midline of the foot, on an imaginary line from the heel midline to between the second and third toes. Deviations in forefoot alignment (metatarsus varus or metatarsus valgus), heel pronation, and pain or injury often cause a shift in weight-bearing position ( Fig. 22.37 ).

Pronation of heel.

Note that weight bearing is not through the midline of the foot.

(Courtesy Charles W. Bradley, DPM, MPA, and Caroline Harvey, DPM, California College of Podiatric Medicine.)

Expect the foot to have a longitudinal arch, although the foot may flatten with weight bearing ( Fig. 22.38, A ). Common variations include pes planus ( Fig. 22.38, B ), a foot that remains flat even when not bearing weight, and pes cavus, a high instep ( Fig. 22.38, C ). Pes cavus may be associated with claw toes.

Variations in the longitudinal arch of the foot.

A, Commonly expected arch. B1 and B2, Pes planus (flatfoot). C1 and C2, Pes cavus (high instep). (B2,

Courtesy Charles W. Bradley, DPM, MPA, and Caroline Harvey, DPM, California College of Podiatric Medicine. C2, from Coughlin et al, 2007.)

The toes should be straight forward, flat, and in alignment with each other. Several unexpected deviations of the toes can occur ( Fig. 22.39 ). Hyperextension of the metatarsophalangeal joint with flexion of the toe’s proximal joint is called hammertoe. A flexion deformity at the distal interphalangeal joint is called a mallet toe. Claw toe is hyperextension of the metatarsophalangeal joint with flexion of the toe’s proximal and distal joints. Hallux valgus is lateral deviation of the great toe, which may cause overlapping with the second toe. A bursa often forms at the pressure point and, if it becomes inflamed, forms a painful bunion.

Unexpected findings of the feet.

A, Hallux valgus with bunion. B, Protruding metatarsal heads with callosities. C, Hammertoes. D, Mallet toe. E, Claw toes.

(Courtesy Charles W. Bradley, DPM, MPA, and Caroline Harvey, DPM, California College of Podiatric Medicine.)

Heat, redness, swelling, and tenderness are signs of an inflamed joint, possibly caused by rheumatoid arthritis, gout, septic joint, fracture, or tendonitis. In particular, an inflamed metatarsophalangeal joint of the great toe should make you suspect gouty arthritis.

Palpate the Achilles tendon, the anterior surface of the ankle, and the medial and lateral malleoli. A persistently thickened Achilles tendon may indicate the tendonitis that can develop with spondyloarthritis or from xanthelasma of hyperlipidemia. Use the thumb and fingers of both hands to compress the forefoot and to palpate each metatarsophalangeal joint, looking for discomfort or swelling.

Assess range of motion of the foot and ankle by asking the patient to perform the following movements while sitting:

Point the foot toward the ceiling. Expect dorsiflexion of 20 degrees ( Fig. 22.40, A ).

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  Point the foot toward the floor. Expect plantar flexion of 45 degrees.

  
  
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  Bending the foot at the ankle, turn the sole of the foot toward and then away from the other foot. Expect inversion of 30 degrees and eversion of 20 degrees ( Fig. 22.40, B ).

  
  
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  Rotating the ankle, turn the foot away from and then toward the other foot while the examiner stabilizes the leg. Expect abduction of 10 degrees and adduction of 20 degrees ( Fig. 22.40, C ).

  
  
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  Bend and straighten the toes. Expect flexion and extension, especially of the great toes.

Range of motion of the foot and ankle.

A, Dorsiflexion and plantar flexion. B, Inversion and eversion. C, Abduction and adduction.

Have the patient maintain dorsiflexion and plantar flexion while you apply opposing force to evaluate the strength of the ankle muscles. Abduction and adduction of the ankle and flexion and extension of the great toe may also be used to evaluate muscle strength.

For the assessment of gait, see Chapter 23 .

Data from Dowling et al, 2009 .

Evidence-Based Practice in Physical Examination

Acute Ankle Injury in Adults

In cases of acute ankle injury, the Ottawa Ankle Rules help identify the characteristics of patients needing an ankle radiograph series. There must be pain in the malleolar zone and one of the following:

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  Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus

  
  
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  Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus

  
  
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  Inability to bear weight for four steps both immediately after the injury and in the emergency department

Absolute exclusion criteria for an ankle radiograph series include the following: age younger than 18 years, intoxication, multiple painful (distracting) injuries, pregnancy, head injury, and neurologic deficit.

The Ottawa Ankle Rules have 98.5% sensitivity for detecting an ankle fracture that is present on radiography.

Hand and Wrist Assessment

Several procedures are used to evaluate the integrity of the median nerve, which innervates the palm of the hand and the palmar surface of the thumb, index and middle fingers, and half of the ring finger. Ask the patient to mark the specific locations of pain, numbness, and tingling on the Katz hand diagram ( Fig. 22.41 ). Certain patterns of pain, numbness, and tingling are associated with carpal tunnel syndrome.

Assessment for carpal tunnel syndrome.

A, Katz hand diagram. B, Classic and probable patterns of pain, tingling, and numbness using the Katz hand diagram.

The thumb abduction test isolates the strength of the abductor pollicis brevis muscle, innervated only by the median nerve. Have the patient place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on the thumb to test muscle strength ( Fig. 22.42, A ). Full resistance to pressure is expected. Weakness is associated with carpal tunnel syndrome.

Additional procedures for assessment of carpal tunnel syndrome.

A, Thumb abduction test. B, Phalen maneuver. C, Elicitation of Tinel sign.

To perform the Phalen test, ask the patient to hold both wrists in a fully palmar-flexed position with the dorsal surfaces pressed together for 1 minute ( Fig. 22.42, B ). Numbness and paresthesia in the distribution of the median nerve are suggestive of carpal tunnel syndrome. The reverse Phalen test is performed by placing the palms and fingers together with full wrist extension. The Tinel sign is tested by striking the patient’s wrist with your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament ( Fig. 22.42, C ). A tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive Tinel sign and is suggestive of carpal tunnel syndrome.

Shoulder Assessment

Several procedures are used to evaluate the rotator cuff for impingement (tendonitis or overuse injury from repetitive overhead activities) or a tear.

To perform the Neer test, forward flex the patient’s arm up to 150 degrees while depressing the scapula. This presses the greater tuberosity and supraspinatus muscle against the anteroinferior acromion. Increased shoulder pain is associated with rotator cuff inflammation or a tear ( Fig. 22.43, A ).

Assessment for rotator cuff inflammation or tear.

A, Neer test. B, Hawkins test.

The Hawkins Kennedy test is performed by abducting the shoulder to 90 degrees, flexing the elbow to 90 degrees, and then internally rotating the arm to its limit. Increased shoulder pain is associated with rotator cuff inflammation or a tear ( Fig. 22.43, B ).

To test the strength of the rotator cuff muscles, perform the following maneuvers. A normal result is indicated by the absence of pain or weakness with the following maneuvers:

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  To assess the supraspinatus muscle of the rotator cuff, have the patient place the arm in 90 degrees of abduction, 30 degrees of forward flexion, and internally rotated (thumbs pointing down). Apply downward pressure on the arm against patient resistance.

  
  
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  To assess the subscapularis muscle, have the patient hold the arm at the side, elbow flexed 90 degrees, and rotate the forearm medially against resistance.

  
  
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  To evaluate the infraspinatus and teres minor muscles, have the patient hold the arm at the side, elbow flexed 90 degrees, and rotate the arm laterally against resistance.

  
  
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  Pain and weakness with opposing force is an unexpected finding and may be associated with inflammation or a tear.

Lower Spine Assessment

The straight leg raising test is used to test for nerve root irritation or lumbar disk herniation most commonly seen at the L4, L5, and S1 levels. Have the patient lie supine with the neck slightly flexed. Ask the patient to raise the leg, keeping the knee extended (see Fig. 22.35, A ). No pain should be felt below the knee with leg raising. Radicular pain below the knee may be associated with disk herniation. Flexion of the knee often eliminates the pain with leg raising. Repeat the procedure on the unaffected leg. Crossover pain in the affected leg with this maneuver is more indicative of sciatic nerve impingements.

The femoral stretch test or hip extension test is used to detect inflammation of the nerve root at the L1, L2, L3, and sometimes L4 level. Have the patient lie prone and extend the hip. No pain is expected. The presence of pain on extension is a positive sign of nerve root irritation ( Fig. 22.44 ).

Femoral stretch test for high lumbar nerve root irritation.

Hip Assessment

The Thomas test is used to detect flexion contractures of the hip that may be masked by excessive lumbar lordosis. Have the patient lie supine; fully extend one leg flat on the examining table and flex the other leg with the knee to the chest. Observe the patient’s ability to keep the extended leg flat on the examining table ( Fig. 22.45 ). Lifting the extended leg off the examining table indicates a hip flexion contracture in the extended leg.

Procedures for examination of the hip with the Thomas test.

Note the elevation of the extended leg off the examining table.

The Trendelenburg test is a maneuver to detect weak hip abductor muscles. Ask the patient to stand and balance first on one foot and then the other. Observing from behind, note any asymmetry or change in the level of the iliac crests. When the iliac crest drops on the side of the lifted leg, this indicates the hip abductor muscles on the weight-bearing side are weak ( Fig. 22.46 ).

Test for the Trendelenburg sign.

Note any asymmetry in the level of the iliac crests with weight bearing.

(From Van Tuijl, 2006).

Knee Assessment

Ballottement is used to determine the presence of an effusion in the knee from excess fluid. With the knee extended, apply downward pressure on the suprapatellar pouch with the web or the thumb and forefinger of one hand, and then push the patella quickly downward against the femur with a finger of your other hand. If an effusion is present, a tapping or clicking will be sensed when the patella is pushed against the femur. Release the pressure against the patella, but keep your finger lightly touching it. If an effusion is present, the patella will float out as if a fluid wave were pushing it ( Fig. 22.47 ).

Procedure for ballottement examination of the knee.

Examination for the bulge sign is also used to determine the presence of excess fluid in the knee. With the patient’s knee extended, milk the medial aspect of the knee upward two or three times, and then milk the lateral side of the patella. Observe for a bulge of returning fluid to the hollow area medial to the patella ( Fig. 22.48 ).

Testing for the Bulge sign in examination of the knee.

A, Milk the medial aspect of the knee two or three times. B, Tap the lateral side of the patella.

The McMurray test is used to detect a torn medial or lateral meniscus. Have the patient lie supine and flex one knee. Position your thumb and fingers on either side of the joint space. Hold the heel with your other hand, fully flexing the knee, and rotate the foot and knee outward (valgus stress) to a lateral position. Extend and then flex the patient’s knee. Any palpable or audible click, pain, or limited extension of the knee is a positive sign of a torn medial meniscus. Repeat the procedure, rotating the foot and knee inward (varus stress) ( Fig. 22.49 ). A palpable or audible click, pain, or lack of extension is a positive sign of a torn lateral meniscus.

Procedure for examination of the knee with the McMurray test.

Knee is flexed after lower leg was rotated to medial position.

The anterior and posterior drawer test is used to identify instability of the anterior and posterior cruciate ligaments. Have the patient lie supine and flex the knee 45 to 90 degrees, placing the foot flat on the table. Place both hands on the lower leg with the thumbs on the ridge of the anterior tibia just distal to the tibial tuberosity. Draw the tibia forward, forcing the tibia to slide forward of the femur. Then push the tibia backward ( Fig. 22.50 ). Anterior or posterior movement of the knee greater than 5 mm in either direction is an unexpected finding.

Examination of the knee with the drawer test for anterior and posterior stability.

The Lachman test is used to evaluate anterior cruciate ligament integrity. With the patient supine, flex the knee 10 to 15 degrees with the heel on the table. Place one hand above the knee to stabilize the femur and place the other hand around the proximal tibia. While stabilizing the femur, pull the tibia anteriorly. Attempt to have the patient relax the hamstring muscles for an optimal test. Increased laxity, greater than 5 mm compared with the uninjured side, indicates injury to the ligament.

The varus (abduction) and valgus (adduction) stress tests are used to identify instability of the lateral and medial collateral ligaments. Have the patient lie supine and extend the knee. Stabilize the femur with one hand and hold the ankle with your other hand. Apply varus force against the ankle (toward the midline) and internal rotation. Excessive laxity is felt as joint opening. Laxity in this position indicates injury to the lateral collateral ligament. Then apply valgus force against the ankle (away from the midline) and external rotation. Laxity in this position indicates injury to the medial collateral ligament ( Fig. 22.51 ). Repeat the movements with the patient’s knee flexed to 30 degrees. No excessive medial or lateral movement of the knee is expected.

Valgus stress test of the knee with knee extended.

Limb Measurement

When a difference in length or circumference of matching extremities is suspected, measure and compare the size of both extremities. Leg length is measured from the anterior superior iliac spine to the medial malleolus of the ankle, crossing the knee on the medial side ( Fig. 22.52, A ). Arm length is measured from the acromion process through the olecranon process to the distal ulnar prominence. The circumference of the extremities is measured in centimeters at the same distance on each limb from a major landmark ( Fig. 22.52, B ). Athletes who use the dominant arm almost exclusively in their activities (e.g., pitchers and tennis players) may have some discrepancy in circumference. For most people, no more than a 1-cm discrepancy in length and circumference between matching extremities should be found.

Measuring limb length (A) and leg circumference (B).

Infants

Genetic and fetal conditions can produce musculoskeletal anomalies. The fetus may experience various postural pressures leading to reduced extension of the extremities and torsions of various bones.

Fully undress the infant and observe the posture and spontaneous generalized movements. Use a warming table when examining a newborn. No localized or generalized muscular twitching is expected. Inspect the back for tufts of hair, dimples, discolorations, cysts, or masses near the spine. A mass near the spine is likely to be a meningocele or myelomeningocele.

From about age 2 months, the infant should be able to lift the head and trunk from the prone position, giving you an indication of forearm strength. Assess the curvature of the spine and the strength of the paravertebral muscles with the infant in a sitting position. Kyphosis of the thoracic and lumbar spine will be apparent in the sitting position until the infant can sit without support ( Fig. 22.53 ).

Kyphosis, expected convex curvature of the newborn’s thoracic and lumbar spine.

Inspect the extremities, noting symmetric flexion of arms and legs. The axillary, gluteal, femoral, and popliteal creases should be symmetric, and the limbs should be freely movable. No unusual proportions or asymmetry of limb length or circumference, constricted annular bands, or other deformities should be noted.

Place the newborn in a fetal position to observe how that may have contributed to any asymmetry of flexion, position, or shape of the extremities. Newborns have some resistance to full extension of the elbows, hips, and knees. Movements should be symmetric.

All infants are flat-footed, and many newborns have a slight varus curvature of the tibias (tibial torsion) or forefoot adduction (metatarsus adductus) from fetal positioning. The midline of the foot may bisect the third and fourth toes, rather than the second and third toes. The forefoot should be flexible, straightening with abduction. It is necessary to follow tibial torsion and metatarsus adductus variations carefully, but it is seldom necessary to intervene. As growth and development take place, the expected body habitus is usually achieved.

The hands should open periodically with the fingers fully extended. Observe the palmar and phalangeal creases on each hand. A single crease extending across the entire palm may be associated with Down syndrome. Count the fingers and toes, noting polydactyly (six or more digits on an extremity) or syndactyly (two or more digits fused together) ( Fig. 22.54 ).

Anomalies of the newborn’s hand.

A, Simian crease. B, Syndactyly. C, Polydactyly. (A,

from Davidson, 2008; B, courtesy Dr. Joseph Imbriglia, Allegheny General Hospital; C, from Chung, 2009.)

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