Ortho

Tue 08-10-02

• Clavicle
• Acromion process
• Acromioclavicular joint
• Humeral head
• Sternum
• Coracoid
• Spine of scapula

• Articulation: humeral head and glenoid cavity of scapula, glenoid cavity deepened by fibrocartilaginous rim: glenoid labrum.
• Type: ball and socket joint
• Wide range: Abd, Add, F, E, IR, ER, circumduction
• AC jt and SC jt: synovial plane joint, gliding movement,
• Scapular rotation: every 3^o of abduction: 2^o in G-H joint, 1 ^o by scapular rotation. At 120^o abduction, the greater tuberosity hits the acromion, Abd by rotation of scapula.
• Rotator cuff: stability of joint depends on tone of short muscles: Subscapularis, Supraspinatus, Infraspinatus, Teres minor; during abduction, long head of triceps.
• Muscle action around the shoulder.

1. Flexion: ant. deltoid, pectoris. major, biceps, coracobrachialis
2. Extension: post deltoid, L dorsi, teres major
3. Abduction: mid-deltoid, supraspinatus (initiation); >120^o: serratus anterior and trapezius.
4. Adduction: pect major, L dorsi, teres major, teres minor
5. Ext rotation: infraspinatus, teres minor, post deltoid.
6. Int. rotation: subscapularis, L dorsi, teres major, pect. major, deltoid.
7. Circumduction: combination.
8. Protraction: serratus anterior
9. Retraction: rhomboid major and minor

• Referred from neck, mediastinum, diaphragm. True shoulder pain or pain is felt over deltoid muscle, radiating down the arm. Pain on top of the shoulder suggests acromioclavicular joint dysfunction. Pain in the supraclavicular region is usually referred from the cervical spine; rotator cuff impingement.

• Deformity: e.g. prominence of the acromioclavicular joint or winging of the scapula
• Loss of function: inability to reach behind the back and difficulty with combing the hair or dressing

• Include upper limb, cervical spine

• Front and from behind: both upper limbs, the neck and the chest must be visible
• Skin: scars, sinuses, axilla
• Shape: asymmetry of the shoulders, winging of scapula, wasting of the deltoid, short rotators; joint swelling or wasting, pectoral muscles, joint effusion may ‘point’ in the axilla; acromioclavicular dislocation seen from behind;
• Compare the two sides for swelling
• Acromioclavicular joint, sternoclavicular joint.
• Wasting of the deltoid suggests a nerve lesion, (wasting of supraspinatus indicate either a full-thickness tear or a suprascapular nerve lesion.
• Position : position of arm, abnormal in dislocation, internally rotated in brachial plexus injury

• Skin
• Soft tissues, bony points
• Start from sternoclavicular joint, then follow the clavicle laterally to the acromioclavicular joint onto the anterior edge of the acromion and around the acromion to the back of the joint.
• With the shoulder held in extension, the supraspinatus tendon can be pinpointed just under the anterior edge of the acromion; below this, the bony prominence bounding the bicipital groove is easily felt, especially if the arm is gently rotated so that the hard ridge slips medially and laterally under the palpating fingers. Tenderness and crepitus can often be accurately localised to a particular structure.

• Active movements
• Observed first from in front and then from behind, with the patient either standing or sitting. Sideways elevation of the arms normally occurs in the plane of the scapula - i.e. about halfway between the coronal and sagittal planes - with the arm rising through an arc of 180 degrees.
• Abduction: early phase of movement takes place almost entirely at the glenohumeral joint, but as the arm rises, the scapula begins to rotate on the thorax and in the last 60 degrees of abduction, movement is almost entirely scapulothoracic. Rhythmic transition is disturbed by disorders in the joint or by dysfunction of the stabilising tendons around the joint
• Abduction may be (1) difficult to initiate, (2) diminished in range or (3) altered in rhythm, scapula moving too early and creating a shrugging effect. When movement is painful, the arc of pain must be noted; pain in the mid-range of abduction suggests a minor rotator cuff tear or supraspinatus tendinitis or subacromial bursitis; pain at the end of abduction is often due to acromioclavicular arthritis.
• Adduction: Arm across the front of his body. Rotation is tested: first, with the arms close to the body and the elbows flexed to 90^o, the hands are separated as widely as possible across the body (external rotation); then the patient is asked to clasp his fingers behind his neck (external rotation in abduction); then to reach up his back with his fingers (internal rotation in adduction).
• Flexion and extension
• Internal rotation & external rotation
• Passive movements
• Even with a stiff shoulder, the arm can be raised to 90 degrees by scapulothoracic movement. Scapula must first be anchored; examiner pressing firmly down on the top of the shoulder with one hand while the other hand moves the patient’s arm
• Glenohumeral joint abduction: stabilise scapula with one hand pressing firmly on acromium, the other hand moves patient’s arm.

• Deltoid: abducts against resistance
• Serratus anterior: push forcefully against a wall with both hands.
• Pectoralis major is tested by having the patient thrust both hands firmly into the waist.
• Arm abducted to right angle, int rotation can be assessed without the trunk getting in the way.

Other joints as indicated

Cervical spine

Generalised joint laxity

• Medial epicondyle, lateral epicondyle, olecranon
• Radial head: (felt to rotate during pronation and supination), ulnar nerve
• Elbow extended: 3 landmarks lie on same straight line
• Elbow flexed: 3 landmarks form the boundaries of equilateral triangle., cubital fossa (boundaries: pronator teres, brachioradialis, brachialis, supinator), basilic vein, medial cubital vein
• Radial head: felt to rotate during pronation + supination
• Ulnar nerve
• Articulation: between trochlea/capitulum and trochlear notch of ulna/radial head
• Type: synovial hinge joint. spherical hollow of radial head to fit capitulum
• Flexion: limited by anterior surface of forearm and arm coming into contact by (brachialis, biceps, brachioradialis pronator teres). 0^o/140^o
• Extension: tension by anterior ligament and brachialis muscle (by triceps, ancoeus) -10^o / 0^o
• Carrying angle: M 10^o , F 13^o (disappears with elbow flexion)
• Long axis of extended forearm lies at an angle to long axis of arm.
• Superior radioulnar joint:
• Articulation: circumference of head of radius, annular ligament and radial notch on ulna.
• Type: synovial pivot joint
• Pronation and supination: rotatory movement around a vertical axis at PRUJ and DRUJ; axis: radial head to ulnar styloid.
• Pronation: pronator teres and quadratus (90^o )
• Supination: bicep and supinator, supinator more powerful. (90^o)
• Movements of radio-humeral joint: gliding during pronation and supination

• Pain: localised to the medial or lateral condyle is usually due to tendinitis. Pain arising in the joint is more diffuse, referred pain form the cervical spine.
• Stiffness: reach up to the mouth (loss of flexion) perineum (loss of extension); limited supination makes it difficult to carry large objects.
• Swelling: due to injury or inflammation; a soft lump on the back of the elbow suggests an olecranon bursitis
• Instability: RA
• Ulnar nerve symptoms: tingling, numbness and weakness of the hand

• Both upper limbs must be completely exposed. The patient holds his arms alongside his body with palms forwards. Varus or valgus deformity when elbow extends fully. He then holds his arms out sideways at right angles to the body with palms upwards and elbows straight. In this position, wasting or lumps are easily seen.

• Back of the joint is palpated for warmth, subcutaneous nodules, synovial thickening and fluid, (fluctuation on each side of the olecranon), bony prominences; tenderness and to determine whether the bony points are correctly placed.
• The joint line can be located laterally by feeling for the head of the radius (pronating and supinating the forearm makes this easier), but medially it is difficult to find.
• Ulnar nerve rolled under the fingers to feel if it is thickened or hypersensitive.

• Dorsiflex, palmarflex, ulnar deviation, radial deviation
• Distal RU joint: between sigmoid notch + ulnar end
• Pronation + supination together with proximal RU joint

• Radial border: APL, EPB tendon
• Ulnar border: EPL tendon at level of Lister tubercle.
• Floor: radial styloid, scaphoid, trapesium, base of 1st MC. Radial artery, cephalic vein
• Movement: DF, PF, RD, UD., P&S
• DRUJ: sigmoid notch and ulnar end.
• Transverse creases:
• Proximal - at level of wrist joint.
• distal - proximal border of flexor retinaculum
• Action of long extensors (EDC, EI, EDM):
• MPJ extension of fingers, assist intrinsics to extend PIPJ and DIPJ
• EPL: extension of IPJ of thumb
• EPB: extension of MPJ of thumb
• Long flexors:
• FDS - PIPJ flexion
• FDP - DIPJ flexion
• Intrinsics: include:
• DI, PI, thenar, hypothenar, lumbricals :4 lumbricals arise from tendon of FDP in palm, insert into radial aspect of corresponding extensor expansion (median 2 supplied by median N, 3^rd and 4^th supplied by ulnar nerve
• PI: arises from ulnar side of anterior side of MC 1245
• Action: MP flexion and IP extension (through central slip and lateral bands)
• Supination/ pronation: 2/3 distal RU jt, 1/3 proximal RU jt

Hand is the functional tool - arm is there to place the hand

• Pain: palm, finger joints, neck, shoulder, or mediastinum
• Deformity
• Swelling (1) Many joint simultaneously and proximal joints - RA (1) Distal joints = OA
• Loss of function: handling eating utensils, holding a cup or glass, grasping a doorknob, dressing or personal hygiene
• Sensory change and motor weakness
• Dominant hand (85% of people R-handed)

• Both upper limbs should be bared

• Skin scarred, altered in colour, dry or moist hairy or smooth; Wasting and deformity presence of any lumps, resting posture, swelling, nails

• Temperature and texture of the skin, pulse, nodule underlying tendon should be moved to discover if it is attached; Swelling or thickening may be in the subcutaneous tissue, tendon sheath, a joint or one of the bones; Tenderness should be accurately localised to one of these structures.

• Rapid assessment: most cases, then see if detailed exam required
• Basic movements: opening, extension, CMCJ, MPJ, IPJ, closing (fisting), flex all joints
• Active movements:
• Fisting and opening is a global assessment of long flexors and extensors; look for ‘lagging finger’ Individual movements are then examined first at the metacarpophalangeal joints and each interphalangeal joint in turn; patient is asked to touch the tip of each finger with the tip of the thumb. (opposition)
• Test of intrinsic muscles (interossei, thenar, hypothenar, lumbricals)
• finger abduction and abduction
• thenar and hypothenar action opposition
• MPJ flexion + IPJ extension (combined movement of intrinsic muscles)
• Finger flexion: flexor digitorum superficialis/ profundus/ sublimis (hold 2,4,5^th fingers straight and flex 3^rd DIPJ)
• Passive range of movement:
• Grip strength: squeeze the examiner’s finger; diminished because of muscle weakness, finger stiffness or wrist instability. (instrument: Jammer)
• Pinch grip: try to break Pt's pinch grip
• Neurological assessment. If numbness, tingling or weakness exist full neurological examination of the upper limbs should be carried out, testing power reflexes and sensation two-point discrimination, heat, and cold, stereognosis and 2PD.
• Functional tests: holding a pencil, turning a key, picking up a pin, gripping a small-handled tool and holding a glass.
• Rapid assessment : most cases a rapid assessment can be carried out, and this will indicate whether a more detailed examination is required