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Monday, October 31, 2011

Examination of the Extremities and Back

Equipment Needed

None

General Considerations

The patient should be undressed and gowned as needed for this examination.
Some portions of the examination may not be appropriate depending on the clinical situation (performing range of motion on a fractured leg for example).
The musculoskeletal exam is all about anatomy. Think of the underlying anatomy as you obtain the history and examine the patient.
When taking a history for an acute problem always inquire about the mechanism of injury, loss of function, onset of swelling (< 24 hours), and initial treatment.
When taking a history for a chronic problem always inquire about past injuries, past treatments, effect on function, and current symptoms.
The cardinal signs of musculoskeletal disease are pain, redness (erythema), swelling, increased warmth, deformity, and loss of function.
Always begin with inspection, palpation and range of motion, regardless of the region you are examining. Specialized tests are often omitted unless a specific abnormality is suspected. A complete evaluation will include a focused neurologic exam of the effected area.

Regional Considerations

Remember that the clavicle is part of the shoulder. Be sure to include it in your examination. [p468]
The patella is much easier to examine if the leg is extended and relaxed. [p473]
Be sure to palpate over the spinous process of each vertebrae. [p477]
It is always helpful to observe the patient standing and walking.
Always consider referred pain, from the neck or chest to the shoulder, from the back or pelvis to the hip, and from the hip to the knee.
Pain with, or limitation of, rotation is often the first sign of hip disease.
Diagnostic hints based on location of pain:


 

Back

Side

Front

Shoulder Pain

Muscle Spasm

Bursitis or Rotator Cuff

Glenohumeral Joint

Hip Pain

Sciatica

Bursitis

Hip Joint


Inspection

Look for scars, rashes, or other lesions. [p464] [1]
Look for asymmetry, deformity, or atrophy.
Always compare with the other side.

Palpation

Examine each major joint and muscle group in turn.
Identify any areas of tenderness. [2]
Identify any areas of deformity.
Always compare with the other side.

Range of Motion

Start by asking the patient to move through an active range of motion (joints moved by patient). Proceed to passive range of motion (joints moved by examiner) if active range of motion is abnormal.

Active

Ask the patient to move each joint through a full range of motion.
Note the degree and type (pain, weakness, etc.) of any limitations.
Note any increased range of motion or instability.
Always compare with the other side.
Proceed to passive range of motion if abnormalities are found.

Passive

Ask the patient to relax and allow you to support the extremity to be examined. ++ [3]
Gently move each joint through its full range of motion.
Note the degree and type (pain or mechanical) of any limitation. [4]
If increased range of motion is detected, perform special tests for instability as appropriate.
Always compare with the other side.

Specific Joints

Fingers - flexion/extension; abduction/adduction [p466]
Thumb - flexion/extension; abduction/adduction; opposition
Wrist - flexion/extension; radial/ulnar deviation [p467]
Forearm - pronation/supination (function of BOTH elbow and wrist) [p468]
Elbow - flexion/extension
Shoulder - flexion/extension; internal/external rotation; abduction/adduction (2/3 glenohumeral joint, 1/3 scapulo-thoracic) [p468] [5]
Hip - flexion/extension; abduction/adduction; internal/external rotation [p474]
Knee - flexion/extension [p473]
Ankle - flexion (plantarflexion)/extension (dorsiflexion) [p470]
Foot - inversion/eversion [p469]
Toes - flexion/extension
Spine - flexion/extension; right/left bending; right/left rotation [p466, p477]

Vascular

Pulses

Check the radial pulses on both sides. If the radial pulse is absent or weak, check the brachial pulses. [p433]
Check the posterior tibial and dorsalis pedis pulses on both sides. If these pulses are absent or weak, check the popliteal and femoral pulses. [p435]

Capillary Refill

Press down firmly on the patient's finger or toe nail so it blanches. ++
Release the pressure and observe how long it takes the nail bed to "pink" up.
Capillary refill times greater than 2 to 3 seconds suggest peripheral vascular disease, arterial blockage, heart failure, or shock.

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