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I
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i
ATLS OF
r h I C i (
Exaian f teCricral Js
Many students learn the details of skeeta anatomy bt ten nd it dicult to reate
that knowledge to rea uman bengs when they present for clinica examnaton
and assessment. Ths atas aims to the nfomation gap between descrptive
and papato anatomy and to elp the stdent make the nk between the two.
It addresses the cnca appeaance of noma tissues and thei function, andprovides gudance on how to examne and assess nomal joints.
Key features
ntroduces te basics of cncal emnation
Provdes step-bystep gudance to te cnca assessment of the periphea
jon and ter associated tssues and stuctues
Details the examnation of te mao oints of the body one by one:
Souder/Ebow/Wist/Hip/Knee/Foot and descbes the nomal ndings
n heathy ndviduas
Emphaszes the mportance of performing dagnostc movements corectly
Addresses te common mistakes in examnaton techniques and expains
where peope go wrong
Profusey ustrated with hgh quali photogaphs and diagams
Text desgn ensures that the ustatons appear close to the elevant text
Ths o Ohopdic xminon o h Piphl/oin wl provide an
nvaluable souce of efeence fo medca students and membes of all heat
care pofessons concerned wth the anagement of oopedic problems
W. B SAUNDERS9 780702 021244
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l Ex l J
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I1stratio by: Kei Ma
F W. 8 Sa"nd
Editial Diet, Heath Science Ma awHad f Prje Mngement wa Ha
et Devepment Mage Dah hoSei Deige Juh W
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Atlas of Orhopedic
Examination of thePeiphea Joints
Ludwig Ombregt MDMedical Practitoner n Orthopedic Medcne. Kanegem Begu;Intenatona Lecre n Ohopedc Medce
Pierre Bisschopysoteapst speciaizing n Orthopedic Medicine, Knesseae Begnteationa ectue in Oopedc Medcne
W. B AUNDEREdnbugh ondon New Yok Phiadephia ouis Sydney Toono
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w. B SAUNDERSAn imprint of Harcourt Bace and Company imited
Hacour Brace and Company imited
Al igh ed No pat of ths publicaion may repoucd, tored in a erieva yem, o ranmitedin any fom o by any mean elecronic mechanicalpotoopyin ecoding or oterwi, withou ete epro prmiion of te puble (Hacou Bace andCompany Limited 2-2 Ova Road, ondon WI X)or a icence pemng etied copying in e ntedKngdom iued by e Copyright ienng Ageny90 Totenam Cout Road, London W P Ol
Fr pubihed
SB 72 224
bay taogung n ubton ataA caaogue recod for ti bk i avaiabe from he Britihibray
by of ongress togng in ubcon aaA caalog cod for thi bk i aaiabe from the brayof Cong
NoteMedica nowledge i conany changing newnfomaon becme avaiabe, ang in reatmen,p qpm and h of rug omeneceay e autho and e pubiher have, a fa a it poble aen care o enue tat the infomaton given in
thi text accurate and up-to-date However, reader arerongy adved o conf a e nfoation, epeiallywth regard to drg uage, ompe wth the latetlegiation and tandard of patice
Pned i n Chna
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Contents
Pa ii
Ioduo ix
1. Sod 1
2 Eow
3. Ws
4 Hp 6
5 K 81
6 A ad oo
d 11
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Preface
s ausp was dvlopd as a aual o
da ad psoap suds s puposs o l sg oao ad aggap w dspv aao ad paolog o ppal jos
Dug ou ouss oopd dw a alos dal ood posgaduasuds (o psoapss ad doos)wo do o av paal kowldg opogap,sua ad uoa aao Dsp a a a lal sklls sa w a ud
sadg o oal sd o lalappaa o oa ssus ad avou dug aual aao ss o agossl gld aa o dal duao
s ook ssal addsss lalappaa o oa ssus ad uo,ad povds guda o aao adassss o oa jos W od ousvs o a dsusso o os poa ssusd oopd d a lavlspl o po ad av a ga s
al s ss (av,passv ad ssdovs) a apd oopd d, psoap ad aua ap as as ss o a good lal valuao o j uso s ook ouss o pa uo o ovs Mu oou g w av o olud a poolodud ss o gv o oaoad o lad o aua dagoss Wlv a ou ag p a o
ga lp o ad ad o w av
lsd os suds os ul ak
so o 'oo saksA sall so o oo paologal
suaos olows a dsusso o aluo o s, ad dgs oalsujs s so oud ousg a dsd s s o a o dagos podu o d odo Alal dag dos o l o ouo oo sgl s u s ad o paoo a lal pa ( od ouo o a
s o la ss) pao o paologal dgs ad udg up o lapas s o w sop o s ook sd ad s d o ou lal ook Sysm of Oopc Mcpulsd Sauds 1995 I s wok, apaologal odos ad osvavas a dsussd oougl
ckowledgemens
W would lk o ak ollagus wo aas o Oopad Md aoa(MI) ad wo povdd sga lp Wa paulal gau o E Baa,
a Maual ap a Uvo Busss, wo ad as a ll advs,povdg o ps ad osuvs
ollowg gus av ak o
Og,Bssop P, V H Va d Vld
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v REFCE
1995 A system of orhopaedc medcne W BSuders odo: 18-116, 118-134; 21 23,24 28-212, 214-216 219-221 224-235 33,34 36, 310, 31 315, 316 318, 323 324,327-360; 45,411,43,414,41642042232
435436; 56-51,5.14,518 521543, 54555065 612616 6.18, 620 62443
KegemTel1999 Ldwg OmbregPerre Bsschop
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Inroducion
The pupose o eamaon and / o esng po
cedues ohopedc medcne s o eamne hec/o o he dee ssues o he movgpas The echques ae ased o he pncpleo 'elecve eso'
Each ssue o he ody has s pacuaucon I acs ehe as a solaed sucueo as pa o a goup o sucues Fucodes,depedg on whehe a ssue s u omake ohe ssues move (musculoedoussucues), o cool ange o movemen
capsuogamenous sucues), o aclaemoveme (usae) o o acvae movemeneve sucues)
The musculoendnous un has he heecapaly o coac s a 'coace ssue'wheeas a he ohe sucues do o possesshs capaly hey ae 'e' Conacesuces can e esed (= pu unde eso)y povong a mamal somec coaconIe sucues ae esed y pung hem udemama sech.
ctve movemets
A acve moveme s peomed as a as may go I does o ollow he pcple oesng y selecve eson: a lo o sucuesae pu ude sess The eamne o oy gesa dea o he ple age o moo n hejon omal, med o ecessve), he s alsonomed aou he egy o he musculo
endous appaaus
Passve movemets
A passve movemen ngs a jon o he ed ohe nomal age The omal amplude desom he heoecal ange o moo Aculasuaces aow a cea amou o movemen,u he moveme s usualy sopped as a esuo eso n he capsulogameous sucesThe moveme heeoe no oly noms heeamne aou he noma ange, u also aouhe sucues ha sop he moveme omgog uhe Ths happe y assessng he
endeel o a moveme whch ca e eheelasc capsula), had (ony o gamenous) oso (ssue appomaon)
Passve movemens ae good ess o eamehe ne sucues ad gve an aswe o heollowg quesos:
a Does he ne suce uncon nomaly? Ino, pa may e elced and / o he agemay have dmnshed
oes allow a omal ange o moo Ino, he edee wll have chaged
Fom he echnca pon o vew he eameshould poson hm o hese n such a way hahe moveme can e eecued ove he eneple age o moo and ca e ougho he end o he age n ode o es he endeel I may e ecessay o ae he sujecsody o pa o he suec's lm n ode oavod paasay movemens ha would gve se
o an coec answe
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x NRODUCO
Resisted movemens
A essed moveme s me o es hemusu ssue o I sould e eeued some w hee hodg e o
e eul poso: s pus s o heoe ssue u eves he e suuesueded The es ves e musleso musle goups ( dee musles w hesme uo) I oms he eme oue om segh o e oo
Ressed movemes es he ole suue: he whole o he musle ell e musuloedous juo he od o e edo de seo oo e oe Whe leso oe o hese ps s pese he oo wll
esu p wh o whou wekess Dmuo o segh s e esul o ehe upue oo poem wh e evou ssem vge musle
The eme should poso hm o hesel suh w he o she s soge h hesuje he ol w o eeue he movemes
some w The jo s oug ohe eul poso lowg e e ssueso el d he suje s sked o peom oo wh mm seg The emeesss e moveme hee o lowg
u moveme ll He o se heeoepus hs o he hds suh w h oe hdees pessue whle he ohe gves ouepessue
Te oeess o he eh eeuo o heess guees he oeess o he swe
Futher eading
Diel igh 99 Mcle eg ueLd
pji I 7 pyigy f he j v hl Lvge Ebgh
Ombeg L Bh P, Vee H V de Vede 15 Ayem f hpe meie ue L
ety } Mre A P 998 Nemuelelemi eme: hdb f heh Lvge Edbgh
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CAPTER CONNTS
Sua and palpatoy anaomy 1Bny lndm Pltn fsf t 3
Funciona examinaon of he shouer 8Atv tt
Atv lvtn Pv tt Pv lvtn Psv xl ttn Psv xl ttn wt th dr n
dtn Pssv ntrn ttn Pv lnrl dctn
Imt cntcn Rtd ddtn Rtd dtn Rtd x rttn Rtd ntrnl rttn Rtd x th lw 5
Rtd xtnn f t lw S tt Pv ntl ddtn Ahnn tt n xt tn Ahnn tt n nt ttn Ant dwr tt 9Ptr dwr tt 9
Shoulder
SURFACE AND PAPATORYANAOMY
e shuder is inextricl und up with theshulder girdle, nteril vi the clvicle ndt the psterir spect vi the scpu. hese twn structures re esil detectle ndmrkst strt the plptn f the shuder structures
Bony landmarks
Anterolatea (Figs 1 nd he clvicle A is the mst prminent nend is esil detectle ecuse t lies sucutneusl. Its medil prt is cnvex nd te lterthird is cncve Its medil end sternl end isubus nd rticultes with te sternum
e terl end is fttened nd rticultes wth
Fg. 1 Antr vw th hl (n vv
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ATLAS OF ORTHOPEDI EXAAIO
g eio view o he shoule (skeeo)
the scpul's crmin (B whic cn be recgni s flt bn vring h sulr jintPlpte he nterir spect f the cvice ncntinu furtr ltr unti h crmi nC is flt Just trl it smll inentinis ppble befre e cler nerir brer f
the crmin is reche his inentin is hentrir n f he crmiclviculr jin. Bmving th ppting fngr n p f th shulrth crmil n f t clvicl cn b f lieslightl iger tn te crmin When thefingr is in cnct with h tw bns thecvicle n he crmn it ies n the crmicvicur jint f whic h uppr pr f hcpsul is rinfrc wih t suprir crmicvicur igment
n e infrclviculr fss jus belw hecncve erl prt f te clvic bn prmi
nnc cn b ft his is th scpuls crciprcess (D, f which nl t tip n te melsurfce re plpbl frm he pints frigin fr th shrt h f h bicps brchiimuscle n fr th crcbrchiis musclrspctivl
Plc t fingr n he crci prcss n g1 cm wn Nw mve th finger lter unti shrp bn strucure is reche his is te esserubersit f he he f the umerus Ppehis bn n fl fr its ltrl brr hmi lip f th interubrcur sulcus
Just lerl t tis brer lis t bicipitgrv tht cntins he ng he f te bicepshis inerubercur sulcus is plpbe wih he
thumb plce flt n it n uring rtr mvmns f h umerus efin t bicipitgrv, use he subjec's frrm s lever nrte the umerus er unt he mei ipf the sulcus its h thumb hen rt th rmmi unti h tr ip ctcs h humb
At he lterl spect f t sulcus greertubrc cn b plp his is h grrubersit ( When mving th pping fingerupwrs eprssin cn be flt bfr th
lrl brr f t crmin is rch
Posolaal (Figs 3 n 4)
h scpul (A is th ms imprtn bn th psrir si f he thrx It hs vprminent spine (B h is es t ppte el
D
g .3 Vew o he sholder fom above
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Fg. oeroaeral vew o e oler elo
r th pstrr margin th spin and llwthis urthr latray whr it cms mrprminnt h spn can t t mak a 90rwards turn th acrmia ang C - r itrms th acrmin (D) gthr wth th acrmial n th clavicl and th cracacrmaligamnt it rms th cracacrmal r
h spin divids th scapua int a supraspinus ssa E) and an inraspinus ssa (,in which li, rspctvy th supraspinatus andth nraspinatus musc llis
Pac th suct sitting with th arm in 90aductin and papat in th supraspnus ssain a latra dirctin h spin th scapula ist t mt th clavicl At this pint lis thpstrir aspct th acrmclavicular jnt (G)
(Fg. 15. Plac th thum at this pnt and papat smultanusy r th antrir indntatn
SHOULDER
g .5 Papaio of e upapou foa (ode nabduco
twn th clavicl and acrmin h acrmiclavicular jint li jins ths tw pints
Palpatio of soft ssue
Palpaion of he delod muscle
h dltid musc is asy t rcgni trms th mst imprtant muscuar mass thshudr and is rspnsl r its rund k(Fg 16 h antrir prtin (A) vrlis thantrir rdr th acrmin and th lssrrsity h midd prtn (B lis vr thlatral rdr th acrmn and th gratrtursity and th pstrir prtin (C uildsth pstrir aspct th shuldr and cvrsth atra part th spin th scapula
c
g. aeral vew of e oler n vvo
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4 ATAS OF OOPIC XAMINAON
Flg. 1. Vew o e deoid musce coaco)
Ask th subct to abdct th arm agaistrsistac A groov (D) (Fig 17) ca b palpatdbtw th atrior ad middl portios of thdltoid This ovrlis th bicipital groov
Plpion of he suprspius muscle
Musl by an musulonnous junon Thsubct sits with th arm i full abdctio adrstd o th couch Th lbow ow is o thsam lv as th shouldr Th xamir stadsbhid th sbjct h trapzius muscl is wllrlaxd ad palpatio ca b prformd throughthat muscl Palpat for th spi of th scapulaTh muscl by yig just abov th spi of thscapula is th spraspiatus muscl It fills up thsupraspious fossa Mov th papatig figrmor latraly uti it rachs th corr formdbtw th clavicl ad th spi of th scapulaTh figr ow s o th muscuotdious
uctio of th supraspiatus which ca b flt tocotiu latrally udr th acromio Fig. .8)
Inson on h rar urosy Now positioth subjct with th forarm bhid th back. Tharm is ow i ful itral rotatio alpat forth latral bordr of th acromio follow it i thatrior dirctio util th corr is ft btwth latra ad atrior bordr ad idtify thlattr Also look for th acromioclavicuar joitad kp th papatig figr atra to it Movth figr forwards so that it coms to o th
Fg. 18 Palaio of he msuoedios jtio o espaspatus
gratr tubrosi of th humrus but is sti icotact with th acromio as wll Exrt a prssr vrtically dowwards agaist th humrsTh figr ow is o th supraspiatus tdoof which th mdia bordr ca b ft quitclary (Fig 19)
Papaton of h nfraspaus mus Fig 1.1Th sbjct is i pro lyig ad rsts o th
bows Th uppr arm should b kpt vrticaad i slight adductio. Th subjct thrforlas towards th shouldr to b palpatd Withth had h grasps th dg of th couch Thisrsts i som xtral rotatio of th shouldras wl Th xamir looks for th spi of thscapula ad papats blow it i th ifraspiousfossa Th thumb ow lis o th ifraspiausmuscl blly Plac th thumb just udr thspi of scapula ad palpat mor ad morlatrally A tdo will b flt that rus parallto this spi. This is th ifraspiats tdo.
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Fg 1.9 alatio o e eoeoseal ucio o esuraspiatus
I ca b wd uil h aachm hga ubiy i fud Th b ca b flhugh h diu ma alpa m laaly uil h humb li h ga ubiyTh diu ucu ca b f ay m.Cm back pviu pi wh bb ad d a f Ti i h
apaon of he subscapuas endon
h ubcapula mucl blly ca ly bachd by bgig h had i bw h
SHOULDER
g .10 alpatio of e eoeiosea uco o tifaspatus
capula ad a I ca aly bpalpad Th diu ii h lubiy wv ca aiy b palpad
Th ubjc i i a half lyig pii a
cuch h upp am alg h bdy ad hlbw fld 90 h xami gap h
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6 TS O OROD XIO
g 11 ushi the teds f the sh head bcesad f rarahals ediay
subjt's had ad bigs th should ito afw dgs tal otatio Pla th thumbof th oth had o th lss tubosiy of thhumrus. t ow is o th istio of thsubsapulais tdo Th otat is ot ditbaus th istio is paty ovd by o tho had th tdos of th shot had of th
bips ad of th oaobahialis both uigtowads th oaod poss ad o th othhad th atio potio of th dltoid muslruig th dtio of th aromio Tuth thumb so that ts tip lis i th dtio ofth xiphid poss of th stum (Fig. 1.1).
Push th musula mass fowads l ththumb ad om bak towads th ss ubosiy h two tdos a b lt sappig away.Thy ow li mdially to th thumb At th sam
tim dltoid fibs hav b daw idwaysad li latay to th thumb whih ow is idit otat with th subsapulais istio(Fgs 11 ad 1.13)
Papaton of e ong ead of bicep (Fg 1.14)
a th fig i th goov btw th atio ad middl potios of th dtoid musl.Mov th fig atioly ad distaly It owis o th biipta goov whih is stuatd
mo latally tha is usually supposd
g 1 alpati f the subscauas (upper pat)
2
3
Fg. 13 tei vew f he shde: 1t lei ise the bces; 2 a , iceps e; se f thesscauais sce
dtify th itubula sulus by plaigth thumb flat o it ad by utig smallotatoy movmts of th humrus Th latalad mdial lips a b flt athig agaist ththumb I this goov is th tdo of th loghad of bips It is diffiult to palpat as it isovd with a tasvs ligamt. Mov ththumb upwads utl th upp pat of th goov
is ahd ust bow th aomio Ask fo
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114 alpaio o e o ead o bces i e sus
n civ fxin f h lbw d ri hmvmn Tighig f h d c b fl
apaon o he peoas majo muse(Fig 1)
h lrl pc f h pcrli mjr muclfrm h nrir brdr f h xill whri infrir brdr c b ppd vry wlpciy during rid dduci f h rm
h nd ir h cr f h grrbry ju blw h lrl brdr f hbicipl c
apaon o he assmus dos muse(Fig 16)
Th r pc f h im dr muclbd h prir brdr f h xi I fl crc during rid ddcin f h rm
inrin i rrly h cr f hr briy
SHOULDER 7
F 1.15 apaio of he muscle be o e ecoralsmajor
F. 16 alpaio o e aar pa o he aissis os.
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8 TS O OTHOPDI XNTION
g 17 eror vew of e aia
Palpaion o e axilla
Bring the subjets arm into 90 abdution. Askhim to press the arm downwards and resist thismoement During palpation in the anteroposterior diretion the following strutures anbe identified (Fig 117): petoralis major (A),forming the anterior border of the ailla, thetendon of the short head of bieps (B), the orao
brahiais musle C and the atissimus dorsiD), orming the posterior border
FUNCTONAL EXAMINATION OF THESHOUDER
Inroucion/general remarks
Shouder lesions gie rise to pain felt mostly inthe proimal part of the upper imb The shoulder
eamination is therefore ommonly used inth dignosis o pp m pain Howe theeaminer shoud realize that symptoms in theregion of the shouder an also originate fromthe eria spine, the upper thorai spneand the shouder grdle The eamination of theshouder is to be onsidered as an element in thediagnosti proedures for lesions of the upperquadrant
ACTVE TEST
Acive eevaion
POSo he subjet stands wth the armshangng aongside the body he eaminer standsbehind.
Prour. Ask the subet to bring up both armsideways as high as possible (ig 118)
Commo msaks:
The moement s not performed to the eryend of the possible range
The arms are brought up in a sagitta pane The arms are kept in internal rotation, whih
makes fu moement impibe.
Nomal foal aaomy
/ 180 Ss d Many strutures are
ommitted The moement is started by thesupraspinatus musle and ontinued by the
118 tive eevao of he am
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mile prti te elti a by the lgea biceps Rtati the scapla s emay by the serrats aterir mscle,spprte by te trapezs mscle, especially
twars the e rage The memet alsstretces a/ r sqeezes seera strctressc as the capsle the glehmera jitthe sbet brsa a the sterclaicara acrmcaicar gamets
M Ths a ery speciic test wichs almst always istrbe whe a sher rher girle pathlgy is preset It as gies
a iea te patiet's wiigess t cperatePai at mirage may iicate a strctre
betee the hmeral hea a the cracacraarc eiter e the tes spraspiats,raspiats, sbscaplaris, g hea bceps,
r the sbacrmial brsa r ierir acrmiaicar gamet - beig pay pche
Te patet te ais pa mpgemet byag a aterr cmpet er part thememet
Lmtati wit r wtht pai ccrs iser artritis r arthrsis certai extra
apsar esis a sm ergical cis casig weakess the shler eeatrs
PASSI TSTS
Passve eevaon
POSo The sbct stas wth the armshagig agsie te by The examer
tas beh the sbect a taes l thebw at the ista part the pper arm
Poc Tae te arm p seways therta pae as ar as pssibe Allw sme exera rtat abt 90 abct. Reachighe e rage ge cterpressre wit the
ter a at the sbject's ppste slerFig 9)
Common msts
Whe the arm is graspe stally t tesbject elbw, elbw memet preets
assessmet eee The arm s t awe t extealy rtate
g19 asse eea e am
HULE 9
The memet s stppe bere the e
te pssble rage is reace At the e rage te arm is tae
backwars i a sagitta plae sicet cterpressre reslts i te
sbject ielexig the by.
Norml nco tomy:
Ralge: 80 Ede elastic Limitilg structurs:
- the axillary part the jit capsle- stretchig the acrmiaiar asterclaclar igamets
- the actrs a iteral rtatrs tesler
- ctact betwee the lesser tbersty thehmers a the pper part the gleilabrm
Common ptholocl sutons he eet c be pai i sbet
brsis i rtatr c teiitis, as welas i acrmaclar lesis
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1 AAS O OROPDC XAMATIO
Lmtion ours n rthrtis nd thosis ofthe shouder nd in serious etrpsuonditions
Passive exernal otaonPostonn he subet stnds with the perm ongside the od nd the eow fleed to ght ngle he emner stnds leve with thesubets rm nd stbiizes the elbow with histunk One hnd is pled on the ontrltershoulde to stbilize the shouder gde ndtrunk; the other tkes hold of the dist forerm.
Por Rotte the rm outwrds menwhe
ssuring the vertl position of the hmeusuntil the movement omes to n elsti sto(g 1
Common msts
he shouder gidle is not well enough fiedso tht tunk movement is llowed to hpen
he elbow s not we stbiized so thtshoulde bduton or etension ors
he movement is not eformed to the end ofthe ossibe nge.
g 0 asse eera roao e o eeomera joi
ormlunton ntomy
o Rag Edleei: esti LmHg c:
the nteio portion of the oint sule- the intern ottor muses of the shoude- ontt eween te gete tuerosit o
the humeus nd the posterio pt of theglenod rum
Common ptolol stuons
Pin on u ssve eternl rottion is one ofthe first signs of shoude rthtis Etenrottion lso stethes the romioviulligments nd the subspris tendon nd
sueezes the subdeltoid urs solted iton os n ontre of te
nterior sue nd n soroid ursits he movement is mred mited s rt of
sulr ttern of limittion of movementn moderte or moe dvned rthtisepending on the ondton being eitherute o honi the endfeel will be either ofmuse spsm or hd
Eessive rnge m indite shoudeinstbilit.
Passive exernal rotaion wh teshouder n 90 abduction
Postonn he subet stnds with the mhnging longsde the bod nd the eow eedto . he eminer stnds leve wth the subet's rm he ontrtel hnd tes hold ofthe eow nd bings the rm into 9 of bdution. he other hnd gss the dist foerm
Pod Put the shoulder into ete rottion menwhile stzng the ebow Fg 2)
Common mstks. f the movement is too nfuthe ptient will move the od bkwrds
Norm fnonl nomy
Rg: d-J elsti
mng rr: the nterior prt of the ont psule
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g. .2 Pive oriot eterl otto
he ddutrs nd inern rttrs f the
shuder
Common atologa statons
he mement is mited in rhris ndrhrsis f the shulder nd s in isledntrture f the nterir r f the jintsule.
Eesse memen my resent inshude instty
Passve nernal oaonPostog he suje stnds wth the uerrm ngside he bdy nd the ew lexed t righ ngle he exminer stnds leel withthe sujets rm nd stiizes the ew withhis trunk One hnd is led n the siteshuder t sze the shulder girdle ndrunk he ther tkes hld f the disl frerm
Pror Bring the sujes frerm ehind her
k nd me her hnd wy frm her dy sfr s ssile (ig. .
HL
g. .22 ive tel rotto tet for teleohue oit
Commo mstaks
The shulder is hed n muh dun he ew is uled kwrds whih rees
n extensin f the shuder insted finern rtn
he hnd is med uwrds insted fkwrds
ormal ntonal anatomy
g 9 d: esti Lmng r
- he serir r f the jint sule
- the exernl rttr musles f the shuder- ntt between the esser uersity f he
humerus nd he nterr rt f heglenid lrum f he su.
Commo pathoogal statons
Pin t the end f rnge my ur in lesinsf the nfrsntus nd sursntustendns, nd ls f the rmiliulrligments
n t mdrnge my ur in rtr uffendinis r n surmil ursis
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ATLA F THPEIC EXAIATI
Mr r l itati i u a pat acapuar patr ita t irat an r arthi
ci rag ay iicat hulritaility
Passive genomeral abdcion
Posonn Th ujct ta with th upprar algi th y Th air ta with a hi th ujc ar Oha tak hl th lw jut a th jit.Th thu th thr ha i plac agait thatral apct th lwr agl th capula
Procur.Auct th ar lwly awhilprtig th capula r ig ig .23.
E rag i rach wh th capua ca lgr taiiz a tart t lip urth thu
Common msaks
Th capua t tailiz uficity- Attiv chiqu Wh th lwr agl
th capula catb tailiz, thlatra arg ay u. Th capula
ca al tailiz y placig haup th acr
g3 assie samea abd es f e
emea jit
Mt i t prr t th thpil rag
Nomal nconal anaomy
g 90
Eldf ligatu Limitig scts:
th aillary part th jit capul ctact w t gratr turity a
th uppr part th gli aru.
Common paholocal saons
h t i liit i hulr artriti It ay al c rtrict i acut
uti uriti
ISOMERIC CONTRACTIONS
Resised addcon
Posonn Th ujct ta with th arhagig a lghtly auct Th airta ll with th ujct ar plac ha agat th ipatral hip a th thrha agait th ir apct th lw
Procur Rit th ujct attpt t auct
hr ar ig. 24)
Fg 24 Resised addi e shude,
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Commo mses
T lbow is allow to lx Momt is allow at t soulr
Aoml sres ese
Muscle function:
Ipotat actos toalis mao Latssimus orsi Trs major Trs mior
Lss i/potat aos Log a o trps braii Sort a o bips braii
Claiular pat o ltoi Spial part o to.
Neura funcon
Msce
Peas a
asss ds
ees aj
ees nr
ces ba
Bs acDed
sa a
aca a
Peea
Pea
Tadsa
Sscaa
Axay
Iea
Rada
MscaesAxay
Axay
Pea
Commo pool sos
Nee o
C5-C
C6) C c)
C5-CCSC6C). C7 C)
C5,C6CSC6CSC6C5C
ai suggsts a lsio i o o t automusls or i t toai wal
Wass ours i sr C7 r root palsy aiu wass is pri i rib raturs
a mor ray i a ruptur o t ptoalismajor musl
Resisted abdion
Poso. T subjt stas wit t armagig a sligtly abut. T amirstas l wit t subjts arm H plaso a agaist t opposit ip a t otra agaist t outr aspt o t lbow.
Proeue Rsist t subjts ampt to abut arm Fig 125)
SHOULDE
Fig 5 ssd abd sudr
Commo mskes. Momt is aow at tsoul
Aoml srues ese
Musce functon
Impotant abctos ltoi Supraspiatus
Lss potat abtos Log a o bips braii
Neural funcon
Msce
Ded
Sasas
Bs bac
Inea
Peea
Axay
Sascaa
Mscaes
Commo polo sos
ee
CS (CCS CsC6
ai is usuay t rsult o a supraspiaustiits, mor rarly o a lsio o tltoi but may also our i subtoi
burstis Wass ours i total ruptur o t
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4 ATAS OF OTOPIC XAMINATON
supaspinaus tndn r in nurlgicalcnditins, such as lsins th axarynr, th suprascapular nr th C5nr rt.
Painul waknss is indicati a rcnt
parta rupur th supraspinatus tndn
esisted extern rottion
Poson. h suct stands with th uppram aganst th dy and th lw lxd t arght ang h rarm is hd in th sagittalplan s kping th shudr in a nutral psitn. h xaminr stands ll with th sujctsarm H pacs n hand n th ppst shudr
and th th hand against th ut and distalaspct th arm which h supprts
Poceure Ask th suct t kp th waganst th trunk and rsist th attmpt t puhth hand latrally ig. 1.26.
ommon msaes h suct tnds t xcutth tst wrngly ithr y nging th shuldr
g 26 essed eel otio of he shouler
int aductin r y xtnding th lw spially whn waknss is prsnt
Aaomcal srucures ese
Mcle fncn
mprtant xtra rtatr aspnatus rs mnr
ss mprtat xtO rtatrs Spinal part dtid
Nea fncn
sc
Inasnaus
Ts mno
Od
Pa
Suascaa
Axa
Axa
Iaon
ommon paolocal suaos
oo
e5.(eG)
e5. (eGIe5. (eG)
Pain ccurs n inraspinatus tndntis utmay as psnt n sudtd urstis
Waknss indicats a tta ruptur thinraspnaus tndn r a nurlgcalcndtn g C5 nr rt palsy supra
scapular nr pasy, nuragic amytrphyBilatral waknss is suggsti mypathy Painu waknss is th sut a patia
ruptur th nraspinatus tndn.
esisted intern rottion
Poso h sujct stands with th upparm aganst th dy and th lw lxd t aright ang h rarm is hd in th sagittal
pan, s kping th shuldr in a nutra psitin h xaminr stands with th sujcts arm H pacs n hand n th ppsitshuld and th th hand against th innand distal aspct th rarm
Proceure Rsist th sujct's attmpt t pu hhand twads hr (ig 127)
ommon msakes:
h shuldr is awd t aduct Mmnt is awd at th shuldr
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Fg. 12 esste te oao of he se
Anaomical scts tstd
Muscle uncon
mpot "te otos- Sucapuari Pecrali majr Lamu dri- ere majr
s pott ten ottos Ln head f cep rach Claicuar par delid
Neral uncon:
Muscle Inevato
Subsapas
ecorahs majo
LatssmusdTees majo
Bps ai
Detod
cavca pa
Pepea
SubscapuaPecoa
TrclSubscapua
Musutaeos
ectoa
Neve t
CC8CC8(C6, C7(C8)C8CSC6
CC8
SHOUDE 5
Common ahooical siaions Pain i he reul f a ein f he
ucapuai pecrai majr r aimudi endn r mucle and mre rarely f
he ere majr Iaed weakne ccur n al rupure fhe ucapulari endn.
ss flxion of t lbow
Posiionn The ec and wih he armalnde he dy he elw en a rihane and he frearm in ul upinain Theeaminer and lee wih he ujec' hand
One hand i n p f he hulder and he hern he dia apec f he frearm
Procdr Rei he ujec' aemp fle heew Fi .
g. 28 Resiste fe te ebw
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1 ATLAS O OTOPEDIC EXAMINATION
Commo msas The ubje hrug up he houlde i he
hope of exerig ore regh Movee i lowed he elbow I rog ubje flexio o uffiiely
b reied if he reie i o gieperpediulr o he ubje' forer
Anaomal srutus ts
Muce fuco:
mpoa xos- Brhili Biep brhii
ss impotat o Brhiordili
Neua uco
Me
epe
et
Bc
Bcep cf
BcH
Mcte ()
Mcte
R
Commo patoloal stuaons
ee rt
CC6C5C6C56
Pi i he regio of he houlder ourwhe leio i pree i eiher he loghed or he hor hed of biep.
Weke i he reul of eiher C5 or C6ere roo leio
Resisted exension o e elow
Poston. The ube d wih he rlogide he body d he elbow be o righ
gle wih he forer i upiio Theeier d leel wih he ubje' forerOe hd i o op of he houlder, he oher ohe di pe of he forer
Pour. Rei he ubje' ep o exedhe elbow (ig 9)
Common msas
eo i lowed he houlder Movee llowed he ebow
Fg 1.9 Resste eteson of the eo
Aaomal sruurs tstd
Muce uco
Most mpot1Jt xtso Triep brhii
ss mportat tso: Aoeu.
Neua fuco:
Mce
epea
Tcep c R
Aces R
Ie
Common paoloal stuatos
ee r
C7-C8C7C8
i eliied i he houder regio i hereu of he hueru beig pulled upwrdgi he roil rh d pihig ifled ubroi ruure Thi hppei ubdeloid burii or edii o oe ofhe edo of he roor uff
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P o eeso moe aey idicaesiceps edis
Weakess is say e est o a 7 eeoot palsy
SPECIFIC TESTS
assve orizona addcon
gnfan This tes stesses te acomioclaila ad steoclaca jois ad ligamets aso sqeezes te sbcoacoid bsa ad the
ppe pa o he isetio o te sbscaplaisedo to te lesse tubeosty o the hmes
PStonng The sbject sads with the amshagg aogide the body The eamie sadsee wi the sbjects am Oe had gasps theelbow at the distal pat o he ppe am Te othehad is placed a the back o te oe solde
Pro Take the am io abdctio is adhe bg t oiotally i ot o te body,
pessig e elbow towads te cotalatealolde ig 130
Fg. 130 ss hozo duto of he shouder
SOLE 17
Common mstaks Te sbects sode gidles ot wel stabilied so ha she may twist awayom the pesse
Appeension es n exernaroaion
gnfan The tes s peomed o detececet ateio dslocaio o the sholde.Te es is positie whe he paiet gets heeelig that te solde moes o o place soecogiig e sympoms
Postonng Te sbject lies spie wh te
am alogide the body ad the ebow leedto 90 Te eamie sits leel with the sbectssholde. Oe had is o te sbjects shodewith the iges aeioly ad the hmb posteioly agaist the hmeal head. The othe hadaes old o the oeam
Prou Bg te sbects am ito etea oaio, meawhe eetig a ateio pesse o he mes with the thmbig 131 Repeat ths tes i dieet degees o
abdctio
Appreension es in inernal roaion
gnfan Te test is peoed o deec ecet poseio dislocatio o he soldeThe est is positie whe e patiet gets heeelg ha the sholde moes ot o place soecogizig he symptoms.
PStonng Te sbjec sits o a chai te ami sigt abdctio ad te oeam behid theback The eamie sits leel with he sbjectshode Oe ad is o the sbject soldewit the hmb ateioly ad the gesposteioly agaist the hmea head. The othead gasps the oeam
Po Bg he sbjects am io sigtabdctio ad ft eal otatio ad eet
a poseio pesse o the hmes with hetmb ig 13
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18 ATS OF OTOPC XAMINAON
11 pprhs s r rr r sl
. 2 pprs s r rurr ps s
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Aneor rawer tes
ia his es is ea ee aerirhypeiliy i he glehuera i
Poson he sue es supe he uhwih he a ey he ege he exaiersas lee wih he shuler He sailies hesapla wh he raaera ha, he hu fwhh is plae he rai pess a hefigers he ari he a is ugh iau 20 f a a i sligh exi
F 1 T teror rwer tes
SOLE
he frea is seee ewee he exaiersr a he psilaeal a he ha f whihgasps he heus i he axila ig 33
Po he hera hea is firs rgh iis era psii i he gle fssa (ae')a he glie i he aeir irei.
Poserior rawer est
nfa hs es is ea ee psehypeiy i he gehueral ji
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0 AA O ORODC AMNAON
g 134 he posterio dwe tes
Positoning. Te ubect lie upine on te cocwi e arm beyond e edge Te examiner
tand level wit te oulder e abie tecapula wt e cotralaeal and, te tumb ofwic placed on e coracoid proce and tefinger on te acromon Te am i brougt inoabo 20 of abducton and into gt flexione oream i queeed beween te examer'
runk and e pilaeral arm, te a of wicgrap te umeru in e axilla Fig 1.34)
Procedure Te mera ead i firt brug o neutra poition in e glenoid foa 'loadedand ten gded in te poterior direction andigly lateally.
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CHAPTER CONTNTS
uace and papatory aatomy Anor
Bon nd pon o o
Bon nd pon o o
oor Bon nd pon o o 8T ub nn 8
Md 9Bon nd 9pon o o u 9
uctoa exmaton of he ebow 3
on non ponon
upnon
Io onon d on d non d ponon d upnon 5d non of w d fon of h w
Elbow
SURFACE AND PALPATORY
ANATOMY
ANTERIOR
Bony landmarks
hr ar no ra bony landarks rogniablat th antrior aspt of th bow Idntify thbital fossa Just bow it and deeply throughth ss of th antrior and ppr part of thorar, palpat latrally for th radial had (
and day for t oronoid pross o t ulna(2 (ig. 2 s bony parts an b idntifidor asily whn onsidring th latra anddial aspts of t lbow (s blow
Papation of soft issue
Palpation of the bceps muscle and the
neurovascula structures in the cubtal fossa
Kp th subt's bow slighty fld. Ask for
an ati flion and papat anwil in thbital ossa with a pinhing grip for thbiipital tndon (ig. 22 A as an outstandingtat stutur. It runs distaly to attah to th radiatubosity Mda to th tndon ts aponurosis( an b ft, and atra to th tndon th bllyo th brahioradiais usl (C rXially tbips broadns and its usotndinos junton D an b privd, and vn or proially its usl belly (ig 23 and ig 22 E)
Mdial to th biipital tndon, deep undrth aponurosis li th brahial arty and th
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AS O OOD XAMIAO
ig. 1 Ane vew 0 he elw selet
F. Ane vew he elw vv
Fi. 3 alan f the es sle ey
di rv T rr i plg, te tter rd strd
apan f e racais musce
Ak bjc crc t bicep lce tb d gr te idt bsde e bicpil ted (e lr ddil bicipit grv d w k r ietrc ei dr te figer d bd bicp ted e ctrci tebrcili cl (F c be flt rg rei ts scl, it bely, wic r rrdisy te cle bely e bicep, cbe pped wi pcg grp e brciir t r tbrty
apa f e prar eres musce
e sbect ld i lbw i 0 fle d erer i e r psiti betwe prti d pti Ak e bject prte
te rr d ri t oveet ptewt e tr d i tic clr s
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. 4 aaton o te onato tees se
ust dista t the cubital fssa (Fi 24 A rund
nd strn muscle can be felt runnin frmhe medial epicndyle t midradius. his is thernatr teres muscle (G).
LATERAL
Boy admaks (F 25)
he subject hlds his ebw n 0 f flexn andhe frearm supinated The ateral epicndye (Aan be palpated as the mst prminent bne
rm its anterir aspect riinates the extensrarpi radias brevis muscle The epicndylarrder cntinues prximally in the ateral suprandylar ride B evel wth it and frm thenterir surface f the humerus riinate therachiradiais and just belw it the extensrarpi radialis lnus musces
alpate distal t the epicndyle fr a depresin - the radihumeral jint ine (C ts prximampnent the ateral ede f the humeral capi
ulum 0 can be felt as a spherical structure.
ELBO
5 atea vew o te elbow (skeeto
The dista cmpnent - the head f the radius ()- is we perceivable when small rtaty mve
ments f the frearm are perfrmed The jintline becmes a bit wider and thus even betterpalpable when the elbw is bruht twardsmre extensin Feel fr the lwer brder fthe head f the radius and place the finer justdistally t it. It nw lies n the radial neck (F
Palpatio of soft issu
alpan f the brachradials muscle
(Fi 26The subject's elbw is held in 0 flexin and thefrearm in the neutra psitin between prnatin and supinatin Ask the subect t flex theelbw and resist the mvement. The cntractinf the brachiradialis muscle (A is wel palpableand visble and the structure can by palpatin inthe psterir drectin easily be fwed furtherprximaUy n its curse until its insertin atthe anterir aspect f the humerus level with the
atera supracndyar ride
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4 ATAS O OTHOPEDIC EXAMINATION
i 6 Vew o te raoradas use
lpin f he ril exensrs he ws
(Fi 27
The muscles are nw relaxed Brin the subjectsfrearm nt supiai and ask him t d acmbined active memet f extensin andradial deviati f the wrist Just dista t therin the brachiradialis muscle (A betwee this muscle and the ateral epicndyle -the cntracti f the extensr carpi radiais
lnus 8 can be een By pressn the psterir directi ts riin can be palpated aainat the anterir aspect f the humerus (Fi 28
G mre distaly and papate nw the ateriraspect f the lateral epicndyle (E) A flat tedinus structue is recnized which is the riinf the extensr carp radialis brevs muscle(Fi 2 and Fi 2, C
Brn the subject elbw int mre extensin30-35 and int prnati Over the head f
the radius (F the teds wrist and finer extensrs (Fi 20 ad F 7, D can be palpated
aea vew of he elbow n vvo
8 aaon o the extensor ar raals onssle
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9 Palpan f h n cap ada bv muc
.1
F0 alpatn h wt n
bl
ELBO 5
I
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26 A TAS O OTOPEIC EXAMATIO
low and foea ae again ougt into 0fleion and supination. U a pining gip andstat palpaton leve wit te ne of te adius(ig 2.11) Ove a distane of 3 downwads
g 211 po o u b o o pd onu nd b
g. 1 Eno of h w 1, o of o pdl o 2 on of no p d b
do o o p d b;4.
by o op d b
te ellies of aoadialis (supefiia) andetensos api adialis longus and evis (deep)(Fig 212) an e fet, te atte espeally wente suet atively etends is wist
apaon o he exenso ai ulnas muse(Fig 213)
e eow and foea ae st eld in te saestatng position (0 fleion, supination) Plaete palpatng finge elow te latea epiondyle(A) As te suet to pefo ulna deviationof te wist ension an b felt in te tendonof te etenso api unais (ig. 2.14 andFig 213, A), wi uns towads te oleanon
lg.213 Vw o no n u
g24 h o p l u
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alpaon o he supnaor muse F 2.15)
Plae the subets ebw n 313 extensnand n pnatn denty th adus m theada head dwnwads Identy the ulna mhe leann dwnwads. he spnat mseF. 26) s knwn t le n the ntspae bween adus and ulna between the elbw and
F 15 Papan f pna ml
i 16 h pa ml
ELBO 27
mdam Ask th subet t supna andesst ths attmpt Cntatn an b e.
POSTERORBony landmarks Fs 217 and 218)
hee bny pmnenes an be dented On anxtendd lbw tey e n ne ln aally sstuated the lateal pndyle A and mdallyth meda epndyle B) In bewen s tleann C) ss and pmnent. unlexn th elbw the leann mves dwnwads whh makes ts apx asly papabl Ina bent ebw the thee bnes m an sselestanl. Btwen the leann and te mdalepndyle les the sulus the ulna neve 0)
g.21 v f (k)
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8 S O OHOPEDC EXMNON
Papation of soft tissueFigs 2.18 and 29
Over he oecraon es he olecrao bursa,which is oly really palpable when i becoes
inflaed and swoeKeep he subecs elbow flexed Palpae for he
upper border apex of he olecranon Fl uslaera o his apex for he isertion o he endo
8 sr w bw (n
F 1 9 apan f h s ndn
of he riceps uscle Move he figersupwards: a broad ad fla endon is el and edsn he sculoendnous uncio F, shaped asan invered U Fig 22
Disally ad sghly laera o he oecraohe ancoeus usce (G) ca be fe durig aaep o acively overeend he ebow
Palpaon o a fleed elbow bewee heolecrao ad he edia epicondye dscloseshe scs i whch he nar erve - a sof andrond srucure - can be fod is covered byhe poserior par o he unar collaeral gae The nerve courses nder he edia headof he riceps use, he behind he ediaepicondyle and he furher disally n bewee
he wo heads o he lexor carpi naris sclewhich or a aponeuroic arch
The cubita tunne
The cubial nnel Fig 221 s b fro heedial epicondyle, he oecranon, he ularcollaera gae and he aponeurotc arch.
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F 0 T p mu: 1, lndnnn; 2 dy f h ndn npa n
F 1 ubal unn
J
ELBO
MEDIA
ony landmarks Fi 222
The medi epiondyle i reonized s very
promnen bone whih lie ju ubuneouly
Palpation of soft tissFi 223 nd 4
Keep he sbje ebow mos ompeelyexended d n ful upinion. Move he finerrom he med pe of he medil epiondyeA bou 115 m owd he nerior pePpe for ouh round ruure. Th i heommon endon of he flexor Fi 2.25 nd
Fi 223 B
. da vw lw (kn
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3 ATLAS O OTHOPEDC EAMATIO
i 3 a vw h w n vv
05 r diay, ju w th infrirrdr f th picndy and with th wighty fxd a thck and rnd ucuar ai papa th ucutndinu juntin fthi xr grup (C cniting f, r dia
i 5 h cmmn r nn 1, na 2munnu
t ara th fxr carp Lnari, thp lm ri
ng, h fxr arpi radiai and th pron tetr
atra th cn fxr tndn th darv i papa a a ud u t ruur
i 4 apan f h cmmn ndn f f
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UNCTONAL EXAMNATON OF THELBOW
ASSVE TESTSassive fexin
sitonng. h u and wih h ahd. h xain nd v wih u a H pla n hand aain ak h huld and ap h diaa wh h hand
ocedure Bin h hand wad huldy ailizin h a uni h vn
a p (Fi. 226).
mmon mistakes nadqua aiizain alw hud v akwad
mal fuctoal anatomy:R'ge au 16-ee n wll uld u a f p y
. 6 n
ELBO 3
iu appxiain h ul f ha in in na wih h ulf h upp a
n ply uld u a ah had
p f n nain wih n iitig tte:
- in wll uld u: h uulaa f h upp a and fain in na wih ah h
- in ply uld u ny nawn 1) h nid fa f hhuu and nid p f h ulnaand (2 h had f h adiu and adiafa f h huu
nin in h pi pa f h in
apu.
Commo pathoogica stuatios Painful liiain u in aii (a pa f
h apula yp f liiain whn a dy i pn in h ani pa fh in
Painl liiain i pn nunpiad ahi.
Passive extensin
Posoig h u and wih h ahd h xan and v wi hu lw On hand aiiz h wand h h and ap h dial fa
Pocee an v hand in ppi
din - dial and dwnwad and
pxial hand upwad Fi. 227) ndfl in h u lw
in lih flxn and v hand auplyu nly in ppi din wadxnin
Common mistakes lw i n n plupnain.
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3 ATAS O OOEDIC EXAMAION
g Pav n
Nomal fcioa aaomy Rnge: geneay 0 in he male; in emale
be and in hypemobile peonoeexenon of a fe degees may beposibe
Er-fel: had op of bone engaging hbone
Limitiug srtres:- bony ona beeen he oeanon poes
and oeraon fosa enion in he aneio pa of he join
aple.
Commo ahological siaos A painfl limiaion ous in ahi of he
elbo jon and alo hen a looe body ipeen in he poeio pa o he jon
A painle limiaion i peen innompiaed ahois
Passve ponaon
Posiioig The bje and ih he amhanging and he elbo ben o a igh anglehe examine sand n on of he bje Bohhand enile he dia oeam in h a ayha he heel of he onalaeal hand i paed
again he ola pa of he na and he fingeof he ohe hand again he doal aspe of headi.
Pocede. Bing he be foeam ino fuponaion by a imlaneo moemen o bohhands in opposie dieion (Fig 228)
Commo msaes The bje sholde bogh ino
abdion Too mh loal pese on he adi/na
may pooke endene
omal fcioa aaomy
Ra: abo 85 Ed-eel: eai imiig srcfres: ehing o he
neoeo membane and qeezing of heneon of he bipial endon beeen headial beosiy and he na
Commo aological saios The moemeni painfl in leon of he poximal adiolnaoin in biipioadial bi and n endiniiof he bep bah a he ineion ono headia ubeoiy
g. 8 Pav pnan
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ave upinaton
Positonng Th ubect tand with th armhanging and the bow bnt to a right anglThe examiner tand in front of the ubect. Bothhand encircl th dital forearm in uch a wayhat th heel of the ipiatera hand placed
againt th doral part of th lna and the fingrof the other hand againt th olar apct of theadi
Pocede. Bring the ubect fora into uupinaon by a imultaneou moement of both
hand in oppoite direction Fig 229)
Coon istaes. Too much local prure onhe radiu ulna may prooke tendern
Nora fncoa anatoy Rg abot 9 -ee elatic Uitg trctre
tenion in th introeou mmbran theobique cord and the antrior igament ofthe dital radioulnar oint
tenion i the extenor carpi unari tndonwhen th potrior apct o th nar
Fg. ass supnan
EBO 33
notch of the radi impact againt thetylid proce of the una
Coon paologcal stations. Th moemen
i pain when th proximal radiolnar oint iaffected
ISOMETRIC CONTRACTIONS
Reed flexion
Postioning. Th ubect tand with the armhanging th ebow flxd to a right angle andthe forearm upinatd The examinr tand lelwith the elbow One hand i on th dital part
of the forearm and th othr hand on top of theholder
Procedre Rit th bct' attmpt to lx thebw (Fg 23
Coon saes In trong ubect fxion cannot fficiently
be reited if the reitance i not ginprpndiclar to the bect' forearm.
Moement i alowed at th lbow Th bct perform hodr eleatio
Fg 30 ssd n
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S O OHOEDIC EXMNON
Anatomial stutes tested
Muscle function:
Ipor exor Bchili
- Bicp bchii e ipor exor Bhidii
Ex cpi dii lgu- P
Neural functon
Msc Ivai
BacasBicps bachiiBacadiais
pa N
Musccuas C6Musccuas C6adia C6
Exs capi dias s adia C C7C C7a s Mdia
Common patologia situations Pi idct i ith th bip
bchii h bh uc Pil w u i th C
C6 t
Piful w i uggti fu f th di tuby
Reted exenion
Postioning. h ubjct td with th mgid th bdy, h bw fxd t 90 dh fm upi h xmi td with h bw. O hd uppt th ditl
pt f th fm d h h hd i tp th hud
Poede. Rit th ubjt ttmp xdh bw Fig 231)
Common mistakes: tg bt, fxi c
ufitly b d th itc it gi ppdiu h ubjt
fm Mmt wd t th lbw
g. 31 d xnon
Anatomia sttues tested
Muscle function
Mos ipor exeor:- cp bh
e por1 exe1or:
- Au
Neua unctn
Musc
Tcps baccs
pa
adiaadia
Iva
Common patologia sitations:
N
C7-C8
C78
h tt i piful wh li f t tipi pt.
W cu li ih h dil h C7 t.
Piul w my idict ptil rupf th icp u f th lc
Reited pronaton
Positionng. h ubjt d wh h m
lgd th bdy, h lbw bt ighg d h fm i l piti h
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amr sads i ro o h subj hpsara had arris h orarm h hargais h palmar ad disa asp o h radiusd h igrs agais h dorsal asp o h
la. h ohr had riors: har o uad igrs o radius
oede. Rsis h subs amp o proah orarm Fig 22
ommo mitakeh subj adus h shouldroo mh oa prssur o h radius/ulama proo drssMom is allod a h bo
atomial tte teted
Musce fucti
Proaor rsProaor quadraus
Neura functn
sc
a sa qadas
pa
MdiaMdia
g 2.32 Ressted pronao
Iai
N
I7CT1
ELBOW 35
Commo pathologal itato Pai ors golrs bo a so o h ommo lordo or a soad sio o h proaorrs musl
Resisted supnatn
Poitoig h subj sads ih h armaogsid h ody h bo b o 90 ad horarm ra poso h amir sads ro o h suj h ipsaral had arrish orarm h har agains h disa ad palmarasp o h ua. h har o h ohr had isplad agais h dorsal asp o h radius
Poedue Ris h subs amp o spah orarm (Fg 2)
Commo mitake h sub ds h lbo Mom is allod a h bo oo muh loa prsur o h radu/ ua
ma prook drss
Aatomial ttue teted:
Musce functin Ms ipa p Supaor Bps brahi
Fg 233 Ressed supao
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ATAS O OTHOPEDIC EXAIATION
Lss importaNt sup;alor:- Brachiradialis
Neua uio
Musle Inneaion
Peripheral Nere oo
SunatoBes bacBraoradials
RadaMuslouaeosRada
C5CSC8
Commo pahologcal siaios Pain is th rsutof a sin f h bicps or, mo ay a lsin fth supinatr muscl
Resisted extension of he wrisPosioig Th subct stands with th amhanging th lbw xtndd and h wrist nnura positin btwn pronain and supnaton and btwn flxion and xnsin Thxamin stands l wih h subt's lbowTh nraatral am lifts and carris h lbowand ps it xndd. h hand stabis thforarm Th h hand is pacd a th drsumof h sub's hand
Pocere. Rsis th subcts attmp t xndh wrist ig. 234
F. 234 Ressted exenso of the ws
Commo misakes Th sub s allwd t lift am up h bow is allwd t flx This can b
prnd by th xaminrs arm png thsub's lbw w raid
h wst s n hld i nura psin wchpus srss n nnnrac suurs
Aaomical srces ese
Muse futio
Ipora1t wrist extenorsExtnsr digitum cmmnisExtnsr carp radialis longus
Extnsr arp radiais bis- Extnso carp unaris
Le portt wrist extenor Extnsr indis prprius- Extns plliis ngus- Extns digii minimi
Neura utio
usle nervaion
Exensor digioum ommusExensor ap radais longusExen arp radais bevisExensor arpi unaisExen ds oisExensor Us losExensor di minm
Peperal
Rada
AadialRadiaAadialRadalRadalRadal
Commo pahologica siaos
erve oo
C&C8C&C7C7C7C8C&C8C8CC8
Whn lbw pai is id, tns lbow - alsin in th radia xnsrs f th wris ss pbabl Ohr pssbs a a sinf th xnsr arp ulnas r f h xnsrdigitum
Wanss may rsu fm a adia nrlsin fm ithr h C r C8 nr rBilara wanss suggss ith ladpsng, r brnchus arinma a mrgnra nurlgial disas.
Resisted fexion of he ws
Posioig. Th subct sands wih th amhanging h lbw xtndd and h wis n
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ura posio (w proao ad supaio ad w io ad so hamr sads v wih h sucs ow
h coraara arm lifs ad carris h ow
d kps i dd h had sailzs horarm h ohr had is pacd a h pam ofh sucs had.
roee Rss h su's amp o l hwris (ig 23
Commo make h suc s aowd o push h arm dow
F 235 Reed fleon of he w
BOW 37
I his happs i is h rs o aduaiao
h wris s o hld ra posio whhps sss o ocorc srucurs
Anaoma rue eed
Muscle funtion:
/po wit xo- or digorum suprficiais- For oru proudus lor carpi ularis- lor carpi radialis
mott i o: Aducor pollicis ogus
- Palmars ogus.
Nral funon:
Muscle Inneation
Fexo dgom specasFexo dgom pofndsFexo cap nasFexo ca adasAbdco pocs ons
Pamas ons
Pephera Nee oo
Medan C7-T1Medan C7-TUna C7-C8Medan C7-T1Rada C7-C8Medan C7-T
Commo paooga iao Pai a h ow occurs gor's ow a
so i h commo or do Wakss suggss a C7 or C rv roo
so
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HAPER ONTENTS
n pp ny 3Radal 3
Bony andmak 3Palation of o t 4
oa 4Bony landmar 4
Palaton of ot t 42Ulna 43Bony landar 43Palation o ot t 43
Pama Bony landar h aa nn 4h tnnl of Guyon Palpaton of oft tu 46
nn n Pav t o dtal adionar ont 4
Pav ponaon 48Paiv pnation 4
Pav t o t r on 4Pav fon Pav non Pav adal dvaon 5Pav unar dvao 5
Paiv fo h tapzum- maaaljont 5
Bckad movmn drn ton 5Ioc contacon 2
Mcl conrolln h rt 2Mucl nrolln th tumb Mucl conrolln h fin 7ntnc uc of h and
Siic t 6
Phan' t 6n tt Gnd tt fo h tzuf macaal
oin 62Fnktn 62
Wrist
SURFACE AND PALPATORY
ANATOMY
RADIAL
Bony landmaks g 3 3 ad 33)
the dtal ed f the radu the tyd prce) ca be palpaed. lghly re prxally the radu a all grve ca be fud.Jut dtally t the tyld prce the caphdavcular) be ( papabe. t ca be ade
re pre by ag he ubjec t executeular deva f the wrt. Whe the palpatgger he avcular be e a depre bewee w ed, caed he 'aatal uffbx' t the da ed f the uffbxthe jt e ca be palpated betwee thecaphd be ad the trapezu epecally
Fg. 3 Rada v of t t (to
3
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ATLAS O ORHOPEI EMNION
3 ony landaks at te radal side o he st nvvo)
F 33 oy strutes at the ada sde the st
whe the ubect ve the thub 7 e dty ther jt e plpble - thee betwee the trpezu be d the frtetcrpl be h t le well plpbledurg veet f the frt etcrpl befee f the hft f the ft etcrp bewth e fger d ve prxlly twrdthe be f the be C he jt le c befet ut prxlly t the pxl bder f the
be, epecly whle the ther hd ve theft etcrp t d fr
Palpation of soft tissue
Pce the plptg fger jut dty t thetyld pce d feel fr the tghteg f therd cter lget dug ur devt
It ttche t the cphd be (Fg 3Mve the fger lghty twrd the plpect k the ubect t exted the thub(Fg. 35) w trg ted c be ecgzed(Fg. 36) frt the exter pllc brev ()whch ee t ru twrd the be f theprxl phlx t fr the rd brde fthe 'tc uffbx' Next t t the bduct
. 3. he ada olateal liaent
F 35 e o the etensos ad aduto o th thub
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. 36 ends a e ada aspec e wrs
olls logs () s elt, sertg at the base h rs aarpa oe
DORSAL
Bony andmars (Fgs 3 ad 38
adus ad ula ar asl palpabe The stodroess o th rads dsds a bt urthrsta ha he stod proess o he ula.The dsta radoular jot a b rogzd
graspg the dstal ed o he radus wthe had ad the dstal ed o the ula wth thther, ad ovg both hads opposterosThe dstal border o th radus s sharp ad
a be el as beg he proa bordr o th
3 rs vew he ws (seen)
WRIST 4
. 3.8 Bn adas a he dsa sde he ws (n.
radoarpa jot, whh has a wde o e.Oe grwdth or proa, o th dorsaaspt o th radus, a odular bo a b lThs s he dorsal tuerl (A) o th radswhh ors a portat adark. A hular sd th thk had o h ula s palpatd
The arpa bos oss o wo rows I thproxal row th saphod, luat, trquetraad psor bos
Dsta o th eror order o the radus, twooes a be papatd. Th ost radal o s harad deeed saphod bo It s el orelarl durg ular devato o he wrs Theost ular bo s th uate boe () whhs palpale o a leed wrst ar to th uaad arulag wth he ua les he trqutralbo. It s to ov whe the had s agabrought o rada dvato
The dsa row oas h trapzu, rapezod, aptate ad haate boes.
Dsa ad a bt or rada to the saphodles th trapezu w h uate ad hebase o the hrd aarpal o a dprsso(C) s el whh he aptat bo s palpabTh apae arulates wth the base o thhrd etaarpal bo (D). Th bo btwe thapae ad the rapzu s th trapod bo,whh s or dul o papae
To the ular sd o the apat ad sowhator dstal ad rada tha the trqutral, th
haat oe s elt artulas a wththe ourth etaarpal bo
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42 ATAS OF ORTOPIC AMINATON
Palpation o sot tissue
Place oe ger jus radall o he dorsal uberceo he radus (A (Fg. 39 Ask e subjec oae a rs ad o squeeze ad usueeze
Durg hs aco edous gheg ca bee These are he edos o he exesor carpradas logus ad exesor carp radals brevs(Fg. 30 We he subjec coues hese uscular coracos he edos ca be ollowedapproxae c ore dsal, u he powere e separae B) The os rada edo
F 39 Vew te exesrs te wst ( vv
Fig. 310 he extens c ds nus () nd revs2
(logus (C) s e o ser a e rada aspeco he base o he secod eacarpa boe ade ore ular edo brevs D sers a herada aspec o he base o e rd eacarpa
boe Fg 3.Pace oe ger jus ular o he dorsauberce o e radus. Ask he subjec o exede hub Feel or e exesor pollcs logus(Fg 3 A edo, whch s he uar bordero e aaocal subox I ca be palpaedul s sero oo he dsa palax o he
F 311 Pt the extens crp dls ns
i312 Vew te extesr ps s vv
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Vew e exess he es (i vv)
humb: he endon tus 45 arond the dorsalbecle of the radiu croe over he extensoarpi adiali ongus and bevis and goesowards he humb
Papate he doal apec of the wri whilehe ubject exends the ingers Movement can beelt o the endon of he extenor digorum com
mns an o the extenso indicis propiu. Whenne finger i extended at a ime the diffeenndons can be palpated one by one
Plce one inge ut adiay to the head of thena Ak he ubject to extend the ittle nger andee or he extenso digiti minimi Thi tendonvere he dia aionar join
Plce one inge a the infeio and ulnaroer o the head of the ulna ig 34 A) Askh ubec to perorm an ulnar deviation ungxenion. The stong and hick endon o he
1 View the extens cap unas (i vv)
WRS
F he extens cai ars
Fi 16 Papatin e extensr carp nais
extensor carpi nari B) i fet igs 35 and3 It can be ollowed to i inerion a the baseo he ifh metacapal bone
ULNAR
Bony landmaks ig 37
A the dital end o the una the ma tyoid pocess A is palpabe Ju dita o i the riquera bone 8 becomes prominent when the ubjectmove the hand in radial deviaton When thepapating inge move even more distally andthe hand is brought back to the neral positionthe bae o the fith meacapal bone C) encountered
Palpation o sot tissue
Pace the finger jus dista to he tyloid processand move the subjecS hand in radia deviation
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ALA O ORTHOPEDC EXAMNAON
A C
g. 3.7 Bo amarks at te a se o the wst (vvo)
Tghg c b fl of h ulr cor
PALMAR
Bony landmars Fg 3 d 3.0)
Rdu d ul c b dfd A h dd ul d of h ul bo pomcc b fl: h pform bo A. Pu h rphgl o of h humb oo h pformd drc h humb owd h b of hdx fgr of h ubc lx h humb dfl p ouch h hook of hm hrough hmucl of h hpohr.
gm Fg 3 whch go owrd h Arurl bo Ak h ubc o mo hhd owrd h ul d d o xdh wr Ugh Aog h dl p of hul h do of h xor crp ur plpbl
g. 38 he la olatea amet
g39 o admaks at te almar se o the wst( vvo
Fg. 32 almar view o te wist (skeeto
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t he dia end of he radiu the promnentberle of apoid 8 i well palpable Pute interpaangea on of he hmb onto heapoid' uberle and diret te thumb towarde bae of te thumb lex he thumb and feel iip ou he trapezim bone. Laterall and ditalo it lie e bae of he firt metaarpa (C)
When te finger moe from he aphod ine dreon of he index finger the bae of heeond meaarpal bone an be palpated troughe mle of the thenar
e capa tunne (ig 3 3 and 33
Te arpal tnne e beween on the nar ide
te piform bone () and te ook of tehamae bone 8 and on he radial de - theubere of he aphoid bone C) and he rapeim bone (0)
I an be loalized on the heel of he and andomewhat oward te unar de It i oered
b the tranere ligamen.he ontent of e arpa tunnel i:
te median nere e flexor poll i longu he flexor arpi radiali he flexor digitorm uperfiai and
profund
g. 321 bundae f he aal une n vv)
WRIS 45
F 322 Vew e caa nel (ecme)
1-
2
g 323 he bundae f e aalune ri ha
ama vew cahd; 2, aeum 3, sfm hamae
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ATLA O ORTHOPDC XAMNATION
F 324 The la ee asses thr he nel Gyn
he tunnel o Guyon ig 324)
pe fo he inespce beeen he pisifomnd he oo o me his is uons unne conins he un neve nd n end is coveed b he psohme ligmen
Palpation o sot tissueigs 325 nd 326)
eel fo e pisifom bone nd plce he p
ping finge gins is poxim spec Ashe subjec o cvel bduc he lile finge heighening of he flexo cpi ulnis A cn befe igs 327 nd 328) he endon cn no befooed disl o he pisifom unil is inseonon he bse of he fifh mecpl bone. hepisfom is sesmod bone in he endon of heflexo cpi ulnis.
ce he humb dil o he pevious endon he disl p of he foem I no ies on heendons of e fexo digioum speficilis B)
g 325 View te lexs o wst and nes vv.
0
g 32 Radial vew o the wrist vvo)
F. 327 he leor ai ars
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g 328 aaon o he exor ai uars
o whh the moemet e elt dig tveleo d eteio o the iger ig. 9
I deepr lyer he preee o he leodigitorm pod e imged
Move the iger i more towrd the rdide d k the jet to oppoe he thmd litle ige d o imeoly le the
wri he th tedo o he plmi log C
g 329 aatio o e exo ioum seas
WRT 47
eome pomiet t iert o he plmpoeoi o the hd t h o e rememeed tht th mle iott
Appomely m diy to the pmri
log he rog d hik tedo o the leorrpi di (0) i ppe ig. 0) epeiywhe he et lee d dilly detehe wit It er he e o the eodmetpl oe ig 1
Fg 33 The exo a raiais
ig 331 aaton o te lexor ai aialis
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ALA O OHOEDIC EXAMINAION
In bwn h plmris longus nd h florrpi rdilis in dpr lr th tndon o thflor pollis longus n b fl o mo duringion d tnsion momns of th humbigs 2 nd )
Fg 332 e feor ollcis ons ee o the fismeaara; 2 eve of the arus
Fg. 3.33 Paaton o the feo os ons (a the ws)
Btwn th flor rp rdlis nd thbdutor poliis ongus th pulstions of hrdil rtr ) n b
FUNCIONAL EXAMINATION OF THEWRIST
Introductio/geeral remarks
Emnon of h wris shoud inlud ll struturs tht n b rsponsbl for pin ft in hrgion lld 'wrist b th pit
This ompriss th dis rdioulnr join hwris join h rpzium-firs mrpl join
d lso th tndons th ontro h wris, humbd fingrs d th inrins muss o h hnd
PASSIVE TESTS OF THE DISTALRADIOULNAR JOINT
Passive ponation
Poonng Th subt stnds with h rmhgng nd th lbow bn to 90 Th minrsnds i front of h subjt Both hnds nirh dis pr of th forrm n suh w hh h of h otrlrl hnd is pd on hplmr sp of h un nd h ingrs o hohr hnd li t th dors sp o h rdus
Podu Brng h subjs orrm ino fupronton b smunous tion of boh hndsin opposit dirions ig 4)
Common mak:
Th subt is owd o bdut h shoudr Too muh prssur on h rdius or ul m
proo o ndrnss
Nomal unonal anaomy:
Rg bout 5 E-: lsti itig stcs imption of th rdius
ginst th uln ogthr with srhing oth inrossous mmbrn
Common pahooga uaon Pn full
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g 3.34 ave onaton
rge suggests trts or rtross of te dstlrdoulr jot
Passive supination
oiioning e subjet stds wt te rmgg d te elbow bet to 0 e exmestds rot of te subjet ot ds erlee dstl prt of te orerm su wy tte eel of te psterl d s ped o te
dors spet o te ul d te ges o teoter d t te pmr spet of te rdus
Podu rg te subjets forerm to fusupto by smuteous moemet of botds opposte dretos Fg 33
Common m oo u pessue o dusor u my pooe loal tedeess
om unon nom
Rg: bout 0 Ed-fel: elst Liing scs:
- teso te terosseous membe te
obue od d te teo lgmet ofte dstl rdoulr jot
WRT 49
g 3.3 Pave uiao
teso te extesor rp us tedowe te posteror spet of te urot of te rdus mpts gst testyod poess o te ul
Common pthoog iuon:
P t fu ge ous rtts orrtross o te dst rdour jot dso tedts of te extesor rp ulrsleel wt te dst ed of te u
Lmtto dtes muted Colles'frture
PAIVE E O HE WRI
JOINRemark
e wst ot s proxm prt - te rdorp ot - d dstl oe - te terrpjot e tests desbed ts pter testte wrst jot s wole d do ot test tsstruures seprtely
A moemets re exeuted wt te wrsted te eutrl posto:
lfwy betwee flexo d exteso lfwy beee rdl d ulr deto.
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50 ATLA OF ORTHOPDIC XAMIATION
The oiionng fo ive e of he woin i he me.
Poiioning fo ing h mobiity o th wt
The uje nd wih he m hnging he
eow fleed o igh ngle nd he foemoned The emine nd ne o he uec The onle hnd ie he ue'foem whih i ke eween he eminem nd unk The ohe hnd g heuje' hnd dily on he mel
Passive flexon
Podu Bng he uje' wi ino mimlfleion Fig 6)
Common mitak None
oma unional anaomy Rag: 85 l-f li Lng scs: ehing of he do
gmen of he u, of he inelgmen nd he ule of he dffeeninel oin
Common pahoogia uaion in he dol e ou in a leion of
he do gmen o he eeno endonof he wi
in he m e my ou ineioii, moly of he hod one
F . assve fex f the wst
inful imiion my ndie hiiinle miion hoi.
Passive extenson
Podu Bing he ue' w ino mmeenion Fg .7)
Common miak None
oma funtona anaomy Rang 8 l-f: he hd g scts
- ehing of he lm ligmen of he
u nd of he ne igmen ndue- on of he oim ow of l one
gn he diu
Common pathoogia ituaion
Pin full nge nd fe he do emy ugge eioii of he dieihy of he du o dol gnglionm in my e ovoked in leion ofhe m igmen of he wi o of one ofhe feo endon
nfu miion i een in hii, luluon uully of he ie onend ei neoi uully of he neone
nle imiion i yil fo hoi
Fg. 7 assve extes he wst
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Fg. ave adia deviat f te wt
Passive adal deviation
Podu Push h sbjes ws o he dide il h ed of g is hed (g 338)
oon ita Noe
oal untona anatoy
Rge: bo 15 -f/ he hd
Ltg sructL sehg of he ulollel gm d of he eeso pils
oon pahoogia uaion
i h ul side is yp fo lsio ofh ul oll gm o h eesopi ulis.
Pi h di sid my be povoked i deQuevs dses s h sul o gidg ohe edos of bdo pollis logus dso pois bvis h ifmdsheh.
Passive una deviaton
odu Pll he sbjes wis o h ulde il h d of ge is ehed (ig 339)
oon a he humb is uded i hmovem should b lef f o vod s
ive shig of he dos o he eesosd log bduo
Fg. .9 Pave ua deva f he w
Noal untiona anaoy Rag bo 5 E-f he hd
W 5
fgm di o gm
oon pahologial tuaion
P h di sde fll ge is pesei spi o he dil oe gme os h es of gdg of dos i ifmd shh i ovgiis of bduo
poiis logs d eeso pollis bevis(d Quevis disese)
P h sd b liid by lesio of he igu fboilgousomp
PAVE E O EAPEZIUM-I MEACAPALJON
Bacwads movement dungextenson
Potoning Th subje sds wih he mhgig d h ebow be o 9 d supio he m es h sub O hdgsps he hd d sbzes
Podu h ohe hd movs h humb iosio fis d h bkwds ig 3
oon ita he humb is hypeeeddi he mpophge oi so h mos
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52 AA O ORTOPDIC XAMNATION
F. 0 assve vee the hb
stress s on tis oint nd not on te trpeziuirst etrp one
Noma unciona anatomy:
Rlg: until te oveent stops E-f lsti L/g scs streting o te
nterolterl prt o te oint psue o tetrpeziu-irst etrpl oint
Common athoogica ituaion
Pin indites rtritis or rtrosisrzrtrosis genery o te oint betweente trpeziu nd te irst etrpl bonesMore exeptiony it is te oint betweentrpeziu nd spoid bones
Exessive rnge o otion ours terrupture o te ulnr spet o teetrpopngel oint psule
OMERC CONRACION
Muscles controlng the wrist
Remarks
s ost uses tke teir origin t t elbownd overrun it te subets ebow sould wysbe ed n extenson to put xi stress ontese strutures
ll oveents re exeuted wit te wristeld in te neutr postion:
lwy between lexion nd extenson lwy betwen rd nd ulnr devition
Te positioning s te se or te our tests
Poioning o eing e eied movement
o te i Te subet stnds wit te rnging te elbow extended nd te orerin neutr position Te exiner stnds levewit te subets ebow Te ontrlterl rlits nd rries te ebow nd kps it extendede nd stbilizes te orer Te oter ndgrsps te subets nd disty on te etrps to pply resistne
Ressted exon
ocedue Resist te subets ttept to lex tewrist Fig 34
Common miake:
Te subet is llowed to pus te r down ts ppens t is te resut o indeuteixtion
e ebow s not ed in extension
Anaomical tuctue eed:
Muscle funco:
Ipon wi xo Flexor digitoru superilis
F. . essed lexn he ws
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Feo digitorum proundusFeo arpi unarisFeo arpi radialis
Less i1lportat wrst fexors:
dutor poliis ongus Pamaris ongus
Neural (uti
Muscle Inneation
Peiphera Neve rt
eo dgiom supeas edan C7-T
exo digiom pofundus edian C7-T1
exo car unas Una C78
exo cari adas edian C7-T
duo iis ongs Rada C78
amais ongs edian C7T
Commo polog iuio
Pain at the wrist ours in tendinitis o theleo arpi radialis eor arpi unais andeo digitorum profundusWeakness is found n C7 and C8 neve rootesions
Ressted eteso
odu esist the sujets attempt to etendhe wrst Fig 342.
g .2 esised exensi te wist
WRT 3
Commo mik
The subjet is allowed to push the armupwards If this happens it is the resut ofnadequate fiaton
The elbow is not held in etenson.
Aomil uu d
Musle (u
ImportHt wrst etensorstensor digitoum ommunstensor arp radialis longustensor arp radialis bevistensor arp ulnas
ess mpotut wrst etesors
tenor indiis propustensor poiis longustensor digiti minm
Neual futi
Musce Innevaon
Extenso digitom commnis
Extenso capi adias ongs
Extenso capi adias beVS
Extenso capi unas
Extenso ndicis ois
Extenso pocis ongus
Extenso digiti mnim
eipea
Rada
Rada
Rada
Rada
Rada
Rada
Rada
Commo polog uo
ee t
CHB
CH7
C7
C7C8
CHB
C7C8
CHB
Pain at the wist is indiatve of tendinitiso etenso arpi adialis longus and/orrevis etenso api ulnaris etensondiis popius or etensor digitoumommunis
niatea weaness is aused eithe by anerve root lesion espeially C and C8 or ya eson of the radia nerve
Bilatera weakness suggests eithe leadpoisoning o bonhus arinoma o a moregenera neurologal disease
Vaao: ressted eteso of the wst wth thefges held actvey feed
Sigii Ths test an e used to differenateetween wrist etensos and inge etensors
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4 AA O OROPDC XAMINAO
Acv conrcion o ingr lxor inib ingr xnor Abnc o pin indic wn on i prn i in on o ngr xnor
Poioning ubjc i nding nd old xndd r orwrd H quz bningr ino p o i nd xinrnd vl wi ubjc r nd biz orr wi on nd or nd ipcd dor o ubjc' ndg. 33
Podu R ubjc p o xnd wr
Common ma: n r i id up bow i no d n xnon
Ressted radial devat
Pod Ri ubc' p o ov nd rdly (ig 3
Common miak: ub i no l r ru o wic
i ub xnor nd bducorbco dircy involvd
lbow no p xndd
. 3.3 Ressted exeso o te wst w eexed
3. essted ada deato o te wst
Anaomia uu d
Mucle unction
xnor crpi rdili long Abdcor pollici ongu Exnor pollici longu xor crpi rd lxor pollic longu Brachoradas
Neurl unction
se o
Extnso cpi dis ogs
Aduo poicis ongus
Exnso poiis ongus
exo pi diis
exo oIcs ogs
hiodiis
Peiphe
d
di
d
di
d
di
Common ahoogial iao:
ee ot
n i o coony prn n ndino r xnor crp rdi ongund /or brvi or lxor crp rdli
y o b pnul in d Qurvn'novgni - on o bducorpollici longu nd xnor poici brv inr coon ndon
Resisted ular deati
Pod bjc p o p nd ovr o ulnr id ig. 3
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Fl35 ss la dai rs
Common mk bw t xtdd
Anom uu d
Mscle cio
Iotat l1 vats: Extr crp ur Flxr crp ulr
ss tat na vats: Extr dtrum cmmu Extr dt mm.
e fco
Ms
xtsor c as api narsxtsr dtm mmsxtsr dti mm
Pa
adaaadaada
Common polog uon
vat
v roo
C7C
C78
C&8
C&8
P t rult f tdt t f txtr crp ulr r f t flxr crpul.
Wk dct uuy CB rv rt
Muscles controling te tumb
Rmaks
pt f t ubjct t m f tur tt. S t pt f t mr
RIST 55
ox 3. Diis
Aci mb ms m a pama pssally ji pla f macarpas
Aci T mb ms a plmar dicaay rm pa f macaas
xsi A camacapal macappalaal a irpalaal jis r is amm raial rc y
xi
a pla para pla f macaas
A capmacaa, macappalaal a irpalaal js r s amm i ar irci rly ia pa parall pa0 rmcarpas
xcpt tt fr fx d xt Bx 3f dt) tc v t t dtlp d f bduct d dduct t tdt prt d f t frt mtcrp b
Poonng ubjct td wt t rm, t lbw bt t rt l tfm d d t utr pt d
t tumb pt upwrd. mr fct ubjct ctrtrl d cr tubjct wt tr d t tumb
Rsstd xon
Podu Rt t ubjct ttmpt t fx ttumb F 36
F 36 Rsis fl m
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56 ALAS O OHOEDC EXAMNAON
Common mtak thumb allwd thypxtnd at th mtacapphaanal nt
Aatomica tuctu ttd
Mu unon
Imprtt thmb frs:- Fx pllc nu- Fx pllc v
s mprt hmb f Adduct p
Nura unon
Muscle Inevation
Fexor pocs ongsFe)or pocs bevs
supefca headeep ea
Aduco pocs
Pephera
Medan
MedanUnaUna
Common patoogical ituation
Nee roo
S
lBS
Pan nt n a tnynvt f th lx lnu
Wa utv f a ln a ancf t mdan nv - th ant
ntu nv - and m ay f tulna nv
Rssd xs
Pocdu Rt th ct' attmt t xtndt thumb F 47)
g 37 esste eeso o the thm
Common mitak Hypxtnn f th ftmtacaphalanal nt tak pac
Aatomical tuctu ttd
Mu unon
xtn pc lnu Extn pc v Abduct pc; nu
Nura unon
Msce Inevaon
Exenso pocs osExensor pocs es
bdcor pocs os
erphea
RadaRada
Rada
Common patoogica ituaton:
Nee oo
S
Pan ccu n tndnu n thabdct c nu and xtn cbv d Quvan da) and xtnpc n cptatn tnynvt)
Wan pby th ult f a uptu fth xtn pll lnu t may andcat a ncal cndtn t f th
ada nv f t 8 v t
Rssd bduc
Pocdu Rt t ct attmpt t abductth thumb F 48)
g 38 esste ato of the thm
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ommon miae Ric i gin on il pnx.
naomical uctue eted
Mue funon
Abdco poici longAbdco poici bixnor polli bri(Flxor pollici bri)
Neura unon
sce Ievt
bt cS s
bct cs esxtes cs esex cs es, ee e
Pee
Me
ommon pahoogical iuaton
Nee t
6B)
Pn i o do o o bdco poici log nd xno pollicbi g d Qri' di ocping oynoiiWk occ n nr on g
porio oo nr or din n
aco
ocedue R bjc' p o ddc b (Fg 349
ommon mitake Ric gin il px
. .9 ssd addto o t
Anatomical tucue eed:
Mue unon
Impott thm ddcto Addcor pollici
pott thm ddto
RST 5
- Fxo pollici bri prficil d- Opponn poici
Neua funtion
Msce Iet
Act csex cs bes
sec e
Oes cs
Pee
Me
Me
Common pahoogca iuaon
eve r
Pin occr n on of ddcopollici lly i obliq porion
W occ i lio o i nn or C8 nr roo
Muscles contolling te inges
xo of ach fgr paraloiionng and pocedue T bjc prni d p downwd xi biliz wi wi o d W o ppli ric o di plx o cfing rpciy Fig 30
Fg. .50 Rsstd eenson of one ne
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LS O OROEDIC EMION
ommon mtak e
Aaoma uu d
Msce fncon
Exei f e idex figer Exer idii prpr Tedo o e dex fger f e exeor
digiorm omm me Exeio of e mdde figer
- Tedo e middle fger of e exeordigiorm ommi me
Exeio of e rig figer- Ted o e rig figer f e exeor
digiorm ommi me Exei f e ie figer
- Exer igiti ni Tedo o e e figer of e exeor
digorm omm mce
Nea fncton
M nnan
Prphra Nr r
ns ds ppsns m mmsns mnm
RaaRaaRaa
ommo athooga uato
C&8C&8C&8
Pa ediiti f e exerid prpri r f e f e ed fe exeor digirm omm
Weake ma or i a leio f e radiaerve
Resisted exn f ech nge septey
Potong ad odu Te be presei ad palm dowward. Te examier abiize e wri w oe ad. Wi e oerad e applie reiae o e dial paaxof ea figer repeivel ig 3
ommon mak Noe
Anaoma utu ttd
Msce fncton:
lexor digiorm perfiali lexor digorm profd
Fg 3.51 R x n
Nera fnction
Msc Ira
l dgm scas digrm pds
pha
MdanMan
ommon aologa uaon
N
7-7
We reed moveme of oe peififiger i paif, e e io, if pree,m lie i e edo goig o afiger
Pai i all e rel of a leio of oe ofe edo of e fexor dgiorm profdeier a e wri or more dia
Intinsic musces of the and
RemkWe ris mscle f e ad are affeted,i i all a leio i e dora ierei. Teemle mai abd e figer awa frm emiddle fger ig. 35 ef)
Tere are for doral eroei ad ree palmar oe e laer add e figer owarde middle figer ig. 352, rig).
Tee mle a be eed b preadig efiger agai reiae followed b qeeig
e examier figer Te ombaio of poive awer idiae wi me affeed.
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- f
I
\H!I
I
f 1/g 352 () Aduo, o oa neoe )to, t paa noe
he postonng s the same for a s testsWhen spreadng the examner appes resstane
t the dstal phalanges Durng squeeng thexamne plaes hs fnger beween he promalnerphalangea jonts
here are no ommon mstakes
Speading 1-11
odu Resst he subjet's atempt to speadhe nde and mddle fngers Fg 353)
Anaomal uu d
Muscle uncon:
Inteosseus dorsals IInerosseus dorsals m
Spreadng I-I
odu Resst the subet's attemp to spreadhe mddle and rng fngers Fg. 3.5
Anaomia uu d
Muscle funcon
Interosseus dorsals 11 Interosseus dorsals lV
WRST 5
g. 353 Rt eaao o he ners IIIII
g.3.54 Rt paao o g lIV.
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60 AAS O ORHOEDIC EAMINAON
Fg.55 ee eparao o te fie: V-V
Sredng VV
Podu Rit t ubjt attmpt to pradt ring and littl fingr ig. 355).
Anoi uu d:
Muse utio ntrou pamari IV Abdutor digiti minimi.
Squeezing 111
Podu Rit t ubct attmpt to uzyour fingr bwn indx and middl fingrig. 3.56.
Fg. 56 Squee he e: I-II
Fg .57 Sqeez e e: -IV
Anoil uu d:
Mue uo:
ntrou palmari II Introu dorai II
Squeezing II-IV
Podu Rit t ubjt' attmpt to uyour fingr btwn middl nd rng fingrig 357
Aoi uu d:
Musle uto:
Introu dora II Introu pamar IV
Squeeng IVV
Podu Rit t ubjt' attmpt to uzyour fngr bwn ring and itt fingr ig 3.58)
l 5 Squee te e: VV
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Anaomal uu d:
Musce fucti
Itereu dra IV Itereu palmar V
Neura cti
sce
Da neePama eeAbdct dgit ini
Peea
aaa
nevi
Neve
CTCC
Common pahoogia uaion:
Pa uuall the reut a le e the dral tere The mbat ptve tet hw whh e aeted
Weae ma be e the rt g atrp atera er r vlvemet the T1 erve rt It ma adate a le the ular erve
SPECIFIC TESTS
Phalen's test= forced flexion of thewist g 3
Signiian h a mpre tet r themeda eve the arpa tuel Releae
F. 39 hles tes
WRIST
the preure aue praethe the terrtr the meda erve - 3 ger medal adpamar.
Poiioning he ubjet preet the hadhe eamer grap the dta rearm wth thetraater had Wth the ther had he taehld the ubjet' had
Podu Brg the ubjet wrt pavet u le ad keep t that ptr abut a mute he uddel reeae thempre
Tinel s test percussion of the carpaltunnel Fg. 360
Sgniian h a per tet r themeda erve the rpal tue r r the ulaerve Gu' tue It huld elt paraethea the terrtr ether the medaerve 3- ger medall d plmar r theuar erve - 1 ular ger.
Poioning he ubjet preet the had pmupward he emer grp the wrt wthe had he ther hd ue the peruhammer.
Podu Gve a lght peru the rpaltuel
Gve a lght peru Gu tuel
F. 3.60 nel's tes
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62 ATLS O ORTOEDIC EAMIAO
Grind tt or th rapzium-irtmtacarpal joint Fig 361)
Significance This es is me dee repus
s smpm idiig rhrss.
Positoing The sube sds wih he rmhgig d he elbw 90 lexed. The exmiersds leve wih he subjes hd The rlerl hd grsps d sbies he wris heher hd es hld he dis pr he irsmerp be
Procedue. Exer xil pressure d irumduhe irs merpl be
F 361 Gr e
Fin kltn tt ig 3.62)
Significance. This es is me irm hepresee de Quervis disese I shuldbe mre piul h he ulr devii es s
desried pge 5
Posiioig. The subje sds wih he rmhgig he elbw lexed righ gle dhe rerm pred. The exmer sds ex he sbje The rler hd rries hererm whih is ep bewee his rm d ru.The her hd grsps he subes hd disll he merps irs merp uded.
Pocedue. Pull he sbjes wrs he lrside uil he ed rge is rehed.
F 362 keen' e
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CAPER CONENS
Surface and papatory anaomy 63Anteror 6
Bon andaks 6Papation o sot tisse 6
Posteror 66Bon andaks 66
Papation o sot tisse68
Fctoa exaiation of he hp 69Pasive ests 0
Passve exon 0Passve extea oation 0Passve ea otaon Passve adon Passive addon 7Passive extenson 7
soetr onrations Resisted lexon Resisted adtion Resisted adtion
Resisted exension Resised edia roation Resisted laeal rotation 6Resisted lexon o he knee Resisted exension o he nee
Sei tests 8Biateral passive edia roaton n one
oson 8Adon in exion 9Forel pwas hrs to he ee 9Ooans test 9r te 0
Hip
SURFACE AD PAPATORY
AATOMY
ATEROR
Bony landmarks Fig 4.
Th ingunl old cn ly idntfid I covrt inguinl ligmn (A) ht cn pptd rong firou nd
Th nrior uprior c pin i octdt th rniolr] nd of h fold Th ony
prominnc orm h poin o origin of oh roriu mucl nd th nor fci
Fg. 4.1 Bon landaks n vivo
C
63
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AAS O ORHOPEDIC EXAMNAION
msles The sine oninues aeraly an osalyn e ia es C.
A he meial en of e ingna fo anoherbony romnene an be alae he iuberle O Normay i lies leve wih he serior ase of he greaer rohaner oviesaahmen fo he meial en of e nguinalgamen an for e enon of he reusabominis Te enon of he auo ongusoginaes jus beow is ubee
Palpation of sot tssue
Plpn f h supicil xrs: h lrlfrl ngl Fg 4
Plae e aaing finger a few enimeresisal o he aneio suerior ilia sine an ashe aen o lif an a he ene egTwo srures an be fel an I or seen, one a
aeraemoraale
mse
Meial
ale
Gaismse
ig 2 B ladmaks
ea se of he finge foming an invee V (eaera emoal riangle) Te saoris (A) is emeial an he ensor fasae laae e aeralmsle (6) (ig 43 Noe also he bey of eeus femoris C a few enimees isa o heinvee V (ig 44.
e oigin of he ae is fel eely n heaeal femora riangle abou 5 m isa o heaneio sueior a sine As he aen oeen he nee ben he hi o 60' an asome resisane hs movemen makes he bellyof he musle beer visible Paae a bony omnene he nferior a sine from whie musle oginaes
Fig .3 atea emora trae
ig es emors he laeal emoal ane
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Me femr nge (gnum f Scrp)ig 45)
he meial emal tiangle is eine seriryy the ingina igament meialy by the
tr lngs an ateally y the sartriUhe lr the triangle is me by rtins
the ilisas n the latera sie an theetines n the meia sie
Definton n vvo
To define the bey of the saorus. Stan eve withhe nee the sjet at the isilatera sien ae the hi The hi is slightly ent anightly abte Kee the knee 90 exe with
ts lateal sie resting against y hi
. .5 o w of mc: 1 innalamn looa moa ay; cn; addco on; 6 acl; ao 8 c fmo o faca aa
I 65
As the atient t erm a lexin an latealrtatin at the hi The rmer is resiste with thentalateral han the latte with the isiateralne The mse bemes even mre visile i the
sbjet is ase t a sme lexin mve