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CLINICAL SIGNS

Aaron’s Sign

A feeling of pain/discomfort in epigastric region when the pressure is applied over the McBurney’s point in appendicitis. This is because developmentally appendix is a midline structure.

Babinski’s Sign (Extensor Plantar Response)

In upper motor neuron (UMN) lesions, on stroking the lateral border of sole, there is fanning of small toes and dorsiflexion of big toe (cf. normally there is flexion of all the toes) (Fig. 16.1). This is due to the loss of control of UMNs on the lower motor neurons (LMNs).

Ballance’s Sign

In case of splenic rupture, there is persistence dullness on the left side of abdomen due to early coagulation of splenic blood.

Battle’s Sign

In the fracture of the posterior cranial fossa behind foramen magnum, a patch of ecchymosis appears near the tip of mastoid process within three or four days. It is called the ‘Battle’s sign’.

Anatomical Basis of Clinical Signs and Tests 16

Fanning ofsmall toes

Dorsiflexionof big toe

B

Figure 16.1 Babinski’s sign. (A) Normal toe flexion, (B) Positive Babinski’s sign (dorsiflexion of big toe and fanning of other toes).

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142 ANATOMY FOR EXCELLENCE

Bezold’s Sign

Presence of swelling and tenderness in the mastoid area. It occurs due to formation of abscess beneath the sternocleido-mastoid muscle. Presence of this sign indicates mastoiditis (Fig. 16.2).

Boas’ Sign

An area of hyperaesthesia between the 9th and 11th ribs posteriorly, on the right side. This sign is suggestive of acute cholecystitis.

Chvostek–Weiss Sign

In parathyroid tetany, a gentle tap on facial nerve as it emerges in front of the external auditory meatus, i.e. just anterior to ear lobule, will cause a brisk muscular twitch on the same side of the face. This sign occurs due to hypocalcaemia.

Clenched Fist Sign

A characteristic gesture of a patient with angina pectoris. He clenches his fist in front of sternum to indicate constricting quality of pain/discomfort.

Cullen’s Sign

See Grey–Turner’s sign.

Dalrymple’s Sign

The abnormally wide palpebral fissure with visibility of upper sclera due to retraction of upper eyelid in the case of exophthalmos. To detect this sign of thyrotoxicosis, observe the eyes while patient focuses on a fixed point.

Drawer Sign

This sign is diagnostic of injury to the cruciate ligaments of the knee joint. It is elicited as follows:

The patient lies in supine position and knee is flexed at right angle keeping the foot on the bed. The clinician sits on the foot of the patient to fix the leg. Now the upper part of the tibia is pulled forward or pushed backward. If the anterior cruciate ligament is rup-tured, there will be increased anterior mobility; and if the posterior cruciate ligament is ruptured, there will be increased posterior mobility (Fig. 16.3).

Femoral Sign

In acute appendicitis, pain is elicited by passive extension of the right hip due to irritation of the psoas major muscle.

Froment’s Thumb Sign

In case of paralysis of adductor pollicis due to ulnar nerve injury, when the patient pinches a piece of paper/book between the thumb and index finger and pulls it, the distal phalanx

Swelling andtenderness

in mastoid area

Figure 16.2 Bezold’s sign.


143ANATOMICAL BASIS OF CLINICAL SIGNS AND TESTS

of thumb on affected side flexes. This is due to weakness of adductor pollicis muscle (Fig. 16.4).

Grey–Turner’s Sign

This sign indicates massive retroperitoneal haemorrhage due to rupture of duodenal ulcer, ectopic pregnancy, abdominal aneurysm or in acute haemorrhagic pancreatitis, the blood/haemorrhagic fluid tracks along the abdominal wall diffuses through subcutaneous tissue and causes bluish discolouration of loin (Grey–Turner’s sign) and around umbilicus (Cullen’s sign).

Homans’ Sign

In deep vein thrombosis of the calf, the forcible dorsiflexion of the foot leads to pain in the calf due to stretching of calf muscles. The pain results from venous thrombosis or inflam-mation of calf muscles (Fig. 16.5).

Joffroy’s Sign

When the patient with exophthalmos looks upwards with the face inclined downwards, wrinkling on forehead does not appear.

Kehr’s Sign

It is a cardinal sign in haemorrhage within the peritoneal cavity, viz. splenic rupture. In this the pain is referred to the tip of left shoulder due to irritation of the left dome of the diaphragm by splenic blood. There may be hyperaesthesia in the area of left shoulder. The pain usually arises when patient assumes the supine position and lowers his head.

This sign is elicited by elevating the foot end of the bed for 15 minutes, because this makes the blood to accumulate underneath the left dome of the diaphragm.

Anteriorcruciate

ligament

Rupturedanteriorcruciateligament

Posteriorcruciate

ligament

Rupturedposteriorcruciateligament

A

B

Figure 16.3 Drawer sign. (A) Rupture of anterior cruciate ligament, (B) Rupture of posterior cruciate ligament.

Figure 16.4 Froment’s thumb sign.



Kenawy Sign

In case of splenomegaly with portal hypertension, the clinician may hear a loud venous hum on inspiration with stethoscope placed just below the xiphoid process.

This is due to engorgement of splenic vein and the hum is due to the spleen being com-pressed, during inspiration.

Kernig’s Sign

It is a reliable indicator of meningitis. To elicit this sign, place the patient in supine position. Flex his/her leg at the hip and knee. Now try to extend the knee while the knee and hip are both flexed 90°. If patient feels pain and spasm in the hamstrings muscles, the Kernig’s sign is positive, i.e. meningial irritation has occured. This occurs due to involvement of spinal nerve roots by irritated meninges which surround them (Fig. 16.6).

N.B. Normally the knee can be extended up to 135° but in meningitis, it is restricted due to the spasm of hamstring muscles.

Figure 16.5 Homans’ sign.

Figure 16.6 Kernig’s sign.



Lasègue’s Sign

It is elicited to distinguish hip joint disease from sciatica. To elicit this sign, place the patient in supine position; then raise one of his legs and bend the knee to flex the hip joint. Pain with this movement indicates hip joint disease. With hip still flexed, slowly extend the knee. If the pain evokes at the angle above 40°, it indicates tension on nerve root. Now, the ankle is passively dorsiflexed. This causes aggravation of pain due to traction exerted on the irritated sciatic nerve. This indicates sciatica.

Laugier’s Sign

An abnormal spatial relationship of the radial and ulnar styloid processes. Normally the styloid process of radius projects 1 cm lower than the styloid process of ulna. But in fracture of distal end of radius (Colles’ fracture), the radial styloid process migrates proximally, so that it lies at the same level or at a higher level than that of ulnar styloid process (Fig. 16.7).

Lhermitte’s Sign

This sign detects the protrusion/prolapse of cervical intervertebral disc or the pres-ence of an extradural spinal tumour irritating the spinal dura.

The patient sits on the table. Now the head of the patient is bent downwards and for-ward passively (flexing the cervical spine) and simultaneously the lower limbs are lifted (flexing the hip joints). This will cause sharp pain (electric-like shocks) radiating down the spine and to both the upper extremities.

Llyod’s Sign

The referred pain in loin elicited by percussion over the kidney. This sign is positive in renal calculi.

London’s Sign

In case of the abdominal injuries, the characteristic ‘pattern’ bruising (an imprint of clothing or seat belt) on the abdominal wall indicates crushing force, which may have ruptured the bowel against the vertebral column.

A B

1 cm

Ulnar styloidprocess

Radial styloidprocess

Fracture

Figure 16.7 Laugier’s sign. (A) Normal, (B) Laugier’s sign position.



Ludloff’s Sign

In avulsion fracture of the lesser trochanter of femur (classically occurs in school going boys by a violent contraction of the iliopsoas muscle), the patient is unable to flex his hip joint but other movements are normal.

Macewen’s Sign

A ‘Cracked-pot’ sound is heard on light percussion over the anterior fontanelle if infant or young child is suffering from hydrocephalus. It is done to detect early hydrocephalus.

Mallet–Guy’s Sign

The pancreas being deeply located in abdomen, cannot be palpated normally, until a growth or cyst develops in it. The best way to palpate the pancreas is to turn the patient to the right with hips and knees flexed. Now the deep palpation underneath the left costal margin and epigastric region will evoke tenderness, in the acute and sometimes in the chronic pancreatitis (Mallet–Guy’s sign).

Möbius Sign

The patient with Grave’s disease (exophthalmos) shows the inability or failure to converge eyeballs.

Moses Sign

It is a sign elicited to diagnose the deep vein thrombosis of the leg. Squeezing of the relaxed calf muscles (gastrocnemius and soleus) from side-to-side leads to pain due to deep vein thrombosis in the calf, in which the vein is always tender due to inflammation.

Moynihan’s Sign

See Murphy’s sign described next.

Murphy’s Sign

This sign detects the tenderness in cholecystitis. To elicit it, the clinician places his/her right hand just below the right costal margin on the lateral border of the right rectus abdominis muscle. Now a moderate pressure is exerted with fingers to palpate the fundus of gallbladder. The patient is asked to take a deep breath (deep inspiration), the inflamed gallbladder descends and hurts itself to the examining fingers. Consequently, the patient will immedi-ately wince with a ‘catch’ in breath. The Murphy’s sign is a classic sign of acute cholecystitis.

Peau d’orange Sign

It is a classical sign in case of carcinoma of the breast. This is due to blockage of the subcu-ticular lymphatics with oedema of the skin, which deepens the mouths of sweat glands and hair follicles giving rise to the typical ‘orange peal’ appearance of the breast skin (Fig. 16.8).

Pemberton’s Sign

The obstruction of major veins in the thorax leads to engorgement of neck veins. This sign becomes obvious when the patient is asked to raise his/her hands above the head with arms touching the ears (Pemberton’s sign).



Phalen’s Sign

In case of ‘carpal tunnel syndrome’ when the patient is asked to flex the wrist, there will be exacerbation of the symptoms particularly paraesthesia within 1 minute and symptoms will disappear as soon as the wrist is straightened (wrist flexion test/Phalen’s sign) (Fig. 16.9).

Popeye’s Sign

When the biceps brachii muscle (BBC) contracts to flex the elbow joint there is a charac-teristic prominent bulge on the front of arm (especially in body builders). The bulge is produced by the contracted muscle belly of BBC. This is termed ‘Popeye’s sign’. Also see p. 126.

Prehn’s Sign

This sign differentiate epididymitis from testicular torsion. The relief of pain with elevation and support of scrotum indicates epididymitis.

Cancer

Subcuticular lymphvessels of the breast

Deepenedhair follicles

Oedematousskin

Figure 16.8 Peau d’orange (orange peel skin).

Median nerve Wrist flexed

Figure 16.9 Phalen’s sign.



Romberg’s Sign

This is a sign elicited to differentiate sensory ataxia from cerebellar ataxia (see Romberg’s test on p. 151).

Rotch’s Sign

Dullness on percussion over right lung, in 5th intercostal space indicates pericardial effusion.

Rovsing’s Sign

The tenderness is elicited at McBurney’s point in the right lower quadrant of abdomen by palpation and quick withdrawal of fingers over the point corresponding to McBurney’s point in the left lower quadrant of abdomen. This referred rebound tenderness suggests ‘appendicitis’.

Schamroth’s Sign

Normally when the two fingers are held together with nails touching each other, a space is seen, at the level of proximal nail fold. Loss of this space indicates clubbing (Fig. 16.10).

N.B. Clubbing is a condition in which nails are curved posteriorly both in transverse and longitu-dinal directions. It occurs due to bulbous enlargement of soft tissue underneath the nail.

Stellwag’s Sign

In the patient with exophthalmos (Graves’ disease) there is staring look, incomplete and infrequent blinking of the eyes, and widening of palpebral fissure. This is due to toxic con-traction of striated muscle fibres of levator palpebrae superioris.

Tinel’s Sign

In case of carpal tunnel syndrome, the percussion over flexor retinaculum results in paraesthesia (tingling and numbness) in the region of median nerve distribution of hand (Fig. 16.11).

Trendelenburg’s Sign

In normal state, the pelvis is held horizontally when the subject is standing on one leg. The gluteus medius and gluteus minimus contract as soon as the contralateral foot leaves the

A B

Space presentNo space

Figure 16.10 Schamroth’s sign. (A) Normal, (B) Schamroth’s sign positive.



ground, preventing the drop of pelvis to the unsupported side. If the pelvis tilts or drops towards the opposite side (i.e. normal side) when that foot is off the ground, the sign is positive and indicates such conditions as paralysis of gluteus medius and gluteus minimus, dislocation of hip joint or fracture neck of femur (defective abductor apparatus of hip joint) (Fig. 16.12).

N.B. The pelvis always drops/sinks on the normal side when patient tries to stand on the limb of affected side. This leads to ‘lurching gait’.

Troisier’s Sign

The enlargement of left supraclavicular lymph nodes (Virchow’s lymph nodes) indicates metastasis from primary carcinoma in the upper abdomen, often the stomach.

Flexor retinaculum

Figure 16.11 Tinel’s sign.

D D

X

AB

DD

NN

N

N

Figure 16.12 Trendelenburg’s sign. (A) Person standing on healthy leg, (B) Person standing on the defective leg (side on which abductor mechanism of hip joint is defective).



Trousseau’s Sign

In parathyroid tetany, if cuff of sphygmomanometer is bound around the arm and pressure is raised to or above 200 mmHg, the typical contractions in the hand are seen within five minutes.

Turner’s Sign

A bluish (bruse-like) discolouration of the skin of flanks is seen after 6–24 hours after the onset of retroperitoneal haemorrhage in acute pancreatitis.

von Graefe’s Sign

The patient with exophthalmos, if asked to look downwards, the upper eyelid lags behind the eyeball. This is because eyelids are retracted in exophthalmos.

CLINICAL TESTS

Adson’s Test

The Adson’s test is positive if an individual is suffering from cervical rib or scalenus anterior syndrome.

The patient sits on stool. He is asked to take deep breath in and to turn his face to the affected side. The clinician examines his radial pulse, which is often obliterated due to compression of the subclavian artery.

Apley’s Distraction Test

It is done to diagnose the tear in the collateral ligaments of the knee joint. The patient lies supine on the bed with thigh flexed. Now the clinician pulls and rotates the leg. If the patient complains of pain while the leg is pulled upwards and rotated laterally, it indicates the tear of medial collateral ligament. If the patient complains of pain while the leg is pulled upwards and rotated internally, it indicates the tear in the lateral collateral ligament (which is very rare).

Apley’s Grinding Test

It is done to diagnose the tear in the semilunar cartilages (menisci) of the knee joint. The patient lies prone on the table with knee joint flexed at the right angle on the affected side. Now rotate the leg from foot (cf. grinding). If the patient complains of pain while the leg rotates laterally, it indicates the tear in the medial lemniscus. On the other hand, if he feels pain while the leg rotates medially, it indicates tear in the lateral meniscus.

Baldwin’s Test

It is done to diagnose the retrocaecal appendicitis. A hand is placed over the right flank of the patient. Now the patient is asked to raise the right lower limb off the bed keeping the knee extended. The patient will immediately complain of pain in the case of retrocaecal



appendicitis. This is because the retrocaecal appendix remains in close contact with the psoas which became contracted during flexion of the hip joint.

Cope’s Psoas Test

It is also done to diagnose the retrocaecal appendicitis. The retrocaecal appendix lies on the psoas major muscle. Inflammation of retrocaecal appendix will therefore cause irritation of psoas major muscle (the chief flexor of the hip joint). The patient is turned to the left side and his right hip joint is hyperextended. The patient immediately complains of pain.

Obturator Test

It is done to diagnose the pelvic appendicitis. A pelvic appendix lies on the obturator internus muscle. When the pelvic appendix becomes inflamed, the internal rotation of the hip joint will stretch the obturator internus and the patient will wince in pain.

Ochsner’s Disk Test

In case of the median nerve injury involving flexor digitorum superficialis (FDS) and lateral half of flexor digitorum profundus (FDP), if the patient is asked to clasp his hands, the index finger on the affected side fails to flex and remains as a ‘pointing index’.

Perthes’ Test (Modified)

This test is done in the case of varicose veins of lower limbs primarily to know whether the deep veins and communicating veins/perforators (which connect superficial and deep veins) are normal or not.

A tourniquet is tied around the upper part of the thigh, tight enough to prevent any venous reflux down the saphenous vein. The patient is asked to walk quickly with tourni-quet in place. If the communicating and deep veins are normal the varicose veins will shrink, but if they are blocked, the varicose veins will be more distended.

Romberg’s Test

It is done to differentiate the sensory ataxia from the cerebellar ataxia. The sensory ataxia occurs due to loss of proprioceptive sensations in the lower limbs, while the cerebel-lar ataxia occurs due to cerebellar lesion. The Romberg’s test is elicited as follows: the patient is asked to stand up with heels together and arms at his side. Now note his posture and balance, first with his eyes open, then closed. If he is able to maintain posture and bal-ance with minimal swaying when the eyes are open or closed, he is suffering from cerebellar ataxia. But if he is not able to maintain posture and balance (with increased swaying) when the eyes are closed, he is suffering from sensory ataxia (Fig. 16.13).

Simmond’s Test

In rupture of tendo-achilles, the Simmond’s test is positive. With patient lying prone and feet hanging over the edge of the couch, the calf is squeezed, no plantar flexion is seen. (Note plantar flexion occurs if the tendo-achilles is intact).

N.B. Rupture of tendo-achilles commonly occurs about 5 cm above the insertion in middle-aged males, particularly while playing racquet sports, viz. lawn tennis, badminton, etc.



Trendelenburg’s Test

It is done to demonstrate, valvular incompetence of saphenous vein and insufficiency of perforators (communicating veins) at various levels. To perform this test, raise the patient’s legs above the heart level until the veins empty; then rapidly lower his legs. If the valves are incompetent, the veins will immediately distend.

A B C

Eyesclosed

Eyesopen

Figure 16.13 Romberg’s test. (A) Normal (patient can stand straight with eyes open and legs together), (B) Sensory ataxia (patient becomes unsteady when eyes closed), (C) Cerebellar ataxia (patient cannot stand straight with eyes open and legs together).


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