PHYSICAL EXAMINATION OF THE SPINE AND EXTREMITIES STANLEY HOPPENFELD, M.D. ‘Associate Clinical Professor of Orthopedic Surgery, Director of Scoliosis Service, Albert Einstein College of Medicine, Bronx, New York; Deputy Director of Orthopedic ‘Surgery, Attending Physician, Bronx Municipal Hospital Genter, Bronx, New York; Asso- Ciate Attending Physician, Hospital for Joint Dis- eases, New York, New York In collaboration with I[CHARD HUTTON Medical iNustrations by HUGH THOMAS, PRENTICE HALL UPPER SADDLE RIVER, NJ 07458Contents Acknowledgments Preface 1, Puysican ExAMINAaTION OF THE SHOULDER 2. Puysica EXaMmnaTION oF THE ELBOW 8B. Prysicat EXAMINATION OF THE Waist anp Hann Prysicat, EXAMINATION OF THE CERVICAL Spine AND TEMPOROMANDIBULAR JOINT a Examination or Garr PuysicaL EXAMINATION OF THE Hip AND PELvis PrysicaL EXAMINATION OF THE KNEE ora PiysicaL EXAMINATION OF THE Foor AND ANKLE 9. PrysicaL EXAMINATION OF THE Lumpar SPINE Bibliography Index Medical portal MedWedi.ru 35 7” 105 133 143 im 197 237 265 2671 Physical Examination of the Shoulder INSPECTION BONY PALPATION Suprasternal Notch Sternoclavicular Joint Clavicle Coracoid Process Acromioclavicular Articulat ‘Acromion Greater Tuberosity of the Humerus Bicipital Groove Spine of the Scapula Vertebral Border of the Scapula SOFT TISSUE PALPATION BY CLINICAL ZONES Zone | — Rotator Cuff Zone || — Subacromial and Subdeltoid Bursa Zone Ill — The Axilla Zone IV — Prominent Muscles of the Shoulder Girdle RANGE OF MOTION Active Range of Motion Tests Quick Tests, Passive Range of Motion Tests ‘Abduction ____ 180° ‘Adduction 4 (ay Extension 45° Internal Rotation 55° External Rotation 40°45" NEUROLOGIC. EXAMINATION Muscle Testing Reflex Testing ‘Sensation Testing SPECIAL TESTS ‘The Yergason Test Drop Arm Test Apprehension Test for Shoulder Dislocation EXAMINATION OF RELATED AREAS2 PHYSICAL EXAMINATION OF THE SHOULDER ACROMIOCLAVICULAR JT. GLENOHUMERAL ST (eHoULDER JoMNT) Fig. 1. The shoulder girdle. ‘The shoulder gicdle is composed of three joints and one “articulation”: 1) the sternoclavicular joint 2) the acromioclavicular joint 3) the glenohumeral joint (the shoulder joint) 4) the seapulothoracie articulation All four work together in a synchronous rhythm to permit universal motion (Fig. 1). Un- like the hip, which is a stable joint having deep Fig. 2. The humerus has very minimal osseous support. Notice the shallow glenoid fossa in the shoulder as ‘compared to the deep acetabular socket of the hip. acetabular socket support, the shoulder is a mobile joint with a shallow glenoid fossa (Fig. 2). The humerus is suspended from the scapula by soft tissue, muscles, ligaments, and a joint capsule, and has only minimal osseous support. Examination of the shoulder begins with a careful visual inspection, followed by a detailed palpation of the bony structures and soft tissues comprising the shoulder girdle. Range of motion determination, muscle testing, neurologic assess ment, and special tests complete the examination. INSPECTION Inspection begins as the patient enters the examining room. As he walks, evaluate the even- ness and symmetry of his motion; the upper ex- tremity, in normal gait, swings in tandem with the opposite lower extremity. As the patient dis robes to the waist, observe the rhythm of his shoulder movement. Normal motion has a smooth, natural, bilateral quality; abnormal motion ap- ‘pears unilaterally jerky or distorted, and often rep- resents the patient's attempt to substitute an inefficient, painless movement for one that was once efficient but has since become painful. Initial inspection should, of course, include a topical scan for blebs, discoloration, abrasions, scars, and other signs of present or previous pathology. Medical portal MedWedi.ruPHYSICAL EXAMINATION OF THE SHOULDER 3 As you inspect, compare each area bilaterally, noting any indications of pathology as well as the condition and general contour of the anatomy. The easiest way to determine the presence of abnormal- ity is by bilateral comparison, for such comparison more often than not reveals any variation that may be present. This method is one of the keys to good physical examination, and holds true not only for inspection, but for the palpation, range of motion testing, and neurologic portions of your examina- tion as well. Asymmetry is usually quite obvious, For ex- ample, one arm may hang in an unnatural position, either adducted (toward the midline) across the front of the body, or abducted away from it, leav- ing a visible space in the axilla, Or, the arm may be internally rotated and adducted, in the position of a waiter asking for a tip (Erb’s palsy) (Fig. 3) Now, tum your attention to the most prom- inent bone of the shoulder’s anterior aspect, the clavicle (Fig. 4). The clavicle is a strut bone that keeps the scapula on the posterior aspect of the thorax and prevents the glenoid from turning Fig. 3. Erb's palsy. anteriorly. It rises medially from the manubrial portion of the sternum and extends laterally to the actomion. Only the thin platysma muscle crosses its superior surface. The clavicle is almost subcutaneous, clearly etching the overlying skin, and a fracture or dislocation at either terminal is usually quite obvious, In the absence of the clav- ile, the normal ridges on the skin which define it (davicular contour) are also absent, and exagger- ated rounded shoulders are a visible result. Next inspect the deltoid portion of the shoulder, the most prominent mass of the shoulder girdle’s anterior aspect. The rounded look of the shoulder is a result of the draping of the deltoid muscle from the acromion over the greater tuber- osity of the humerus. Normally, the shoulder mass is full and round, and the two sides are symmetrical (Fig. 4). However, if the deltoid has atrophied, the underlying greater tuberosity of the humerus be- comes more prominent, and the deltoid no longer fills out the contours of the shoulder mass, Ab- normality of shoulder contour may also be caused by shoulder dislocation if the greater tuberosity is ; fh fh. yor ‘The clavicle is almost subcutaneous and clearly ‘etches the overlying skin. Medical portal MedWedi.ruPHYSICAL EXAMINATION OF THE SHOULDER Fig. 5. Dislocation of the shoulder. Fig. 6 The scapulae—Sprengel's deformity—partally undescended scapula. Fig. 8. Excessively kyphotic thoracic spine—Scheuer- Fig. 7. Lateral curvature of the spine (soollosis). __mann’s disease or juvenile kyphosis. Medical portal MedWedi.ruPHYSICAL EXAMINATION OF THE SHOULDER 5 displaced forward, as is usually the case; the shoulder loses its full lateral contour and appears indented under the point of the shoulder. The arm is held slightly away from the trunk (Fig. 5) ‘The deltopectoral groove lies medial to the shoulder mass and just inferior to the lateral con- cavity of the clavicle (Fig. 4). The groove is formed by the meeting of the deltoid muscle fibers and the pectoralis major muscle and is one of the most efficient locations in the shoulder’s anterior region for surgical incision. It also represents the surface marking for the cephalic vein, used for a venous cutdown if no other vein is easily acces sible. Now, direct your attention to the posterior aspect of the shoulder girdle (Fig. 21). The most prominent bony landmark is the scapula, a triangu- lar bone that rests upon the thoracic cage. The out- line of its ridges upon the skin makes the scapula easy to locate. In its resting position, it covers ribs ‘two to seven; its medial border lies approximately two inches from the spinous processes (Fig. 22). ‘The smooth, triangular area of the spine of the scapula is opposite spinous process T3, The scapula conforms to the shape of the rib cage, contributing to the slightly kyphotic shape of the thoracic spine. Any asymmetry in the relationship between the scapulae and the thorax may indicate weakness or atrophy of the serratus anterior muscle and may CLAVICLE SPINE OF SCAPULA -ACROMION. present asa winged effect (Fig, 66). Another cause of scapular asymmetry is Sprengel’s deformity, wherein the scapula has only partially descended from the neck to the thorax. This high-iding scapula may cause an apparent webbing or shorten- ing of the neck (Fig. 6) ‘The posterior midline of the body, with its visible spinous processes, lies midway between the scapulae. Notice whether the spine is straight, with- ciut lateral curvature (scoliosis) (Fig. 7). A spinal curvature may make one shoulder appear lower than the other, with the dominant side being more muscular, Occasionally, the thoracic spine is exces- sively rounded or kyphotic, usually a result of Scheuermann’s disease or juvenile kyphosis (Fig. 8). BONY PALPATION For the examiner, the palpation of bony struc- tures provides a systematic and orderly method of evaluating the relevant anatomy. Position yourself behind the seated patient; place your hands upon the deltoid and acromion. This frst contact with the patient should be gentle but frm to instill a feeling of security. A natural cupped position for your hands is most efficient and allows the finger- tips to gauge skin temperature, <2" wansRioM oF STERNUM 4 Fig. 9. Anterior aspect of the shoulder's bone structure, Medical portal MedWedi.ru