Physical Examination Of The Spine And Extremities Hoppenfeld.pdf

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 Center, Bronx, New York; Asso-

ciate Attending Physician, Hospital for Joint Dis-

eases, New York, New York

In collaboration with

RICHARD HUTTON

Medical illustrations by

HUGH THOMAS

APPLETON & LANGE

Norwalk, Connecticut

PHYSICAL

Contents

Acknowledgments

vii

Preface

PHYSICAL EXAMINATION OF THE SHOULDER

PHYSICAL EXAMINATION OF THE ELBOW

PHYSICAL EXAMINATION OF THE

WRIST AND HAND

PHYSICAL EXAMINATION OF THE CERVICAL

SPINE AND TEMPOROMANDIBULAR JOINT

105

EXAMINATION OF GAIT

133

PHYSICAL EXAMINATION OF THE HIP AND PELVIS

143

PHYSICAL EXAMINATION OF THE KNEE

171

PHYSICAL EXAMINATION OF THE

FOOT AND ANKLE

197

PHYSICAL EXAMINATION OF THE LUMBAR SPINE

237

Bibliography

265

Index

267

Physical

Examination of the

Shoulder

INSPECTION

BONY PALPATION

Suprasternal Notch

Sternoclavicular Joint

Clavicle

Coracoid Process

Acromioclavicular Articulation

Acromion

Greater Tuberosity of the Humerus

Bicipital Groove

Spine of the Scapula

Vertebral Border of the Scapula

SOFT TISSUE PALPATION BY CLINICAL ZONES

Zone I — Rotator Cuff

Zone II — Subacromial and Subdeltoid Bursa

Zone III — 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

45°

Flexion

90°

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

PHYSICAL EXAMINATION OF THE SHOULDER

GLENO HUMERAL Jr

(SHOULDER JOINT)

Fig. 1. The shoulder girdle.

The shoulder girdle is composed of three joints

and one "articulation":

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.

1) the sternoclavicular joint

2) the acromioclavicular joint

3) the glenohumeral joint (the shoulder

joint)

4) the scapulothoracic 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

INSPECTION

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.

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.

PHYSICAL EXAMINATION OF THE SHOULDER

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, turn 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

anteriorly. It rises medially from the manubrial

portion of the- sternum and extends laterally to

the acromion. 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-

icle, the normal ridges on the skin which define it

(clavicular 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

Fig. 3. Erb's palsy.

Fig. 4. The clavicle is almost subcutaneous and clearly

etches the overlying skin.

Plik z chomika:

Inne pliki z tego folderu:

Inne foldery tego chomika: