1 SEMIOLOGY ORTHOPEDIC FOR PHYSICIAN ASSISTANT AND MEDICAL EXPERT José Heitor Machado Fernandes, MD Visiting professor of occupational medicine course of postgraduate at the Faculty of Medicine, UFRGS. Ex-Visiting professor of occupational medicine course of postgraduate at the Faculty of Medicine, (FFFCMPA since 1997 until 2003) UFCSPA. Professor of medical expertise in postgraduate at Institute of Hospital Administration and Health Sciences, Porto Alegre / RS. International Member of the AAOS since 1978 until 2013. Member Jubilated SBOT since 1974 until 2013. ______________________________________________________________________ You can find the “Illustrated E-book of Semiology Orthopedic” in these addresses: 1) – On the blog of the semiology orthopedic for physician assistant and medical expert. http://www.semiologiaortopedica.com.br/ http://www.semiologiaortopedica.com.br/p/livro-eletronico-ilustrado-de.html Or: 2)- On Slide Share: “Illustrated E-book of Semiology Orthopedic”. http://www.slideshare.net/semiologiaortopedica/livro-eletrnico-de-semiologia- ortopdica-mdulo-10 Or: 3) On the Internet: by typing in Google: http://www.ufrgs.br/semiologiaortopedica/ (Illustrated E-book of Semiology Orthopedic with index) ______________________________________________________________________Module 7 - ORTHOPAEDIC PHYSICAL EXAMINATION – Part 1
2Module 7 issues • Approach to Medicine • Instruments for orthopaedic physical examination • Orthopaedic physical examination considerations • Minimum required anatomical knowledge • Dermatomes, miótomos and esclerótomos • Spinal cord injury levels and extent of paralysis • Standardized Neurological classification of Spinal Cord Injury-ASIA • Principles of orthopaedic physical examination • Examination of specific joints • ADAMA (evaluation of joint motion range) • Table for direction finding • Evaluation of muscle strength • Table for muscle strength test • Musculoskeletal evaluation form • Patient authorization • Neurological examination of motility • Neurological examination of the sensitivity • Special physical tests • Postural assessment • Orthopedic semiology armada (basics of Arthroscopy) • Semiology of the rheumatic patient • Rheumatic diseases • Interpretation of laboratory tests in rheumatology • Musculoskeletal Radiology • Orthopedics Examination Videos; L.B.Conochie, MD, F.C.R.S. Assistant Professor Department of Surgery Mc Gill University • Videos about Orthopaedic physical examination of SBOT
3________________________________________________________________________Transcript of presentation the topics and the text in the "slides" from module 7 .pdf inE-book Illustrated of Semiology Orthopedic.________________________________________________________________________ Approach to Medicine Instruments for physical examination • Pencil for marking of the skin • Tape Measure • Goniometers • Reflex Hammer • Cotton or Small bristle Brush • Hypodermic needle or metal Clip • Test tubes with Plastic Stopper • Stethoscope • Tuning Fork • Surgical skin Markers • Tuning fork-256Hz, 126Hz, 512Hz The Stethoscope The French physician René Théophile Hyacinthe Laennec (1781-1826) was a young overweight, but it was difficult to ausculatá it how they did so: through touch. To see boys playing with a Brazilian, the doctor had an idea. Upon returning to the hospital, used a card and gave him the form of a cylinder. Touched it on the back of the patient and put the ear on the other end. So, could hear the heart of the girl – was invented the stethoscope. From there, Laennec perfected his invention until you get small wooden trumpets for sounding that were the basis of todays instrument used by medical science. In 1839, the Czech Skoda has perfected the device, Joseph equipping it with two hollow tubes, which caused both ears could be used.
4 "Achologia" versus scientific method ORTHOPAEDIC PHYSICAL EXAMINATION(See figures in "slides"module 7 .pdf) • What is a physical examination? -The physical examination is the inspection, palpation, auscultation and measure the body and its parts. Is the step that follows the making of a patients history and precedes the request for laboratory tests in the diagnosis process. • What is the purpose of the physical examination? -The physical examination has two distinct purposes. The first is find a complaint, that is, to associate the complaint to a specific anatomical region. The second purpose of a physical exam is to qualify a patient complaints. Qualify the complaint involves describing his character (e.g. wave, deaf, twinge, etc.), quantify their severity (grades I, II, III) and define its relationship with the movement and function. • What is the usefulness of orthopaedic physical examination? Linking a patients complaints with an anatomical structure, physical examination clarifies the story and the symptoms of a patient. This, however, presupposes that the examiner has a thorough knowledge of anatomy. Also requires a methodology for analyzing logic and an application of the information obtained from the history and physical examination of a patient. This methodology is derived from a clinical philosophy based on specific concepts. These concepts include: 1) if the person knows the structure of a system and understand its function, it is possible to predict how the system is vulnerable to breakage and to insufficient (injury).
5 2)-A biological system is no different than an inorganic system and is subject to the same laws of nature (physics, chemistry, mechanics, engineering, etc.). However, the biological system, unlike inorganic system, has the potential not only to meet, but also to adapt to changes in their environment. These concepts form the basis for the understanding of the information collected on physical examination. • The musculoskeletal system, like any biological system is not static. Are in a State of equilibrium constant, which is termed homeostasis. (See figures in "slides"module 7 .pdf)• The Anatomists use the terms upper and upper limb to describe a structure known popularly as arm, and lower extremity or limb to designate what commonly is known as leg.• When you identify the segments that comprise the members there is some confusion. Anatomically the forearm and thigh terms correspond to their popular meanings, which does not occur with the words arm and leg, which, in the vernacular, refers to the top and bottom members, respectively.• In our text the term arm describes the segment of the upper limb between the shoulder and the elbow, while the term leg refers to the segment of the lower limb between the knee and the ankle.• This E-book is organized into 26 modules of didactic way.• Most of these modules addresses each one of them, an anatomical segment for a major joint or a part of the spine.• This Division is somewhat arbitrary, because the anatomical structures and the symptoms presented by the patient often overlap the adjacent body segments.• Therefore, both the hip joint as the lumbar spine are closely related with the pelvis, while the upper leg could be included with the study of the hip and knee.• In the body of this work are listed numerous other hypertext links, articles, videos, other images and sound, pertaining to a same subject that can be accessed, in this text, directly from the Internet.• Is the interconnectedness of the WEB that interweaves the media, allowing a more comprehensive understanding of science in the 21st century.
6• Musculoskeletal examination of adult patients is almost always directed by the symptoms.• Regional musculoskeletal complaints are very common and formal clinical training restricted that most clinicians receive evaluation and conduct this kind of disease explains their impact on the generalist daily professional activities.• Most patients have back pain at some point in their lives. The back pain is second only to the upper respiratory diseases as reasons for outpatient care.• The goal is to make sure that the back pain does not indicate the presence of a systemic disease and delete neurosurgical emergencies.• The patients history helps to assess the possibility of an underlying systemic disease (age, history of systemic malignancy, unexplained weight loss, pain, response to prior therapy, intravenous drug use, urinary tract infection or fever)• All the most important findings of the physical examination of lumbar hernia in patients with sciatica have excellent reliability, including pain caused by lifting straight leg (straight leg), pain caused by lifting the leg straight and contralateral ankle dorsiflexion to paresis or hallux (all with K > 0.6).• In the adult patient with knee discomfort, the practitioner should assess the presence of laceration of meniscus or ligaments.• The best manoeuvres to highlight a rupture of the anterior cruciate ligament are the anterior drawer sign and Lachman maneuver, in which the examiner detects the absence of a secluded end tip when the tibia is pushed toward the examiner with the patient stabilized femur.• Various maneuvers that assess pain, crackling or creaks along the joint between the femur and the tibia are used to search for meniscus tears.• As in several Diseases Musculoskeletal, no isolated finding has the accuracy of examination of orthopedist, that elaborates their chances from the anamnesis and clinical findings.• The shoulder exam aims to evaluate the amplitude of movements, maneuvers that cause discomfort and incapacitation.• Hip osteoarthritis is detected by restriction of evidence internal rotation and abduction of the affected hip. General practitioners often ask for x-rays to determine the need for referral to orthopedists, but plain radiographs are unnecessary at the beginning of the evolution of the disease. The degree of pain and disabling presented by the patient may confirm the diagnosis and indicate the referral to orthopaedic evaluation.
7 • Hands and feet may show evidence of osteoarthritis (local or as part of a systemic process) rheumatoid arthritis, gout or other connective tissue diseases. • In addition to the regional musculoskeletal disorders, such as carpal tunnel syndrome, various clinical and neurological disorders, assume the routine examination of distal ends to prevent complications e.g., diabetes [Neuropathies or ulcers] or sensory-motor neuropathy hereditary [clawing toe deformity]. ORTHOPAEDIC PHYSICAL EXAMINATION-SUMMARY OF FINDINGS OF PATIENTS The doctor should summarize the positive and negative findings relevant to the patient and not embarrass to express uncertainties, as long as they follow a plan of action (e.g., "I will examine it in the next query"). The reason to request laboratory tests, images and other nature must be explained. In addition, you need to program the return and the clarification of the results for the patient, especially if there is the possibility of having to give bad news to the patient. Some doctors ask the patient whether you want "something more" is discussed. Patients who refer new complaints at the end of the query may have been afraid to mention them before (e.g., "Incidentally, doctor, Im having a lot of chest pain"), although this does not necessarily become less important. ORTHOPAEDIC PHYSICAL EXAMINATION (See figures in "slides"module 7 .pdf)• The principles and methods employed in the clinical evaluation of locomotive system are the same as those used for other clinical specialties.• From the data of the anamnesis, complemented by observations during the physical examination, diagnostic hypotheses are elaborated and, from them, decisions are made about the need for further investigation by means of complementary methods, definition of a therapeutic plan or a prognosis.• It is useful to recognize some peculiarities of the locomotor system, especially in view of the difficulties of doctors not experts in the clinical assessment of patients. ORTHOPAEDIC PHYSICAL EXAMINATION
8• There is a need for solid knowledge of Anatomy and physiology of the musculoskeletal system for the correct interpretation of the data obtained and Semiologic. Unfortunately, this area of knowledge is often neglected in medical education, as well as in clinical practice of non-specialists.• Apart from the pathologies of traumatic origin, most clinical disorders of the locomotor system (also known by the generic term of rheumatism) does not have a well- understood etiopathogenesis.• Therefore, their Nosological classification is based more on the pattern recognition of common manifestations of that in complementary methods. An exception are the microcrystalline arthropathies, that the identification of certain Crystal in synovial fluid sets. The experts have been struggling in "define diagnostic criteria" for the various rheumatism.On the other hand, often it is necessary to seek clinical findings that extrapolate the locomotor system: in fact, some diagnostic criteria involve demonstrations in virtually all important systems. ORTHOPAEDIC PHYSICAL EXAMINATION The absence of specific complementary exams end up requiring the doctor, a fairly broad and sophisticated knowledge of semiology in the diagnostic evaluation of rheumatic. Due to recent demographic and sociological developments that have been taking place in post-industrial societies, particularly in relation to aging of populations (with consequent increased prevalence of rheumatism) and the greater amount of time available for leisure (with an increase of traumatic events), there is no doubt that diagnose and treat disorders of the locomotor system will be increasingly necessary skills of physicians not specialists. In the first decade of the 21st century witnessed the rise of urban violence, kidnapping, assaults by white weapons or firearms, homicides, the spread of drug trafficking in the capital and inland regions of the country and the world, the growing number of deaths in road traffic by major accidents ... all this complaining about urgent medical assistance, because the survivors were on the border between life and death. ORTHOPAEDIC PHYSICAL EXAMINATION The absence of specific complementary exams will eventually require the physician assistant, a fairly broad and sophisticated knowledge of semiology in the diagnostic evaluation of rheumatic.
9 Due to recent demographic and sociological developments that have been taking place in post-industrial societies, particularly in relation to aging of populations (with consequent increased prevalence of rheumatism) and the greater amount of time available for leisure (with an increase of traumatic events), there is no doubt that diagnose and treat disorders of the locomotor system will be increasingly necessary skills of non-medical specialists. In the first decade of the 21st century witnessed the rise of urban violence, kidnapping, assaults by white weapons or firearms, homicides, the spread of drug trafficking in the capital and inland regions of the country and the world, the growing number of deaths in road traffic by major accidents ... all this complaining about urgent medical assistance, because the survivors were on the border between life and death. ORTHOPAEDIC PHYSICAL EXAMINATION• The physical examination, in general medicine, is divided in steps or phases: inspection, palpation, percussion, auscultation and handling or special tests.• Auscultation and percussion orthopedic physical examination were eliminated.• Rarely used, except for auscultation to detect noises due to vascular constrictions or aneurysms or crackles of tendons, bone rubbing against Aponeurosis ("hip hip" snapping or Cap) worn by joints or osteoarthritis.• As the top and bottom members are not hollow structures, the percussion is not useful as it is to the design of the size of the organs in the chest and abdomen. ORTHOPAEDIC PHYSICAL EXAMINATION• The individual should be examined with minimal clothing, especially when the complaints include areas normally covered. The shame and the modesty of the patient must be respected.• The range of joint motion is given in degrees (direction finding), with some exceptions, considering the point "zero" that the anatomical position.• In assessing the movement of a joint calls, first, that the patient perform any active movement, and then search the passive movement.• So, the doctor has an idea of the patients pain and limitations and will lead its examination more properly.• The active drive incorporates, in evaluation, muscle strength, while passive movement is studying the joint tour.
10 ORTHOPAEDIC PHYSICAL EXAMINATION• When some specific test is done it should be done, first, in normal or less affected side.• According to the complaints of the patient, formulate the appropriate questions that you provide clues to their diagnostic hypotheses.• If possible, think and write the questions that make to your patient.• Make a table for the differential diagnosis between the suspected pathologies.• Use pictures of the human body in Anatomical position to register graphically its findings. Use graphic symbols with legend.• During the physical examination, perform the appropriate tests taking into view: procedure to conduct and condition to be detected. ORTHOPAEDIC PHYSICAL EXAMINATION• The physical examination of the patient begins with the inspection of the same, when you enter the Office.• Make your take on well-lit environment and broad enough to allow the completion of the maneuvers.• Make sure that the instruments to be used for the exam are at your fingertips.• Examine your scantily-clad patient to better visualize the body.• If possible do it accompanied by his Secretary or nurse during the examination of the patient.• Examine the patients posture and can change this stance.• Evaluate active and passive movements of the joints.• When necessary to make the angular measurement of these movements and record these measurements in the medical or clinical chip for evolutionary comparisons later. ORTHOPAEDIC PHYSICAL EXAMINATION• Make the assessment of the degree of strength of the muscular groups and compare with the contralateral side.• Test your reflexes and miotendíneos-abdominal skin.
11 • Note the mood of your patient. • Alert your patient that some tests can wake up pain when done . • If it considers it appropriate, before performing the physical examination of the patient, make an "informed" consent/authorization with date, signature and witness. • If remaining doubt with some spaceflight do it again until you clarify your question. • Always make a good exam! This leaves your patient happy. • A good atlas of Anatomy is always indispensable. • The specialized texts complete the necessary technical knowledge. Normal structure and function of the Musculoskeletal Tissues (See figures in "slides"module 7 .pdf) "Anatomy is to Physiology, as well as the geography is history: she describes the stage of events." Jean Ferme (1497-1558) On the Natural Part of Medicine (ch. 1) MUSCULOSKELETAL ANATOMY(See figures in "slides"module 7 .pdf) • ANATOMY-BRACHIAL PLEXUS • ANATOMY-LOMBOSSACRO PLEXUS • FORMATION OF A SPINAL NERVEFROM DORSAL NERVE ROOTS (SENSORY) AND VENTRAL (MOTOR) THAT PROTRUDE OUT OF THE CORD. • Relate the muscle strength with the branches: - The previous Division of L2, L3 and L4-obturator nerve and adductor of the thigh; - Posterior division of L2, L3 and L4-femoral nerve and contraction of the quadriceps muscle; - L4-quadriceps and thigh adductors;
12 - L5-extensor of hallux; Dermatomes• The sensory distribution of each nerve root is called a dermatome.• A dermatome is defined as the skin area innervated by a single nerve root. Each patient has minor differences and the dermatomes also exhibit a large degree of overlap.• The spinal nerve roots have a poorly developed epineurium and have no perineuro. This development makes the nerve root more susceptible to compressive forces, traction deformation, chemical irritants (e.g., alcohol, lead, arsenic) and metabolic disorders. Miótomos• The miótomos are defined as groups of muscles innervated by a single nerve root. The injury of a single nerve root is usually associated with paresis (incomplete paralysis) of miótomo (muscles) by she innervated. Consequently, it takes some time so that any weakness becomes evident in the isometric test resisted or miótomo. For this reason, the isomértrico test of miótomos is maintained for at least 5 seconds.• On the other hand, a peripheral nerve lesion causes complete paralysis of the muscles innervated by it, especially when the injury results in a axonotmesis and neurotmesis and, consequently, the weakness is immediately evident.• Differences in the magnitude of the resulting paralysis is due to the fact that more than one miótomo contribute Embryological point of view, for the formation of a muscle. Esclerótomos• A esclerótomo is a bone or fascia area innervated by a single nerve root.• As well as the dermatomes, esclerótomos can table a great variability between individuals.• Is the complex nature of dermatomes, miótomos and esclerótomos supplied by that nerve root that can lead to the referred pain, which is pain felt in one part of the body that usually lies a considerable distance from the tissues that gave origin. The referred pain is explained as an error of perception on the part of the brain.
13 Usually, the pain may be referred to in miótomo, or esclerótomo of any dermatome somatic or visceral tissues innervated by a nerve root, but strangely, it sometimes is not referred to according to a specific pattern. It is not known why this occurs, but medically it was found that is so. The referred pain is common in problems associated with musculoskeletal system. Musculoskeletal Assessment- Principles and concepts• "To complete a musculoskeletal evaluation of a patient, it is important to undertake a systematic examination, appropriate and detailed.• A correct diagnosis depends on a knowledge of functional anatomy, an accurate anamnesis, the diligent observation and scrutiny. The process of differential diagnosis involves the interpretation of clinical signs and symptoms, physical examination, knowledge of pathology and mechanisms of injury, provocative tests, palpation (joint motion and muscle strength), laboratory techniques and Imaging tests. Only through a comprehensive and systematic assessment it is possible to establish a correct diagnosis.• It is amazing to see how the Orthopedic physical examination is in a stage of continuous advancement.• The expansion of the clinical and biomechanical research, for example, led to the development of many new tests for the evaluation of abnormal ligament laxity (ligament instabilities).• Arthroscopy and advanced image technology, illuminated by the technicality of the 21st century, made it possible to discover new conditions and new clinical tests have been proposed to detect them.• Some techniques fell into disrepute or are no longer tracks, while others emerged to replace them or supplement them.• The examination of the musculoskeletal system through the prism of Orthopedics practice reveals a landscape in constant change.• The orthopedics is one of the few specialties in which the physical examination is a topic sufficiently extensive to serve as subject of a complete book.• To start the description of the Orthopedic physical examination, it is important to remember that a precise anamnesis and a targeted physical examination, combined with simple, complementary examinations requested only when essential, account for the vast majority of musculoskeletal conditions investigated.
14• One should be careful with the account of the patients main complaint, because even that relates to a specific anatomical region, this complaint may be a manifestation of systemic disease.• Examine the patient in light and spacious environment in such a way that allows the examiners drive around the examination stretcher.There must be enough room to test the March and the active and passive mobility of alljoints examined. Source: Musculoskeletal Assessment – David j. Magee PRINCIPLES OF PHYSICAL EXAMINATION 1-tell the patient what you are doing; 2-Test first the normal side (not involved); 3-Perform first active movements, followed by passive movements and then by isometric movements; 4-painful movements are performed by the latter; 5-Apply an under pressure to test the "end feel"; 6-Repeat the movements or maintain certain postures or positions when there is indication in history; 7-Perform isometric resistance movements in rest position; 8 us passive movements and to evaluate both the degree ligament as the quality (sensation produced) of openness are important; 9-To test the ligaments repeat the test with increased stress applied; 10-when testing a miótomo, contractions should be maintained for 5 seconds; 11-Warn the patient that the examination may cause exacerbation of symptoms; 12-respect and maintain the dignity of the patient; 13-refer the patient for specialized consultation if necessary (remember the warning signs- red flag); WARNING SIGNS (RED FLAGS-"RED FLAGS") THE EXAMINATION THAT INDICATE THE NEED FOR A MEDICAL CONSULTATION
15• Continuous severe Pain• Unaffected by Pain medication or position• Intense night Pain• Severe pain with no history of injury• Severe Spasm• Psychological Component SEGMENTAL EXAMINATION• The segmental examination described in this E-book emphasizes the joints of the body, its movements and its stability.• It is necessary that all appropriate tissues are examined to outline the affected area, which can then be examined in detail.• The application of tension, détente or Isometric Contraction in specific tissues produces both a normal response as an abnormal.• This action allows the examiner to determine the nature and location of the symptoms present and the patients response to them.• The examination reveals if certain activities cause or alter the patients pain. In this way, the examiner can focus attention on the subjective response (of feelings or opinions) as well as in the test findings.• The patient should be well informed regarding the exam.• Like all reviews the examination segment will depend on what the examiner found in history and observation. The examination Segment is used when: -There is no history of trauma; -There are root signs; -There is trauma with root signs; -Change sensitivity on the Member Exists; -There are Medullary signs ("Long paths"); -The patient has normal standards; -There is suspicion of psychogenic pain;
16 EXAMINATION OF SPECIFIC JOINTS • The examiner must use a constant and systematic method of examination, with minimal variations, to elaborate certain evidence provided by history or by asymmetric responses. For example, if the history is characteristic of a disc injury, the examination of all tissues that may be affected by disk should be thorough and should be brief for all other joints to delete mixed signals. • If the story suggest hip arthritis, hip examination must be thorough and should be brief for the other, again, to delete mixed signals. • When the story suggests a muscular injury, the pain will likely be triggered when the upper limb is examined. Even so, the supposedly normal structures should not be omitted in the examination.(See figures in "slides"module 7 .pdf) The following steps are performed with the patient standing, sitting and prowling. • 1. Inspect the skeleton and endsby comparing sides to: • Alignment • Contour and symmetry of body parts • Size • Gross deformity • 2. Inspect the skin and subcutaneous tissues on the muscles and joints and search: • Color • Number of skin folds • Swelling, Scarring • Pasta Inspection The information that is provided visually includes factors such as symmetric or compensatory movement in functional activities, body posture, muscular contours, body proportions and color, blemishes, scars, and skin folds. The body segment being evaluated must be well exposed to visual inspection. 3. Inspect the muscles and contralateral sides to compare:
17 • Size • Symmetry • Fasciculations and spasms 4. Palpate all the bones, joints and muscles surrounding it to: • Muscle tone • Heat • Localized pain • Edema • Crackles 4. Palpate all the bones, joints and muscles surrounding The bony landmarks are also used as benchmarks in order to measure the circumference of the members or of the trunk. The examiner must be skilled in palpation to determine the presence or absence of muscular contraction to evaluate muscle strength. Palpation is used to identify the bone or soft tissue deficiencies. The competence on palpation is achieved through practice and experience. There is so much individual variation in human anatomy that is necessary to perform the palpation in the greatest possible number of individuals. 4. Palpate all the bones, joints and muscles surrounding Palpation is the examination of body surface by touch (touch). Palpation is done to evaluate bone and soft tissue contours, the consistency of soft tissue and skin temperature and texture. The examiner uses the inspection (visual observation) and palpation to "show" the anatomy. The examiner should be able to locate the bony landmarks in order to align the goniometer to assess correctly the articular range of motion (ADM articulate).Palpate the members (examination of the peripheral vascular system) • Temperature, as compared to the contralateral limb. • Palpate the pulses peripherals : femoral, popliteal, posterior tibial, pediosos, axillary, brachial, radial and ulnar, noting its amplitude.
18• The description of the wrists is made by a range of zero to two crosses that is consensus published in 2000. 0 = absent pulse + = reduced ++ = normal• Research of thrillers(indicative of turbulent flow caused by stenosis or arteriovenous fistula).• Pulsatile Mass in arterial paths (suggestive of aneurysm)• Locker formation in regions of edema (absence of locker suggests Lymphedema)• Pain on palpation or hardening of muscle stores(crushing) may be linked to deep vein thrombosis DVT Active range of motion evaluation (ADAMA)• An overview of the evaluation of articular range of motion (ADMA), upper and lower limb and spine can be obtained with the use of tests that include the simultaneous movement in several joints.• For a detailed evaluation of the ADMA, the patient performs all active movements that occur normally in the affected joints as well as in the joints above and below them.• The examiner observes while the performer examinedeach movement active at a time and, if possible, bilaterally and symmetrically.• The ADMA provides the examiner information about patient disposition in jogging, coordination, level of consciousness, the degree of attention of the joint movement of movements that cause or aggravate the pain, muscle strength and the ability to comply with the instructions and perform functional activities.• The ADM may be diminished because of restricted joint mobility of the patient, muscle weakness, pain, inability to comply with the instructions or ill will in executing the move.• When evaluating the ADMA, make sure that the movement occurs only in the joint that is being evaluated. There may be movement of cheating or substitutes.• The passive ADM is evaluated in order to determine the amount of movement possible in the joint.• The passive ADM tends to be slightly larger and the ADM active due to the lightweight stretch (stretching) elastic tissues and, in some circumstances, the smaller mass of muscles relaxed.
19• The examiner leads the body segment through a passive ADM in order to estimate the ADM of each joint, to determine the quality of the movement across the whole of the ADM and the perception, to observe the presence of pain and determine if there is a default or not motion capsular capsular.• After this evaluation of passive ADM, the examiner repeats the passive ADM to measure it and register it with the use of a goniometer or measuring tape.• Hiperelasticidade Ligament tests. THEHyperextension of the elbow (B). Thumb at forearm C.Hyperextension of the art. Metacarpofalangiana of the index finger. D. Hyperextension of the knee Evaluation of joint motion range (ADAMA) Evaluation of muscle strength – Individual Assessment of movements. Medical Research Council scale. - Scale MRC (Medical Research Council)• A. Test of the strength of the m. quadriceps against gravity and resisted. B. Test of the strength of the Quadriceps femoris with gravity.• Note! For further study of the musculoskeletal evaluation it is recommended the book "Musculoskeletal Review by Hazel m. Clarkson", published in 2nd Edition, in Brazil, by Nd, 2002 Guanabara. In a single volume, this text presents the principles and methodology of the evaluation of both the range of motion (ROM) joint/goniometria manual muscle strength as well as for the head, neck, trunk, and extremities. Motility test• Upper Motor neuron Lesions or Central nervous system Entailing: Weakness: In the upper extremities, weakness is characterized by misuse of an outstretched arm of contralateral to the lesion side, with Extenders usually weaker than the flexors. In the lower extremities the flexors are usually weaker than the Extenders.
20 Muscle tone is increased to passive movements (spasticity); in fact might be "Pocket knife spring"; pyramidal tract lesions initials can cause sagging, then evolves to spasticity in a matter of days. Muscle tone is increased to passive movements (spasticity); There may be effects of "Pocket knife spring"; pyramidal tract lesions initials can cause sagging, then evolves to spasticity in a matter of days. The rigidity is a change of tone similar to spasticity, except not to depend on the speed of movement of the limb; changed commonly in extrapyramidal disorders (e.g. Parkinsons disease); not associated with increased reflexes or signs of Babinski. Deep tendon reflexes are exaggerated. Pathological Reflexes often are present, including the reflection of Hoffman (finger flexor reflex increased) and Babinski signs. Lower Motor neuron lesions or peripheral nervous system Entailing: The weakness is confined to muscles innervated involved (e.g. an ulnar nerve lesion will involve many intrinsic muscles of the hand and the flexor Carpi ulnaris, Peroneal nerve damage will entail the fall of the foot). Muscle tone is always reduced (sagging). Fasciculations may be present. Deep tendon reflexes are reduced or absent. Are not present pathological reflexes (e.g., Babinskis sign). Muscle strength scale (0-5) 0: Absence of muscular contraction 1: muscle contraction is present, but the end may not be moved 2: there is some movement, but the patient is unable to sustain the end against gravity 3: the tip can be moved against gravity, but not against an external resistance 4: able to move against some resistance 5: full Force
21 Useful Miótomos• C5:Deltoid (upper arm abduction), biceps (elbow flexure)• C6:Handle extension• C7:Wrist flexion• C8:Flexion of the fingers• T1:Adduction and abduction of the fingers• L1, L2, L3:Iliopsoas (flexion of the hip)• L2, L3, L4:Quadriceps (knee length)• L5:Dorsiflexion, eversion and inversion of the foot• S1:Plantar flexion• If, S3, S4:Anal external investigation Test of Deep Tendon Reflexes• Deep tendinous reflexes usually include the supinator reflex (C6-radial nerve), the biceps reflex (C5-basically muscle nerve), the reflex of triceps (C7-radial nerve), the patellar reflex (basically L4-femoral nerve) and the reflection of the ankle (S1-posterior tibial nerve).• The generalized hyperreflexia suggests a peripheral neuropathy.• A unilateral hiporreflexia suggests Radiculopathy, plexopathy, mononeuropathy.• The hiper-reflexia suggests an upper motor neuron disease and is associated usually spasticity and the Babinski sign.• The hiporreflexia of the upper extremities with hiper-reflexia of lower extremities suggests SHE or involvement of the cervical spine.• The Babinskis sign indicates an upper motor neuron disease, but it is normal in infants.
22• The mandibular reflex should be tested if they suspect a pseudobulbar palsy. Surface reflections (e.g., abdominal reflexes) may be absent in normal patients. Research method of Reflections Method: -percussion with rubber mallet:• Always make the right reflex be followed by left (or vice versa);• Position the patient so that the members are relaxed, and in symmetric position;• On test the glabellar reflex, nasolabial and mentale;• In the upper limbs, test the reflexes of digit flexors, the estilorradial, the estilocubital, the biceps and the triceps. If there is evidence of hyperreflexia is proceeding and ascertain the presence of pectoral and reflection of pathological reflexes of Hoffmann and Trömner (variants of finger flexor);• In the lower limbs, the patellar reflex test, adductor of the thigh and Achilles.• Pathological Reflexes of Hoffmann and Trömner(variants of finger flexor) in the MMSS; Hoffmann reflex- a sudden squeeze on the nail of the index finger, middle finger and the ring produces terminal phalanx thumb in pushups and the second and third phalanx of some other fingers. Trömner reflex- Scale of Reflexes• 0 = absent Reflex• 1 = decreased Reflex• 2 = normal Reflex• 3 = increased Reflection• 4 = transitional Clono (repeated contraction of a member hiperestendido)• 5 = extended Clono
23Scale of reflexes, how to register?0 = absent Reflex+ = Decreased Reflex+ + = Normal reflex+++ = Reflection increased, but not pathologic++++ = markedly hyperactive, with Clônus * associated* (repeated contraction of a member hiperestendido)+++++ = Clônus extended • Axial Reflections of the Face(See figures in "slides"module 7 .pdf) • Reflections of the MMSS • Reflections of the trunk • Reflections of LL • A. Outlining an area of sensitivity changed. B. two-point discrimination test, for peripheral nerve lesions or Radiculopathy affecting your fingertips (clip curved in such a way that the distance between your two tips is of 5 mm). CLONO or CLÔNUS • Clono (or Clônus) is a series of muscle contractions involuntary, rhythmic and clonic seizures induced by sudden passive stretch a muscle or tendon . • The duration is variable, subject to the time in which it keeps the distention. He often accompanies the spasticity and hyperactive deep tendon reflexes often seen in the corticospinal involvement. • The most common sites of clônus are: ankle (foot clono), knee (patellar clono), handle (hand and fingers clono) and jaw. • Clono sustained not disappears after a few hits and sustained (or prolonged) clono persists while the examiner continue to maintain light pressure on the foot
24 dorsiflexion. Non-sustained Clono (transitional, esgotável) and symmetrical ankle can occur in normal individuals with RTP physiologically alive.• Clono sustained, however, is never normal .• When the spasticity is particularly intense, may trigger the clono excitations that oftenhas denounced during the research of deep tendon reflexes of the sural triceps,quadriceps, masseter or digit flexors.• Even a slight plantar flexion, as pressure to step on the accelerator of a car, can cause violent, uncontrollable and repeated concussions. Ankle Clono• The ankle clono consists of a series of pushups and alternating rhythmic ankle extensions .• It is easier to get it if the examiner supporting leg, preferably with one hand under the knee or calf, hold the foot underneath with the other hand and make quick dorsiflexion of the foot while keeping slight pressure on the sole of the foot to the end of the movement.• The lower leg and the foot should be well relaxed, knee and ankle in moderate flexion and slight foot eversion. The answer is a series of alternating contractions. Patellar Clono• The PATELLAR CLONO consists of a series of rhythmic movements of the patella for up and down.• It can be raised if the examiner handling the patella between the index finger and thumb and perform a sudden and sharp downward movement, suspending the downward pressure at the end of the movement.• The leg should be extended and relaxed.• Clono patella can be obtained during the research of patellar reflex. WRIST Clono• CLONO-WRIST can be produced by sudden passive extension of the wrist or fingers. THE MAXILLARY CLONO occurs occasionally.
25 • At the ankle, usually can be done to stop a true clono by passive plantar flexion of the foot or acute hallucis; a fake clono (seen in psychogenic disorders) is not changed by this maneuver, besides being irregular when the frequency, rhythm and excursion. Fisopatologia of Clono Pathophysiological point of view (two mechanisms may be involved). • DOUBLE STRETCH1- A simpler explanation consists of alternating Extenders reflexes. Acute dorsiflexion of the foot may trigger a reflection in the Plantar flexors, with extensor plantar flexion teasing then a reflection in the dorsiflexors Extender, which results in a rhythmic oscillation by alternating contraction and relaxation of agonist and antagonist. • SPINDLE/GOLGI APPARATUS 2-in the ankle clono, the sudden extension of gastrossóleo evokes a twitch muscle basically analogous to an Extender that causes a reflex contraction resulting in plantar flexion of the foot. The walk down. This contraction raises the tension in the tendon Golgi tendon organs gastrossóleo, sending a pulse by Ib fibers saves that inhibit the contraction of gastrossóleo and facilitate the contraction of its antagonist, the Tibialis anterior muscle. The walk rises. This in turn extends passively the gastrossóleo and the cycle is repeated. Examination of Sensitivity Evaluate the sensations of Pain, temperature, and light touch • Pain, temperature and light touch are transmitted by sensory nerve endings, the treatment espinotalâmicos, the core ventroposterolateral (NVL) of the thalamus and the sensory cortex Central Post Office in the parietal lobe. • The feeling of pain is tested by the use of a PIN.In the case of lesions of the CNS, test the entire side of the body.In the presence of a sensory cortical dysfunction, the arm will deviate without a direction setwhen extended.In cases of suspected spinal cord injury, look for a sensorial level (an area of the trunk in whichthere is a clear difference in sensation). In the lesions of the peripheral nervous system, thePIN must be used on dermatomes or on the distribution of peripheral nerves. Evaluate the sensations of Pain, temperature, and light touch
26 • The findings for the consideration of the temperature will be the same as for the sensation of pain. • The light touch is tested by using a finger or a cotton ball.Rarely it is entirely absent, due to large overlap in sensitive system. Evaluate the vibratory sensation and Positional • Vibrational and positional sensations are transmitted by sensory nerve endings, the posterior columns of the spinal cord, the medial lemniscus pathway, thalamus and the sensory cortex. • The vibrating sensation is tested by moving a tuning fork (128 Hz) on each joint, starting with the toes. • The sense of joint position is tested by moving a joint or a finger quickly and asking if the patient in which direction the finger moved. This is the ideal test for the function of the posterior column. • The Romberg sign evaluates whether the patient can remain stable when standing with eyes closed.The Unsteadiness with eyes closed indicates a dysfunction of peripheral nerves of large fibresor of subsequent columns in the lower extremities.The Unsteadiness with eyes open indicates a Cerebellar lesion. Evaluate the Cortical Sensation (Evaluate Parietal function) • Two-point discrimination test (2 Peter) • Grafestesia: ability to identify numbers "written" on the Palm of each hand with the examiners finger. • Topognosia: ability to locate the feeling (the patient must determine whether it is being apalpado with eyes closed). • Estereognosia: ability to identify shapes and sizes by tact (put the objects in the patients Palm) Examination of Sensitivity Dermatomes and Segmental Motion • C5:Deltoid (upper arm abduction), biceps (elbow flexure) • C6:Handle extension • C7:Wrist flexion
27• C8:Flexion of the fingers• T1:Adduction and abduction of the fingers• L1, L2, L3 : Iliopsoas (flexion of the hip)• L2, L3, L4:Quadriceps (knee length)• L5:Dorsiflexion, eversion and inversion of the foot• S1:Plantar flexion• S2, S3, S4:External anal sphincter A. Outlining an area of sensitivity changed. B. two-point discrimination test, for peripheral nerve lesions or Radiculopathy affecting your fingertips (clip curved in such a way that the distance between your two tips is of 5 mm). Precautions in physical examination• List of conditions that deserve special attention during the testing of range of motion or orthopedic and neurological physical tests:- Dislocation- Non-consolidated fracture- Myositis ossificans/ectopic ossification- Joint infection- Severe osteoporosis- Bony ankylosis- Consolidated fracture recently (newly formed bone callus)- Immediately post-op and/or late Specific physical tests-early care• The physical tests, specific orthopedic are designed to overwhelm functionally isolated tissue structures in terms of underlying pathology .• The physical tests do not constitute a diagnosis alone, and Yes, a biomechanical evaluation to be used as part of a complete medical examination.
28 • Before performing certain specific tests you must be sure that they will not be harmful to the patients condition. • If it is established that the specific physical tests may affect the patient, must be used structural and/or functional tests, such as x-rays, CT SCAN, MRI, ENMG before any physical test. Sensitivity/Reliability of special tests Each special test this presentation has its degree of sensitivity/reliability evaluated by a scale. • For each diagnosis presented there are various tests. • Some of them are more sensitive/reliable than others. • The tests were classified based on the Biomechanics of movement to isolate the affected structures. • The scale is numbered from 0 to 4, with a degree of sensitivity/reliability of 1 to 2 is bad, from 2 to 3 is moderate and 3 to 4 is very good. • More sensitive tests/reliability should be applied first. This helps to assess the State of the patient more quickly. Sensitivity Range/Reliability of Semiological Special Test "Based on the Biomechanics of movement to isolate the anatomical structures affected."Score range: 0 to 4Sensitivity/reliability of BAD Test = (1-2)Test/reliability sensitivity MODERATE = (2-3)Sensibilida of test Reliability/ VERY GOOD = (3-4)Source: - Cyprian, j.- Orthopedic and neurological tests Manual, 4th ed.-Manole 2005 SUMMARY OF SPECIAL TESTS OF THE MUSCULOSKELETAL SYSTEM Musculoskeletal Examination Welcome to Musculoskeletal Examination Worldortho
29http://www.worldortho.com/dev/index.php?option=com_content & view=article & id= 411&Itemid= 15(To open the desired text click on the link.)Neck Shoulder Elbow Wrist & HandBack Hip Knee • For each joint of the body and to the different segments of the cervical spine, there is a specific module, with the description of the corresponding orthopedic exam. • For a detailed description with illustrations of maneuvers and conditions detected you need access, in this hypertext, the module of interest articulation. • Then, to see the approach of physical tests for Knee open module 18.pdf Musculoskeletal Assessment- Principles and concepts • It is amazing to see how the orthopedic physical examination is in a stage of continuous advancement. • The expansion of the clinical and biomechanical research, for example, led to the development of many new tests for the evaluation of abnormal ligament laxity (ligament instabilities). • Arthroscopy and advanced image technology, illuminated by the technicality of the 21st century, made it possible to discover new conditions and new clinical tests have been proposed to detect them. • Some techniques fell into disrepute or are no longer tracks, while others emerged to replace them or supplement them. • The examination of the musculoskeletal system through the prism of Orthopedics practice reveals a landscape in constant change. • The orthopedics is one of the few specialties in which the physical examination is a topic sufficiently extensive to serve as subject of a complete book . Tests for Cervical Spine To see pictures of the achievement of maneuvers specific tests access the respective modules of the large joints, in the E-book: modules 8-19.pdf • The intrinsic muscle motor examination of cervical column indicates any muscular hypotonia and determines the integrity of nerve supply. • The neurologic exam tests all upper limb by neurological levels.
30 • -Flexion: the patient sitting, attach the upper chest (sternum) of the patient, with one hand in a manner preventing substitution flexion of the neck by bending of the thorax.Place the Palm of your hand that will print resistance against the patients forehead, keepingthe fixed in order to establish a firm base of support. Then ask the patient to duck the neckslowly.When he does so, gradually increase the pressure to determine maximum resistance that it iscapable of supporting. Correlate their findings with the muscle efficiency. Tests for Cervical Spine • -Lateral rotation: we were standing in front of the patient and put his hand over the left shoulder of sway patient, what will prevent it from overriding the rotation of cervical spine by rotating the thoracolumbar column. Flatten the hand that will offer resistance along the right edge of the jaw. Ask the patient to turn his head toward your hand imposing maximum resistance that it is capable of supporting. Compare the results of the examination to the right and left. • -Side slope: the examiner puts his hand on the right shoulder of sway patient, preventing the replacement of movement that wants to evaluate for scapular elevation. Flatten the hand that will impose resistance on the right side of the patients head. To obtain a firm basis of resistance, the Palm of the examiner should overlap the patients temple, with the fingers stretching afterwards. Ask the patient to tilt your head sideways toward your Palm, trying to pull the ear on the shoulder. When he starts to tilt your head, go gradually increasing the pressure to determine the maximum strength that he is capable of winning. • -Cervical spine Distraction: traction relieves the pain caused by narrowing of the neural foramina (which results in nerve compression), is able to enlarge the foramen and relieves muscle spasm because it gets the relaxation of muscles contracted. Place your hand flat under the Chin of the patient, while the other hand is placed in the occipital. Then lift (tracione) my head by removing the weight that it carries on the neck. • -Compression of the cervical spine (Spurling test): you will be able to help locate the neurological level of pathology that may exist. But can aggravate the pain caused by narrowing of the neural foramina: pressure on the joint surfaces of the vertebrae and muscle spasm. Press down the top of the patients head, which must be seated. Observed-if the pain is limited to some of the dermatomes. • Valsalva test: this test increases the intrathecal pressure. If the cervical canal is taken by some injury that occupies space vertebral intra-canal, such as tumors or herniated cervical disk, the CSF pressure will cause the patient complain of pain. The pain may radiate through the distribution of the dermatomo corresponding to the neurological level of cervical spine pathology. Ask the patient to hold your breath and do strength as if he wanted to evacuate. Then asks the patient if the pain got worse, and if so asks for describing the location of pain in upper limb. Is a subjective test, which requires patients precise answers.
31 • Adsons test: serves to determine the permeability of the subclavian artery, which may be compressed by the scalenus muscles Contracture, cervical rib, by congenital aderençais flanges. Palpate the patients radial pulse, continue palpating and abduza, extend and rotate the arm examined externally. Then ask them to hold your breath and head back toward the arm examined. If there is compression of the subclavian artery, the radial pulse will decrease range, and could even disappear (Thoracic outlet syndrome). Tests for Cervical Spine-X Strain Sprain: Sprain is a series of injuries depending on the type and the intensity of thetrauma, not enough to cause dislocation, resulting in ligament trauma. Bloating is an excessiveand/or violent pull that causes displacement or fountain.With the patient in the sitting position, the patient will perform all movements of the cervicalspine in its full range of motion with the examiner actively enforcing it, and followingresistance movements will take place passively.Pain during the movements against resistance or isometric muscle contraction means muscledistension.Tests for Cervical Spine • Isometric Contraction also known as static contraction is muscle contraction that does not cause movement or shifting joint, the muscle has a static work. There is no change in muscle length, but rather an increase in the maximum voltage. Pain during passive movement can indicate a sprain of the ligaments. • Note: this maneuver can be applied to any joint to determine ligament or muscle impairment.During a movement against the resistance the main structure to be tested is the muscle, andduring the passive motion the main structure to be tested is the ligament.Therefore, it should be able to determine between Muscular Distension or Ligament Sprain, ora combination of these. Vertebral-artery test • Used to diagnose artery stenosis vertebral, which causes signs and symptoms such as dizziness, vertigo and nystagmus. • The patient is positioned supine, and the column is sequentially placed in different positions (extension, left and right rotation and extension), which are maintained for 30 seconds. • The onset of symptoms indicates the diagnosis.
32 Lhermitte-test • The patient is kept in a sitting position, while the examiner makes the passive flexion of the cervical spine • In cases of meningeal irritation or multiple sclerosis, patients present pain radiated to the trunk or to the members. Brudzinski-testUsed to determine if there are meningeal irritation. In supine position, the examiner tries toduck passively the patients cervical spine.Meningeal irritation, when this is impossible and can be accompanied by bending the knees. Neural Stress for upper limbs* Median nerve (C5 to T1): patient in supine position of elbow flexion, and extension of thewrist and shoulder abducted. The examiner will perform a full extension of the elbow andwrist. The test must be done first and then passively done actively. The head should be roundto the opposite side to the test.* Radial Nerve (C5 to T1): patient in supine position of elbow flexion, and flexion of wrist andshoulder abducted. The therapist will perform a total extension of elbow flexion and totalhandle. The test must be done first and then passively done actively. The head should beround to the opposite side to the test.* Ulnar Nerve (C7 to T1) or bilateral elbow flexion test: patient in supine position, with elbowextension and extension of the wrist and shoulder abducted. The examiner will perform totalshoulder abduction, flexion of the elbow and a total length of handle. The test must be donefirst and then passively done actively. The head should be round to the opposite side to thetest. Testing for thoracic spine (To see pictures of the achievement of maneuvers specific tests to access the respective modules of large joints, in the E-book: 8 the 19.pdf modules) • Adams-maneuver (minute) The patient in standing position, is instructed to make the previous trunk inclination.The examiner then you observe the tangential way column.
33In cases of escolioses structured, will be noticed a deviation or a giba on the side of theconvexity of the curve.In cases of curves unstructured (lower limb dismetria and curvature caused by pain), theasymmetry in the trunk is corrected. Tests for the lumbar spine (To see pictures of the achievement of maneuvers specific tests to access the respective modules of large joints, in the E-book: 8 the 19.pdf modules) • The lumbar spine gives back mobility, provides support to the trunk and transmit the weight of the body to the pelvis and the LL. The patient should undress. The presence of signs or hair patches on the skin color of Cafe-au-lait, the back can translate some disturbance in the column. Note If the patient avoids bowing, twisting and promote other movements. If the patient has localized lower back pain with no root component, then you can if you suspect of lumbar muscle spasm or facetária capsulitis. • -Sciatica: Serves to evaluate whether there are lumbar disc herniation or an expansive lesion that can compress the nerve roots and may raise the sciatic nerve. Sciatic nerve pain thigh runs down the knee toward the foot, and splits in the tibial and fibular nerve terminals. The examiner must duck the hip of the patient and find the midpoint between the isquiática and the great trochanter tuberosity. Will then press firmly at that point, palpating the nerve that is easy to place. Tests for the lumbar spine • -Lateral flexion: contralateral movement, with pain on the other side, to investigate the joint capsule. • -Tilt: detects ligament injury. Secure the patients iliac Crest and asks for it to tilt the torso to the right and/or left. Compare the two sides. For passive tilt test, fix the patients pelvis and hold the shoulder, leaning to the right and then to the left. Check both sides.
34 • -Rotation: put yourself behind the patient and stare at the pelvis by placing your hand over the iliac Crest and the other on the shoulder, then attach the trunk that will be achieved by rotating the pelvis and shoulder later. Check both sides. • -Modified Lasegues test: flexion + supply + rot. int. (reversal) + leg elevation. If the feel pain patient , to suspect of lumbosciatalgia (true sciatica). • Test of lower-limb elevationThe patient in dorsal decubitus, has his high knee lower limb extended (straight leg raisingtest).From 35° to 70°, the patients with Radiculopathy secondary to compression of the roots at theL4-L5 or L5-S1 (lower lumbar roots) have their symptoms exacerbated.When the pain is exacerbated in the contralateral lower limb to being high, the positivepredictive value for a hernia is very large.Not to be confused with Radiculopathy pain later in the thigh by shortening of mm.hamstrings. • Schober-test The patient is kept in standing position.One point to S1 level is marked on your skin with a pen dermográfica (S1 is at the level of theposterior-superior iliac spines).From that point, are marked another two, one 5 cm distal and another 10 cm proximal to thebrand.Then, the patient is asked to make maximum flexion of the lumbar spine.In normal situations, this distance must increase in 6 to 8 cm with flexion.If that doesnt occur, the patient may present diagnosis of ankylosing spondylitis. • Femoral stretch Test-Used to diagnose lumbar roots high compression that give rise to the femoral nerve (L2-L4roots).The patient in prone position (pronated), is subjected to hip extension and passive kneeflexion.
35It will present more pain or paresthesia in the anteromedial surface of the thigh (territoryinnervated by no femoral) if these roots Radiculopathy. • Test of spondylolysis-The patient in standing position, is driven to keep the weight only on one of the lower limbsand to extend the lumbar spine (approaching the spinous processes from each other).There will be pain in those with fracture of the pars intearticularis or pathology of articularfacets. • Hoover test- • Used to detect patients with complaints.In this test, the patient is supine, with both heels on the palms of the examiner, being orientedto promote actively a lower limbs.In normal situations, the contralateral lower limb presses the Palm of the hand of theexaminer.If that doesnt occur, the patient is faking that cant raise the lower limb. Neural Stress to the lower limbs* Femoral Nerve (L2, L3 and L4): patient standing supports one of the knees (flexed to 90°) ona Chair, then asks to make the side slope of the trunk. The test will be positive if sciatica(irritation of the upper lumbar roots that form the femoral nerve). If the problem is local painis in the hip joint capsule;* Sciatic Nerve (L4-S3): can you use the Lasegues test (true), Slump and Shim (patientstanding and with the ante foot supported on a spacer, for example a book, the examiner asksthe patient make flexion of the trunk. If so there will be sciatica). Tests for art. Sacroiliac Joints (To see pictures of the achievement of maneuvers specific tests to access the respective modules of large joints, in the E-book: 8 the 19.pdf modules) Gaenslens testThe patient in dorsal decubitus, with both knees together to the body, is placed on the edge ofthe examination table (maca)
36The Member to be tested is taken toward the ground, always having support of the examiner.The pain in the sacroiliac region will ispsilateral of patients with inflammatory or degenerativepathology of this joint. Patrick s test-The patient is positioned supine, with flexion, abduction and external rotation of the hip.The ankle is positioned on the lower limb contralateral knee.The examiner applies force down on the knee of the Member to be tested with one hand andthe contralateral pelvis with the other.If there is inflammation in the sacroiliac joint, there will be the appearance of pain. Special Shoulder Tests (To see pictures of the achievement of maneuvers specific tests to access the respective modules of large joints, in the E-book: 8 the 19.pdf modules)Tests for tendons • Speeds test • Yergasons test • Empty/full can tests • External rotation lag sign • Lift-off signImpact test • Neers sign • Hawkins-Kennedy impingement test • Internal rotation resistance strength test • Posterior impingement testTests to the glenoid labrum • Crank test • Biceps load test II • Previous slide test
37 • SLAP test prehensionTests for instability • Apprehension and relocation test • Load and shift test • Norwood stress test • Sulcus signTest for acromioclavicular joint • Active compression test • Scarf test • Shear test Tests for Shoulder • Test of Supraspinatus (Neer)Indicates change of supraespinhaso that is tested by active upper limb elevation (in the planeof the scapula) in neutral rotation and extension against resistance by the examiner, theanswer might just be pain in the anterolateral shoulder face whether or not accompanied byreduction in force or even the inability to raise the upper limb indicating since tendinitis untilcomplete supraspinatus Tendon ruptures. • Assurance of Supraspinatus (Hawkins) –Used to diagnose subacromial of the supraspinatus impact against the coracoacromialligament.The patient remains in standing position, and your shoulder is positioned at 90° of abduction.After, the wheel shoulder internally examiner looking cause pain. • "Drop arm test"- arm drop testIndicated to determine the presence of Rotator cuff injuries.Positioning the patients shoulder at 90° of abduction, requesting, then it returns the shoulderto neutral position.When there is an injury of the rotator cuff, he may not be able to perform this motion slowly,leaving the arm fall.
38 • Test of Supraspinatus (Jobe)The patient makes active upper limb elevation (in the plane of the scapula) in extension andinternal rotation against resistance by the examiner, a position that sensitizes the tensionexerted on the supraspinatus tendon; the answer might just be pain in the anterolateral aspectof whether or not accompanied by reduction in force or even the inability to raise the upperlimb indicating since tendinitis until complete Tendon ruptures. If the test is inconclusive doesanaesthetic test of Neer and repeats the test of Jobe. • Test for the Infraespinhoso-The patient in ortostatism, with the shoulders in neutral position and bending of elbows to 90°,is oriented to perform forced external rotationIs considered positive when causes pain or loss of strength, indicating tendinitis and ruptures,respectively.This same muscle can be tested by Patte maneuver, when an external rotation againstresistance is made with the shoulder abducted to 90° and the elbow flexed at 90°. • Biceps brachii test (Test Speed)Indicates the presence of alteration of the long head of the biceps (long portion of bicepstendonitis). Is tested by active flexion of the upper limb, in extension and external rotationagainst resistance by the examiner; the patient complains of pain intertubercular Groove(bicipital Groove of the humerus) with or without associated functional impotence. • Subscapular test (test of Gerber)The patient places the back of the hand to the level of L5 and actively seeks to move it back byturning the arm internally, the inability to do so or to maintain the spacing of the lumbarregion features, indicates m. subscapularis injury. • Yergason test-Used to diagnose tendon pathology of the long head of the biceps (tendinitis or subluxation).The patient may be sitting or at ortostatism.The shoulder is positioned in neutral position, with elbow flexion to 90°.
39The patient is then instructed to resist the external rotation of the shoulder, elbow extensionand pronation of the forearm. • Previous Seizure testThe examiner, putting himself behind the patient, does, with one hand, abduction, andexternal rotation forced passive extension of the patients arm, at the same time pressing withthe thumb of the other hand to the posterior aspect of the humeral head; When there isanterior instability the sensation of impending dislocation causes fear and apprehension ofthe patient. (He tests the integrity of the inferior glenohumeral ligament, anterior capsule,tendons of the rotator cuff and glenoid labrum). • Posterior Instability-testThe examiner makes the adduction, flexion and passive internal rotation of the arm of thepatient looking for shift later the head of the humerus; When there are subsequent instabilitythe humeral head slips in the posterior edge of the glenoid and inferiorly subluxates. (posteriorglenohumeral instability). • Fukuda testUsed to detect subsequent instabilities.The shoulder of the patient is subjected to flexion, adduction and internal rotation.An axial force is exerted on his elbow with the intention of luxá it later.The test is considered positive if the patient seizure or generate the glenohumeral subluxationlater. • Rockwood testUsed to detect instabilities.The patient should remain in standing position.The examiner applies an external rotation of the shoulder of the patient with abduction of 0°to 120°.The test is considered positive when the patient display pain and seizureaccentuated the 90°. • Groove-Test
40Used to detect bottom or multidirectional instability .A longitudinal traction is exerted downward on the upper limb of the patient, who may besitting or ortostatism, with the shoulder in neutral position.In cases of instability, there will be a lower translation increased, with the appearance of aGroove under the acromion.The external rotation of the shoulder tends to normalize this Groove by tensioning of Rotatorinterval. Special tests for Elbow (To see pictures of the achievement of maneuvers specific tests to access the respective modules of large joints, in the E-book: 8 the 19.pdf modules)Tests for tendon • Tennis elbow test • Golfers elbow testTests for ligamentous instability • Valgus test • Varus test • Posterolateral pivot shift test • Chair push-up testNeurological Tests • Tinels test • Pressure provocation test • Ulnar nerve Flex test Tests for Elbow • -Test for Medial Epicondylitis (golfers elbow Tennis): patient sitting, extends the elbow and the wrist and hand supine; patient will Flex the wrist against resistance. The tendons that Flex the wrist are attached to the medial epicondyle. If it caused pain in the medial epicondyle, one must suspect your inflammation (medial epicondylitis). • -Test for Lateral epicondylitis (Tennis elbbow): fix the forearm in pronation, and ask the patient to close the hand and extend the handle. Then, force the handle extended to
41 flexion against resistance of the examiner. If it caused pain in the lateral epicondyle (common extensor origin), you should suspect of lateral epicondylitis (Cozen test). • Mills testHas the same purpose as the Cozen test (investigation of lateral epicondylitis), and is done in asimilar way, but the patient is kept in elbow extension. • Extension against resistance test of 3° finger –Serves to investigate lateral epicondylitis.The patient keeps the elbow and wrist extended. The hand is in pronation. The examineropposes active extension resistance 3° the finger examined. If there is inflammation at theinsertion of extensor muscle-supinadora, the patient will refer pain in the lateral epicondyle. • -Stress test of Adduction: with the patient seated, stabilize the arm medially, and put a pressure of adduction (valgus) on the forearm side. If it is provoked a backlash and pain at the site, are indicative of radial collateral ligament instability. • -Stress test of Abduction: with the patient seated, stabilize the arm laterally, and put a pressure of abduction (Varus) forearm medially. If it is provoked a backlash and pain at the site, are indicators of instability of the ulnar collateral ligament. • Pivot testIndicated to diagnose the instabilities posterolaterais roundabouts.The patient is positioned supine, with the elbows semi-flexed and the forearm supinated.The examiner extends the elbow, while applying an axial compression and a valgus stress.The test will be positive when, near full extension, the radial head subluxar for later. Special tests for wrist and hand (To see pictures of the achievement of maneuvers specific tests to access the respective modules of large joints, in the E-book: 8 the 19.pdf modules)
42Tests for ligamentous instability • Piano key test • Radial collateral ligament stress test • Ulnar collateral ligament stress test • Scaphoid shift test • Lunotriquetral shear test • Capitate apprehension testTriangular Fibrocartilage • COMPLEX (TFCC) TESTS or (TCCT) test for the triangular cartilage complex • TFCC load testTests for the Thumb • Axial compression test • Finkelsteins test • Ulnar collateral ligament laxity testTests for Carpal Tunnel • Phalens test • Tinels test • Carpal compression test Tests for Wrist • -Inverted Phalen: patient should extend the handle by joining the palms against each other, during 1 minute. Tingling in the fingers (thumb, index finger, middle and half side of the void) can indicate a compression of the median nerve in the carpal tunnel, due to inflammation of the flexor tendons that pass beneath the flexor retinaculum of the Carpus. • -Phalen: Flex both wrists and placing them, keeping for 60 seconds. If the patient feel burning, pain, or paresthesia in the first three fingers, the examiner will suspect of a compression of the median nerve (carpal tunnel). • -Compression Test of paragraph wrist median: has great sensitivity to diagnose carpal tunnel syndrome. The examiner press with your thumb the volar side of handle on the cutaneous folds underwear (earlier) from the handle (median of input in the carpal
43 tunnel), during 1 minute. If there is paresthesia and pain reported median path in palmar aspect, the test is positive. • - Abduction of the thumb Test against resistance: test with high sensitivity and specificity for the diagnosis of CTS. Patient with the Palm of the hand in Supination and thumb away in abduction. The examiner between resistance to active abduction of the thumb is made by examined. If there are decreased muscle strength pair perform the abduction of the thumb, the test is positive. M. thumb abductor is supplied exclusively by no median. • -Allens test: to check the radial and ulnar arteries irrigation, ask the patient to open and close your hand a few times and releasing an artery at a time, observing the colour of the Palm (white or pale color becomes normal test rosea). • Finkelsteins test: tests the abductor pollicis longus tendon and extensor short thumb PLA ECP. Close the handle and force it with radial deviation. Pain distal to the styloid process of the RADIUS is indicative of carotid thumb tendon tenosynovitis (de Quervains disease). • Guyons canal syndrome: inspect and palpate the patient s, trying to handle pain on palpation over the Guyons canal, finger annul claw and hypothenar atrophy. If these signs are positive, shall indicate, ulnar nerve entrapment within Guyons canal. • -Clamping-test (test of Froment): ask the patient to poke a piece of paper between the toes of the thumb, index and Middle by 1minuto, while the examiner pulls the piece of paper. With the compression of the median nerve, the patient may, if the test is positive, leave the piece of paper escape their digital caliper which is made digital pulp pulp, and mention numbness and/or finger cramping from that region (anterior interosseous nerve syndrome that innervates the flexor pollicis longus m.). • Finkelsteins test:-Used to diagnose carotid de Quervain Tenosynovitis, which is inflammation of the tendons thatpass through the wrist extensor compartment first, namely: abductor pollicis longus tendonALP and short extensor tendon of thumb ACP.The handle of the patient is subjected to a forced ulnar deviation, with the thumb bent overthe back and under the other digits.The onset of pain in the radial styloid is typical of De Quervain Tendonitis.But, you need to make the differential diagnosis with trapéziometacarpiana joint arthrosis thatalso produces pain at this location.
44 • Watsons Test:-The examiner stabilizes the patients handle with one hand and presses the tubercle of thescaphoid with your thumb.After, the examiner moves the ulnar deviation wrist to radial.On palpation, there will be a click (which may be audible) accompanied by pain, whichtranslates a dissociation escafossemilunar. • Shear test (test of Kleinman):-Used to diagnose the Lunate instability-pyramidal.The examiner stabilizes, with one hand, the lunate, and with the other attempts to bring aboutan anteroposterior translation of the pyramid.When positive, the test will present a click accompanied by pain. Tests for Wrist • "Catch-up clunk test":-Used to diagnose the instabilities mediocarpais.The handle is subjected to axial load and radial deviation for powered ulnar flexed andpronated forearm being.The presence of a "click" is heard during the test points for the diagnosis. • Ulnocarpal impact test:-Indicated to diagnose the ulnocarpal impact.If present, the patient aprtesentará pain on the ulnar side of the handle when it is subjected toaxial compression and ulnar deviation, while the forearm in pronation. State test ulnar and radial artery at the wrist • Allens test:-Used to diagnose the blood flow to the hand.The examiner compresses the ulnar and radial arteries at the level of the face volar (previous)handle. Prompts the patient to perform a forced hand grip to improve venous return.
45Then, the patient is instructed to fully open the hand.At that time, the examiner will notice that the Palm of the hand is pale.Then, the examiner releases one of the arteries to check for revascu-larização (the Palm ofpale becomes rosea).The test must be repeated, but with the release of another artery.In this way the professional can determine whether both the arteries are pervious andotherwise, which is not. Tests for Digits • -Stress test in Varus and Valgus: testing the integrity of the collateral ligaments and the capsule that surrounds the joints. With a hold on clamp, catch the suspected joint (distal or proximal interphalangeal) with one hand. With the opposite hand, grab as grab the adjacent bone and put a Varus or valgus stress on the joint. If pain is caused (positive test), then a capsular sprain, subluxation or dislocation of the joint will be suspected; and a laxity can indicate a break in the joint capsule or collateral ligaments, secondary to trauma. • -Test of the common digital extensor: with fingers flexed, instruct the patient to extend them. Inability to extend any of the fingers, is indicative of an injury of this particular portion of common digital extensor tendon. • Test for the superficial flexor of the fingers:- Each finger must be tested separately, keeping the rest in neutral position. Asked, then, to the patient that makes the finger flexion. If the superficial flexor is running, there will be joint flexion IFP. • Test to the flexor Digitorum profundus:- Each finger must be tested separately, keeping the rest in neutral position. The finger tested should have its joint IFP also stabilized in the neutral position. Asked, then, to the patient that the inflection of the IFD. If this is possible, the deep flexor of finger is healthy.
46 Tests for Hip (To see pictures of the achievement of maneuvers specific tests to access the respective modules of large joints, in the E-book: 8 the 19.pdf modules) Joint tests• FAIR test• McCarthy test• FABER test• Torque test• Active straight leg raise (SLR) testTests for muscles and Tendons• Thomass test• Modified Obers test• Trendelenburg testOther Tests• Craigs test• Sign of the buttock Tests for Hip Thomas test: Mandatory test is being used to check for hip flexion CONTRACTURE. Intra-articular pathology or hip neighborhood often trigger a reflex response for pain in the hip which is in semiflexão. Generally, this attitude is not perceived because it is offset by the tilt of the pelvis.• The maneuver of Thomas consists of the Elimination of the compensatory attitude of the pelvis, to observe the actual position of the hip. The patient is placed lying supine.Flexion is of both hips. This undoes the pelvic tilt. The normal maximum flexion hip to hold the pelvis and slowly stretches the hip if you want to test. When there is no
47hip flexion Contracture extends completely and the angle formed between theposterior aspect of the thigh and the plane of the examination table corresponds toexisting flexion CONTRACTURE.-Trendelenburg Maneuver:Is used to check for the gluteus medius muscle insufficiency. As seen, this muscle hasthe important function of maintaining the pelvis level during the March.If it is insufficient the pelvis tends to fall to the opposite side of the support. Theinadequacies of the gluteus medius and minimum are frequent occurrences in hip andpathologies may exist for diseases of the muscle itself or its innervation (examples:sequelae of poliomyelitis, myopathies, injury of nerve roots), or by shortening thedistance between the origin and insertion of the muscle.This makes it relatively loose and lose efficiency. Examples include congenital hipdislocation and Varus deformity of the proximal third of the femur (upper leg stick orsequelae of fracture).Tests for Hip-Trendelenburg Maneuver:To perform the maneuver the patient is standing, facing the examiner. Safely,securely, both hands of the patient and asks that he raise the foot of the normal side,making that side support if you want to test. With this, the pelvis tends to fall to theother side and the gluteus medius muscle contracts to keep the leveling it.If the gluteus medius is insufficient flatness is not maintained and the pelvis drops tothe opposite side of the support. Reflexively, the patient not to unbalance, leans thetorso to the side of member support.With this, he manages to bring the center of gravity over the hips, lowering the leverarm and relieving muscle.Condition detectedTherefore, the Trendelenburg test the support side muscle and when is positive, thepelvis drops to the opposite side and support the trunk leans to the same side of thesupport. The move is made, first, in normal or less-affected side. Tests for Sacroiliac and Hip-Patrick (PATRICK S) Test:This test is intended to detect both the hip pathologies, such as SIJ. With the patientsupine, place the heel of the lower limb in question on the opposite knee; the
48examiner then applies a force on the knee bent and the other on the opposite anteriorsuperior iliac spine, as if you were opening a book.If the pain is referred in the inguinal region, there may be hip joint pathology; the caseis referred pain in the posterior, in pathology might be SIJ. This test is also calledFabere, by virtue of the position that the Member assumes during its realization.Test for HipObers test:Used to diagnose iliotibial tract CONTRACTURE.The patient is positioned laterally, with the hip to be tested positioned upward.The hip and the knee is flexed to 90°.The examiner extends the hip up to 0° by checking if there is enough to rest the kneeadduction on the examination table.If this is not possible, the Contracture is diagnosed.The test can also be performed with the knee extended.Thus, the examindor can detect more subtle contractures.Test for HipEly test:-The patient is positioned in ventral decubitus.In normal situations, the knee can be fully flexed, until the patients heel reaches thegluteal region.When there is retraction of the rectus femoris, this is not possible, or only the will andipsilateral hip flexion associated.Craig test:-The patient is positioned in ventral decubitus, and the knee is flexed at 90°, afterpalpa-if the greater trochanter.The hip is rotated internally until the greater trochanter, get in more possible side ofthe thigh.The angle formed between the leg and the vertical provides an idea of femoral neckanteversion.
49 Test for Infant Hip Ortolani test: this test is used to diagnose hip instability. Placing the child in supine position, holding the legs by turning the hips and knees at 90 degrees; the thumb is placed on the medial aspect of the thigh and the index and middle fingers on the greater trochanter. From this position it is simultaneously for the two abduction hips or attaches to one side and the other. When there is instability, we feel a bump while performing this maneuver (positive Ortolani sign). Ortolani test: Classically, this Ridge is described as a "click". The thigh is now then adducted and exerting a force with his thumb toward the side, the head suffers a new bounce and the "click" is again realized. Should be researched rather in the first two days of life, because after your perception is impeded. We should also highlight that this signal is present in cases of mild and moderate hip dysplasia, when can we mobilize abnormally the femoral head within the acetabulum, denoting the instability; in cases of severe Dysplasia, the rebound is not produced, because the femoral head is fixed at a position offset in neoacetábulo and may not be brought against real acetabulum. Test for Infant Hip Galeazzi test: detects unilateral congenital dislocation of the hip in children. The child is positioned in DD with the hips flexed to 90 degrees and completely flexed knees. The test is positive if a knee is taller than the other. -Barlow: provocative Test identifies instability of hip in infants. With the baby at the same location used for the test of Ortolani, the examiner stabilizes the pelvis between the pubic and the Holy with one hand. With the thumb of the other hand, the examiner tries to move the hip with a later take firmer pressure. Hip Engines tests -Hip Engines Tests: the muscles are tested by groups, as described earlier.• Bender (innervated by L1, L2 and L3) are tested with the patient seated with legs hanging out of the Bureau, requesting that the same Flex the hip while the examiner offers resistance in the distal third of the thigh.
50 • To test the Extenders (S1) the patient should be in prone and with the knee flexed, trying to extend the hip while the examiner offers resistance in the posterior aspect of the thigh. • The abductors (L5) are tested with the patient in dorsal decubitus, while the examiner puts his hands on the sides of the ankles, resistance and asking the patient to abduza members; can also be tested with the patient in lateral decubitus, whereupon the examiner places resistance on the lateral aspect of the thigh. • And the adductors (L2, L3 and L4) are tested with the patient supine and the members abducted and with the examiner in imposing resistance on the inner surface of the ankles while the patient is asked to perform the movement of adduction. Sensitive tests of the hip • -Sensitive Tests of the hip: the roots that supply sensitivamente the skin of the hip and thigh region are: • T12 (area of inguinal ligament), L1 (upper third of the thigh), L2 (the middle third of the thigh), L3 (lower third of the thigh), all these on the anterior surface of the Member. • On the back of the Member, the roots of S1 and S2 provide extensive sensitivity area that goes from the gluteal fold up the popliteal fossa. Special tests for Knee (To see pictures of the achievement of maneuvers specific tests to access the respective modules of large joints, in the E-book: 8 the 19.pdf modules)A test plan • Valgus test • Varus test • Posterior drawer test • Anterior drawer test • Lachmans testMultiple Test Plans • Anteromedial rotatory instability • (AMRI) • Slocum (AMRI) test • • Rotatory instability Anterolateral (ALRI) • Slocum (ALRI) test
51 • Pivot shift test • • Rotatory instability Posteromedial (PMRI) • Posteromedial drawer test • Posterolateral rotatory instability • (PLRI)KNEE • Posterolateral drawer test • Reverse pivot shift test • Dial test • External rotation test recurvatumMeniscal Tests • Apleys test • McMurrays test • Weight-bearing/meniscal rotation test Patelofemorais Tests • McConnell test • Patella apprehension test • Patellofemoral grind testOther Tests • Nobles compression test • Mediopatellar plica test Tests for Knee • Pending Member: patient in prone with legs out of the litter to observe the tensioning of ísquiostibiais. • -Flexion and extension (active and passive): observe the degree of muscle strength, always testing first actively and passively.
52• -Patella: check if there is excess liquid; test of rejection (strike with 2 fingers on top of the patella and observe if it will float). Observe also the movement of it (passively), if there is crackling or hypersensitivity.• -Test for Jumpers knee: offer resistance against the knee extension movement; detects patellar tendinitis (infra, supra) or quadriceps (above 3 fingers).• Anterior drawer test: detects the anterior instability of the knee. The patient lies supine, with the knee flexed at a 90° angle. The examiner sits on the back of the patient. With the patients foot in neutral rotation, the examiner pulls forward, holding the proximal part of the calf.• Both lower limbs are tested. The test is positive if there are previous excessive movement (> 5 mm) of the tibia in relation to the femur.• -Cross-Test: detects anterolateral knee instability. With the patient standing and with the leg cross-over the unaffected leg test, the examiner name test leg foot putting your own walk carefully on it. The patient runs back to the opposite side of the injured leg approximately 90º. In this position the patient is asked to contract the quadriceps muscles. If the contraction producing a sensation of "failed" in the knee, then the test is positive.• -Godfrey test: detects the PCL laxity. Patient supine position, secure the patients leg distally in a 90° angle. Positive test if there is a slip of the tibia posteriorly, in comparison with the contralateral side.• -Childress: detects meniscal injury. Patient will crouch with one leg bent and the other extended. Ask for it to rise; If the meniscal injury patient will report pain in this movement.• -Hugston test and Losee- jerk test (bump): identifies the presence of rotational anterolateral knee instability.• Performed with the patient supine, 45 hip flexion and knee of 90. The knee is subjected to a stress in valgus and internal rotation as it is expanded• The test is positive when the knee is extended gradually, between 30 and 40° of flexion, then the lateral tibial plateau suddenly gives a kickback (inferiorly subluxates forward with a bump). -Test of Lachman: identifies injured anterior cruciate ligament (ACL). The patient lies down supine and the examiner stabilizes the distal femur with one hand and holding the proximal tibia with the other hand. With the knee in flexion light 20, maintained the tibia is walked forward on the femur. The test is positive when there is a final feel soft and an excessive movement of the tibia (> 5 mm).• -Losee: test identifies anterolateral rotational instability of the knee. With the patient supine and relaxed, the examiner supports the patients foot so that the knee is flexed
53 at 30 and the leg externally rotated and leaning on the abdomen of the examiner. Hand on the fibula + leg extension + rot. int. (reversal) + valgus knee support.• -MacIntosh Test (lateral pivot shift): identifies anterolateral rotational instability. The examiner holds the leg with one hand and place your other hand over proximal lateral aspect. With the knee in extension, applies a valgus force wheel and internally the leg while the knee is flexed. Between 30° to 40° of flexion, there is a sudden jump when the lateral tibial plateau, which had previously subluxado in relation to the femoral condyle, suddenly is reduced• -Test Slocum ALRI: identifies anterolateral rotational instability. The patient lies down in lateral decubitus on the unaffected leg, with hips and knees flexed to 45. The test leg foot is resting on the table in medial rotation with the knee in extension. The examiner applies a knee valgus force while the flexes. The test is positive if the knee subluxation is reduced between 25 and 45.• -Test of Slocum: identifies anterolateral knee injury. The patient is positioned supine, with the knee flexed at the hip flexed at 90º and 45º. the examiner sits on the patients foot, which is rotated internally to 30. the examiner holds the tibia and apply on it a force directed earlier. The test is positive if the movement primarily occurs on the lateral tibial. The test can also be used to identify anteromedial rotatory instability.• This version of the test is made with the foot turned sideways to 15; the test is positive if movement occurs primarily in tibial medial side.• -Touch Test or sliding (esfregadela): identifies a light knee effusion. Starting below the joint line on the medial aspect of the patella, the examiner slides proximally to the Palm and fingers to the suprapatellar Bursa. With the opposite hand, the examiner glides her fingers on the lateral surface of the patella. The test is positive if a fluid wave appears as a slight protrusion on the edge of patella medial distal.• -Patellar Coup: test identifies significant joint effusion. The knee is flexed or extended through the discomfort and the examiner beats lightly over the surface of the patella. The test is positive if the examiner feel floating patella.• -Stress testing of Adduction (varo): the examiner applies a patients knee Varus stress while the ankle is stabilized. The test is done with the patients knee in full extension and then with 20 to 30° of flexion. A positive test with the knee extended suggests a major disruption of the ligaments of the knee, while a positive test with the knee flexed is indicative of injury of lateral collateral ligament.• -Stress testing (valgus) abduction: the examiner applies a valgus stress on the patients knee while the ankle is stabilized. The test is first made with the knee in full extension and then repeated with the knee at 20º flexion. The excessive movement of the tibia
54 distancing himself from femur indicates a positive test. The positive findings with the knee in full extension indicate a major disruption of the ligaments of the knee. A positive test with the knee flexed is indicative of medial collateral ligament injury.• -Compression test of Apley (grind test): detects meniscal injuries. The patient lies down in prone with the knees flexed at a 90° angle. The examiner applies a compressor in the sole force down and makes internal and external rotation. The test is positive if the patient reports pain on either side of the knee meniscal injury indicator, its painful side.• -Traction Apley Test (test of distraction): detects ligament injury. The patient in the same position of the test above, but if doing a pull rather than a compression. The test will be positive if the patient reports pain.• -Deviation test on palpation of Steinman: with the patient in the dorsal decúbiro, Flex the hip and the knee at 90 degrees. Place the thumb and index finger on the medial and lateral joint line of the knee respectively. With the opposite hand, grabbing the ankle and alternately flexing and extending the knee while you palpa the joint line. When the knee is extended, the meniscus moves forward; and when it is flexed, the meniscus moves backward. If the patient feel the "pain" move earlier in the extension, or later when the knee is flexed; then it is suspected a rupture or meniscus injury.• -Return Test: identify meniscal injury. The patient lies down supine and the examiner holds the patients heel with his Palm. The patients knee is fully extended and then passively flexed. If the extension is not complete or submit a tensile sense ("elastic block"), the test is positive.• -Test of Hughston Plica: identifies a suprapatellar abnormal. The patient in supine position the examiner flexes the knee and medially rotates the tibia with arm and hand while with the other hand, the patella is displaced slightly medially with the fingers over the course of the replica. The test is positive if a "pop" is caused in the replica while the knee is flexed and extended by the examiner.• -McMurray test: identify meniscal injury. With the patient in supine position, the examiner holds the foot with one hand the palpa the joint line with the other. The knee is flexed completely and the tibia walked back and forth and then held alternately in internal and external rotation while the knee is extended. A click or Crackle can be felt on the joint line in the case of posterior meniscal injury, when the knee is extended.• -Wilson: Test identifies osteochondritis dissecans. The patient sits with the leg in the pendent position. The patient extends the knee with the tibia medially round until the
55 pain increase. The test is repeated with the tibia laterally round during the extension. The test is positive if there is pain when the tibia is turned sideways.• -Seizure: Test identifies displacement of the patella. The patient lies down in supine position with the knee in flexion 30. The examiner painstakingly slowly shifts the patella laterally. If the patient appears apprehensive and tries to contract the quadriceps to bring the patella back to neutral position, the test is positive.• Clarke: sign identifies the presence of Chondromalacia of patella. The patient lies down relaxed with knees extended while the examiner press proximally to the base of the patella with the hand. The patient is then asked to contract the quadriceps while the examiner applies more force. The test is positive if the patient fails to complete the contraction without pain.• -Test of Waldron: identifies Chondromalacia patella. The patient makes several slow and pronounced knee pushups while the examiner palpates the patella. The test is positive if pain and Crackle during movement.• -Lateral Posterior Drawer test Hughston: detects the presence of posterolateral rotatory instability of the knee. The procedure is similar to the post test-medial of Hughston, except that the patients foot is slightly turned sideways. The test is positive if the tibia rotates too much later on the lateral surface when the examiner pulls later.• -Medial Posterior drawer Test of Hughston: identifies rotational knee posteromedial instability. The patient in supine position with the knee flexed at a 90° angle. The examiner shall fix the foot in light rotation. Test danush (pivot-shift reverse):- The patient is positioned supine with the hip flexed at 45° and knee to 90. A valgus stress to the knee, which is kept in external rotation.As is extended progressivamante, there is a ridge (reduction of the lateral tibial plateauposterior subluxation) 20 of flexion. Despite presenting a major false positive index, its positive points to the diagnosis of injury of CPL (posterolateral compartment. Special tests for ankle and foot (To see pictures of the achievement of maneuvers specific tests to access the respective modules of large joints, in the E-book: 8 the 19.pdf modules) Ligamentous stress tests• Anterior talofibular ligament stress test• Calcaneofibular ligament stress test
56• Calcaneocuboid ligament stress test• Medial collateral ligament stress test Ligamentous Instability tests• External rotation stress test• Talar tilt test• Drawer test• Other Tests• Thompsons test• Peroneal subluxation test• Metatarsal squeeze test Tests for Ankle• -Thompson Test: detects Achilles ruptures. The patient is placed in ventral decubitus or on your knees with your feet extended over the edge of the bed. The middle third of the calf is compressed by the examiner, and in the absence of a normal plantar flexion, one must suspect Achilles tendon rupture.• Homan sign: detects the existence of deep venous Stenosis, in the lower part of the leg. The ankle is dorsifletido passively observing any sudden increase in pain in the calf or in the popliteal space.• Previous: Drawer sign identifies ankle ligamentous instability. The patient lies down supine and the examiner stabilizes the distal portion of the tibia and fibula with one hand while holding the foot in 20 of plantar flexion with the other hand. The test is positive if the bring the talus forward into the ankle, the previous translation is greater than the unaffected side.• -Kleiger test: detects lesions in the deltoid ligament. The patient is sitting with the knees at 90 degrees. The examiner holds the patients foot and tries to abduct the back. The test is positive if the patient complains of pain medially and laterally. The examiner may feel the Astragalus move lightly of the medial malleolus.• -Talar Tilt: identifies calcaneofibular ligament injuries. The patient is supine or lateral position with the knee flexed at a 90° angle. With the foot in neutral position, the Astragalus is leaning medially. The test is positive if the adduction of the affected side is excessive.
57 Compression leg laterolateral test:- The compression of the fibula against the tibia by the examiners hands causes stress in the distal tibiofibulares and ligaments pain in cases of injury of the syndesmosis. The external rotation of the foot, keeping the tibia in neutral position, cause similar effect.• Ankle Varus Stress:- When there is excessive ankle Varus indicates lateral ligament complex injury. The examiner applies the Varus stress on the lateral surface of the calcaneus while stabilizes the tibia. Can be done with x-rays, thus demonstrating a given goal when compared with the normal side.• Ankle valgus Stress:- When there is excessive hind ankle, medial ligament complex injury indicates, and runs in a manner opposite to the previous one. Tests for Foot Mulder: signal- The lateral head lateral compression of metatarsal bones cause a palpable click for Mortons neuroma.• Coleman and Chesnut test:- Test performed in three phases in which blocks of wood are placed in such a way as to determine the cause of the hindfoot Varus: first ray, forefoot and rearfoot. It is important to note that this test works only in cases of Varus.• Jack test:- Passive extension of the hallux plantar arch and lift cause indicates subtalar mobility. Active or passive rotation of the tibia on the walk has the same result and meaning that the test Jack.• The tiptoe Test:- The hind foot has a physiological valgus when Plantigrade and supported on the ground. When the patient is asked to stand on tiptoe, a progressive Varus hindfoot, which indicates a motor unit of the Tibialis posterior is available and a mobile subtalar joint.
58 This Varus does not occur in cases of flat feet and hard in advanced phases of inadequacy of m. Tibialis posterior, or in cases of meibomian bars. ______________________________________________________________________ POSTURAL ASSESSMENT www.fm.usp.br/fofito/fisio/pessoal/isabel/.../ pdf /Postura. pdf ______________________________________________________________________ Basics of Arthroscopy (To see pictures of the achievement of maneuvers specific tests to access the corresponding module in the E-book: 07.pdf module)• Instruments and equipment• Arthroscope:Three basic optical systems are used in hard artroscópios: 1 – Classic thin lens system; 2-thick lens system designed by Hopkins; 3 -lens system of graduated index (GRIN). Arthroscope• The light and images are transmitted through the exchange of lenses, so a lens eyepiece, which in turn transmits the image to the eye of the observer.• Thick lens system is the most used in modern appliances. Lenses• Important aspects: diameter (1.7 to 7 mm), tilt angle (angle between the axis of the arthroscope and a line perpendicular to the lens surface ranges from 0 to 120°) and the field of vision (comprehensive angle on the lens ranges from 90 to 105°). Lighting sources• Xenon light source, tungsten and halogen 300 to 500 watts.• Fiber optic cable: delicate.• For each 30 cm of cable lost 8% of light.• Television cameras• Improved position of surgeon, reduction of infection.• Can be sterilized in gas chambers or cidex.
59• Currently there are systems that connect the lens directly on the arthroscope. Instruments accessories• Arthroscope of 30 and 70°.• Probe (probe): "ARTROSCOPISTAS FINGER".• Scissors.• Forceps in basket(basketball).• Retaining Clamps(hold).• Knives with blades.• Cutter and motor trimmer(shaver) for meniscus.• Laser and Electrosurgical Instruments.• Instruments accessories Care and sterilization• Best method is by gas (ethylene oxide).• Most use glutaraldehyde activated -CIDEX.• Minimum time of 10 minutes. Irrigation system• Saline Solution during surgery. Advantages• Reduction of postoperative morbidity.• Smaller incisions.• Less intense inflammatory response.• More efficient diagnoses.• Absence of side effects.• Hospital cost reduction.• Reducing the percentage of complications.• Better evaluation in the accompaniment.• Possibility of making poison via open procedures.
60 Disadvantages• There are few. In General for lack of patience and dedication of the surgeon.• Advantages are greater.• Indications and contraindications• Diagnosis: for pre-operative evaluation and confirmation of the clinical diagnosis. Into disuse.• Therapy: for almost all the joints especially the knee, shoulder, elbow, ankle and hip.• Contraindications: risk of sepsis articular, partial or complete ankylosis, cápsulo-excessive ligamentous injury that will allow extravasation of serum. Arthroscopy• Principle of Triangulation: the arthroscope forms the apex with the other instruments.• Complications: hemarthrosis, infection, thromboembolic disease, anesthetic complications, algodistrofia, paresis ppr Withers, neurological and vascular lesion, artrofibrose and fractures. Arthroscopy portals• Knee. - Common portals: anterolateral (most important), anterior-medial, posterior- medial and lateral-overcome ´. - Optional: posterolateral, medium proximal medial and lateral patellar; Accessories: medial and lateral. Central transtendãopatelar or Swedish portal.• Knee Portals Arthroscopy portals• Ankle. The previous three: lateral, medial and central. Three later: medial, lateral and transtendão of Achilles. Transmaleolares. Arthroscopy portals• Hip. Arthroscopy portals• Shoulder: how to achieve the joint?
61 Later, anterior and lateral. Arthroscopy portals• Elbow lateral, medial, anterior and posterior. Bibliography for Arthroscopy• Campbells orthopedic surgery, Volume 3.• Arthroscopy http://www.iof.com.br/int_default. php ? p = articles/ art_artroscopia• Arthroscopy of the knee http://www.wheelessonline.com/ortho/arthroscopy_of_the_knee• Arthroscopy-Textbook (click here)• ACL MovieRebuiltpost 6 and 12anos ( Prof. Dejour) http://www.cto.med.br/cirurgia_joelho/artroscopia/lca12.rm• InjuriesMeniscal-Text and photos• Lateral meniscus cyst-MRI• Class on:Arthroscopyknee-Dr.OlavMoretzsohn• Knee study group of Campinas http://www.grupodojoelho.com.br/• Joint Arthroscopy: ankle arthroscopy elbow arthroscopy hip arthroscopy arthroscopy of the knee joint shoulder arthroscopy - arthroscopic rotator cuff repair wrist arthroscopy
62 The Effect of Irrigation Solution at Different Temperatures on Articular Cartilage Metabolism Original Text by Clifford r. Wheeless, III, MD. Last updated by Trace Staff Date on Wednesday, July 27, 2011 3:20 pm Patients Rheumatism semiology (See figures in "slides" module 7.pdf) Rheumatic diseases-risk factors• Age - The most frequently observed > 50-65 years• Sex - The female is more hit by these diseases.• Profession - The industrial population is more affected (50%)• Racial and genetic Factors• Metabolic Factors - Obesity (osteoarthritis, osteoporosis)• Static mechanical factors and Defects - Static Defects; Sport.• Smoking - Osteoporosis• Pregnancy - Postpartum and worsening of AIR• Fertility - Reduced Fertility associated with the risk of AIR• Oral contraceptives - Associated with a lower risk of AIR• Medicines
63 - Corticosteroids and heparin associated with the risk of osteoporosis. Clinical History 1-patient Identification• Sex -drop, E.A. (male) - A.R., Lupus (female)• Age -F.R., A.R., (young) - Drop (middle age) - Arthritis (> 40-50 years)• Profession -arthrosis of the elbow (op. C.) -cervicartroses (datilógrafas) -dorsartroses (Dockers) -lombartroses (Chargers) Clinical History 2-current Disease• How and when did the disease?• As it has evolved?• What treatments did and with what results? Rheumatological semiology• Musculoskeletal Manifestations -pain -joint stiffness -joint swelling -limitation of movement• Systemic Manifestations
64 PAIN• Start mode• Location• Type• Intensity• Duration and opening hours• Character• Irradiation• Relationship with the movements and home• Response to medication Rheumatological semiology Pain• Start mode: - Sudden - Flashing - Insidious• Intensity: - Strong - Weak - ….• Location: - Articulate - All the Member - …..• Extension: - Location - generalized
65 Topography of joints affected:• A.R.-MCF, IFP, MTF (symmetrically)• Drop-MTF of 1st finger• Shoulder-Bursitis• Referred Pain Referred pain• Coxofemural injuryKnee• Groin and anterior surface of the thigh• Greater trochanter• Buttock and posterior aspect of the thigh• Iliac Crest• The inner side of the thigh Referred pain Pain irradiation Because, almost always, the commitment of a trunk or a nerve root.• Cervicobraquialgias• Sciatica• Intercostal Nevrites• Cruralgia• Other Pain pattern• Jumpy• Articular Involvement by adding• Bilateral symmetric joint Involvement.• Rheumatological Semiology Rhythms of pain
66• Inflammatory Rhythm• Rhythm mechanic Inflammatory rhythm• Intense upon awakening extending throughout the morning.• Requires the patient to stand up one or more times during the night.• Rheumatological Semiology Pain Rhythm mechanic• May arise in the morning, upon waking, but are short-lived.• Exacerbate the overload situations.• Relieve with rest.• Do not disturb sleep.• Rheumatological Semiology Joint stiffness• Long-term Inflammatory (several hours)• Short duration Mechanical (a few minutes) Functional capacity• Assess the patients degree of difficulty in performing their tasks (of their profession and of their daily activities-Dlas)• There are numerous tables.• Clinical Profiles of rheumatic diseases frequently
67• Other manifestations : - Asthenia - Adinamia - Anorexia - Weight loss - Febrícula - Cutaneous lesions (malar rash in Raynauds phenomenon in LED; s). Rheumatological semiology• As it has evolved? - For brief spurts (as at the beginning of the drop); - For more prolonged outbreaks and of lesser intensity (initial stage of arthrosis); - Outbreaks of painful feeling about a painful background (on air or more advanced stage of arthrosis); - Evolution of continuous mode (some situations or other conectivites);• Personal history• Places of residence• Previous Professions• Previous: Diseases -Infections: tonsillitis. tuberculosis, brucellosis, ... -Trauma -Skin diseases -Eye diseases• Arthritis and your eyes• Skin Diseases and rheumatism• Family history• Existence of rheumatic diseases in the family
68 - We should try to characterize them. • Other diseases Take Aim • Clinical History Take Aim Bear in mind the notions of: Anatomy, Physiology Only then it is possible the interpretation of musculoskeletal semiology(See figures in "slides" module 7.pdf) • Osteoarticular objective Examination • Inspection • Palpation • Percussion • Assessment of movements: -Active -liabilities • Osteoarticular-inspection objective Examination • Patient Attitude • Difficulty in walking • Joint Deformity • How moves: sit, lie down, stand up. • Look at the different sides of the joint . • The skin that lines the joint: - Coloring Changes - The presence of bruises:
69 • Previous trauma. • Tendon Ruptures •…• Muscle mass: - Isolated or diffuse Atrophy: • Nerve Injury. • Disuse.• Changes of articular reliefs: - Sequelae of fracture - Degenerative processes - Inflammatory processes• Take aim-Palpation• Identification of areas or tender points: - Joint line. - Tendon insertion Areas.• Enjoy skin temperature change: - Synovitis - Bursitis• Search tactile sensation of crackling during the joint mobilization• Objective examination-exploitation of movements• Allows You To: - Location of pain and its source. - Quantify the degree of limitation of joint mobility.• The analysis should include: - Active Movements. - Passive movements.
70 - Thwarted Movements. Active movements • We should appreciate the amplitude of movements - If there are limited we must quantify it in degrees. • For abolition: - Neurological Lesions with déficet engine. - Complete rupture of a tendon. Passive movements • His running exploits, fundamentally: - The joint capsule - Joint.(See figures in "slides" module 7.pdf) • Arthritis: - Passive movements globally committed • Tendonitis: - Passive movements kept Exploration of movements • Allows You To: - Evaluating muscle strength. - Explore, elective surgery, each of musculoskeletal structures. - Locate lesions responsible for patients complaints. • Source: Almeida, M; Regional Hospital South Wing/SES/DF, 2009 Laboratory tests to be addressed: Cbc
71 Muscle enzymes Urinary assessment Dosage of C3 and C4 fractions of the complement VHS PCR Alpha-1-acid glycoprotein ASLO Rheumatoid factor FAN Non-specific tests Introduction• Laboratory research of rheumatic diseases should be examined critically, subject to each patients symptomatology.• Rarely have high specificity exams.• The presence or absence of certain laboratory hardly change sets or exclude a diagnosis. Cbc Essential for initial research Leukocytosis, anemia and thrombocytosis: juvenile idiopathic arthritis (JIA) Pancytopenia-Hemolytic Anemia: Lupus Thrombocytosis: Kawasaki syndrome Muscle Enzymes DHL, CPK, aldolase, SGOT, SGPT Urine Proteinuria, hematuria, blood cylinders Creatinine Clearance Complement system
72 Non-specific Tests VHS-erythrocyte sedimentation rate• Reflects indirectly the amount of acute phase proteins in the blood.• Factors that change: - Quantity and shape of red blood cells; - Age, gender; - Other non-acute phase proteins; - Drugs.• Non-specific Tests PCR – C-reactive protein Acute phase protein produced by the liver. Significant changes and quickly against a nonspecific inflammatory stimulus. Serum levels fall in parallel with the resolution of the inflammatory process. In the disease process, has values above 0.5 mg/dl. Changes for various clinical situations, such as VHS.• Non-specific Tests Alpha-1-acid glycoprotein• Acute phase protein long used in the control of rheumatic carditis.• Maintains high levels until it stops the process of carditis.• Useful for determining the time of corticotherapy and the moment of the beginning of the gradual withdrawal of corticosteroids.• ASLO Antistreptolysin O Antibody directed against cellular components of str. Important for the diagnosis of rheumatic fever (RF), but the determination of isolated ASLO, devoid of FR clinic, indicates only contact with this bacterium. Undetectable serum levels is not with secondary prophylaxis for FR. The serum of ASLO curve varies among patients. Normal serum levels
73 Up to 5 years: 330 UI Above 5 years: 500 IU• Rheumatoid Factor• IgM antibody against the Fc portion of human IgG.• Do not have diagnostic utility in the disease process.• Used only as an indicator of classification and prognosis in AIJ.• Clinical conditions associated with rheumatoid factor: bacterial and viral infections, parasitic infections, neoplasms.• FAN• The antinuclear factor (FAN) is a group of autoantibodies;• The FAN may be detected by Autoantigens in the nucleus, nucleolus, cytoplasm or mitotic apparatus;• Is associated with autoimmune diseases, but can occur in various other situations.• HEp-2 cells with immunofluorescence: gold standard, qualitative and quantitative test.• Titles• Nuclear standard smooth• Associations of FAN Rheumatic diseases Systemic Lupus Erythematosus (SLE) Mixed connective tissue disease Inflammatory Miosites (Dermatomyositis, polymyositis) Other situations Neoplasms Hepatitis (B or C, autoimmune) Infections Silicone implants Healthy subjects (5-15%)
74 Individuals over 60 years (30-40%) Source: Dellavence, Junior AG, Cintra AFU et al. II Brazilian Consensus of Antinuclear Factor in HEp-2 Cells. Rev 4 Br• Nomenclature• 1. FAN-antibodies against components of the nucleus, nucleolus, cytoplasm and mitotic apparatus• 2. FAN – research of autoantibodies• 3. search of autoantibodies (FAN and cytoplasmic antigens)• 4. antibodies against core components (FAN), nucleolus, cytoplasm and mitotic apparatus• 5. search of autoantibodies-core (FAN), nucleolus, cytoplasm and mitotic apparatus• 6. search of autoantibodies against intracellular antigens (FAN).• Source: Dellavence the junior AG, Cintra AFU et al. II Brazilian Consensus of Antinuclear Factor in HEp-2 Cells. Rev Bras Reumatol 2003; 43 (3): 129-40.• Prevalence of FAN• FAN in clinical practice• Limitations - Do not allow definitive diagnosis, - Prevalence of up to 15% in healthy population - Specificity of 20 to 40% - Positive predictive value 10 to 30%• Screening Examination - 90 to 95% sensitivity - High negative predictive value• FAN in clinical practice• Misuse of the examination - Requests without indication - Misinterpretation - To maximize the usefulness of the FAN
75 - Request as screening only in patients with strong clinical suspicion of rheumatic disease - Attention to the IFIS and titration - Confirm the specific antibodies___________________________________________________________________________ • MUSCULOESQUELETICA RADIOLOGY http://www.info-radiologie.ch/index-portugues.php • Conventional or Simple x-ray Radiology Musculoskeletal • X-ray of the cervical spine • X-ray of the thoracic spine • X-ray of the lumbar spine • Radiography of chest • Radiograph of shoulder • Radiograph of elbow • Radiograph of forearm • Radiograph of handle • X-ray of the hand • Radiograph of abdomen • X-ray of the pelvis (pelvis) • Radiograph of hip • Musculoskeletal MRI • Magnetic Resonance shoulder • Magnetic Resonance elbow • Magnetic Resonance hip • Magnetic resonance imaging (MRI) of thigh • Magnetic Resonance knee • Magnetic Resonance ankle
76 • • Musculoskeletal TC • Computed tomography of ankle and foot ______________________________________________________________________Orthopedics Examination VideosL.B.Conochie, MD, F.C.R.S.Assistant Professor, Department of SurgeryMc Gill UniversityAssociate Orthopaedic Surgeon, Montreal General HospitalSource: You TubeSent in 7/28/2011 http://imedrxtv.blogspot.com/ 1- Orthopedic Physical Examination- Gait (Video of the AAOS; ACO; McGill University)http://www.youtube.com/watch?v=EHcNQ_qG7Tw 2- Orthopedic Physical Examination- Hip (Video of the AAOS; ACO; McGill University)http://www.youtube.com/watch?v=CCBOccgQZ0o&playnext=1&list=PL90197F6B45FE7955&feature=results_main 3- Orthopedic Physical Examination-knee (Video of the AAOS; ACO; McGill University)http://www.youtube.com/watch?v=sm8HLlGvcVU 4- Orthopedic Physical Examination-knee_2 (Video of the AAOS; ACO; McGill University)http://www.youtube.com/watch?v=10vHiJqRBuQ 5- Orthopedic Physical Examination-Foot_Ankle (Video of the AAOS; ACO; McGill University)http://www.youtube.com/watch?v=jbNxnz0jSfw 6- Orthopedic Physical Examination-cervical_spine
77 (Video of the AAOS; ACO; McGill University)http://www.youtube.com/watch?v=gxcI7BTwO2A 7- Orthopedic Physical Examination-lumbar_spine (Video of the AAOS; ACO; McGill University)http://www.youtube.com/watch?v=TBysuTEAd2Q 8- Orthopedic Physical Examination-Shoulder_elbow (Video of the AAOS; ACO; McGill University)http://www.youtube.com/watch?v=CcNZSQRtkNs 9- Hand & Wrist Examinationhttp://www.youtube.com/watch?v=65mjCLGrGTESent in 11/18/2007 by:How to do the Hand & Wrist screening thing. The produced byhttp://www.arthritisresearchuk.org/ 10- ImedrxTv The Video Blog University of Utah Pediatric Neurologic Examination Normal Newbornhttp://www.youtube.com/watch?v=e6YMh1fC7dA 11- Sacroiliac Joint Dysfunction and PainBy Nabil A. Ebraheim , MDSent in 7/15/2010Sacroiliac joint pain and dysfunction can be confused with other conditions that arisesfrom the spine and the hip. Not only can these conditions be overlapped, but they can beassociatedhttp://www.youtube.com/watch?v=1iwmcCw4bAw 12- SI Joint Anatomy, Biomechanics & PrevalenceCarlton, Orthopedic Surgeon RecklingSent in 11/29/2011http://www.youtube.com/watch?v=D6NTMgWCSaU 13- The Importance of Diagnosing SI Joint Disorders in Surgical PracticeCarlton, Orthopedic Surgeon Reckling
78Sent in 11/29/2011http://www.youtube.com/watch?v=SgThNw_HTZM 14- Free TMJ (Temporomandibular Joint) ExamJohn Burchhttp://www.youtube.com/watch?v=hBY5mwE5SGQPosted on 4/18/2012 15- TMD and Jaw Pain SymptomsCAESY-Education Systemhttp://www.youtube.com/watch?v=M0X5pwhvSh0NYC Smile DesigSent in 5/12/2010If you are experiencing jaw pain, headaches, jaw muscle spasms, or jaw joint problems you mayhave symptoms of Temporomandibular Dysfunction (TMD).New York City___________________________________________________________________________ 16- Neural and Musculoskeletal System (Mark H Swartz video)Mark H Swartz-Neural and Musculoskeletal Systemhttp://imedrxtv.blogspot.com.br/search/label/Musculoskeletal%20system a. Bates-Musculoskeletal system ExaminationBates-Musculoskeletal system Examinationhttp://imedrxtv.blogspot.com.br/search/label/Musculoskeletal%20systemVideos of the Sociedade Brasileira de Ortopedia e Traumatologia (SBOT)About Orthopaedic physical examination with Special Physical tests 1- Semiology of Knee-IYou need Adobe Flash Player to view this video.http://www.youtube.com/watch?v=xz6KEJgoWWU 2- emiologia of Knee-II
79http://www.youtube.com/watch?v=4nMSQSEoxrA 3- Cervical Spine -propaedeutics and clinical findingsYou need Adobe Flash Player to view this video.http://www.youtube.com/watch?v=0PccppQk-Ko 4- Semiology of the Thoracic and lumbar spineYou need Adobe Flash Player to view this video.http://www.youtube.com/watch?v=suG_ZyM3aDg 5- Semiology of spinal cord injuryYou need Adobe Flash Player to view this video.http://www.youtube.com/watch?v=xSu3S6unAko 6- Semiology of the ShoulderYou need Adobe Flash Player to view this video.http://www.youtube.com/watch?v=899joSbCMpI 7- Instability of the Elbow – Propaedeutics and clinical findings http://www.youtube.com/watch?v=vRhLpHC1xL8You need Adobe Flash Player to view this video. 8- Semiology of the Hand and FingersYou need Adobe Flash Player to view this video.http://www.youtube.com/watch?v=p5wIOWlvkC0 9- Semiology of ankle and footYou need Adobe Flash Player to view this video.http://www.youtube.com/watch?v=Y_PpSJ6YBMA 10- Examination of GaitYou need Adobe Flash Player to view this video.http://www.youtube.com/watch?v=MF8GexW9xLs___________________________________________________________