Examination of the upper extremities

2021-01-26 12:00 AM

In case of rupture of anterior cross ligament, tibial plateau protrudes anteriorly and when a posterior cross ligament ruptures, tibial plateau falls back.

Rule

Chiropractic examination in specialized clinics has sufficient facilities for examination.

Sequential examination: seeing, touching, measuring limbs and measuring the movement amplitude of the joint.

2 side comparison.

Tools needed for the examination

Clinic: Spacious, clean, cool. The patient makes movements and moves freely so that the physician can easily observe.

One examination bed has a flat surface (no sideboard). A stool (a chair without an armrest).

Tools for examination: A cloth ruler, 1 protractor, 1 reflex hammer, skin markers, needles and cotton swabs for sensation examination. There is also a need to add wooden boards with a thickness of 0.5 - 3 cm to quickly measure the length of the lower limbs compared to the healthy side.

How to examine chi

Look An important first step, very valuable for suggesting a diagnosis. Some bone-joint diseases can be diagnosed just by looking at them.

Looking at the patient's general posture when going to the examination: going straight to the knee like a reviewer is a sign of knee joint disease, walking like a "flap" is the ability to paralysis of the hip.

Observe the patient's skin: Are there any injuries? Are you floating? Is there any discolouration compared to the healthy side Deflection of the limb? ... For example the front of the shins - injured hand - the patient is susceptible to tendon lesions, the fistula at the ends of the bone are found in children - prone to osteomyelitis. 

Touch: select landmarks and markers.

Bone markers are usually protruding tubers and protrusions under the skin or a palpable joint. Never choose mould as software as it will be inaccurate when the patient changes position. Once a landmark has been identified, a marker should be used.

Upper limbs: Apical extremities, large tubers of arm bones, protruding protrusions on outer spheres, vague on inner convex, elbows, the rotating top of bones, rotating crowns, pillars ...

Lower extremities: Upper anterior pelvic spines, large displacement, outer spherical convex, outer knee joint, pre-tibial convex, fibular cap, inner ankle, outer ankle.

Touch for the signs:

Is there a sore spot?

Are there lumps, tumours or not: solid tumours (bone tumours, cancers ...), soft lumps (fibroids, hemangiomas ...)?

Sensory examination: shallow, deep.

Measure chi:

There are three ways to measure chi: measuring the chi axis, measuring the length, measuring the circumference of the chi.

Measuring the chi axis:

Upper limb: Is a line connecting from the tip of the shoulder, going through the middle of the elbow fold, to the middle of the wrist fold (between the 3rd finger), the elbow joint opens out at an angle of 10 degrees.

Lower limb axis: A-line connecting from the upper anterior pelvic spine, passing between the knee joint, to the middle of the ankle fold (between the fingers 1 and 2). The knee joint opens to a 10-degree angle.

Measure the circumference:

From a selected bone mark, measure up or down a 10, 15, 20 cm stretch, mark this place, then use a measuring tape to measure the circumference where the healthy side comparison was marked.

Length measurement:

Use a tape measure to measure the length between the two selected bone markers.

Relative Length: Length measured across a joint.

Absolute Length: Length measured not across a joint.

Only need to measure

Relative length

Absolute length

Arm

From the apex of the shoulder to the ridge on the protrusion of the outer bridge

From large tubers to the convex of the outer bridge.

Arm

From the apex on the outer convex to the spinning top

From the crankshaft to the crown of the pillar

Lower extremities

From the upper anterior pelvic spine to the top of the clear ankle

From the paw moved to the top of the outer ankle

 How to measure and record the movement amplitude of the joint:

Measure and record the movement amplitude of the joint according to the starting position O (Zero starting position).

O-starting posture is "normal anatomical posture" of an upright person, with their big toes touching each other, hands hanging down the body, palms facing inward. In this position, all joints in the body are considered 0o and are calculated from here to measure the movement of a certain joint.

Movement of joints is examined in pairs, for example: folding - stretching, tummy - back, inner rotation - outer rotation, form - closed, tilt - tilt ...

How to name joint movements:

The folding movement is the movement of a joint from the 0-starting position.

Stretching is the movement of a joint back to its starting position. The ankle flexion is called the soles of the feet and the instep.

Stretching is the movement in the opposite direction to folding.

Shrinking is bringing the limb gradually closed to the body axis.

The form is to move the limb away from the body axis. Particularly on the wrist, or use the noun tilting the pillar, or tilting the rotation side.

Back is a movement of turning palms, feet facing the front of the body or upwards. Tummy is the opposite, facing the back or down.

Example: Measuring folding range - stretching the elbow is the following parameters:

Elbow joints

Fold

Stretching

Playback

How to write

Disease scene 1

150 degrees

0 degree

 

150/0

Disease scene 2

150 degrees

0 degree

5 degrees

150/0/5

Disease scene 3

150 degrees

90 degrees

 

150/0/0

Disease scene 4

90 degrees

0 degree

 

90/0/0

Illness scene 5

90 degrees

90 degrees

 

90/90/0

 Scenario 1 and 2: The elbow is completely normal.

Illness 3: The elbows are fully folded but cannot straighten, only 90 degrees, 0 behind.

Illness 4: The elbows are all stretched, but only 90 degrees ... 

Example: Below is a better illustration of this notation:

Tummy forearm examination of 6 cases with the following results:

 

Result

Meaning

first

S - N: 85 - 0 - 90

Approach 85 degrees and back 90 degrees (normal range of motion)

2

S - N: 90 - 60 - 0

The forearms cannot be backwards, the forearms are always in a prone position from 60 to 90 degrees

3

S - N: 0 - 60 - 90

Not able to fall forearms, forearms are always in the supine position from 60 to 90 degrees

4

S - N: 0 - 0 - 0

The forearms are always in a moderate position, not on the stomach and on the back

5

S - N: 0 - 60 - 60

Forearms are always 60 degrees backwards

6

S - N: 60 - 60 - 0

Forearms are always tummy 60 degrees

 Examine the shoulder and arm area

The shoulder joint is around elbow, supported by the shoulder blade again, so there are many movements. When motor examination of the shoulder area, it is necessary to know the actual movement amplitude of the shoulder joint by restraining the shoulder blade, otherwise the amplitude of the shoulder is very large.

Campaign examination

Shoulder joint does not brake

Real shoulder joint amplitude

Form - closed

180/0/75

90/0/20

Give before - after

180/0/60

90/0/40

Rotate outside - in

90/0/80

90/0/30

 Note the starting position on the motor exam:

Form - closed, anterior - posterior: arms down the body.

Outward rotation - inward rotation: elbow 90 degrees folded, forearm facing forward (or let arm 90 degrees, forearm horizontal: inner rotation; forearm down, outward rotation; forearm up).

Tests usually do in the shoulder area:

The active muscle contraction test has pain-holding resistance: identifies the pain area and movements.

Yorgason manoeuvre (back forearm withhold resistance): double-headed tendon examination.

Sprained arm test: an examination of the muscles on the thorn.

Examination of shoulder joint variability: ligament examination and shoulder sheath.

Examine the elbow and arm area

Regarding bone markers at the elbows:

Related to 3 bone landmarks:

Peakon pulley

Crankshaft

Peaks on bridge convex

Elbows: 3 landmarks on a horizontal line (Nelaton Street)

Elbows 90o: 3 landmarks form the lower isosceles triangle (Hueter triangle)

(Normal elbow joint)

Not aligned or horizontal.

An isosceles triangle or an inverse triangle.

(elbow joint pathology)

Dynamic examination of the elbow:

The elbow is a pulley joint, so there are only 2 folds and stretches, no horizontal swing. If there is a joint pathology.

Tummy - back is a movement of the forearm. The bones rotate, revolve around the pillar bone in one axis, which is the path connecting the crest to the abutment.

Fold - stretch (elbow): 150/0/0 (male), 150/0/10 (female)

Tummy - back (arms): 90/0/90

Examine the hand and wrist area

Points to note when examining:

Related 2 tram

The rotating crown is 1 - 1.5 cm lower than that of the pillar

Brooch rotated horizontally or higher than the cylindrical crown (fracture of the head below rotating bone)

Boat bone position

at the bottom of the hole (between the stretched tendons and the long form of the thumb), little pain is pressed

Painful pressure (boat fracture)

The position of the half-moon bone

in front of the wrist between the mound and a little mound

 

Axis fingers

When stretching: the axes of the table bones meet in the semicircular bone.

When folding: the axis 2 - 5 fingers meet at the bone of the boat.

Discrepancy when there is a fracture or dislocation

 Examine the movements

Wrist movements:

Folded - stretched: 90 - 0 - 70, tilted - tilted; 25 - 0 - 80.

Finger joint manipulation:

Finger 1:

Fold - finger joint stretch: 50 - 0 - 5

Fold - joint flexion: 85 - 0 - 15

Type - closed ladder joints: 95 - 0 - 45

Fingers 2 - 5:

Folded - flexed knuckles: 95 - 0 - 45

Fold - stretch joint joints 1: 100 - 0 - 0

Fold - stretch joint joints 2: 80 - 0 - 0  

Physical examination of folding tendons:

Rib folds deeply: keep burning 2 for folding 3

The folds shall be shallow: keep the knuckles 1 for folding 2 at the same time keep the neighbouring fingers from being folded.

Palm sensory examination (rotating, medial, cylindrical): based on the sensory regions of the nerves.

Examine the groin and thigh area

Points to note when examining

Observe

Normal

Weirdo

Relationship between bone markers (upper anterior pelvic spine, large nodule, seated dock)

The line connecting the 2 pelvic crests when standing upright is a horizontal line (perpendicular to the spinal axis at L4 - L5)

The line connecting the upper anterior pelvic spines is also horizontal (in a quick measurement of the shortness of the limbs: we have the patient stand on wooden planks and observe the upper anterior pelvic spines, the board thickness is the degree of shortness)

Bryant's triangle: an isosceles right triangle

Nelaton – Roser straight line

The seams are not horizontal.

Unbalanced triangle and meandering line

Scarpa triangle (thigh bow - chance - closed muscle)

The pressure is not painful, the inguinal lymph nodes are not large, the hard tumor is the femoral neck.

Enlargement of the groin, flaccid mass (apex), not touching the neck of the femur (hollow joint)

Physical examination of the hip joints

3 pairs of movement.

Fold - stretch: 130 - 0 - 10

Form - closed: 50 - 0 - 30

Inner rotation - outer rotation: 50 - 0 - 45

Pay attention to postures when examining

Stretching movement: Patient lies on the side on the opposite leg and keeps this leg average.

Close movement: Must lift the opposite thigh up.

Rotation movement: The patient lies on his back and groin 900 flexes the legs out to rotate inward, bringing the leg inward is the outer rotation. 

Signs and procedures (test) in the lower extremities

Trendelenburg signs:

Normal: Standing on the right side of the good leg, the other leg is on the abdomen, the buttock on the side of the leg will be higher than the one on the side of the standing leg (because the glute pulls the pelvis)

In case of gluteus paralysis or glute slack, buttock will fall lower or sideways without contracting. 

Tips Thomas:

Lie on your back, allow maximum hip flexion on one side (2 arms hugging knees bent to abdomen), another leg still straight 90 0.

In the case of groin shrinkage and slight flex, when lying on his back, his legs are still stretched because it is compensated by the displacement of the pelvis (the back of the spine is maximized).

If the patient fully flexes the healthy side thigh into the abdomen (for the pelvis to stand straight, the leg will contract the hip joint up. The degree of bending depends on the degree of contraction à Thomas (+). 

Tricks Obert:

Normal: when lying on one foot. The examiner lifts the other thigh up so that he is in a posture (90o knee bend, thigh does not rotate), when he suddenly let go of his hand, the thigh falls.

In the case of leg muscle contraction, thigh weight, it does not fall down but remains in the posture - Obert (+).

Examination of the knee and lower leg area 

Examination of the knee

Movement of the knee: Fold - stretch: 150 - 0 - 0

The knee joint is a pulley joint, so there is no horizontal swing, if any, is a sheath injury, ligament or fracture.

Examining the signs of kneecap bones

Normally, there is synovial fluid in the joint, so the kneecap is always lying on two bridge protrusions.

In the case of a lot of fluid in the joint will push the kneecap up, when we press it down with our fingers, it will touch the femur convex and release it to bob back.

If there is relatively little fluid in the joint, squeeze it into the same pocket with your fingers to accumulate fluid.

Look for signs of ligament and synovial damage:

Drawer sign

The patient lies on his back, groin 45o, pillow 90o. The examiner sits on the back of the patient's legs to stabilize, his hands placed behind 1/3 of the upper legs pull the shins forward (front drawer sign) or pushes back (the rear drawer sign).

In case of rupture of the anterior cross ligament, tibial plateau protrudes anteriorly and when a posterior cross ligament ruptures, tibial plateau falls back. 

The Lachman manoeuvres

The patient lies on his back with 200 folded pillows.

The person examines one hand fixed at 1/3 below the thigh, the other hand grabs 1/3 of the upper leg, pulls forward or pushes backwards to feel the tibia slide forward or backward compared to the femur in the case of the anterior cross or posterior cross ligament rupture.

The McMurray manoeuvres

The patient lies on his stomach with 90 ° folded pillow

One hand is held by the examiner, the other hand is placed on the heel area and the foot presses down on the axis of the shin while rotating in or out of the leg. When the cartilage is damaged inside or out, the patient's inner or outer rotation will be very painful.

Legal test - legs closed

Leg form test: examines internal ligaments.

The patient lies on his back; the pillow is fully stretched. One hand is fixed on the examination leg, the other hand exerts a force on the outer side of the knee joint. If the inner ligament breaks, the lower leg will curl outward.

Legs closed test: posture as above. One hand is fixed to the ankle, the other hand exerts a force on the inside of the knee joint. If the outer ligament breaks, the leg will curl inward.

Examine the ankle and foot area 

Points to note when examining

Observe

Normal

Weirdo

Shafts - feet

Through the second toe in the back through the middle heel

Axial displacement (ankle fracture, heel fracture)

2 ankle position

The outer ankle is 1 - 1.5 cm lower than the ankle

Change in ankle fracture.