Page 101 Guide to Pain Management in Low-Resource Settings

Physical Examination: Orthopedics 89

How to perform an examination passively: fl exion/extension, abduction and internal and
of the extremities external rotation.
3) Test rotator cuff impingement (shoulder fl exion/
Th e extremity examination should include a careful evalu- abduction against resistance).
ation of the important tissues. In general order of impor- 4) Evaluate sensory nerve function of the axillary,
tance, these include the skin, vascular supply, nerve, func- median, ulnar and radial nerves. Hint: the volar tip of
tion, muscle, joint function, including ligament stability, index fi nger = median; the little fi nger tip = ulnar; the
and bone. Th e parameters to examine are listed in Table 1. dorsal thumb web space = radial, the tip of the shoulder
Judgment is an important skill to practice. = axillary.
If a bone is obviously broken, it may not be prudent
to attempt to evaluate range of motion or ligament Elbows:
stability in a nearby joint. However, it is possible to 1) Palpate the surface location of the medial and lat-
examine the joint for swelling, effusion, tenderness, eral epicondyles, the radial head, the olecranon process,
and the olecranon bursa.
2) Check elbow range of motion: fl exion/extension
Table 1 and pronation/supination.
Evaluation of the extremities
3) Test the biceps muscle strength with elbow fl ex-
Skin Look for swelling, redness, induration, open wounds,
palpate for tenderness ion and supination.
4) Tap the ulnar nerve beneath the medial epicon-
Vascular Palpate major pulses, evaluate capillary refi ll, tem-
system perature, and color dyle (“funny bone”)—increased tenderness signifi es
Nerves Evaluate skin sensation, muscle function, and major compression.
deep tendon refl exes; try to determine if there is loss 5) Check the biceps and triceps refl exes.
in a dermatome or peripheral nerve distribution
Muscles Palpate for tenderness and swelling; test for strength Hands and wrists:
Joints Evaluate for swelling (fl uid in the tissue around the 1) Palpate the surface location of the radial and ul-
joint), eff usion (fl uid within the joint), range of mo-
tion (active/passive), stability (test major ligament nar styloid processes, the thumb abductor tendons, and
groups), tenderness (around the joint and the liga- the anatomical “snuff box.”
ment and tendon attachments)
2) Palpate the radial and ulnar pulses.
Bones Look for alignment: normal, angled, or rotated; look 3) Evaluate the range of motion of the wrist joint: fl ex-
for localized swelling and tenderness
ion/extension, pronation/supination, radial/ulnar deviation.
4) Assess for carpal tunnel syndrome: tap the me-
and deformity and gain an understanding of whether dian nerve at the wrist (Tinel’s test), test sensation as
the joint is or is not likely to be involved in the in- above, fl ex the wrist and hold to create tingling, and pal-
jury. Likewise, the skin may show redness, increased pate the thenar muscle mass.
temperature, induration, mild or extreme tenderness,
Hip and pelvis:
some swelling, or tenseness, all indicating the de-
gree of underlying pathology; from a mild bruise to It is easiest to do tests 1–3 with the patient supine and
severe infection. Systemic signs of fever, weight loss, test 4 with the patient standing.
or chronic fatigue, along with basic laboratory tests, 1) Palpate the surface location of the pubic tubercle,
should also be used. the anterior superior iliac spines, the greater trochan-
Th e following is a simple checklist to follow ters, and the ischial tuberosities.
when performing the basic extremity examination. 2) Check hip range of motion (passive is easiest):
When possible, it is easiest to do with the patient sitting. fl exion/extension, internal and external rotation, and
adduction/abduction.
Shoulder: 3) Palpate pulses—femoral, popliteal, and anterior
1) Palpate the surface of the clavicle, the acromio- and posterior tibial.
clavicular joint, the subacromial space, the coracoid 4) Test hip abductor strength—with the patient
process, and the deltoid muscle insertion. standing, ask them to lift one leg off the fl oor. Normally
2) Test shoulder joint range of motion actively or the ipsilateral pelvic rim will elevate. If the abductor