Tài liệu Clinical Tests for the Musculoskeletal System doc

on the joint that roubles the patient, hut the examination must olien be exlended to inchide the nerves and tnusc]es that are responsible for movements in the joint: some of the.. BE CLI

CLINICAL

ORTHOPAEDIC

EXAMINATION

Ronald McRae

FRCS (Fng, Glas) FChS (Hon} AIMBI, Fallow of the British Orthopacdic Assacialion

With orginal drawings by “he author

FIFIII EDIIION

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PREFACE

The ability 19 make a good clinical examination can

enly be mustered by practice, and 1 have no doubt that

the basiv techniques are hest leurncdl by performance

under supervision, Unforturately, the size of stuglent

classes in relation to teactiing staff, ark! Une abt

infrequent dcarth of an adequate range of suitable

slinical eases, makes this ideal difficult to achieve in

practice, Many students my accpize only: a shetcly

knowledge of the fechaiques oF exarninuion, which are

fundamental to diagnesis and trealment Lis hoped that

this book nuay help ta fil sere of these inevitable ga

{UHL sound practice bused on experience is uchieved

The text

tis assumed that the sulue of good history laking is

appreciated and practised

Patients parade theic complaints on an unatonieal

basis, and the fevt hss been sevanged avcoutlingly, The

euuptiasis in euch section i on Ute common rather than,

the rare conditions to hệ found in the wegion Atough

this approucl is open w criticism, it iy nevertheless true

to say that although the obscure will tax the must

experienced, the most lrequent rnistake is a Tuihue lo

điagtuse thẻ conuuan, Án eneyelobaetie text

commendable on the araunc of complerenes,

nevertheless often conguse, expecially where no

indication is aiven of the incidence af the conditions

observed I have purposely avoided detail, and where

this is ceguized « Tuller orthupaculic lexthook rust he

consulted In some areas ona T have muse deliberate,

simplifications where a blight of tenninology suggests

may

the inilepersience af i auruher of conditions thal cannot

be distinguished by sympeoruatolugy oF ines

The illustrations

The illustrations dealing with the practical aspects of

clinical examinutive have been anrunged in an

essentially linear sequence following the traditional

Jines of inspection, palpation, and the exauuituion oF

movernents and pertinent anstornieal stevetnres, Te

practice, this logical onder is often altered by the

experienced examiner tp avoid undue moventent of the

patient Ie must be stressed that nat all the tess

described need be curried out raullinely Muy are

performed only when a specific condition is suspected,

and it 1s ussumed that this will be obvious to te reader

Ii particulag, in any joint assessment, itis necessary to discover if there is any restriction of movement Tn may cases simple sereening tests will suffice, and these are highlighted in most sections The owe: detailed examination and recording af movement are generally reserved fur cases under lengthy continucus, observation ad lor inedico Tepal work

Radiographic examination plays an essential pant it the investigation af most orthopaedic cases, and te wid the ineaperiemved | have wide some observations regarding the views moranally cuken and hosy they uy

be interpreted Only a fraction of the possible pathology

cen be illustrated iw small work, but | ave concentrated on the cooumon or intern The spatial renticements of the captions have set some restiction on their content this discipline has resulted in brevity al the expense in places of completeness, Nevertheless wherever possible I have tried to show nol only how each test should he carried fot hot alsa its significance

7 have taken the opporumily that this new rth edition hus afforded af reyeneking all of the previous drawings, These I have digitized, tiled up wtere nnceussury, and used a vatialy of urey Fills to inuprove their clarity Th audition, the text has been uplated and reorganized in thang places, and a nurnher of new lasts have been incluuted

Conventions and references

For clarity in ilustrating tte tectiniques of examination, the patient and the exauniner ate shoven in shales of Tight and dark grey respectively

Where two limbs are iThustrated, the pathology is shown o1 the patients right side

Where several conditions ate descuibed, sind one represealalive illustration only is given, itreters to the first condition mentianed

When joint inovements ure being considered, the, patient's nerntal side stinuld sf possible be used! for comparison, Angular measurennl is an approximation, and the Tigures quoted are in mnst cases valves raunded

to the nearest 5° from figures published by the Anterivan Academy of Orthopedic Surgeas!

Kapanidii”, Lusted and Keats’ or Boone and Aree

Abbreviations

left and right lateral sind medial interior and posterior

References

Smeciein Academy of Ontunelie Sarr

mahie ví measareng ant recnrding, Chill Livingstone

Hlinbures

Kapandji 1974 The plysiokagy ef Ce jints Chun

Lixingsowe, Edinburgh

3 Lust 1B Keals TE (972 Audis of coertyenogeay

racasutem, Yeas Book Medical Publis Landen

4.fhoure CD Ager PS 1979 Nomad rarge of mvtina of joints

tate sists, Jounal ot one ara ot Surgery SL 75649

CONTENTS

1 General principles in the examination of a patient with an orthopaedic

problem 1

2 Segmental and peripheral nerves of the limbs 11

3 The cervical spine 33

BÉ CLINICAL ORTHOPAEDIC EXAMINATION

In practice, the primary stea of interest uf the orthopaedic surgeon is ta the joints of the Jannbs und spine, and how well they function The nigjor part of manst orthopaedic exantinations is therefore centred! on the joint that roubles the patient, hut the examination must olien be exlended to inchide the nerves and tnusc]es that are responsible for movements in the joint: some of the patients other joints may also have to be checked io see if duey are wlected

as well Joints possess a remarkable degree Of individuality, anc! ic follows char the lechniques for examining one joint enary hare lo be varied when ic comes 16 look al another, However, a common sequence is Followed, and it may he hhelpfa to keep it im enna, Ut is assumed thst a full, relevant histary has been obtained, and any general physical examination has been carried out.) The exantination of the join itself may be broken down into six distinct steps:

note its position in relation lo the underlying anatomical structures, as this May give a-clue to its possible

2 Is there bruising? this mighl suggest truma, with 3 point of impact

cr gravitetiooal or other spread,

3 Is there any ofher discolora

Irom pain or other incapacily or from denervation of the enuscles affected

5, Is there any alteration in shape or posture, or is there evidence of shortening? ‘There are méaty possible causes Tor ech of these abnormalities {including congenital abnormalities, past trauma, disturbances af hone, mineralization ancl destructive joint disease); their presedce should be noted,

aind explored in liwther detail during the course of the exansinasion,

GENERAL PRINCIPLES IN THE EXAMINATION [ES

Suine of the points you should note include the following

1, Is the joint warm? If so note whether the temperature increase is dilluse or localized, always bearing in sina the false impression that may be caused by the effects af local handing A diffese increase in heat Occurs when a substantial tissue muss is involved, and is seen most commonly ia jvmis involved in pyogenic and non-pyogenic inflammatory processes and

in cases where there is anastomotic dilatation proximal to an arterial block Away from the jvints themsclves, infection and tumour sould be borac in mind A hicalized increase in temperature generally pinpaimts an

influmeatory process 10 the underlying anatomical seructure, Asemmerrical coldness of 1 tim commonty occurs where the limb circulation is impaired, c.g from atherosclerosis

BE CLINICAL ORTHOPAEDIC EXAMINATION

STEP 3: MOVEMENTS

‘Most (but nut ull}, onhopacdic conditions are associated with some reslriction of movements in che related joint(s) Complete loss of movements follows surgical abladion of a joint artheodesibJ, or nhay occur in the course

of same peathelogieal process (such us inlection) where fibrous oF bony tissoe binds the articular surtaves 1ygether (iibrous or bony anksytesish the joint then cannat be moved either actively ur passively In many conltions there

is tuss of that part of the range of movements which allows the ent tờ be brought into its neutral position The eonmonest loss of this type prevents the joint trom being Tully extended; this is known as a fixed flexion

dlefonnily Hixed defimnities may bs: caused lor example by the contraction

af joint capsules, muscles and tenduns, or by the interposition of sol tissues

or bong between the articular surfaces (e.g, tou menisci, Loose bedi} Estimation of the range of maveinents in the join is an essential part of any orthopaedic examination To assess any sleviation Irom aural the yund side say he compared with the bad; wher: this is not suitable (e.g when both sides are involved) resort muse he made to published tigmes of calculated average tunges Restriction of the range uf movements in tr joint is neatly always de to mecharncal causes and is cunsequently a sure indicator of pathology TẾ the muscles cemtrclling a joint are paralysed thon the passive range of movernents thust be assessed occasionally pai or other factors may restrict the arzive range of movements co a range that is less than the passive Seanetiones a partly or totally paralysed join! can be persuaded co move bự invoking gravity or mavement elsewhere (rick movements), anxk the confirmation uf paralysis generally hegs the detecuination of its cause

GENERAL PRINCIPLES IN THE EXAMINATION 15 |

1,9 Measnis the ange of avements and Tel, Test For maveneat in abnormal slenes 1,11, Nove any aio evepins

recunl auyfiged deri

Ta mang jnints i is also mandatory to lunk for evidence of anevements ôm

«an abvormat plane To do this the joint is genetally stressed in a panieular plane and excessive mavements are assessed by inspection or by the exunination of radingrapts, Ober accompaniments uF movement may sequive assessment Rangh articular surfaces will produce grating sensations (erepitas) when the joint is moved, and this may be detected by palpation or auscultation Clicks ecmang front the joint on saovement thay bê pRadueed through soft rissnes moving aver bony prominenees (generally of Tite importance), fram soit tissues within the joint fe.g displaced menisci, or foam disturbances m bony contuurs (e.g, from irregularities in a joint susface following a fracture involving the joint),

Ihe sivengti of muscle contraction (and hence che strength of each joint uvyements must be ciefully assessed and especially if Lutind seduces, recorded on the Medical Research Couetl (MIRC) seule:

MO No active contraction ean be detected MLA flicker of contruction cam be seen or Found by patpation ever the

“mlusele, but the activity is insufficient to cause any joint meaveme M2 Contraction is very weak, but can just produce movement so Fong as the weight of the puri can be countered by carelil positioning of the limb

M3 Conteaction is still very weak, but ean pinduce movement against gravitational resistany the quadriceps being able tw extend the khoe with the patient in u Sting pusitiun

M4 Strenatt is nol full, but can prudhice mavement against gravity and

added resistance)

MB Nornuil power is present

Muscle strength may be impaired by pain, wasting from disuse, disease or denervation nally, attention should be paid 10 any unpaitment of overall function in the affected limb as a result of disturbance of movement ur muscle pewer: in the case of the legs, this implies an assessment of the grit, Many tests anv available to detect disturbance of separate aspects uf upper lìmb [unetiem

BE CLINICAL ORTHOPAEDIC EXAMINATION

ligumenls and lor the examinatien of structures associated with the joint (e.g, the menise’ in the knee), OF particular importance is aux appropriate neurological examination (€.2 the lesting oF specilie muscle geeups and the dleweernination of any sensory loss}, When applicable ihe MRC eradinng uf motor and sensory levels should he recorded, Lhe latter is us Follows:

SH) Absence of all modalities ef sensation in the area exclusively supplied hry the alfected nerve

S1 Recovery of deep pain sensation

$2 Recovery of protective sensation fxkin touch, pain and thermal sensation)

STEP 5: EXAMINATION OF RADIOGRAPHS

When a radiograph is request comprising an anteropesteriar (APY and a Lateral projcction will he provided Someone experienced in looking at cxtiographs will recognize whe min

1 Are the bones of normal shape, sige and cuntows or are they thicker vr thiover than oorml, shorter ar longer thao usual, or abnormally curved or angled’?

2 Al the juinis themselves are the bony components in correct alignment, 0¢ ate they displaced of angled!?

Looking a Uirtle more clesely note whether the bone texture appears norial

or disturbed such as in osteoporasis Paget's disease, avascular necrosis, osteoporosis ele, Note il thers

subperiosteal new bone foritation ele, Note: whether there are amy areas of bone desimetion, snch as may be found in the presence af many tumours

infection (or an inflammatory process) trauma, neoplasm metabolic

GENERAL PRINCIPLES IN THE EXAMINATION [Pall

disturbance, dogeneration: a list mmuy have un anatomical base: yont might then assess ligamentous altuchuricms, joo margins, the joint space, and the cortical aiid eancelleux boNe elentenls,

Tn some situations radiographs adđidonal to the standard AP and lateral projections may be mquired These may include:

* Comparison films Here films of the other limb may he tsken so that the two sides may be compared: this nay be indivaled where there fs some Uifficulty in interpreting the radiographs {for eample in the elbow region

in children, where che epiphyseal sicuctures are continually changing or where Ihere is same unexplained shadow or a congerilal abaurmality) + Obtique projections In the case of the hand und foo! an oblique projection may be helpful, especially when the normal literal view gives, rise to conlusion owing Io the superimposition of many bone structtues Such ablique projections may have to be specifically requested when they sue nol part of un X-fay depdtenett’s rwutine

Localized views Where there is marked local Londernwss, but routine Citas are nezmal, coned-clown localized views may give sufficient gain in detail

to reveal lor example, ä hairline fraclune

‘= Stress films Stress films can by of value in certain situations, especially lien a substantial car of a major ligament is suspected Har example, swhere the lateral ligament of the ankle is thought to Ix: loro, radiographs

of the joint laken with the Fupt in forced inversion may demonstrate inscability of the talus in the ankle nuortice

STEP 6: ARRANGING FURTHER INVESTIGATIONS

This Just stage is not aheays requuted, but the indications are usually quite clear The clinical and radiological cxatninations may bse cesuled ina differential diagnosis thal requnres additional wsts to allow ä im diagnosis

to be made in nuiy cases the allitional tests serve to eanfirnt a song, impression Occasionally clinical exaaninalion fails to clrily the problem and one reanains baNled by the cause of the complaint: further investigation

‘may throw sante light aw the siuation, pechaps indicating am area that shunt

Fe concentzalod upon, ur suggesting thal temperrzatina ans! abservation may

be cinbarked upon with safety or necasionally it may suggest Ula sont Teast of the cunplaint suay have a fumetinnal basis

The commonest screening tests include the following:

1, Brythracyte sedimentation rate SR) tad, in certain cases, C-reactive protein)

Full Mood count with differentia

4 Bglintalion of theuntateid Factor

4, Scrum calcium, phoaphatz and ailedine phosphatase

5 Serum uric avid

6, Chest Xray Other regional investigations include the followin ADDITIONAL IMAGING TECHNIQUES

1 €T scans These can show tissue ices in any plune, but characteristically in the cnedian sagittal, parasagical, coronal and, most imporlandly, the transverse planes The last projection euonot be readily oblaincd with plain X-rays, and catt often provide useful addidoaal

KẾ cunicAi orTHOPAEDIC EXAMINATION

information which is uot otherwise available In addition, in che CT scan, lliete is u greater range of erey-seate sepwation, allowing a greier differentiation af tissue types,

2 AP and lateral lomography In this X-tuy technique the wibe ant film

ue rotated for Sid) in pppasite directions ducing de exposure Their

abort the karee anid hauhler found Ultrasound imaging, which is generally regarded as being readily available and ineapensive hus grout sensitivity and is oF value in assessing the presence of fuid (# g hlood) within and around yoiats, tas Weel! as discontinuities in soll lissue structures IL is frequently used in evaluating cases of developmental dysplasia of the hip

FUNCTIONAL IMAGING TECHNIQUES

1 ‘Techinetium hone seams, Hone sens may be performed aller the injection of technetium-tazged snethyfene dipbosphonate C"Ve-tuethy ene diphosphonate (MDP), The facility is widely available, inexpensive, and ives rapid results, En the trauma field such seans may assist im the diagnesis,

ol the seaphoid, shin, or neck of Feunur) They unay assist in gauging the age of a fraetuye, and in detecling avascular necrosis of bone, They are of value in the investigation of wexplained pain io the long bones and spine infections in bone and in the region of prostheses, ancl in ascescing Sudeck’s alrophy (complex regional pain syndrome

2 SPECY (single-photon emission controlled tomography) This echrique may he used to give better localization and assessTuent of an active area discowered by a technetium bone scan Tris nf parieular value in the investigation of baok pin

3 PET (fnorodcoxygiucose (FDG)-positron emission tomography)

bè of value in localizing infection within a bone Other metheds in the

ARTHROSCOPY Methods fur the exanination of all the major joints have heen developed and iMlow direct visuslization of the articular surlaces, the joint capsule, unany assuciated ligaments and, it the case of the knee, the sncoisel At the same session biopsy suumples unay be taken iF requires anil sometimes trẻatiyn procedures may'be carried out,

EQUIPMENT REQUIREMENTS

The special ruuls required for the clinical examinariva of a patient with an

waracter Four are desirable:

orthopaedic complaint are modes! in el

1, A tape measure (preferubly uf the type used by tullorsy for measuring such things as limb lengths and girths (for evidence of inequality in

GENERAL PRINCIPLES IN THE EXAMINATION za

length, or evidence of mdscle wasting), an sometimes for assessing movement (e4, in the spine, knee sand rib cage),

A goniometer, preferably with un easily read scale with secipracals, for

measuring the range of movements in a joint

A tendon hammer for eliciting limb reffexes

A disposable sharp point (by detaull a hypodermic needle), fresh for each case, for assessing suy disturbance of sensation te pinprick,

CHAPTER

2

Segmental and peripheral

nerves of the limbs

#aree hạc lớn 3

Bierides Far aks 1A

is sat "4

HEAD cuinicat ORTHOPAEDIC EXAMINATION

to the plexus

plexus with the roots al the segmental spins! nerves, which are intrathecal C5 and C6 Torun the upper tram, C7 lvetns the onidéle trunk, and C8 and TT orm he dower trunk (Progangtionic sympalleli¢ nerve fibres to the upper limi arise from T3216, ascend in the sympathetic trunk, symapse im corvigothoracie ganglia, and pass to the upper limb enainly Gieough the lower tvunk of the plexus, An important localizing puint to nute is that

preganglionic [ihres en route w the eye via Ue Sellate ganglion arine froca

TL The trunks are found ia the posterior triangle af the neck, The subclavian artery lies in fronc of the luwer iromk,

Each trunk forms an anterior and a posterior division, rhe divisions Hie behind the clavicle The three posterior divisiuns Form the posterior cord, the anterior divisions of the wpper nd middle trimks form the favero? cord and the anterior division of the lower trunk contiaues as the sedi! cond The divisions and conmrencement of Ue cords lic in Uke posterior Iriangle of the neck

SEGMENTAL AND PERIPHERAL NERVES OF THE LIMBS fey

MEDIAN

UPPER SUBSCAPULAR THORAGODORSAL

RADIAL AXILLARY

BRANCHES FROM NERVE ROOTS

he fiest brancies of the plexus ly be given ul themselves Two important branches in this categar

1 The nerve to the rhomiboids (dorsal seapular nerve} I arises from the Cổ root alone

2, The nerve to serratus anmesiur (long thoracic nerve), It has contributions trom C5 6 and 7, Its most proxinial par! arises in voxjunction with the nerve ta rhombvids

vise frum the nerve routs

C5 also contributes lo che phrenic nerve, and C5 6, scalenes antl Lungus colli Although oul striclly branches of the brachial plexus, these segniental branches are of some importance: paralysis uf the hemidiaphsagsn, whi found afleca bructal plexus injury, andicates a proximal lestun

and & supply the

FREE CLINICAL ORTHOPAEDIC EXAMINATION

BRANCHES FROM THE TRUNKS There are two branches ouly at this level:

1, The suprascapular nerve is important, supplying the supraspinatus and

dlislocation of the shoulder

3 Tn eratuntic plexts lesions i adults the cornmonest patlerns of injury are ta) C5 6 (th type: (bì C3, 6 7: (6 CST inclusive

THE BRACHIAL PLEXUS: AXILLARY PART _

The corels for the most purt Be in che axilla, and are closely related to the asillary aatery, (Ube axillary artery commences ut the outer harder of the first Tắb and onds at the Lower burder of teres mais The second purt of the axillary artery lies behind the pectonilis minor with the first and bird parts

uf she arrery lying abos@ and below it, the uhree cords enter the axilla above thẻ it part, embrace te second part ia the position indicated by their names, an give olf thei branches around the thine prt.)

BRANCHES FROM THE CORDS

The foreral cond (C5, 6, 7) ‘This gives aff the Following branches

1 The lateral pectoral (which supplies pectoralis major)

2 The musculocutaneous {which sopplies coracobrachialis and biceps?

3 ‘The lateral ru0L oF the median cxrve

The medial cord (C8, T1) This gives off

12 Tbe medial pectoral nerve (which sunplien pectoralis majo!

2 The međid cuaneous merve uf the ur (sehich supplies the skin over the

front and the medial side of the acm)

3 The medial cutuncins nerve ol the Forcarm (avhich supplies the skin over

the tower part of the arm and the medial side of the forearm)

4, Thế medial root of tke modi nerve

‘The ulnar nerve Cin 90% ol cases the ulnar nerve receives a branch (CG, 71 from the lareral cord)

The posterior cord (C5, 6, 7, 8, TH) This gives off

{The upper subsenpular nerve (C5, 6), which pactly supplies subscapularis

2 The lower subscapular norve (CS 6), which supplies subscapularis aud

njon

teres

SEGMENTAL AND PERIPHERAL NERVES OF THE LIMBS [EES

3, The thoracodorsal nerve (C6, 7, 8), which supplies kaissirmts dorsi

4 The raial nerve (CS, 6, 7, 8, TÌ)

5, The axillary nerve (C5, 6Ì

Dbetsils of fhe soos important branches truệdian, ulnar, rafal, axillary are ghen later

2.2, Segmental diattbufien: Whece vau —— 2.8, Myolomes [1j; Nasdlytarnore 2.4 Nyefomes

suspect savolvesient of sping eres ralher

than perisral nerees ja muses bo the

spits 0: heal phx, cores sponds

fe} you must examine nyoloztes and

wes, Thess ve th Masel aunses ad

sarsas uf kin sappite by single spinal serves

fo saller ow the nerve bees whi the

spinal eves a Fallot

Hb plexuses and pesipherl newest

+ sal tế proimal tine the foe hi Segmeate inwcived der

by plus or “ings che, sọ thế Theory the seule shoul be corzelled hy Cá 36.7 More C4 as baen suppressed, Wi Pe result thar abduct is edited vag CS one dalled supraspinatus 4) Acaluction Uinvete me principally peetrsils maier Ìs sweullel by Cñ-

produce tmseertent of a jamin ge ngoioa,

fn Lyin anole, Thị rae a the eT

‘where weakness of ellos ein ad an absent biceps toads jth iieate 5,6 ingulzestent ind whore weakness al CXRndlen A1 an ches reps j27k ges 8 C25 esion, This gensrd rele followed theeughout tie iawerfimb but is soiled tho highty spesalizes upper lr

2.8, Myotomes {3} ALG wrist vẻ

{GF would ave buen expocted to gantaL

lis Desivu vuly ise cape tat these

Feo segments camtol dnsilesiom a w!

2b Myotomas (4); Roth Nevion ard tsuension of the fagers are sontolled by cas

27 Myotomes ( pronation and sopingicn a single spinal Segments ivoived, nately Ch

HE CLINICAL ORTHOPAEDIC EXAMINATION

“2,8, Myolemes {6}: A sinsle semen

game sls 1 involved in proeicing

duction ad asuctin othe ngơi th

ements ar? cae at by the sake

rmseesitrinsien af th hand Nn: In

testing for msoraines the abiliy to perdi

the ahnse movempnts shall be assessed by

MRC arn snd nite ova of the segments

fest Oren de detect can be lucie

at, casilycememihered seqpenve OF

ry ehstrihuion sou the preaxil Hine ot the inh

fd he elavinsctust Fa (sstgangivnic

Th lesa say he taneione Fear TS

te axon segenerate usmeucesis, Fegensmation seen a the rate a Tag, provided she axons cau penehile oe fetraneurs) sea

2.11, Lesions with ruptured nerve

roots (2 fis more severe mjurits [72 nerves

are supa al che ae level ÔN si!

inervencion can offer ay hove ef resvvery

hu ropa, even wilt nerve yiting, ty he

impossible hecause cf extensive iroarpoi

slaiage Tis importa w uiferect

betseon lesions oF this cgpe less i

contin Frere the Iretiment is expect,

sa cond coking ese ttre the

lesions (8): the gee roe rons are spare sở hat

‘ear rhe ay Be the prison oF elas paraTis sccumpatied by presevation of senmativ, The promos fr he ot ese then slicurratnces sls hopes gh the

et value of Carls

‘Tear ster lings esamination a Farthr inceatigating, in xang cases the piste is feomplex oweng 40 the fag hal omer eHEe oF

‘these injuries nay be nine,

SEGMENTAL AND PERIPHERAL NERVES OF THE LIMBS NHẤT

2.14, Long-standing plexus lesions (1}t

In Lab's palsy supper sbsetical psy hà

alfeeas the pp tha she bral plexus

fan hence CS there we detoemily sf

Vib, shies eld in shareterisic

posiinn: the ri is lesa poate, a

fre finger esed The lbee is catetdlal am

fis shauhler tory erat Gwar tip

dstoruis The netee to chamfeies nnd 2e

dung (hatte nore age usally spe

2.15 Long-stonding plexus lesions (2}:

Lu Risse * pase te sl eens nse clung he hyEetieuar and therat pepe, ars wasted end thewe ie ela hang dency There conse hn The rid Sec the Fvear aud wish fa many aes these is an assocluled Horne syndrrne, Sote sala 0 385% patents wee reoeine ediaray or hreta gạfcInorma đevelen 4 Pacha) aeucopaths.>

2.16, tang-standing plexus lessons {3}:

ne "TT rot aan! may eine the Soe Sigs msing wasting of the eral muscles ot

Ce hand, fueling the therar greug, along

‘ei sereory Ins an the medf se of hand oly Eesians of this pe ave see a lve lnwer be pales cervical sperisosi, ceca Sondre, aewaibremaasic, and apical and metastatic

lesions of the 2.17, Acute traumat

brachial plexus:

anges sol inj "neBlse epson

‘hauls combined sth aera lesion of

neck (the oppisite sds, of tcton on

frm, Mocoreyaieansiderts ats the single

rset cou cavie On inspeto lok Te

ths presence of Ulla nsieg oxe the

shuns oF al the ect of “he nee, othe

more severe es the arm hangs Fly a the

sức

2.18, Assessment {1}: Ú fesermining the eazeur of the Tes,

when

2.19, Assessment (2p Alter determine the XepeH- re sci you shon mỳ

se fue an ppiinn a te he pe oF inary

“Taisen he allie 9 hei Bọ he re cenence there is 0: proannal dana he pion Machange of card avian aad a pane progmsis Honr's syaurome charsterize

De (AY provlepesis, (By sPaliness ol the pup om Uke altel se, and C7 oye fhe hana feat absstce af sealing, secans sshem the 71 rst is involves ola 1 anal

BEN CuNICAL ORTHOPAEDIC EXAMINATION

2,20 Assessment (3]: Luck for sensory

ss neve he clave, Vhs aren bs nol

Supplied hy C3, aif his alected

seemerally edict tha the Fry hát biện

Sevens char ihe Hot only isle the pews

bat tbe ruts above: iis esually inieath ot

4 proximal ay witht poor preanais, Deep

bruising inthe posterior tame i ls

stooagly soggestive of 9 aregang vnc Ieion

2.23, Assosimont (6}: Sur

nerve (CH This ave urine Fo Iho

Igpee oink a te plexns and suplics the

Supteny! 106 and indraspinatas, To est for

er viy in = supcaspinas, ask the pation co

yaa

THy abd he ae pat rasstaree: toe?

fc apse contnerin an0¥e te spins af the

seupuba, Ue iat may be lex by

fegling fr muscle comtaeron Selves the pine

‘ofrhe sami stile the petit ames

rutate Ure shoe fee enteral.»

2.21 Assessment (A}j Now wst the frst tures that cea ol the plexus Nerve 20 iowioids (CI: Ask the parent place De pruduces weinging uf rhe seapla, ch is and ọn the Lập std to estat te elhoe eingt—emaly demonstrated "y aking “he patient Dus foswark fee tor eoureation the ate with aul hare agama wall HP sombgad mescles, Absence of utivity Us ost ay have tan ahànđoneđim the Indicative ofa esi prota the presence of an extensive plexus lesion, (Nore formation o¢ the upped tank of the plexus th he nero: eo scan tori my

‘ond sopeestize nf word avnsiony Pescence of — damages ia sotation through ling very sorvity means a Tein dil Ce Ineasy weirs

interveribraléovumen,

2.22 Assessment (5ft erve so seins

ti 56.7: DaNnge tw this nerve

2.28, Assessment {7]: Omer ests, cbservation snd investgasions 11s Het stam Tap Yignroushy.r ths icc u te nee working Gon above downwards in the Ene of the nerve rors

as tae emtenge fom she spine, The tes is poiive i ere ie azkse, paint paassthes in tewftspegdlile cermatoie: foe example tapping weer the Ch nom prodiees vers porn and linglny inte thump A posinvs es generally indicates a rapanied meres Fear and &

psigangionic lesion (Tis sil hooseves, Ml ee tet may sly 36 porve in Use preeesce oF

a avulsed posterior ront ganglion

£2) ray and MRE apn lại Pai films of the seevical spine should be wbtsined Alough these ase principal sahss in eliminating wher parhalogs thy may cosasionay eal & lnusverse pmicess(ralure: suet raciue i indcalive of the severly of a= jy Hl te probity ofan inecewerable lesivn (b) pla PA zaliugraph ofthe chest may reveal Paralysis ola etnidiaphragm indicative of» ponsimnlly ete sia, (02 An MIR) scan may

“HN th vc để mere eEsruption,paresey an the cape uf preganglioait Peaoes,

HH Mydlogriphy uy pve eluant alormation romding ‘ke presence or absense af signs af seulsion of so9ts trom the coed Sigas indealive ef a paw saps ine ade Waua tweningeecee, Tons oe iniution ut enaggerainn of nan paughey aul eystie acuraior ot (St shin the spinal cá

G3) Bloimangography: Iss bees reeorminerded hut ut eas tu causes supplied hy each rot should he esamined hy the insectine ot anedle ckumntes tha prescave af ang action poteatals soil indisatd sete ceinuiy u al es,

Fay Seoncars endecton: Sensory senatetion way he assessed 18 Co 4ý: lại bự implaing 1% he median mevvo a ae Bai, aa Dy means OF sepiate elects LEM

to pickup eewltas: potentials over ‘he plexus or inthe acck yevoked potentials)

bt scimuring ray he median newve Fhe il, and attempuing us pick up putea dade

bề team ring ekecedes round the index Ginger Csensery sein antadrnnic: pena, 7 Inter thd pears peti, One side compared withthe mr Ft sees ar fe sa, this segpestsw severe br compte pregarglinals Psion (sew sign a notte wus "om Gee See

am sence agtion poets ave SDRC on th njuned ide, Lis suggests postganglionic son ai diuieshed aati poemtials represent mined lesion is hike

15) Micauine text chop oF 1S histamine x place sox Hh eee of cach eve do matome tnd the shin priched tureugh ils he monn’ side swe 84 tolrnl, Ôn the nal se tere Souk he the usual wiple resus wih the Slave Lolly developed within 1 minutes Absence ot

2 Hlare on the injure side suggest postgaaglonic Jomlage 1 aural Uiple response fs Found perassig ace 8 wecks in anaesthere skin, 9 pogang]anieIssoa l Vay centaim

FEEL cunicat ortHopacpic EXAMINATION

2.81, Radial nerves Sensiry distribution

04) le smal bar th se đi

aervel supplies the rial sade the back vf

the hand UB The posovew canes Rene

‘oF Ge radi given inthe Upper pat the

asm, suppciwa varia aaa on te bask of

tie an and fore

fr The Pack of shia the 20 called hese an vbvivus wis drop? it ts there

“Sanurday nih pacsys iB: Midchameres wasting uf he orca mses? 14 Is here tifsez rmacceres and tape” palsice) (C) at wasting ul the tricens suzuestany 4 big aan besos the elbow ‘egal cisloeanons of (quote! sion?

the eters, Meneagia trclures 8angliets,

a sun nes suppl ranma Focowing exposes in Mis regia

3.34 Examination of the radial nerve

je Tas: th extensors ot she wrist and

4 how soll b> Axed nad the

Tapa e2u in pronation Support the ats

find ask he natn firs tor and sagen

th fers ant sn top back ths writ if

ther ty ari, jd he strength by

plying cameteypessure ea the agerx er

tang

2.85 Examination of the radial nerve 2,36, Exar (Ble Now tet the supintor muse Te (a eaghiora tls the 2a tha GA hệ 0504 Wo imine the Ki ex the bo in the midprone positioe supinatiag 4cxon o1 Weeas Ask rhe pationr to asiase ev.stes, Feel an loek li turn his hang hve you ayaty eaumeriorce contraction in ths use Loss af power Lens uf supintcon singgete sean and Suggests Kvionabnve pres tới Re tie odie exit he amunatortungel Lark tor seine ened

teudemmess over the tuna

3.35 Summary of signs indicative of a

poor prognosis in haumaie lesion of

the plawust

1, Às mplek kelm onsokdsg.l By ron

3, Sensory hs ave the elvis el

tine postior anwte

Facts of 4 nsvese ram

Paalis of reid sed eras

Retention of semecy conduction me

ok Se parent S82 58 Hệ the aim From Es 2S, pein permting, while you resist ans Insesemens, Look od feel Fee welt cenhaedon Sorzitesthịc ali 19 sess, che tro sides S2aul be cally samparsi Cese ty ary danht

2.28, Axillary nerve (8k Lưới lo ke

Senecio over fas egimantal idee” arog uf

(Ge alles tsi e a

supple hy the alan ne

Sal: fap pit to mene fog IF

Artocatedt loss uf season i sulci,

cesidence of anifsey nerve involves at

‘without town misete power

2.29, Radial nerve: {pastorior cord]

5.8.7.8 [IN titan dred CA 2 to sper ar ths rial nerve supplies inceps,

eB teva of the eB Pp brachoradilis, extnsor cup radals loapus

2.30 Radial nerve {motor distribution] cde (C In he spina tunel the postion arose banc: ul Ore rats! spies the Fev ot s.pinaor: lune here ny use local tendecuess ‘D1 On leaving smpinars below

th ethno it supplies extensor agterein

‘mrs ees git nimi gd indi, extensor cap ulhars, shdueeor pales Jangus, and ex.sor polis longus bev,

SEGMENTAL AND PERIPHERAL NERVES OF THE LIMBS [PA

2.90, Ulnar nerves Se imme 2.81 Ulnar nerves common sites

‘None kat these re variainns ia he aes affected {I} 1A Tn the ule tel

supulisd by ae medisn and haar sivas in avidiewne, Waste Fe gees pases Denese esmypENson a pasos Bete tne We fhe nund: the carttenes.Jadtem 3e lusl.sed — the is and the hook of ie Haste lez sls of exes wap elnars aloes "unt Tis branch supplying the duesur iA) ines eon ie presi ofa wagon o¢ 4 hok of ssadcanie} (DY ACIS level of dhe medial ins Forci: hse re ffir w Iesivy——Rascare RteUzex The max dhươl leioe cpicondyls fe im ulnar neuritis secondary 10 rosin he wrist, alfet the deep pelo sve and ate caticly ——“ocal arian, proeame or stot hiay, a8 my

roto 15 Avthe wis espesally fev vecur in cabits valgus al valet, Teeretions cezopatiaval fume nd thề te ples, asa result of wm, ganglione ai lam 8e si in fas ate

HEEB CLINICAL ORTHOPAEDIC EXAMINATION

2.43, Ulnar nerve examinotion (1

Note the praseace of AV irene

abdcion oF the lil Finger: 18) hpothensr

‘ersting iC) ulezration othe skis britleress

fof the ha sand ang othr is

hime 0 ope

2.88, Ulnar nerve exomination (2):

None wether ‘here i am alta eke bad

‘si leader: se cing and le Fingers: thề prosienl IP joints the distal Pes Tene ay vl, this sugyest Dal te digloram pulumdue ie me am thế eiur ists placed: ie pracy the Meloy nity of is Test marked in desis pu peri ht eno fs

te hol post of the pate i len wat skin

2 fasion proximate erat Cun

Forza il the othe

2.48, Ulnar nerve examination [6]: ko!

inger bows the mela

"ng

x 89 (vớt cada the medial presence uf any texlenes 10F Ihe production oF at unasual

SEGMENTAL AND PERIPHERAL NERVES OF THE LIMBS [ETS

Toller H don athe region of

Israel hat Fingsrs The Pgess wo bs lly eared, posi a as mn va zee while ym stun louking furundie enderness Willa the paper and eae dee uesistanee aap ever he afew Lak ad el Fou

a offer In x complere palsy the belle linger extraction i te Cir sal eserdsseous

nonblLy led sight abductign an tee Patlet Be eauhle be pp he ps ral

3.82 Ulnar nerve exarvinotion (10: 2.59 Ulnar nerve examination {11}: 2.54 Ulnar nerve examination {12}:

‘Testing absiuet lig oe simi As ‘Teste abun pollicis 113 Ase he porent Testing suduetor poll's :21 Alternates Datu 19 tess ns yt alencs the exteaded to grasp asheot ot paper etwreen the thumbs teste ps e's ability 30 grasp a sheet of| Hue Enger with sour des, Note the nd Sues of che index singers whe yu ealer le bewzen the hams an the resismmce osfved and wompure one rand will alsnip wv ithdrpw i Hibe amen af he fevdor aspect oF the index metacarpal the othe Phe is ouralyseu ths hue wT ey a the

ine-phatrigen joint, in ener: to the guod side iFroments 30

2.55 Ulner nerve examination (13):

eating fiexnreaddfhlnMris Lạ AE the

alent 19 “cast wie yoo temp 0 exe

che He ven, se i the lemon

fn tla surface and sk the pai: sos,

‘while yn acing rec the i

‘Aggon feel for contraction m the tendon, Las

‘uf arity indicates a Igsion proximal 3 he

2.57 Ulnar nerve examination (15): Tessin exur csgileum pro.teddtx CMiy thế kia: alto ei vse fe supp hy the tu: teice Suppi the mike phe 9F the fade Finger an ask the pater sey ấm Mee she sil joint pp comneerprest n

te ngerip une note vesisiace, Loss of power mficnes a lesion neu or above the

2.58 Ulnar nerve examination (16%:

‘Teving fi stiarinn Test foray ctu

af pinpnck sensacien che anea sapplil y

the azree, Note ui sens Ines em

torso is ialicaine of lesion peso to

2.59 Median nerve (lateral and

‘medial cords] €(5}6,7,8, TI: Mr sistem (AY Hal the when selena the lates, so humbrials, BỊ Toream

‘eu ts auteria mlenussenuy bente

‘exe pafliss lous, Bll of Dexoedigio-ona profiel, pranacar qals (C1 Nese he slbus: Neate digitorsm: supericilie nis, flexor epi ada, palmar Jongus and pronator tres

I sexing aspere of Os asd

Plas! pat ot ast epee [sags cia cal nerve The omeraomasypastory sensory diane 1 show,

SEGMENTAL AND PERIPHERAL NERVES OF THE LIMBS [PE

2.61 Median nerve: common sites

affetted: 4: dette cual nel “eg carnal

Tunnel syndrome, std stm tscturs ad

islocasonsahowt the uie 1B) At the mui

(e.g Tom Teens), (CJ AI the lou Ce

ale ells eislocations in đhlereml tD) In

the imuuim (aNRtoof HEoolegefiS r3) Tim

Forearm bone Fsctures, ur by att issue

Ud atthe origin of the smpeticialis (EY ust

sisal the elbow, tthe prouor teres nerve

2.69 Median nerva examination (2f: lu Issines of me amorioniterusseous Sane or the median were tel a ave the loon, hết uy be wasting ofthe ler spect of the forearm, ane the ines" hein

2 postion of extension 'benedisaw tude tur pow ut soe quaplers au ar ve ply witha olnar cla hạng Sát canfbringhy

2.68 Madian norve examination (3k:

testisy pruoae teres, Extee Ce pales

ow and fel tor scsmetion ine nse

she altupls to pronule De arm gu

resistanes Loss hnicats «lesion a oF above

the claw Acenmpanying pam and kinderiese

‘ver priate tees is fous ip the prosaiar

Bie§ tofnntmenh Syndmne,

2.45 Madian nerve exerminnfion |):

anterior snernsserrs Bristle (12 Test te petier of fsxorpalicis ngs in he thanh, and fesor eigtorum profundus m the index

hy ashing ths patient (9 yt Mes the snpropnat al joa whe yon suppor the pens presimal Ws i, Lass of pose bene may alse occu it mean ner lesions rosie 6 z8 nufefertlet6vsevds Bch

2.66 Median nerva examination (5): consereoriverosseous bvarch "2: Sereing fests Ask the eset eo tonm ä che th híc index ane thumb az press ther tips bly 'o@efhe lun ahteie itZi84©eNIS palsy the efeiml phalaages oŸ tho thumb ad inex ssl hyperextead ussog to paralysis of flexor pallies ents and eh aera hat af Hexoe thgtoram profuncus, be se thenur muscles

‘wil eomatn intact

BEEON CUNICAL GRTHOPAEDIC EXAMINATION

Screening lien le has hee fod

Hai het a ICM gh aay greta

is aked ty Se the sid jl wf te aes

Finger he sil use his ser hand 2s dn

“This shows Pp he understands the rete

thot mevement of we finger ist pont (as

itmielt be au eumparment senda) nd

Hạt ha IBPEelg th he is able ute

the muvetnent setvely

2.68 Median nerve examination (7):

Fira cate the pasting fs hres a tae ist Ask he sian a Tex | serial Meo ternpt extend TL Hi hề resists, Lonk othe tnlons hich are rami a he it, near the midline, Polat te ate of mecesery The aerve Bes henseen (A fsser cap vais longs anh (81 palms longus tor ail v9 Meer cams

‘als Tongus if he le as absent

ination (8): tsa oF ah roe

2.70, Median nerve examination (9):

“Teoting tv oe 9 Bevis Ws: This

rnusele is ineariably and cvelosively spl

3.71 Median nerve examination (10):

Taine Rowe ik

ca 49 ise is đưnh 3¢4 1 to Fateh elt hs fends 0 moe his hand bide ating so, stewhy it ith sour her hand, sess Ws ai ty cay on the rsverment che may nel eae Wk i acd wok fay contest in the anaes,

2.72 Median nerve examination {11}:

“Toaing abductor pollicis brevis (31, ASK Dati ta eesst while yee aemgr to force the (anh puck: coun to the eating pst

Xe the esistone ulfoed palpate the

‘nucle confirm as tne and elk, ond timgpare the poe on the affete side with that of the aber

SEGMENTAL AND PERIPHERAL NERVES OF THE LIMBS: Ea

3.73, Median nerve examination (12):

“Teatne fr sensation: Lavk “ar ieapsirmest

setwatun is rape in he he oF

fistula the nese

2.74, Segmental nerves in the lower

ml thaDatesc7.-A› pnoiaufy Iescbed inex y the uaper ‘mb ths Senora:

avungement thr fer snsecisive «Pinal

‘cements eamllcagk ae: Tình Ki, Tá thế

ca ae lae nh sdhervnes te thà plam

TC Ts prusrescon of coat Eun hip to unkle is shoo in the diagra™

2.75, Myatames (2) Flexion ofthe Zip main itopsoas? is eoneled by 12.5 niow of the rip Conny ebmesis mesic

sa the bing i eon by LAS

TL bã ah cone icra naiuen ane 23 esters rtaien othe hit

2.76, Myeterss [S]t kecengie of The kuec

and the hee jerk caIidlisgS)Ìš arffole bỹ

124 Tleaion of he kaos fain hast iags)

ss canmbed by LS Sl

2.77, Myotomes (4}: Doviflexion of the uke is contzoled yp E45 silyl deúa: gi te long ecsetzs ofthe Sell, fev toes Pama Fes is onic by SL? casinly the ausels§ ofthe cul Tức sce sepmetts ence Ihe aakls jek

2.78, Myotames (5): is ako usor

Fo a imei [nay its amterior 1s controlled by 1A Keer fs 0 Ie By

15, $I the peronet

Ea CLINICAL ORTHOPAEDIC EXAMINATION

2.79, Dermatomes: He ¬cnhter hy

Felling: “he sale of We fut SL is eummen'y inetvad a 15°81 sive Tesians ES sweeps fom he eedial side oF De foot next tee S19 she lat side of the kệ L4 neues the masta siee, 2.8 aeeuny the thích, | say be hebpel to rember "we stand ou $:-kueel os L3, sau sitoa $5

lube sacral punk FEMORAL luiEmøm| |ổLurra LÌ

-2,80 Parigharel norvos oF tho lower limbs:

The aves portant eres of The Tower ub te

1, The feral (12,8381

2 the abtorate (12.3.4)

3 The supcrinyghneal 14,5 8°

4 The iferor glues (LS 5:9)

5 The ssiaie sL45 $1.2.3) und is two divisions tho tibial (LAS S121 aad onsamnn peroneal 14.8 $1 2,2

Other braneties Semen inchade the penal {82.2.1 te inhspugaste sind shoinguinal (Land the cenilofermoral iL 1.2, Nou Tstated ae

th luteal eutanedis nerve of the this (L2.3), the aves Uo aes fettons an the inetior peellu :L4.5 81), the nesves tn ebmiracor resus andthe superar gomelins CLS $1), ho norve A pifiRrmi 01121, the rerves Wo leva gird the exiorualsphraeie 4

The lrabosaerl trenk formed fvcz Li und Ltn its puoazess ik reves the binagle uF Malle (boubled =edaHl by L3,itesiovy by the proximal par of the sacrum, an laterally bự he meckat burder of pin’ where it aty he vulderable wo local pressure oF useion, (Some consider Thata ume of eases of dup tot ad oer aeicologicel problems assy in Tate pgrgrey ty bệ đe í TnVHl9emc ớt the7uƠhonaefel teva sarc thn se pratgpse.)

SEGMENTAL AND PERIPHERAL NERVES OF THE LIMES Ea

at die LAI Alone Tiế bhevimal

ts the Ingo Egat the fered nerve

uppliet NioptosE (8 8 inguinal

Tigament i supplias the quaÖicxpA, ettrius

af he leg a the fae,

2.83, Femoral nerve (3) inontements Closed sk

parva are “ere, Damage may haematoma Forme in fausing Yael pressure Ths is soen tị hacia und in extetnion anti of the

ip

tes of mora tle

2.84, Femoral nerve {4}: eats: (hi Te:

he qudrceps by ack he pie eo exes

the knee wpuint live (BỊ

itiepseas (hip econ guint resistence) ‘te

espons ro these tote should detaraine the

level wf any les En douNÍ cikz$ hy 20

cect uke Knee jerk Observe any qulceps

‘susting, and 68 fas Joss of eration 4

Eiepfidk n thề a’ea supplied by the nerve

2.85, Common peroneal nerve (lateral pepliealz L4, 5, S1, 2 ly net ts 2A2 Khndlo dÏ hệ Medar

omparetent bias aieror edemor halt

pron omer pron brevis wn Bg) {C0 te Font, exons tonim MeN

2.86 Common perones! nerve (2): Sere aerdution: The Gt eh spice

‘eep povonea’ contriborons (8) The on

‘oF Toland Ue foc ad leo Ue Je {supe-ical peronsal egniitaton’

BE cunicat oRTHOPAEDIC EXAMINATION

vend te later, Figamerd ines of

‘irl Mowe ant fans piste,

i ite pase easter Ms sie ine 8

Towns sping varglion sce

‘ueniget I is alsa iavolvos an nuaier of

neurleyi.aldisonde, (Ú‡ Di the

Cibulay reek, eg ir the anterior sree nt

Syndracie, snare eae eTnneai anh

ay he alfected

2.88 Common peronesl nerve (4):

Dagens eee ave re fun tnd thers wll be disur ane: ofthe pa ther the leg il he ited high 3 lon the plancaMexed tone eae te Bind, the Jot i 32 sit aves the group resulting ut api ml duyious unilgerdl are he shoe)

2.89, Common peroneal nerve (Sh: Fess TAI Asa the patzn to dorsles he foot

1đSEà peroneal reshy and) i ever the toe Cemperticial po-nneal branch Test for senate inte atca Ta bien of the nerve, Nie any wasting uF Be tro or sie

2.90 Tibial nerve [medial popliteal]

(Ui: 14,8, 1,23: Moor cise tài

Sales and en’ degs nhi e of Ihe poster

esmparmect Mi poseelur LIexar hailiis

Tonys exe divitoruz tongs 18) Al thề

camels the sole a Us ront thre is

tercsinas hrarches af the medial and Litera

planar nereos Hea sippy piscine mins

"elo pining es ie lea ah,

AN The sole of fot thn the tneial and lateral lsntar serves, whuse temlony inclauet TÚI the nho ant sta AliEg or e dufsdl iftees AF te me Sete that the ride uf the font i snppiedt hy fhe sural Ferves whic ie serve Troan me tial uve an the sham peroneal ete

2.92 Tibial nerve (3): Canam sites of ver Av Wher pasty under the sole anu eg Euan proxine bi]

Iacture (R) From ischaemic esis othe

AI (ep fs Hip plaster and the paderise Fampadtacnt syinsines, svt Fem diabesie heuhneụ, LCI When posing Lehi te medial malleus fg, Eom lavealios td reacties, UD When inthe lon! fe inh rays tue syadsune

SEGMENTAL AND PERIPHERAL NERVES OF THE LIMBS Ei

2.93 Ti I nerve (4: Diagnosis: Nowe

‘eating the so%e nf He Fe,

lasing of di toes and tuple lean,

1H) he ain oF toe cxlen, (C7 T apk

fa Sensory Lace the aca sod by fae

2.94, Tibial nerve {5}: Westone of

fe sees Ce i ies Ce popliteal Goa sre uncememon gap “a the pests

‘ned bythe sermning st tssucs and the space availabe 0 cuUsaodate

£esandin kelons The Hndie are esse I the sae a in ar ons, bat swith yang and Ios ul poe of plastiflexion oicine paral astrornerrius a8 EL} athe Sous

2.96, Sciatic nerve (2}t Sensory for

TA) Che ene ake of te fi 14) The

boson af she Gs, (CH The Jace aspext

the leg und lateral Raf wf de cal Nee that

Ute asl sce ofthe el und “aol ae spaved

the posterior sutarenns ner ots thigh 1

inyalocdl dhe is Luss ot senmation te ick,

The thợ,

2.97, Sciatic nerve {3}: Ses {) Bohnnd she hip 2 Hl pusteror ailucstion ofthe ip, rarely alter sue pelvic Teaeuires and afer hip surgery Pllosing deep rads the hack of he ugh ech freak uncomman Dy uot cams sie vals wt cao inv ulvemeut i intervenes Ase pols,

2.98, Sciatic nerve (Af Pings Note extensive rusting in (A> the gh (D> the

ex and uf the: porunci and iC}, ee sole uf

RẺ Fest, Note a drop teas Observe any Uwuphie Lleeatiue, Nate ss of poser im ue hamstrings and in all ees seperti below ine hase, at abvem nile eth, ai extersive khu Mạ,

Ea CLINICAL ORTHOPAEDIC EXAMINATION

2.99 Lateral cutaneous nerve of thigh

(1) (€2, 3} The carve pisoes or passes

tuncer the Tera portien a ue nga

Jigaanene und supplies the lateral aspect se

Sigh Thay he eorapresed by the nga

mes giving rise to pain an: pan1eghesiie

“the eg imeraiga pacaesthetica, Note

oxi, Pal sso wth the same

Aisvibution may pexur secoucay ty spl

ead equine 11 (hs Gaser goal Ccumplunces halder sensation age nlnrtary etteina an tediaded Linnghi pathy sticking between he hin at hệ sacral corte (75

‘eliza of the spiscter as coup.ete

emptying remains cova 200 4C0 qH of rie «2 passed every 2-4 hors, (he refs ejtD, helre rigeeved by ising Blader resale or sie simula

adder ot cư biaoser

t ng infection, and muscle spasms, TÃulemumus or soot aos Place} In summary, thệelftex nhe Hai a>

depsndest nthe Lose oie

FEZ CLINicat ORTHOPAEDIC EXAMINATION

POSTURAL NECK PAIN

In this commian condition, juin ia the neck and shoulders acer

assuciution with some abnormality of neck posture 11 is coramanest in fexnales under the age uf 40, many of wham have sedentary jobs (such as computer operators? whieh entail the hezd being maintsined for Jong periuds

in a position thal may be short of ideal, In some cases there may be a history

of minor ttauntia which exacerbates or precipitates the complaint, Clinivally the lead and neck may be beld in 4 somewhat protracted position, with seine Joss uf the nurmal verview! cureuture, but there is usually a full range of ech movements with normal radivgraphs Analgesics und physiotherapy are usually helpful in the acute case, but in the long teem change of work, practices und in the patient's working environment are likely co he of the greatest bevelil

ACUTE NECK PAIN IN THE YOUNG ADULT

In the 20~15-yEar age group, wid olten belore there is any radiological evidence of arthritic change in the spine, a sudden mavement of the neck may produce severe neck and arm pain accompanied by striking protective muscle squsm und limitation of cervical movements Jn some cases thesé

syrmtoms are prostoced hy un acute dise prolapse similar to those occurring more lamiliacly in the lumbar region In others, with identical symptoms, investigations including MRT scans may be quile negalive: some disturbance

of the Lavet joints ur related structures is often thought responsible, Most aves respond 16 a period uf rest in a ceevivat collar, ur physiotherapy in the form of traction, In a few resistant cases gentle manipulation uf the cervical spine my be helpful

CERVICAL SPONDYLOSIS (CERVICAL OSTEOARTHROSIS: OSTEOARTHRITIS OF THE CERVICAL SPINE)

Cervical spondylosis is easily the most comnoan condition affecting the neck, Degencrative changes appear carly in life in te cervical sping, oilen ducing

te thitd decade, The disc space between the fifth and sixth cervicl sertehrae is most Frequently involved, ‘The earliest changes ate vonfined 10 the dise, but the facer joints and the uncoverrebral joints Goints of Luscka)) may soon become involved, There is inevituble restriction of movesuents it the affected level but this is often inmossible to detect clinically as iis masked by persisting mobility in the joints above and below Lhe condition may in fact never attract attention, Put unfortunately i many cases symptoms do occur, sometimes being triggered by «nioar trauma, Pain may

be felt centrally in the neck and may radiate to the occiput, giving rise lo severe occipital headache which may be confused with migeaine: pain my also radiate distally, often and inexplicably Turther than might be expected on anatomical grounds, to the region of the lower scapuluc Often there is pain

al the side of the neck, quite shuply localized, or in the supraclavien region, Wath nerve ruvt involvement from atric changes in the facet or uncosertcbral joints, theré may be radiation of pain inti lhe shoulders, arms and bands, with paraesthesia and, an rare accasians, demonstrable

peoralogical involvement: this may include absent arsn reflexes, muscle weukdess, and sensory innpairment