Orthopedics 2 Test Notes

Orthopedics

Samuel Moya

Elbow 1) EPICONDYLITIS A) Kaplan’s Sign (lateral epicondylitis/ Tennis elbow) a. Pt. seated b. Have the patient grab your forearm and squeeze c. Then you grip their forearm below the lateral epicondyle and have them squeeze your forearm again d. If their grip is stronger when you grip their forearm this is a positive test for lateral epicondylitis e. Testing for strength test with incidental pain B) Mills’ (lateral epicondylitis) a. Looking for PAIN response at lateral epicondyle b. Pt. seated c. Start with pt. elbow flexed (in curl position) then max flex their wrist and internally rotate the wrist to maximum. Finally lockout their elbow. d. Make sure you don’t touch their epicondyle region b/c you might get premature pain C) Cozen’s a. Pt. seated b. Place pt. arm in supination with wrist in extension c. Dr. tries to flex the wrist as the patient resists d. Looking for PAIN at lateral epicondyle e. Hold position for 5 secs D) Golfer’s Elbow a. PT. seated with arm supinated and wrist is in flexion b. Dr. tries to passively extend the wrist c. Looking for pain at the medial epicondlye d. Hold position for 5 secs 2) LIGAMENTOUS INSTABILITY A) Ligamentous instability 1. testing medial and lateral collateral ligaments 2. pt. is seated with arm extended (almost max) in supination 3. Dr. stress the elbow joint in varus and valgus direction 4. feeling for ligamentous laxity 5. pain is an incidental finding 3) NEUROPATHY 6. Tinel’s sign a) Seated b) Dr. raises the pt. arm to a 90 degree angle c) Using a hammer tap around the ulnar nerve until you get an ulnar reflex (jumping of the arm)

Orthopedics

Samuel Moya d) Then you tap around the lateral epicondyle looking for a radial nerve response. You are actually hitting a radial nerve branch. Have to swing the hammer harder than ulnar nerve test e) Looking for an extreme pain that lasts a good time after test (+) test f) (+) test- neuropathy of that nerve

7. Elbow flexion a) Seated with arm fully flexed actively squeezing that bicep b) Hold for 30 secs c) Ask the pt if they have any type of PAIN, NUMBNESS, TINGLING d) (+) test equals ulnar nerve problems FOREARM, WRIST, AND HAND 1. Vascular obstruction a. Allen’s test i. Pt. seated with arm supinated ii. DR. occludes the radial and ulnar arteries looking for blanching followed by redness when you release the arteries iii. Ask pt. to make a fist when you occlude the arteries iv. Looking for how fast the hand becomes red again v. 5 seconds is normal time for the hand to turn red again vi. Pain, tingling is secondary findings vii. Cold hands and numbness is a positive finding though b/c it does indicate vascular insuffiency 2. Localized unspecified pathologic process a. Wringing i. Ask the patient to wring a cloth in both directions ii. Used to localize a wrist pain iii. Non-specific test iv. Need to ID a carpal bone that is in the area of the pain 3. Osteopathy a. Finsterer’s i. Pt. seated ii. Bend the phalangies to make the metacarpophangeal joint taught iii. Hit the metacarpophangeal joint iv. Looking for pain in wrist as you strike the MP joint v. Pain in the carpals is a positive test. Pain in the Metacarpals would also make it a positive test 4. Infectious/Inflammatory

Orthopedics

Samuel Moya

a. Cascade i. Overlapping of the phalanges= (+) test ii. Ask the pt. place the finger flat on the palms but not in a fist. Looking to see if the fingers line up straight iii. If the fingers overlap it is a positive test indicating Rheumatoid arthritis b. Bunnel-Littler i. Testing PIP joint using the MC joint ii. If the PIP joint extends when you extend the MC joint move on to the test iii. Push the MC joint back and then flex the PIP if it flexes easily it’s a negative test iv. If positive you then flex the MC joint then you try to flex the PIP again if it flexes easier than in step 2 this is a positive test v. Tight capsule- the finger remains tight in both positions vi. Testing interossie muscles vii. If PIP flex easier in second part of test= interossie mm. tightness c. Bracelet i. Elevate the pt.s arm and squeeze the pt’s. wrist and look for elongation of the wrist ii. Looking for pain and lose of elasticity of the wrist (the wrist is not elongating) iii. Pain= (+) test for arthritis 5. Muscular/Ligamentous a. Test for Tight Retinacular Ligament i. Testing PIP and DIP ii. Force PIP in full extension and see what happens with DIP iii. PIP in extension then you try to flex the DIP iv. If tight DIP throughout the test= tight capsule v. If loser in one step than the other= retinacular ligaments vi. Report: have to describe exactly what is happening with each joint that you test b. Finkelsteins i. Testing for Dequervians disease (stenosing tenosynovitis AKA paratenonitis of the extensor pollicis longus) ii. Ask the pt to tuck their thumb into their fist and passively ulnar deviate the wrist making sure to stress the wrist iii. Looking for extreme pain with minimal ulnar deviation of the wrist c. Carpal Lift i. Place the pt’s. hand flat on a hard surface and ask them to left their fingers one at a time

Orthopedics

Samuel Moya

ii. Then you resist them as they try to raise their fingers one at a time. Looking for the tendons to pop up as they try to raise their fingers iii. Looking for carpal or metacarpal pain iv. Pain= (+) test d. Maisonneuve’s i. Extend the patients wrist and look for pain in the distal part of the wrist ii. If you go past 90 degrees with extreme pain it indicates a radius Fx (collies fx) 6. Neuropathy or palsy a. Froment’s Paper b. Wartenberg’s c. Pinch Grip d. Phalen’s e. Tinel’s f. Interphalangeal Neuroma g. Shrivel

Thoracic spine A) Scoliosis 1) Adams position i. Ask pt. to strength out their arms and touch their palms ii. Ask pt. to bend over and you stand behind them to see the horizontal plane of the back iii. Look very carefully at the horizontal plane of the back to see if there is any deviations in the spine iv. Diagnosis: describe the rib hump does it point to the right or left. The vertebral body points in the direction of the convexity of the hump. Name the scoliosis according to the convexity: Dextroscoliosis and levoscoliosis.

Orthopedics

Samuel Moya

B) Ankylosing spondylitis 1) Chest Expansion i. Pt. seated upright ii. Place the tape under the axillae iii. Cross the tape and read the tape iv. Ask the patient to take a normal breath then exhale totally and measure and then totally inhale the difference in readings is the chest expansion v. Report in centimeters vi. No such thing as a normal range vii. This is just good for future reference has no real clinical application at the time that you take it 2) Amoss’s i. Pt. lying prone then ask them to lay down and then sit up again ii. Looking to see if they have to bend in weird positions and use extremitites iii. Test for thoracic inflexability 3) Foresteir’s Bowstring i. test for restriction of spine ii. place your hand on the pts. back and ask them to laterally flex and feel the muscles tension iii. the contralateral side should get tighter and ipsilateral side should become less tight iv. (+) test= ipsilateral side becomes tighter than contralateral side C) Infectious/inflammatory process 1) ***Anghelescu’s i. Pt. lying down and ask them to do an opisthotons postion ii. Approximates a opisthotons position (pt. arched so that only the heels and back touch the ground) iii. Tests for arthritis of the spine 2) Sponge i. Pt. lying prone ii. Wet a sponge or any device that creates moisture heat and move it down the back starting for the neck down. iii. You are looking for redness in back which indicates paraspinal musculature inflammation D) Costal fixation 1) Rib motion i. Pt. prone ii. Dr. places their fingers on the ribs and ask the pt. to take a deep breath and exhale. You are looking for a lack of movement in the ribs

Orthopedics

Samuel Moya

iii. The rib causing the problem will be the most superior rib during inhalation. In exhalation it will be the inferior most rib that is the one causing lack of motion in a group of ribs lacking motion. 2) Schepelmann’s i. Start off in ROOS postion ii. Have pt. laterally flex to both sides iii. Looking for pain on either side iv. Wrap around pain- intercostal neuritis usually on concave side of motion v. Convex side pain- muscle issues its pain running along the length of the paraspinal muscles vi. Local pain to back- subluxtion vii. Pleurisy- deep, sheering, tearing pain on the convex side viii. Does not differentiate b/w pleurisy and intercostal neuritis. History will differentiate these two. E) Myelopathy 1) Valsalva maneuver 2) Dejerine’s 3) Beevor’s F) Neuropathy 1) First thoracic nerve root 2) Passive Scapular Approximation G) Osteopathy 1) Spinal percussion 2) Sternal compression