OLFU MD2024 | CLINICAL MEDICINE 1st SEM

EXTREMITIES AND SPINE 1&2

September 27, 2021 | Dr. Paulino
Lecture PPT | PPT | Bate’s Guide to Physical Examination 11th Ed

A. UPPER EXTREMITIES SMALL HANDS

Includes the structure of the neck, shoulder girdle, upper arm, Congenital anomaly of obscure cause;
ACROMICRIA
forearm, and hand Abnormal smallness of extremities

I. HANDS
Includes carpal, metacarpal, phalangeal bones, joints and the
covering soft tissues.

LARGE HANDS
Growth occurs
Acromegaly
after epiphyseal
and Gigantism
closure in which
are both due to
ACROMEGALY hands, feet, face
overgrowth of
head and soft
bone and soft
tissues are
tissues.
enlarged.
Stimulated by
excess of
Condition occurs somatotropic
before epiphyseal hormone →
closure, enlarged eosinophilic
GIGANTISM
skeleton is adenoma of
perfectly anterior LONG SLENDER HANDS
proportioned. pituitary gland →Spider fingers;
→Long, slender fingers typical of
All dimensions of hands are included patients with Marfan syndrome (MFS)
as in acromegaly, but condition
accompanied by extreme clubbing of
fingers and parrot-beak nails.

HYPERTROPHIC ARACHNODACTYLY
OSTEOARTHROPATHY

→ All long bones

are slender and
MARFAN’S
elongated often
SYNDROME
with hyper
extensible joints

→Body habitus that is tall, slim and

underweight, with long legs and long
EUNUCHOIDISM
arms;
→Gonadotropin (GnRH) deficiency

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 TESTS FOR MARFAN’S SYNDROME MALPOSTURE
→Steinberg sign;
→Positive thumb sign means that the distal Claw is formed by hyperextension
THUMB SIGN of the metacarpophalangeal joints
phalanx of the adducted thumb extends
beyond the ulnar border of the palm and flexion of interphalangeal
→Walker–Murdoch sign; articulations
WRIST SIGN →Thumb and little finger overlap, when
CLAWHAND Causes:
grasping the wrist of the opposite hand.
 Brachial plexus or ulnar nerve
injuries
 Muscular atrophy
 Syringomyelia or acute
poliomyelitis
Thumb held in extension by its
inability to flex

APE HANDS Occurs in:

 Syringomyelia
 Progressive muscular dystrophy
 Amyotrophic lateral sclerosis
Pronated hand drops from the wrist
from weakness of the extensors

Due to:
WRIST DROP  Radial nerve palsy
 Poliomyelitis
 Lead poisoning
 Arsenic
 Alcohol
The ring and little fingers are flex
while the other digits move
SHORT THICK HANDS normally, may extend to produce
CRETINISM →Short, thick, and fat hands BENEDICTION HAND the posture
(PREACHER’S HAND)
→Short and thick, thumb diverges Occurs in:
MONGOLISM from nearer the wrist than N, little  Ulnar nerve palsy
finger is curved  Syringomyelia

CRETINISM

MONGOLISM

Syringomyelia → Fluid-filled cyst that forms within the spinal cord

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 PALM
→Characterized by orange
pigmentation of the skin, resulting
from carotene deposition mainly in
the stratum corneum.
→Congenital or hereditary;
SYNDACTYLY →Condition in which children are born
with fused or webbed finger

CAROTENODERMA

→Thenar atrophy suggests a median

nerve disorder such as carpal tunnel
syndrome

THENAR ATROPHY

→Hypothenar atrophy suggests an

ulnar nerve disorder

HYPOTHENAR
ATROPHY

→Skin condition that makes palms
of hands turn red;
→May be hereditary or due to health
conditions such as cirrhosis,
pregnancy, or valvular heart disease
→Indentations that run across the nails;
Appears when growth under the cuticle
is interrupted by injury or illness
BEAU’S LINES

PALMAR ERYTHEMA

→Skin infection around fingernails/

toenails

FINGERS
PARONCHYIA
MALFORMATION:
→Congenital, familial, or associated
with certain syndrome;
POLYDACTYLY
→Anomaly causing supernumerary or
extra fingers

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 →The first sign of a Dupuytren contracture
is a thickened band overlying the flexor
tendon of the fourth finger and possibly the
little finger near the distal palmar crease;
→Skin in this area puckers, and a thickened
fibrotic cord develops between the palm
and finger;
→Finger extension is limited, but flexion is
usually normal.

DUPUYTREN’S
CONTRACTURE

Acute Rheumatoid Arthritis

→ Tender, painful, stiff joints in RA, usually with
symmetric involvement on both sides of the
body.
→ The distal interphalangeal (DIP),
metacarpophalangeal (MCP), and wrist joints DIGITAL INFECTION
are the most frequently affected
→ Swollen skin over the mantle of
the nail and the lateral folds
Chronic Rheumatoid Arthritis
→ Note the swelling and thickening of the MCP
and PIP joints.
RHEUMATOID
→ Range of motion becomes limited, and
NODULES
fingers may deviate toward the ulnar side. PARONYCHIA
→ The interosseous muscles atrophy. The
fingers may show “swan neck” deformities
(hyperextension of the PIP joints with
fixed flexion of the distal interphalangeal joints)

HAYAGARTH’S NODES
→ Bony growths in the area of the finger joints
occurring in rheumatoid arthritis, leading to
ankylosis and associated with lateral deflection
of the fingers toward the ulnar side.
HEBERDEN’S NODES
→ Heberden nodes on the dorsolateral
aspects of the DIP joints from bony
overgrowth of OA. Usually hard and
painless,
OSTEOARTHRITIS → Flexion and deviation deformities may
develop.
→ Injury to the fingertip may result
in infection of the enclosed fascial
spaces of the distal pulp or phalanx
pad of the fingertip, usually from
Staphylococcus aureus
→ Severe pain, localized
tenderness, swelling, and dusky
redness are characteristics.
FELON

BOUCHARD NODES
→ Found on the PIP joints are less
common. The MCP joints are spared.

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 THENAR ATROPHY → Spoon nails
→ Concave nails in saucer form,
hypochromic anemias, iron deficiency

KOILONYCHIA

HYPOTHENAR ATROPHY

→ Eggshell nails
→ Vitamin A deficiency
→ Soft, bends easily, semitransparent,
splits at the end

HAPALONYCHIA

NAIL CONDITIONS
→ Absence of nails
→Hypertrophy of nail plates:
→ Congenital anomaly associated with
→ Due to chronic fungal infection or
ichthyosis
familial
→ Disorder that causes fingernails or
toenails to grow abnormally thick

ANONYCHIA
ONYCHAUXIS

→ Bitten nails

→ Nails of cardiac failure

ONYCHOPHAGIA

RED LUNULA

SQUARE ROUND
→ Seen in acromegaly and cretinism
NAIL PLATES

LONG NARROW → Seen in eunuchoidism and

NAIL PLATES hypopituitarism

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 → Nails of hepatolenticular
degeneration
AZURE LUNULA
→ Painless separation of the nail from
the nail bed
ONYCHOLYSIS
→ Splinter hemorrhages
→ Subacute Bacterial Endocarditis:
Disruption of fine capillaries along
subungual dermal ridges
→ Trichinosis: Disease that people can
get by eating raw or undercooked meat
from animals infected with the
microscopic parasite Trichinella.
→ Blood and fluid collect underneath
the fingernail or toenail
SUBUNGUAL
HEMATOMA
→ Enlargement of fingertips and
downward sloping of nails
FINGER
CLUBBING
→ Vertical ridges on nails
ONYCHORREXIS
WRIST
Examination of:
 Inspect and palpate for swelling, tenderness and deformities
 Palpate for crepitus
 Wrist motion:
o Dorsiflexion
o Palmar flexion
CARPAL TUNNEL SYNDROME (compression neuropathy of the
median nerve in the carpal tunnel)
SYMPTOMS: (In right hand particularly)
 Numbness
 Tingling
 Pain
PHYSICAL SIGNS:
1. Atrophy of the radial half of the thenar eminence
2. Hyperesthesia distributed on the palmar aspects of the 3 ½
radial digits of the hand and the distal 2/3 of the dorsal aspects
of the same finger supplied by the median nerve
3. Progressive weakness and awkwardness in the finer
movements of the fingers.
4. Tinel’s sign: Light percussion on the radial side of the palmaris
longus tendon produces a tingling sensation
CLINICAL OCCURRENCE:
1. Trauma from excessive flexion of the wrist
2. Impingement upon carpal tunnel by arthritis, sarcoidosis,
amyloid deposits
II. FOREARM
 Radius and ulna are practically subcutaneous so they can be
palpated throughout their extent.
 Dorsal muscle mass formed by the extensors of the hand
 Volar mass: Formed by flexors
 Motions of the forearm:
o Pronation
o Supination
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 DEFORMITY OF THE ELBOW
Normal angle is 170 degrees

COELLE’S FRACTURE → <170° or deviation >160°

CUBITUS VALGUS → Distal end of forearm goes
The radius is fractured within 1 in. Of its distal end; concomitant
away from midline laterally
fracture of the ulnar styloid process occurs in half the cases.
o Most common cause: A fall on the outstretched hand → Angle >170° or deviation
from the line of the arm is <10°
CUBITUS VARUS
→ Distal end of forearm goes
towards midline

ARTHRITIS OF THE ELBOW

SUPPURATIVE ARTHRITIS
RHEUMATIC FEVER
ACUTE RHEUMATOID ARTHRITIS
→ Painful swelling with
evidence of pus in the joint
→ Bacterial infection in
the joint
→ Affects heart, joints,
brain, and skin
→ Autoimmune disease

EXAMINATION OF THE ELBOW III. UPPER ARM

 Includes shaft of the humerus and its covering muscles principally
Inspect and palpate the region for tenderness, swelling, deformities,
biceps and triceps brachii
and atrophy
 Rupture of biceps brachii
Swellings: More common on extensor surface
o Traumatic ruptures occur suddenly from lifting excessive
Rheumatoid nodules: Found in olecranon bursa
weight.
Elbow motion:
o Forearm flexion is weak
Extension
Movements of humeroulnar joint
Flexion FRACTURE OF THE HUMERAL SHAFT
Pronation  Caused by a direct blow
Humeroradial and proximal radioulnar joints TRANSVERSE FX
Supination  There is unmistakable angular deformity
 No deformity
SPIRAL FX
 Due to fall
*In all cases of fractured humerus, feel the radial artery pulse and
test for radial nerve injury

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 IV. SHOULDER, JOINT, AND GIRDLE  Congenital condition with unilateral
 Includes: Scapulohumeral joint or bilateral winged scapulae
 Clavicle, Scapula and their ligamentous connections

 Damage to the cartilage inside the

shoulder join
 Tenderness is localized over the
acromioclavicular joint SPRENGEL’S
 Patients report pain with DEFORMITY
movements of the scapula and arm
abduction
ACROMIOCLAVICULAR
ARTHRITIS

 Subacute inflammation of entire
rotator cuff
 Manifested by diffuse, dull, aching
pain in the shoulder and progressive
restriction of active and passive
range of motion, especially in
external rotation, with localized
tenderness
SHOULDER JOINT
Techniques for examination:
Test Range of Motion (ROM)
1. Raise both arms to a vertical position at the sides of the head
2. Both hands behind the neck with elbows out to the side (external
rotation and abduction)
3. Both hands behind the small of the back
 Inspect the shoulders anteriorly, note for swelling, deformity or
muscular atrophy
 Inspect the scapulae and related muscles posteriorly

ADHESIVE
CAPSULTIIS
(FROZEN SHOULDER)

1 No serious joint disease

2 Partial rupture of supraspinatus tendon or chronic
supraspinatus tendinitis
3 Fracture, dislocation, complete rupture of supraspinatus
tendon
4 Arthritis

PAIN IN THE SHOULDER

SHOULDER JOINT Arthritis
 The medial border of the scapula TENDON Supraspinatus tendinitis
juts backward MUSCLE Muscle Strain
 Weakness of trapezius or serratus BONES Fracture of humeral neck
anterior muscle, or injury to long NERVES Compression
thoracic nerve VASCULAR Aneurysm
 Test for scapular winging
PAIN REFERRED TO THE SHOULDER
WINGED SCAPULA CVS Angina Pectoris
RESPIRATORY Pneumonia
GIT Gastritis, Peptic Ulcer

LENGTH OF ARM
 Tip of the most prominent portion of lateral side of the clavicle up
to the tip of the middle finger

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 LENGTH OF LOWER EXTREMITY PAIN IN THE NECK AND SHOULDER
 From anterior superior iliac spine to the tip of medial malleolus
with the tape crossing the patella PANCOAST’S SYNDROME
(Superior Pulmonary Sulcus Syndrome)
 Tumor in:
o Pulmonary apex
o Upper mediastinum
o Superior thoracic aperture
 Symptoms:
o Pain in the posterior part of shoulder and axilla
o Often with shooting pain down the arm
o Acro paresthesia
o Paresis or atrophy of the arm
o Horner Syndrome

V. SPINE
 Seven (7) cervical vertebrae; 3 are specialized
o C1 – Atlas
o C2 – Axis
o C7 – Vertebral Prominence

NODDING AND LIFTING

Occurs at atlanto-occipital joint
THE HEAD

FLEXION AND
Involves C3 to C7
EXTENSION

LATERAL BENDING Midcervical Vertebrae CERVICAL SPONDYLOSIS

(Cervical Osteoarthritis)
ROTATION Atlanto-axial joint  Spondylosis: Describe the complications from degeneration of
the vertebra and intervertebral disks, with traumatic rupture or
degeneration of the nucleus pulposus
 Symptoms:
o Pain in the neck, shoulder, occipital scalp, or down the arm
o Numbness and tingling of
hands (frequent)
o Muscle atrophy (rare)
o Crepitus may be heart by the
PT, palpated or auscultated by
the examiner
o X-ray findings are diagnostic
for degenerative disease of
cervical spine

EXAMINATION OF THE CERVICAL SPINE

 View of the neck from the front sides and back for deformities
and unusual posture
 Test active motions of the neck
 Palpate for muscle spasm
 Test for tenderness of spinous process
 Auscultate for crepitus

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 NUCHAL HEADACHE  Palpate spinous processes with thumb
 Begins in the occipital region o Take note of tenderness
 Percuss the spine for tenderness by thumping with the ulnar
surface of your fist
 Inspect and palpate paravertebral muscles for tenderness and
spasm
 Skin dimple: Overlies the posterior iliac spine and guides us to the
sacroiliac area

THORACOLUMBAR SPINE AND PELVIS

 12- Thoracic
5 – Lumbar
5- Sacral
POST-TRAUMATIC NECK PAIN AND HEADACHE 4- Coccygeal
 Eg. Whiplash cervical injury
o Sudden, forceful hyperextension of the neck with flexion  4 curves of vertebral column
recoil viewed laterally:
 The ligamentum nuchae is ruptured; rarely the spine of C7 is o Cervical curve – Convex
fractured forward C2-T2
 Neck pains, spasm of neck muscles, torticollis o Thoracic curve – Concave
forward T2-T12
o Lumbar curve – Convex
forward T12 to lumbosacral jt
o Pelvic curve – Concave
forward and downward from
lumbosacral joint to tip of
coccyx

 KYPHOSIS: Forward concavity of

thoracic curve is accentuated,
producing hunchback

 Smooth curve results from:

o Faulty posture
o Rigid kyphosis of adolescence (Scheuermann’s Kyphosis)
o Ankylosing spondylitis (Marie-Strumpell Disease
o Osteitis deformans (Paget’s disease)
o Senile osteoporosis

FLEXION FRACTURE OF THE NECK

 C5 fracture by hyperflexion
 Ex. Diver strikes his head on the bottom
 Result in immediate death or quadriplegia if the patient survives

PARTIAL DISLOCATION FROM HYPEREXTENSION

 A fall or blow on forehead may hyperextend the neck and lead to
rupture of anterior longitudinal ligament
 This will result to neck pain and paraplegia

FLEXION OF THE ATLAS (C1)

 If immediate death does not result, the patient is unable to nod
the head and there will be severe occipital pain

EXAMINATION OF THE SPINE  ANGULAR CURVE-GIBBUS caused by:

 From the side: Inspect the spinal profile o Collapse of bodies of vertebra from compression fracture
o Note the cervical, thoracic, and lumbar curves o Metastatic Cancer
 From behind: Inspect for lateral curves o Infectious spondylitis
o Take note of height of shoulder, iliac crests, imaginary line T1  LORDOSIS:
(gluteal cleft) o Accentuated posterior concavity of the lumbar spine
o Deep furrow between lumbar paraspinous muscles
o Pot belly
CHECK RANGE OF MOTION
o Causes:
 Bend forward – Flexion ▪ Pregnancy
 Bend sideways – lateral bending ▪ Flexion contractures of the hips
 Bend backwards toward you – extension ▪ Short Achilles tendon

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 GAENSLEN’S SIGN
→ Used to detect musculoskeletal abnormalities and primary-
chronic inflammation of the lumbar vertebrae and Sacroiliac joint
→ The patient lay supine, with the tested-side leg hanging over the
edge of the table and the other leg flexed to the chest

TEST OF THE HIP JOINT

STRAIGHT LEG RAISING TEST

→ Lasegue test
→ Aims to assess for lumbosacral nerve root irritation
→ A positive Lasègue's sign is one when leg pain is reproduced or
pain in the gluteal region passive straight leg raising
→ With the patient in the supine position, the knee is extended and
the hip is flexed until a complaint of pain or tightness is reached

THOMAS TEST (FOR LORDOSIS)

→ Used to measure the flexibility of the hip flexors, which includes
the iliopsoas muscle group, the rectus femoris, pectineus, gracillis as
well as the tensor fascia latae and the sartorius.
→ The patient lies supine on the examination table and holds the
uninvolved knee to his or her chest, while allowing the involved
extremity to lie flat. Holding the knee to the chest flattens out the
lumbar lordosis and stabilizes the pelvis

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 PATRICK TEST/FABER TEST
→ Flexion, Abduction and External Rotation (Figure of 4)
→ If the test reproduces posterior pelvic pain contralaterally, it is
considered a positive test indicating that the sacroiliac joint is
involved
→ It is done by having the leg flexed and thigh abducted and
externally rotated with the patient lying supine. The knee and hip are
flexed to 90 degrees and the foot of the examined extremity is
placed on top of the opposite knee (“figure 4” position). The thigh is
then gradually abducted and externally rotated toward the
examining table

VI. KNEE
General examination:
 Patient standing:
o Inspect for deformities, swelling, and muscle atrophy
o Note for position of patella
o Search for point of tenderness
SCOLIOSIS  Patient supine:
 Lateral curvature of spine o Test for extension and flexion
 Note for
o Loss of symmetry
o Compare tips of scapula
o Top of hips
o Dimples of Venus
 Structural scoliosis
o Occurs in congenital deformities
o Paralysis of back or abdominal muscle

DEFORMITY
GENU VARUM (BOWLEG)
 Legs deviate toward the midline and knees are farther apart
 Occurs in rickets, Paget’s disease, occupational cowboys and
jockeys

GENU VALGUM (KNOCK-KNEE)

 Lateral deviation of the leg from midline

GENU RECURVATUM
 Knees fixed in hyperextension with little ability to flex
PAINLESS LIMPING
 Dislocation of the hip
o Shortening of the thigh
o Trendelenburg sign
▪ Ask patient to stand on one leg
▪ Normally, the free buttock is raised when the pelvis tilts

TRENDELENBURG SIGN
 In Trendelenburg sign, the free buttock falls because the muscles
are not strong enough to sustain position when the femur is not
engaged in the acetabulum

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 EFFUSION OR HYDRARTHROSIS ANTERIOR KNEE CYST
 Synovial fluid in the knee joint 1. PREPATELLAR BURSITIS (HOUSEMAID’S KNEE)
→ Swelling over the patella occurs

2. INTRAPATELLAR BURSITIS (CLERGYMAN’S KNEE)

→ Swelling over the tibial tubercle

*If more medial, ANSERINE BURSITIS

HEMARTHROSIS
 Blood in the joint cavity

POPILITEAL CYST
1. POPLITEAL ABSCESS
• Minimal swelling in popliteal fossa
PYARTHROSIS • Knee hold in partial flexion to relieve pain
 Pus in joint cavity • Extension is painful
• Examine the foot for source of infection

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2. MORRANT BAKER’S CYST SIMMONDS TEST
• Pressure diverticulum of synovial sac protruding thru the  Squeeze calf muscle transversely
joint capsule of knee  No motion when tendon is severed
• Complication of RA  Test for evaluating Achilles tendon rupture
• Popliteal artery entrapment syndrome

FRACTURE OF TIBIAL SHAFT

 Due to fall onto the leg
 Direct blow to anterior tibia
 Severe pain
 Leg cannot bear weight

VII. LEG
SOLEUS TEAR
 Trauma causing extreme dorsiflexion of foot
 Severe pain and tenderness

FRACTURE OF FIBULAR SHAFT

 Direct blow on the anterolateral aspect of leg
 Pain on anterior leg
 Patient can walk

RUPTURE OF ACHILLES TENDON

 Injury incurred when body weight is forcefully applies to the ball
of the foot in plantar flexion
 Physical Examination:
o Affected foot in less plantar flexion
o Distal portion of affected tendon seems thicker and less
stretched

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 FRACTURE OF BOTH TIBIA AND FIBULA IX. FOOT
 Most common cause of compound fracture TALIPES (pedal deformity)
 Foot turned inward in obvious deformity  Five principal varieties:
TALIPES VARUS Inversion
TALIPES VALGUS Eversion
TALIPES EQUINES Plantar Flexion
TALIPES CALCANEOUS Dorsiflexion
PES CAVUS Hallowing of the instep

VIII. ANKLE JOINT

SWELLING
 Subcutaneous edema, effusion


CUTANEOUS LESIONS (thickening of the skin)

1. HARD CORN (Heloma Durum)
• Undue pressure on the skin, especially that covering the toes

LATERAL ANKLE PAIN

 Rupture of joint capsule
 Forceful plantar flexion with eversion of the foot
 Breaks anterolateral portion of the articular capsule

1. CALLUS
• Thickening of the sole

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 X. TOES HAMMERTOE
HALLUX VALGUS  Fixation of the 2nd toe in flexion
 Lateral deviation of the great toe
 Produces abnormal prominence of the first metatarsophalangeal
joint

BUNION
 Inflamed bursa over the prominent metatarsophalangeal joint XI. TOENAILS
INGROWN TOENAIL (Onychocryptosis)
 Presence of transverse growth of nail plate
 Causes lateral edge to lacerate the nail fold

RAM’S HORN NAIL (Onychogryphosis)

 Overgrowth of toe nail
 Nail thickened, conical, and curved like a ram’s horn
HALLUX RIGIDUS
 Stiffened great toe
 Chronic arthritis of the 1st MTP joint from injury or wearing short
shoes → ankylosis → extension

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