EXAMINATION OF KNEE

---aged male patient mr. …………..residing at ……by occupation has come to our hospital with
the presenting complaints of …………
• c/o pain
• swelling
• deformity
History Of Present Illness:
pt was apparently normal before……months
h/ fall –mode of injury
-high/low velocity
-compound or closed
-Whether walked immediately after event
-if native treatment taken-number of splints,duration of each, extent of splint,any fever/ blister
during that period
1. pain:
• site
• Duration
• Onset
• Type of pain/character
• Nature- progressive/ static 10 points
• Radiation
• Aggravating factors/relieving factors
• Stiffness
• Night pain/night cry
• Remissions and exacerbations
2. swelling
• Duration
• Site
• Extent of swelling
• Onset, progression
3.deformity
• Duration
• Onset
• Progression
h/o difficulty in doing day to day activities
• walking
• sitting crosslegged
• squatting
 • climbing / getting down from stairs
h/o fever- TB/ inflammation
h/o giving way sensation-ACL
h/o locking / unlocking episodes- meniscus injury
h/o noise from joint-clicks/crepitus/clunks

h/o cough with expectoration

h/o breathlessness-
h/o loss of weght TB
h/o loss of apetite
h/o chronic drug intake

h/o other joint involvement

h/o morning symptoms
h/o small joint involvement r/o RA
h/o remissions and exacerbations
h/o multiple swelling over body

h/o redness of eyes

h/o burning micturition- r/o reiters disease

h/o recurrent trivial fall

h/o limping-acl/pcl
h/o recurrent episodes of dislocation of patella- episodes,duration, treatment

Past History:
h/o medication
h/o surgery
h/ocontact with tuberculosis
h/o bleeding disorders

Treatment History:
native treatment
personal history:smoker-no of cigarattes per day
alcoholic
Family H/O TB

General Examination:
• built
• nourishment
• anemic
 • generalized lymphadenopathy
• genearalised ligamentous laxity
• polio limb if present
• neuro cutaneous markers
Local Examination:
patient lying in supine position
Attitude-
• patella facing outwards ankle and foot in neutral, hip in neutral.
• limb length discrepancy
• muscle wasting
• obvious deformity
Inspection-Anterior Aspect
• swelling
• patellar prominence
• parapatellar hollowness
• skin over swelling
• sinuses
• scars
• visible pulsation
Medial Aspect-swelling ,sinuses ,scars,visible pulsation
Lateral Aspect- swelling ,sinuses ,scars,visible pulsation
Posterior Aspect-
• flexor crease
• swelling-extent
• disappearance on flexion
• sinuses
• scars, visible pulsation
Palpation
Anterior Aspect-
• warmth
• tenderness
• patella –surface, irregularity, thickening [non union patella
o fluid shift
o cross fluctuation
o patellar tap
o transillumination
o synovium thickening-doughy feel
• parapatellar tenderness on flexion
• patellar facet tenderness
 • patellar glide
• patellar grind test
• tibial tubercle-tenderness, thickening,crepitus

Medial Aspect-
• joint line tenderness-90 degree flexion
• warmth
• palpate for bursa,cysts
o size, extent, consistency, surface, depth, plane, mobility, fluctuation
transillumination
Lateral Aspect-warmth, tenderness, cysts/bursa
Posterior Aspect-swelling, warmth, tenderness,popliteal artery pulsation on flexion
Movements:
• Range Of Movement
• Fixed Flexion Deformity
• Abnormal Mobility
Measurement:
1. Linear-
• apparent-xiphisternum to medial malleolus
• True length-ASIS to medial malleolus
o Intermalleolar
o Intercondylar of femur
2. Circumference-quadriceps wasting
3. Angular-varus/valgus normal 6 degree valgus
Q angle-supine male-8-10degree
Female:15-+5
Tuber sulcus angle
4. Torsional-tibial torsion
Femoral anteversion
Special Tests
o Anterior Drawer Test
o Posterior Drawer Test
o Lachmans
o Pivot Shift Test
o Mcmurray Test
o Apleys Grinding Test
o Valgus/varus stress test-extension/ 20’flexion

Other joints, gait

Spine
Other system
Distal neurovascular deficit-
o sensory
o Motor-power, reflex,jerk
Summary
……yrs old male…..came with c/o…..positve history and positive findings….no distal
neurovascular deficit

Diagnosis
1. b/l genu valgum/varus deformity secondary to post traumatic,
idiopathic,rickets,epiphyseal dysplasia,tumour,infection
2. triple deformity knee secondary to tuberculosis-h/o tb, h/o drug intake, clinical triple
deformity,generalized lymphadenopathy
3. anterior instability of knee due to acl tear
anterior cruciate ligament insufficiency
4. exostosis of distal femur/proximal tibia
EXAMINATION OF FOOT
Complaints:
• deformity since birth-informant –mother
• pain
• swelling
History Of Present Illness:
• mother noticed deformity at child foot on day of birth
• h/o manipulation by mother
• h/o serial casting-number/interval
• h/o any surgery-tenotomy/JESS/how many surgeries/age of surgery
• pain and swelling-trauma cases
• tell about milestones crawling,sitting,standing,wlking
• h/o trauma-tell in detail
• h/o loss of apetite/evening rise of temperature
• h/o other joint involvement-RA
• h/o small joint/morning stiffness-RA

Past History:
• H/O Previous Surgeries-Detail
• h/o indeginous treatment
• h/o contact with TB-ATT
Family History:
• similar deformity in family-club foot
• birth history:
• born of 2* consanguineous marriage
• through normal delivery
• breech presentation
• cried immediately after birth
• no birth related complications

Immunization H/O:
• immunization up to age

General Examination:
• built
• nourishment
• general lymphadenopathy-TB
• neurocutaneous markers
 • swelling at theback-spina bifida

Regional Examination:
• attitude of lowerlimb
• deformity
• muscle wasting
• limb length discrepancy

Inspection:
• attitude of foot

• dorsal
o deformity
o medial and lateral curvature
o anatomical alignment of foot and toes
o overriding of toes
o bony prominence
o callosities
o swelling/edema
o hyperpigmentation
o scars
o sinuses

• plantar:
o skin condition
o anatomical disposition
o callosities
o corns
o trophic ulcer
o any prominence/swelling

• Behind:
o size and shape of heel
o valgus and varus of heel
o tendoachillis prominence
o fullness at either side of tendoachillis

• Medial:
o medial longitudinal arch
o medial/ lateral deviation
 o bony prominence/swelling

• Lateral:
o longitudinal arch
o any bony prominence

Palpation:
• warmth
• tenderness
• swelling-details
• callosity-consistancy/ extent/ tenderness
• dorsalis pedis artery and posterior tibial artery pulsation

Movements:
Ankle Dorsiflexion 0-25*
Plantar flexion 0-30-55*
Subtalar Inversion 0-35*
Eversion 0-25*
Midtarsal Adduction 0-5*
Abduction 0-5*
Supination 35*
Pronation 20*

Measurement:
• Longitudinal measurement
Heel to great toe tip
Heel to 5 th toe tip
Or
Medial malleolus to great toe tip
Lateral malleolus to 5 th to tip

• Cicumferential Measurement:
Metatarsal head level
Maximum height of medial arch
Just behind the ankle

➢ Measurement of equines and calcaneous deformity:

➢ Examination of knee& hip &other joints
➢ Regional lymph nodes-popliteal& inguinal nodes
➢ Neurovascular deficit
➢ Gait
 ➢ Other systems: spine-spina bifida

Summary:
….month /day old child born of 2* consanguineous marriage, breech , deformity since birth
……findings…..with outdistal neurovascular deficit

Diagnosis
1. Congenital talipes equino varus deformity B/L
Neglected
Recurrent
Resistant
Relapsed

2. congenital flat foot

EXAMINATION OF ELBOW
Complaints:
• Pain swelling
• Stiffness/deformity

History Of Present Illness:

• Pt was apparently norml….months ago
• He sustained a fall from height of 30 feets
• Mode of injury- fall from height /RTA
• Velocity of injury
• Significant/insignificant
• Mode of fall- fall on outstretched hand/ fall on elbow
• Closed/ open injury
• Immediately not moved the limb after injury
Treatment details:
• Medical treatment
• Native treatment
o h/o massage
o splintage-extent/ number/ duration
o h/o attempted manipulation
o h/o blisters/fever during splintage
1. pain:
• site
• Duration
• Onset
• Type of pain/character
• Nature- progressive/ static
• Radiation
• Aggravating factors/relieving factors
• Stiffness
• Night pain/night cry
• Remissions and exacerbations
2. swelling
• Duration
• Site
• Extent of swelling
• Onset, progression
• Associated with pain /fever

3. Stiffness/ deformity
• Pt noticed deformity after remal of plaster /native splints
• Duration
• Associated with pain
• History of difficulty in doing day to day activities- eating /combing/ lifting objects/
putting buttons
• Pt noticed shortning of upper limb after removal of splint
• h/o numbness
• h/o instability of elbow
h/o cough with expectoration
h/o breathlessness-
h/o loss of weght TB
h/o loss of apetite
h/o chronic drug intake

h/o other joint involvement

h/o morning symptoms
h/o small joint involvement r/o RA
h/o remissions and exacerbations
h/o multiple swelling over body

h/o bleeding manifestations- R/O haemophiliac

h/o discharging sinus associated with
• bone spicules
• foul smelling
• amount of discharge

Past History
h/o treatment for the injury-surgery
h/o ATT INTAKE

Personal H/O
alcoholic
smoker

Family H/O
trauma- not significant
others-contact with TB
H/O ATT in family members

General examinations:
Built
Nourishment
Generalized lymphadenopathy

Regional Examination:

Patient in standing position

Attitude:
• Shoulder by the side of chest wall
• Elbow in extension
• Wrist in mild dorsiflexion
• Flexion of fingers

➢ Deformity- any flexion deformity

➢ Cubitus valgus/ varus
➢ Muscle wasting-arm/ forearm/ hand
➢ Obvious limb shortening

Inspection:
Anterior:
➢ Swelling over cubital fossa
 ➢ Flexion crease obliterated-1 to 2 cm above intercondylar axis
➢ Skin-stretched and shiny
➢ Any dislocation
➢ Any abnormal bony prominence [myositis]
➢ Biceps bulge
➢ Biceps tendon prominence
➢ Scars
➢ Sinuses
➢ Engorged veins
➢ Carrying angle-only in extended supinated elbow

Lateral:
➢ Anteroposterior broadening
➢ Bulge of brachioradialis and long extensor of wrist
➢ Lateral supracondylar ridge-prominence /posterior sagging of elbowin supracondylar
#
➢ Skin
➢ Sinuses
➢ Scar
➢ Engorged veins

Posterior:
➢ Medio lateral broadening compared to opposite side
➢ Olecranon prominence
➢ Para olecranon fossa- seen or obliterated
➢ Any swelling
➢ Abnormal bony prominence
➢ Callosities
➢ Any hollowness at proximal ilna
➢ Skin, sinuses,scar, engorged veins

Medially:
➢ Swelling
➢ Abnormal mass
➢ Medial condylar prominent
➢ Skin/sinuses/scars/engorged veins

Palpation:
Anterior
Warmth
 Tenderness
Any bony tenderness
Any bony mass [myositis ]
Consistency of mass –firm to hard

• Swelling
o Site/size/ skin
o Shape
o Surface
o Consistency
o Extent
o Margins
o Tenderness
o Mobility
o Transillumination
o Fluctuation

Lateral :
• Warmth
• Tenderness
• Lateral supracondylar ridge-thickening
• Irregularity
• Tenderness
• Discontinuity
• Abnormal mobility
• Loss of contour
• Lateral epicondylar ridge-made out or not
• Thickening
• Irregularity
• Abnormal mobility
• Lateral joint line tenderness-elbow 35 to 45 * flexion
• Radial head- palpated normally anterior and inferior to latera l epicondyle
• Tenderness thickening
• Crepitus
• Moving with supination and pronation of forearm
• No abnormal mass palpable

Posterior:
• Warmth
 • Tenderness
• Olecranon tenderness
• Thickness
• Discontinuity
• Abnormal mobility
• Crepitus
• Para olecranon fossa-swelling/ cross fluctuation
• 3 point bony relation ship normal/altered compared to opposite side
• Any abnormal bony masses
• Supracondylar hollowness-post dislocation
• Proximal ulna
Medial-
• warmth
• Tenderness
• Medial epicondyle-tenderness
• Thickening
• Irregularity
• Abnormal mobility
• Crepitus
• Ulnar nerve-tenderness
• Thickening where palpated
• Medial supracondylar ridge
• Medial supra trochlear nodes

Movements:
➢ FFD-further flexion active /passive
➢ Supination
➢ Pronation
➢ Abnormal mobility
➢ Valgus/varus mobility

Measurements:
➢ Arm length-acromian process to lateral epicondyle
➢ Forearm length-medial/ lateral [lateral epicondyle to radial styloid process ]
➢ 3 point relationship- measurement
➢ Circumferential –muscle wasting

Special tests-valgus/ varus stress/ pivot shift, others

Examination of shoulder-tenderness
➢ Movements-int rotation/ ext rotation
Examination of Wrist
Regional lymphadenopathy-axillary / epitrochlear
No distal neurovascular deficit

Summary:
23 year male ……h/o fall ….came with pain deformity…findings…..deformity

Diagnosis:
Post traumatic malunited supracondylar fracture of humerus with cubitus varus deformity with
fixed flexion deformity 30* with out neurological deficit

EXAMINATION OF NERVE INJURY :

Complaints:
• Inability to use upper and lower limbs
• Deformity of hand

History of present illness

Patient was apparently normal …….months back
• Sustained injury by rta-mode of injury
• Open/closed
• Any associated fracture
• Details of treatment
• Penetrating-gunshot
• Whether able to move the limb after injury
• h/o injections gluteal or deltoid
o associated with shooting pain
o unable to use limbs after few days of injection
• h/o insidious onset of weakness
• leprosy
• lumbar disc disease

inability to use upperlimb/ lowerlimb -4 months

 • insidious onset
• progressive nature
• not associated with pain
• associated with numbness
• h/o loss of sensation
• h/o tingling/numbness
• h/o difficulty in walking , lifting objects ,putting shirts,butons, lift shoulder, eating
• cleaning perineum, combing
h/o fever
h/o skin lesions-patches-R/O laprosy
h/o non healing ulcers-R/Odm
h/o radiating back pain- R/O LDD
h/o loss of sensation- R/O leprosy
h/o deformity of fingers- R/O LEPROSY

Past History:
H/O Dm
H/O Loss Of Sensation, Skin Patches
H/O Prolonged Drug Intake
H/O Surgery-LDD
• Nerve repair
• Fracture fixation
• Nature of treatment
Previous h/o trauma

Natal h/o:
• Birth trauma
• Mode of delivery
• Presentation

Personal h/o
Smoking
Alcohol

Occupational- lead /painting workers

General examination:
• Built
• Nourishment
• Anemic
 Regional examination:
UL/LL
Inspection
Attitude-
• clawing-finger- ulnar nerve palsy
• Shoulder by side of chest
• Elbow in extension
• Forearm pronation- brachial plexus
• Wrist palmar flexion-wrist drop

Deformity
• wrist drop
• Foot drop
• Winging scapula
• Claw hand
• Ape thumb deformity

Wasting of muscles
Deltoid,arm,forearm, Thenar, hypothenar, Hollowness b/w metacarpals, Calf muscles

Skin
Dry ,glossy, smoot disappearance of cutaneous folds and subcutaneous fat-complete paralysis
Pallor, cyanosis, excess sweating trophic changes-brittle nails, ridged nails—partial paralysis

Scar/ wound-
• site
• Length
• Nature of healing- primary/ secondary intension
• Hypertrophic scar /keloid

Palpation:
• Temperature –cold –paralysis compared with normal size
• Tenderness –at fracture site and joints
• Muscles-softer, flabby paralysed muscles
• Skin-loss of sensation
• Hyperaesthesia-regeneration
• Scar –tenderness
• Adhesion to scar
Muscles power
Root Muscles supplied Tests specific
value
1 Brachial C5, c6 Deltoid, teres Abduct shoulder, Policeman tip hand
plexus minor, flexion of elbow
[upper-erb’s, supraspinatous,
duchenne infraspinatous,
clavicular head of
pectoralis major,
biceps ,
brachiradialis,
supinator,
brachialis
2 Brachial C8,T1 Intrinsic muscles Claw hand , horners
plexus- of hand syndrome
lower-
klumpke’s
3 Axillary, C5C6 Deltoid, teres Abduct shoulder> Regimental batch
circumflex minor 30* area
humeral
4 Brachial C5-T1 Muscles of arm, Pancoast tumour
plexus whole forearm, hand
arm / mixed
type
5 Nerve to C5,C6 Serratus anterior Press against wall[
serratus medial border
anterior prominent
6 Median C678T1 Pronator teres, Oschner’s clasping Ape thumb
nerve Palmaris longus test, pen test, tight Carpal tunnel
[martin FDS, FDP fist, kiloh nevi sign syndrome,
gruber [lateral1/2],FCR, [AIN ] “ok” benediction attitude
anastomosi- FPL,Pronator Oppose thumb to
b/w ulnar quadratus,abd. ring fingers
and median Pollicis brevis,
or ulnar and opponens, flexor
AIN pollicis brevis, 1st
and 2 nd
lumbricals
7 Ulnar nerve C8T1 FDP[ medialhalf], Froment’s sign- Tardy nerve palsy
FCU, Palmaris adductor pollicis Ulnar paradox
brevis, flexor Card test, egawa test
digiti minimi,
addictor digiti
minimi, opponens
digiti minimi,
 interosseous-
palmar & dorsal,
lumbricals -3rd &4
th, adductor
pollicis
Flexor pollicis
brevis [partial]
8 Radial nerve C5678T1 Triceps, Axillary crutch
anconeous, palsy, saturday
brachioradialis,EC night palsy,
RL,ECRB, operation table
brachialis palsy, holstein lewis
[lateral], fracture,
supinator, EPL, wartenberg’s
EPB, EI, ED, disease [cheiragia
EDM, ECU, APL paresthesia-sensory
braonch of radial
nerve
9 Sciatic nerve L45S123 Hamstring Foot dorsiflexion Foot drop to flail
muscles of leg and SLRT, +IR—more foot
foot pain Clawing of toes
Trophic ulcer
10 Lateral L45S12 TA,EHL,EDL, Stand on heel, evert Foot drop
popliteal PT,PL,PB the foot
nerve-
common
peroneal
nerve ]
11 Medial L45 S123 Gastro Stand on toes CLAWING OF
popliteal soleus,TP,FDL,F TOES
nerve-or HL,INTRINSICS
tibial nerve OF foot

Sensation:
• Tactile sensitivity- light touch
• Tactile localization
• Pressure
• 2 point discrimination
• Pain-superficial-pinprick, Deep-muscles bone

• Temperature- cold /warm- test tubes

• Recognition of size shape and form of objects
 • Posterior column- asteriognosis
• Position sense- passive appreciation of movements
• Appreciation of vibration-128 hz

Reflexes
Upper limb C5C6 C6C7 C5C6
Biceps Triceps Supinator Decreased
Lower limb L123 S12 L234
KNEE ANKLE PATELLAR decreased

Superficial reflexes:
• Abdominal-T7-T12
• Cremastric- L1
• Anal-S3,4
• Bulbocavernous-S3,4
• Plantar-L5S1

Palpaion of nerve
• Tenderness
• Texture
• Girth
• Uniformity
• Pliability
• Bending
• Thickening
Neuroma-distal end of proximal segment, firm, tender, nodular mass
Glioma- proximal end of distal segment –firm tender, nodular mass
Tinel sign-
• sensory component
• Start from periphery
• Regeneration

Movements at joints: Active / passive

Vasomotor assessment: Sweat test-starch / iodine
Gait-foot drop high sepping gait
Opposite limb /other systems / vascular deficit

Summary:
40 yr male….rta / fall ….inabilty to use …limb….h/o surgery….wrist / foot drop….associated
findings

Diagnosis:
1. Post traumatic high radial nerve palsy with wrist,thumb and finger drop
2. Posttraumatic low ulnar nerve palsy- claw hand
3. Post traumatic PIN palsy- with finger drop
4. Foot drop due to lumbar disc disease-post surgical, injection paralysis
5. Post traumatic preganglionic upper trunk brachial plexus injury

Examination of Swelling
Complaints
• Pain
• Swelling
• Inability to use upper /lower limb
History of present illness
Patient was apparently normal before…months
Pain:
• site
• Duration
• Onset
• Type of pain/character
• Nature- progressive/ static
• Radiation
• Aggravating factors/relieving factors
• Stiffness
• Night pain/night cry
• Remissions and exacerbations
Swelling-
• pain followed by swelling-OS
• Swelling followed by pain-others
• Duration
• Site
• Mode of onset
• Progression
• Regression[ if chemo given ]
• Associated with ulceration, foul smelling discharge-fungation
• Inability to use limbs-duration
 • Associated with limping
• Able to walk with crutch
• Associated with pain
h/o difficulty in doing day to day activities- walking, squatting, sitting cross legs, climbing
up and downstairs
h/o fever- acute osteomyelitis
h/o trauma-significant / insignificant
h/o similar swellings anywhere in the body-exostosis
h/o loss of weight /apetite- malignancy
h/o difficulty in breathing / hemoptysis/chest pain/ abdominal pain –secondaries lung
h/o suggestive of pathological fracture
h/o weakness of distal parts of limb-pressure symptoms

Past H/O:
h/o chemotherapy-duration, number of cycles,interval, details
h/o radiotherapy-duration /number of cycles
h/o indegineous treatment-splintage /interval / duration
h/o surgery-biopsy ,recurrence
h/o childwood radiation

Personal H/O:
smoking ,alcoholism
type of occupation-radiation exposure, chemical exposure

Family H/O
h/o similar complaints in the family
• familial diaphyseal acalasia
• achondroplasia
• marble bone disease
• osteogenesis imperfeca
• neuroblastoma

General Examination
• built
• nourishment
• anemia
• jaundice
• general lymphadenopathy
• multiple swelling of the body –exostosis
• alopecia-chemotherapy
 • posture
• pigmentation of skin-radiotherapy
• neurocutaneous markers

Regional Examination
• attitude of limb
• deformity
• muscle wasting
• limb length discrepancy

Inspection:
swelling –
• site
• shape
• size
• well defined-benign
• extent
• surface
• skin
• margins
• engorgrd veins
• visible pulsations-telengiactatic osteosarcoma, ABC, secondaries
• any scar /ulcer- biopsy
• any discharge- fowl smelling
• distal limb edema
• swelling moves with the limb

Palpation:
• warmth
• tenderness
• inspector findings confirmed
swelling-
• size
• site
• shape
• consistency-bony[osteoma], egg shell –GCT, variable- osteosaoma
• surface-lobulated [benign ], irregular –malignant
• margin-well defined [benign ], ill defined- malignant
• fixity to bone
 • plane of swelling
• fluctuation
• transillumination
• extension to joints
• sensation-anaesthesia/ hyperesthesia
• crepitus- pathological fractures
• auscultation: systolic bruit-telengiactatic OS, secondaries
• movement: adjacent joint, any deformity
Measurement:
• limb length-linear
• circumferential- muscle wasting
• midthigh-15 cm above patella
• mid calf-10 cm below tibial tuberosity
• arm-10 cm above olecranon
• forearm-10 cm below olecranon

Regional Lymph Nodes:

vertical group of superficial lypm nodes-lower limb tumours
axillary, cervical –upper limb
external iliac-lower limb

Examination Of Adjacent Joints

Distal Neurovascular Deficit
Gait- Not Needed
Other System-Cvs, Rs,R/O Primary Abdomen

Summary
15 yrs …..swelling left thigh 5 months…no trauma….progressive….h/o
chemotherapy…alopecia….findings….with out distal neurovascular deficit

Diagnosis
1. Benign tumour involving right distal femur -Metaphyseal,epiphyseal, diaphyseal
2. Malignant bone tumour involving distal femur-- Metaphyseal,epiphyseal, diaphyseal
Give differential diagnosis

Examination Of Wrist:
Complaints
 • Pain
• Swelling
• Deformity
History of present illness:
h/o fall or trauma-mode of injury
• closed/open
• mode of treatment
• details of native treatment
pain:
• site
• Duration
• Onset
• Type of pain/character
• Nature- progressive/ static
• Radiation
• Aggravating factors/relieving factors
• Stiffness
• Night pain/night cry
• Remissions and exacerbations
Swelling-
• duration
• Site
• Mode of onset
• Progressive
• Associated with pain
• Any other swellings in the body
Deformity
• Duration
• When noted first- after removal of splints
• Progressive / static
• Associated with restricted movements
h/o difficulty in doing activity of daily livings
h/o fever / evening rise of temperature
h/o loss of weight /loss of apetite
h/o early morning stiffness / other joint involvement
h/o remissions and exacerbations
h/o loss of sensation over hand / fingers
h/o tingling / numbness
Past H/O:
h/o childhood injury
h/o surgery and its details
h/o TB/ RA/ THYROID – and its treatment details

Personal History
smoking
alcoholism

Family History
similar complaints-hereditary

General Examination:
• built
• nourishment
Regional Examination:
• attitude of upper limb-shoulder, elbow, forearm, wrist and hand
• wasting of muscles
• deformity
• limb length discrepancy

Examination Of Wrist Proper:

Inspection:
attitude-
• dinner fork deformity-colle’s
• mannus valgus-madelung
• flexion and ulnar deviation-RA
• wrist drop-radial nerve injury
• arrow head deformity of ulna- diaphyseal acalasia
Dorsal Aspect-
• position of wrist
• swelling and its details
• skin
• ulnar styloid prominence
• venous prominence
• muscle wasting
Radial Side:
• anatomical snuff box
• any abnormal bony prominence
 • skin,sinuses, scar
• engorged veins
Palmar-
• skin crease
• swelling and its details -compound palmar ganglion
• thenar and hypothenar wastings
• sinuses and scars
Ulnar
skin, swelling, sinuses, scars

Palpation:
• warmth
• tenderness
• swelling-size,size, shape, margins, edge, consistency, fixity to bone, tendon
• transillumination / cross fluctuation
• joint line tenderness –dorsally
• palpation of styloid process
• any abnormal bony projections
• distal radio ulnar instability
• ulnar variance-positive / negative
• palpation of anatomical snuff box [radial styloid process ]
• palpation of tendons at snuff box [dequervains disease ]
• any scar – adhesive to bone
Movements:
wrist dorsiflexion 0* to 70* to 90*
Palmar flexion 0* to 70* to 90*
Radial deviation 0* to 15* to 25*
Ulnar deviation 0* to 25* to 35*
circumduction
Forearm Supination 0*to 90*
Pronation 0* to 80*

Measurements:
Linear-total limb length
Arm segment
Fore arm
Circumferential-midforearm level
Wrist level-styloid level

Tests for tendons

 • EPL
• ED
• PL
• FCU

Tests for nerves

• Radial
• Median
• Ulnar nerve
Examination of elbow shoulder fingers
Special tests
Dequervains disease-
• firm fist
• Finkelstein s test
o Extend & abduct against resistance
Carpal tunnel syndrome-
• thumb pressure over tunnel
• Phalen’s test
• Tinel’s sign
• Tourniquet test
• Provocative test
• Motor/ sensory for median nerve
Scaphoid instability-
• scaphoid shift test
• Tenderness at snuff box
Distal radius fracture:
• Step sign
• Dinner fork /garden spade deformity
GCT:egg shell crackling on palpation
Compound palmar ganglion- cross fluctuation / transillumination
Madelung-
• ulnar variance
• Radial bowing & thickening
No distal neurovascular deficit
No regional lyphadenopathy

Summary
Diagnosis
 1. Benign bone/tendon tumour involving distal radius epiphysis /epiphyseo-metaphyseal
region-probably GCT
2. Post traumatic manus valgus deformity- due to madelung/ non union distal radius

Non-union long bones

h/o mode of injury and treatment details
h/o fever
h/osinus with discharge
h/o bony chips coming out
h/o fowl smelling discharge
Personal H/O
Smoking

Findings
• number of sinus
• attatchment to bone
• tenderness
• bony thickening
• abnormal mobility
• loss of transmitted mobility
adjacent joints;-proximal and distal

Diagnosis:
infected non-union of long bone

Chronic Osteomyelitis:
h/o injury and treatment details
h/o fever
h/o sinus with discharge, bony chip, fowl smelling

Personal
smoking h/o
other comorbid illness

Findings:
• number of sinuses
• active discharge
 • fowl smelling
• attatchment to bone
• bony irregularity
• abnormal mobility
Diagnosis:
acute exacerbation of chronic osteomyelitis of bone involving metaphysic

Ctev

It is the congenital deformity of foot and ankle joint complex charecterised by forefoot
adduction , heel varus and ankle equines

Idiopathic /non-idiopathic

Mechanical factors in utero

Intrauterine positioning

Decreased amniotic fluid, oligohydromnios- dec fetal movements-vulnerale to external pressure

Twins/large baby-dec space in utero

Incidence:

1-2 /1000 live births

M=f 2.5:1

Bilateral -50% more resistant than unilateral

Family history-5-50%

Pathognomonic signs :

--dorsiflexion is impossible

Deep cleft just above the heel

Clinical features:

equines,varus, forefoot adduction and cavus

Medial border of the foot isconcave and short and elevated

Lateral border is convex ,lenghthened and depressed in full contact with ground

Heel is small,posterior aspect of calcaneum is difficult to palpate and less visible

Skin over dorsolateral aspect of foot is usually stretched out,thin and atrophied

Deep cleft present on plantar and medial aspect of foot

Deep medial longitudinal arch-cavus deformity

Single deep cleft just above the heel

Long standing cases-callosity

Head and neck of talus palbable dorso laterally

Soft tissue contractures:

Posterior contractures

Tendoachillis, tibiotalar capsule, posterior talofibular lig,talocalcaneal capsule,calcaneofibular

ligament

Medial plantar contractures

Tibialis posterior tendon,deltoid ligament,talonavicular capsule,plantar calcaneonavicular

ligament[ spring] ligamentflexor hallucis longus/flexor digitorum longus

Subtalar contractures

Talocalcaneal interosseous ligament, bifurcated y ligament

Plantar contractures :

Abductor hallucis,intrinsic toe flexors, quadratus plantae,plantar aponeurosis

Primary Bil genu varum Bil genu valgum Morant baker

osteoarthritis- cyst
efffusion
Attitude Hip neutral,knee Hip in neutral, Hip in neutral, Hip in neutral,
in extension, foot outward deviation knee joint knee in
in ease position /convexity touching each extension, foot
/bowing of both other/lateral in ease position
/single knee,and deviation of leg,
foot in ease and foot in ease
position position
Inspectio • Diffuse • Diffuse • Diffuse • Patella
n swelling swelling swelling facing
anterior of knee of knee of knee upper
• Parapatell • Parapatell • Parapatell and
ar fullness ar fullness ar fullness lateral
present present present • skin over
• Patella • Patella • Patella swelling
facing facing facing • sinuses
upper and outward upward • scars
lateral and lateral and • visible
• skin over • skin over slightly pulsation
swelling swelling medially
• sinuses • sinuses • skin over
• scars • scars swelling
• visible • visible • sinuses
pulsation pulsation • scars
visible pulsation

Medial
Lateral
posterior • Flexor
crease
obliterate
d
• Swelling
of size
4*5 cm
extendin
g 5cm
above the
joint and
2 cm
below
the joint.
• Lateral
extension
3 cm
from
midline
 • Medial
extension
-2 cm
from
midline

• Swelling
decreases
in size or
disappear
s on
flexion
of knee

• sinuses
• scars,
visible
pulsation
•
palpation
•
•
•
•
•
•
•