EXTREMITIES AND SPINE 2.

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Pain in the Shoulder

shoulder joint – arthritis

Tendon – supraspinatus tendinitis
Muscle – muscle strain
Bones – fracture of humeral neck
Nerves – compression
Vascular - aneurysm
Pain referred to the shoulder

CVS – angina pectoris

Resp. – pneumonia
GIT – gastritis, peptic ulcer
1. Length of arm
tip of the most prominent portion of lateral side
of the clavicle up to the tip of the middle finger

2. Length of lower extremity

from anterior superior iliac spine to the tip of
medial malleolus with the tape crossing the
patella
Shoulder joint
 The Spine

- 7 cervical vertebrae; 3 are specialized:

C1 - atlas
C2 - axis
C7 - vertebral prominence
- Nodding and lifting the head – occurs at
atlanto-occipital joint

- Flexion and extension – involves C3 to C7

- Lateral bending - midcervical vertebrae

- Rotation – atlanto-axial joint

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 processes
- Auscultate for crepitus
Pain in the Neck and Shoulder

1. Pancoast’s Syndrome (superior pulmonary

sulcus syndrome)
Tumor in: - pulmonary apex
- upper mediastinum
- superior thoracic aperture
Symptoms: - pain in the posterior part of the
shoulder & axilla, often w/ shooting pain
down the arm; Acroparesthesia; Paresis or
atrophy of the arm; Horner Syndrome..
2. Cervical Spondylosis (cervical osteoarthritis)
- Spondylosis – describe the complications from
degeneration the vertebrae and their
intervertebral disks, with traumatic rupture or
degeneration of the nucleus pulposus

- Symptoms:
- Pain in the neck, shoulder, occipital scalp or
down the arm;
- Numbness and tingling of the hands (frequent)
- Muscle atrophy (rare)
- Crepitus may be heard by the pt. , palpated or
auscultated by the examiner.
- X-ray findings are diagnostic for degenerative
disease of cervical spine

3. Nuchal headache – begins in the occipital region

4. Post-traumatic neck pain and headache
eg. Whiplash cervical injury
- sudden, forceful hyperextension of the neck
with the flexion recoil
- The ligamentum nuchae is ruptured; rarely the
spine of C7 is fractured.
- /s Post. neck pains, spasm of the neck muscles,
torticollis

5. Flexion fracture of the neck

C5 is fx. by hyperflexion
Ex. Diver strikes his head on the botton
Result in immediate death or quadriplegia if the
pt. survive .
6.Partial dislocation from
hyperextension

A fall or blow on forehead may hyperextend

the neck --- rupture anterior longitudinal
ligament
Result neck pain
paraplegia
7. Fracture of the atlas (C1)
- if immediate death does not results, the
patient is unable to nod the head & there will
be severe occipital pain
Examination of the spine

from the side: inspect the spinal profile

note: cervical, thoracic, lumbar curves

From behind: inspect for lateral curves, take

note of heights of shoulders, iliac crests
imaginary line T1 – gluteal cleft
Check ROM

1. Bend forward – flexion

2. Bend sideways – lateral bending
3. Bend backwards toward you (extension)

Palpate spinous processes with thumb, take

note of tenderness
 Percuss the spine for tenderness by
thumping it 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
4 – coccygeal
4 curves of vertebral column viewed laterally
1. Cervical curve – convex forward C2-T2
2. Thoracic curve – concave forward T2 –T12
3. Lumbar curve – convex forward T12 to
lumbosacral joint
4. Pelvic curve – concave forward and
downward from lumbosacral joint to tip of
coccyx
 Kyphosis- forward concavity of thoracic curve is
accentuated producing a hunchback

Smooth curve results from:

1. Faulty posture
2. Rigid kyphosis of adolescence (Scheuermann’s
Kyphosis)
3. Ankylosing spondylitis (Marie-Strumpell Dis.)
4. Osteitis deformans (Paget’s Disease)
5. Senile osteoporosis
Ankylosing spondylitis
 Angular curve – gibbus caused by:
1. Collapse of bodies of vertebra from compression
fracture
2. Metastatic CA
3. Infectious spondylitis
Lordosis:
- Accentuated posterior concavity of the lumbar
spine
- Deep furrow between lumbar paraspinous muscles
- Pot belly
- Causes:
- Pregnancy, Flexion contractures of the hips
- Short achilles tendon
Spinal cord
Osteogenesis imperfecta
Thomas test (for lordosis)
Gaenslen’s sign
Test of the hip joint

A. straight leg raising test

B. Patrick’s test
Scoliosis: lateral curvature of the spine
Note for:
loss of symmetry
compare tips of scapula
top of hips
dimples of venus

Structural scoliosis
occurs in congenital deformities
paralysis of back or abdominal muscle
Painless limping

Dislocation of the hip

- shortening of the thigh
- 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 bec. The muscles are not
strong enough to sustain position when the femur is not engaged in the
acetabulum
 The Knee
General examination
patient standing:
- inspect for deformities, swelling, and
muscle atrophy
- note for position of patella
- search for point tenderness
patient supine:
- test for extension and flexion
Movement of the knee
Flexion
Extension
Deformity
1. Genu varum (bowleg)
- Legs deviate toward the midline and knees are
farther apart
- Occurs in rickets, Paget’s dse., occupational,
cowboys and jockeys
2. Genu valgum (knock-knee)
-lateral deviation of the leg from midline
3. Genu recurvatum
- knees fixed in hyperextension with little ability
to flex
Genu valgum genu varum
Genu recurvatum
- Effusion or hydrarthrosis - synovial fluid in the
knee joint
- Hemarthrosis – blood in the joint cavity
- Pyarthrosis – pus in joint cavity

Anterior knee cyst:

1. Prepatellar bursitis (housemaid’s knee)
2. Intrapatellar bursitis (clergyman’s knee)
Housemaid’s knee
Clergyman’s knee
Popliteal cyst:
1. Popliteal abscess
- Minimal swelling in popliteal fossa
- Knee hold in partial flexion to relieve pain
- Extension is painful
- Examine the foot for source of infection
2. Morrant baker’s cyst
- pressure diverticulum of synovial sac
protruding thru the joint capsule of knee
- complication of RA
- Popliteal artery entrapment syndrome
Baker’s cyst
The leg
1. Soleus tear – trauma causing extreme
dorsiflexion of foot . Severe pain and
tenderness
2. Rupture of achilles tendon
- Injury incurred when body weight is forcefully
applied to the ball of the foot in plantar flexion
P.E.
- Affected foot in less plantar flexion
- Distal portion of affected tendon seems thicker and
less stretched
Simmonds test
- squeeze calf muscles transversely – no motion
when tendon is severed

3. Fracture of tibial shaft

- due to fall ont the leg
- direct blow to anterior tibia
- sever pain
- leg cannot bear weight
4. Fracture of fibular shaft
- direct blow on the anterolateral aspect of leg
- pain on anterior leg
- patient can walk

5. Fracture of both tibia and fibula

- Most common cause of compound fracture
- Foot turned inward in obvious deformity
Ankle joint

Swelling – subcutaneous edema, effusion

Lateral ankle pain – rupture of joint capsule

- forceful plantar flexion with eversion of the
foot – breaks anterolateral portion of the
articular capsule
The foot
Pedal deformity: Talipes

5 principal varieties
1. talipes varus – inversion
2. talipes valgus – eversion
3. Talipes equines – plantar flexion
4. talipes calcaneous – dorsiflexion
5. pes cavus – hallowing of the instep
Pes cavus
Cutaneous lesions: thickening of the skin
1. hard corn (heloma durum) – undue pressure
on the skin especialy that covering the toes

2. callus – thickening of the sole

 The toes
Hallux valgus
- lateral deviation of the great toe
- produces abnormal prominence of the first
metatarsophalangeal joint
Bunion – inflamed bursa over the prominent
metatarsophalangeal joint
Hallux rigidus
- stiffened great toe
- chronic arthritis of the 1st MTP joint from injury
or wearing short shoes – ankylosis – extension
Hammertoe – fixation of the 2nd toe in flexion
The toenails
- ingrown toenail (onychocryptosis) - presence
of transverse growth of nail plate – causes lateral
edge to lacerate the nail fold
- overgrowth of toe nail – Ram’s horn nail
(onychogryphosis) – nail thickened, conical, and
curved like a ram’s horn
Thank you!