CLINICAL EXAMINATION IN

MUSCULOSKELETAL SYSTEM

PROF. KONSTANTIN MITEV, MD, PHD

ZAN MITREV CLINIC
SKOPJE, N. MACEDONIA
 CLINICAL EXAMINATION IN
MUSCULOSKELETAL SYSTEM
• MECHANICAL TRAUMA IS AN INJURY TO ANY PORTION OF THE BODY
FROM BLOW, CRUSH, CUT OR PENETRATING WOUND.
• TRAUMA IS EVENT RESULTING IN PHYSICAL HARM, EMOTIONAL HARM
AND LIFE THREATING HARM
• THE COMPLICATIONS OF MECHANICAL TRAUMA ARE USUALLY
RELATED TO FRACTURE, HEMORRHAGE AND INFECTION.
 CLINICAL EXAM
UPPER EXTREMITY
 GENERAL ORTHO PHYSICAL EXAM
MANEUVERS

• INSPECTION
• PALPATION
• RANGE OF MOTION
• MUSCLE STRENGTH
• SPECIAL TESTS
• ALWAYS THINK ABOUT THE JOINT ABOVE AND BELOW WHERE
THE PAIN IS AND EXAMINE THAT JOINT
 INSPECTION
• USUALLY NORMAL IN THE
SHOULDER EXAM WITH A
FEW NOTABLE EXCEPTIONS
• SQUARED OFF SHOULDER:
ANTERIOR SHOULDER
DISLOCATION
• LOOK FOR SIGNS OF
INFECTION (REDNESS,
SWELLING, WARMTH):
THINK SEPTIC JOINT
Anterior shoulder dislocation
 PALPATION
• PALPATE THE ENTIRE SHOULDER
JOINT LOOKING FOR POINT
TENDERNESS OR DEFORMITY
• STERNOCLAVICULAR JOINT
• CLAVICLE
• ACROMIOCLAVICULAR JOINT
(MAY BE TENDER AT BASELINE)
• HUMERAL HEAD
• BICIPITAL TENDON IN BICIPITAL
GROOVE
• ARM AT 90 DEGREES,
EXTERNALLY ROTATE TO FEEL
THE TENDON MOVING (MAY
BE TENDER) PALPATION OF BICIPITAL TENDON IN GROOVE
 RANGE OF MOTION
• KNOW WHAT NORMAL RANGES ARE
• FORWARD FLEXION: 150-170O
• EXTENSION: 50-70O
• EXTERNAL ROTATION: ABOUT 90O
• INTERNAL ROTATION: PLACE HANDS
BEHIND THE BACK WITH PALM OUT
• MEASURE LEVEL OF SPINOUS
PROCESS OF THUMB
• NORMAL IS ABOVE T7
• COMPARE BOTH SIDES (DOMINANT
HAND USUALLY IS 2 SPINOUS
PROCESS BELOW NON-DOMINANT
HAND)
INTERNAL ROTATION
 ROM (CONTINUED)

• IF NORMAL ACTIVE ROM, PROBABLY NO MECHANICAL LIMITATION

• CAN BASICALLY RULE OUT:
• HUMERAL HEAD FRACTURE
• DISLOCATION
• ADHESIVE CAPSULITIS (FROZEN SHOULDER)

• IF PASSIVE ROM PRESERVED, BUT PT HAS IMPAIRED ACTIVE ROM, THINK OF

PAIN-LIMITED INJURY
• ROTATOR CUFF PATHOLOGY
• BURSITIS
• TENDONITIS
 STRENGTH TESTING

• ROTATOR CUFF MUSCLES

• SUPRASPINATUS
• INFRASPINATUS
• TERES MINOR
• SUBSCAPULARIS

• HINT FOR ROTATOR CUFF MUSCLE ACTIONS

• REMEMBER THAT SUPRASPINATUS, TERES MINOR AND INFRASPINATUS INSERT ON POST
SURFACE OF SCAPULA; SUBSCAPULARIS INSERTS ON THE ANTERIOR SURFACE OF THE
SCAPULA
 STRENGTH TESTING: SUPRASPINATUS

• SUPRASPINATUS: ABDUCTION (WITH DELTOID)

• EMPTY BEER CAN TEST
• ARM TO 90O, FORWARD FLEXION TO 30O, INTERNAL ROTATION OF HAND WITH
THUMBS DOWN, PUSH UP AGAINST RESISTANCE
 STRENGTH TESTING: TERES
MINOR/INFRASPINATUS
• TERES MINOR/INFRASPINATUS: EXTERNAL ROTATION
• EXTERNAL ROTATION AGAINST RESISTANCE
 STRENGTH TESTING: SUBSCAPULARIS
• SUBSCAPULARIS: INTERNAL ROTATION
• INTERNAL ROTATION AGAINST RESISTANCE
 IMPINGEMENT TESTS: NEER’S TEST

• FORWARD FLEXION WITH ARM INTERNALLY ROTATED

 IMPINGEMENT TESTS: HAWKINS TEST

• ARM AT 90O, 30O OF FORWARD FLEXION, BEND ELBOW AND TAKE

FROM EXTERNAL ROTATION TO INTERNAL ROTATION
 OTHER SPECIAL TESTS: O’BRIEN’S TEST

• LABRUM TEARS
• ARM AT 90O, FLEXED AT 90O, BRING ARM ACROSS MIDLINE AND THEN UP
AGAINST RESISTANCE
• INTERNALLY ROTATED (THUMB DOWN)-> IF PAIN, LABRUM TEAR
• EXTERNALLY ROTATED (THUMB UP) -> IF PAIN, BICEPS PATHOLOGY
 OTHER SPECIAL TESTS: SPEED’S TEST

• BICEPS INJURY
• GRAB HAND AS IF HANDSHAKE AND DO RESISTED SUPINATION, LOOK
FOR PAIN
 CLINICAL EXAM
LOWER EXTREMITY
 GENERAL ORTHO PHYSICAL EXAM
MANEUVERS

• INSPECTION
• PALPATION
• RANGE OF MOTION
• MUSCLE STRENGTH
• SPECIAL TESTS
• ALWAYS THINK ABOUT THE JOINT ABOVE AND BELOW WHERE THE
PAIN IS AND EXAMINE THAT JOINT
 INSPECTION
• LOOK FOR REDNESS, SWELLING, WARMTH -
> THINK SEPTIC ARTHRITIS
• EXAMINE THE PATIENT’S GAIT IF POSSIBLE
• EVALUATE LEG LENGTH AND ALIGNMENT
• POSTERIOR DISLOCATION (90% OF HIP
DISLOCATIONS) – AFFECTED LEG IS
SHORTENED AND INTERNALLY ROTATED
• ANTERIOR DISLOCATION – AFFECT LEG IS
SLIGHTLY SHORTENED AND EXTERNALLY
ROTATED
 PALPATION
• PALPATE THE ISCHIAL SPINES AND PUBIC
RAMI
• ALSO ASSESS THE FEMUR AND KNEE
FOR ADDITIONAL INJURIES
• PALPATE THE GREATER TROCHANTER
AND ASSESS FOR BURSITIS
• WHILE PALPATING THE TROCHANTER,
GENTLY ROCK THE EXTENDED LEG ON
THE TABLE FROM SIDE TO SIDE TO
ASSESS FOR TROCHANTERIC BURSITIS
 RANGE OF MOTION

• FLEXION: 135 DEGREES

• EXTENSION: 15 DEGREES
• EXTERNAL ROTATION: 45 DEGREES
• INTERNAL ROTATION: 35 DEGREES
• ABDUCTION, ADDUCTION
• IN A PATIENT WITH SEVERE PAIN, SIMPLY ROCK THE AFFECTED LEG
FROM SIDE TO SIDE ON THE EXAM TABLE – IF A PATIENT IS UNABLE TO
TOLERATE THIS, SUSPECT ACUTE INJURY SUCH AS A HIP FRACTURE
 SPECIAL TESTS
• OBER’S TEST – EVALUATES FOR TIGHTNESS
OF THE ILIOTIBIAL BAND
• HAVE THE PATIENT LIE ON HIS UNAFFECTED
SIDE WITH THE AFFECTED LEG STRAIGHT
• STABILIZE THE HIP WITH ONE HAND AND
USE THE OTHER HAND TO LIFT THE
AFFECTED LEG, BENDING THE LEG AT THE
KNEE
• ALLOW THE LEG TO DROP
• IF THE LEG DOES NOT FULLY ADDUCT, THE
TEST IS POSITIVE FOR TIGHT IT BAND
 KNEE EXAM
WEEK 1 ORTHO CURRICULUM
 GENERAL ORTHO PHYSICAL EXAM
• INSPECTION MANEUVERS
• PALPATION
• RANGE OF MOTION
• STABILITY
• SPECIAL TESTS
• ALWAYS THINK ABOUT THE
JOINT ABOVE AND BELOW
WHERE THE PAIN IS AND
EXAMINE THAT JOINT
 INSPECTION
• LOOK FOR REDNESS, SWELLING,
WARMTH -> THINK SEPTIC ARTHRITIS
• LOOK FOR EFFUSION – OCCURS IN
ACUTE INJURY
• IS THE EFFUSION MILD, MODERATE, OR
SEVERE?

• LOOK FOR DISPLACEMENT OF THE

PATELLA
• BAKER’S CYST – SWELLING OVER
POSTERIOR ASPECT OF THE KNEE
• DON’T FORGET TO WATCH THE PATIENT
WALK
• IS THE PATIENT ABLE TO BEAR WEIGHT?
• DOES THE PATIENT HAVE AN ANTALGIC
GAIT? (LIMPING GAIT) INDICATES PAIN
WITH WEIGHT BEARING
 PALPATION
• GRASP THE LOWER EXTREMITY JUST
DISTAL TO THE KNEE AND PUSH
UPWARD, ATTEMPTING TO “MILK”
ANY EFFUSION THAT MAY BE
PRESENT
• IF THERE IS A SIGNIFICANT
EFFUSION, YOU WILL SEE IT FILL THE
CREVICES ON THE MEDIAL AND
LATERAL SIDES OF THE PATELLA

• PALPATE THE PATELLA – SHOULD BE

MOBILE
• PALPATE THE ENTIRE KNEE, LOOKING
FOR ANY POINT TENDERNESS
• EVALUATE JOINT LINE TENDERNESS
WITH THE THUMB
 RANGE OF MOTION

• NORMAL FUNCTIONAL ROM

• 3 DEGREES OF HYPEREXTENSION
• 140 DEGREES OF FLEXION
• ALWAYS COMPARE THE SYMPTOMATIC KNEE TO THE CONTRALATERAL
NORMAL KNEE
• FORCED FLEXION
• PATIENT WITH A MENISCAL TEAR WILL BE UNABLE TO TOLERATE
• LIMITED EXTENSION – CONSIDER MENISCAL TEAR OR EFFUSION
• HYPEREXTENSION – CONSIDER PCL TEAR
 STABILITY

• LACHMAN
• EVALUATES FOR ACL INJURY
• POSTERIOR DRAWER
• EVALUATES FOR PCL INJURY
• VARUS AND VALGUS STRESS
• EVALUATES FOR MCL, LCL INJURIES

• MCMURRAY
• EVALUATES FOR MENISCAL INJURY
 LACHMAN
• WITH THE KNEE FLEXED AT 30 DEGREES,
GRASP THE INNER ASPECT OF THE CALF
WITH ONE HAND, GRASP OUTER
ASPECT OF DISTAL THIGH WITH THE
OTHER HAND
• PULL ON THE TIBIA TO ASSESS THE
AMOUNT OF ANTERIOR MOTION OF
THE TIBIA IN COMPARISON TO THE
FEMUR
• ACL INJURY – INCREASED FORWARD
TRANSLATION OF THE TIBIA AT THE END
OF MOVEMENT
 POSTERIOR DRAWER
• WITH THE KNEE FLEXED TO 90 DEGREES AND THE PATIENT’S FOOT FLAT ON THE
TABLE, GRASP THE TIBIA WITH BOTH HANDS AND PUSH POSTERIORLY
• LAXITY AT THE CONCLUSION OF MOVEMENT IS INDICATIVE OF A PCL INJURY
 VARUS AND VALGUS STRESS
• PLACE THE PATIENT’S LEG OVER THE
EXAMINATION TABLE WITH ONE HAND
OVER THE LATERAL JOINT LINE AND THE
OTHER HAND HOLDING THE DISTAL
PORTION OF THE EXTREMITY
• FLEX THE KNEE TO 30 DEGREES AND APPLY
A VARUS FORCE (ADDUCTION), THEN APPLY
A VALGUS FORCE (ABDUCTION)
• LAXITY WITH VARUS STRESS INDICATES LCL
INJURY
• LAXITY WITH VALGUS STRESS INDICATES
MCL INJURY
 MCMURRAY
• WITH THE KNEE FLEXED TO 90 DEGREES, PLACE
ONE HAND ALONG THE LATERAL JOINT LINE
AND GRASP THE FOOT WITH THE OTHER HAND
• PROVIDE A VARUS STRESS ON THE KNEE
• ROTATE THE LEG EXTERNALLY AND EXTEND THE
KNEE
• IF THE PATIENT EXPERIENCES PAIN OR A CLICK IS
FELT WITH THE MOTION, A MEDIAL MENISCAL
INJURY SHOULD BE SUSPECTED
• A LATERAL MENISCAL INJURY CAN BE
EVALUATED WITH THE SAME TEST BY
STABILIZING THE MEDIAL KNEE, INTERNALLY
ROTATING THE LEG AND EXTENDING THE KNEE
•
SPECIAL
PATELLAR APPREHENSION TEST
TESTS
• MANUALLY SUBLUXATE THE PATELLA LATERALLY
• IN A PATELLER TENDON INJURY, THE PATIENT WILL NOT
TOLERATE THIS TEST

• PATELLAR GRIND
• HAVE THE PATIENT FLEX HIS QUADRICEP, THEN APPLY A
POSTERIORLY-DIRECTED FORCE TO THE PATELLA Apley’s test
• APLEY’S TEST
• WITH THE PATIENT PRONE, FLEX THE AFFECTED KNEE TO 90
DEGREES, GRASP THE FOOT AND ROTATE THE KNEE,
APPLYING A DOWNWARD FORCE
• REPRODUCTION OF PAIN INDICATES A MENISCAL INJURY

• DUCK WALK
• HAVE THE PATIENT ATTEMPT TO WALK WHILE IN A
SQUATTING POSITION
• IF THE PATIENT IS ABLE TO WALK, HE/SHE LIKELY DOES NOT
HAVE A MENISCAL INJURY
Duck walk
CLINICAL EXAM
FOOT/ANKLE
 GENERAL ORTHO PHYSICAL EXAM
• INSPECTION MANEUVERS
• PALPATION
• RANGE OF MOTION
• MUSCLE STRENGTH
• SPECIAL TESTS
• ALWAYS THINK ABOUT THE JOINT
ABOVE AND BELOW WHERE THE
PAIN IS AND EXAMINE THAT JOINT
 INSPECTION

• LOOK FOR REDNESS,

SWELLING, WARMTH ->
THINK SEPTIC ARTHRITIS
• EVALUATE FOR EFFUSION
• LOOK FOR GROSS
DEFORMITY
 PALPATION

• MEDIAL AND LATERAL MALLEOLI

• PALPATE ALONG THE FIBULA TO ASSESS FOR TENDERNESS, POSSIBLE FIBULAR FRACTURE
• ANTERIOR AND POSTERIOR TALOFIBULAR LIGAMENTS, DELTOID LIGAMENT, CALCANEOFIBULAR
LIGAMENT
• TALAR NECK
• CALCANEUS
• MID-FOOT
• 5TH METATARSAL
• CONSIDER JONES FRACTURE – CONCERN FOR AVASCULAR NECROSIS

• PALPATE THE MID-FOOT, ASSESSING FOR LISFRANC FRACTURE

PALPATION
 RANGE OF MOTION

• PLANTAR FLEXION: 50 DEGREES

• DORSIFLEXION: 20 DEGREES
• FOOT INVERSION: 35 DEGREES
• FOOT EVERSION: 25 DEGREES
• ANTERIOR DRAWER
SPECIAL TESTS
• ASSESSES THE ANTERIOR TALOFIBULAR LIGAMENT
• HAVE THE PATIENT SIT WITH THE KNEE FLEXED OVER THE EDGE OF THE
TABLE
• STABILIZE THE DISTAL LOWER EXTREMITY WITH ONE HAND AND APPLY AN
ANTERIOR FORCE TO THE HEEL WITH THE OTHER HAND, ATTEMPTING TO
SUBLUXATE THE TALUS ANTERIORLY
• TALAR TILT
• EVALUATES FOR TALAR INSTABILITY Anterior drawer
• WITH THE PATIENT SEATED AND WITH THE ANKLE AND FOOT
UNSUPPORTED IN APPROX 15 DEGREES OF PLANTAR FLEXION, STABILIZE
THE MEDIAL ASPECT OF THE DISTAL LOWER EXTREMITY AND APPLY AN
INVERSION FORCE TO THE HINDFOOT WITH THE OTHER HAND

• THOMPSON TEST
• EVALUATES FOR ACHILLES TENDON RUPTURE
• WITH THE PATIENT PRONE, FLEX THE KNEE TO 90 DEGREES AND SQUEEZE
THE CALF
• THE FOOT SHOULD PLANTAR FLEX – IF IT DOES NOT, SUSPECT TENDON
INJURY
ASSESSMENT, MANAGEMENT AND
DECISION MAKING IN THE
TREATMENT OF POLYTRAUMA
PATIENTS WITH
HEAD INJURIES

PROF. KONSTANTIN MITEV, MD, PHD

ZAN MITREV CLINIC
SKOPJE, N. MACEDONIA
 EPIDEMIOLOGIC ASPECTS

• 80,000 SURVIVORS OF HEAD INJURY ANNUALLY

• 125,000 CHILDREN <15YO HEAD INJURED ANNUALLY
• 40-60% OF HEAD INJURED PATIENTS HAVE EXTREMITY INJURY
• 32,000-48,000 HEAD INJURY SURVIVORS WITH ORTHOPAEDIC
INJURIES ANNUALLY
 OVERVIEW
• PATHOPHYSIOLOGY
• INITIAL EVALUATION
• PROGNOSIS
• MANAGEMENT OF HEAD INJURY
• ORTHOPAEDIC ISSUES
• OPERATIVE VS. NONOPERATIVE TREATMENT
• TIMING OF SURGERY
• METHODS
• FRACTURE HEALING IN HEAD INJURY
• ASSOCIATED INJURIES
• COMPLICATIONS
 2nd
hit
1st hit
1st hit: Head 2nd hit: Head
• mechanical • release of
insult to brain inflammatory
tissue mediators
• blunt or •Hypoxia
penetrating •Acidosis
•Coagulopathy
1st hit: body
• mechanical 2nd hit: body
insult • systemic
•chest, inflammation
abdomen • SURGERY
•extremities
 EVALUATION

• ATLS—ABC’S
• HISTORY
• LOSS OF CONSCIOUSNESS

• PHYSICAL EXAM
• GLASGOW COMA SCALE

• RADIOGRAPHIC STUDIES
• CT SCAN
 EVALUATION

• MUST EXCLUDE HEAD INJURY BY EVALUATION IF

• HISTORY OF LOSS OF CONSCIOUSNESS
• SIGNIFICANT AMNESIA
• CONFUSION, COMBATIVENESS
• CANNOT BE SIMPLY ATTRIBUTED TO DRUG OR ALCOHOL USE
• NEUROLOGIC DEFICITS ON EXAM OF CRANIAL NERVES OR EXTREMITIES
 PHYSICAL EXAM

• EXAM OF HEAD AND CRANIAL NERVES FOR LATERALIZING SIGNS

• DILATED OR SLUGGISH PUPIL(S)

• EXTREMITIES
• UNILATERAL WEAKNESS
• POSTURING
• DECORTICATE (FLEXOR)
• DECEREBRATE (EXTENSOR)
 GLASGOW COMA SCALE

• EYE OPENING: 1-4

• MOTOR RESPONSE: 1-6
• VERBAL RESPONSE: 1-5
 GLASGOW COMA SCALE
• SUM SCORES (3-15)
• <9 CONSIDERED SEVERE
• 9-12 MODERATE
• 13-15 MILD*
• MODIFIERS—XT– IF INTUBATED (BEST SCORE POSSIBLE 11T)
XTP – IF INTUBATED AND PARALYZED (BEST
SCORE POSSIBLE IS 3TP)

• DONE IN THE FIELD BUT BEST IN TRAUMA BAY

FOLLOWING INITIAL RESUSCITATION
 RADIOGRAPHIC STUDIES
Frontal
Contusion
• CT SCAN
• REQUIRED IN ALL CASES EXCEPT:
• LOC IS BRIEF
AND
• PATIENT CAN BE SERIALLY EXAMINED
• LESIONS
• FOCAL--EPIDURAL, SUBDURAL HEMATOMA,
CONTUSIONS
• DIFFUSE--DIFFUSE AXONAL INJURY

• PLAIN FILMS
• USEFUL ONLY TO DETECT SKULL FRACTURE BUT
IN THE TRAUMA SETTING WASTES TIME
• INITIAL TREATMENT
• INTUBATION IF UNRESPONSIVE OR
COMBATIVE TO GIVE CONTROLLED
VENTILATION
• PHARMACOLOGIC PARALYSIS
• AFTER NEUROLOGIC EXAM IS COMPLETED
• BLOOD PRESSURE AND O2 SATURATION
MONITORING
• KEEP SYSTOLIC > 90 MM HG
• 100% O2 SATURATION
 ICP MONITORING

• INDICATIONS
• SEVERE HEAD INJURY (GCS < 9)
• ABNORMAL HEAD CT
OR
• COMA >6 HRS
• INTRACRANIAL HEMATOMA REQUIRING EVACUATION
• DELAYED NEUROLOGIC DETERIORATION FROM MILD TO MODERATE
(GCS>9) TO SEVERE (GCS < 8)
• REQUIREMENT FOR PROLONGED VENTILATION
• PULMONARY INJURY, SURGERY ETC.
 ICU MANAGEMENT GOALS

• O2 SATURATION 100%
• MEAN ARTERIAL PRESSURE 90-110 MM
HG
• ICP < 20 MM HG
• CEREBRAL PERFUSION PRESSURE
(CPP=MAP-ICP) >70 MM HG
 ICU ADJUNCTS
• HCT~ 30-33%
• PACO2= 35±2 MM HG
• CVP= 8-14 MM HG
• AVOID DEXTROSE IV
• MAINTAIN EUTHERMIA OR MILD
HYPOTHERMIA
 FACTORS INFLUENCING PROGNOSIS
• AGE
• YOUNGER PTS HAVE GREATEST POTENTIAL FOR
SURVIVAL AND RECOVERY
• 61-75% MORTALITY IF OVER 65
• 90% MORTALITY IN ELDERLY WITH ICP >20 AND
COMA FOR MORE THAN 3 DAYS
• 100% MORTALITY IF GCS < 5, UNI- OR BILATERAL
DILATED PUPILS, AND AGE OVER 75
Bottom line: survival and recovery not predictable except in old pts
• Treat presuming recovery
 FACTORS INFLUENCING PROGNOSIS

• HYPOTENSION--50% INCREASE IN MORTALITY

WITH SINGLE EPISODE OF HYPOTENSION
• HYPOXIA
• DELAY IN TREATMENT
• PROLONGED TRANSPORT
• SURGICAL DELAY WHEN LATERALIZING SIGNS PRESENT

Potentially controllable!!
 OUTCOME

• GLASGOW OUTCOME SCORE:

• 1-DEAD
• 2-VEGETATIVE
• 3-CANNOT SELF CARE
• 4-DEFICITS BUT ABLE TO SELF CARE
• 5-RETURN TO PREINJURY LEVEL OF FUNCTION
 OUTCOME PREDICTION

• SERUM MARKERS (S-100B)

• ACCURACY OF 83% (WOERTGEN, J TRAUMA, 1999)
• GOOD SENSITIVITY IN MODERATE TO SEVERE INJURY EVEN WITH
EXTRACRANIAL INJURY (SAVOLA, J TRAUMA, 2004)
• MAY BE ELEVATED IN 29% FX PTS WITHOUT HEAD INJURY (UNDEN, J
TRAUMA, 2005)

Clinical utility not defined

 PROGNOSIS
• SIGNIFICANT DISABILITY @ 1 YR
• DISABILITY EVEN IN “MILD” INJURY
• GLASGOW COHORT: 742 PTS WITH 71% FOLLOW-UP
• RATE OF COMBINED SEVERE AND MODERATE DISABILITY SIMILAR
AMONG GROUPS (48%, 45% AND 48%)
• AGE >40, PREVIOUS HEAD INJURY, COMORBIDITIES INCREASED
DISABILITY
Dead or Severe (THORNHILL,
Moderate
BMJ, 2000) Good
vegetative disability disability recovery
Mild (GCS 13-15) 8% 20% 28% 45%
Mod (GCS 9-12) 16% 22% 24% 38%
Severe (GCS <9) 38% 29% 19% 14%
 ORTHOPAEDIC ISSUES IN THE HEAD
INJURED PATIENT
• ROLE IN RESUSCITATION
• PELVIC RING INJURY
• OPEN INJURIES
• LONG BONE FRACTURES

• TREATMENT METHODS AND TIMING

• ASSOCIATED INJURIES
• COMPLICATIONS
 FRACTURE CARE

• ULTIMATE NEUROLOGIC OUTCOME CONTINUES TO BE DIFFICULT TO

PREDICT
• PRESUME RECOVERY
• AVOID TREATMENTS THAT MAY COMPROMISE NEUROLOGIC OUTCOME
• ALL INTERVENTIONS MUST STRIVE TO REDUCE MUSCULOSKELETAL
COMPLICATIONS INHERENT IN THE HEAD INJURED PATIENT
• MANAGEMENT DECISIONS MADE IN CONJUNCTION WITH
TRAUMA/NEUROSURGICAL TEAM
 ALGORITHM FOR FRACTURE CARE IN
HEAD INJURED
• SEVERE HEAD INJURY (GCS<9) OR UNSTABLE PT
DAMAGE CONTROL SURGERY
CONVERT TO DEFINITIVE AT 5+ DAYS
• MILD HEAD INJURY (GCS 13-15); STABLE PT
CONSIDER EARLY TOTAL CARE

• INTERMEDIATE HEAD INJURY

DETERMINED BY PT STABILITY; COMPLEXITY OF SURGERY
 NONOPERATIVE FRACTURE
MANAGEMENT
• TREATMENT OF CHOICE WHEN
• NONOPERATIVE MEANS BEST TREAT THAT PARTICULAR FRACTURE
• OPERATIVE RISKS OUTWEIGH POTENTIAL BENEFITS

• MODALITIES
• SPLINT
• BRACE
• CAST
• TRACTION

• CAVEAT
• DEVICE MUST BE REMOVED PERIODICALLY TO INSPECT UNDERLYING SKIN FOR DECUBITI
 C SPINE INJURY
• INCIDENCE INCREASES WITH INCREASING SEVERITY OF
HEAD INJURY C spine injury
GCS Incidence
13-15 1.4%
9-12 6.8%
<9 10.2%
DEMETRAIADES, J TRAUMA, ’00

• EVALUATION MORE DIFFICULT

• OPTIMAL PROTOCOL FOR EVALUATION AND
MANAGEMENT CONTROVERSIAL
 C SPINE INJURY

• MINIMUM REQUIREMENT
• CERVICAL COLLAR
• CT ENTIRE C SPINE WITH RECONSTRUCTIONS
• ADJUNCTS
• MRI
• DIFFICULT IN VENT PATIENT
• MAY OVER CALL INJURY
• “DYNAMIC” FLEXION EXTENSION RADIOGRAPHS IN
THE OBTUNDED PATIENT
• SAFETY AND RELIABILITY NOT ESTABLISHED
 SUMMARY
• ORTHOPAEDIC INJURIES ARE COMMON IN HEAD
INJURED POLYTRAUMA PATIENTS
• HEAD INJURY OUTCOME IS DIFFICULT TO PREDICT
• MANAGEMENT REQUIRES MULTIDISCIPLINARY
APPROACH
• OPERATIVE MANAGEMENT IS SAFE AND OFTEN
IMPROVES FUNCTIONAL OUTCOME IF SECONDARY
BRAIN INSULTS ARE AVOIDED
• HYPOTENSION, HYPOXIA, INCREASED ICP
PHYSICAL EXAM OF THE
SPINE
 GOALS
•Systematic approach to performing a
spine physical exam

•Improve understanding of physical

exam findings

•Synthesize information from exam to

help achieve diagnosis
 OVERVIEW
• General Principles
• Patient care setting
• Priorities, setting up for success
• Look, listen, feel….
• Motor
• Sensory
• Special tests
• Examining more than the spine…
• Hip-Spine Syndrome
 GENERAL PRINCIPLES
• PHYSICAL EXAM IS EXCEPTIONALLY CRITICAL IN IDENTIFYING SURGICAL VS.
NONSURGICAL PATHOLOGY IN SPINE
• NEUROLOGIC STATUS OFTEN DETERMINES INTERVENTION
• SYSTEMATIC APPROACH TO AVOID MISTAKES
• WHEN DOES YOUR EVALUATION START?
• BEFORE YOU WALK IN THE ROOM!
• WHEN DOES THE PHYSICAL EXAM START?
• WHEN YOU FIRST “SEE” THE PATIENT!
 GENERAL PRINCIPLES
• Setting of evaluation
• Special considerations depending on situation
• Trauma bay
• ER consult
• Inpatient consult
• Outpatient setting
• Paying careful attention to physical exam decreases risk of missed
injuries, delay to diagnosis, timely imaging, and improved accuracy
of diagnosis
 SPINE TRAUMA EVALUATION AND EXAM
• Considerations before you
step in the trauma bay
• High energy?
• MVC, fall of a ladder, etc..
• Low energy?
• Ground level fall? Step off a curb?
• Age
• Osteoporosis fracture risk?
• Pathologic fracture risk?
• Awake and Alert?
• Intubated or obtunded?
 SPINE TRAUMA EVALUATION AND
EXAM
• THINGS TO • Primary Survey
REMEMBER! • Airway
• ALWAYS START WITH • Breathing
ABC’S • Circulation
• BE PRESENT • Disability
FOR LOGROLL • Exposure
(IF POSSIBLE) • Secondary Survey
• IF NOT, THEN • Typically, when you come in…
REPEAT • Not to interfere with ABC’s
• “ER INTERN SAID
THE RECTAL WAS
FINE…”
• REPEAT WHEN
NECESSARY
 SPINE TRAUMA EVALUATION AND EXAM
• Phases of spine trauma physical exam

• 1) Inspection and palpation

• Identify other injuries
• Anterior
• Posterior- log roll (can be part of primary or
secondary survey)
• 2) Neurologic
• Motor
• Sensory
• Reflexes
 INSPECTION- ANTERIOR
• Start with head-to-toe
visual inspection
• Remove all clothes
• Head- Racoon Eyes, bleeding
from auditory meatus, etc
• Basal Skull fracture
• Neck- Cock-robin posture
• Atlantoaxial rotatory subluxation,
facet dislocation
• Chest
• Chest contusions
• Flail Chest
 INSPECTION- ANTERIOR
• Extremities
• Chest/ Abdomen • Limb Deformities/ injury
• ER position of hip, etc
• Seat belt sign
• Bruising/ Swelling
• Palpate all large joints
• Perineum/ Pelvis • If intubated, patient may withdraw
from pain
• Scrotal swelling • Gross movement/ muscle tone
• Vaginal bruising
• Every bruised, swollen or tender
extremity gets an Xray!
 INSPECTION- POSTERIOR
• Log Roll
• Inspect
• Bruising
• Open wounds
• Probe if necessary
• Palpate
• Spinous processes from skull
to sacrum
• Ribs, SI joints
• Be sure to have help to turn
• Maintain spine precautions
NEUROLOGIC
EXAM
• Motor

• Sensory

• Reflexes
 MOTOR EXAM- CERVICAL SPINE

• Stick to ASIA classification • C5- Elbow Flexors

for testing • C6- Wrist extensors
• C7- Elbow Extensor
• C8- Finger flexor
• Isolate muscle group for • T1- Finger abductors
exam
 MOTOR EXAM- LUMBAR SPINE

• Stick to ASIA classification • L2- HIP FLEXOR

for testing • L3- KNEE EXTENSION
• L4- ANKLE DORSIFLEXION
• Isolate muscle group for • L5- LONG TOE EXTENSOR (EHL)
exam • S1- ANKLE PLANTARFLEXION
 MOTOR EXAM- PEARLS & PITFALLS
• Test muscle in contracted
position

• Compare strength between

sides

• Test one extremity at a time,

write down the results
 MOTOR EXAM- PEARLS & PITFALLS
• For L2-
• isolate hip flexors by flexing
knee and testing in 90
degrees of hip flexion

• Weakness with straight leg

raise may not necessarily
indicate weak hip flexion
MOTOR EXAM- PEARLS & PITFALLS
• For C5-
• May also isolate and test
deltoid function
• Innervated by axillary nerve
which is almost purely C5
• Elbow flexion (biceps) has
some contribution from C6

Brown et al. 2011

 MOTOR EXAM- PEARLS & PITFALLS
• For S1-
• Frequently taught to evaluate by
plantarflexing ankle
• However, given the high cross-
sectional area of the GS complex,
it can be difficult to detect subtle
weakness
• Solution:
• Isolate Peroneus Longus (S1) by
placing your thumb on the plantar
surface of the first metatarsal
• Then, patient plantarflexes
MOTOR EXAM- MOTOR GRADE (ASIA)
• 5/5
• Active movement, full ROM against gravity, sufficient resistance
• 4/5
• Active movement, full ROM against gravity, moderate resistance
• 3/5
• Active movement, full ROM against gravity
• 2/5
• Active movement, full ROM with gravity eliminated
• 1/5
• Palpable or visible contraction
•0
• Total paralysis
NEUROLOGIC EXAM

• Motor

• Sensory

• Reflexes
 SENSORY EXAM- CERVICAL SPINE

• C5-
• Anterior lateral
shoulder
• C6-
• Dorsal Thumb
• C7-
• Dorsal MF
• C8-
• Dorsal 4/5th digit
• T1-
• Medial Forearm
 SENSORY EXAM- LUMBAR SPINE

• L2-
• Proximal medial thigh
• L3-
• Distal medial thigh
• L4-
• Medial ankle
• L5-
• 1st web space
• S1-
• Lateral ankle/ heel
SENSORY EXAM- SENSORY GRADING (ASIA)

•0
• Absent
•1
• Altered (decreased, impaired, or
hypersensitivity)
•2
• Normal
RECTAL EXAM (ASIA)

• Extremely important

• Helps determine cord injury

grade

• Dermatome is S4-5
 RECTAL EXAM (ASIA)
• Exam consists of:
• Sensation
• Light touch (LT)/ pin prick (PP)
• Deep anal pressure (DAP)
• Voluntary Anal Contraction (VAC)

• Grading/ Scoring
• If sensation (LT/ PP) or DAP or VAC are present=
Sacral sparing= incomplete cord injury
NEUROLOGIC EXAM

• Motor

• Sensory

• Reflexes
 REFLEXES

•Cervical •Lumbar

• C5- Bicep • L4- Patella

• C6- Brachioradialis • S1- Achilles

• C7- Tricep
REFLEXES- GRADING
•0
• Absent
• 1+
• Hyporeflexic
• 2+
• Normal
• 3+
• Hyperreflexic
• 4+/ CL
• Associated with Clonus
 UMN PATHOLOGIC REFLEXES
• Hoffman
• Clonus
• >3 beats
• Babinski
• Inverted radial reflex
• Finger flexion when test BR reflex
• Hyperreflexia
 OTHER PATIENT SETTINGS-
CONSIDERATIONS
• Non-trauma evaluation
• ER consult
• Inpatient consults
• Outpatient visits
• Gait analysis
• Walking aids (walker, cane, walking stick, etc)
• Trendelenburg gait- L5 palsy?
• Wide based- myelopathy?
• Flat back posture- claudication?
• Pitch-forward posture- Sagittal imbalance? Adult spinal deformity?
 CONSIDERATIONS: HIP-SPINE
SYNDROME
• Anterior Hip Capsule
• Branches of obturator and femoral
nerve

• Posterior Hip Capsule

• Branches from nerve to quadratus,
superior gluteal, and sciatic nerve
 HIP-SPINE SYNDROME- REFERRED
PAIN
HIP CAPSULE Innervation
• FEMORAL NERVE L2-4
• OBTURATOR NERVE- L2-L4
• SUPERIOR GLUTEAL NERVE L4-S1
• SCIATIC NERVE L4-S3
Extremity Cutaneous Nerve
Innervation
• Genitofemoral L1-L2
• LFCN L2-3
• Anterior FCN L2-L3
• Saphenous/ Medial Crural Nerve
L3-4
• Superficial Peroneal Nerve L4-S1
• Common Peroneal/ Lateral Sural
Nerve L4-S2
 HIP- SPINE SYNDROME: EXAM
• Every spine exam needs a hip exam!
• ROM
• Contractures?
• Pain with internal or external rotation?
• Stinchfield positive?
• Resisted active hip flexion at 30-45 deg
• Painful response may indicate intraarticular
hip pathology
• Positive findings? → GET HIP XRAYS!
• Consider diagnostic and therapeutic
intraarticular hip injection
 CONCLUSION

• PHYSICAL EXAM IS EXCEPTIONALLY CRITICAL IN

IDENTIFYING SURGICAL VS. NONSURGICAL
PATHOLOGY IN SPINE
• NEUROLOGIC STATUS OFTEN DETERMINES INTERVENTION
• SYSTEMATIC APPROACH TO AVOID MISTAKES
• WHEN DOES YOUR EVALUATION START?
• BEFORE YOU WALK IN THE ROOM!
• WHEN DOES THE PHYSICAL EXAM START?
• WHEN YOU FIRST “SEE” THE PATIENT!
PRACTICAL PROCEDURES:
SPLINTING
 INDICATIONS FOR SPLINTING

• ACUTE ARTHRITIS, INCLUDING ACUTE GOUT

• SEVERE CONTUSIONS AND ABRASIONS
• SKIN LACERATIONS THAT CROSS JOINTS
• TENDON LACERATIONS
• TENOSYNOVITIS
• PUNCTURE WOUNDS/BITES TO THE HANDS, FEET, AND JOINTS
• FRACTURES AND SPRAINS
• REDUCED JOINT DISLOCATIONS
 SPLINTING EQUIPMENT
• STOCKINETTE
• SPLINTING MATERIAL
• PLASTER OF PARIS (AT NMH)
• STRIPS OR ROLLS (2-, 3-, 4- OR 6-INCH WIDTHS)
• PREFABRICATED SPLINT ROLLS
• PLASTER
• FIBERGLASS WITH POLYPROPYLENE PADDING (AT CMH)

• PADDING (WEBRIL)
• ACE WRAP
• BUCKET/RECEPTACLE OF WARM WATER
• TRAUMA SHEERS
 PLASTER PREPARATION
• LENGTH: MEASURE OUT THE DRY SPLINT AT THE
EXTREMITY TO BE SPLINTED
• REMEMBER THE PLASTER SHRINKS SLIGHTLY WHEN
WET, IF TOO LONG, THE ENDS CAN BE FOLDED BACK
• USE PLASTER WIDTH THAT IS SLIGHTLY GREATER
THAN THE DIAMETER OF THE LIMB
• CAN BE MEASURED ON THE CONTRALATERAL
EXTREMITY TO AVOID EXCESSIVE MANIPULATION OF
THE INJURED EXTREMITY

• THICKNESS:
• UE: 8-10 LAYERS
• LE 10-12 LAYERS
LONG ARM POSTERIOR
POSTERIOR KNEE SPLINT
SPLINT
 FINGER SPLINTS
• BUDDY TAPE • ALUMINUM FINGER SPLINTS
• INDICATIONS: MINOR • PHALANX FRACTURES
FINGER SPRAINS • AFTER TENDON REPAIRS
 PRACTICAL PROCEDURES:
CERVICAL SPINE PRECAUTIONS
& CERVICAL COLLAR BASICS
 WHAT IS A CERVICAL COLLAR (C-
COLLAR)?

• A MEDICAL DEVICE WORN AROUND THE NECK TO SUPPORT AND

IMMOBILIZE THE CERVICAL SPINE
• ALSO KNOWN AS A “NECK BRACE”
• FREQUENTLY WORN AFTER TRAUMA, SURGERY, OR FOR ACUTE PAIN

EXAMPLES:
• SEMI-RIGID “TRAUMA” COLLAR
• INEXPENSIVE (~$10), COMMON, EASILY ADJUSTABLE
• COMMON BRAND NAMES: AMBU, LAERDAL

• CUSHIONED, SIZABLE CERVICAL COLLAR

• INCREASED COMFORT AND LOWER RISK OF SKIN BREAKDOWN WITH LONG-TERM WEAR,
MULTIPLE SIZES, COSTLIER (~$50-100)
• COMMON BRAND NAMES: ASPEN VISTA, OSSUR MIAMI J

• SOFT COLLAR
• NOT AN IMMOBILIZATION DEVICE
• FOR PATIENT COMFORT, AVOID LONG-TERM USE TO AVOID WORSENING STIFFNESS & MUSCLE
ATROPHY
 INITIAL CONSIDERATIONS FOR C-
COLLAR PLACEMENT
• TRAUMA
• NOT ROUTINELY RECOMMENDED FOR NEUROLOGICALLY INTACT PATIENTS WITH PENETRATING
TRAUMA
• CURRENTLY RECOMMENDED FOR SOME PATIENTS WITH BLUNT TRAUMATIC INJURY

• EMERGENCY MEDICAL SERVICES (EMS) WILL LIKELY PLACE A C-COLLAR +/- RIGID
BACKBOARD ON ANY PATIENT PRESENTING IMMEDIATELY AFTER A BLUNT
TRAUMATIC INJURY WITH SIGNIFICANT MECHANISM
• RIGID BACKBOARDS ARE FOR TRANSPORT ONLY AND SHOULD BE REMOVED ON ARRIVAL TO
THE ED
• CAUSE DISCOMFORT AND CAN LEAD TO SKIN BREAKDOWN FAIRLY QUICKLY IF NOT
REMOVED
• ADDITIONAL ITEMS ALSO USED BY EMS, SUCH AS TAPE AND BLOCKS AROUND THE HEAD AND
NECK, CAN BE ALSO BE REMOVED BY CLINICIANS IN ED
 INDICATIONS FOR C-COLLAR
PLACEMENT
• BEST PRACTICES AND INDICATIONS FOR C-COLLAR PLACEMENT ON INDIVIDUAL PATIENTS ARE DEBATED AND REQUIRE
BEST JUDGMENT BY A TRAINED CLINICIAN BASED ON THE CLINICAL SITUATION

• IN GENERAL, IF A C-COLLAR IS NOT PLACED IN THE FIELD OR A PATIENT IS BROUGHT IN BY PRIVATE VEHICLE, A CLINICIAN
SHOULD USE CLINICAL JUDGMENT AND CONSIDER APPLYING TO THE FOLLOWING PATIENT POPULATIONS:
• PATIENTS WITH A NEUROLOGIC DEFICIT ON EXAM
• PATIENTS SUFFERING FROM BLUNT TRAUMA AND WITH:
• UNSTABLE VITALS SIGNS
• ALTERED MENTAL STATUS (GCS ≤ 14)
• EVIDENCE OF FACIAL OR NECK INJURIES
• SIGNIFICANT NECK PAIN
• INABILITY TO COMPLETE NEUROLOGIC EXAM BASED ON PATIENT FACTORS (INTOXICATION, ALTERED MENTAL STATUS)
• ADVANCED AGE OR FRAILTY (AS DETERMINED BY PHYSICIAN DISCRETION)

• PATIENTS WHO ARRIVE AMBULATORY, NEUROLOGICALLY INTACT, WITHOUT C-COLLAR IN PLACE, OR THOSE WHO HAVE
DELAYED PRESENTATIONS AFTER TRAUMATIC INJURY ARE UNLIKELY TO BENEFIT FROM C-COLLAR PLACEMENT
TECHNIQUE FOR C-COLLAR PLACEMENT
 MOBILITY FOR A PATIENT WITH
SUSPECTED CERVICAL SPINE INJURY
• HAVE AT LEAST THREE PEOPLE AVAILABLE TO ASSIST

• INSTRUCT PATIENT NOT TO MOVE

• HAVE TRAINED CLINICIAN HOLD INLINE IMMOBILIZATION OF THE CERVICAL SPINE

• RECOMMENDATION: PERSON AT HEAD OF BED, WHO IS HOLDING INLINE STA BILIZATION,
SHOULD COUNT OUT LOUD (“1,2,3”) TO HELP COORDINATE SYNCHRONIZED LOG ROLL AND
PATIENT TRANSFER

• HAVE TWO ADDITIONAL CLINICIANS TURN THE PATIENT UTILIZING LOG ROLL
Log roll technique
TECHNIQUE
• HARD BACKBOARD CAN BE REMOVED WHEN PATIENT IS ON THEIR SIDE
• PATIENTS OFTEN FEEL LIKE THEY ARE “FALLING” WHEN BOARD IS REMOVED, WARN THEM OF
THIS AHEAD OF TIME
• DURING A TRAUMA WORKUP/SECONDARY SURVEY, THIS TECHNIQUE CAN BE U SED TO
FACILITATE EXAMINATION OF THE BACK AND PALPATION OF THE THORACIC AND LUMBAR SPINE

• PLACE PATIENT ON A FLEXIBLE BACKBOARD FOR TRANSFERS, REMOVE ONCE

TRANSFER IS COMPLETE

• RETURN PATIENT TO LYING POSITION WITH SYNCHRONIZED, SLOW LOWERING

• HEAD OF BED CAN AGAIN COUNT OUT LOAD TO COORDINATE THIS MOVEMENT
Transfer using backboard
 INLINE C-SPINE STABILIZATION DURING
INTUBATION
• THE FIRST STEP IN MANAGEMENT OF TRAUMA PATIENTS IS ASSESSING AND SECURING THEIR AIRWAY
• THIS MAY REQUIRE ENDOTRACHEAL INTUBATION

• STUDIES HAVE SHOWN THAT IT IS MORE DIFFICULT TO SUCCESSFULLY INTUBATE A PATIENT WEARING A
RIGID C-COLLAR
 Removal of the c-collar and manual in-line
stabilization (MILS) is recommended to increase
chance of successful intubation
 There are two most common techniques
 Both require a second clinician, who:
 Crouches next to the patient and intubating
clinician, holding the occiput on both sides of the
head
 Stands facing the intubating clinician, holding
forearms against the patient’s chest with fingers
extending to both sides of the head
 CERVICAL SPINE CLEARANCE AND C-
COLLAR REMOVAL
• HOW?
• USE CLINICAL DECISION RULES
• CANADIAN C-SPINE RULE
(CCR)
• NEXUS
• OBTAIN IMAGING, IF NECESSARY
• CT CERVICAL SPINE WITHOUT
CONTRAST
• IF POSITIVE IMAGING FINDINGS:
• REMAIN IN C-COLLAR WITH
PRECAUTIONS
• INVOLVE CONSULTANTS
• IF NEGATIVE IMAGING AND
RESOLVED PAIN:
• REMOVE C-COLLAR
C-COLLAR REMOVAL FOR PATIENT WITH
PERSISTENT PAIN
• PERSISTENT C-SPINE TENDERNESS AFTER NEGATIVE IMAGING IS A COMMON ISSUE IN TRAUMA PATIENTS
• ONE STUDY SUGGESTED A MAJORITY OF PATIENTS WITHOUT REPORTED HEAD OR NECK TRAUMA WILL HAVE MIDLINE
CERVICAL SPINE TENDERNESS

• RECOMMENDATIONS FOR MANAGEMENT IN THIS PATIENT POPULATION VARY, WITH THE MAJORITY OF
SOCIETIES SUGGESTING ONE OF THE FOLLOWING:
• OBTAIN MRI CERVICAL SPINE
• DISCHARGE PATIENT IN CERVICAL COLLAR AND SET UP FOLLOW-UP IN TWO WEEKS
• CLEAR CERVICAL SPINE AND REMOVE COLLAR IF NEGATIVE CT IMAGING, EVEN WITH PERSISTENT PAIN

• BECAUSE OF THE LACK OF CONSENSUS IN BEST CLINICAL PRACTICE, NEARLY EVERY TRAUMA CENTER HAS
GUIDELINES FOR MANAGEMENT OF THESE PATIENTS
• CLINICIANS SHOULD CONSULT THEIR INSTITUTIONAL GUIDELINES AND USE BEST CLINICAL JUDGMENT IN THIS
PATIENT POPULATION