PHYSICAL EXAMINATION THE SPINEOrthopaedic and Traumatology DepartmentMedical Faculty of Hasanuddin UniversityMakassar2015Supervisor :dr. Jainal Arifin, M.Kes, Sp.OT

Advisor : dr. Mervin O. Jakarmilenadr. Rico Alexanderdr. Zuwanda Then Text Book Reading January 2015

GENERAL INFORMATION33 Vertebrae:7 Cervical (lordosis)12 Thoracic (kyphosis)5 Lumbar (lordosis)5 Sacral fused (kyphosis)4 Coccygeal (fused)Source: Netters Concise Orthopaedic Anatomy, 2nd ed.ANATOMY OF SPINE

GENERAL INFORMATIONRoot exit spinal column via intervertebral foramenC1-7 : exit above their vertebraC8-L5 : exit below their vertebra (C7 exit above C7 vertebra and C8 exit below C7 vertebra)Medula spinalis end at L1 (Conus Medullaris)Lumbar and sacral nerve form cauda equina in spinal canal before exitSource: Netters Concise Orthopaedic Anatomy, 2nd ed.

DENIS SPINE COLUMNSAnterior : of anterior body of vertebra of discus vertebralisAnterior longitudinal ligamentMiddle : of posterior body of vertebra of discus vertebralisPosterior longitudinal ligamentPosterior : PediclesFacet jointLaminaSpinous processInterspinous, supraspinous ligamentLigamentum FlavumSource: Netters Concise Orthopaedic Anatomy, 2nd ed.; Review of Orthopaedics, 5th ed.

FACET JOINTThere are four facet joints associated with each vertebra. A pair that face upward and another pair that face downward. These interlock with the adjacent vertebrae and provide stability to the spine. The vertebrae are separated by intervertebral discs which act as cushions between the bones.Source: Review of Orthopaedics, 5th ed.

CERVICAL VERTEBRASource: Netters Concise Orthopaedic Anatomy, 2nd ed.

CERVICAL VERTEBRASource: Netters Concise Orthopaedic Anatomy, 2nd ed.

THORACAL VERTEBRASource: Netters Concise Orthopaedic Anatomy, 2nd ed.

LUMBAL VERTEBRASource: Netters Concise Orthopaedic Anatomy, 2nd ed.

SACRUM AND COCCYGEAL VERTEBRASource: Netters Concise Orthopaedic Anatomy, 2nd ed.

CORESPONDING STRUCTUREOF VERTEBRASource: Netters Concise Orthopaedic Anatomy, 2nd ed.

SPINAL CORDSource: Review of Orthopaedics, 5th ed.

CERVICAL EXAMINATION

SYMMETRY/ ASYMMETRYDEFORMITYTORTICOLISHEMATOMAINSPEKSI

TendernessTumor massPALPATIONSTEPS ONEPalpate the lateral aspects of the vertebraSTEPS TWOSTEPS THREEContinue palpation into the supraclavicular fossaSTEPS FOURExamine the anterior aspect of the neck

MOVEMENTSTEPS ONEFlexionAsk the patient to bend the head forwardSTEPS TWOExtensionAsk the patient to till the head backwardSTEPS THREEUsing a spatula in the clenched teeth as a pointer. Then ask the patient to flex the head forward. Normal range = 80

STEPS FOURAsk the patient to extend the head. Normal range = 50The total range in the flexion and extension planes should be assessed. Normal range = 130STEPS FIVELateral flexionAsk the patient to tilt his head on to his right shoruldeSTEPS SIXLaterral flexionFor accurancy, using a spatula as a pointer. Normal range = 45

STEPS SEVENIf lateral flexion cannot be carried out without forward flexion, this is indicative of pathology involving the atlantoaxial and atlanto-occipital joints.STEPS EIGHTRotationAsk to patient to look over the shoulder.STEPS NINERotationAgain a spatula use a pointer. Normal range = 80

SPECIAL TEST

THORACAL PHYSICAL EXAMINATION

INSPECTION

PALPATION

PERCUSSION

MOVEMENT

MOVEMENT FLEXIONSchobers method : a 10 cm length of lumbar spine is used as a base, where a 15 cm length of spine is employed. Begin by positioning a tape measure with the 10 cm mark level with the dimples of Venus (which mark the posterior superior iliac spines).

MOVEMENT FLEXIONAnchor the top of the tape with a finger and ask the patient to flex as far forward as he can.

MOVEMENT FLEXIONFlexion in the thoracic spine may be measured with the upper point 30 cm from the previous zero mark.

MOVEMENT EXTENTIONpatient arches his back, assisting him by steadying the pelvis and pulling back on the shoulder

MOVEMENT LATERAL FLEXIONmeasure the angle formed between a line drawn through T1, S1 and the vertical

MOVEMENT ROTATIONThe patient should be seated, and asked to twist round to each side. Rotation is measured between the plane of the shoulders and the pelvis. The normal maximum range is 40 and is almost entirely thoracic

SUSPECTED THORACIC CORD COMPRESSIONUse a blunt object such as the handle of a tendon hammer to stroke the skin in each paraumbilical skin quadrant. Failure of the umbilicus to twitch in the direction of the stimulated quadrant suggests cor compression on that side at the appropriate level

SUSPECTED THORACIC MOTOR ROOT DYSFUNCTIONBeevors signThe patient places his hands behind his head, flex his knees, and sit upSee the movement of the umbilicus to one side (and up or down) suggests that the abdominal muscles on that side are unopposed i.e. there is weakness on the opposite side

SUSPECTED ANKYLOSING SPONDYLITISCheck the patients chest expansion at the level of the 4thn interspaceLess than 2.5 cm is regarded as highly suggestive of ankylosing spondylitis

Lumbal Examination

LUMBAL PHYSICAL EXAMINATION

INSPECTION

PALPATION

PERCUSSION

MOVEMENTS

NEUROLOGICAL EXAMINATION(SENSORIC)

SENSORIC EXAMINATION

LIGHT TOUCH SENSATION All sensory testing is carried out with the patients eyes closed.For screening purposes, light touch can be tested by lightly stroking the patients skin with a soft object, such as a small paintbrush, a cotton wisp or a tissue. Normal sensation is established by comparison with sensation on the face, or another area with normal sensation, if sensation of the face is affected. Impaired sensation is any sensation that differs from that on the normal area.0 Absent1 Impaired2 NormalNT Not testableSource: The Orthopedic Physical Examination, 2nd edition

SHARP-DULL DISCRIMINATIONUsed to confirm the results of a light touch examination.In this case, the patient is asked to identify whether the area being examined is being touched with the sharp or dull end of a safety pin.In an area of diminished sensation, the patient has difficulty distinguishing between sharp and dull.Source: The Orthopedic Physical Examination, 2nd edition

TEMPERATURE SENSATION Ask the patient to distinguish between warm and coldWith the eyes closed, touch the skin with glass tubes of hot and cold water. Source: The Orthopedic Physical Examination, 2nd edition

PROPRIOCEPTIVE SENSATIONTo assess proprioception, the patient is instructed to close his eyes and the examiner grasps one of the patients fingers or toes.The examiner then alternately flexes and extends the digit several times, randomly stopping in flexion or extension.The patient should be able to identify whether the digit ends the maneuver in extension or flexion.Source: The Orthopedic Physical Examination, 2nd edition

VIBRATORY SENSATIONVibration sense can be tested using a tuning fork of 256 Hz over bony prominences such as the humeral epicondyles or the radial styloid.The examiner rests the base of the vibrating fork on the bony prominence and asks the patient to report when the vibration stops.The examiner then stops the vibration suddenly with the free hand.Normally, the patient identifies the cessation of vibration quite readily.Source: The Orthopedic Physical Examination, 2nd edition

PHYSICAL EXAMINATIONNEUROLOGICAL EXAMINATION(MOTORIC)

MOTORIC EXAMINATION

SCORINGTotal paralysis0Palpable or visible contraction1Active movement, gravity eleminated2Active movement, against gravity3Active movement, against some resistance4Active movement, against full resistance5Not testableNT

PHYSICAL EXAMINATIONNEUROLOGICAL EXAMINATION(PHYSIOLOGICAL REFLEX)

UPPER EXTREMITYBiceps reflexBrachioradialis reflexTriceps reflex

LOWER EXTREMITYPatellar tendon reflexSource: The Orthopedic Clinical Examination, 2nd edition Achilles tendon reflex

PHYSICAL EXAMINATIONNEUROLOGICAL EXAMINATION(PATHOLOGICAL REFLEX)

UPPER EXTREMITY

Hoffman-Tromner ReflexSource: AAOS Comprehensive Orthopaedics Review; Fundamental of Neurology

LOWER EXTREMITYBabinsky ReflexGordon ReflexOppenheim ReflexSource: Fundamental of Neurology

RECTAL EXAMINATIONThe coccyx is palpable through a rectal examination that is performed in combination with the examination for sphincter tone and sacral root defects, if necessary.Performed in all patients who have sustainedTraumatic injuryBowel or bladder dysfunctionKey elementAnal winkBulbocavernosus reflexSource: AAOS Comprehensive Orthopaedics Review

******Source?*Source?*Source lain?#This is done in a lateral decubitus position to reduce discomfort to the patient and is usually performed at the end of the examination*