Clinical Orthopaedic Examination

333 Pages·2010·88.61 MB·English

by  Ronald McRae

Clinical
Orthopaedic
Examination
Senior Commissioning Editor: Laurence Hunter
Development Editor: Sheila Black
Project Manager: Joannah Duncan
Designer: Kirsteen Wright
Clinical
Orthopaedic
Examination
Ronald McRae
FRCS(Eng, Glas) FChS(Hon) AIMBI,
Fellow of the British Orthopaedic Association
With original drawings by the author
SIXTH EDITION
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2010
An imprint of Elsevier Limited
© Longman Group Limited 1976, 1983
© Longman Group UK Limited 1990, assigned to Pearson Professional 1995
© Pearson Professional Limited 1997
© Elsevier Science Limited 2004
© 2010, Elsevier Limited. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing from
the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: [phone] (US) or
([phone] (UK); fax: [phone]; e-mail: [email protected]. You may also complete
your request on-line via the Elsevier website at http://www.elsevier.com/permissions.
ISBN 978-0-7020-3393-3
International Edition: 978-0-7020-3392-6
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Notice
Neither the Publisher nor the Author assumes any responsibility for any loss or injury and/or damage to persons or
property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating
practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method
of application for the patient.
The Publisher
The
Working together to grow
publisher’s
libraries in developing countries policy is to use
paper manufactured
from sustainable forests
www.elsevier.com | www.bookaid.org | www.sabre.org
Printed in China
CONTENTS
Preface vii
1. General principles in the examination of a patient with an orthopaedic
problem 1
2. Segmental and peripheral nerves of the limbs 11
3. The cervical spine 33
4. The shoulder 49
5. The elbow 75
6. The wrist 91
7. The hand 111
8. The thoracic and lumbar spine 131
9. The hip 169
10. The knee 205
11. The tibia 249
12. The ankle 259
13. The foot 275
Index 313
This page intentionally left blank
PREFACE
The ability to make a good clinical examination can lines of inspection, palpation, and the examination of
only be mastered by practice, and I have no doubt that movements and pertinent anatomical structures. In
the basic techniques are best learned by performance practice, this logical order is often altered by the
under supervision. Unfortunately, the size of student experienced examiner to avoid undue movement of the
classes in relation to teaching staff, and the not patient. It must be stressed that not all the tests
infrequent dearth of an adequate range of suitable described need be carried out routinely. Many are
clinical cases, makes this ideal difficult to achieve in performed only when a specific condition is suspected,
practice. Many students may acquire only a sketchy and it is assumed that this will be obvious to the reader.
knowledge of the techniques of examination, which In particular, in any joint assessment, it is necessary to
are fundamental to diagnosis and treatment. It is hoped discover if there is any restriction of movement. In
that this book may help to fill some of these inevitable many cases simple screening tests will suffice, and these
gaps until sound practice based on experience is are highlighted in most sections. The more detailed
achieved. examination and recording of movement are generally
reserved for cases under lengthy continuous observation
THE TEXT and for medico-legal work.
Radiographic examination plays an essential part
It is assumed that the value of good history-taking is
in the investigation of most orthopaedic cases, and to
appreciated and practised.
aid the inexperienced I have made some observations
Patients parade their complaints on an anatomical
regarding the views normally taken and how they
basis, and the text has been arranged accordingly. The
may be interpreted. Only a fraction of the possible
emphasis in each section is on the common rather than
pathology can be illustrated in a small work, but
the rare conditions to be found in the region. Although
I have concentrated on the common or informative.
this approach is open to criticism, it is nevertheless true
The spatial requirements of the captions have set
to say that although the obscure will tax the most
some restriction on their content; this discipline has
experienced, the most frequent mistake is a failure to
resulted in brevity at the expense, in places, of
diagnose the common. An encyclopaedic text,
completeness. Nevertheless, wherever possible I have
commendable on the ground of completeness, may
tried to show not only how each test should be carried
nevertheless often confuse, especially where no
out, but also its significance.
indication is given of the incidence of the conditions
I have taken the opportunity in this new sixth edition
observed. I have purposely avoided detail, and where
to update the text in a number of areas, and to include a
this is required a fuller orthopaedic textbook must be
number of new tests and methods of assessing overall
consulted. In some areas too I have made deliberate
limb function.
simplifications where a blight of terminology suggests
the independence of a number of conditions that cannot
be distinguished by symptomatology or investigation.
CONvENTIONs AND REfERENCEs
For clarity in illustrating the techniques of examination,
THE ILLusTRATIONs the patient and the examiner are shown in shades of
The illustrations dealing with the practical aspects of light and dark grey respectively.
clinical examination have been arranged in an Where two limbs are illustrated, the pathology is
essentially linear sequence following the traditional shown on the patient’s right side.
viii PREfACE
Where several conditions are described, and one 2. Kapandji A 1974 The physiology of the joints.
representative illustration only is given, it refers to the Churchill Livingstone, Edinburgh
first condition mentioned. 3. Lusted L B, Keats T E 1972 Atlas of roentgenographic
measurement. Year Book Medical Publishers, London
When joint movements are being considered, the
4. Boone C D, Azen P S 1979 Normal range of motion of
patient’s normal side should, if possible, be used for
joints in male subjects. J Bone Joint Surg 61A/5: 756–759
comparison. Angular measurement is an approximation,
and the figures quoted are in most cases values rounded
to the nearest 5° from figures published by the American AbbREvIATIONs
Academy of Orthopedic Surgeons,1 Kapandji,2 Lusted L & R = left and right
and Keats3 or Boone and Azen.4 L & M = lateral and medial
A & P = anterior and posterior
REfERENCEs
Ronald McRae
1. American Academy of Orthopedic Surgeons 1965 Joint
Gourock, 2010
motion: method of measuring and recording. Churchill
Livingstone, Edinburgh
1
ChaPTEr
1

General principles in the
examination of a patient with
an orthopaedic problem
Step 1: Inspection 2
Step 2: Palpation 3
Step 3: Movements 4
Step 4: Conduction of special tests 6
Step 5: Examination of radiographs 6
Step 6: Arranging further
investigations 7
Additional imaging techniques 8
Functional imaging techniques 8
Arthroscopy 9
Equipment requirements 9