SCRIPT FOR SHOULDER EXAMINATION

* Exposure – whole upper body

* Position – standing

1. Inspection
• Any splint, bandage, arm sling
• Anterior:
o Symmetrical
o Scar
o Swelling
o Muscle wasting – TRAPEZIUS, STERNOMASTOID, DELTOID, PECTORALIS MAJOR
o Contour of the shoulders are rounded
o The attitude of the upper limb
▪ Normal
▪ Int. @ Ext. rotated
▪ Elbow flexed
▪ Wrist @ fingers deformity
• Lateral
o Scar
o Swelling
o Muscle wasting – TRAPEZIUS, DELTOID, SUPRASPINATUS, INFRASPINATUS,
LATISMUS DORSI
o Sulcus sign – sublaxation of glenohumeral jt.
• Posterior
o Scar
o Swelling
o Muscle wasting – SUPRASPINATUS, INFRASPINATUS
o Winging scapula – serratus anterior (long thoracic nv.)

2. Palpation
• Temperature DDx shoulder pain
• Tenderness over the bone and joint line – examine both • Young – glenohumaral instability,
side simultaneously rotator cuff, impingement, frozen
− Sternal notch → SCJ → clavicle → ACJ → shoulder
acromion → Scapular spine → medial border → • Old – OA, impingement, rotator
angle → lateral border. cuff instability

3. Movement
i. Abduction
− ROM is full for both shoulders, which is 0 – 180
i. 0 – 30 : supraspinatus
ii. 30 – 120 : deltoid
iii. 120 – 180 : serratus anterior
− Painful arc (60 - 105) – impingement of supraspinatus
− Drop arm – rotator cuff tear
ii. Adduction: 0 – 15 – pectoralis major, latissimus dorsi, teres major
iii. Flexion: 0 – 180 – pectoralis major, ant. deltoid
iv. Extension: 0 – 70 – pectoralis major, latissimus dorsi, teres major
v. Internal rotation: 0 – 90 – subscapularis
vi. External rotation: 0 – 90 – teres minor & infraspinatus/
4. Special test
i. Shoulder instability
1. Anterior shoulder instability
• APPREHENSION & RELOCATION TEST
− Patient supine + flex shoulder 90 & elbow 90
− Hand on wrist & anterior of shoulder → ext. rotate hand → push
shoulder forward → body prominence?
− Push back into socket → further ext. rotate.
• ANT. DRAWER TEST
− Patient supine + shoulder abduct 80 → examiner’s index & middle
fingers on scapula spine + thumb on coracoid → push on spine →
laxity?
2. Inferior shoulder instability
• SULCUS SIGN
− Adduct hand
− Pull hand → sulcus under lateral acromion?
3. Posterior shoulder instability
• POST. DRAWER TEST
− Patient supine + shoulder abduct 80 → examiner’s index & middle
fingers on scapula spine + thumb on coracoid → push on coracoid →
laxity?
ii. Rotator Cuff
1. Supraspinatus
• JOBE’S TEST
− Abduct 30 + flex 90 + thumb pointing downwards → resist
examiner’s downwards force
• DROP ARM
− Done during abduction
2. Infraspinatus & Teres minor
• EXT. ROTATION LAG SIGN
− Elbow flex 90 → ext. rotate against examiner’s resistance
3. Subscapularis
• GERBER LIFT OFF TEST
− Int. rotate 90 + elbow flex 90 + hand dorsum on back → examiner
apply resistance on palm → ask patient to lift the hand
• NAPOLEON BELLY PRESS TEST
− Put palm on stomach → press belly as hard as possible → no int.
rotation of shoulder?
4. Rotator cuff tendon impingement
• HAWKIN TEST
− Passive test
− Examiner’s hand on humerus & wrist → shoulder flex 90 + elbow
flex 90 → int. rotate → pain?
• NEER’S TEST
− Passive test
− Examiner’s hand on post. shoulder & elbow → shoulder flex 90 →
int. rotate → flex 180 → pain?
− To confirm: inject Lignocaine 10mg → repeat Neer’s test
• PAINFUL ARC
− Done during abduction
 iii. Labrum Tear – Slap Lesion
• O’ BRIEN TEST
− Shoulder flex 90 + adduct 15 + thumb down → resist downward
force on arm → pain @ painful clicking? → thumb up → resist
downward force on arm → pain decreased or gone?
iv. Biceps – Biceps Tendinitis
• SPEED’S TEST
− Shoulder flex 90 + elbow extend + hand supine → resist downward
force → pain in bicipital groove?
v. Deltoid – Brachial plexus injury causing deltoid weakness
• TELESCOPING TEST
− Passive test
− Patient supine + shoulder at the edge / sitting / standing
− Examiner stabilize shoulder + hold mid-arm → push towards & away
from acromion → shoulder sublaxation?

I would like to complete my examination with neurovascular examination

Flow: Sulcus sign → Apprehension test → Hawkin’s test → Neer sign → Gaber lift off test→ Jobe
empty can test → External rotation lag sign

Exam Technique Clinical application

Special test
Glenohumeral Instability
Apprehension test -passive Throwing position. Abduct, Anterior instability
external rotated, full extent passive
flexion
Sulcus Pull down on adducted arm Sulcus under lateral acromion
indicates inferior instability
Rotator cuff
Neer’s sign –passive Empty can position (internal Pain indicates impingement
rotation) , tgn straight, passive FF syndrome
>900
Hawkins test-passive FF 900 then IR
Jobe empty can Pronate arm resisted FF in scapular Pain / weakness indicates rotator
plane cuff (supraspinatus) tear
Drop arm Abduction..then drop slowly Supraspinatus tear
Belly press(Napolean) Hand on belly, push toward belly Subscapularis tear
(pilih la salah satu test)
Gaber Lift off test Hand behind back, resist
External rotation lag sign External rotate first...resist Infraspinatus and teres minor
Biceps/ superior arm
Speed’s test Resisted flexion in scapular spine Pain indicates biceps lesion/
tendinitis
Other test
Spurling’s test Lateral flex/ axially compress neck Reproduction of symptoms indicates
cervical neck pathology

Mr Ash
1. Kill 3 birds with 1 stone
Mase abduction :-
• ROM
• Painful arc syndrome
• Drop arm sign
• scapulot-horacic motion
2. Neer’s test :- to confirm after positive Neer sign..so cmne? Kne inject lignocaine 10ml..then repeat Neer’
sign..patient may not fell pain anymore.
3. Tgk muke patient!
4. Ntok lebih smooth, follow this flow :-
- Sulcus sign → Apprehension test → Hawkin’s test → Neer sign → Gaber lift off test → Jobe empty can test
→ External rotation lag sign
5. for inspection, 3s + 1m (skin changes, swelling, scar, muscle wasting
 SCRIPT FOR HAND EXAMINATION
* Exposure – hand to shoulder
* Position – siting & hand on pillow

1. Inspection
• Palmar
− Pink / pallor / cyanosed
− Erythema
− Dupuytren contracture
− Scar
− Swelling
− Muscle wasting
1. THENAR EMINENCE – median nv.
a. FLEXOR POLICIS BREVIS
b. ABD. POLICIS BREVIS
c. OPPONEN POLICIS
2. HYPOTHENAR EMINENCE – ulnar nv.
a. FLEXOR DIGITI MINIMI BREVIS
b. ABD. DIGITI MINIMI
• Dorsal
− Scar
− Swelling
− Nail – normal / clubbing / brittle / koilonychias
− Muscle wasting (guttering) – ulnar nv.
a. DORSAL INTEROSSSEI
b. ABD. DIGITI MINIMI
• Deformity
− MEDIAN NV.
1. Benediction sign – 1st & 2nd FDP + 1st & 2nd LUMBRICALS
2. Ape hand – OPPONEN POLICIS + ABD. POLICIS
− ULNAR NV.
1. Claw hand – LUMRICALS
− RADIAL NV.
1. Wrist drop – ECRL + ECRB + ED + EDM
2. Finger drop (POST. INTEROSSEOUS NV.) - ED + EDM
− Osteoarthritis
1. Heberden’s nodes
2. Bouchard’s nodes
− Rheumatoid Arthritis
1. Swan neck deformity
2. Boutonier deformity
− Mallet fingers
• Cascade Sign – all fingers towards scaphoid – fracture of phalanx @ metacarpal
• OK Signs:
− Thumb against index – OP, FPB, 1st LUMB, 1ST FDS, 1ST FDP – median nv.
− Abduction 3 medial fingers – PALMAR INTEROSSEI – ulnar nv.
− Extend wrist – ECU, ECRL, ECRB – radial nv.
2. Palpation
• Temperature
• Bone & joint tenderness
• Palmar thickening – Dupuytren’s contracture
• Radial pulse
• Sensation:
− MEDIAN NV. (lateral 3½ of palm) –
index finger
− ULNAR NV. (medial 1½ of palm &
dorsal) – little finger
− RADIAL NV. (lateral 3½ of dorsal) –
anatomical snuffbox

3. Movement
• Make a fist → open fist → extend wrist → flex wrist → pronate → supinate
• MEDIAN NERVE
1. OK sign with resistance
• OPPONEN POLICIS
• FLEXOR POLICIS
• LUMBRICALS 1 & 2 (MCP)
• FDS (PIP)
• FDP 1 & 2 (DIP)
2. ABDUCTOR POLICIS – pen test with resistance
3. PRONATOR TERES – hold patient hand → pronate with resistance
4. CARPAL TUNNEL SYND. – Durcan Compression Test / Phalen Test / Tinel sign
• ULNAR NERVE
1. ADDUCTOR POLICIS – Froment’s Sign (use flexion to resist withdrawal of paper)
2. PALMAR INTEROSSEI – finger adduction with withdrawal of paper
3. DORSAL INTEROSSEI – finger abduction
4. LUMBRICAL 3 & 4 – flex MCP with resistance
5. FDP – flex DIP with resistance
6. FDMB – flex MCP little finger
7. ABDUCTOR DIGITI MINIMI – oppose with examiner little finger
8. FCU – flex wrist
• RADIAL NERVE
1. ECU, ECRL, ECRB – hold radius → extend wrist
2. ED, EDM – hold metacarpals → extend finger
3. SUPINATOR – hold patient → supine with resistance
4. BRACHIORADIALIS – midprone, flex forearm, with resistance
5. TRICEPS – extend forearm with resistance
HAND AND PERIPHERAL NERVES EXAMINATIONS
Introduce.

Suruh pt bukak baju. Kalau pompuan, “for patient’s modesty, the chest downwards is covered”
Letak tgn atas bantal. Duduk tepi katil.

LOOK
On inspection of the dorsal aspect of the hand, there is no scar, no swelling, no skin changes, no
muscle wasting, no deformity, and no finger clubbing.
On inspection of the palmar aspect of the hand, there is no muscle wasting of the thenar and
hypothenar muscles, no scar, no swelling, no skin changes.

FEEL
The temperature is normal.
All bones and joints are non-tender.

MOVE
The patient is able to make a fist and open the fist, flex and extend the wrist and is able to pronate
and supinate, with full range of motion.

SCREENING
Ok sign (AIN of median nerve), extend medial 3 fingers (ulnar nerve), extend wrist (radial n), raise
forearm.
Klu prof masbah- power grip

MEDIAN N (palsy- benediction sign, ape thumb)

Pronator teres- salam pt, pronate with resistance
Lumbricals- flex MCP, extend IP (dh check masa buat fist)
Opponens pollicis (OK sign, try resist)
Abductor pollicis (pen test, try resist jugak)
Flexor pollicis
Carpal tunnel syndrome - durcan compression test (most preferred), phalen test - inverted prayer,
tinel sign - tap from distal part of index finger upwards
Sensory - tip of index finger
The motor innervation to pronator teres, LOAF are intact. Durcan compression test, phalen test and
tinel sign are negative. The sensory innervation of med n is intact

ULNAR N (partial claw hand) FCU-flex wrist

FDS- flex MCP
FDP-flex DIP
Adductor pollicis-Froment’s test. Put a piece of paper between the thumb and index finger, ask
patient tor esist withdrawal of paper. If the innervation is not intact, it will be compensated by the
flexion of thumb by flexor pollicis?
Palmar interossei- finger adduction (PAD). Ask patient to resist withdrawal of paper
Abductor digiti minimi
Sensory- ujung little finger The motor innervation to FCU, FDP, FDS, add pollicis, palmar
interossei, abd digiti minimi are intact. Froment’s test is negative. The sensory innervation of ulnar n
is intact
**Ulnar paradox: in a high lesion of ulnar n (elbow), the partial claw hand will be less prominent, as the lat part
of FDP is denervated.
**In lower lesion (wrist), the partial claw hand is more prominent as the FDP is still intact and flex the IP joints.
RADIAL N (wrist drop, finger drop)
Triceps-extend forearm, resist
Brachioradialis – in midprone position, flex forearm, resist
Supinator – slm patient, suruh supinate, resist
ECRL, ECRB, ED, EI,EDM,ECU – extend elbow, extend fingers. Look for wrist drop finger drop
Sensory- 1st web space, prof masbah:anatomical snuff box
Motor and sensory innervation of radial n is intact
 SCRIPT FOR HIP EXAMINATION
* Exposure – groin to toes

1. Inspection – eye level on hip

• *standing
• Walking aids – walking sticks/crutches/wheel chair
• Anterior
− Attitude – normal and symmetrical / int. @ ext. rotated
− Scar
− Swelling
− Muscle wasting – THIGH MUSCLES
− Bone deformity
− Pelvic tilt.
• Lateral hip
− Scar
− Deformity
− Lumbar lordosis – normal / increase / loss of
• Post hip
− Scar
− Swelling
− Symmetrical shoulder
− Spine is straight – no scoliosis
− Gluteal folds are symmetrical
− Muscle wasting – GLUTEAL MUSCLES
• GAIT – ask patient to walk 5 steps & U-turn & another 5 steps
− Normal
− Antalgic – short stance phase
− Trendelenburg – hip abductor defect, hip dislocation, coxa vara
− Short limb
− High stepping – extensors of foot & ankle defect
− Shuffling – UMNL / extrapyramidal dis.
− broadbase
• TRENDELENBURG TEST
− Hip abductors – gluteus medius/minimus
− Examiner behind → put hand on ASIS → ask patient lift 1 foot & change → pelvic
tilt to normal side + shoulder sag on the affected side?
− SOUND SIDE SAG = while standing on affected limb, the opposite pelvis and
shoulder sag, trunk swings towards opposite site

2. Palpation
• *supine
• Temperature
• Bony tenderness – ASIS, GT, PSIS & lateral femoral condyle
• If muscle atrophy of quadriceps, measure
• Length
*** square pelvis (put hand on ASIS bilat. perpendicular to trunk place lower
limb symmetrically)
***tanda di xiphi, ASIS, GT, medial jt line, medial maleolus
***apparent length : xperlu square pelvic, measure from xiphi med.
maleolus
 ***true length : square pelvis, measure ASIS med. maleolus
− APPARENT LENGTH
• Measure xiphi → medial malleolus → both sides → compare
− TRUE LENGTH
• Need to square pelvis 1st
- Identify & mark: xiphi, ASIS, GT, medial malleolus
- Put forearm on both ASIS → move legs until perpendicular with
bed-edge
• Measure ASIS → medial malleolus
• +ve shortening →
- ALLIS TEST / GALEAZZI SIGN
- Flex knee → put paper on tibial tuberosity → femoral
condyle
1. Femoral condyle difference – below knee
shortening
2. Tibial tuberosity difference – above knee
shortening
- BRYANT’S TRIANGLE
- Compare base of line between ASIS to GT
- Fracture of neck of femur
- Fracture of head of femur
- Severe OA
- AVN

3. Movement
• THOMAS TEST – fixed flexion deformity
− Put hand under patient’s back → flex hip & knee until lumbar lordosis
obliterated → any flexion on the other hip? Try to correct flexion. Measure
flexion if fixed.
• Range of Movement
− Flexion: 0 – 140 – iliopsoas
− Internal rotation: 0 – 30 – gluteus medius & minimus
− External rotation: 0 – 60 – obturator externus, internus, gluteus maximus
− Abduction: 0 – 40 (square pelvis) – gluteus medius & minimus
− Adduction: 0 – 20 (square pelvis) – adductor longus, brevis, magnus
− Extension: 0 – 15 (in prone/lateral position) – hamstrings, gluteus maximus
• PATRICK TEST (FABER)
− Flex + abduct + external rotate → press on opposite ASIS & knee (figure of four)
→ pain?
− AVN
− Inflammation on hip joint

I would like to complete my examination by doing neurovascular examination

The limb is not ischemic
There’s no hypothermia
The sensation is normal
There’s no foot drop
Gallezi’s test Flex knee both, sole of foot flat on bed, obeserve patella of both lower limb.

In below knee shortening, the affected limb, patella will be lower than normal

Bryant’s triangle Draw vertical line from ASIS , then a perpendicular line from GT

Distance between GT to the 1st line = base of bryant’s triangle

Compare both limb

Thomas test Put hand below lumbar lordosis, flex hip and knee of normal LL until lumbar lordosis is obliterated

Observe if other LL flex too

 SCRIPT FOR KNEE EXAMINATION

* Exposure – whole lower limb

1. Inspection
• Walking aids - crutches/ walking sticks/crutches/wheel chair
• Anterior
− Scar
− Swelling
− Muscle wasting – QUADRICEPS
− Attitude – normal & symmetrical / Valgus / Varus deformity
− Erythema/laceration
• Lateral knee
− Scar
− Swelling
− Attitude – normal / flexion
− Genu recurvatum – OA
• Posterior
− Scar
− Swelling
− Muscle wasting – GLUTEAL MUSCLES, HAMSTRING AND CALF MUSCLE
• Walk 5 steps forwards → U turn → 5 steps
− Gait is normal.
• Patella
− *sitting at edge of bed
− There’s no J and reverse J – sublaxation / dislocation of patella (injury of med.
Patella-femoral ligament)
• Med. / lat. parapatellar gutter
− *supine
− loss → swelling

2. Palpation
• *lie on bed
• Temperature
• If there is muscle wasting – measure circumference from femoral condyle – compare
• PATELLA TEST:
− Patellar effusion
1. PATELLAR TAP – gross swelling
- Push fluid into patella superior & inferiorly → tap on patella →
bouncing?
2. PATELLA FLUID SHIFT – smaller amount
- Fix knee inferiorly → empty lat. knee joint → use thumb to
empty lat. parapatellar gutter → bulging in med. gutter?
− Patellofemoral OA – PATELLA GRINDING TEST
- Grind patella against intracondyle groove of femur → pain?
− Synovitis – PATELLA LIFT OFF TEST
 • Tenderness
− Palpate lat. & med. patella facet
− Bone & knee joint tenderness - Flex 90 + sit on patient’s foot
Tibial tuberosity → medial joint line → medial collateral lig. → postero-
medial joint space
Lateral joint line → lat. collateral lig. → postero-lateral joint space
Patella tendon → patella bone → quadriceps tendon → hamstring tendon
• Posterior sagging
− Knee flexed 90
− Look from side → height of tibial tuberosity

3. Movement
• Flexion – 0 – 160 – hamstrings muscle
− Drag heel to buttock
• Extension – 0 – quadriceps
− Flex hip + extend knee
− Hyperextension? →
Any hyperextension on lifting leg? → Record (Mr. Ron)
Leg on bed → fix femur → lift the foot → N: -5 (Mr. Ash)

4. SPECIAL TEST
• COLLATERAL LIG.
− VAGUS & VALGUS STRESS TEST – extend knee / flex 30
1. Varus ST: outward pressure on thigh + inward pressure on med.
malleolus → widening of lat. gap / pain → lat. collateral lig. laxity
2. Valgus ST: inward pressure on thigh + outward pressure on med.
malleolus → widening of med. gap / pain → med. collateral lig. laxity
• CRUCIATE LIG.
− LACHMANN’S TEST
Flex 30 + put knee on examiner’s thigh → stabilize femur with 1 hand → pull
tibia anteriorly with other hand + thumb at med. joint line → Ant. CL laxity
− DRAWER TEST
Flex 90 + sit on patient’s foot → thumb at tibial tuberosity + at med. joint
line → relax hamstring
1. → pull tibia → ACL injury
2. → push tibia → PCL injury
• MENISCUS
− MCMURRAY’S TEST
Flex knee fully → 1 hand at foot + 1 at knee
→ Ext. rotate → slowly extend → click sound / pain → med. meniscus injury
→ Int. rotate → slowly extend → click sound / pain → lat. meniscus injury

I would like to complete my examination with neurovascular examination

SCRIPT FOR KNEE EXAMINATION

Assalamualaikum encik/puan/cik, saya pelajar perubatan usim. Hari ni, sy nak periksa bahagian lutut. Boleh angkat kain
(buat cawat)? Boleh berdiri?

Inspection

Walking aids - crutches/ walking sticks/crutches/wheel chair

On inspection of the ant knee, the knee is symmetrical, there’s no valgus and varus deformity, no scar, no erythema, no
laceration, no swelling, no ms wasting (quads m).
On inspection of lateral knee, the attitude is normal, there’s no genu recurvatum, no flexion and no scar.
On inspection of post knee, there’s no gluteal hamstring and calf wasting and no swelling at popliteal fossa, no hindfoot
valgus

**Encik/puan/cik boleh jalan 5 langkah ke hadapan, kemudian pusing balik?

The gait is normal.

** sitting at edge of bed

There’s no J and reverse J. (no dislocation of patella)

** Encik/puan/cik boleh baring x? Saya sentuh kat sini ada sakit tak puan?

Palpation
The temperature is normal and there’s no fullness of the med/lat gutter. The patella fluid shift/ tap is negative.

** Encik/puan/cik boleh bengkok kaki? Check presence of posterior sagging. Then palpate………...-->

There’s no tenderness and no popliteal fossa swelling.

There’s no post sagging

Movement
**Encik boleh luruskan kaki dan bengkokkan sampai habis?
The active and passive flexion (0-170) and extension (0) are full and there’s no crepitus can be felt.

Special test
**Saya duduk atas kaki ye, minta maaf (lapik kaki dgn selimut)

The ant and post drawer tests are (-)ve

The lachman test is (-)ve
The varus and valgus stress tests are (-)ve
The Mcmurray test for both medial and lateral meniscus are (-)ve

***I would like to complete my examination with neurovascular examination

McMurray (meniscus) Med meniscus : palpate med jt line → grap heel → ext rotate →flex knee
Lat meniscus : palpate lat jt line → grap heel → int rotate →flex knee
Lachman (ACL) Flex 30, stabilize femur, grap femur with hand, tibial on the other hand, pull upwards
to displace tibia and femur
Varus and valgus Varus (outward force at knee), valgus (inward force at knee)
2 position
-full extension
-30 degree
 NEUROVASCULAR EXAMINATION OF LOWER LIMB

NEUROLOGICAL EXAMINATION:
1. INSPECTION
• Scar
• Swelling
• Fasciculation – tap over quadriceps & ant. tibia

2. MOTOR SYSTEM
i. TONE – normal, hypotonia, hypertonia, atonia
− Ask patient to relax
− Test at:
1. Knee joint: flex & extend
2. Ankle joint: flex & extend
3. Roll patient’s leg
ii. POWER (0 – 5)
− Test at:
1. Hip: flex (L2), extend (L5), abduct (L2), abduct
2. Knee: extend (L3), flex (L5) – hyporeflexia - cerebellar sign
3. Ankle: dorsiflex (L4), plantar flex (S1)
4. Big toe: dorsiflex (L5), plantar flex (L5)
iii. REFLEXES – normal, hyperreflexia, hyporeflexia, areflexia
− Test at:
1. Knee jerk (L3) – put patient’s knee on hand
2. Ankle jerk (S1) – flex knee to lateral → force dorsiflex → hit on Achilles’
tendon.
*if absent: Jurisick’s manoeuvre: clench teeth + clasped hands
3. Babinski reflex – N: down going
Up going – UMNL
iv. CLONUS – UMNL, cerebellar sign
− Flex knee to lateral → passively dorsiflex & plantar-flex ankle → end with
dorsiflex → watch for flattening of gastrocnemius

2. SENSORY
i. Pin prick – compare with forehead / sternum + close eyes
− L2 – middle of medial thigh
− L3 – medial to patella
− L4 – on medial malleolus
− L5 – between 1st & 2nd metatarsal
− S1 – behind lateral malleolus

VASCULAR EXAMINATION:
1. Check pulses:
i. Dorsalis Pedis Artery – distal to navicular bone
ii. Post. Tibialis Artery – between medial malleolus & Achilles’ tendon
iii. Popliteal Artery – ask patient to go relax muscle → grab knee with both hand → flex
knee → palpate popliteal fossa with fingers
− Difficult in obese & muscular patients
 SCRIPT X-RAY

• This is an AP / lateral / oblique (view) radiograph...

• Of right humerus / right elbow joint / right humerus and elbow joint (bone/joint/bone+joint)
** principle of xray. One joint above and one joint below
• Belongs to (name pt), taken on (date)

• The xray shows complete / incomplete # (extent of #),

• Spiral / oblique / transverse / comminuted # (pattern of #)
• of proximal or distal 1/3 / midshaft (part of bone affected)
• of right humerus (bone) How to comment x-ray post reduction?

On AP view, comment,
• With
o Angulation – post. / ant. / med. / lat. 1-radial height
o Displacement – med. / lat. / proximal / distal
2-angulation of radius
o Shortening
On lateral view,
- for pelvic xray – mention about Shenton’s line
1-wrist jt, ade dorsal/volar tilt?
o Disrupted or not?
o Disruption usually seen in #NOF and DDH.

Shenton's line is an imaginary line drawn along the inferior border of the
superior pubic ramus (superior border of the obturator foramen) and along
the inferomedial border of the neck of femur. This line should be
continuous and smooth.
 SCRIPT FOR EXTERNAL FIXATOR

- General inspection.

- Patient is on ext. fixator,

- On left leg
- with 3 schanz pin
- one inserted at calcaneum, the other 2 are inserted at tibia,
- The pins are attached to 2 tubular rods, 6 elements and 1 plane.

• What are the indications?

o Open #
o Closed fracture with severe soft tissue injury
o Infected #
o Infected non-union
o Multiple # / segmental # (for temporary fix, for acute setting)
o Bone lengthening
o Compartment syndrome after fasciotomy

• What are the complications?

o EARLY
▪ Injuries to soft tissues (muscle, tendons, nerve & vessels)
o LATE
▪ Pin infection
▪ Osteomyelitis
▪ Pin loosening (d/t local mechanical overload)
▪ Non-union of #
▪ Dt disuse:
• Muscle atrophy
• Stiffness in on joint
• Disuse osteopenia

• How to manage patient with EF?

o Daily pin site dressing to make wound clean
o Monitor union of # by serial x-ray
o Check neurovascular (movement/sensation)
o Monitor vital signs (temperature/pain)
 SCRIPT FOR SKIN TRACTION

- Patient is on skin traction

- At the left leg,
- With bandage extending up to mid-thigh,
- Attach to 3 kg weight with pulley,
- Supported by foot cradle / buck’s traction/ perkin’s traction
- So, it is a balanced traction.

• Use of traction?
o Relieve pain
o Muscle relaxation
o Bone alignment
o Temporary management to help surgeon in definitive management

• What are the indications?

o Temporary management of NOF #
o Management # of femur shaft
o Undisplaced # of acetabulum
o After reduction of hip dislocation
o Definitive treatment for paediatrics

• Contraindications?
o Abrasion
o Laceration
o Allergy to plaster
o Impaired circulation
o Deformity of tibia
o Skin diseases

• What are the complication?

o Allergic to plaster
o Excoriation of skin
o Pressure sore
o Peroneal nerve palsy

• Two types:
o adhesive (be cautious to use adhesive in elderly – skin very fragile)
o non-adhesive
 SCRIPT FOR SKELETAL TRACTION

- Patient is on skeletal traction

- At the left leg
- With tibia pin
- Attached to 5 kg weight with pulley.
- So, it is a balanced pulley.

• Sites :
o Femoral condyle
o Tibial tubercle
o Lower tibia
o Calcaneum
o Olecranon
o Metacarpals

• What are the indications?

o Strong traction is required – obese
o Skin traction is not possible (contraindicated eg. In open #)

• What are the complications?

o EARLY
▪ Nerve / vascular injury
o LATE
▪ Pin tract infection
▪ Loosening of pin wire
▪ Osteomyelitis
▪ Pain and failure of traction – d/t incorrect placement of pin
▪ Distraction at the # site when large traction force is applied
▪ Damage to epiphyseal growth plate if applied to children

• Daily care
o Change sterile dressing
o Avoid movement
o Inspect stir-up & weight
o Check circulation of distal limb
 WOUND EXAMINATION

1. INSPECTION
• Site
• Size – measure
• Shape
• Clean/contaminated
• Edges – granulated, macerated, clean, rolled
• Margin – well-defined, poorly defined
• Exposed structures – bone, tendon
• Presence of foreign bodies
• Blood – oozing, spurting
• Discharge
• Surrounding skin
− Normal skin
− Erythematous
− Bruising
− Skin peeling
− Hyper-pigmented
− Hypo-pigmented
• Distal to ulcer – pale, cyanosis?

2. PALPATION
• Temperature around wound
• Tenderness around wound
• Distal neurovascular status
− Vascular: pulses & CRT
− Neuro: sensation & motor function
 LUMPS EXAMINATION

1. INSPECTION
• Site
• Size
• Shape
• Contour – regular, lobulated
• Colour of skin – red, hyper-pigmented, hypo-pigmented
• Abnormalities on skin – skin peeling, scar
• Pulsation

2. PALPATION
• Temperature
• Tenderness on lump & surrounding skin
• Measure size
• Surface – smooth, lobulated
• Consistency – soft, firm, hard, rubbery
• Fluctuation
• Thrill/pulsation
• Can get above / below (mass from bone)

3. MOVE
• Mobile/ immobile – move lump vertical & horizontally
• Pinch skin over – attach to skin
• Ask patient to move muscle at the area
− Mobile – attach to muscle
− Become less obvious – below muscle
− Become more obvious – above muscle

4. SPECIAL TEST
• Trans-illumination – if suspect fluid (must use black paper)
• Auscultation – if suspect present of bruit

5. REGIONAL LYMPH NODES

• Palpate main lymph nodes according to its drainage