Clin Ortho Practical 2 - Wrist thoracic lumbar pelvis

Froment's Test:

"take the paper FROM ME" 1. Patient sitting to the side of the table. With the medial aspect of forearm on the table and the thumb up. 2. Doctor sitting opposite the patient on the other side of the table with a piece of paper for the patient to hold on to. 3. Doctor instructs the patient to pinch the paper between their thumb and the lateral aspect of their index finger tightly. 4. The doctor tells the patient to hold tightly and do not let me pull the paper away. 5. Wait for a response from the patient. 6. Repeat and compare with the involved side.

Abnormal finding of watson

* For abnormal finding, sensation you would feel would be a "clunking" which could be due to a fracture, dislocation, or weak integrity of the scapholunate ligament. Normally shouldn't have a shift or jerk to it, should be nice and smooth pattern.

What is the purpose of adam's test?

* You want to note any distortions that were seen originally in an upright postural exam and see if there's any changes or if they go away after this exam. This allows for differentiation between what is functional and what is structural.

What is the purpose of the carpal compression test?

*Looks for median nerve entrapment at the carpal tunnel. This would involve loss of sensation or possible tingling at the thumb, index finger, and possibly the middle finger as well.

What are the alternative names for Fajersztajn's?

- crossed or contralateral straight leg raise - well leg raising test

What are the alternative names for Bechterew

- sitting SLR - sitting lasegue

In schelpelmann's sign, what does concavity/ convexity indicate?

-side of *concavity* indicates intercostal neuralgia or neuritis (pins, needles, numbness, tingling) -side of *convexity* is myofascial issue from the pull and strain of opposing muscles

Adam's Test

1. Have the patient standing looking straight ahead with their feet together. 2. Doctor stands behind the patient observing their posture and any asymmetries of the spine. 3. Doctor then has the patient put their hands together and bend forward (arms hanging and head down) as far as they can. Making sure that the knees remain locked in extension. 4. Doctor observes any changes from the up-right position. 5. Doctor then has the patient rise slowly having the patient stop at intervals to objectify any spinal distortions (scoliometer).

Bonnet's

1. Have the patient supine on the table. 2. Doctor stands on the side of the leg being raised. Uninvolved first. 3. Doctor then places their hand under the ankle of the leg to be lifted. The other hand is making sure that the knee remains locked in extension. 4. Doctor slowly & passively lifts the patient's leg until symptoms are reproduced or exacerbated. Not to exceed 90°. 5. If no response or only a mild response is noted then the doctor internally rotates to the entire leg. 6. If no response or only a mild response is noted then the doctor adds cross body adduction to the entire leg. 7. Repeat on involved side. 8. After a response, the doctor attempts to localize symptoms.

Bragard's

1. Have the patient supine on the table. 2. Doctor stands on the side of the leg being raised. Uninvolved first. 3. Doctor then places their hand under the ankle of the leg to be lifted. The other hand is making sure that the knee remains locked in extension. 4. Doctor slowly & passively lifts the patient's leg until symptoms are reproduced or exacerbated. Not to exceed 90°. 5. Once symptoms are reproduced or exacerbated the doctor backs off until symptoms subside (which is about 5°) and holds that position. 6. Doctor then slowly & passively dorsi-flexes the Ankle until symptoms return. 7. Repeat on involved side. 8. After a response, the doctor attempts to localize symptoms.

Passive Straight Leg Raise

1. Have the patient supine on the table. 2. Doctor stands on the side of the leg being raised. Uninvolved first. 3. Doctor then places their hand under the ankle of the leg to be lifted. The other hand is making sure that the knee remains locked in extension. 4. Doctor slowly & passively lifts the patient's leg until symptoms are reproduced or exacerbated. Not to exceed 90°. Try to document angle with inclinometer. 5. Repeat on involved side. 6. After a response, the doctor attempts to localize symptoms.

Crossed or Contralateral Straight Leg Raise, Well Leg Raising Test, Fajersztajn's

1. Have the patient supine on the table. 2. Doctor stands on the side of the uninvolved leg being raised. 3. Doctor then places their hand under the ankle of the leg to be lifted. The other hand is making sure that the knee remains locked in extension. 4. Doctor slowly & passively lifts the patient's leg until symptoms are reproduced or exacerbated down the involved side. Not to exceed 90°. Try to document angle with inclinometer. 5. After a response, the doctor attempts to localize symptoms.

what does the Ulno Meniscal Triquetral test test?

*Tests the integrity of TFCC (triangular fibrocartilage complex)

Iliac - Compression (gap posterior)

1. Patient is Side lying on the table. Have them move back towards you. 2. Doctor is Standing to the side of the table behind the patient. 3. Make sure the patients' shoulder and pelvis are in line with each other and perpendicular to the table. 4. Doctor contacts the *lateral aspect of the patients' ASIS* (stay OFF the greater trochanter) with a reinforced calcaneal hand contact. 5. Doctor applies gentle and steady lateral to medial pressure straight down towards the table. 6. Allow patient to respond and look for reproduction or exacerbation of the patient's symptoms. - The side that is being tested it the UP side. So if the Pt is laying on their *left* shoulder, the *right* ilium is the one being tested, since it is closest to the ceiling.

Gaenslen's

1. Patient is Supine on the table to the side closest to you. 2. Doctor is Standing to the side of the table facing the patient. 3. Doctor instructs the patient to flex the opposite knee towards the chest while palpating for the lumbar lordosis to reduce. 4. When it first touches the doctors' hand they are told to stop and grab the knee to maintain it. 5. The doctor then pivots the patient so the leg that is closest to the doctor falls off the table. 6. The doctor then places one hand on top of the patients' hands holding their flexed knee and the other is placed over the thigh that is off the table and applies downward pressure. Allow patient to respond and look for reproduction or exacerbation of the patient's symptoms. * The leg that is hanging towards the floor is the one that is being tested.

Distraction (gap anterior)

1. Patient is Supine on the table. 2. Doctor is Standing to the side of the table facing the patient. 3. Doctor contacts the anterior aspect of both of the patients' ASIS's with a calcaneal hand contact. 4. Doctor applies gentle and steady anterior to posterior pressure straight down towards the table. Allow patient to respond and look for reproduction or exacerbation of the patient's symptoms.

Thigh Thrust

1. Patient is Supine on the table. 2. Doctor is Standing to the side of the table facing the patient. 3. The doctor then passively flexes the patients' leg closest to him to 90°. 4. He then adducts the thigh to force the pelvis to raise allowing access to palpate over the patients' SI. 5. He then returns the pelvis to the table op top of the doctors' hand. 6. The doctor then places the patients' knee towards his axilla and applies axial pressure straight down towards the table feeling for motion. 7. Allow patient to respond and look for reproduction or exacerbation of the patient's symptoms. * Drives the same side innominate into COUNTERnutation

Sacral Thrust

1. Patient is prone on the table. 2. Doctor is positioned to the side of the table facing the patient. 3. The doctor takes their inferior hand using a midline calcaneal contact and places it over the patients S3 segment with the fingers pointing cephalad. 4. The doctor then reinforces the contact with their superior hand. 5. The doctor then gently but firmly pushes P-A & S-I over the sacrum. 6. Allow patient to respond and look for reproduction or exacerbation of the patient's symptoms.

SLUMP Test

1. Patient is sitting UP STRAIGHT on the edge of the table with legs hanging free. 2. Popliteal areas against the table. 3. Arms behind their back with hands clasped. 4. Doctor checks for sacrum to be vertical and remain vertical throughout the procedure. 5. Doctor standing to the side of the patient. 6. Next have the patient slump forward at the thoracic and lumbar spine keeping the head & cervical spine extended. (thoracic and lumbar flexion is the SLUMP component) 7. Are symptoms are reproduced or exacerbated? 8. Then the doctor places their anterior free hand on the patient's forehead and has the patient SLOWLY tuck their chin to their chest as the doctor controls the speed and amplitude of the neck flexion by the doctors' posterior hand. 9. See if it changed any of their symptoms, reproduced or exacerbated? 10. The anterior hand is freed up to deal with the lower extremity. 11. The posterior hand that lies over the patient's C-T junction & occiput and is preventing release of cervical flexion rather than applying overpressure into flexion. 12. Then the lower leg of the uninvolved leg first is extended (Passively or Actively) until symptoms are reproduced or exacerbated. 13. Then Passively or Actively apply dorsiflexion to the foot until symptoms are reproduced or exacerbated. 14. Repeat #12 & #13 on the involved side. 15. After a response, the doctor attempts to localize symptoms.

Bechterew, Sitting SLR, Sitting Lasègue

1. Patient is sitting on the edge of the table with legs hanging free. 2. Perform on uninvolved leg first. 3. The lower leg is extended (Passively or Actively) until symptoms are reproduced or exacerbated. Not to exceed 90° of hip flexion. 4. Repeat on involved side. 5. After a response, the doctor attempts to localize symptoms. 6. If the patient leans back and places their hands behind them (usually oblique to the test side) then this is termed Tripod Sign. If Tripod Sign happens quickly and somewhat dramatically then this is termed Flip Sign.

A-SLR

1. Patient is supine on table. 2. Doctor is at the foot of the table. 3. Doctor instructs the patient to actively raise one leg approximately 20cm off the table and hold it there for at least 5 seconds. Without bending the knee. Doctor observes for compensatory patterns of trunk rotation and an increase in SI pain usually *contralateral* to the side being tested. * Purely a loading procedure for the S-I joint and evaluates S-I function. Has NOTHING to do with nerve tension. If the symptoms are really subtle, you can add a little tension (press on the raised leg) and try to exacerbate the pain. Have the Pt point to the pain so that you can confirm it is the opposite side that is hurting.

Carpal Compression Test:

1. Patient sitting or standing. 2. Doctor stands in front of the patient. 3. Patient is instructed to present their hand and wrist palm up. 4. Doctor makes a double thumb contact over the patients' Carpal Tunnel which is just lateral to the palmaris longus tendon between the proximal & distal flexor creases of the wrist. 5. Doctor applies deep pressure through the double thumb contact then slightly flexes to about 30-40 degrees at the wrist. 6. Wait for a response from the patient (approx. within 30 seconds).

Kemp's

1. The patient is standing. 2. The doctor is standing behind the patient slightly off to one side. 3. The doctor places their thumb at the site in question (level & side). Right on right and left on left. 4. Test uninvolved side first. Example: doctors' right thumb is placed over the patients' right area of the L-S facets (area in question). 5. Doctors left hand is placed on the patients' left shoulder to control movement. 6. With the doctors left hand he puts the patient into RLF 1st. 7. Then he extends the patient. 8. Then he contralaterally rotates the patient's torso so they are leaning in a posterior oblique position to the right until leg symptoms are reproduced or exacerbated. 9. Repeat #4 & #8 on the involved side. 10. After a response, the doctor attempts to localize symptoms.

Scaphoid Shift Test of Watson

1. Patient sitting to the side of the table with their elbow up on the table. Forearm pronated with the palm to the doctor. Uninvolved side first. 2. Doctor sitting opposite the patient on the other side of the table. 3. The doctor grabs the patients' hand on the lateral side (side of 5th digit) and places the patients' hand in the starting position of *ulnar deviation and extension*. 4. With the doctors' other hand placed over the proximal part of the scaphoid. 5. Doctors' index in the snuff box, thumb on the palmer surface of the scaphoid and the middle finger over the dorsal surface of the scaphoid. 6. The doctor applies slight anterior to posterior pressure through their thumb and maintains this throughout the maneuver. 7. With applied pressure on scaphoid, take hand out of extension and into neutral. 8. Then take hand from ulnar deviation to radial deviation. *This is the step you often feel the little "jerk" or mechanism of scaphoid flexing forward.* 9. Repeat and compare with the involved side.

Ulno Meniscal Triquetral test

1. Patient sitting to the side of the table. Medial aspect of forearm presented to doctor (Like Hawkins-Kennedy Position). 2. Doctor sitting opposite the patient on the other side of the table and supporting the patients arm in the above position. 3. The doctor places their thumb over the pisiform (triquetrum) and their index finger over the ulnar styloid. 4. The doctor then applies pressure through the thumb in an anterior to posterior direction while the index finger simultaneously applies pressure in a posterior to anterior direction. 5. Repeat and compare with the involved side.

Phalen's Test:

1. Patient standing or sitting. 2. Doctor instructs the patient to internally rotate their arms and place the dorsal surfaces of their hands together at about waist level. 3. Doctor then instructs the patient bring their hands up to about chest level, so the wrists are at 90 degrees. 4. Wait for a response from the patient (approx. within 60 seconds).

Median Tinel:

1. Patient standing or sitting. 2. Doctor stands in front of the patient. 3. Patient is instructed to present their hand and wrist palm up. Uninvolved side first. 4. The doctor places his middle finger over the patients' Carpal Tunnel which is just lateral to the palmaris longus tendon between the proximal & distal flexor creases of the wrist. 5. The doctors index & ring fingers placed on either side of the middle finger for stability and held there. 6. The doctor then raises the middle finger and taps lightly over the carpal tunnel. 7. Repeat and compare with the involved side.

Varus- Wrist

1. Patient standing or sitting. 2. Patient presents with a supinated forearm and hand palm up. 3. Doctor stands in front of the patient grasping the uninvolved wrist first. 4. With doctors' thumbs on the palmer surface over both thenar and hypothenar eminences. 5. The doctors' index fingers are placed at the *medial and lateral* joint space of the wrist. 6. With the doctors' medial hand, he drives medial to lateral through the joint space of the patients' wrist. 7. This stresses the *lateral collateral ligaments*. 8. Repeat and compare with the involved side.

Valgus wrist

1. Patient standing or sitting. 2. Patient presents with a supinated forearm and hand palm up. 3. Doctor stands in front of the patient grasping the uninvolved wrist first. 4. With doctors' thumbs on the palmer surface over both thenar and hypothenar eminences. 5. The doctors' index fingers are placed at the medial and lateral joint space of the wrist. 6. With the doctors' lateral hand, he drives *lateral to medial* through the joint space of the patients' wrist. 7. This stresses the *medial collateral ligaments*. 8. Repeat and compare with the involved side.

Prone Instability Test

1. The patient is prone and has slid down to where their ASIS's are on the bottom edge of the table. 2. The doctor is standing to the side of the table localizes the segment in question as above from the Spring test. 3. The doctor maintains his contact over the area but without force. 4. Doctor instructs the patient to lift both feet off the floor just enough to clear the floor. 5. The doctor reapplies a gentle but firm force in a P-A direction over the segment again. 6. See if symptoms are reduced or abated.

Spring Test

1. The patient is prone. 2. The doctor is standing to the side of the table. 3. Starting above or below the segment in question. 4. Doctor places their hypothenar eminence (knife edge) perpendicularly over the spinous process and reinforced with the other hand. 5. Apply a gentle but firm force in a P-A direction. 6. Check for differences in motion (quantity & quality). 7. See if symptoms are reproduced or exacerbated.

Prone Knee Bend, Femoral Nerve Stress Test, Nachlas, Ely's and Modified Ely's

1. The patient is prone. 2. The doctor is standing to the side of the table. Perform on the opposite side of symptoms first. 3. Doctor grasps the patients' ankle and passively & slowly flexes the patients' lower leg taking the heel towards the same buttock = Nachlas. 4. Doctor grasps the patients' ankle and passively & slowly flexes the patients' lower leg taking the heel towards the opposite buttock = Ely's. 5. Doctor grasps the patients' ankle and passively & slowly flexes the patients' lower leg taking the heel towards the opposite buttock then adds hyperextension of the thigh = Modified Ely's. 6. Prone Knee Bend and Femoral Nerve Stress Test are performed the same as Nachlas. 7. Repeat on the side of symptoms. 8. All are done until symptoms are reproduced or exacerbated. 9. LPB &/or SI pain = + Nachlas & Ely's 10. Neurological symptoms in the anterior upper thigh = + Modified Ely's, Prone Knee Bend and Femoral Nerve Stress Test (done side lying). 11. Duncan-Ely (not listed above) allows one to measure the angle of the Tibia relative to the table at that point when the ASIS raises off the table = Tight Rectus Femoris. This may be seen while performing the other tests.

Schepelmann's Sign

1. The patient is sitting or standing looking straight ahead with their feet together. 2. Doctor standing in front or behind the patient. 3. The doctor instructs the patient to raise both arms over their head and lean to one side. 4. The doctor observes which side recreates or exacerbates the patient symptoms. 5. The doctor then determines if it was on the side spinal convexity or concavity. 6. Repeat on the other side.

What is the purpose of phalen's test

Looking for distribution of numbness, tingling, pins-and-needles from the median nerve. This will often show in the thumb, index, and possibly middle finger

What is the purpose of the froment's test?

Looks for paralysis of ulnar innervated muscles. Normally the thumb will be nice and flat, but with paralysis, the thumb will slide up and hyper flex at the distal joint (almost looks like a goose neck) when squeezing the paper.

What is a positive kemp's test?

What the maximum cervical compression is to the cervical spine, Kemp's is to the lumbars. Symptoms will be pain shooting down the leg, especially below the knee. L4 and down.