Orthopaedic Surgery: Back to Basics

One of the most important assets that an orthopaedic surgeon must have is good physical examination skills. It is definitely not as glamorous as the surgical procedures, but is important at determining the diagnosis, treatment, and possible surgical options.

The next few posts will be specifically about physical examination. I will provide a description of the physical examination, a video to demonstrate the examination, and an example of what should be documented.

All of the orthopaedic examinations consist of:

• Observation includes posture, position, gait, and skin in multiple positions.
• ROM includes ranges of motion for all of the examined joints.
• Neurologic Examination
• Special examinations are specific to the areas being examined.

When documenting these for coding purposes, you must remember to make mention of all of these points. It is also important to mention that you examined both sides. For example, if you are examining a knee, you examine the knee in question with the other knee used as a comparison. This assumes that the other knee is normal.

For the orthopaedic examination, the neurologic examination has several components:

• Motor Examination
• Strength
• Tone
• Movement
• Posture
• Sensory Examination
• Light touch/Pain
• 2 point discrimination
• Reflexes
• Gait

Gait Cycle

• The following goals must be achieved in normal human gait
• balancing head/arms/trunk segment of body at hips (HAT constitutes about 70% of body mass)
• transfer and support of body mass to one leg during single leg support phase of stance
• ground clearance of swinging foot during swing phase
• generation of sufficient propulsive force for forward progression
• It is also desirable to achieve these goals with minimum energy expenditure.

There are 2 phases of gait:

• Stance Phase
  
• consists of initial heel contact, foot flat, mid-stance (hip moves over ankle), heeloff, toe-off
  
• constitutes about 60% of stride duration at preferred walking speed
• double leg support begins with heel contact, followed by foot flat (comprises about 15% of stride)
• two periods of double support as weight is transferred from one leg to the other (at beginning and end of stance) constitute about half of stance phase
  
• single leg support begins immediately after foot flat as trailing leg is lifted from ground
• Swing Phase
  
• consists of early swing (acceleration), mid-swing, late swing (deceleration)
• constitutes about 40% of stride duration at preferred walking speed

Normal Gait



Hemiplegic Gait



Diplegic Gait



Neuropathic Gait



Myopathic Gait



Choreiform Gait



Ataxic Gait

Reflexes

Stretch or Deep Tendon Reflexes (DTR's)

• Biceps – C5-6
• Brachioradialis – C5-6
• Triceps – C7
• Finger Flexors – C8
• Patellar or Knee – L2-4
• Ankle – S1-2

Grading DTR's

1. Absent
2. Decreased but present
3. Normal
4. Brisk and excessive
5. With clonus

Upper Extremity DTRs



Abnormal Upper Extremity DTRs



Lower Extremity DTRs



Abnormal Lower Extremity DTRs



Plantar Response






Abnormal Plantar Response



Hoffmann's Sign

Tone

Muscle tone is assessed by putting selected muscle groups through passive range of motion. The most commonly used maneuvers for the lower extremities are flexion and extension at the knee and ankle.

Upper Extremity Tone






Abnormal Upper Extremity Tone



Lower Extremity Tone






Abnormal Lower Extremity Tone

Dermatomes



(Image credit)

Light Touch

Light touch (both posterior column and spinothalamic tracts) is usually tested with a wisp of cotton swab.



Abnormal Soft Touch Exam




Pain

Pain (spinothalamic tract) sense can be tested with a splintered cotton tip applicator or broken tongue blade.

Upper Extremity Pain Exam



Abnormal Upper Extremity Pain Exam



Lower Extremity Pain Exam



Abnormal Lower Extremity Pain Exam

Strength Testing

Muscle strength is rated on a scale of 0/5 to 5/5:

• 0/5: no contraction
• 1/5: muscle flicker, but no movement
• 2/5: movement through a full range of motion, but not against gravity (test the joint in its horizontal plane)
• 3/5: movement through a full range of motion, but not against resistance by the examiner
• 4/5: movement possible against some resistance by the examiner (sometimes this category is subdivided further into 4^–/5, 4/5, and 4⁺/5)
• 5/5: normal strength

Upper extremity Motor Testing

Abnormal Upper Extremity Motor Exam



Detailed Hand Motor Testing

Action	Muscles	Nerves	Nerve Roots
Finger extension	Extensor digitorum, Extensor indicis, Extensor digiti minimi	Radial nerve (posterior interosseous nerve)	C7, C8
Thumb abduction in plane of palm	Abductor pollicis longus	Radial nerve (posterior interosseous nerve)	C7, C8
Finger abduction	Dorsal interossei, Abductor digiti minimi	Ulnar nerve	C8, T1
Finger and thumb adduction in plane of palm	Adductor pollicis, Palmar interossei	Ulnar nerve	C8, T1
Thumb opposition	Opponens pollicis	Median nerve	C8, T1
Thumb abduction perpendicular to plane of palm	Abductor pollicis brevis	Median nerve	C8, T1
Flexion at distal interphalangeal joints digits 2, 3	Flexor digitorum profundus to digits 2, 3	Median nerve	C7, C8
Flexion at distal interphalangeal joints digits 4, 5	Flexor digitorum profundus to digits 4, 5	Ulnar nerve	C7, C8
Wrist flexion and hand abduction	Flexor carpi radialis	Median nerve	C6, C7
Wrist flexion and hand adduction	Flexor carpi ulnaris	Ulnar nerve	C7, C8, T1
Wrist extension and hand abduction	Extensor carpi radialis	Radial nerve	C5, C6
Elbow flexion (with forearm supinated)	Biceps, Brachialis	Musculocutaneous nerve	C5, C6
Elbow extension	Triceps	Radial nerve	C6, C7, C8
Arm abduction at shoulder	Deltoid	Axillary nerve	C5, C6

Lower Extremity Strength Testing

Abnormal Lower Extremity Motor Exam

Action	Muscles	Nerves	Nerve Roots
Hip flexion	Iliopsoas	Femoral nerve, and L1-L3 nerve roots	L1, L2, L3, L4
Knee extension	Quadriceps	Femoral nerve	L2, L3, L4
Knee flexion	Hamstrings (semitendinosus, semimembranosus, biceps femoris)	Sciatic nerve	L5, S1, S2
Leg abduction	Gluteus medius, Gluteus minimus, Tensor fasciae latae	Superior gluteal nerve	L4, L5, S1
Leg adduction	Obturator externus, Adductor longus, magnus, and brevis, Gracilis	Obturator nerve	L2, L3, L4
Toe dorsiflexion	Extensor hallucis longus, Extensor digitorum longus	Deep peroneal nerve	L5, S1
Foot dorsiflexion	Tibialis anterior	Deep peroneal nerve	L4, L5
Foot plantar flexion	Triceps surae (gastrocnemius, soleus)	Tibial nerve	S1, S2
Foot eversion	Peroneus longus, Peroneus brevis	Superficial peroneal nerve	L5, S1
Foot inversion	Tibalis posterior	Tibal nerve	L4, L5

Global Strength Testing



Abnormal Global Strength Testing