TRUNK

AND SHOUDER
REGIONS
EXAMINATION
OF
THE TRUNK
 PAIN
 What caused the pain? (acute or chronic)
 Where is the pain?
 Radiation? (to & from)
 Character
 Abnormal sensation
 Exacerbation and relief?
 Course (progressive, regressive , stationary)
 IMPORTANT POINTS
 Patients occupation
 Faulty postural habits?
 Abnormal gait?
 Medications?
 Sphincter & sex abnormalities
PAST HISTORY
- SYSTEMIC DISEASE
- MEDICATION
- SURGERY

FAMILY HISTORY
Examination of the Dorso lumbar Spine
Attitude:
+ PAIN
Patient examined standing
LOSS OF LUMBAR LORDOSIS
LIST
SCOLIOSIS
Attitude:
 + PAIN
 Sciatic list.
 Decreased lumbar lordosis.
 Scoliosis.

.”bending forward test“

Active Spine movements
 Forward flexion (to 90)
 (Extension (20-35⁰)
 side flexion (15-20⁰)
 Rotation (3-20⁰)
Walking on heels (L4,5)

Walking on toes (S1)

 Hip flexion Supine position
 L2
 Knee extension
 L3
 Ankle extension
 L4
 Toe extension
 L5
 Ankle flexion
 S1
 Ankle eversion
 S1
 Special tests
 SLR
 Femoral stretch test
 SPINAL (PRIMITIVE REFLEXES)
ABRASIONS,CONTUSIONS
KYPHUS
 Dermatomes (L1 L4)
 L1 back of trochanter
and groin
 L2  front of thigh
knee, back of iliac crest
 L3 upper buttock, front
of thigh, & knee &
medial lower leg
 L4  inner buttock, outer
thigh, inside of leg,
dorsum of foot
& great toe
 Dermatomes (L5 S4)
 L5  buttock, lat. Aspect of leg
& dorsum of foot, inner
sole & first three toes
 S1  buttock, back of thigh and
leg
 S2  same as S1
 S3  groin, inner thigh,
perinium
 S4 & S5
 perineum genitals &
lower sacrum
AUTONOMOUS SENSORY ZONES
nipple line (T4),

xiphoid process
(T7)

Umbilicus
(T10)

perineum and perianal region

inguinal region S2, S3, and S4).
(T12, L1)

Dermatomal (sensory) distribution

 Reflexes
 Knee  L3
 Ankle  S1
 Medial hamstrings L5
 Lateral hamstring  S1
 PRIMITIVE (spinal) REFLEXES

Anus

Glans

Babiniski test

Bulbo-cavernosus test
 Palpation
 Posterior: spinous processes, facets, sacrum
coccyx, iliac crest, ischial
tuberosity and sciatic nerve
 Anterior: abdomen organs, aorta,
inguinal area, iliac crest, symphysis

Prone position
Hip extension  S1
Knee flexion  S1 & S2
 Lumber Root Syndromes
Root pain
Dermatome
Muscle weakness
Reflexes abn.
Sensory examination.
 Special tests
 SLR
 Femoral stretch test
 SPINAL (PRIMITIVE REFLEXES)
Special tests
Malingerer patient
PLAIN X-RAY
CT
D CT 3
MRI
BONE SCAN
THE SHOULDER
 The shoulder region is made of
three bones

 Proximal humeral end.

 Clavicle.
 Scapula
 THE SHOULDER
 INJURIES
 TUMOURS
 DEGENERATIVE CHANGES
Injuries of the Shoulder
Region
Fractures of the clavicle
 Clavicle is a S shaped bone, with double curves

 Functions of the clavicle:

1- Power and stability of the arm.
2- Motion of the shoulder girdle.
3- Muscle attachments.
4- Protection of the neurovascular structures.
Related important structures
 Fracture of the clavicle
 Middle third, Most common.
 Lateral third.
 Medial third

Latera Medial
l
 Mechanism of injury

 Direct trauma.

 Indirect trauma:
-fall on outstretched hand(most common)
- fall on the point of the shoulder.
 Clinical picture
 Pain, swelling.
 Deformity, tenderness &
crepitus at the site of fracture.
 Drooping of the affected
shoulder.
 The patient supports the arm
of the affected side to
decrease the painful
movements.
PATIENT SHOULD BE EXAMINED
FOR:
 Other skeletal injuries.
 Distal pulsations.?
 Investigations
 Plain X-ray
 Complications
 Neurovasular injury.
 Nonunion.
 Malunion.
 Treatment
 Conservative treatment:
(main line)
1- Figure of 8 bandage:
NOT RECOMMENDED.
(Why?)

2- Simple arm support

 Open reduction and internal fixation:

1- patients with neurovascular injuries,

2- Lateral end fractures.
3- Nonunited fractures
Fractures of the proximal
end of the humerus
 Anatomy
It is formed of 4 parts:
 Fractures of the proximal end may be:

1- Non displaced fracture.

2- Displaced fracture.
 Mode of trauma
 Fall on outstretched hand.
 Minor trauma to old osteoporotic patients.
 Major trauma to young patients.
 Clinical picture
 Pain, swelling & inability to move the shoulder.
 Ecchymosis & crepitus over the affected
shoulder.
 Deformity due to fracture or to associated
dislocation.
 Neurological and vascular examination:
axillary nerve
Plain X ray
C.T scan
 Complications
 Axillary nerve injury

Deltoid wasting
 Malunion
 Treatment

 Non operative treatment: Non or minimally

displaced fracrtures
 Open reduction and internal fixation.
Big fragments, mild comminution
 Arthroplasty. Comminuted fractures, fractures
involving the head
 Fractures of the glenoid
(Very rare)

 Extra-articular: not involving the articular surface.

 Intra-articular: extends to the articular surface.
Shoulder Dislocation
Shoulder dislocations are divided into:

 Acute dislocation.

 Chronic (negelected) dislocation.

 Recurrent dislocation.
 Direction of dislocation
Described according to the relation of the head
to the glenoid

 Anterior: most common type.

 Posterior.

 Inferior.
 Mechanism of injury

 Indirect force: combined abduction, extension

and external rotation.

 Direct force: blow directed to the proximal

humerus.
 Clinical picture
 Pain & inability to move the shoulder.
 Deformity of the shoulder joint, the humeral head is
palpable in the dislocated position.
 The arm is held in abduction and slight external
rotation (anterior dislocation).
 Associated axillary nerve injury.
 Vascular injury.
X ray
 Complications
 Vascular injury: Axillary artery injury, at the time
of dislocation and at the time of relocation.
 Neural injury: to the brachial plexus. Neural
injury may be Neurapraxia, Axonotmesis, or
Neurotmesis. Most common injury involves the
axillary nerve.
 Recurrence of dislocation.
 Recurrence of dislocation
 This is the most common complication.
 Causes of recurrence:
1- Patient age: High incidence below the age of
40 years.
2- Inadequate immobilization: less than 3 weeks.
3- associated head fractures: (Hill-Sachs lesion)
increase the incidence of recurrence.
4- Glenoid labral injury (Bankart lesion)
Mechanism of Hill Sachs lesion
Treatment
 Acute dislocation

 Closed reduction under general anesthesia

as urgent as possible.
Neurovascular examination is mandatory after
closed reduction.

 Open reduction is rarely needed in cases of

locked dislocations
 Closed reduction

Traction & counter traction

 Recurrent dislocation

 Operative treatment: for soft tissue balance,

repair ,or blocking the dislocation mechanism.

 Physiotherapy program.
 TUMOURS
IN THE SHOULDER REGION
A- BENGIN
OSTEOCHONDROMA
 TUMOURS
IN THE SHOULDER REGION

A- BENGIN
CHONDROBLASTOMA
 TUMOURS
IN THE SHOULDER REGION
B-MALIGNANT
CHONDROSARCOMA
 TUMOURS
IN THE SHOULDER REGION
B-MALIGNANT
CHONDROSARCOMA
 TUMOURS
IN THE SHOULDER REGION

B-MALIGNANT
SECONDARIES
PATHOLOGICALFRACTURES
IN THE SHOULDER REGION
DEGENERATIVE ARTHROSIS
SUMMERY
 Fractures of the middle third of the clavicle is
the most common fracture site.
 Axillary artery may be injured in fractures of the
clavicle.
 Conservative treatment is the main line of
treatment.
 Minor trauma to the upper limb should not be
neglected in old persons.
 Axillary nerve is the most commonly affected
nerve in fractures and dislocations of the
proximal end of the humerus.
 Open reduction or arthroplasty are the main
line of treatment in cases of displaced fractures
of the proximal humeral end.
 Anterior shoulder dislocation is the most
common type of shoulder dislocations.
 In anterior shoulder dislocation, the arm is held
in abduction and slight external rotation.
 Shoulder immobilization for three weeks is
needed after closed reduction of shoulder
dislocation.
 Recurrent shoulder dislocation is the most
common complication of acute dislocation.