By Ahmad Tahir Bin Awang

Supervised by : Dr Nurul Akma Binti Azmi

OUTLINE
 General examination
 Inspection
 Palpation
 Range of movement
 Special test
 Neurological examination
 “The eye does not
History
overview see what the mind
does not know”

DIAGNOSIS

Investigation
Examination
@ imaging
 GENERAL 4 BASIC RULEs OF
EXAMINATION EXAMINATION

• General • Look = inspection

appearance – body • Feel = palpation
built, posture • Move = ROM
• Any skin lesion • Special test
(cafe-au-lait spots,
vesicles, petechial
rashes ) • ***Neurological
examination
• Abdomen – liver,
spleen, kidney,
bladder, ect.
Before starting...
 Introduce ourself and get consent
 Hand washing
 Ensure adequate exposure
 Tell the patient to let you know if anything you do is
uncomfortable or painful
 Chaperone
Inspection
1. Standing (look from infront and
behind)
 Head & Neck Posture
(Torticollis, tilting to one side)
 Scoliosis (lateral curvature of
spine)
 Postural – scoliosis disappears
with forward flexion of the spine
 Structural – scoliosis persists
with forward flexion of the spine
 Shoulder tilt
 Pelvic tilt
Inspection
1. Standing (look from infront
and behind)
 Skin changes over the spine
(hair tuft ; spina bifida, sinus,
colour changes/pigmentation,
scar)
 Swelling
 Prominent crease of the trunk
 Muscle wasting (glutei, over
scapula, calf muscle)
Inspection
2. Standing (look from the side)
 Normal spine (cervical lordosis,
thoracic kyphosis, lumbar lordosis)
 Increased in kyphosis (senile,
scheuermann’s disease, gibbus –
angular kyphosis)
 Flattening or reversal of lumbar
lordosis (prolapsed intervertebral
disc, ankylosing spondylitis)
 Increased in lumbar lordosis
(normal in woman,
spondylolisthesis)
Inspection
3. Gait
 Normal walking
 Wide base gait  cervical myelopathy
 Waddling gait  proximal myopathy
 Walking on tip toe  S1 weakness
 Walking on heels  L5 weakness
Palpation
 Along spinous process –
tenderness, warm
 Paravertebral muscle
spasm
 Sacro-iliac joint –
tenderness
 step deformity as in
spondylolisthesis – usually
at lumbosacral juction
RANGE OF MOVEMENT
Cervical spine
1. Flexion
• Ask patient to bend the head forward – chin should be able to touch
the chest ; normal 80°
2. Extension
o Ask patient to look up and back ; normal 50°
3. Lateral flexion
 Ask patient to touch his shoulder with the ear ; normal 45° (involve
atlanto-axial and antlanto-occipital joints)
4. Rotation
 Ask patient to look over his shoulder ; normal 80° - restricted and
painful in cervical spondylitis
RANGE OF MOVEMENT
Thoracolumbar spine
1. Flexion
• Ask patient to try to touch his toes
• Watch the smoothness of movement and any area of restriction
• Patient with advanced ankylosing spondylitis have flat spine – all the bending
occur at the hip ***Lumbar spine excursion test (schober’s method)
2. Extension
o Ask patient to arch his back (steadying his pelvis and may pulling back his
shoulder) ; normal 30°
3. Lateral flexion
 Ask patient to slide his hand down the side of each leg as far as he can ; normal 30-
45°
4. Rotation
 Pateint seated to fix the pelvis (or by examiner)
 Ask patient to twist round to each side ; normal 45°
RANGE OF MOVEMENT
SPECIAL TEST – Cervical spine
 COMPRESSION TEST
 Press down upon the top of
patient’s head
 If there is increase pain in
either cervical spine or upper
extremity, note its exact
distribution
 A narrowing of neural foramen,
pressure on the facet joints or
muscle spasm can cause
increase pain upon
compression
SPECIAL TEST – Cervical spine
 DISTRACTION TEST
 Place the upon palm of one hand
under the pt’s chin and the other
hand is upon occiput
 Gradually lift (distract) the head
to remove its weight from the
neck
 Demonstrate the effect that neck
traction might have help in
relieving the pain by decreasing
pressure on the joint capsules
around the facet joints
SPECIAL TEST – Cervical spine
 VALSAVAL TEST
 Ask pt to hold his breath and bear
down as if he were moving his
bowels
 Then, ask wheather he feels any
increase in pain and describe the
location
 This test increase intratechal
pressure. Patient may develop pain
in cervical spine secondary to
increase pressure (space occupying
lesion such as a herniated disc or a
tumour present in cervical canal)
 The pain also may radiate to the
dermatome distribution of cervical
spin pathology
SPECIAL TEST – Cervical spine
 SWALLOWING TEST
 Difficulty or pain upon
swallowing can sometimes
caused by cervical spine
pathology such as:
 Bony protuberance
 Bony asteophytes
 Soft tissue swelling due to
hematomas, infection or
tumour in anterior portion
of cervical spine
SPECIAL TEST – Cervical spine
 ADSON TEST
 Pull the arm downwards
 Plapate the radial pulse
 Turn the pt’s head to the
same side while feeling the
radial pulse
 Fading of the radial pulse
indicates positive thoracic
outlet obstruction
SPECIAL TEST – Thoracolumbar spine
 STRAIGHT LEG RAISING TEST
(SLR Test)
 With the knee extended,
passively flex the hip in order to
lift the lower limb
 The pt will feeel pain over the
back and radiating to the lower
limb
 Watch the distribution of pain
indicating the involved nerve
root
SPECIAL TEST – Thoracolumbar spine
 SCIATIC STRETCH TEST
 Following the SLR test,
drop the limb for about 10
degrees to relieve tension
on the irritated nerve root
 Dorsiflex the ankle to
reproduce the stretching
effect on the nerve root
(sciatica pain)
SPECIAL TEST – Thoracolumbar spine
 FEMORAL STRETCH TEST
(reverse SLR test)
 Look for lumbar root tension
 Ask pt to lie prone
 Flex the knee
 Lift up the hip into extension
 Pain may be felt in front of
the thigh and the back
 Done to exclude higher disc
prolapsed (rare)
NEUROLOGICAL EXAMINATION
 UPPER LIMB
 Tone
 power
NEUROLOGICAL EXAMINATION
 UPPER LIMB
 Reflexes
 Biceps (c5-c6)
 Brachioradialis
 Triceps (c7-c8)
 Sensation
NEUROLOGICAL EXAMINATION
 LOWER LIMB
 Tone
 power
NEUROLOGICAL EXAMINATION
 LOWER LIMB
 Reflexes
 Knee jerk (L3-L4)
 Ankle jerk (S1-S2)
 Babinski’s reflex
 Clonus
 BCR (S2-S4)
 Sensation
NEUROLOGICAL EXAMINATION
NEUROLOGICAL EXAMINATION
REFERRENCES
 https://asia-spinalinjury.org/
 Clinical Examination method in orthopedic
(supplement to textbook of orthopedic, fourth
edition)
 Apley and Solomon’s Concise System of Orthopaedics
and Trauma, fourth edition