Part 4 Boards - Ortho
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. What would you like to do?
Range of motions...
- Show the pt what to do.
- *Shoulder: start from neutral for int & ext rot. (Flexion down, extension up... int rotation down, ext rotation up).
- *Elbow: neutral is thumb up... Keep elbows bent.
- *Thoracolumbar: lean forward for rotation... standing.
- *Hip: do standing unless told otherwise.
- *Ankle: pt seated.
What should you say if the patient experiences pain during an ortho test?
"Show me where it hurts."
1. What should you do before performing FCT?
2. What does a positive radicular FCT indicate?
- 1. Before doing FCT, check rotation.
- 2. (+) FCT w/ radiating SX = NRC... (+) FCT w/ local pain = foraminal encroachment.
- *Pt actively rotates head, then the dr applies pressure in neutral, then rotation.
- *Make sure to ask: "Any pain with that?"
Describe Jackson's Compression Test...
- Pt seated, dr laterally flexes the pt's head & then applies downward pressure.
- *Do bilaterally.
- *Radicular pain = NRC.
- *Screen first by doing LF.
Verbal component for Cervical Distraction Test?
- "Let me know what you experience."
- *Decreased pain = NRC.
- *Increased pain = sprain/strain.
2 MC locations they ask us to do O'Donohue's?
- 1. C-spine: F, E, LF, rot.
- 2. Ankle: dorsiflexion, plantar flexion, inversion, eversion.
- *Do AROM first, followed by PROM.
- *AROM = tendon.
- *PROM = ligament.
A (+) Valsalva indicates a SOL; for NBCE MCly D/T ______.
A (+) Valsalva indicates a SOL; for NBCE MCly D/T disc.
Describe the 2 steps for Max CCT...
- 1. Pt seated; actively rotate head & hyperextends the neck to one side.
- 2. If no pain; maximally LF the neck.
- *Perform bilaterally.
- *NO COMPRESSION APPLIED!!!!
What does a (+) Max CCT indicate?
Nerve root compression.
A (+) Shoulder Depressor Test indicates...
- Pain = Nerve Root Adhesion.
- *W/ the dr's arms criss crossing & the pt seated; depress the shoulder while LFing the C-spine away from the shoulder.
- *Do bilaterally.
What are the 2 indications associated with Soto Hall Sign?
- 1. Anterior localized pain = FX.
- 2. Posterior localized pain = ligament.
- *Pt supine; Dr places one hand on the sternum while passively flexing the pt's head towards chest.
What is an A/K/A for the Shoulder ABduction Test?
- Bakody's Test.
- *Pt seated; pt actively places affected arm on top of their head.
- *Relief of pain = IVF encroachment.
ALLEN'S TEST NBCE style...
- 1. Pt's hand on their thigh.
- 2. Occlude the A's.
- 3. Have them pump their fist 3 x's, then clinch & open.
- *Delay of more than 10 seconds for the blood to return = occlusion of the corresponding A.
Which (+) TOS test indicates compression between the first rib & clavicle?
- Costoclavicular Maneuver (Eden's Test).
- *Dr palpates the radial pulse while bringing the shoulder down & arm back... then the pt flexes their chin to chest.
- *Alteration in radial pulse amplitude = compression between the 1st rib & clavicle.
A (+) Adson's Test indicates compression by....
- A/K/A Scalenus Anticus Test = the anterior scalene &/or cervical rib.
- *Pt seated, doctor slightly ABducts/extends/externally rotates the arm while taking the radial pulse... Pt rotates the head towards the tested side & extends the head... Pt takes a deep breath in & holds.
Which structures are involved with a positive Modified Adson's Test?
- The subclavian A & medial scalene.
- *If Adson's is negative; have the pt rotate their head to the opposite side, extend their head & take a deep breath & hold while dr feels radial pulse.
How far do you ABduct the arms with Wright's Test?
- Both arms @ once to 180 degrees.
- *Note the angle in which the pulse decreases... >10 degrees = asymmetrical pec minor syndrome (compression of the Ax A).
What is Reverse Bakody's testing for?
- *Pt seated; places palm on top of head = increased pain.
A (+) Halstead's indicates...
- Cervical rib.
- *Pt extends head back & dr exerts downward traction & slight ABduction of the arm while taking the pulse.
- *Test both arms at once.
What exercise should be prescribed for shoulder complaints?
- Codman's Pendulum Exercises.
- *DX via MRI.
Which ortho test is for degenerative tendonitis of the rotator cuff?
- Apley's Test: pain or decreased motion = degenerative tendonitis.
- *Pt seated; touch sup & inf angles of both scapulas.
- *Show pt how to do it then go behind them to observe.
Which 2 shoulder tests are used to DX a supraspinatus tear?
- 1. Codman's Drop Arm.
- 2. Empty the Can Test (Supraspinatus Press Test).
A look of apprehension on the patients face when testing the shoulder indicates...
- Apprehension Test = chronic shoulder dislocation.
- *Pt seated; dr ABducts the arm slowly then rotates the shoulder w/ stabilization.
A (+) Dugas Test indicates...
You are palpating the shoulder for which 2 ortho tests?
Which ortho test for the shoulder DX's bicipital tendon instability?
- *Pt seated; dr places LIGHT pressure @ the biceps tendon against resistance.
- *Audible click in the bicipital groove = bicipital tendon instability.
Which shoulder ortho test is (+) when the pain is decreased?
- *Pt seated; deep palpation over the subacromial bursa elicits pain... dr ABducts arm & pain is decreased.
Which ortho test causes the greater tuberosity to jam against the acromial surface?
- Impingement Sign.
- *Pt seated; arm slightly ABducted, the doctor moves the shoulder through full flexion.
- *Pain = overuse of tendons.
A/K/A for Empty Can Test?
- Supraspinatus Press Test.
- *Pt seated; shoulders ABducted to 90, then apply resistance. Have pt flex their shoulders to 30 degrees & point thumbs downward & apply resistance again... (Test like deltoid, then pour it out).
- *Weakness = Supraspinatus Tear.
(+) finding for Speeds Test?
Pain = bicipital tendonitis.
SUBACROMIAL PUSH BUTTON TEST
- Dr applies quick deep pressure over the subacromial bursa.
- *Pain = supraspinatus degeneration, subacromial bursitis.
PASSIVE SHOULDER APPROXIMATION
- Pt is standing; dr approximates the scapulae by lifting the shoulders up & back.
- *Scapular pain = T1 or T2 NR problem on the side of pain.
- Dr observes the pt's posture & notes the heights of the ax folds.
- *Lower ax fold on involved side = shoulder dislocation.
A/K/A for Radiohumeral Bursitis?
- Lateral Epicondylitis / Tennis Elbow.
- *Pain w/ wrist extension & elbow pronation.
A/K/A for Little Leaguer's Elbow?
- Medial epicondylitis / Golfer's Elbow.
- *Pain w/ wrist flexion @ the medial portion of the elbow.
- *TX = TFM, US, counterforce, stretch, cross friction & strengthening.
What are the 2 tests for lateral epicondylitis?
- 1. Cozen's Test.
- 2. Mill's Test.
- Test how I learned Mill's Test.
- *Pain @ medial elbow = medial epicondylitis.
- Dr passive flexes the fingers, wrist & elbow, then brings the elbow around into max pronation & extension.
- *Pain @ lateral elbow = lateral epicondylitis.
What is the positive finding for tinel's sign @ the wrist? What does it indicate?
- Tingling into the lateral 3 fingers = CTS.
- Medial 2 fingers = Ulnar N impingement.
- *Tap pisiform & retinaculum.
(+) finding for Phalen's Sign?
- Tingling into the lat 3 fingers = CTS.
- *Have the pt mirror you.
- *The patient flexes the wrists maximally & holds the position for 1 min by pushing both wrists together.
- "58,59,60 - ok relax."
A/K/A for Reverse Phalen's?
A (+) pinch grip test indicates a problem with...
- Pt approximates pads of fingers together = Median N lesion.
- *Have pt approximate the tip of the index finters to the tip of the thumb.
- "Put your fingers like this - tip to tip."
A (+) Froment's Paper Sign indicates a problem with which nerve?
- Ulnar N.
- *Unable to keep paper between fingers = Ulnar N palsy.
- Dr applies moderate compression to the distal aspect of the radius & ulna (Squeeze hand).
- *Pain = RA if bilateral & fits HX, or sprain/strain injury if unilateral.
A (+) SLR indicates...
- Sciatic, disc or lumbar lesion on the affected side.
- *Place one hand under the heel & one over the knee.
What are the 4 SLR-like tests?
- 1. Lasegue Rebound Test.
- 2. Bragard's Sign.
- 3. Sicard's Sign.
- 4. Well Leg Raiser.
LASEGUE REBOUND TEST
- Following a (+) SLR; the Dr gradually drops the pt's leg.
- *Increased pain = sciatica, disc or mm spasm.
What does a (+) Bragard's sign indicate?
- Increased pain = primary sciatica.
- *Following a (+) SLR; the leg is lowered 5 degrees & the foot is sharply dorsiflexed.
Describe Sicard's Sign...
- Perform the SLR, drop 5 degrees & dorsiflex the big toe.
- *Pain in affected leg = sciatica.
Which test for sciatica includes dorsiflexion of the big toe?
- Turyn's Sign.
- *Pt supine; Dr dorsiflexes the big toe.
- *Pain in affected leg = sciatica.
WELL LEG-RAISER (FAJERSTAZN'S)
- SLR w/ dorsiflexion of the foot performed on the asymptomatic side.
- *Pain on symptomatic side = medial disc lesion.
A (+) Millgram's indicates...
- *Pt supine; hold legs 6" off table for 30 seconds.
- *Pain = SOL.
LEG LOWERING TEST
- Pt supine; Dr picks up the pt's legs to 90 degrees & asks the pt to lower legs slowly to the table.
- *LBP = SOL.
DOUBLE LEG RAISE TEST (BILATERAL SLR TEST)
- Pt supine; Dr does a SLR on each side noting the degree of pain... then does both legs & notes the degree of pain.
- *Single, single, double.
- *Pain occurs earlier when both legs are raised = lumbosacral joint lesion.
What are the 3 (+)'s for Goldwaith's Sign?
- 1. 0-30: SI-joints.
- 2. 30-60: lumbosacral joint.
- 3. 60-90: lumbar spine or contralateral SI joint.
- *Pt supine; raise affected leg slowly w/ hand under lumbar portion of the spine.
What 4 ortho tests are the same but with a different indication?
- 1. Soto Hall: FX or ligament sprain.
- 2. Brudzinski's: meningitis.
- 3. L'Hermittes: MS.
- 4. Lindler's: root sciatica.
A (+) Lindner's Sign indicates...
Pain in the lumbar spine radiating to the sciatic N = NR sciatica.
With which ortho test is the patient's leg on your shoulder as you place pressure over the popliteal fossa?
- *Pain in the lumbar region/radiculopathy = sciatica on side being tested.
- *Dr performs a SLR to the point of pain; knee flexed slightly & placed on the dr's shoulder... digital pressure in the popliteal fossa.
What is the ortho test for piriformis syndrome?
- Bonnet's Sign.
- *Pt supine; Dr stands on being tested & internally rotates & adducts the leg, then SLR's it.
- *Radicular pain into the limb = piriformis syndrome.
- *"Squeeze your boner."
Name this test...
- Sitting Becterew's.
- *Pt seated; pt extends one leg at a time. Dr applies resistance to one leg at a time & then both.
- *Pain or leaning back = postmed disc protrusion if pain when good leg raised.
A (+) Minor's Sign indicates...
- *Ask pt to rise from a seated position... (+) when they crawl up their leg when standing up.
NBCE instructions for Kemp's...
- Cross arms, lean forward, then bring them back into extension.
- *Radiating sciatic pain = disc.
- *Local symptoms = facet.
How many steps should the pt take for heel walk & toe walk?
- Heel walk = L5.
- Toe walk = S1.
What are the (+) findings for the Supported Adam's Test?
- No pain w/ stabilization = SI lesion.
- Pain w/ stabilization = lumbar.
- *Belt test.
Name this test
- *SI-joint pain = SI-joint lesion.
Name this test
- Lewin Gaenslen's.
- *SI-joint pain = SI-joint lesion.
What does a (+) Iliac Compression Test indicate?
SI-joint pain = SI-joint lesion.
Hip ABduction Stress Test: pt is side-lying w/ involved side up. ________ ABducts the leg & the Dr _________________.
- Hip ABduction Stress Test: pt is side-lying w/ involved side up. Pt actively ABducts the leg & the Dr exerts downward pressure prox. to the knee.
- *Pain @ the PSIS = SI-joint problems.
- *Weakness = Glute med weakness.
I NEED HELP WITH FEMORAL NERVE TRACTION TEST...
Which side do you stabilize for Hibb's Test?
- Stand on the side you stabilize, test the other side.
- *SI pain = SI lesion.
- *Or pt points to hip pain.
Which side do you stabilize with Nachlas Test?
- Stand, stabilize & test same side.
- *Heel approximated to same side butt.
- *SI pain = SI lesion.
Is there stabilization with Yeoman's Test?
- Stabilize same side of leg you are raising.
- *Dr stabilizes SI-joint testing & lifts the knee off the table bring it towards the pt's butt.
- *Deep SI pain = SI joint lesion.
PRONE HYPEREXTENSION TEST
- Pt prone & Dr stabilizes the lumbosacral area. Dr lifts involved leg into hyperextension while the knee remains extended.
- *Lift leg prox. to the knee.
- *Localized lumbar pain w/ ant thigh pain = L3/4 NR lesion.
Which test makes a 4 with the pt's leg?
- Patrick's / Fabere.
- *Pain in the hip = hip lesion.
A (+) Laguerre's Test indicates...
Pain in the hip = hip joint lesion.
- Pt supine; thigh flexed w/ knee bent to abdomen.
- *Opposite thigh/knee rises off the tale = hip flexion contracture.
(+) Anvil Test indicates...
- Pain in the hip = hip joint pathology.
- *Can be heel, tibia, fibula or femur FX.
- *Elevate the leg before striking.
What is a lazy Nachlas?
- Ely's Sign.
- *Pt prone; heel approximated to the butt after flexion of the knee.
- *Hip elevates = hip flexor contracture.
________: heel approximated to the opposite butt.
- Ely's Test: heel approximated to the opposite buttock.
- *Pain = hip lesion.
Which side is tested w/ Trendelenberg's?
- Supported leg.
- *Buttock on foot that is elevated drops = glute med weakness on leg they are standing on.
A (+) Neri's Sign indicates...
Knee buckles = tight hamstrings.
What is the MCly injured mm of the knee?
3 mm's that make up the Terrible Triad?
- 1. MCL.
- 2. ACL.
- 3. Medial meniscus.
What is the MCly injured knee ligament?
Which mm is responsible for chondromalacia patella?
When you tear your meniscus, when does swelling show up?
12-24 hours post injury.
When does swelling show up after a ligament tear?
A (+) Apley's Distraction Test of the knee indicates...
- Pain in the knee = collateral ligament tear.
- *Exaggerate elbow movements!
- *Heel points towards the side being tested.
A (+) Apley's Compression Test indicates...
- Pain in the knee = meniscal tear.
- *Grasp proximal to the foot.
- *Rotate leg internally & externally while applying downward pressure.
- *Heel points towards side being test.
Pulling P-A (anteriorly) with the Drawer Test of the knee is testing which ligament?
- *Pulling A-P (posteriorly) = PCL.
- Pt supine; knee flexed to 30 degrees... Dr stabilizes the femur & twists the leg.
- *Soft end-feel = ACL instability.
Applying L-M pressure at the knee is known as __________ stress test A/K/A ______ stress test.
- Applying L-M pressure at the knee is known as VALGUS stress test A/K/A ABDUCTION stress test.
- *Testing the MCL.
- *Pushing in = valgus stress = testing medial.
- NEED TO LEARN HOW TO DO IT NBCE STYLE...
- Painful click or snap heard...
- *Int rotation = lat meniscus.
- *Ext rotation = medial meniscus.
(+) for the Apprehension Test (Patella)...
- Look of apprehension = chronic patellar dislocation.
- *Push patella M-L.
Where are you looking for Clarke's Sign?
At the pt's face = chondromalacia patella.
NOBLE COMPRESSION TEST
- Dr places the leg in the 90/90 position & applies pressure to the distal lat femur, then the Dr extends the knee.
- *Put pressure on the IT-band.
- *Increased pain = TFL contracture.
- Pt side-lying, ISU; Dr places one hand on the pelvis. Thigh is ABducted & extended. Dr allows the leg to drop into addiction.
- *Knee stays elevated = TFL contracture.
- *They love this test.
Where is the MC location for a Morton's Neuroma?
Between the 3rd & 4th metaT heads.
Where does a March FX occur?
A heel spur is worse ________.
- A heel spur is worse when waking in the morning... Improves as the day progresses.
- *Plantar fasciitis.
Pain & burning on the sole of the foot indicates a problem with...
- Tarsal Tunnel Syndrome = medial plantar N.
- *Tap behind medial malleolus.
Hand placement for the Anterior Drawer Test of the ankle?
- Pt supine; hand around the ant. aspect of the lower tibia, grasp calcaneus & pull the calcaneus forward.
- *Talus slides forward = ant. talofibular lig. instability.
Hand placement for the Posterior Drawer Test of the ankle?
- Pt supine; hand around the post. aspect of the lower tibia while pushing the talus post.
- *Talus slides back = post. talofibuar lig. instability.
A (+) Ankle Stability Test indicates...
- Excessive gapping w/ inversion = ant talofib lig tear.
- Excessive gapping w/ eversion = deltoid lig tear.
- *Pt seated or supine; grasp pt's foot & passively inverts or everts it.
A (+) Tinel's Test of the ankle indicates...
- Pain & tingling on the sole of the foot = TTS.
- *Pt supine; percuss post to the med. malleolus.
Thompson's VS Thomas test...
- Thompson: pt prone; flex knee to 90 & pump the calf... no plantar flexion = achilles rupture.
- Thomas: pt supine; thigh flexed w/ knee bent to abdomen... opposite thigh/knee rises off the tale = hip flexion contracture.
A/K/A for Thompson's Test?
What are the 4 malingering tests?
- 1. Burn's Bench Test
- 2. Hoover's Sign
- 3. Magnusson's: have pt point to pain, then do it again later.
- 4. Mannkopf's Sign: take pulse & apply pressure.
What are the 4 tests for AS?
- 1. Chest expansion test
- 2. Amos' Sign
- 3. Lewin Supine
- 4. Forrestier's Bowstring Test
What is the WNL range for the Chest Expansion Test?
- Women: <1.5"
- Men: <2"
- *Tape measure placed at T4.
- *Have pt exhale completely & take a measurement, then inhale deeply & measure again.
- *Do 3 breaths.
- *(+) = AS.
Describe Amos' Sign.
- Pt asked to go from side-lying to standing.
- *Localized pain &/or lack of ROM = AS, severe IVD, or sprain/strain.
LEWIN SUPINE TEST
- Pt supine; Dr holds the ankles on the table & does a partial sit up (to make an L) w/o using their hands.
- *Unable to perform = AS.
FORRESTIER'S BOWSTRING SIGN
- Pt standing; side bending to both sides.
- *Tight mm's on the concave side = AS.
What are the 3 tests for Meningeal Irritation?
- 1. Brudzinski Sign
- 2. Bikele's Sign
- 3. Kernig's Sign
Describe Brudzinski's Sign.
- Pt supine; Dr passively flexes the pt's head to the chest.
- *Buckling of the pt's knees = meningitis.
Name this test...
- *Pt supine; resists extension which causes a kicking motion = meningitis.
BIKELE'S SIGN ???
- Pt actively ABducts shoulder to 90 degrees w/ elbow flexed to 90 degree, then extends the shoulder, then extends the elbow.
- *Up, back, extend ???
- *Resistance = increased radicular pain = meningeal irritation, TOS, brachial plexus neuritis.
What is the ortho test associated with MS?
- Lhermitte's Sign.
- *Pt seated or supine; pt passively flexes head towards chest.
- *Sharp electric shock like sensation down the spine into the extremities = MS, myelopathy.
What ortho test is used to DX a rib FX?
- Sternal compression test.
- *Pt supine; Dr applies downward pressure on the sternum.
- *Pain localized at the lateral rib border = rib FX.
A pt just got back from Vietnam & presents w/ a red hot swollen calf... what ortho test should you do (for boards)?
- Homan's Sign.
- *Pt supine; dr puts leg in 90/90 position & squeezes the calf while dorsiflexing the foot.
- *Deep pain = DVT.
- *Send to ER for anticoagulant therapy.
Pain on the concave side w/ Schepelmann's Sign indicates...
- Intercostal neuralgia.
- *Pain on convexity = pleurisy.
- *Pt raises both arms over their head while seated & lat bends to both sides.
- *Incidental finding: shingles.
- "Where does it hurt?"
Pain _______ indicates intermittent claudication.
Claudication test: pt marches in place, taking 2 steps/second... pain in the calves = intermittent claudication.
Describe the 3 steps for Adam's Test...
- 1. Dr observes the pt's posture from back.
- 2. Observe posture while bending over from back.
- 3. Observe posture while bending over from front.
If the asymmetry does not change with Adam's Positions, that indicates...
- Structural scoliosis (MCly D/T hemi vertebra).
- *Asymmetry changes = functional scoliosis.
Describe the Rib Compression Test.
- Stand behind the pt & wrap your arms around the pt's chest, then extend your elbows thus applying pressure to the lateral aspect of the rib cage.
- *Localized pain = costochondritis.
How do you preform the Spinal Percussion Test?
- Percuss over each SP, then repeat again on the musculature.
- *Call out segments you are on as you are doing it.
- *Time consuming! If you do not have time, skip the mm's.
- *Pain = FX, lig sprain, disc herniation or mm strain.
Which tuining fork do you use for the Spinal Vibration Test?
- The earmuffed one.
- *Pain = VB FX.
- Dr applies finger pressure over the MP. Increase pressure until the pt has discomfort.
- *Used to determine pain threshold.
Verbal compnent for Rust Sign?
- "I noticed you have your hands on your neck. Can you tell me more about this?"
- *Rust sign = cervical instability.
- Dr observes the pt's umbilicus while they do a partial sit-up.
- *Umbilicus moves laterally = T10 NR lesion.
- *Goes up = T11/12 lesion.
- *Goes down = T7-9 lesion.
What would you like to do?
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