Can we have some cell phone ettiquette, please ?Can we have some cell phone ettiquette, please ?

CLINICAL EXAMCLINICAL EXAM

History TakingHistory Taking Keep the question simpleKeep the question simple Ask one at a timeAsk one at a time Get an answer before proceeding to next oneGet an answer before proceeding to next one Avoid putting words into patients mouthAvoid putting words into patients mouth Give equal value to awkward pointsGive equal value to awkward points

CLINICAL EXAMCLINICAL EXAM

MANDATORY QUESTIONSMANDATORY QUESTIONS

CERVICAL REGIONCERVICAL REGION ? VERTIGO,BLACKOUT,DROP ATTACK? VERTIGO,BLACKOUT,DROP ATTACK H/O URT INFECTION (IN JUNIORS)H/O URT INFECTION (IN JUNIORS) H/O RHTD.ARTHRITIS,STEROIDS,ANTICOAGULANTSH/O RHTD.ARTHRITIS,STEROIDS,ANTICOAGULANTS

CLINICAL EXAMCLINICAL EXAM

THORACIC REGIONTHORACIC REGION ? NEUROLOGICAL SIGNS IN LOWER ? NEUROLOGICAL SIGNS IN LOWER

LIMBSLIMBS

LUMBAR REGIONSLUMBAR REGIONS ? PERINEAL ANAESTHESIA? PERINEAL ANAESTHESIA ? CHANGE IN MICTURITION HABITS? CHANGE IN MICTURITION HABITS ? SPHINCTER TROUBLE? SPHINCTER TROUBLE

CLINICAL EXAM OF NECKCLINICAL EXAM OF NECK

SymptomsSymptoms

Pain-Neck itself / Ref. To shoulder & armsPain-Neck itself / Ref. To shoulder & arms Relation to PostureRelation to Posture StiffnessStiffness

Intermittent / continuousIntermittent / continuous DeformityDeformity

Neck fixed in flexionNeck fixed in flexion

CLINICAL EXAM OF NECKCLINICAL EXAM OF NECKCLINICAL EXAM OF NECKCLINICAL EXAM OF NECK

Numbness, tingling & weaknessNumbness, tingling & weakness Headache-suspect other causesHeadache-suspect other causes ““Tension”- ‘Try to read’ the patientsTension”- ‘Try to read’ the patients Target zone for psychosomatic illnessTarget zone for psychosomatic illness

TWO ARMS = ONE NECKTWO ARMS = ONE NECK (If both arms are affected suspect (If both arms are affected suspect

neck)neck)

CLINICAL EXAM OF NECKCLINICAL EXAM OF NECKCLINICAL EXAM OF NECKCLINICAL EXAM OF NECK

LookLook - Deformity- Deformity FeelFeel - Tender areas in muscles /front- Tender areas in muscles /front

- Cervical rib- Cervical rib MoveMove - Forw.flex / ext / lat.flex / rotation- Forw.flex / ext / lat.flex / rotation PulsesPulses - Radial - at rest – on traction- Radial - at rest – on traction NeuroNeuro - Mandatory in upper limbs- Mandatory in upper limbs X-rayX-ray - AP / Lateral- AP / Lateral

EXAMINATIONEXAMINATION

FLEXION / EXTENSION / ROTATION TILT / TESTING POWER ELBOW & WRIST

READING A LAT.FILM OF C.SPINEREADING A LAT.FILM OF C.SPINE

ALIGNMENT ALIGNMENT BONY INTEGRITYBONY INTEGRITY CARTILAGINOUS SPACESCARTILAGINOUS SPACES SURROUNDING SOFT TISSUESSURROUNDING SOFT TISSUES PRE VERTEBRAL SOFT TISSUE PRE VERTEBRAL SOFT TISSUE

SHADOWSHADOW BLOOD / FLUID / PUS / TUMOR MATERIALBLOOD / FLUID / PUS / TUMOR MATERIAL

ANATOMY OF C - SPINEANATOMY OF C - SPINE

TORTICOLLIS

NATURAL HISTORY

EARLY DEFORMITY

STERNOMASTOID DIVIDED

RESULT AFTER SURGERY

SPASMODIC TORTICOLLIS - NOTE THE MUSCLE IN SPASM

CERVICAL DISC LESIONCERVICAL DISC LESION

STRAIGHTENING OF LORDOSIS / MRI SCAN SHOWS C5/6 DISC

CERVICAL SPONDYLOSISCERVICAL SPONDYLOSIS

DISC DEGENERATION & OSTEOPHYTES

PYOGENIC INFECTIONPYOGENIC INFECTION

DESTRUCTION TAKES 2 TO 3 WEEKS

RHEUMATOID ARTHRITISRHEUMATOID ARTHRITIS

BEWARE OF ATLANTO - AXIAL SUBLUXATION

NEURALGIC AMYOTROTHYNEURALGIC AMYOTROTHY

WASTING – WEAKNESS MAY BE PERMANENT

CERVICAL RIB CERVICAL RIB

UNILATERAL / BILATERAL PULSATING LUMP / TEACH SHRUGGING EXCERCISES

MALIGNANT DEPOSITS MALIGNANT DEPOSITS

NOTE THE PAN - COAST TUMOUR

OTHER CAUSES OF NECK & ARM PAINOTHER CAUSES OF NECK & ARM PAIN

CARPAL TUNNEL SYNDROME

SUPRA SPINATUS TENDON LESION

CERVICAL TUMOURS

THORACIC OUTLET SYNDROME

THORACIC SPINETHORACIC SPINE

LOOK LOOK -- DEFORMITIESDEFORMITIES FEELFEEL - - TENDERNESSTENDERNESS NEUROLOGYNEUROLOGY -- TB / PYOGENIC TB / PYOGENIC

/ /

-- METASTASISMETASTASIS TRACKING OF COLD ABSCESSTRACKING OF COLD ABSCESS

CONGENITAL MYELODYSPLASIA

SCHEUERMANN’S THORACIC KYPHOSIS

SCHEUERMANN’S LUMBAR KYPHOSIS

PARALYTIC SCOLIOSIS

OTHER CAUSES OF SCOLIOSIS

CLINICALEVALUATION

ANATOMY OF SPINAL NERVES

NOTE THE RELATIONSHIP OF DISC TO THE ROOTS

YOU STAND ON S1 & SIT ON S3

PRIMARY MUSCLE ACTIONPRIMARY MUSCLE ACTION

HIP FLEXION – PSOAS / ILIACUS = L 2 / 3HIP FLEXION – PSOAS / ILIACUS = L 2 / 3

KNEE EXTEN – VAST INTER = L 3 / 4KNEE EXTEN – VAST INTER = L 3 / 4

ANKLE FLEX – SOLEUS = S 1 / 2ANKLE FLEX – SOLEUS = S 1 / 2

EXCEPTIONEXCEPTION E H L – L 5 ROOTE H L – L 5 ROOT

EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE

PAIN - SCIATICA / PAIN - SCIATICA / COUGH / SNEEZECOUGH / SNEEZE STIFFNESS – DISC / A S / ARTHRITISSTIFFNESS – DISC / A S / ARTHRITIS DEFORMITYDEFORMITY NUMBNESS & / PARAESTHESIANUMBNESS & / PARAESTHESIA ASK ASK WALKING / STANDING / WALKING / STANDING / REST REST ? URETHRAL DISCHARGE/ DIARRHOEA / ? URETHRAL DISCHARGE/ DIARRHOEA /

SORE EYESSORE EYES

EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE

LOOKLOOK – SKIN SCARS / PIGMENTATION – SKIN SCARS / PIGMENTATION

ABNORMAL HAIRS / UNUSUAL SKIN CREASEABNORMAL HAIRS / UNUSUAL SKIN CREASE

SHAPE & POSTURE AFFECTEDSHAPE & POSTURE AFFECTED FEELFEEL – BONYSTRUCTURES / I V TISSUE / PARA – BONYSTRUCTURES / I V TISSUE / PARA

MUSCLESMUSCLES MOVEMOVE – FLEX / EXTD / LAT. BEND / ROTATION – FLEX / EXTD / LAT. BEND / ROTATION

CHEST EXPANSIONCHEST EXPANSION MUSCLE POWERMUSCLE POWER – –

STAND ON TOES STAND ON TOES (PLANTAR FLEXION)(PLANTAR FLEXION)

ROCK BACK ON HEELS ROCK BACK ON HEELS (DORSIFLEXION)(DORSIFLEXION)

EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE

IMAGING – IMAGING – X – RAYSX – RAYS PLEASE PREPARE BOWEL PLEASE PREPARE BOWEL

AP / LATERAL / OBLIQUE & P A VIEW FOR S I Jt.AP / LATERAL / OBLIQUE & P A VIEW FOR S I Jt.

COMPUTED TOMOGRAPHYCOMPUTED TOMOGRAPHY BONE TUMOUR / Sp.CANAL STENOSISBONE TUMOUR / Sp.CANAL STENOSIS

MRI SCANMRI SCAN – FOR SOFT TISSUE – FOR SOFT TISSUE

BEWARE FALSE POSITIVE FINDINGS ( >30%)BEWARE FALSE POSITIVE FINDINGS ( >30%)

EXAMINATION

STANDS WITH A TILT / LTD FORW. FLEX / LAT. FLEX

EXAMINATION

METHOD OF MEASURING EXCURSION

LYING ON HIS BACK

SLRSTRETCH+

HIP & KNEE

EHL

SENSATION

REFLEX

HERNIATED LUMBAR DISC

CHARACTERISTIC POSTURE

L3/4 DISCL4 ROOT

L4/5 DISCL5 ROOT

L5/S1 DISCS1 ROOT

SPINE TUBERCULOSIS

SHOWING PROGRESSIVE DESTRUCTION

SPINE TUBERCULOSIS

PATHOLOGICAL DESTRUCTION & ABSCESS

PYOGENIC SPONDYLITIS

EVIDENCE OF BONE DESTRUCTION + +

MOBILE SCOLIOSIS

POSTURAL FLEXION

SHORTLEG SITTING

PROLAPSED DISC ON TTMT

FIXED SCOLIOSIS

INCREASING CURVE OVER THE YEARS

INFANTILE THORACIC

ADOLESCENT THORACIC

THORACO - LUMBAR

LUMBAR

COMBINED

IDIOPATHIC SCOLIOSIS

TRANSITIONAL LUMBO-SACRAL VERTIBRA

SPODYLOLYSIS & SPONDYLOLISTHESIS

ANKYLOSING SPONDYLITIS

REDUCED CHEST EXPANSION / OSSIFIED LIGAMENTS

DEGENERATIVE OSTEO ARTHRITIS

SPINAL CANAL STENOSIS

CLINICAL FEATURES

MECHANICAL CAUSES OF LOW BACK PAIN

GOOD POSTURE & POOR POSTURE

EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE

EXTENSIVE LAB TESTEXTENSIVE LAB TEST

WHEN CLINICIAN SUSPECTSWHEN CLINICIAN SUSPECTS

MALIGNANCY MALIGNANCY

METABOLIC DISTURBANCEMETABOLIC DISTURBANCE

CHRONIC INFECTIONCHRONIC INFECTION

TUMOURS OF SPINE

OSTEIOD OSTEOMA HEMANGIOMA

BENIGN LESIONS

MYELOMA

SECONDARY TUMOURS

EXTRA DURALFIBROBLASTOMA

EXTRAMEDULLARY MENINGIOMA

INTRA MEDULLARY EPENDYMOMA

CHRONIC BACKACHECHRONIC BACKACHE

TB OM DISCITIS

SI Jt. TB OST. CONDENS. ILII

PSYCHOSOMATIC MANIFESTATION

“ From the unreal lead me to the real ! From darkness lead me to light ! From death lead me to immortality ! Brihad – aranyaka Upanishad

Thank YouThank You

© Dept. of © Dept. of OrthopaedicsOrthopaedics,,Govt. Medical College, Govt. Medical College, ThrissurThrissur