PHYSICAL EXAMINATION VIDEOS: Part 3

Shoulder Examination

Wrist and Hand Examination

 

(Source: Youtube, Credit: MedRevise)

Hip Examination

Knee Examination

Foot and Ankle Examination:

Spine Examination:

All these videos are from Youtube. Majority of them from GeekyMedics. We have just tried to put them together here. These videos are for educational purposes only.

Emergency Orthopedics

Series of Video Lectures on Emergency Orthopedics for residents from West Virginia University

Lecture 1: 

Lecture 2:

Lecture 3:

Lecture 4:

Lecture 5:

The videos were part of Residency Teaching Modules at the Emergency Medicine Residency Program at the West Virginia University and were conducted by Dr. A. J. Monseau. Thank you Dr. Monseau for the wonderful review on Emergency Orthopedics.

Joint Examinations for MCEM OSCE (Videos Included)

For all Joint Exams:

Gel In

Introduction:

Hi, My Name is Dr.  XYZ, I am one of the ED Registrars who will be taking care of you today.

May I ask know your name please? How old are you? And What do you do for your living?

As I understand you are having pain in the Knee/Shoulder/Wrist/Hip? Let me offer you some pain medications before we begin your examination. I have been asked to examine you, is that okay with you?

But before I begin, I want to know since when are you having this pain, and is it radiating anywhere, Did you get hurt or injured? Are you on any medications like steroids? Are you having any medical illness? If Upper limb, ask if they are right or left handed.  Are you having any other symptoms?

I would like to get your vitals signs recorded.

I would examine your  Joint by looking and then feeling, and then doing some specific tests and then we can summarize. Does that sound Okay?

I begin with your general appearance, and you appear to be in hemodynamically stable.

Ideally, I would like to expose and examine one joint above and below, maintaining privacy (Chaperone if female patient)

On inspecting both your joints from front, sides, and back, I am looking for any gross deformity of skin, any scars, bruises, signs of inflammation, any muscle atrophy, and the overall integrity of your joint.

Now, I would like to palpate the joint: Feel the temperature and crepitus, feel the joints and associted structures.

Next, we move on movements (Active & Passive)

Special tests:

Shoulder: Test for Impingement (NEER), Integrity of Infraspinatus & Teres minor (External Rotation), Internal Rotation (GERBER), Drop arm test (Supraspinatus)

Wrist & Hand:

Median Nerve: Abductor pollicis, FDP Index, Volar flexion of palm

Ulnar Nerve: FDP Little finger, Abbductor (Paper between Ring & Middle)

Radial Nerve: Dorsiflexion

Brachioradialis: Flexion at elbow

Radial: Extension at Elbow (Triceps)

Hip: Thomas Test, ER, IR, Abduction, FABER, FADIR

Knee: Drawer Tests, Collateral Stretch, Mc Murray Test

(In lower limb joints, Check Gait)

Finally, end the examination by thanking the patient and inform them that you would like to examine the joints above and below, and do a detailed neurovascular assessment soon.

Inform them the possible diagnosis, and tests required and further management plan.

Ask if the have any concerns.

Thank the examiner (Present to the examiner)

Gel out!!!

Look at these good videos on Hip & Knee Examination from OXFORD Medical

Hip Examination

Knee Examination

Send me your feedback and suggestions in the comment section below.

Good Luck with your exams!!!

Ottawa Knee Rule: Mnemonic

WAIT get an X Ray of Knee if:

W     Inability to bear weight (4 steps) both immediately and in ED
A      Age greater than or equal to 55
I      Inability to Flex Knee to 90 degrees
T     Tenderness isolated to patella or head of fibula

Lower Back Pain

A frequently tested topic in the OSCE part of the MCEM Examinations

History taking
Examination

Remember if the station involves history, go about in these steps:

Hi, My name is Dr.                                , one of the emergency department registrars. May I know your name please? How old are you? And What do you do for your living?

I understand that you have back pain.... I would like to give you some medications for your pain. Well,... I have been asked to take a history about your pain, Is that Okay with you?

Ask SOCRATES of pain, Past similar complaints, Allergies, Past Medical & Surgical History, Medications, Urinary and GI habits, Social history.

Remember to look for REDFLAGS: TUNA FISH

T     Trauma, Tuberculosis
U     Unexplained loss of weight, Night sweats
N     Neurological Deficits, Bowel & Bladder incontinence
A     <20 and="">55
F     Fever
I      IVDU
S     Steroid use or immunosuppressed
H    History of Cancer, early morning stiffness

Ask for Physical examination to be performed, and certain tests like FBC, U & E, CRP, X ray and/or MRI

Thank the patient and Examiner

1. For OSCEs asking for physical examination, remember the following things:

Hi, My name is Dr.                                , one of the emergency department registrars. I understand that you have back pain.... I would like to give you some medications for your pain. Also, I would like to do a physical examination on you. Is that Okay with you?

Before I begin, I would like to know/obtain the vital signs of my patient.

The examination of spine consists of:

1. Range of movements of spine
2. Neurological examination of the lower limb
3. Nerve Stretch tests: SLR, Femoral Stretch tests
4. Gait

Read the question carefully, as they may just ask you to perform specific components. Look for the following videos for further idea about the examination.

(Video Credits: Dr Claire B. & Dr Simon C.)

Back Pain RED FLAGS Mnemonic

(Courtesy: Dr Salim Rezaie)

Ottawa Ankle & Foot Rule

Ottowa Ankle and Foot rules
Ankle radiographs are only required if there is pain in the malleolar area and any one of the following:
Bone tenderness over the distal 6cm of the posterior edge or tip of the lateral malleolus
Bone tenderness over the distal 6cm of the posterior edge or tip of the medial malleolus
Inability to weight bear immediately and in the Emergency Department

Foot radiographs are only required if there is pain in the midfoot area and any one of the following:
Bone tenderness at the base of the fifth metatarsal
Bone tenderness at the navicular bone
Inability to weight bear immediately and in the Emergency Department

Ottowa rules do not apply to the following

Pregnant women
Head injury patients with diminished ability to follow test
Intoxicated patients with diminished ability to follow test
Children under 6

Ankle Fractures: Weber Classification

Weber classification system for ankle fractures

Type A – fracture below the level of the syndesmosis
Type B – fracture at the level of the syndesmosis
Type C – fracture above the level of the syndesmosis



(Source: Radiopedia, 2014)

Case Study 3: Orthopedic Emergencies

55 year old male presents to ED with history of fall on right shoulder when his bike slipped on the freeway. He is concious and oriented, but complains of severe pain on right chest dorsally and shoulder region. His vitals are stable, and chest examination has normal findings, except for minor bruises near shoulder and back. The ED physician orders a CXR (AP/Lat) as the patient was in severe pain, and insisted on getting an X ray done. The X ray films are as below. What would be the diagnosis and management in the ED?