1. Orthopaedic Examinations
Sohaib Deen

2. Introductions Wash hands
“Hello, my name is Sohaib Deen and I’m a 4th year medical student. Can I confirm your name and date of birth?”
“It’s James Day, 4/10/1965”
Nice to meet James. Today, I’ve been asked to perform a shoulder examination on you. This will involve having a look and feel of both your shoulders, before putting them through a range of movements. Will that be ok?
“Yes, that’s fine”
“Before we begin, are you in any pain at the moment?”
“Yes, my right shoulder is hurting” -> “Ok, I’ll begin by examining your left shoulder”
“No” -> “Brilliant”
“For this examination, I need you to undress from the waist upwards.”
Women: no need to remove bra -> male doctors may wish to offer chaperone
“Can you just stand opposite me to begin with.”

3. Look
Observe patient from all 4 sides, comparing both shoulders -> look for
Asymmetry
Muscle wasting: deltoids
Surgical scars
Obvious swelling or redness
Winging of scapula
Slanted/hunched posture
Tattoos
Ask the patient to move (makes you look much more professional)
“On general inspection, there is no sign of any asymmetry, muscle wasting, surgical scars or obvious swelling or redness”

4. Feel
“I’m now going to have a feel of your shoulder joint. You said that your right shoulder was hurting, so I will start by feeling the left side.”
“Please let me know if you feel any discomfort”
Look at patient to see if they look in pain
Assess temperature: use sweeping motion with back of hand
Sternum -> along clavicle -> acromio-clavicular joint -> coracoid process -> around head of humerus -> spine of scapula -> back up
Assess inflammation: palpate around joint margins
Do other shoulder!

5. Move
“Now I’m going to assess the movement of your shoulders. Is that ok?”
“Copy what I do”
Active movements:
Flexion: “Bring our hands all the way up as far as you can” -> 180
Extension: “And now all the way back” -> 45
Abduction: “Now all the way out to the sides and above your head) -> 180
Mid-arc pain (60-120) indicates impingement
High-arch pain ( ) indicates acromio-clavicular joint pathology
Adduction: “And now back down and across” -> 45
External rotation: “Can you hold your elbows at 90 degrees and tuck them into your sides, then move your arms outwards” -> 70
Internal rotation: “And finally can turn around and put your hand behind your back and reach up as high as you can” -> T4/T5 (T4 = nipple line)
Passive movements:
“Now we’re going to do the same movements again, but I’m going to do them for you. Can you let your arm go nice and floppy for me.”
Start with unhurt side
“Let me know if you experience any discomfort”
1 hand on shoulder (feel for crepitus) and the other on forearm

6. Special Tests: Winged Scapula
Ask patient to hold hands out and push against wall
Observe for winging of scapula from behind patient
Most likely differential: serratus anterior weakness/paralysis due to damage/impingement to the long thoracic nerve
Can sometimes notice this during ‘Look’ of ‘Look, Feel, Move’

7. Special Tests: Impingement
Passively abduct arm
“Can you slowly bring your arm down”
Pain between indicates impingement (known as painful arc)
Most likely differential: supraspinatus tendinitis -> impingement beneath of the supraspinatus tendon under the acromium causing inflammation
“The patient displays a positive impingement test on his right side, which is a sign of supraspinatus tendinitis”
Other impingement tests: Empty Can Test; Hawkins’ Test

8. Special Tests: Scarf Test
Ask patient to flex elbow and shoulder 90, and place hand on opposite shoulder
Push forcefully backwards to put pressure on acromio-clavicular joint
Pain indicates ACJ pathology

9. Special Tests: Rotator Cuff Muscles
Supraspinatus: Jobe’s Test
“Can you put your arms out like this (15-30) and stick your thumbs down to the floor”
“Push against my hand as hard as you can”
Subscapularis: Gerber’s Lift Off Test
“Can you put your hand on your back (mid-lumbar level) with the back of your hand touching your back”
Hold their hand in position
Try and lift your hand as high as you can”
Infraspinatus and Teres Minor
“Can you bend your arm 90 and push out against my hand”
Findings:
Loss of power suggests a tear
Pain suggests tendonitis

10. Finishing Off
“That’s the end of the examination, thank you for letting me examine you today. You can now put your clothes back on.”
Wash hands
Summarise to examiner: “in summary, this is a shoulder examination of Mr Day, who is 51 years old. Upon inspection, there were no gross abnormalities of either shoulder. On palpation, there was no warmth or swelling of either joint. There was a normal range of active and passive movements with no crepitations. There was no abnormalities found on any of the special tests”
“To complete my examination, I would like to examine the joint above, which is the cervical spine, and the joint below, which is the elbow. I would to perform a full neurovascular examination of the upper limb (and if indicated, I would like to view any plain radiographs that are available).
TIP: if you’re running short of time and can’t do/remember the special tests, add them into the ‘to complete my examination section…”

11. Practice Questions What movements do the rotator cuff muscles perform?
Subscapularis
Supraspinatus
Infraspinatus
Teres Minor
What is a positive impingement test most likely to indicate?
Which nerve roots supply supraspinatus?

12. Rotator Cuff Muscles Muscle Movement Innervation Subscapularis
Internal Rotation
Upper and Lower Subscapular Nerves (C5-C6)
Supraspinatus
Abduction
Suprascapular Nerve (C5)
Infraspinatus
External Rotation
Suprascapular Nerve (C5-C6)
Teres Minor
Axillary Nerve (C5)

13. Knee Examination
Same introduction as shoulder exam, except remove trousers instead of shirt

14. Look Look around bedside for:
Walking aids: crutches; wheelchair; Zimmerframe
Observe patient from all 4 sides, comparing both knees -> look for
Alignment: genu valgus (knock-knees) or genu varus (bow-legged)
Muscle wasting: quadriceps
Surgical scars: ACL repair; knee replacement; arthroscopy (can be discrete)
Obvious swelling or redness: effusion; infection; Baker’s cyst
Skin changes: psoriasis; eczema; arthritic nodules
Tattoos
Assess gait
“Can you just walk towards the door for me… and back. Was there
any pain there?”
Observe for antalgia (limp), signs of pain etc.
“On general inspection, there is no sign of any asymmetry, muscle wasting,
surgical scars or obvious swelling or redness. Gait appeared normal with no
signs of antalgia.”

15. Feel
“Could you please lie down on the bed for me. I’m now going to have a feel of your knee joint. You said that your right knee was hurting, so I will start by feeling the left side.”
“Please let me know if you feel any discomfort”
Look at patient to see if they look in pain
Assess temperature: use sweeping motion with back of hand
Anterior thigh -> medial and lateral joint lines -> patella -> tibial tuberosity -> MCL and ACL course -> popliteal fossa
Compare both sides
Assess inflammation: palpate around joint margins
Test for effusion:
Firmly force any fluid out of suprapatellar pouch (an extension of the synovial sac) -> occlude pouch with 1 hand -> lightly tap patella -> positive result: excess fluid will push patella downwards
“There was no sign of warmth or inflammation around either knee joint, nor any effusion.”

16. Move “Now I’m going to assess the movement of your knee. Is that ok?”
Active movements:
Flexion: “Bend your knee and bring your heel towards your bottom as far as you can. Keep your foot on the bed” -> 135
If the patient can’t flex to 135, is it due to pain or stiffness?
Extension: “And now all the way back” -> 0
Passive movements:
“Now I’m doing to do it. Can you let your leg go nice and floppy for me.”
Start with unhurt side
“Let me know if you experience any discomfort”
1 hand on knee (feel for crepitus) and the other on ankle

17. Special Tests: Collateral Ligaments
Tuck the knee under your armpit and hold knee with other hand
Medial collateral: push knee medially
Lateral collateral: push knee laterally
Repeat tests at flexion and full extension -> this helps to test function of ligaments at partial and full laxity
If patient is in pain, ask whether which side of the knee is hurting -> it might be the side that you are pressing!
Diagnosis: torn collateral ligament

18. Special Tests: Cruciate Ligaments
Flex the knee 90 and sit on foot (ask if there is any pain in their foot first!)
Place hands on proximal tibia with thumbs on tibial tuberosity and fingers on posterior tibia
Anterior drawer test: pull tibia forwards firmly
Posterior drawer test: push tibia backwards firmly
Look for major movement of the tibia away from the femur
“There was no sign of any tears or abnormalities of either the collateral or cruciate ligaments”
Remember to ask and look for signs of pain!

19. Special Tests: McMurray’s Test
Flex knee 90
Place palm over anterior surface of knee, with fingers on medial joint line and thumb on lateral joint line
Place right hand on patient’s foot
Test medial meniscus: palpate medial joint line whilst externally rotating and extending the knee, pushing the leg in a valgus direction
Test lateral meniscus: palpate lateral joint line whilst internally rotating and extending the knee, pushing the leg in a varus direction
Meniscal injury: popping or pain at joint line

20. Finishing Off
Same as shoulder -> joint above is hip and joint below is ankle

21. Practice Questions What is a Baker’s cyst?
What are the common symptoms of osteoarthritis?
What conservative/medical/surgical treatments would you suggest for a patient with osteoarthritis?

22. Orthopaedic Examination Tips
Don’t panic if you forget -> ALL orthopaedic examination follow the same ‘Look, Feel, Move’ template (except GALS)
If you come across an exam you haven’t practiced, think about the movement of the joints and test them actively and passively
Give yourself extra thinking time by learning the introductions perfectly
Regularly ask about pain, and show compassion
Compare both sides
Remember to tell patient to re-dress after completing the examination, before turning to the examiner
If there is something you miss out, go back and do it at the end, even after you have summarised
If you haven’t finished with 1 min left, finish what you’re doing and then summarise to the examiner -> add in the bits you skipped in the ‘to complete my examination’ section

23. OSCE Revision Tips Make a list of the stations you need to learn
Practice in groups of 3+ (1 examiner, 1 patient, 1 doctor) -> always give 1 piece of advice for improvement to the doctor after each practice
Practice like an OSCE -> do proper introductions and stick to the time constraints
Understand WHY you are performing each step in an examination, e.g. Gerber’s test is to look for abnormal subscapularis pathology
Practice summarising quickly -> use phrases like ‘there are no peripheral abnormalities/stigmata’ and …
Watch online videos -> there are many ways to examine so the more you watch, the more ideas you will have. Geeky medics are excellent for Y3 OSCE level
Don’t overlearn 1 exam to perfection -> cover as many bases as you can

24. Mark Schemes