The Orthopaedic Examination: A Comprehensive Overview

Angular Deformity

The clinician first needs to know and recognize the normal alignment and deviations of the limbs of the growing child. Infants usually appear to have bowed and internally rotated lower extremities which gradually straighten with growth. Parents need education and reassurance relative to normal deviations, and clinicians need to recognize more significant deviations from normal.

Alignment deviations in the coronal plane are described as valgus, in which the apex of angulation points to the midline, and varus, in which the apex points away from the midline ( Figs. 3.1 and 3.2 ). Thus, “knock knee” is called genu valgus and the term for bowlegs is genu varus ( Fig. 3.3 ). Deviations in the sagittal plane are termed procurvatum in which the apex of the bow is anterior and recurvatum with the angulation pointing posteriorly ( Fig. 3.4 ).

Most clinicians describe angulation by a visual estimate. A hinged goniometer may be used for greater accuracy. ^{, ,} Clinical photographs are especially useful to determine if deformities are improving or worsening over time.

So-called “normal” alignment variations have been studied extensively. ^{, ,} With the elbow in full extension, the angle at the elbow, called the carrying angle, is approximately 15 degrees of valgus. Normal variations range from a near zero degrees of valgus to 20 degrees or more. Malunited elbow fractures often result in a varus deformity.

The lower extremity alignment in infancy is usually 10 to 15 degrees of varus angulation. Between ages 14 and 22 months the knee is usually straight, or at zero degrees of angulation. By age 3 there is approximately 10 to 15 degrees of valgus angulation. This angulation decreases such that by age 7 or 8 the adult alignment of 5 to 7 degrees of valgus has been reached. ^,

Most clinicians describe angulation as visual estimates, and for greater accuracy a hinged goniometer may be used. Clinical photographs are very useful to determine if deformities are improving or worsening over time.

The Shoulder

The shoulder has the greatest range of motion of any joint in the body, allowing a myriad of positions and planes of motion. Shoulder motion is divided into true glenohumeral motion, pure scapulothoracic motion, and combined glenohumeral and scapulothoracic motion ( Fig. 3.5 ). Extension (backward motion) and flexion (forward motion) of the shoulder occur in the sagittal plane ( Fig. 3.6 ). Abduction and adduction of the shoulder occur only in the horizontal plane from the midsagittal zero position of the body ( Fig. 3.7 ). Abduction is motion of the arm away from the midsagittal axis of the body; adduction is movement of the arm toward the axis.

During the physical examination, shoulder motion is assessed with the patient standing. The term elevation (i.e., flexion) is used to define all upward motions of the humerus in any plane (see Fig. 3.6B ). The zero starting position is with the arm at the side of the body. When assessing range of elevation of the glenohumeral joint, the examiner immobilizes the scapula against the thorax (see Fig. 3.5A ). In combined glenohumeral and scapulothoracic motion, the scapula rotates upward and forward over the chest wall, allowing the shoulder to elevate to 180 degrees (see Fig. 3.5B and C ).

When the shoulder is elevated, the first 20 degrees of motion represents pure glenohumeral joint motion, and the scapula does not move ( Fig. 3.8A ). After this point, continued elevation of the arm results in combined movement of the glenohumeral and scapulothoracic articulations in a 2:1 ratio (i.e., for every 3 degrees of total shoulder elevation, 2 degrees of elevation represents motion of the glenohumeral joint and 1 degree of elevation comes from the scapulothoracic joint ; see Fig. 3.8B ). When the scapula is immobilized, pure glenohumeral elevation is approximately 90 degrees (see Fig. 3.8C ). At approximately 120 degrees of combined shoulder elevation, the surgical neck of the humerus abuts the acromion process (see Fig. 3.8D ). Complete elevation of the shoulder (i.e., 180 degrees) is a combined glenohumeral and scapulothoracic movement (see Fig. 3.8E ).

Shoulder extension (posterior elevation) is motion of the extended arm in the opposite direction from that of forward elevation (see Fig. 3.6A ). For maximum extension, the shoulder must rotate internally. Normally, the shoulder is able to extend 45 to 55 degrees.

Internal and external shoulder rotation are assessed with the patient’s arm in the neutral position and the examiner standing in front of the patient. The patient’s elbow must be at the side of the body and flexed 90 degrees. The forearm, which is parallel to the sagittal plane of the body, is rotated internally toward the sagittal axis of the body and externally away from the body. The shoulder is the axis and the forearm is the indicator of motion ( Fig. 3.9A ). The normal range of internal shoulder rotation is 50 to 60 degrees (the chest wall blocks its motion), and the normal range of external shoulder rotation is 40 to 45 degrees.

Shoulder rotation may also be assessed with the neutral zero position of the shoulder at 90 degrees of elevation and 90 degrees of abduction, and with the forearm parallel to the floor (see Fig. 3.9B ). In internal rotation, the arm is moved inferiorly toward the floor, with the average internal rotation approximately 70 degrees. Restricted internal rotation in this position may be due to shoulder instability. In external rotation, the shoulder is moved superiorly toward the ceiling, with the average external rotation approximately 100 degrees.

There are a number of quick and easy methods of clinically estimating active shoulder range of motion. To measure shoulder elevation, the patient should stand with elbows straight and forearms fully supinated, and then raise both arms vertically and touch the fingers over the head ( Fig. 3.10A ). To measure horizontal abduction and external rotation, the patient should place both hands behind the neck and push the elbows posteriorly (see Fig. 3.10B ). Adduction and internal rotation are measured by having the patient reach across the chest and touch the opposite shoulder (see Fig. 3.10C ). Extension, internal rotation, and adduction are tested by having the patient reach behind the back and touch the lower angle of the opposite scapula (see Fig. 3.10D ). Elevation, internal rotation, and adduction are tested by having the patient reach behind the head and neck and touch the upper angle of the opposite scapula (see Fig. 3.10E ). Finally, having the patient reach behind the back and touch the opposite buttock allows the examiner to measure extension, adduction, and internal rotation (see Fig. 3.10F ). (These measurements are best used comparing both sides.)

The Elbow

The elbow is a joint with both a hinge component between the humerus and the radial head and the ulna, and a rotary component between the capitellum and the radial head ( Fig. 3.11 ). ^, The hinge component allows flexion to around 160 degrees and extension to neutral or zero degrees. In some individuals hyperextension to 10 or 15 degrees is found. ^,

The Forearm

The rotary motion of the forearm is termed pronation as the hand is rotated to the palm down position. The opposite motion of turning the hand upward is termed supination. This motion of the forearm involves the humerocapitellar joint, the proximal radioulnar joint, and the distal radioulnar joint. The neutral position is when the palm is parallel to the sagittal plane, and pronation usually reaches 80 degrees and supination 90 degrees ( Fig. 3.12 ). ^{, ,}

The Cervical Spine

In the neutral position the head is level with the ears parallel to the ground, the orbits facing ahead, and the chin centered over the midline. Head motions are termed tilt, or lateral bending ( Fig. 3.13 ) as the ear approaches the shoulder in the coronal plane, rotation as the head moves in the horizontal plane with the chin approaching the shoulder ( Fig. 3.14 ), flexion and extension as the chin moves toward and away from the sternum in the sagittal plane ( Fig. 3.15 ). Right and left tilt occur to around 50 degrees, right and left rotation to 90 degrees, and flexion usually allows the chin to touch the sternum and extension to approximately 70 degrees. ^b

b References , , , , , , .

The vertebral levels involved in cervical motions are noted in Boxes 3.2 and 3.3 .

Box 3.2

Cervical Range of Motion at Different Vertebral Levels

• Occiput to C1: Substantially greater extension than flexion

• C1–6: Flexion and extension approximately equal

• Lower cervical segments: Flexion/extension greater, with maximum movement at C5–6

• C6–T1: Flexion greater than extension, particularly at C7–T1

Box 3.3

Movement of the Vertebrae at Various Levels of the Cervical Spine

• C1–2: 55%–60% of rotation occurs at this level.

• Occiput to C5: Flexion is coupled with rotation.

• C5–7: Extension is combined with rotation.

• Upper cervical spine: Lateral bending goes in opposite direction of rotation.

• Lower cervical spine: Bending goes in same direction as rotation.