Examination of the Spine, lumps, bumps and ulcer 2.pptx

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1. Examination of the Spine

2. Cervical spine examination

3. I nspection Deformity Instability of the cervical spine Abnormal head posture Torticollis (affected side and chin often tilted to opposite side

4. Palpation T enderness and masses Midline tenderness in the cervical spine Lateral aspects of vertebrae Paraspinal tenderness Crepitation

5. Cervical movement Flexion Extension Lateral flexion Lateral rotation

6. Neurological involvement C5 nerve root: Muscle weakness: shoulder abduction and flexion/elbow flexion. Reflex changes: biceps. Sensory changes: lateral arm. C6 nerve root: Muscle weakness: elbow flexion/wrist extension. Reflex changes: biceps/supinator. Sensory changes: lateral forearm, thumb, index finger. C7 nerve root: Muscle weakness: elbow extension, wrist flexion, finger extension. Reflex changes: triceps. Sensory changes: middle finger. C8 nerve root: Muscle weakness: finger flexion. Reflex changes: none. Sensory changes: medial side lower forearm, ring and little finger. T1 nerve root: Muscle weakness: finger abduction and adduction. Reflex changes: none. Sensory changes: medial side upper arm/lower arm.

7. Thoraco-lumbar spine examination

8. Inspection A bnormal gait and posture Superficial landmarks include: C7 is the most prominent spinous process at the base of the neck T7/T8: lower border of scapulae. L4: iliac crests. Assess curvature Other abnormalities Functional overlay

9. Palpation Tenderness of the spine Palpate from first thoracic vetebra and move downward to sacrum Movements Range of motion Dorsal spine Rotation to left and right Normal 45 degree Lumbar spine Forward flexion (schober’s test) Normal 0 to 60 Extension Normal 0 to 25 degrees Lateral flexion Normal 0 to 30 degress

10. Forward flexion(modified schober test) Locate L5 spinous process Level of posterior superior iliac spine Mark points 5cm below and 10 cm above Ask patient to touch the toes Measure distance between marks Normal >5cm Abnormal <2.5cm

11. Extension Flesche test The occiput to wall distance should be zero

12. Lateral Flexion Angle between the imaginary vertical midline axis and the straighht line joining T1 and S1 vertebra is measured

13. Suspected prolapsed intervertebral disc Straight leg raising Bowstring test Lasegue's sign Femoral stretch test

14. Hip and sacroiliac joint examination R ange of movement and for pain or limitation Osteoarthritis of the hip may be clinically confused with low back pain, particularly prolapsed intervertebral disc. To assess the sacroiliac joint: With the patient lying prone, elicit sacroiliac joint tenderness by applying firm pressure with one hand over the sacrum and the upper natal cleft. Then flex the hip and knee, and then adduct the hip

15. Lumps, bumps and ulcers

16. Site Anatomical location Usually expressed in terms of distance from a bony prominence Relationship to surrounding structures It may be possible to determine the anatomical plane from information given in the history or on examination Size Measured using a tape measure or ruler At least two dimensions (and three where possible)

17. Shape Three dimensions when describing its shape Surface (appearance and colour) Appearance Is it smooth or rough; flat or raised; regular or irregular? Is there any evidence of ulceration (skin breakdown) or necrosis (blackened, usually secondary to ischaemia)? Normal skin often overlies deep lumps, while superficial swellings are more likely to result in a change in the overlying skin Colour The lump may be the colour of the overlying skin or may appear red and inflamed Certain lumps are abnormally pigmented Surface (appearance and colour) Appearance Is it smooth or rough; flat or raised; regular or irregular? Is there any evidence of ulceration (skin breakdown) or necrosis Normal skin often overlies deep lumps, while superficial swellings are more likely to result in a change in the overlying skin discharges Colour The lump may be the colour of the overlying skin or may appear red and inflamed Certain lumps are abnormally pigmented

18. Consistency Hard, firm (rubbery or spongy) or soft Pulsatility Is it pulsatile, suggesting a vascular origin Try to determine whether the pulsation originates from the lump itself or whether it is transmitted from a nearby vessel Fluctuation To test for fluctuation put your fingers on either side of the lump, opposite each other. Press with one finger and feel whether the lump bounces against your other finger This indicates a fluid- or fat-filled lump If the lump is thought to contain fluid, this can sometimes be confirmed by eliciting a ‘fluid thrill’

19. Mobility Observe first whether the lump moves spontaneously, on respiration or with muscular contraction Certain lumps have a characteristic mobility. The mobility of other swellings may vary depending on anatomic site and other factors Lesions that lie superficial to a muscle group should be tested for mobility with the underlying muscles both relaxed and contracted If a previously mobile lump becomes fixed on contraction of the underlying muscles it is likely that the lesion has infiltrated the muscle layer Mobility can also be reduced by ‘skin tethering’, which reflects an inflammatory or neoplastic process Tethering can be demonstrated by gently moving the lump in two planes, looking carefully for wrinkling or pulling of the skin Transillumination Using a pen torch, shine a light across the lump – ideally in a dark room A swelling containing clear fluid will glow when this test is performed, such as in: Simple cyst Hydrocele Cystic hygroma It is important to note, however, that lipomas (fat-filled lumps) will also transilluminate