orthopedic tests

Rather than listing and describing regional orthopedic tests, I’d like to share a few videos I found. The anatomy and test are well described so I found them easy to follow. I hope these help you the way they have helped me. Corrections are welcome!

**NB the thomas test displayed is done incorrectly. Patient should be supine with both knees and hips flexed initially, extending one leg to test. The shown test can give false positive results**

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Ascending Spinal tracts

Tract Functions Path Decussation Tests
Dorsal Columns:

Fasciculus Cuneatus (UEX)

Fasciculus Gracilic (LEX)

Fine touch

Discriminatory touch

Proprioception

Cuneatus:

Fibres from UEX enter at upper thoracic and cervical levels.

Gracilis

Fibres from LEX enter at lower thoracic,lumbar and sacral levels.

Both:

Travel between dorsal median sulcus and horn.Terminate at corresponding nuclei at medulla oblongata.

Medulla Oblongata 2 point discrimination

Joint position

Spinothalamic Pain

Temperature

Pressure

Coarse touch

Fibres ascend in ventral half of lateral funinculus.

Terminates at the thalamus.

Ventral white commisure Neuotips

Cold tuning fork

Spinocerebellar Muscle and joint receptors to cerebellum Cell bodies originate from base of dorsal horn. Fibres pass through dorsolateral and ventrolateral spina cord.
Terminates at the cerebellar cortex.
Ventral:
Anterior white commisure

Dorsal:

No decussation

Joint position test

Finger to nose

Heel to shin

Brain Structures

Brain structures

Structure

Function

Blood Supply

Symptoms of dysfunction

Tests

Cerebellum Motor coordination, precision and timing – Superior Cerebellar art.

– Posterior Inferior Cerebellar art. (PICA)

– Anterior Inferior Cerebellar art. (AICA)

Dysdiadochokene..
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
Wide based gait

Imbalance/toppling forward

Rapid alternating hand

Heel-to-shin

Finger-to-nose

Midbrain Control of eye movement and localisation of sound (with pons) Of Basilar art:
– Posterior Cerebral art.
– Superior Cerebellar

– Posterior Communicating art.

– Anterior Chorodial art.

Ipsilateral CNIII palsy
– weak lateral gaze
Contralateral hemiparesis
‘H’ test

Motor testing

Pons Regulation of breathing, sleep cycles, arousal, relaying info between cerebellum and cerebrum Pontine branches of Basilar:

– Paramedian Branches

– Short Circumferencial art.

– Long circumferencial art.

– AICA

Ipsilateral medial strabismus

Contrlateral hemiparesis

Observation and ‘H’ test

Motor testing

Medulla Oblongata Regulation of breathing, digestion, sneezing, swallowing, heart and blood vessel function Anterior spinal artery:

Hypoglossal nerve, Vagus nerve, median longitudinal fasciculus (MLF), pyramids, medial lemniscus

 

 

 

 

 


– – – – – – – – – – –  

PICA

Spinothalamic tract

Nucleus ambiguus

Hypothalamic spinal tract

Medial Medullary syndrome

Ipsliateral tongue deviation

Contralateral hemiparesis

Contralateral reduced discriminatory touch

Contralateral reduced proprioception

Contralateral reduced vibration sense

– – – – – – – – – – – 

Lateral Medullary Sydrome
Dysphagia
Dysarthria
Dysphonia
Ipsi. Reduced facial pain and temp
Ipsi. Horner’s syndrome
Ipsi. Cerebellar symptoms
Contra. reduced body pain and temp
Vertigo
Vomiting

Protrusion of tongueMotor testing
2 point discriminatory

Joint position test
Vibrating tuning fork

 

 

 

 

 

——————

 

Observation

Further questioning

Neurotips

Cold tuning fork

Ptosis, Miosis etc
DANISH

Brachial plexus – part 2.

In part 1 the roots, trunks, divisions and branches are covered. Here I will be looking at the structures supplied by the branches.

upper extremity peripheral innervation

Root nerves:

Dorsal scapular (C5) – Rhomboid major, rhomboid minor and levator scapulae.
Long thoracic (C5, 6, 7) – Serratus anterior.

Superior trunk nerves:

Subclavian (C5, 6) – Subclavius.
Suprascapular (C5, 6) – Supraspinatus, infraspinatus.

Lateral cord nerves:

Lateral pectoral (C5, 6, 7) – Pectoralis major.
Musculocutaneous (C5, 6, 7) – Biceps brachii, coracobrachialis, brachialis.

musculocutaneous nerve

Posterior cord nerves:

Upper subscapular (C5, 6) – Subscapularis.
Lower subscapular (C5, 6) – Subscapularis.
Thoracodorsal (C6, 7, 8) – Lattisimus dorsi.
Axillary (C5, 6) – Deltoid, teres minor.
Radial (C5 – T1) – Triceps brachii, supinator, anconeus, brachioradialis, extensor carpi radialis.

radial

Medial cord nerves:

Medial pectoral (C8, T1) – Pectoralis major, pectoralis minor.
Ulnar nerve (C8, T1) – Flexor carpi ulnaris, flexor digitorum profundus, LOAF of the hands.

ulnar nerve

*Median nerve receives branches from the lateral (C6, 7) and medial cords (C8, T1) – Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor digitorum profundus, flexor policis longus, pronator quadratus.

750px-Brachial_plexus_2.svg

The brachial plexus also has dermatomes:

brachial dermatomes

Major nerves of the brachial plexus.

Median nerve (C5) C6 – T1.
– Through anterior compartment of arm.
– Lateral to brachial artery (medial arm).
– Crosses to medial side of brachial artery.
– Cubital fossa (anterior elbow).
– Between the two heads of pronator teres. Overworked??
– Between flexor digitorum superficialis and profundus.
– Superficial proximal to wrist.
– Through carpal tunnel.

Radial nerve C5 – C8 (T1).
– Back of arm, same with hand.
– Posterior axilla, behind artery.
– Posterior compartment of arm.
– Between long and medial head of triceps.
– Through radial groove (posterior humerus).
– Pierces intermuscular septum.
Enters anterior compartment.
Anterior elbow.
2 branches:
Superficial: anterolateral forearm.
Deep: posterior forearm.

 

Brachial plexus – part 1.

Formed by the ventral rami of C5 down to T1 providing the entire nerve supply of the shoulder and upper limbs. The plexus extends inferolaterally either side of the last four cervical and first thoracic vertebrae, proceeding to pass over the first rib, behind the clavicle and in to the axilla before continuing along the arms.

The brachial plexus consists of 5 components: roots, trunks, divisions, cords and branches (Rob Taylor drinks cold beer).

brachial plex 1

Trunks.

– Roots of C5 and 6 pass down between anterior and medial scalenes, then unite to form the superior trunk.
– The root of C7 passes through the scalenes muscles and emerges at the lateral border of the anterior scalenes as the medial trunk.
– Roots the C8 and T1 unite behind Sibson’s fascia, beneath the subclavian artery to form the inferior trunk.

All three trunks traverse the supraclavicular fossa, protected by cervical and scalene muscles.

Each trunk splits in two to form anterior and posterior divisions.

Cords.

– The posterior cord is formed of the three posterior divisions of the trunks (C5 – T1).
– The lateral cord is formed of the anterior divisions of the superior and medial trunk (C5 – 7).
– The medial cord is the anterior division of the inferior trunk continued (C8 – T1).

The cords pass through the thoracic outlet and give off major branches.

Branches.

Lateral cord (LML):
– Lateral pectoral nerve (C5 – 7).
– Musculocutaneous nerve (C5 -7).
– Lateral head of Median nerve (C5 -7).

Medial cord (M4U):
Medial pectoral nerve (C8 – T1).
Medial cutaneous nerve of the arm (C8 – T1).
Medial cutaneous nerve of the forearm (C8 – T1).
– Medial head of the median nerve (C8 – T1).
– Ulnar nerve (C7 – T1).

Posterior cord (ULNAR):
– Subscapular nerve (upper and lower) (C5 – C7).
– Thoraco-dorsal nerve (nerve to latissimus dorsi)(C5 – 7).
– Axillary nerve (C5 – 6).
– Radial nerve (C5 – 8).

brachial plex 2

Cervical plexus – part 1.

The anterior rami of nerves C1-4 form the cervical plexus. This plexus lies deep to the sternocleidomastoid (SCM) and internal jugular vein, superficial to the scalenes and levator scapula. Each of the primary rami, except C1, divide into two. C1 joins the upper branch of C2. The adjacent upper and lower branches of C2 and C3 fuse as do C3 and C4. The lower branch of C4 joins C5 and contributes to the brachial plexus.

cervical_plexus1342596044233

C1 joins the upper branch of C2.
The lower branch of C2 fuses with the upper branch of C3.
The lower branch of C3 fuses with the upper branch of C4.
The lower branch of C4 joins C5 and contributes to the brachial plexus.

cervical plexus 1

C1:
– Emerges between occipital bone and 1st cervical vertebrae.
– Often without a dorsal root.
– Consists exclusively of motor axons which innervate the subocciptal muscles, as well as the geniohyoid and infrahyoid muscles via the hypoglossal nerve (CN XII)
– Lacks sensory axons thus no dermatomes.

Deep muscular and communicating branches:

Medial muscular:

Rectus capitis lateralis – C1.
Rectus capitis anterior – C1, 2.
Longus capitis – C1, 2, 3.
Longus coli – C2, 3, 4.
Inferior root of ansa cervicalis – C2, 3.
Phrenic nerve (diaphragm) – C3, 4, 5.

Medial communicating (with):

Hypoglossal – C1, 2.
Vagus – C1, 2, 3, 4.
Sympathetic – C1, 2.

Lateral muscular:

SCM – C2,3,4.
Trapezius – C2(3).
Levator scapulae – C3, 4.
Medial scalenes – C3, 4.

Lateral communicating (with):

Accessory nerve – C2, 3, 4.

Superficial or cutaneous branches:

Ascending branches.

Lesser occipital nerve – C2 (3)
Great auricular nerve – C2-3
Transverse cervical nerve – C2-3

Descending branches.

Medial supraclavicular*
Intermediate supraclavicular*
Lateral supraclavicular*
* All arise from a common trunk formed by the 3rd and 4th ventral rami and emerge from the posterior border of the sternocleidomastoid (SCM).

Lesser occipital nerve.

Supplies skin of ear’s auricle and adjacent portion of the scalp.
Connects with posterior branch of great auricular nerve.

Great auricular nerve.

Largest ascending branch of cervical plexus.
Encircles posterior border of SCM.
Supplies skin over mastoid process, the back of the auricle, the lobule and the concha.

Transverse cutaneous nerve.

Curves around posterior border of SCM.
Supplies upper anterior skin of the neck as well as anterolaterally as far as the sternum.

Medial supraclavicular nerve.

Supplies sternoclavicular joint and skin as far as the midline and down to the level of the 2nd rib.

Intermediate supraclavicular nerve.

Cross the clavicle to supply skin over pectoralis major and deltoids, down to level of 2nd rib.

Lateral supraclavicular nerve.

Supplies skin of upper and posterior shoulder.

Cranial nerves – revision.

cranial nerves

CN I – Olfactory nerve.

Sensory: Smell.

Path: Forebrain – Cribriform plate of Ethmoid bone (remains in skull).

Tests: Asking patient to close eyes and to block one nostril at a time, provide a commonly recognised scent (ie mint or coffee). Request the patient inhales through unblocked nostril and identifies the scent.

Pathologies: Head trauma, upper respiratory infections, sinus diseases, space occupying lesions (SOL).

olfactory-nerves-filaments

CN II – Optic nerve.

Sensory: Vision.

Pathway: Occipital cortex – optic tract – optic chiasm (crossing over) – exit via optic foramen – retina.

Tests: Visual fields (periphery), visual acuity (Snellen chart), accommodation (convergence and constriction with item approaching nose), direct and consensual light reflex.

Pathologies: Multiple Sclerosis (MS), optic neuritis, bitemporal hemianopsis, pituitary tumour, berry aneurysms of the internal carotid arteries.

optic-nerve-lateral-geniculate-nucleus-of-thalamus-optic-radiation-visual-cortex

CN III – Oculomotor nerve (see CN IV and CN VI).

Somatic Motor: Eye movement (all but lateral rectus and superior oblique extraocular muscles).

Path: Midbrain – between superior cerebellar and posterior cerebral arteries – cavernous sinus – superior orbital fissure – orbit.

Innervates all of the extraocular muscles except superior rectus and lateral oblique. (LR-6 SR-4).

Pathologies: Extradural haematoma, aneurysm of posterior cerebral or superior cerebellar arteries.

Test: H test (relevant to CN IV and VI). Ask patient to hold head still while watching your finger. Proceed to move finger in a H shape starting from central point.

oculomotor

CN IV – Trochlear nerve (see CN III and CN VI).

Somatic motor and proprioceptive to superior oblique (extraocular muscle).

Path: Dorsal surface of midbrain – passes anteriorly around brainstem – pierces dura mater – lateral wall of cavernous sinus – superior orbital fissure – orbit – superior oblique (inferiomedially).

Pathologies: Diplopia (double vision), severe head trauma.

Tests: see CN III (inferomedial).

trochlear nerve

CN V – Trigeminal nerve.

Somatic motor: muscles of mastication; mylohyoid, anterior belly of digastric, tensor tympani, tensor veli palatini.

Sensory: Dura of anterior and medial cranial fossa, mucous membrane of nasal cavity, paranasal sinuses and mouth.

Path: Lateral surface of pons – medial part of crest of petrous part of temporal bone – trigeminal cave.

** Has THREE branches:

Pathologies: Cranial trauma, space occupying lesions, aneurysms, meningeal infections, poliomyelitis, multiple sclerosis, dental trauma, herpes zoster opthalamicus, trigeminal neuralgia – episodic pain.

Tests: Sensory – Touch path of nerve along skin, gently with cotton wool.
– Corneal reflex – touch sclera gently to invoke blink.

Motor: Resist lateral movement of jaw.
Ask patient to clench jaw, palpate masseter.

trigeminal_nerve.251185132

CN VI – Abducens nerve (see CN III and CN IV).

Somatic motor to lateral rectus (extraocular muscle).

Path: Brainstem (between pons and medulla) – pontine cistern – straddles basilar artery – pierces dura – petrous part of temporal bone – cavernous sinus – orbit – lateral rectus muscle.

Pathologies: Diplopia present in all eye movements, complete paralysis (SOL), medial deviation, atherosclerotic internal carotid artery.

Tests: see CN III and CN IV.

abducens nerve

CN VII – Facial nerve.

Sensory : Taste in anterior 2/3 of tongue. Floor of mouth and palate.

Motor: Platysma, stylohyoid (posterior belly), digastric, stapedius. (proprioceptors to these muscles).

Path: Junction of pons and medulla – posterior cranial fossa – internal acoustic meatus – facial canal – stylomastoid foramen of temporal bone and parotid gland.
– Main trunk forms intraparotid nerve plexus.

Pathologies: Most frequently paralysed of all cranial nerves.
– Lesion near origin: loss of motor, sensory and autonomic functions.
– Central lesion: Paralysis of  inferior (contralateral) facial muscles.
Bells palsy: Upper motor neurone lesion (UMNL) – stroke/CVA in pons. Bi/Unilateral paralysis.
Lower motor neurone lesion (LMNL) – Usually stylomastoid foramen, trauma, herpes zoster, infection/inflammation.
Multiple sclerosis. Myasthenia gravis. Eye dryness, facial numbing, hearing sensitivity.

CN VIII – Vestibulocochlear nerve (auditory).

Sensory: Hearing, equilibrium and motion.

Path: Junction of pons and medulla – internal acoustic meatus – separates to vestibular and cochlear nerves.

– Vestibular: hair cells of vestibular portion of membranous labyrinth – establishes contact with a number of regions for control of posture, maintenance of equilibrium, coordination of head and eye movements – extends through brain stem and spinal cord – descending component is known as medial vestibulospinal tract (concerned with control of balance and posture) – ascending part connects to nuclei of abducens, trochlear and oculomotor (concerned with coordination of head and eye movements).

– Cochlear: Hair cells of the ‘Organ of Corti’ within cochlear duct of inner ear – inhibitory function, modulating transmission of auditory information.

Pathologies: Acoustic neuroma (benign tumour of 8th CN), tinnitis (peripheral lesion), vertigo (trauma), conductive deafness (external/ middle ear), sensorineural deafness (disease in cochlear or path from cochlear to brain).

Tests: Quick hearing – whisper behind patient or rub fingers together 5cm from each ear.

Webers test (512hz tuning fork ) – vibrate fork and place on the vertex of the patient’s skull
– equal = normal or bilateral conductive loss
– unequal = conductive loss in lesser.

Rinne test (512hz tuning fork) – Vibrating tuning fork base held at mastoid process
– compares superiority of air to bone transmission.
– Air conduction normally longer than bone.
– Reverse indicates loss of sensorineural transmission.

vestibulococh nerve

CN IX – Glossopharyngeal nerve.

Somatic motor: stylopharyngeus.

Visceral motor: Otic ganglion (parotid gland).

Sensory: Posterior 1/3 of tongue, pharynx, tympanic cavity, pharyngotympanic cavity, carotid body and sinus (chemoreceptors).

Path: Lateral medulla – anterior jugular foramen – follows stylopharyngeus – between superior and medial pharyngeal constrictor muscles – oropharynx and tongue.

Pathologies: Pain on swallowing, protruding the tongue, touching the palatine tonsil and eating.

Tests: Ask patient to say ‘ah’. Soft palate should rise up straight and in the midline.

glossopharyngeal nerve IXa

CN X – Vagus nerve.

Somatic sensory: Inferior pharynx and larynx, root of tongue and taste buds.

Visceral sensory: Thoracic and abdominal organs (to proximal 1/3 of transverse colon).

Somatic motor: Soft palate, pharynx, intrinsic laryngeal muscles, intrinsic tongue muscles, palatoglossus.

Proprioception: above muscles.

Path – Lateral medulla – jugular foramen – carotid sheath – root of the neck…
~ Right side: across subclavian artery – side of trachea – back of root of lung – posterior pulmonary plexus – (from lower plexus) descends on oesophagus – oesophageal plexus – abdomen via oesophagus – postero-inferior stomach surface – left side of celiac plexus and lienal (splenic) plexus.
Left side: Enters thorax between left subclavian and carotid arteries – crosses left side of aortic arch – behind root of left lung – posterior pulmonary plexus – anterior oesophagus – unites with right in oesophageal plexus – anterosuperior stomach surface – fundus – lesser omentum – hepatic plexus.

Pathologies: Dysphagia, anaesthesia of superior larynx, aneurysms or aortic arch (neck operations), dysphonia, aphonia, inspiratory stridor (high pitch noise), space occupying lesions (larynx/thyroid), L>R due to longer course.

Tests: Same as CN IX.

vagus-nerve-image

CN XI – (Spinal) accessory nerve.

Somatic motor: sternocleidomastoid (SCM) and trapezius.

Path: Anterior horn motor neurones of upper 5 or 6 cervical roots – foramen magnum – joins CN X at jugular foramen – descends along internal carotid artery – SCM – posterior cervical region – trapezius.

Pathologies: Surgery trauma.

Tests: Ask patient to shrug against resistance.
Rotation of head/neck can indicate contralateral nerve damage.

accessory nerve

CN XII – Hypoglossal nerve.

Somatic motor: muscles of the tongue (styloglossus, hyoglossus, genioglossus)

Path: Medulla – hypoglossal canal – joins cervical plexus somatic motor fibres (C1 and 2) – hyoid muscles – dura mater of posterior cranial fossa – angle of mandible – curves anteriorly to tongue.

Pathologies: Deviation to paralysed side on protrusion (ipsilateral to nerve injury).

Tests: Tongue protrusion test.
ask patient to push tongue against inner cheek while resisting on the outside.

hypoglossal