Shoulder Examination

The other day, I did not complete regarding the shoulder cases that I saw in the clinic with Mr Amin. Today Im eagerly would like to share the knowledge that I had. Today, after the session in the clinic had ended & I asked Mr Amin to teach us a proper way to approach shoulder pain.

In my oppinion, eventhough it wont be tested in our professional exam, but during practice, we need still need to know regarding this, right =)

Mr Amin said
"SHoulder is quite difficult for undergraduates & the examination is quite long. So things that Im going to teach today is the basic one" =)

PREPARATION:
1) Expose patient adequately. If male, ask him to take the shirt out. If female, expose the best as you can.
2) make sure the patient shoulder is at the same level as you especially if the patient is too tall or too short. You can examine in sitting position, facing the patient, but make sure the patient did not lean to the seat.
3) Make sure both ( you & the patient) are comfortable.

LOOK: ( Need to do from front, lateral & back. Make sure you compare with the normal side)

Anterior
a) Contour of the shoulder - Shape & any swelling

b) Skin changes - scar, inflammation (redness)

c) Wasting of muscle - indicate prolong immobilisation
- supraclavicular region
- Trapezius, SCM, Deltoid, pectoralis

d) Deformity - any bony prominence such as prominent clavicle due to facture

e) Sulcus sign
- loss of normal shoulder contour with a visible step from the acromion process to the humeral head due to wasting & weakness of the deltoid / subluxation of the glenohumeral joint

f) attitude of both upper limbs
-shoulder internal/external rotation
-elbow flexion / extension
-wrist & fingers deformity

Lateral (go to patient side)
- Skin changes
- WAsting of deltoid muscle

Posterior (go to the back)
a)contour of shoulder

b) skin (scar/inflammation)

c) wasting of muscle
- suprascapular region
- trapezius, deltoid, supraspinatus, infraspinatus, latissimus dorsi

d) prominent medial border of scapulae
- winging of scapula
- long thoracic nerve palsy

FEEL
Palpate along these structures & look for tenderness / feel for any abnormal bony prominence

( Initially stand infront of patient)
From sternal notch --> sternoclavicular joints --> along the clavicle --> acromioclavicular joint --> acromion process

(then, go to the back of patient, continue palpation from the point where you left)
palpate along the spine of the scapulae --> medial border --> tip & lateral border of the scapulae --> until back to the acromion process--> go to subacromion & palpate downwards the humeral head until mid upper arm

tenderness could indicate:-
- sternoclavicular/ acromioclavicular joint OA
- subacromial region for impingement

MOVE
Ask patient to lift the arm upwards with elbow extend in few positions:-
Lateral position (normal position - 20 degree) - 0 - 180 degree
Flexion (0 - 180)
Extension ( 0 - 70 degree)
Abduction (0 - 180 degree)

then ask patient to do:-
Adduction ( 0 - 75 degree)
Internal rotation (0 - 90 degree)
Extrenal rotation ( 0 -90 degree)

Then go to the patient's back & ask patient to flex the elbow & move the shoulder like cycling. Do it simultaneously at both sides, gently & slowly ( but not too slow)
From the back, we put our hand on the scapula, observe & feel the movement.
Normal: there will be slight movement
Abnormal: if the movement is too obvious/marked
Suspect abnormality at the scapula - winging/long thoracic nerve injury

SPECIAL TEST
1) Instability Test (check for any instability - to suspect any dislocation)
a) Anterior drawer test
b) Posterior drawer test
c) With hand dangling downwards, pull the arm downward & observe for sulcus sign
Positive: multidirectional instability

2) Apprehension Test (anterior instability)
- abduct the shoulder & flex the elbow
- then slowly, externally rotate the shoulder
- when patient feels that the shoulder is dislocating anteriorly, he will resist the movement

3) Impingement Test ( empty can sign)
ask patient to abduct the arm
the hands do the thumbs up sign but facing downward (empty can sign)
while patient abducting the arm, we give patient downward resistance
Positive: pain felt at affected shoulder

4) Rotator cuff muscles test
a) Hawkin's test (test supraspinatus muscle)
- abduct the shoulder with elbow flex
- then slowly internal rotate the arm until patient felt pain
- do in few positions as you would like to test the whole supraspinatus muscle
arm abduct, lateral position, flexion
positive: patient felt pain

b) Napolean test (muslim's prayer) - test infraspinatus & teres minor
ask patient to put both hands on the belly like performing prayer
ask patient to push the hand outward & you give resistance to it
positive: patient felt pain at affected side

c) geber's test (test for subscapularis)
- ask patient to put both hands at the back
- try to move the hand upwards until the thumb reach the middle of the back
or you could ask the patient to push outward & you give resistance to it
positive:pain on the affected side

d) felt for biceps tendon tenderness

5) drop arm test
patient lift the arm up
alowly lower the arm
at around 105 degree patient will experience the arm is beyond his control
then arm will drop --> positive

reasons: deltoid muscle requires the intact rotator cuff to pull the humeral head towards the glenoid fossa & stabilise the humeral head to the glenoid fossa in order to allow a lever arm for further abduction by the deltoid
- with tear of the supraspinatus tendon, the leverage is not effective, therefore the deltoid is unable to hold the arm even above 90 degrees

Until here was our lesson with Mr Amin.
But I forget to ask, must we complete examination with checking the sensation
(autonomous area of axillary, radial, median & ulnar)

========End===========

Sports Injury & Shoulder Day

Wednesday in Orthopaedic clinic is for subspecialty (sports injury, paeds case, OA, shoulder, etc)
Yesterday, Mr Shuk advised us to find sports injury cases as it will definitely come for our short case in december. (Soalan bocor!!!hehe)

So we follow Mr Amin, as currently Mr Amin is the one who will do the ligaments reconstruction

me: Mr AMin, can we follow your clinic.
mr AMin: Yes (with a smile)

BUt Mr AMin had a right knee pain today (gout) - syafakallah doctor

1st case is one of IIUM staff.
Previously had underwent Left knee ACL reconstruction in 2004. Currently came with left knee pain.

Examination revealed : positive patella grinding & medial joint line tenderness
Diagnosis : Patellofemoral & medial compartment arthritis
Management: Physiotherapy, cycling, analgesic. TCA 3/12

Later we had lots of shoulder cases

(will complete the entry later.Huuu~ currently something need to be done.)

Day 2 (second part)

Later I went to clinic & follow Mr Shuk Clinic

One of the case was:-
An early 30th gentleman, overweight, walked into the room using stick (both sides)

Mr Shuk: hah, liyana, examined this patient leg. Tell me what you see
Me: terkebil-kebil...ok..here I go~

Look:
There is multiple scars at the left leg
3 vertical scars
1st: medial side estimating about 25cm
2nd: anteriorly but slightly lateral measuring around 30cm
3rd:lateral side estimating 25cm
all of the scars are well healed
There is also multiple puncture scars extending from the distal third of leg up to the lateral thigh - due to external fixator crossing the joint
One irregular healed scar at the middle third of tibia measuring about 10cmx5cm)
Otherwise the leg is not swelling, no deformity & not wasting

Feel:
The scars are non tender,
no edema of the leg
no bony discontinuity felt (try to find bone gap - in case of nonunion)
No bony tenderness (try to locate the fracture site if it is still tender)
pulses equal & CRT <2secs

Move:
fracture site is not mobile
ask patient to move the leg & the joint actively

In conclusion (explanation based on scars)
This patient had closed fracture of upper third of tibia
complicated with compartment syndrome - fasciotomy done (scar at medial&lateral side)
fracture was stabilised with external fixator (external fixator scar)
after wound closed by SSG (the irregular scar), pt undergo plating (the anterior slightly medial scar)


Fuhhh~
Initially dah tertipu ingatkan open fracture due to EF. memandangkan ada fasciotomy trus tuka it is closed fracture. EF was put after fasciotomy done

DAY 2

Yesterday I had one short case session with Mr Azril. He chose Diabetic Foot Ulcer Case & Im the one who examined the patient.

Our session was joined by elective student from Jogja. But since they are still preclinical. So I think many things they still blur.

This is what we had discussed yesterday.

Mr Azril: This patient 37 years old with history of diabetes melitus for 5 years presented with an ulcer. Please do lower limb examination =)

General: (eventhough the Q is LL, but still we need to give the general overview of the patient. Just observe about 30seconds for overview of patient condition. )

This is 37 years old with medium body build
Alert, conscious & comfortable.
Not in pain, not in respiratory distress.

Lower Limb Examination: (make sure to expose the patient adequately)
Look
Both leg is in normal attitude
There was no deformity, no foot drop, no clawing (hyperextension of prox phalanges & flexion of interphalangeal joint) or hammer toes, no pes planus or pes cavus
No muscle wasting ( in this patient - to detect any disuse atrophy)
No scar

There was hyperpigmentation at bilateral leg up to the knee
Skin is very dry & there is some scaly lesion
There is presence of wrinkle sign (indicate previously patient had swollen leg)
There is loss of hair
The nail is brittle
Presence of callosities at the sole

There is a gross, big & deep ulcer at the sole
extending from the big toe to the "ball of 1st toe" --> Mr Azril said to use this term
Estimating about 10cm x 5cm
with regular margin which is due to incision
The ulcer is wet, there's blood & pus with granulation tissue
There is also presence of necrotic tissue
It is foul smelling
There is expose of bone
The surrounding is dry & scally

Feel:
The leg is not warm, no edema
The ulcer is slightly tender
There is no collection of discharge/pus
The bone is not tender (to check any evidence of osteomyelitis)
For Pulse
DPA were palpable bilaterally with equal volume
PTA were not palpable
CRT <2> doc did not discuss detail which I really want to know how it is done
(use 10g monofilament, test at 10 sites..but do no how many pt cudnt feel can we say it is positive)
ABSI (assessment of healing potential)

Q: What is your diagnosis??
Diabetic foot ulcer
based on: (do give reasons straightaway, do not wait for doctor to ask)
- he's DM since 5 years ago
- there is trophic changes, callosity
- site of the ulcer

What is patophysiology behind the DFU?
Triad of neuropathy, ischemic & immune

Neuropathy - sensory, motor & autonomic
what is 1st sensory to loss in DM?? Vibration

How callos is formed?? due to loss of autonomic regulation (the sweat glands), loss of perspiration, later thick, dry callus is form. Could become crack hrough dermis & become source of infection

How clawing happened??
due to imbalance between extensor & flexor of intrinsic muscle of foot
abnormal pressure on plantar expect would lead to either pes planus or pes cavus

How DM have immunosuppression??
impaired leucocyte function (but the number of leucocyte is still the same)
slow chemotaxis & phagocytosis

How you managed this patient???
Investigation
blood investigation
1) FBC - Hb, WBC (as baseline before treatment & as preparation for pt to go to OT)
p/s- eventhough WBC pt normal doesnt mean pt does not have infection of the ulcer. its just because pt is immunosuppressed
2) BUSE
3) Renal Profile (screen for other DM cx)
4) UFEME
5) HbA1c ( glycosylated Hb - to assess the Dm control for past 3months)
6) se albumin - help in healing
7) Lipid profile
8)Swab C&S of wound

Radiological
Xray of the affected toe

===== end of session =====

What A day~

Setinggi-tinggi kesyukuran ke hadrat Ilahi.

Alhamdulillah, I already went through my first day. As usual, I woke up early, pray to Allah to ease my way today & upon reaching JHC, I took good breakfast. I always noticed,having good breakfast in the morning makes my endorphin&serotonin level increased & I feel more relax, happy & could think clearly.

When I reached the ward, I reviewed few patients. Do simple clerking but no PE done yet. I saw Dr Goh reviewed his patient & straight away went to him & introduced myself. But unfortunately he was not the MO doing round that morning. So he just gave me a list of things that I need to cover for my second Professional exam & he told me to focus on it.

So today, I followed Mr Azril at his clinic. He was my supervisor back then when I was Year 4. He still recognised me as one of his mentee.

Currently, Im happy to see Mr Azril in a good health because I still remember previously he had hematemesis & collapse in JHC. He was resuscitated in the A&E & everybody was sooo worried about him. After investigations, he was found to have gastric ulcer due to chronic usage of NSAIDs. After that, he took long MC & we, the mentee had only few classes with him. But that doesnt mean we can skip from going to ward. Instead our groupmates always joined other lecturers for teachings.

Today, most of my time spend in the clinic seeing lots of oncology patients under Mr Azril's supervision.

There was a patient middle age gentleman, medium body build came in with a small lump at his right hand - medial tu cubital fossa. Estimated size was 4x5cm, oval shape, not erythematous, no punctum, no discharge. The mass was non tender & not warm, has regular border, firm to hard consistency, irregular surface, slightly mobile & attach to underlying muscle. suggestive of a tumor.

Mr Azril : What muscle do u think it might attached to / arise from??
Me: Superficial flexor muscle.
Mr Azril: Just say flexor muscle, by palpation it can still arise from deep group muscle.
Me: understood~

Afterwards, mr Azril was flipping through the patient's radiograph but couldnt find the xray of the forearm. But there was CT Scan & MRI belongs to the patient & he look at me....

mr Azril: would like to see the patient's CT scan??
Me: me Looking puzzled~ why?is there any finding??But sorry doctor..what is actually your question?? (laughing~)
Mr Azril: Im trying to find the Xray..so, would you like to look at The CT scan??
Me: No~ (with confident)
Mr Azril: Good..If not I would ask you to go back & read books. (& the laugh continued)

Later,the patient was plan for tru cut biopsy of the small mass to send for HPE next week. The diagnosis was not confirmed yet.

Second patient:
A 50+ year old gentleman came in with a very gross & enlarged swelling of his left arm.

The swelling was from the middle third of upper arm extending down to the middle third of forearm (Series sangat besar - bayangkan macam popeye nye arm. tapi popeye hanya dekat forearm).

Estimated size nearly 40cm length but I coudnt estimate the circumference of the arm. There was scar at the lateral side (incision post biopsy), well healed & presence of dilated veins seen. Otherwise, not erythematous & no discharge
The mass was nontender, not warm, hard in consistency (felt like bone) & irregular surface.

Patient still able to lift the hand, flexed, extend & pronate the hand but the range is reduced compared to the normal side. To my suprise, you could no longer feel the elbow from below when you flexed the affected hand. If you just hold the upper arm & move only the distal forearm. You could feel as if this patient had pseudarthrosis - the forearm was able to move side to side & up& down. The joint was actually destroyed. However, the sensation was intact.

Reviewing the patient's CT scan of left arm. The diagnosis made was synovial chondromatosis. In this patient, it is a benign condition.

Other cases, I able to see were fibrous dysplasia (the deformity in the femur called shepherd's crook deformity - I cant answer this Q, luckily all the HO also cant answer the Q. haha), exostosis & osteoarthritis.

Later, I made an appointment for short case with Mr Azril tomorrow morning at 8.30am before he went for his clinic duty.

Im sooo looking forward for tomorrow's lessons. *Bersemangat mode*

p/s - ouhh ye, one HO asked me "dik, cari ape??" & I was like...erkk..ermm...cari kes tuk shortcase esok with Mr Azril"

HO: kamu year berapa??
Me: Final Year
Ho: bukan exam ke??
Me: saya special skit. kat ortho nie 2mggje
HO: aikk..asal waktu kitorang takde pun??
Me: eh??doktor nie UIA ke??xpenah nampak pun..doktor batch brape??saya sbenarnye remedial...
HO: oo yeke...a'ah.saya batch 8..saya mmg tak duk hostel.duk umah & xbercampur dgn orang sangat. Haha
Me: ouhh 8???atas saya je tue..saya batch 9..meaning doc nie batch mok, nazhan,etc
HO: a'ah angguk2...kamu camane??ada stress2ke??jgn risau ok, kamu mesti boleh wat nye. Kalo ada apa2 xpaham, tanye je saya. tanye je ape2, surgery,paeds, Im, O&G, sume boleh. Nak ajar shortkes pun boleh. If saya takde wad masa tue, call je operator suh sambung kan ke Dr Azrul HO ortho. Biasanya orang macam kamu nie yang akan sambung blaja sampai speacialist... (sambil tersenyum~)
Me: erkkk.. (terkedu seketika)..tima kasih doktor...(dalam hati terkejut dgn keramahan senior yang sorang nie)
later,I end up review some patient with him =)

Sesungguhnya, pertolongan Allah itu selalu ada dimana-mana, btul tak???
Jadinya, kenapa kita selalu bersedih & menyalahkan takdir??
Fikir-fikirkanlah~

Revision & Weekend

Tomorrow will be my first day in Orthopedic department. Its only for 2 weeks.

Last 2 days, I already went to ortho office & inform them of our presence. I did this because they also a human beings & human sometimes do forget. However, the staff there told me to call Mr Shukrimi as previously he was the one who will arrange teachings for us. So, I did.

Mr Shukrimi asked me to informed HOD ; Mr Nazri. BUt since Mr Nazri is about to leave Malaysia for conference next week, he will be the one who will call Mr Nazri. So far the plan for Monday is follow rounds & go to clinic until further notice.

So, here I am. studying for ortho & cancelled my plan to go home his weekend. Yesterday, I went to traumatic course & yeah it did help me in revising the important points in the topic.

Wish me luck in orthopaedic. Hope I can bring my positivities in it.

p/s - Topic for 1st stage revision - common diseases in ortho
- Open Fracture (as well as close fracture)
- Complications of open fracture - compartment syndrome, fat embolism, shock
- Non-union, delayed union, malunion
- Traction, POP
- Diabetic foot ulcer (classification, pathophysio, management & short cases)
- Antibiotics
- Anatomy of Upper Limb & Lower limb
- Nerves (brachial plexus, lumbosacral plexus)
- Peripheral nerves (ulna, median, radial)
& Important physical examinations

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