Chapter VIII :Examination of spine and Extremities

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1 Chapter VIII :Examination of spine and Extremities
原南京中大附属医院神内科主任、硕士生导师 佛山大学医学院医学系孟红旗教授、主任医师 Professor、Doctor director 、Neurologist

2 Section 1 、Examination of Spine
颈神经(cervical nerve) 8对， cervical vertebra= 7 胸神经(thoracic nerve) 12对， thoracic vertebra = 12 腰神经(lumbar nerve) 5对， lumbar vertebra = 5 骶神经(sacral nerve) 5对， sacral vertebra = 5 尾神经(coccygeal nerve) 1对， Coccygeal vertebra = 4

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4 一、Curvature of spine (一)Physiologic curvature
Four curvatures including cervical, thoracic, lumbar and sacral vertebrae can be seen in human when observed laterally, characterized as shape “S”. Lateral curvature may not be inspected in normal people.

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6 (二) curvature of Pathological
Surface positioning

7 Spinous process of cervical vertebra 7

8 1.脊柱后凸(kyphosis) Kyphosis or gibbus

9 kyphosis This condition usually occurs in thoraci spine. Causes:
rachitis: more in children. tuberculosis Rheumatoid spondylitis Osseous retrograde degeneration Others: trauma, dysplasia, or spondylous osteochondritis.

10 a curving of the spine that causes a bowing of the back, such that the apex of the angle points backwards leading to a hunchback驼背 or slouching posture. a spinal deformity that can result from trauma, developmental problems, or degenerative disease. can occur at any age, although it is rare at birth.

11 1.脊柱后凸： 驼背，多发生于胸段。 1）佝偻病： 小儿，胸段明显均匀性向后弯曲，卧位时弯曲可消失。
2）脊柱结核： 棘突明显向后凸，成角畸形，病变常累及下胸段及腰段。 3）强直性脊柱炎： 成年人。脊柱胸段成弧形后凸，常有脊柱强直性固定，仰卧位时也不能伸直。 4）老年人脊柱后凸：退行性变，胸椎椎体被压缩引起。胸椎明显后凸，胸段上半部。 5）其他：发育期姿势不良、外伤压缩性骨折、脊椎骨软骨炎。

12 2.脊柱前凸 Lordosis Lordosis is excessive curvature in the lumbar portion of the spine, which gives a swayback 背部过份凹陷appearance. 多发生于腰椎。腹部明显向前突，臀部明显向后突。妊娠晚期、大量腹水、腹腔巨大肿瘤、髋关节结核及先天性髋关节后脱位等

13 3.scoliosis脊柱侧凸 Scoliosis is an abnormal curve of the spine (backbone). With scoliosis, the spine isn't straight. Instead, the spine is crooked and curves to the side. If the spine is very crooked, the ribs or hips may stick out more on one side than the other side. Also, one shoulder may be lower than the other.

14 scoliosis It is divided into three types as scoliosis of thoracic, lumber, and thoracolumbar segment, based on the developing site; or it can be divided into posture and organic scoliosis, based on the nature of the disease.

15 posture scoliosis The bending of this type is not fixed, especially on early stage. It will be corrected by changing posture. The common causes are: (a) false posture in maturity of childhood; (b) the unilateral lower extremity is much shorter than the other side; (c) prolapse of intervertebral cartilages; (d) poliomyelitis sequelae.

16 Organic Scoliosis The spine has three types of curves: Kyphotic, which typically refers to the outward curve of the thoracic spine (at the level of the ribs) Lordotic, which refers to the inward curve of the lumbar spine (just above the buttocks) Scoliotic, which is a sideways curvature of the spine and which is always abnormal

17 3.脊柱侧凸 胸段、腰段或胸、腰段联合发生。 1）姿势性侧凸： 无结构的异常，平卧或向前弯腰时可使侧凸消失。儿童发育期坐、立姿势不良、下肢长短不齐和肌力不平衡，如椎间盘突出症、脊髓灰质炎等。 2）器质性侧凸：改变体位不能使侧凸得到纠正。 颈段脊柱侧凸：先天性斜颈、颈椎病或一侧颈肌麻痹等。胸段脊柱侧凸：特发性脊柱侧凸症、佝偻病、脊椎损伤、肺纤维化、胸膜肥厚等。腰段脊柱侧凸：椎间盘突出、腰部外伤和一侧腰肌瘫痪等

18 Before surgery

19 After surgery

20 二、Activity of spine 前曲45° 后伸35°
Normal activity: The normal active ranges of cervical and lumbar vertebrae are as follows: 前曲45° 后伸35° 颈椎

21 侧弯45° 侧弯45° 颈椎

22 旋转度70° 旋转度70° 颈椎

23 后伸30° 前屈75° 腰椎

24 侧弯30° 侧弯30° 腰椎

25 旋转度30° 旋转度30° 腰椎

26 （1）软组织损伤：颈、腰肌肌纤维织炎，颈、腰肌韧带劳损等。 （2）骨质增生：颈、腰椎增生性关节炎。 （3）骨质破坏：脊柱结核或肿瘤。
（二）脊柱活动度 1．检查法 颈段活动；腰段活动度。 2．正常活动度 前屈 后伸 左右侧弯 旋转度（一侧） 颈段 ° 55° ° ° 腰段 ° 30° ° ° 3．活动受限 （1）软组织损伤：颈、腰肌肌纤维织炎，颈、腰肌韧带劳损等。 （2）骨质增生：颈、腰椎增生性关节炎。 （3）骨质破坏：脊柱结核或肿瘤。 （4）脊椎骨折或脱位：外伤避免作脊柱活动。 （5）椎间盘突出：腰椎，各方向运动受限。 （二）脊柱活动度 1．检查法 颈段活动；腰段活动度。 2．正常活动度 前屈 后伸 左右侧弯 旋转度（一侧） 颈段 ° 55° ° ° 腰段 ° 30° ° ° 3．活动受限 （1）软组织损伤：颈、腰肌肌纤维织炎，颈、腰肌韧带劳损等。 （2）骨质增生：颈、腰椎增生性关节炎。 （3）骨质破坏：脊柱结核或肿瘤。 （4）脊椎骨折或脱位：外伤避免作脊柱活动。 （5）椎间盘突出：腰椎，各方向运动受限。

27 三、pressing pain and percussive pain
按压脊椎棘突 按压椎旁肌肉

28 脊柱叩击痛的检查方法 直接叩击法—腰椎和胸椎

29 脊柱压痛的检查方法 间接叩击法

30 直腿抬高试验

31 腰骶关节试验（骨盆旋转试验）

32 髋外展外旋试验（“4”字试验）

33 跟臀试验（Ely test）

34 瑞-舒测试法（Wright-Schober test）

35 拾物试验

36 三、脊柱压痛与叩击痛 1．脊柱压痛 （1）检查法：右手拇指自上而下逐个按压脊椎棘突及椎旁肌肉。
（2）临床意义：提示压痛部位的脊柱或肌肉可能有病变或损伤。 2．脊柱叩击痛 （1）检查法：直接叩诊法；间接叩诊法。 （2）临床意义：正常人脊柱无叩击痛，若某一部位有叩击痛，提示该处有病变，如脊柱结核、脊椎骨折、脊椎肿瘤、椎间盘突出等。

37 Section 2 、Examination of Extremities and Articulus
巨人症 肢端肥大

38 二、四肢： 1、腕关节变形：常见于 ⑴ 腱鞘囊肿： ⑵腱鞘滑膜炎： ⑶腱鞘纤维脂肪瘤：

39 2、指关节变形：最常见于类风湿性关节炎。 关节呈梭形畸形，且指间关节或掌指关节活动受限，活动期局部红肿疼痛、晨僵。 见于类风湿性关节炎

40 3、膝关节畸形：①如关节出现红、肿、热、痛和功能障碍见于风湿性关节炎 ；②如关节浮髌试验阳性见于关节腔积液。浮髌试验检查方法：
floating patella phenomenon

41 4、acropachy 杵状指 "Clubbing" of the fingers with thickening of skin at the base of the nails, often with an increase in the curvature of the nails.

42 5、匙状指：又称反甲，指甲中部凹陷，边缘翘起，表面粗糙。多见于缺铁性贫血，偶见风湿热、甲癣等。

43 6.muscle atrophy

44 7.Varicose veins lower extremities

45 8.edema

46 9.膝内翻（“O”形腿Genu varum ） 膝外翻（“X”形腿genu valgum ） 膝反张（过度超伸）

47 10.Flatfoot Definition Foot medial longitudinal arch depression or loss Associated conditions Heel足跟 eversion外翻 (valgus) Forefoot前足 abduction外展

48 脊椎四肢考题 一、脊椎的检查（8分） （一）站位：坐位、充分暴露躯干 （二）手法正确，动作规范
1、脊柱的弯曲度视诊检查（考生从侧位和后位观察） （1）四个生理弯曲 （2）有无侧弯、病理前凸和后凸（口述） 2、脊柱的活动度 （1）颈椎的活动度 （2）腰椎的活动度 固定、前屈、后伸、旋转、左右侧屈 3、脊柱的压痛和直接叩击检查（用叩诊垂或单一手指）

49 二、手部及关节的视诊检查 视诊内容 1、皮损、皮下出血、瘀点、萎缩、红肿 2、关节有无红肿畸形 3、手指末端有无紫绀（杵状指）、指甲有无反甲（匙状指） 问题：浮髌试验阳性提示什么？ 膝关节积液