运动系统检查 Musculoskeletal Examination

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1 运动系统检查 Musculoskeletal Examination
浙江大学医学院附属第一医院骨科 徐三中

2 REVIEW Anatomy: bone ligament muscle nerve Bone numbers of the bones
numbers of the vertebras Ligament ,joint Muscle muscle force 0-V Nerve: upper extremity : axillary（腋神经）,musculocutaneous（肌皮神经）,radial（桡神经）,median（正中神经）,ulnar（尺神经） lower extremity : femoral（股神经） sciatic（坐骨神经）

3 Principles of Examination
Approach patient with Kindness (cause no pain)（亲切、和蔼） Precision (observe patient‘s face and record findings)（精确） Style(方式 )(be cheerful and timely)及时

4 Principles of Examination
Always Look（望） Feel （触） Move（动） Measure(量）

5 运动系统 脊柱：Cervical spine -7
Thoracic spine -12 Lumbar spine -5 Sacral spine -5 Coccyx spine -4 四肢和关节:Upper extremities: shoulder joint, elbow joint,wrist joint Lower extremities: hip joint, knee joint,ankle joint

6 sequence of Examination （检查顺序）
1. Observe the patient as a whole. 2 . Neck--- Back--- Shoulder---Elbow---Wrist&Hand---Hip---Knee---Ankle&Foot

7 whole Walk (carriage): 跛行(神经,血管,关节, 骨骼等) Morphous(shape形态): abnormity
Tenderness(压痛)(superficial or deep) and percussion pain(扣痛)(direct or indirect扣痛)

8 whole Skin (vein edema ) muscle (hypertrophy 肥大 and atrophy 萎缩)
Always bilateral Contrast

9 spine望 脊柱弯曲异常 A . Scoliosis（侧凸） 姿势性的侧凸；器质性侧凸。
特发性的脊柱侧凸(idiopathic scoliosis) 原发性、继发性和先天性的脊柱侧凸

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11 B. Kyphosis（后突） 小儿：佝偻病（rickets) 儿童青少年：胸椎结核 成年人：强直性脊柱炎 老年人：骨质疏松
Healthy spine Kyphotic spine

12 C. Lordosis（前突） 1：pregnance 2：CDH（先髋）

13 spine触-体表定位 1.体表可及的骨突来定位 第三胸椎棘突 第七胸椎棘突 第四腰椎下部 第五腰椎和第 一 骶椎棘突之间

14 spine触 压痛：比较表浅。 叩击痛：直接叩击法和间接叩击法。 腰背肌有无痉挛和萎缩

15 Spine动 1 瑞-舒（Wright-Schober)测试法， 2 拾物试验 3 坐位屈颈试验（Lindner)
2 拾物试验 3 坐位屈颈试验（Lindner) 4 直腿抬高试验和加强试验（Lasegue） 5 腰骶关节试验 6 髋关节“4”字试验 7 跟臀试验（ely test)

16 Spine量

17 Examination of the Neck
1. Observe the neck and shoulders from in front and behind 2. Palpate the front and back of the neck with the patient seated and the examiner behind.

18 Examination of the Neck

19 Examination of the Neck
3. Assess neck flexion（屈） by asking the patient to touch their chest with their chin.（下巴） 4. Assess extension（伸） by asking the patient to look up and as far back as possible

20 Examination of the Neck

21 Examination of the Neck
5. Assess lateral flexion （侧弯）to both sides by asking the patient to touch their shoulder with their ear. 6. Assess rotation（旋转） by asking the patient to look over their shoulder, to the left and right. 7. Begin the neurological assessment of the upper limb by examining the motor（运动） system. This involves asking the patient to assume （采取）a certain position and not let you overcome it. Begin with shoulder abduction.

22 8. Shoulder adduction.（外展）腋神经

23 9. Elbow extension.（伸）桡神经
10. Elbow flexion（屈）肌皮神经

24 Examination of the Neck
11. Wrist flexion（屈）and extension 12，Finger extension（伸）and Finger flexion（屈） 桡神经、正中神经、尺神经，radial ,median, ulnar

25 14. Thumb （拇指）abduction.（外展）
15. Finger abduction

26 16. Elicit（引出） the reflexes of the upper limb beginning with the biceps（二头肌）jerk.
17. Triceps（三头肌） jerk 18. Brachioradialis（桡） jerk..

27 19. Hoffmann征和Babinski征 20 . Test sensation of the upper limb and determine the distribution（分布） of any loss

28

29 Examination of the Back
1. Observe the patient as a whole, front and back. 2. Ask the patient to walk on their toes. 3. Ask the patient to walk on their heels.（跟）

30 Examination of the Back
4. Back extension.

31 Examination of the Back
5. Back flexion.（屈） 瑞-舒（Wright-Schober）。 6. Bony Excursion: measure the distance between two bony points when standing. 7 Ask the patient to flex forward, the bony points should move at least 5 cm. 8. Lateralflexion

32 瑞-舒（Wright-Schober）测试法
测定脊柱前弯时的伸长率，即嘱受试者作立正姿势，以髂嵴为中心，在其上10cm及下5cm处各作一标志，测量两点间距离。正常人弯腰时的两点距离较直立时的15cm增加4~8cm(图3-8-3)。该检查法可对幼年强直性脊柱炎病人进行动态观察

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34 Examination of the Back
9. Rotation (make sure to anchor（固定） pelvis) 10. FABER test. (4字试验),Flexion knee ,Abduction ,External Rotation hip. Press firmly on the knee. Pain in the groin suggests a hip problem and pain in the back refers to the sacroiliac（骶髂） joint. 11 Lasegue征(Straight leg ranging) ,dorsiflexion (背伸)increases the sciatic stretch. Watch for pain and limitation. (2 photos) 12. Femoral stretch test: Hip extension and passive flexion of the knee. Watch for pain and limitation

35 FABER test. (4字试验), Lasegue征(Straight leg ranging) Femoral stretch test:

36 髋外展外旋试验或“4 ”字试验 检查时仰卧，一侧下肢伸直，将对侧足置于伸直侧膝上向下压，如同侧骶髂关节或髋关节疼痛时为阳性，说明骶髂关节或髋关节有病变，但如果腹股沟处有剧烈牵拉痛，应考虑为股内收肌纤维炎或肌腱、肌肉损伤引起，与骶髂关节无关

37 直腿抬高试验 为神经根受刺激的表现。检查时嘱病人仰卧，两下肢伸直，医师一手置于膝关节上，使下肢保持伸直，另一手将下肢抬起。正常人可抬高70°以上，如抬高不到30 °，即出现由上而下的放射性疼痛。见于坐骨神经痛,腰椎间盘突出或骶神经根炎等。为增加坐骨神经牵拉强度可被动使踝关节背屈，如有椎间盘突出症时，坐骨神经的疼痛将明显加剧，此方法又称为直腿抬高加强试验

38 拾物试验 检查患者的脊柱活动，可使其拾取一件放在地上的物品，观察脊柱的活动是否正常。腰椎有病变拾物要屈曲两侧膝、髋关节而腰挺直

39 屈颈试验（Lindner test）,患者仰卧，两下肢自然伸直，医者一手按压患者于胸前，一手置于枕后托住后枕部，托枕之手缓缓用力使患者头部尽量前屈，这时如出现腰痛伴单侧或双侧下肢放射性疼痛即为阳性。

40 跟臀试验（ely test） 俯卧位，患侧屈膝，使足根靠近臂部，这时股神经与股前侧肌群受到牵拉而出现大腿前方放射痛。本试验在腰大肌脓肿，脊柱强直，股四头肌挛缩，骶髂关节病变时，也有疼痛，请注意鉴别

41 跟臀试验（ely test）

42 腰骶关节试验 极度屈曲两髋及膝使臀部离床，腰部被动前屈。下腰部软组织劳损或腰骶椎有病变时则感疼痛，为阳性，椎间盘突出病人常为阴性

43 Examination of the Back
A Neurological examination including: 13. Knee extension. 14. Kneeflexion 15. Knee jerk reflex 16. Ankle jerk reflex.

44

45 Examination of the Back
17. Sensation 18. Pain on compression of the head can often be attributed to non-organic pathology.（非器质性病变）

46 Examination of the Back

47 四肢关节 Upper extremities Lower extremities

48 四肢的一般检查 肌力分六级： 0级－肌肉完全瘫痪。 1级－有肌肉收缩，但无关节活动。 2级－有肢体活动，但不能对抗自身重力
3级－能对抗重力的活动。 4级－能对抗轻微的阻力。 5级－完全正常。

49 四肢的一般检查 常见病症： 1. 肢端肥大：垂体肿瘤，生长激素分泌过多引起的肢端肥大症和巨人症。 2. 肌肉萎缩：神经营养因素 废用性 肌炎
3. 骨折和关节脱位：骨折专有体征－畸形，反常活动， 骨擦音和骨擦感。

50 四肢的一般检查 常见病症： 4. 水肿：静脉回流受阻－静脉血栓形成等。 淋巴回流受阻－象皮肿。指压后无组织凹陷。
4. 水肿：静脉回流受阻－静脉血栓形成等。 淋巴回流受阻－象皮肿。指压后无组织凹陷。 5. 肝掌：掌侧的红斑，与雌激素有关，为肝功能减退 的临床表现之一。 6. 杵状指、趾: 好发与呼吸系统疾病和心血管系统疾病 及营养障碍性疾病，与缺氧代谢障碍中毒等 有关。单侧的见于锁骨下动脉瘤。 7. 匙状指：也称反甲。缺铁性贫血，风湿热等

51 Examination of the Shoulder
1. Observe the whole patient, front and back. (2 photos) 2. Observe the shoulder. 3. Observe the axilla.（腋窝）

52

53 Examination of the Shoulder
4. Palpate for tenderness over the sterno-clavicular（胸锁） joint, clavicle, acromioclavicular（肩锁）joint, acromion process （肩峰）, supraspinatus tendon（岗上肌腱） and the tendon of the long head of biceps. 5. Observe shoulder abduction from in front and behind, through the entire range of movement. Note the presence of difficulty in initiation or a painful arc. (3 photos)

54 ▲ ▲ ▲

55 Examination of the Shoulder
6. Secure （固定）the scapula（肩胛骨） to assess gleno-humeral（肩肱） movement. 7. Assess flexion and extension（屈伸运动）. ( no photos) 8. Assess external rotation （外旋）with elbows in to the sides and flexed（屈） to 90º . 9. Assess internal rotation by asking the patient to place both hands behind the head.

56

57 Examination of the Shoulder
10. Assess internal rotation（内旋） by asking the patient to reach over their opposite shoulder, behind the neck and behind the back. (3 photos)

58 Examination of the Shoulder

59 Examination of the Shoulder
11. Test biceps function by asking the patient to flex the elbow against resistance.

60 Examination of the Elbow
1. Observe the whole patient, front and back, looking especially for deformity（畸形）（肘外、内翻） 三点关系(肱骨内,外上髁和尺骨鹰嘴) 肘后三角：异常－肘关节脱位。 正常－肱骨髁上骨折。 携带角：即10－15度的外翻角。 肘外翻：大于15度。 肘内翻：小于0度。

61 2. Feel for tenderness（痛点）

62 Examination of the Elbow
Accentuate the pain of tennis elbow. 4. Tennis elbow: point tenderness. 5. Tennis elbow: pain on resisted extension. 6. Tennis elbow: pain on passive stretch Golf elbow?

63 Examination of the Elbow
伸肌腱牵拉试验（Mills征）、

64 7. Examine extension.(伸） 8. Examine flexion（屈）

65 9. Examine supination.(旋前） 10. Examine pronation（旋后）

66 11. Provocative（刺激） test for Cubital Tunnel（尺神经根管） Syndrome (puts tension on ulnar nerve at elbow).
Tinel 征

67 12. Palpate the ulnar nerve.

68 Examination of the Wrist and Hand
1. Observe the hand positioned on a pillow（垫子） or a table. Ensure you have adequate（足够） exposure. 2. Observe the palm（掌） of the hand. 3. Observe the dorsum（背） of the hand.

69 Examination of the Wrist and Hand

70 Examination of the Wrist and Hand
4. Review the anatomy of the hand noting the tip of the styloid（茎状） process(突), the anatomical snuffbox（鼻烟窝） bordered by extensor pollicis brevis（拇短伸肌腱） and extensor pollicis longus tendons （拇长伸肌腱）, and the head of the ulna.（尺骨头） 5. Feel for tenderness. (no photos) 6. Test active movements of the wrist. (no photos)

71 Examination of the Wrist and Hand
7. A useful method for screening of flexion and extension of the wrists. (2 photos) 8. Test passive movements of the wrist beginning with extension(伸). 9. Flexion(屈).

72 Examination of the Wrist and Hand

73 Examination of the Wrist and Hand
10. Radial deviation.（桡偏） 11. Ulnar deviation.（尺偏） 12. Pronation.（手掌向下） 13. Supination. （手掌向上）

74 Examination of the Wrist and Hand

75 Examination of the Wrist and Hand
15. Test thumb abduction.（外展） 16. Test thumb adduction.（内收） 17. Test opposition.（对掌）

76 Examination of the Wrist and Hand

77 Examination of the Wrist and Hand
18. Observe movement of fingers from extension to flexion. (2 photos) 19. Test flexor digitorum profundus （指深屈肌腱）function by holding the proximal interphalangeal joint（近节指间关节PIP） extended(伸直) and asking the patient to flex the finger. Successful finger flexion indicates the tendon is intact（完整）. 20. Test flexor digitorum superficialis（指浅屈肌键） function by holding the other fingers extended while asking the patient to flex the finger being tested. Successful flexion indicates the tendon is intact.

78 Examination of the Wrist and Hand

79 Examination of the Wrist and Hand
21. Assess joint hyperextension. 22. Axial（纵向） compression test. 23. Asses ulnar nerve function with Froment's test. 24. Asses ulnar nerve/interosseus（骨间） muscle function by asking the patient to abduct their fingers while slowly pushing the hands together until the weaker one collapses

80 Examination of the Wrist and Hand

81 Examination of the Hip 1. Observe the whole patient.
2. Trendelenburg test (normal).（先髋单足独站试验） 3. Positive Trendelenburg Test. 4. Ask the patient to walk and observe their gait. (no photo) 5. Test iliopsoas（髂腰肌） function by asking the patient to lift their thigh （大腿）off the seat against resistance.

82 － 病人抬起健侧腿，如果患侧下肢可以单独站立，同时健侧臀部皱褶及髂骨翼均上提，为阴性，如果健侧臀部皱褶及髂骨翼均下降，则为阳性。 ＋

83 6. Ensure the Anterior Superior Iliac Spines（髂前上嵴） are horizontal

84 Examination of the Hip 7. Check the position of the medial malleoli.（踝） 8. Measure from the ASIS（髂前上嵴） to the medial malleoli. (3 photos) 9. Measure the distance from the xiphisternum（剑突） to the medial malleoli. 10. Feel for the femoral head. It is deep to the femoral pulse. (No photo)

85 Examination of the Hip

86 Examination of the Hip 11. Thomas Test: Flex both hips to eliminate the lumbar lordosis(腰椎前突), Extend the hip you are examining and if it is normal it should return to the bed. A fixed flexion deformity of the hip will not allow it to extend to the neutral position. (2 photos

87 托马斯 髋关节的屈曲挛缩可以由腰椎的前突来代偿，当平卧而将健侧髋，膝极度屈曲，可使腰部放平而使腰紧贴床面，此时患侧髋关节的屈曲畸形即可以显示，此为托马斯征阳性。记录患肢与床面的角度。

88 Examination of the Hip

89 Examination of the Hip 12. Check the patient is not compensating （代偿）with a lumbar lordosis（前突）. 13. Check the ASIS are horizontal again. Anchor leg over the edge of the bed and abduct the other hip. 14. Assess adduction（内收）.

90 Examination of the Hip 14. Assess adduction. 15. Internal rotation

91 Examination of the Hip

92 Examination of the Knee
1. Observe the patient as a whole. 2. Observe the knee joint front and back. Note any genu valgum （外翻）(a slight degree of which is normal) or genu varum（内翻）. 3. Observe knee from side. Note any genu recurvatum 4. Ask the patient to squat（下蹲）

93 Examination of the Knee

94 Examination of the Knee
5. Assess patellae tracking from extension to flexion. Note quadriceps（四头肌） action. 6. Patellar apprehension test. Apply lateral pressure to patellar as the patient flexes the knee. Observe facial expressions for fear of impending dislocation. 7. Observe the knee with the patient lying on the bed.

95 Examination of the Knee

96 Examination of the Knee
8. Pick a bony landmark（标记） on the knee and measure a fixed distance from it to the approximate centre of the quadriceps. 9. Measure the circumference of the of the knee and leg. 10. Feel the temperature of the knee and leg. 11. Soloman's test. Lift the patella away from the femur. In synovial thickening it will be hard to grasp

97 Examination of the Knee

98 Examination of the Knee
12. Effusion Tap Test(浮髌试验). Push sharply on the patella and with an effusion it will strike the femur and bounce back. 13. Effusion: Feel for fluid fluctuance

99

100 Examination of the Knee
14. Anterior drawer test. Femur should not move forward significantly unless the anterior cruciate ligament is torn. 15. Posterior drawer test. (Posterior cruciate)

101 Examination of the Knee

102 Examination of the Knee
16. MacMurrays test. Place the thumb and finger on the joint line. Watching the patients face for pain, flex the leg, externally rotate the foot, abduct and extend leg to test for medial meniscal "clicks".

103 Examination of the Knee

104 Examination of the Ankle and Foot
Observe patient as a whole from front and back. 1. Check for inversion内翻(tibialis function) and eversion外翻

105 Examination of the Ankle and Foot
2. Simmond's test for AT(achilles tendon). 3. Check pulses, sensation, reflexes

106 -- 腓肠肌挤压试验－跟腱断裂

107 谢谢