CLINICAL ORTHOPAEDIC EXAMINATION Ronald McRae FRCS (Eng, Glas) FChS (Hon) AIMBI, Fellow of the Brilish Orthopaedic Association With original drawings by the author FIFTH EDITION 7) EDINBURGH LONDON Ni YORK OXFORD PHILADELPHIA, STLOUIS SYDNEY TORONTO 2004‘CHURCHILL LIVINGSTONE © Longman Grp Lined 1976, 1980, Langman Gio UK Lined {9 sige to Paron Peon! 195 Penson Prefendonl Lined 197 © 200 Eleie Lite, Alig sred ‘Theriht ofRonald Mek tbe sented ser of dhs mak as ee ete by in ncn shite Copy Desig ot Fates Act 1388, No part of his publication maybe ered, stort i eva systema in ay fom or by ay means seen mecha phoecopying sean or bere, wien ede pr Bevmrson oft pbs oa ence peeing ested copying the Utd King seed 9 {he Copyright Licersing Apeney 80 Tato Co Roa Lanne WIT ILE Permits my be ‘Supt duct fom Ebvie'sHah Scenes Rags Dept Paladin USA. poor (Cif 2ts 259 Sete) 213299806 «ma hapermatens Bete com You may ao pp ou reas inv Ess hme up ceo by ec Sap ast eiton 1976 Secon en 1989 Thdedion 190 Fitneiton 2008 ISBN 18 978-0-448-07007-3 TSBN.10-0-4¢3-07407-0 Reed 2030. 2007 InsrnoalStaen to SBN 974 0-443-07408-0 Inna Sten Eton SBN-10-0-448-0708 8 Brith Library Cataloguing in Publication Data ‘esl bd rts Bok ate nthe Bish ibang Library of Congres Catling in Publiation Data ‘Seager forbs bach vale nn th Lier of Congres Medical hnowedg coral angie, Sams pecans mat be owed. ut ‘esearch a cel experience be ut howled change nesta dr esp ay teeome nes osproprte Redes re advised check he mon Cet proc even ‘rove by the mantra of ah gto be seman coment dae he etd od rate amination. ad comraininss e espoaiy ofthe pacones, lag ‘rperone td Knowledge oft po date ages th et eater er ea ide pat Neher the Publier tre uber asomes ay aay fray inary andr damageta pest ine Patter Working together to grow libraries in developing countries vwwmcleviercom | wonnbookaid.org | wowstbreorg eA a eer cD ian 2s . sworwelsevierhesth com Heese Printed in China =e cpaPREFACE ‘The ability to make a good clinical examination can ‘only be mastered by practice, and I have no doubt that the basic techniques are best learned by performance under supervision. Unfortunately, the size of student classes in relation to teaching staff, and the not infrequent dearth of an adequate range of suitable clinical eases, makes this ideal difficult © achieve in, practice. Many students may acquire only a sketchy knowledge of the techniques of examination, which are fundamental to diagnosis and treatment. Its hoped that this book may help to fill some of these inevitable gaps. ‘until sound practice based on experience is achieved. The text It is assumed that the value of good history-taking is appreciated and practised, Patients parade their complaints on an anatomical basis, and the text has been arranged accordingly, The emphasis in each section is on the common rather than the rare conditions to be found in the region, Although this approach is open to criticism, itis nevertheless true to say that although the obscure will tax the most experienced, the most frequent mistake is a failure 10 diagnose the common, An encyclopaedic text, commendable on the ground of completeness, may nevertheless often confuse, especially where no ndication is given of the incidence of the conditions observed. I have purposely avoided detail, and where this is required a fuller orthopaedic textbook must be consulted. In some areas 0 I have made deliberate simplifications where a blight of terminology suggests the independence of a number of conditions that cannot be distinguished by symptomatology or investigation The illustrations The illustrations dealing with the practical aspects of clinical examination have been arranged in an essentially linear sequence following the traditional lines of inspection, palpation, and the examination of ‘movements and pertinent anatomical structures. In practice, this logical order is often altered by the experienced examiner to avoid undue movement of the patient. It must be stressed that not all the tests described need he carried out routinely. Many are performed only when a specific condition is suspected, and itis assumed that this will be obvious to the reader, In particular, in any joint assessment, itis necessary to discover if there is any restriction of movement, In many cases simple screening tests will suffice, and these are highlighted in most sections. The more detailed examination and recording of movement are generally reserved for cases under lengthy continuous ‘observation and for medico-legal work. Radiographic examination plays an essential part in the investigation of most orthopaedic cases, and to aid the inexperienced I have made some observations regarding the views normally taken and how they may be interpreted, Only a fraction of the possible pathology ‘can be illustrated in @ small work. but I have ‘concentrated on the common or informative ‘The spatial requirements of the captions have set some restriction on their content; this discipline has resulted in brevity at the expense in places of completeness, Nevertheless, wherever possible I have tried to show not only how each test should be carried ‘out, but also its sige 1 have taken the opportunity that this new ftth edition has afforded of reworking all of the previous drawings. These I have digitized, tidied up where necessary, and used a variety of grey fills to improve their clarity. in addition, the text has been updated and reorganized in many places, and a number of new tests have been included. Conventions and references For clarity in illustrating the techniques of examination, the patient and the examiner are shown in shades of light and dark grey respectively. Where two limbs are illustrated, the pathology is shown on the patient’ right side ‘Where several conditions are described, and one representative illustration only is given, it tefers to the first condition mentioned. ‘When joint movements are being considered, the patient's normal side should if possible be used for comparison. Angular measurement is an approximation, and the figures quoted are in most cases values rounded to the nearest 5° from figures published by the American Academy of Orthopedic Surzeons', Kapandj®, Lusted and Keats! or Boone and Azen*,