2. Can we have some cell phone ettiquette, please ?Can we have some cell phone ettiquette, please ?

3. CLINICAL EXAMCLINICAL EXAM
 History TakingHistory Taking
 Keep the question simpleKeep the question simple
 Ask one at a timeAsk one at a time
 Get an answer before proceeding to next oneGet an answer before proceeding to next one
 Avoid putting words into patients mouthAvoid putting words into patients mouth
 Give equal value to awkward pointsGive equal value to awkward points

4. CLINICAL EXAMCLINICAL EXAM
 MANDATORY QUESTIONSMANDATORY QUESTIONS
 CERVICAL REGIONCERVICAL REGION
 ? VERTIGO,BLACKOUT,DROP ATTACK? VERTIGO,BLACKOUT,DROP ATTACK
 H/O URT INFECTION (IN JUNIORS)H/O URT INFECTION (IN JUNIORS)
 H/O RHTD.ARTHRITIS,STEROIDS,ANTICOAGULANTSH/O RHTD.ARTHRITIS,STEROIDS,ANTICOAGULANTS

5. CLINICAL EXAMCLINICAL EXAM
 THORACIC REGIONTHORACIC REGION
 ? NEUROLOGICAL SIGNS IN LOWER? NEUROLOGICAL SIGNS IN LOWER
LIMBSLIMBS
 LUMBAR REGIONSLUMBAR REGIONS
 ? PERINEAL ANAESTHESIA? PERINEAL ANAESTHESIA
 ? CHANGE IN MICTURITION HABITS? CHANGE IN MICTURITION HABITS
 ? SPHINCTER TROUBLE? SPHINCTER TROUBLE

7. CLINICAL EXAM OF NECKCLINICAL EXAM OF NECK
 SymptomsSymptoms
Pain-Neck itself / Ref. To shoulder & armsPain-Neck itself / Ref. To shoulder & arms
 Relation to PostureRelation to Posture
 StiffnessStiffness
Intermittent / continuousIntermittent / continuous
 DeformityDeformity
Neck fixed in flexionNeck fixed in flexion

8. CLINICAL EXAM OF NECKCLINICAL EXAM OF NECK
 Numbness, tingling & weaknessNumbness, tingling & weakness
 Headache-suspect other causesHeadache-suspect other causes
 ““Tension”- ‘Try to read’ the patientsTension”- ‘Try to read’ the patients
 Target zone for psychosomatic illnessTarget zone for psychosomatic illness
 TWO ARMS = ONE NECKTWO ARMS = ONE NECK
 (If both arms are affected suspect(If both arms are affected suspect
neck)neck)

9. CLINICAL EXAM OF NECKCLINICAL EXAM OF NECK
 LookLook - Deformity- Deformity
 FeelFeel - Tender areas in muscles /front- Tender areas in muscles /front
- Cervical rib- Cervical rib
 MoveMove - Forw.flex / ext / lat.flex / rotation- Forw.flex / ext / lat.flex / rotation
 PulsesPulses - Radial - at rest – on traction- Radial - at rest – on traction
 NeuroNeuro - Mandatory in upper limbs- Mandatory in upper limbs
 X-rayX-ray - AP / Lateral- AP / Lateral

10. EXAMINATION
FLEXION / EXTENSION / ROTATION
TILT / TESTING POWER ELBOW & WRIST

11. READING A LAT.FILM OF C.SPINEREADING A LAT.FILM OF C.SPINE
 ALIGNMENTALIGNMENT
 BONY INTEGRITYBONY INTEGRITY
 CARTILAGINOUS SPACESCARTILAGINOUS SPACES
 SURROUNDING SOFT TISSUESSURROUNDING SOFT TISSUES
  PRE VERTEBRAL SOFT TISSUEPRE VERTEBRAL SOFT TISSUE
SHADOWSHADOW
 BLOOD / FLUID / PUS / TUMOR MATERIALBLOOD / FLUID / PUS / TUMOR MATERIAL

12. ANATOMY OF C - SPINE

13. TORTICOLLIS
NATURAL HISTORY
EARLY DEFORMITY
STERNOMASTOID DIVIDED
RESULT AFTER SURGERY

14. SPASMODIC TORTICOLLIS - NOTE THE MUSCLE IN SPASM

15. CERVICAL DISC LESION
STRAIGHTENING OF LORDOSIS / MRI SCAN SHOWS C5/6 DISC

16. CERVICAL SPONDYLOSIS
DISC DEGENERATION & OSTEOPHYTES

17. PYOGENIC INFECTION
DESTRUCTION TAKES 2 TO 3 WEEKS

18. RHEUMATOID ARTHRITIS
BEWARE OF ATLANTO - AXIAL SUBLUXATION

19. NEURALGIC AMYOTROTHY
WASTING – WEAKNESS MAY BE PERMANENT

20. CERVICAL RIB
UNILATERAL / BILATERAL PULSATING LUMP / TEACH SHRUGGING EXCERCISES

21. MALIGNANT DEPOSITS
NOTE THE PAN - COAST TUMOUR

22. OTHER CAUSES OF NECK & ARM PAIN
CARPAL TUNNEL SYNDROME
SUPRA SPINATUS TENDON LESION
CERVICAL TUMOURS
THORACIC OUTLET SYNDROME

24. THORACIC SPINETHORACIC SPINE
 LOOKLOOK -- DEFORMITIESDEFORMITIES
 FEELFEEL -- TENDERNESSTENDERNESS
 NEUROLOGYNEUROLOGY -- TB / PYOGENIC /TB / PYOGENIC /
-- METASTASISMETASTASIS
 TRACKING OF COLD ABSCESSTRACKING OF COLD ABSCESS

25. CONGENITAL MYELODYSPLASIA

26. SCHEUERMANN’S THORACIC KYPHOSIS

27. SCHEUERMANN’S LUMBAR KYPHOSIS

28. PARALYTIC SCOLIOSIS

29. OTHER CAUSES OF SCOLIOSIS

30. CLINICAL
EVALUATION

32. ANATOMY OF SPINAL
NERVES
NOTE THE RELATIONSHIP
OF DISC TO THE ROOTS

33. YOU STAND ON S1
& SIT ON S3

34. PRIMARY MUSCLE ACTIONPRIMARY MUSCLE ACTION
 HIP FLEXION – PSOAS / ILIACUS = L 2 / 3HIP FLEXION – PSOAS / ILIACUS = L 2 / 3
 KNEE EXTEN – VAST INTER = L 3 / 4KNEE EXTEN – VAST INTER = L 3 / 4
 ANKLE FLEX – SOLEUS = S 1 / 2ANKLE FLEX – SOLEUS = S 1 / 2
 EXCEPTIONEXCEPTION
 E H L – L 5 ROOTE H L – L 5 ROOT

35. EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE
 PAIN - SCIATICA /PAIN - SCIATICA /  COUGH / SNEEZECOUGH / SNEEZE
 STIFFNESS – DISC / A S / ARTHRITISSTIFFNESS – DISC / A S / ARTHRITIS
 DEFORMITYDEFORMITY
 NUMBNESS & / PARAESTHESIANUMBNESS & / PARAESTHESIA
 ASKASK  WALKING / STANDING /WALKING / STANDING /  RESTREST
 ? URETHRAL DISCHARGE/ DIARRHOEA /? URETHRAL DISCHARGE/ DIARRHOEA /
SORE EYESSORE EYES

36. EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE
 LOOKLOOK – SKIN SCARS / PIGMENTATION– SKIN SCARS / PIGMENTATION
ABNORMAL HAIRS / UNUSUAL SKIN CREASEABNORMAL HAIRS / UNUSUAL SKIN CREASE
SHAPE & POSTURE AFFECTEDSHAPE & POSTURE AFFECTED
 FEELFEEL – BONYSTRUCTURES / I V TISSUE / PARA– BONYSTRUCTURES / I V TISSUE / PARA
MUSCLESMUSCLES
 MOVEMOVE – FLEX / EXTD / LAT. BEND / ROTATION– FLEX / EXTD / LAT. BEND / ROTATION
CHEST EXPANSIONCHEST EXPANSION
 MUSCLE POWERMUSCLE POWER ––
STAND ON TOESSTAND ON TOES (PLANTAR FLEXION)(PLANTAR FLEXION)
ROCK BACK ON HEELSROCK BACK ON HEELS (DORSIFLEXION)(DORSIFLEXION)

37. EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE
 IMAGING –IMAGING – X – RAYSX – RAYS PLEASE PREPARE BOWELPLEASE PREPARE BOWEL
 AP / LATERAL / OBLIQUE & P A VIEW FOR S I Jt.AP / LATERAL / OBLIQUE & P A VIEW FOR S I Jt.
 COMPUTED TOMOGRAPHYCOMPUTED TOMOGRAPHY
BONE TUMOUR / Sp.CANAL STENOSISBONE TUMOUR / Sp.CANAL STENOSIS
 MRI SCANMRI SCAN – FOR SOFT TISSUE– FOR SOFT TISSUE
 BEWARE FALSE POSITIVE FINDINGS ( >30%)BEWARE FALSE POSITIVE FINDINGS ( >30%)

38. EXAMINATION
STANDS WITH A TILT / LTD FORW. FLEX / LAT. FLEX

39. EXAMINATION
METHOD OF MEASURING EXCURSION

40. LYING ON HIS BACK
SLR
STRETCH+
HIP & KNEE
EHL
SENSATION
REFLEX

41. HERNIATED LUMBAR DISC
CHARACTERISTIC POSTURE

42. L3/4 DISC
L4 ROOT
L4/5 DISC
L5 ROOT
L5/S1 DISC
S1 ROOT

43. SPINE TUBERCULOSIS
SHOWING PROGRESSIVE DESTRUCTION

44. SPINE TUBERCULOSIS
PATHOLOGICAL DESTRUCTION & ABSCESS

45. PYOGENIC SPONDYLITIS
EVIDENCE OF BONE DESTRUCTION + +

46. MOBILE SCOLIOSIS
POSTURAL
 FLEXION
SHORTLEG
 SITTING
PROLAPSED
DISC ON
TTMT

47. FIXED SCOLIOSIS
INCREASING CURVE OVER THE YEARS

48. INFANTILE THORACIC
ADOLESCENT THORACIC
THORACO - LUMBAR
LUMBAR
COMBINED
IDIOPATHIC SCOLIOSIS

49. TRANSITIONAL LUMBO-SACRAL VERTIBRA

50. SPODYLOLYSIS & SPONDYLOLISTHESIS

51. ANKYLOSING SPONDYLITIS
REDUCED CHEST EXPANSION / OSSIFIED LIGAMENTS

52. DEGENERATIVE OSTEO ARTHRITIS

53. SPINAL CANAL
STENOSIS
CLINICAL FEATURES

54. MECHANICAL CAUSES OF LOW BACK PAIN
GOOD POSTURE & POOR POSTURE

56. EXAMINATION OF LUMBAR SPINEEXAMINATION OF LUMBAR SPINE
 EXTENSIVE LAB TESTEXTENSIVE LAB TEST
WHEN CLINICIAN SUSPECTSWHEN CLINICIAN SUSPECTS
MALIGNANCYMALIGNANCY
METABOLIC DISTURBANCEMETABOLIC DISTURBANCE
CHRONIC INFECTIONCHRONIC INFECTION

57. TUMOURS OF SPINE
OSTEIOD OSTEOMA HEMANGIOMA
BENIGN LESIONS

58. MYELOMA
SECONDARY
TUMOURS

59. EXTRA DURAL
FIBROBLASTOMA
EXTRAMEDULLARY
MENINGIOMA
INTRA MEDULLARY
EPENDYMOMA

60. CHRONIC BACKACHECHRONIC BACKACHE
TB OM DISCITIS
SI Jt. TB OST. CONDENS. ILII

61. PSYCHOSOMATIC MANIFESTATION

62. “ From the unreal lead me to the real !
From darkness lead me to light !
From death lead me to immortality !
Brihad – aranyaka Upanishad

63. Thank YouThank You
© Dept. of© Dept. of OrthopaedicsOrthopaedics,,
Govt. Medical College,Govt. Medical College, ThrissurThrissur