CHAPTER 9

The Arms, Legs and Joints

A complete physical examination includes an inspection of the arms, legs, and their joints. In addition, the neck and back should be carefully examined, especially when a person's complaint may be related to muscular or skeletal problems. For this part of the physical examination, the physician relies primarily on the procedures of looking and feeling since listening and tapping are not of as much value.

1. Looking: In general, the arms and legs should appear symmetrical. Usually one foot or hand is minimally larger than the other, and this is normal, especially if that side is the dominant or most often used side. Similarly, the muscles should be roughly the same size on both sides of the body. If there is any doubt, the circumference of both sides should be measured. The muscles of both upper and lower extremities should be carefully observed for signs of wasting, which could be signs of general weight loss from any number of conditions or signs of specific muscle or nervous system diseases. The muscles should be observed for small twitch-like movements (called fasiculations), which can be signs that the nerves which supply them are no longer functioning properly. The patient should be asked about any problems with coordination of their movements, and they should be observed doing simple movements with their hands and arms to see whether the movement is fluid and well-coordinated. An observation of a patient walking, for example, can often reveal much information about the type of disease which may be causing the problem and may give evidence as to whether the problem is in the muscles, joints, nerves or brain.

2. Feeling: Next, it is important for the physician to feel the muscles and joints of the arms and legs because valuable discoveries can be made which were not evident to the eye. Careful survey of all the muscle beds should be made with careful note to any swellings or tender areas. Swollen areas could be bruised or infected tissue, lymph nodes, or even tumors. Tender areas could be caused by some of the same things mentioned above or could be due to injury. In addition, tender areas should be further examined to determine if the tenderness corresponds to bone, muscle, tendons or ligaments. Tendons connect muscles to bones while ligaments connect bones to bones. This may help the doctor to tell what caused the problem and be better able to treat it.

   Examining the Joints: [ Figure 9A ] Joints are examined by looking and feeling. When a doctor is called upon to examine a joint, it is usually because of a complaint of pain on the part of the patient. Joints can be painful because of a large variety of problems including injury, various types of arthritis, local infections, generalized body diseases, and even spread of infections from other parts of the body. It is important to distinguish the cause of a painful joint because early treatment can relieve symptoms and often save the patient from long-lasting complications.

   

   A joint which is painful should be evaluated immediately. First, the doctor should find out if any injury occurred and at what times of day or with what types of activity the joint is most painful. The joint should be observed and palpated while it is in motion. Observation of a moving joint will often reveal at what point in the joint's movement the most pain occurs. Feeling the joint will further identify if the motion is smooth and whether or not the joint is grating or gets stuck at certain positions. Joints, too, can be painful because of bone, tendon, or ligament problems, and the cause should always be sought.

   If a joint is swollen, it is sometimes because the tissues surrounding it are injured and swollen, but it is usually because extra fluid is present in the joint. The fluid may be blood, pus, or an abnormal amount of joint fluid which has accumulated due to inflammation. Usually palpation will reveal whether a joint is swollen because the surrounding tissues are swollen or because the joint has fluid in it. When a joint does have fluid and the fluid is not present for any obvious reason (such as an injured knee which has blood from a torn ligament), the fluid needs to be removed and analyzed. This is useful for two reasons: removal of the fluid will decrease the pain in the joint and a laboratory analysis of the fluid will help to determine the cause and treatment of the problem.

   Examining for fractures: After an injury when a bone may have been fractured, there is always danger that the nerves or the arteries that course along that bone have been damaged too. The first thing that must be established, even before determining whether or not a bone is broken, is that the blood supply and nerves are intact. If not, this is a true emergency since an arm, leg, hand, or foot without blood supply will die within a few hours, while a broken bone can go several days before being set. To establish that the nerves are intact, the person should be asked if there is any numbness or tingling in the affected part. She or he should then be asked to move the joints below the injury. If this cannot be done, a nerve injury should be suspected. To establish that the blood supply is intact, a pulse should be sought below the injured area. For instance, if the elbow is injured, the radial pulse in the wrist should be felt. In addition, the area below the injury should stay warm and pink. If it turns blue or cold and a pulse cannot be felt, an arterial injury should be suspected -- immediate surgical repair is mandatory.

   Having established that the blood supply and nerves are intact, the doctor can begin evaluating the joint or bone afflicted. If there is an obvious deformity, then a fracture or dislocation has occurred. In the absence of obvious deformities, tenderness, redness, and swelling may be signs that a fracture has occurred. These signs, however, may occur in many other types of injuries in which there is no bone broken. Consequently, if a fracture is suspected after careful physical examination, x-rays are needed to confirm the diagnosis.

   Examining the Neck and Back: [ Figure 9B ] Neck and back pain are common complaints which the doctor is called upon to evaluate. The same principles that apply to examination of the other joints apply to the examination of the neck and back. The spinal column should be observed and palpated along its entire length. An attempt should be made to determine if the source of the pain is from muscle, bone, joint, or ligaments. An additional source of pain in the spinal column may arise from the discs (or cushions) between the vertebrae of the back and neck. When one of the discs is damaged or weakened by aging, it can break through its outer coating and press on the spinal cord or on one of the nerve roots coming off the spinal cord. This can be very painful. Several complicated maneuvers involving leg raising and back bending can help the doctor determine if a bulging disc is the problem.

Chapter 10