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position, and skin integrity.

Posture

Observe the patient's resting posture in supine, sitting, and standing

positions. This includes inspection of the head, trunk, and extremities

for alignment, symmetry, deformity, or atrophy.

Limb Position

Observe the resting limb position of the involved extremiry. Compare to both normal anatomic position and to the contralateral side.

Note if the limb is in position naturally or if it is supported with a

pillow, roll, or wedge.

Clinical Tip

• A limb in a dependent position is at risk for edema

formation, even if it is dependent for only a short period

of time.

• Maintain joints in a neutral resting position to preserve

motion and maintain soft tissue length.

Skin Integrity

The patient'S skin integrity should be inspected in general for edema,

discoloration, bruising, or scars. If there is traumatic injury, carefully inspect the skin at the level of and distal to the injury. Note any lacerations or abrasions. If the patient has recently had surgery,

observe the location, direction, and quality of incision(s}. Note any

pressure sores or potential for such. Refer to Chapter 7 for further

discussion of skin integrity evaluation.

MUSCULOSKEU:.iAL SYSTEM

163

Clinical Tip

Pressure sores from prolonged or increased bed rest after

trauma or orthopedic surgery can develop in anyone,

regardless of age or previous functional abilities. Inspect

the uninvolved extremity for skin breakdown too.

Palpatio1l

Palpate skin temperature to touch, capillary refill, and peripheral

pulses at the level of or distal to injury or the surgical site. Refer to

Chapter 6 for further discussion of vascular examination. A discussion of special tests is beyond the scope of this text; however, the therapist should perform special testing if results of the interview or screening process warranr further investigation.

Upper- a1ld Lower-Qllarter Screens

Upper- and lower-quarter screening is the brief evaluation of bilateral

range of motion (ROM), muscle strength, sensation, and deep tendon

reflexes. It is a very efficient examination of gross neuromuscular status that guides the therapist to perform more specific testing.' The therapist should perform both an upper- or lower-quarter screen,

regardless of the extremity involved. For example, for a patient with

lower-extremity involvement who will require the use of an assistive

device for functional mobility, both functional range and strength of

the upper extremities muSt also be assessed. Tables 3-1 and 3-2

describe a modified version of an upper- and lower-quarter screen.

Table 3-3 outlines normal ROM. Peripheral nerve innervations for

the upper and lower extremities are listed in Tables 4-7 and 4-8,

respectively. Dermatomal innervation is shown in Figure 4-6.

The sequencing of the upper- and lower-quarter screen is as

follows2:

1.

Observe active ROM and test myotomes progressing from

proximal to distal and beginning at the spinal level and moving dis-

164 ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Table 3-l. Upper-Quarter Screen

Nerve

Deep

Root

Mymome

Dermatome

Tendon Reflex

CI

Cervical rmation

No innervation

None

C2

Shoulder shrug

Posterior head

None

C3

Shoulder shrug

Posterior neck

None

C4

Shoulder shrug

Acromioclavicular joint

None

C5

Shoulder abduction

Lateral arm

Biceps

C5,6

Elbow flexion

None

C6

Wrist extension

Lateral forearm and

Brachioradialis

palmar tip of rhumb

C7

Elbow extension

Palmar distal phalanx of

Triceps

and wrist flexion

middle finger

C8

Thumb extension

Palmar distal aspect of

None

and finger flexion

litde finger

Tl

Finger abduction

Medial forearm

None

Sources: Adapted from ML Palmer, ME Epler (cds). Clinical Assessment Procedures in

Physical Therapy. Philadelphia: Lippincort, 1990;32; and dara from S Hoppenfeld.

Physical Examination of [he Spine and Extremities. East Nor""alk, Cf: Appleton &

Lange, 1976.

tally to the extremities. Remember that it is imperative to assess these

below the level of injury, as neurologic impairments may exist.

2.

Screen the patient's sensation to light touch, proximally to

distally, as above.

3.

If weakness is found, assess strength using manual muscle

testing. Break testing may also be performed as a modified way to

assess isometric capacity of motor performance. If altered sensation to

light touch is found, assess deep touch or other types of sensation further. Assess deep tendon reflexes if apptopriate. Refer to Table 4-15

fot the reflex grading and interpretation system.

Clinical Tip

• Start the examination or screening process with the uninvolved side to minimize patient anxiety and pain response.

• If manual muscle testing is not possible secondary to

conditions such as altered mental status, describe strength