Orthopaedics

1. 2. 3. 4. 5. 6. Hip Knee Joint Spine Shoulder Elbow Joint Wrist

Common format to examine all joints: 1. GRIPS

Hello Mr X I am DR Y, how are you feeling today? I am here to examine your... While examining, I will be touching you, doing some movements and I will be verbalising my finding with the examiner. I will be as gentle as possible, if it hurts please let me know. I will ensure adequate privacy and I will ask the examiner to be my chaperone.

2. Exposure
Upper limb: can you please undress above waist? Lower limbs: can you please undress keeping your underwear on?

3. Position
Upper limb: standing (for waist joint only- sitting) Lower limbs: Standing Gait lying down on couch

4.

Look (from front and behind and sides)

Formula: Drsss = Discharge, redness, scar, swelling, sinuses> muscle>bone Scars, sinuses, redness, swelling Muscle wasting, any obvious deformity

5.

Feel (is there any sore? If then offer painkiller + warm hands) Move (Examine both sides)

Temperature: compare with the other side. Tenderness: of bony points or prominence.

6.

Flexion, extension, abduction, adduction External and internal rotation Pronation and supination (for upper limbs only)

7.

Special tests (Examine affected side)

8. Neurovascular status
Upper limb: radial pulse + can you please move your fingers? Lower limb: dorsalis pedis + can you please wriggle your toes?

9. Verbalise
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Ideally I would examine the joints above and below.

10. Thank you and can you please dress up.

1. Hip
(Most of the time diagnosis is osteoarthritis) 1. GRIPS Hello Mr X I am DR Y, how are you feeling today? I am here to examine your hip. While examining, I will be touching you, doing some movements and I will be verbalising my finding with the examiner. I will be as gentle as possible, if it hurts please let me know. I will ensure adequate privacy and I will ask the examiner to be my chaperone. 2. Exposure Can you please undress keeping your underwear on? 3. Position Lower limbs: Standing Gait lying down on couch Can you please stand up for me?

Tip: while examining you stand in front of patient.

4. Look (from front and behind and sides)

Verbalise while inspecting: Shoulders are asymmetrical, Look for the ASIS (Anterior superior iliac spine), knees and median malleoli at the same level. I will look for scars, sinuses, redness, swelling and any obvious deformity. There is no Muscle wasting of quadriceps in front, glutei muscles in back. Ask the patient: may I ask you where you have pain? Sorry about that. Trendelenburg test: SOUND SIDE SINKS Can you please stand on your non-effected- leg and lift your other knee and if you fall I will hold you. Can you please stand on your effected- leg and lift your other knee and if you fall I will hold you.

In normal individuals the pelvis ASIS - will rise on the side of leg that has been lifted. With instability, the pelvis may drop on the side of the leg that has been lifted. The sound side would go down. The sound side sinks. This means Trendelenburg test is positive. Trendelenburg test positive due to: Paralysis of gluteous medius / minimus, (abductor muscles of hip) CDH (congenital dislocation of hip) 5. Feel Can you please take steps and lie down on couch?

Tip: While walking to the couch watch his Gait and comment: the patient has antalgic gait.

Normal or Antalgic (limping or walking with pain)

Tip: couchs angel is 0 degree

Measurement

Ask examiner: Can I have a measuring tape please? if you see one, dont ask. Tell the patient: I am going to measure your legs. Apparent limb length- From xiphi sternum to the median malleolus (both sides) Say: apparent limb length is equal in both sides. True limb length- from ASIS to the median malleolus Say: True limb length is equal in both sides. Warm your hands and say: I am going to touch you if any discomfort please let me know. compare hip with other side. Temperature: compare with the other side. There is no localised rise in the temperature. Tenderness: of bony points or prominence. Look at the face of patient. ASIS iliac crest Greater Trochanter femoral head

Tip: in orthopaedics always pain is in the prominences.

Say: Theres some pain in greater Trochanter area, so I wont palpate further. For femoral head say: may I touch your groin and move your leg like this? head of leg is palpable and there is no 6. Move

Tip: Always examine both sides.

(Rule out contraindications) Before we go further, I want to ask have you had any recent knee operation or hip operation like knee replacements? no I want you to do some movements, if you feel uncomfortable just stop examination, is that OK? Flexion: Can you please raise your leg up without bending your knee? Extension: Can you please lie down on your left side? Can you please keep bring your leg towards me as far as possible? you are standing behind the patient. Adduction: Can you please cross your right leg over the other leg? and do the same on the left thank you very much Go to the end of the couch and say. Abduction: Can you please part your legs and try to reach towards the edge of couch? External rotation: Can you please touch your big toes together like this? (Show with your hands) Internal rotation: Can you please move your toes out as far as possible? (Show with your hands)

7. Special tests (Always affected side) I am going to ask you to do some special test. Ok? It might be cause some discomfort, I do apologise. Trochanteric bursitis test - I am going to gently tapping your legs. Look at his face while watching. If he feels pain, say sorry about that. Could you show me where you felt the pain?

Tip: if patient feels pain, Osteoarthritis is positive.

Thomas test I am going to introduce my hand, please bend your unaffected knee and bring it toward your chest with your hand as far as possible. Place your hand behind the lumbar region of the back. There is normally a small gap here due to normal lordosis. Abolish the lumbar lordosis by asking the patient to bend the normal / opposite hip and hold it with his hands. (This straightens the spine) and feel the lumbar lordosis flatten or obliterated out on your hand.

If there is a flexion contracture of the hip, the patient's other leg will rise off the table.
8. Neurovascular status Lower limb: dorsalis pedis Dorsalis pedis artery is palpable bilaterally. + can you please wriggle your toes? 9. Thank you and can you please dress up. Thank you very much for you cooperation. Sorry about causing pain. Now you can dress up.

Tell the examiner: Based on my examination I think most probably the patient has osteoarthritis of hip, but Id like to discuss it with my seniors before further management.
OA On examination:

limp with a positive Trendelenburg sign The patient lies with affected leg adducted and in external rotation. There may be apparent shortening of the affected leg. flexion deformity may be present - positive Thomas' test Restriction of movements at the hip joint.

2. Knee joint
(Most of the time diagnosis is medial collateral ligament damage) 1. GRIPS Hello Mr X I am DR Y, how are you feeling today? I am here to examine your knee. While examining, I will be touching you, doing some movements and I will be verbalising my finding with the examiner. I will be as gentle as possible, if it hurts please let me know. I will ensure adequate privacy and I will ask the examiner to be my chaperone. 2. Exposure Can you please undress keeping your underwear on?

Tip: if patient has shorts dont ask for undress; ask him to roll up his shorts. If he already has, thank for enough exposure.

3. Position Can you please stand up like this? show that palm facing front

Tip: if patient is lying on the couch dont bother him to stand up.

4. Look (from front and behind and sides)

Shoulders are asymmetrical; the hip (ASIA), I cant appreciate that. It is under shorts. The knees are in fixed flexion deformity and medial malleoli are asymmetric. On inspection, there are no (DRsss) Scars, sinuses, redness, and swelling; & Muscle & any visible abnormality in anterior side. And there are no visible abnormality and deformity and fullness in popliteal fossa in posterior aspect of knee. (Muscle wasting of quadriceps in front and hamstrings in back) Any obvious deformity of genu varus or genu valgus Can I ask you kindly take few steps and lie down? Comment: The patient hasnt had any antalgic. Or he has antalgic gait. 5. Feel Warm your hands and say: I am going to touch you if any discomfort please let me know. Is there any sore? If then offer painkiller. Temperature: compare with the other side. There is no localised rise in the temperature. Say: ideally I would check the normal side but because of time constraint I will check the affected side. Tenderness: of bony points or prominence. Start with knee extension; feel around the margins of patella. Flex the knee, feel the medial and lateral joints lines of knee. Posterior aspect for popliteal fossa swelling There is some tenderness on superficial palpation on the medial aspect of the right knee. 6. Move (Both sides) Flexion: can you please fully bend and then straighten your knee please? Extension

There is limited flexion in the right knee. 7. Special tests Collateral ligament assessment:

Medial collateral ligament = valgus stretch test Hold the distal end of tibia and place your other hand over the lateral part of the knee. Maintaining 30 degrees of flexion apply valgus stress (pulling the tibia a bit away from the midline) to the knee joint. If the knee is seen to open up on the medial side, this is indicative of medial collateral damage.

Collateral ligament assessment: Lateral collateral ligament = varus stretch test Hold the distal end of tibia and place your other hand over the medial part of the knee. Maintaining 30 degrees of flexion apply varus stress (pulling the tibia toward the midline) to the knee joint. Widening of the joint on lateral side is indicative of lateral collateral damage.

McMurrays test: medial and lateral menisci assessment

The knee is held by one hand, which is placed along the joint line, and flexed to ninety degrees while the foot is held by the sole with the other

hand. The examiner then places one hand on the lateral side of the knee to stabilize the joint and provide a valgus stress. The other hand rotates the leg externally while extending the knee. If pain or a "click" is felt, this constitutes a "positive McMurray test" for a tear in the medial meniscus. Likewise the medial knee can be stabilized and the leg internally rotated as the leg is extended. A tag, caused by a tear will cause a palpable or even audible click on extension of the knee. A positive test indicates a tear of the lateral meniscus. If heel is pointing laterally> lateral meniscus If heel is pointing medially> medial meniscus

Drawers test (anterior and posterior cruciate ligament)

The drawer test is a test used by providers to detect rupture of the cruciate ligaments in the knee. The patient should be supine with the hips flexed to 45 degrees, the knees flexed to 90 degrees and the feet flat on table. The examiner sits on the patient's feet and grasps the patient's tibia and pulls it forward (anterior drawer test) or backward (posterior drawer test). If the tibia pulls forward or backward more than normal, the test is considered positive. Excessive displacement of the tibia anteriorly indicates that the ACL is likely torn, whereas excessive posterior displacement of the tibia indicates that the PCL is likely torn.

8. Neurovascular status Lower limb: dorsalis pedis + can you please wriggle your toes? 9. Verbalise Ideally I would examine the joints above and below. 10.Thank you and can you please dress up.

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Patella tap test

Hold the knee with one hand and empty the fluid from suprapatellar pouch and tap gently with two fingers (with index and middle) If fluid is present, it will bounce back.

Grind test- press patella up and dawn against femur.

A positive sign on this test is pain in the patellofemoral joint. Look at patient face for any tenderness.

3. Spine
(Most of the time diagnosis is L4 disc prolapse) 1. GRIPS Hello Mr X I am DR Y, how are you feeling today? I am here to examine your spine. While examining, I will be touching you, doing some movements and I will be verbalising my finding with the examiner. I will be as gentle as possible, if it hurts please let me know. I will ensure adequate privacy and I will ask the examiner to be my chaperone.

2. Exposure Can you please undress keeping your underwear on? 3. Position Standing Gait lying down on couch Can you please stand up like this? show that palm facing front

4. Look (from front and behind and sides)

Front: shoulders are symmetrical, ASIS are symmetrical Side: I cannot appreciate any exaggerated Lumbar Lordosis or Kyphosis. Back: any scoliosis Scars, sinuses, redness, swelling Muscle wasting of Para spinal muscle No bony deformity

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5. Feel May I ask you to turn your face to my side, thank you? while examining you are standing in his side in front of his face. Warm your hands and say: I am going to touch you if any discomfort please let me know. Is there any sore? If then offer painkiller. Temperature: compare with the other side (Para spinal areas). There is no localised rise in the temperature. Tenderness: of bony points or prominence. First bony prominence (Start from C7) There is some tenderness on spinal palpation on the lumbar region. Then para spinal areas (with both hands on both sides) On Para spinal palpation, there is some tenderness on lower lumber area. 6. Move Forward Flexion: Can you please touch your toes without bending your knees? Extension: Can you please lean backward I will hold if you fall? Lateral Flexion: Can you please keep your hands like this and slide side to side without bending forward and try to touch your knees?

Tip: show the movement as you asking. It needs to be done on both sides. Lateral rotation: Can you please sit on the edge of the couch and place your hands on the wrist, and look to the right and then to the left without turning the neck? 7. Special tests Can you please lie down on the couch? Straight leg Raising (SLR) test:

Lumbosacral root irritation: Due to the disc prolapse. The test consider positive if pain occurs < 45 degree. With the patient supine the examiner attempts to raise one leg

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at a time, with the knee fully extended until pain is experienced. Repeat the test on the other leg.

Lasegues test:

This is refinement of the SLR test. It aims to assess the limitation of movement due to a sciatic nerve pressure. When the limit of SLR is reached (i.e. the patient experiences the pain.) dorsiflexion of the ankle passively increases pain.

Femoral nerve stretch test:

Patient should lie on his side. Passively extending the hip. In a positive test the patient should feel pain in ipsilateral anterior thigh. (i.e. the distribution of the femoral nerve) 8. Neurovascular status Lower limb: dorsalis pedis + can you please wriggle your toes? Show the. And say: Sir, this is a . Check on his neck and say: you we feel something like that. I am going to touch with this in different points of your legs just say yes when you feel, is that ok? Test L1 L2 L3 L4 Sensory (From belt to sole) Belt Pocket Knee Below the medial malleolus Keep hands on pockets and ask push up please May I ask you to bend your knees? May I ask you just to bring you feet back toward you without L5 S1 1st dorsal web space Sole of foot bending your knee? Could you bring your big toe towards you Push against my hands please (put your hands on soles) 9. Verbalise Motor (From sole to pocket)

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Ideally I would examine the joints above and below. 10.Thank you and can you please dress up.

4. Shoulder
1. GRIPS Hello Mr X I am DR Y, how are you feeling today? I am here to examine your shoulder. While examining, I will be touching you, doing some movements and I will be verbalising my finding with the examiner. I will be as gentle as possible, if it hurts please let me know. I will ensure adequate privacy and I will ask the examiner to be my chaperone. 2. Exposure Can you please undress above waist? 3. Position Standing Gait lying down on couch Can you please stand up?

4. Look (from front and behind and sides)

Front: level of the shoulders, counter of the shoulder. Side: any exaggerated Lumbar Lordosis or Kyphosis. Back: any scoliosis or step deformity Scars, sinuses, redness, swelling Muscle wasting around shoulder girdle, deltoid (front, side) Supraspinatus & infraspinatus Any obvious deformity Any obvious prominence of humeral head or winging of the scapula. 5. Feel May I ask you to turn your face to my side, thank you? Warm your hands and say: I am going to touch you if any discomfort please let me know.

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Is there any sore? If then offer painkiller. Temperature: compare with the other side. . There is no localised rise in the temperature. Tenderness: of bony points or prominence. There is tenderness in SC joint, clavicle, acromion, head of humerus, Spine of scapula, supraspinatus and infraspinatus area. 6. Move

Tip: show the movement as you asking. It needs to be done on both sides.

Flexion: Can you please lift your arms forward as far as you can? Extension: With the elbows straight can you please lift your arms backwards as far as possible? External Rotation: Can you please tuck the elbow at your tummy and make your thumbs up and bring your arms like this (Outward) as far as you can? Internal Rotation: make your thumbs up and bring your hands behind your back like this and try to scratch your back as high as possible?

Tip: note the level of both thumbs. (the lower thumb has limited
internal rotation) Abduction: Can you please raise your arms by your side as high as possible. (Palms facing sides) Adduction: Can you please bring your arm like this and cross them in front? 7. Special tests

Tip: stand by the side of the patient and keep one hand on the shoulder.

Painful arc test:

Painful abduction between 60 120 degree, Supraspinatus tendinitis (part of painful arc syndrome) Can you please lift your arms by your side as far as possible to make a smooth, painless arc to a position with hand above your head?

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Impingement test or emptying can sign:

The empty can test assesses the supraspinatus for instability and the presence of tears. The patient raises his arm to 90 degrees (abducted). You one hand is on the back of shoulder, other hand under elbow. May I ask you to make a thumb up signpush his arm forward and ask and then thumb down sign? The test is positive if there is significant pain or weakness or resistance

Apprehension test:

This is a provocative test for anterior dislocation of the shoulder. Stand behind the patient, shoulder 90 degree abduction, elbow 90 degree flexed. Rotate the shoulder externally by pulling the forearm posterior. Test is positive patient brings his other hand to protect of shoulder or complaining of pain.

Drop arm test: (rotator cuff tear)

Passively extending shoulder 90 degree abduction. Keep your arm up for as long as possible, I will be letting go your arm. In a positive test the patient drops the arm. Signifies rotator cuff tear. (Supraspinatus, infraspinatus, teres minor, subcapularis)

Speeds test: (biceps tendonitis)

Please keep your arm like this elbow flexed to 30 degrees and forearm supinatedyour right hand over the elbow and left behind the triceps and locking his arm try to move your arm up like that against my resistance please. Pain signifies: biceps tendonitis. 8. Neurovascular status

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Upper limb: radial pulse + can you please move your fingers? 9. Verbalise Ideally I would examine the joints above and below. 10.Thank you and can you please dress up.

Examining the shoulder and upper arm of this gentleman who had a trauma:

Offer the painkiller, patient may be wearing a broad arm sling. If he is still wearing a shirt, ask him to remove. If it is too painful, tell the examiner ideally I will cut off the shirt to expose. Then look through the sling for inspection. Do not remove his arm out of the sling. Inspection: swelling, bruises, any wounds. Gently check for any area of tenderness over the arm and shoulder. Ask the patient: can you move your shoulder or elbow at all? If he can, dont force. Check wrist and fingers movement. Check for distal neurovascular status. Tell the examiner: first of all, I will do the x-ray to rule out any fracture or dislocation.

5. Elbow joint

Golfers elbow (medial epicondylitis) / Tennis elbow (lateral epicondylitis) 1. GRIPS Hello Mr X I am DR Y, how are you feeling today? I am here to examine your shoulder. While examining, I will be touching you, doing some movements and I will be verbalising my finding with the examiner. I will be as gentle as possible, if it hurts please let me know.

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I will ensure adequate privacy and I will ask the examiner to be my chaperone. 2. Exposure Can you please undress above elbow? 3. Position Can you please stand up with palms facing me? show him the position while asking. 4. Look Front: on inspection, shoulders are symmetrical, elbows are symmetrical and wrists are at symmetrical level. There is no abnormal carrying angel.

Tip: Carrying angel is normally 15 degrees. Ask the patient: where is the pain? inspect the same side and the examiner: ideally I inspect the unaffected side first. But now because of time constraint I inspect the affected side first. Inspect front and back while elbow is extended and verbalise: There are no Scars, sinuses, redness, and swelling. No fullness in cubital fossa in front and para olecranon fossa in posterior aspect. Go to the back and say: may I ask you to bend your elbow for me? and straighten again Comment: The body prominences are lying up in corresponding position. Muscle wasting of biceps and flexor aspect forearm, triceps, extensor aspect forearm

5. Feel Warm your hands and say: I am going to touch you if any discomfort please let me know. Temperature: compare with the other side. (right anterior= left anterior, left posterior= right posterior) There is no localised rise in the temperature.

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Tenderness: This time, I am going to touch you more deeply if any discomfort please let me know. Hold the arm with left hand and start touching the anterior from mid forearm to mid arm. Then change hands and palpate posterior side with left hand. (3 bony points or prominence = Lateral and medial epicondyle of humerus and olecranon) There is tenderness in medial aspect of right elbow. Radial head: may I ask you to bend your elbow for me? and make a fist and turn your hand in and out you are holding the elbow with both hands. Comment: I can appreciate the radial head. - Stand behind the patient and ask him to bend the elbow to 90 degrees, put the index finger on the lateral epicondyle, middle finger on the tip of the olecranon and ring finger on the medial epicondyle. Now ask the patient to straighten his elbow and see if all your fingers come in a straight line. If fingers dont come in a straight line the patient has had an intercondylar fracture.

6. Move

If they come, verbalise: bony prominence are standing in the corresponding line.

Tip: show the movement as you asking. It needs to be done on both sides.

Can you please copy my movements? Flexion: Can you please bend your elbows like this? Extension: and please straighten them? Supination: Can you please tuck your elbows on your tummy and face your palm upward? Pronation: Can you please tuck your elbows on your tummy and face your palm downward? 7. Special tests

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Medial Epicondylitis (Golfers elbow):

Cozens test: Elbow 90 degree flexed, forearm supinated, rest forearm on your palm, ask him to make a fist and cock up the fist against residence. If patient complains of pain in medial epicondyle area, it is suggestive of medial epicondylitis. Mills manoeuvre: Elbow 90 degree flexed, forearm supinated, rest forearm on your palm, ask him to show the palm and push the palm down. If patient complains of pain in medial epicondyle area, it is suggestive of medial epicondylitis.

Lateral Epicondylitis (Tennis Elbow):

Cozens test: Elbow 90 degree flexed, forearm pronated, rest forearm on your palm, ask him to make a fist and cock up the fist against residence. If patient complains of pain in lateral epicondyle area, it is suggestive of lateral epicondylitis.

Mills manoeuvre:

Elbow 90 degree flexed, forearm pronated, rest forearm on your palm, ask him to show the palm and push the palm down. If patient complains of pain in lateral epicondyle area, it is suggestive of lateral epicondylitis. 8. Neurovascular status Check both radial pulses: may I check your pulses please? + can you please move your fingers?

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9. Thank you and can you please dress up and sit down. 10. Discuss management to the patient:
Base on my examination, you are suffering from (medial epicondylitis) / (lateral epicondylitis), it is also being called Golfers elbow /Tennis elbow. Make sure you have complete rest for 2-3 weeks and Anti inflammatory pain killers. Avoid the activities that precipitate pain. Epicondylitis brace may be helpful. Inter auricular steroid injections is next step. If that doesnt work the worst case scenario is surgery that my consultants will discuss that with you. Do you have any questions?

6. Wrist

1. GRIPS Hello Mr X I am DR Y, how are you feeling today? I am here to examine your wrist. While examining, I will be touching you, doing some movements and I will be verbalising my finding with the examiner. I will be as gentle as possible, if it hurts please let me know. I will ensure adequate privacy and I will ask the examiner to be my chaperone. May I assume you kindly be my chaperone? 2. Exposure Can you please roll your sleeves above elbow?

Tip: if he has already rolled up his sleeves, say: thank you for being adequate exposure.

3. Position Sitting with hands rested on a pillow. (Dont forget the pillow) 4. Look My I see your palms please? Palm: Scars, sinuses, redness, laceration, swelling or any obvious deformity

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Wasting of tenar and hypotenar muscles Can you please turn your hands over? Dorsum: Scars, sinuses, redness, swelling or any obvious deformity Wasting of interossie over the dorsum and over the anatomical snuff box

5. Feel (is there any sore? If then offer painkiller + warm hands)
Temperature: compare with the other side. There is no local rise temperature. Tenderness: phalanges, MCP joints, metacarpals, carpals, Anatomical snuff box, radial styloid and Ulnar styloid Mention: there is some tenderness in the base of the thumb and also anatomical snuff box. 6. Move Can you please copy my movements? Dorsi Flexion: Can you please raise you wrist like this, like stopping the terrific? Palmar Flexion: Can you please put your palm dawn? Dorsiflexion and palmar flexion are restricted in right hand. Radial deviation: Can you please bring your fingers inwards? Ulnar deviation: Can you please bring your fingers outwards? Radial and ulnar deviations are limited on the right side. 7. Special tests I am going to ask you to do some special test, is it OK with you? Axial Loading test: Can you please make thumbs up with the painful hand and then tap on the tip of the thumb with the palm of the other hand? It may be painful. (Warn the patient) Look at the face for tenderness. Pointing sign:

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Can you please point out with index finger of the painful hand and then tap on the tip of the index with the palm of the other hand? It may be painful. (Warn the patient)Look at the face for tenderness. Axial loading test and pointing test is positive in right hand.

8. Neurovascular status Assess median, ulnar and radial nerve: Median nerve: Can you please make an OK sign, I will try to separate the fingers and you will not let me to do this. If easily can separate, there is the median nerve palsy. Ulnar nerve: Can you please fan your fingers against the resistance? I will place a paper in between your fingers, I will pull it and you will try to resist it. If easily pulled, there is the ulnar nerve palsy.

Radial nerve: Can you please cock up your wrist? If wrist drops, there is the redial nerve palsy. Can you please straighten the fingers at the knuckles? If easily can separate, there is the radial nerve palsy. I am going to touch your pulses. Check radial pulse in both hands. Radial pulse has normal rate and rhythm. 9. Thank you and can you please dress up.

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10.Tell the examiner: Based on my examination tenderness in the anatomical snuff box, positive axial loading test and positive pointing sign I think most probably the patient has injured scaphoid bone. What would you like to do now? I would like to have an X-ray of wrist, Anterior-Posterior, lateral and oblique views. He would give you an x-ray.

Always check the ID on the x-ray plate to make sure this is the x-ray of your patient and x-ray will denote left or right wrist. Scaphoid bone can be identified easily Treatment of scaphoid fracture:

Rest / analgesics / physiotherapy Scaphoid cast: I would immobilise the hand in scaphoid cast which extends from below elbow up to the knuckles including proximal part of the thumb in glass holding position. (MCP joints should be free.)

I will review him again in 6 weeks. > if (negative>physiotherapy) again positive > 6weeks>positive refer to orthopaedics

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