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Download Examination of Lower Limb (Special Test)
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LUMBAR SPINE EXAMINATION LOOK SCARS PIGMENTATION (neurofibromatosis) ABNORMAL TUFTS OF HAIR (spina bifida) SHAPE AND POSTURE Scoliosis Kyphosis Gibbus Lordosis FEEL BONE – JOİNT Spinous processes Interspinous spaces Facet joints Iliac crests Coccyx SOFT TISSUES Swelling Para-vertebral Muscle Ligament Umblicus (L3-4) Sacral promontorium MOVE FLEXION EXTENSION ‘WALL TEST’ LATERAL FLEXION ROTATION SCHOBER’S TESTS >20cm is normal If less, suggestive of ankylosing spondylitis SPECIAL TEST Straight-leg raising test - discloses lumbosacral root tension. (L3-L4) Lasègue’s test Contralateral straight-leg raising test SPECIAL TEST Kernig’s sign Valsalva Test (positive-increased intrathecal pressure) Pelvic Rock Femoral Nerve Stretch test NEUROLOGICAL EXAMINATION Sensory Motor Tone Power Reflexes Patellar Calcaneal THANK YOU Knee Orthopaedic Special Tests Ligamentous Stability Anterior Drawer Sign Steps • Patient is lying supine with his/her hip flexed 45 degrees & knee flexed 90 degrees • Examiner sits on the patient's foot & grasps the tibia just below the joint line • Examiner's thumbs are placed along the joint line on either side of the patellar tendon & the index fingers are used to palpate the hamstring tendons • Examiner ensures that the patient is relaxed, esp. the hamstring tendons • Examiner draws the tibia straight forward (no rotation) Positive Test Increased anterior tibial translation, pain Positive Test Implications ACL tear (mainly the anteromedial bundle because the posterolateral bundle is basically laxed in this position) Anterior Drawer Sign Posterior drawer sign Steps • Patient is lying supine with his/her hip flexed to 45 degrees & knee flexed to 90 degrees • Examiner sits on the patient's foot & grasps the tibia just below the joint line • Examiner's thumbs are placed along the joint line on either side of the patellar tendon • Examiner ensures that the patient is relaxed, esp. the quadriceps • Examiner pushes the tibia posteriorly Positive Test Increased posterior tibial translation, pain Positive Test Implications PCL tear Lachman’s Test Procedure: Patient supine. Knee 30° flexion. Grasp thigh with one hand to stabilize. Grasp tibia with opposite hand and pull forward. Positive Test: Softened feel or anterior translation of the tibia suggests a possible tear of: Anterior cruciate ligament Posterior oblique ligament Lachman’s Test Reverse Lachman’s Test Procedure: Patient prone. Flex leg to 30°. Stabilize posterior thigh with one hand. Push tibia posterior with the other hand. Positive Test: Posterior pressure on the tibia stresses the posterior cruciate ligament. A soft end feel and posterior translation of the tibia are positive findings. Reverse Lachman’s Test Pivot shift test “Hip is flexed at 20 to 30 degrees, knee is extended while maintaining a valgus stress at the knee and in some cases an anterior force on the fibula head and the proximal aspect of tibia while flexing knee and in first 10 to 20 degrees of flexion the tibia will sublux posteriorly. Most effective to assess Gr III (total) tears of the ACL Adduction Stress Test Procedure: Patient supine. Stabilize medial thigh. Grasp lower leg and push medially. Positive Test: Excessive movement of the tibia away from the femur indicates a possible tear of: Tibial collateral ligament Posterior meniscofemoral ligament Posterior medial capsule Anterior cruciate ligament Posterior cruciate ligament Abduction Stress Test Procedure: Patient supine. Stabilize lateral thigh. Grasp lower leg and pull it laterally. Positive Test: Excessive movement of the tibia away from the femur indicates a possible tear of: Fibular collateral logaments Posterolateral capsule Posterior cruciate ligament Anterior cruciate ligament Abduction Stress Test Meniscus/Pathology Apley’s Distraction Test Procedure: Patient prone. Flex leg to 90°. Stabilize patient’s thigh with your knee. Pull on the ankle while internally and externally rotating the leg. Positive Test: Distraction of the knee takes pressure off the meniscus and puts strain on the medial and lateral collateral ligaments (non-specific). Apley’s Distraction Test Apley’s Compression Test Procedure: Patient prone. Flex leg to 90 degrees. Grasp the patient’s ankle and apply downward pressure while you internally and externally rotate the leg. Positive Test: Flexing the knee distorts the meniscus. Downward pressure further stresses the meniscus. Pain or crepitus on either side indicates a meniscus injury on that side. Apley’s Compression Test McMurray’s Test Procedure: Patient supine. Flex leg. Externally rotate the leg as you extend. Internally rotate the leg as you extend. Positive Test: Flexion and extension distort the meniscus. Adding external and internal rotation further distorts the meniscus. A palpable or audible click indicates injury of the meniscus. McMurray’s Test Patella Grinding Test Patella Apprehension Test Procedure: Patient supine. Manually displace the patella laterally. Positive Test: A look of apprehension on the patient’s face and a contraction of the quadriceps muscle indicates a chronic tendency to lateral patella dislocation. Pain is also present with this test. Patella Apprehension Test Others Patella Grinding Test Procedure: Patient supine. Move patella medially and laterally while pressing down. Positive Test: Pain under the patella - chondromalacia patellae, retropatellar arthritis, or a chondral fracture. Pain on the patella – osteochondritis. Pain over the patella – prepatellar bursitis. Patella Ballottement Test Procedure: With one hand, encircle and press down on the superior aspect of the patella. With the other hand, push the patella against the femur with your finger. Positive Test: If fluid is present in the knee, the patella will elevate when pressure is applied. When the patella is pushed down, it will strike the femur with a tap. Patella Ballottement Test Q angle test Steps • Patient is lying supine with the knee fully extended • Examiner identifies & marks the ASIS, midpoint of patella & tibial tuberosity • Examiner places a goniometer so that: (a) Axis is located over the patellar midpoint; (b) The center of the stationary arm is over the line from the ASIS to the patella; (c) Moving arm is placed over the line from the patella to the tibial tuberosity Positive Test: Q angle > 13 degrees (men) / 18 degrees (women) Positive Test Implications: Increased lateral forces at the patellofemoral joint Q angle test Examination of Lower Limb (Special Test) Mu’az Jamil M121140134 Basic rules in examination The entire area in question with one joint above and one joint below must be exposed adequately and examined. No Orthopaedic examination is complete unless the joint above, the joint below, the same joint on the opposite side and a detailed neurovascular examination is done. Examination has to proceed with the differential diagnosis made at the end of the history in mind. Sequence in examination : Inspection, Palpation, Movements, Measurements and SPECIAL TESTS. Hip Joint Anatomy Synovial ball and socket type of joint Movement in 3 planes with 6 movements; flexion, extension, abduction, adduction, internal rotation, and external rotation. The femur is held in the acetabulum by bony structure capsule 5 ligaments Ilio-femoral ligament Pubo-femoral ligament Ischio-femoral ligament Transverse acetabular ligament Femoral head ligament Vascular sign of Narath In conditions where the head or neck of the femur are not in place or are destroyed as a complication of a disease process, the femoral pulsation on the affected side is less well felt. Thomas Test When increased lumbar lordosis is present: indicates primary spinal deformity or an underlying fixed flexion deformity of the hip. The degree of deformity has to be measured in degrees by doing the THOMAS test. NB: When fixed deformities are found, movements in the opposite direction is not possible, mmovements in the same direction as the deformity may be possible If the hip being examined rises from the couch, this indicates loss of extension in that hip (also described as a fixed flexion deformity of the hip). Any loss should he measured and recorded. Look for evidence of excessive lumbar lordosis by: looking for light passing through and through the lumbar area (between the back and the couch). Pass the palm of the hand under the lumbar region: this cannot be done in a normal situation. If the palm can be passed under the lumbar region it indicates excess lumbar lordosis. With the palm under the lumbar back, flex the hip on the unaffected side through its full range of flexion and continue to flex it beyond till the lumbar back just touches the hand. Notice the hip on the affected side flexing with this maneuver. With the unaffected hip in the position of flexion as above, passively extend the hip on the affected side as much as possible without allowing the patient to arch his back. The angle that the back of the thigh makes to the couch on the affected side is the amount of fixed flexion deformity in that hip Telescopy test Done for demonstrating a dislocated hip or unstable hip. Sliding the hip in telescoping movement of in and out Barlow’s test • Provocative test of dislocatability • Adduct hip - lateral pressure using thumb • Thud of dislocation can be felt Barlow’s test If the Ortolani test is negative the hip may nevertheless be unstable. Fix the pelvis between symphysis and sacrum with one hand. With the thumb of the other attempt to dislocate the hip by gentle but firm backward pressure. Check both sides. If the head of the femur is felt to sublux backwards, its reduction should be achieved by forward finger pressure or wider abduction. The movement of reduction should also be appreciated with the fingers. If Barlow’s test is positive (and Ortolani’s negative), recheck at weekly intervals. Instability persisting for more than 3 weeks is an indication for splintage, or for further investigation with ultrasound and X-ray. Ortalani’s test • Test for reducibility • Abduct hip with pressure on greater trochanter with attempt to reduce the hip • Click of reduction felt Ortalani’s test To be of any value the examination must be carried out on a relaxed child, preferably after feeding. Flex the knees and encircle them with the hands so that the thumbs lie along the medial sides of the thighs and the fingers over the trochanters. Now flex the hips to a right angle and, starting from a position where the thumbs are touching, abduct the hips smoothly and gently. If a hip is dislocated, as full abduction is approached the femoral head will be felt slipping into the acetabulum. An audible click may accompany the displacement, but in no way must this be considered an essential element of the test. Note that restriction of abduction may be pathological, and represent an irreducible dislocation. A positive Ortolani test is indicative of neonatal instability of the hip (NIH), and is usually an indication for splintage. Trendelenburg test To demonstrate an ineffective abductor mechanism (Gluteus medius weakness, dislocated or destroyed head of femur, nonunion of neck of femur, coxa vara, etc.) The test is positive as a result of (A) gluteal paralysis or weakness (e.g. from polio, muscle-wasting disease); (B) gluteal inhibition (e.g. from pain arising in the hip joint); (C) from gluteal inefficiency from coxa vara; or (D) developmental dislocation of the hip (DDH). Nevertheless, false positives have been recorded in about 10% of patients. When standing on one leg (here the left), the centre of gravity (at S2) is brought over the stance foot by the hip abductors (gluteus medius and minimus). This tilts the pelvis and normally elevates the buttock of the non-stance side. The patient should be able to produce a greater pelvic tilt (by being asked to lift the side higher) and hold the position for 30 seconds. Ask the patient to stand on the affected side: any support (stick or hand) must be on the same side. Now ask him to raise the non-stance leg further. Prevent excessive trunk movements (a vertical dropped from C7 should not fall beyond the foot). If the pelvis drops below the horizontal or cannot be held steady for 30 seconds, the test is positive. It is not valid below age 4: pain, poor cooperation or bad balance may give a false positive. Patrick’s test Basically, this is a variation of abducting the hip from a position of 90° flexion. Pain during the manoeuvre is regarded as being the very first sign of osteoarthritis in a hip. To perform (on the right), flex both hips and knees, place the right foot on the left knee and gently press down on the right knee. This is also knownas the faber sign (flexion, abduction, external rotation). Allis test Apparent shortening If in the last test there was no evidence of shortening above the trochanter, look for causes below the trochanter. Slightly flex both knees and hips, and place a hand behind the heels to check that you now have them squarely together. Galeazzi sign The position of the two knees should be compared. (A) This appearance suggests femoral shortening. (B) This appearance is suggestive of tibial shortening (in the diagram, the right side is as usual the site of the pathology). Look from two views, anterior and lateral view. Ankle Joint Lateral ligament Complete lateral ligament tear. Swelling is rapid, and if seen within 2 hours of injury is eggshaped and placed over the lateral malleolus (McKenzie’s sign). Stress testing For complete ligament lateral tears Grasp the heel and forcibly invert the foot, feeling for any opening-up of the lateral side of the ankle between the tibia and the talus. Lateral ligament stress testing of the anterior talofibular component of the lateral ligament: Instability may sometimes follow tears of the anterior talofibular portion only of the lateral ligament. With the patient prone, press downwards on the heel, looking for anterior displacement of the talus, which is often accompanied by dimpling of the skin on either side of the tendo calcaneus. Thompson Test Normally when the calf is squeezed the foot moves as the ankle plantarflexes. Loss of this movement is pathognomonic of an acute rupture of the tendo calcaneus Tarsal Tunnel Syndrome The posterior tibial nerve may become compressed as it passes beneath the flexor retinaculum into the sole of the foot, giving rise to paraesthesia and burning pain in the sole of the foot and in the toes. The condition is uncommon, but is relieved by division of the flexor retinaculum. The superficial peroneal nerve may also be compressed as it runs under the extensor retinaculum on the dorsum of the foot, giving paraesthesia in the area of its distribution.
