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Bajammal 2008 Physical Examination Lower Extremity
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Physical ExaminationLower ExtremitySohail Bajammal, MBChB, MSc, FRCS(C)
November 4, 2008
ObjectivesFundamentals of DiagnosisPrinciples of Physical ExaminationPrinciples of MSK Physical ExaminationMSK Physical Examination Approach:HipKneeFoot & Ankle
Fundamentals of DiagnosisHave a list of D/D as you read the CCVITAMIN C&D
Re-visit your D/D
Narrow your list by the end of History
Further narrow by the end of Physical
Confirm by further investigations
Principles of Physical ExamPermissionPre-amblePrivacyPolitenessPassionatePacing
Principles of MSK ExamDo not forget the patient General exam, Vital signs
Two sides: right and left
Two joints: above and below
Two surfaces: front and back
Approach to MSK ExamAny Lower Extremity JointGeneral & GaitLook, Feel & MoveSpecial TestsNeurovascular Examination
GeneralWell or ill-lookingCachecticVital signs: febrile, hemodynamic stability
GaitAntalgic gait: painful, short stance phaseTrendelenburg (abductor lurch) gait: weak abductorsWaddling gait: bilateral weak abductors, bilateral DDHSteppage gait: foot dropToe-walkingIn-toeing vs out-toeingOthers: ataxic, scissoring, etc.
Hip
Hip - LookPrinciples:Enough exposureCompare both sidesExamine joint above (back) and joint below
Look for:Leg length discrepancy: blocks vs. tapeAlignment & Asymmetry (wasting)Swelling, Skin changes (erythema), Scars
Hip - FeelPrinciples:Start from non-painful areaFeel for warmth, swelling, tenderness
Sites:From the front: ASIS, pubic tubercleFrom the side: GT, iliotibial bandFrom the back: SI joint, PSIS
Examination of a Mass 6 Students and 3 Teachers go for CAMPFIRESite, Size, Shape, Surface, Skin, ScarTenderness, Temperature, TransilluminationConsistencyAttachmentMobilityPulsationFluctuationIrreducibilityRegional lymph nodesEdge
Hip - MovePrinciples:Active then passiveFeel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation? Do the motor neurological exam now
Movements:Flexion & ExtensionAbduction & AdductionIR & ER in flexion & extension
Hip Move (Motor)
MovementMuscle(s)InnervationFlexionIliopsoasLumbar plexus & femoral nerveExtensionGluteus maximusInferior glutealAbductionGluteus medius & minimusSuperior glutealAdductionAdductor magnus, longus and brevisMainly obturator
Hip Special TestsTrendelenburg test: for abductor strength
Thomas test: for hip flexion contracture
Obers test: for iliotibial band tightness
Patricks (FABER) test: for SI joint
Labral tear test
Knee
Knee - LookPrinciples:Enough exposureCompare both sidesExamine joint above (hip) and joint below
Look for:Leg length discrepancyAlignment (varus, valgus, Q-angle)Asymmetry (wasting)Swelling, Skin changes (erythema), Scars
Knee - FeelPrinciples:Start from non-painful areaFeel for warmth, swelling, effusion, tendernessDo not forget the back of the knee
Sites:Patella: margins and surfaces, quadriceps & patellar tendon & its insertion, bursaeLigaments, tendons, & ITB attachmentJoint line: medial & lateralEffusion: milking test, balloon test, ballotment
Knee - MovePrinciples:Active then passiveFeel for crepitus, excessive movement (laxity), limited movement (contracture, locked knee), painful limitation? Do the motor neurological exam now
Movements:Extension: quadriceps by femoral nerveFlexion: hamstrings by sciatic nerve
Knee Special TestsPatellar tests:Patellar apprehension testPatellofemoral grind test
Meniscal tests:McMurray testApleys test
Ligaments tests: ACL, PCL, MCL, LCL, PLC
Knee Ligaments Special TestsACL: Lachmans, Anterior drawer, Pivot shift
PCL: posterior sag sign, Posterior drawer
MCL: valgus stress in neutral & 30 flexion
LCL: varus stress in neutral & 30 flexion
PLC: dial test
Foot & Ankle
Foot & Ankle - LookPrinciples:Enough exposure, Compare both sidesExamine joint above & below
In hindfoot, midfoot & forefoot, look for:Leg length discrepancyAlignment:Ankle: valgus or varus, Foot: pes planus or cavus, Big toe: hallux valgus or varus Toes: claw, hammer, malletAsymmetry (wasting)Swelling, Skin changes (erythema), Scars
ToesClaw ToesHammer ToeMallet Toe
Foot & Ankle - FeelPrinciples:Start from non-painful areaFeel for warmth, swelling, effusion, tenderness
Sites:Bones: malleoli, bones of the hindfoot, midfoot and forefootAnkle jointTendons: Achilles, posterior tibial, peronealInterdigital neuroma
Foot & Ankle - MovePrinciples:Active then passiveFeel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation? Do the motor neurological exam now
Movements:Ankle: dorsiflexion & plantarflexionSubtalar joint: inversion & eversionForefoot: abduction & adductionToes: extension & flexion
Foot & Ankle Move (Motor)
MovementMuscle(s)InnervationAnkle DFTib AntDeep PeronealAnkle PFGastrocnemiusTibialInversionTib Post mainlyTibialEversionPeroneus longus & brevisSuperficial Peroneal
Foot & Ankle Special TestsTendons:Achilles Tendon: Thompson testPosterior Tibial Tendon: Heel raise test
Instability:Anterior drawer testInversion stress testPeroneal tendon instability test
Mortons test: Mulders click
Neurovascular Examination
Neurological ExaminationIf suspecting peripheral pathology, test motor & sensory for all peripheral nerves
If suspecting spine pathology:Dermatome sensation, myotome power testing & deep tendon reflexes
Peripheral Nerves of Lower Extremities
NerveMotorSensoryFemoralKnee ExtensionSaphenous nObturatorHip AdductionMedial aspect of thighLFCN-Lateral aspect of thighSciaticKnee FlexionAccording to branchesTibialAnkle PFPlantar aspect of footDeep peronealAnkle DF1st web space dorsum of footSuperficial peronealFoot EversionDorsum of foot except 1st web spaceSural-Lateral border of footSaphenous-Medial border of foot
Sensation
Dermatomes & Myotomes
RootSensoryMotorReflexesL1Inguinal ligamentIliopsoasL2Anteromedial thighIliopsoasL3Medial to patellaQuadsL4Medial lower legTib AntPatellarL5Anterolateral leg, dorsum footEHLS1Posterolateral heelGastrocAchillesS2Posterior thighRectalS3-5PerianalRectal
Vascular ExaminationInspection: PallorHair distribution
Palpation:Feel pulses: dorsalis pedis, posterior tibial, popliteal, femoralTemperatureCapillary refillSensation
Special Tests:Compartments checkAnkle-Brachial Index
ReferencesUS$ 65US$ 47
Questions
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