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Physical Examination Lower Extremity

Physical Examination Lower Extremity. Sohail Bajammal, MBChB, MSc, FRCS(C) November 4, 2008. Objectives. Fundamentals of Diagnosis Principles of Physical Examination Principles of MSK Physical Examination MSK Physical Examination Approach: Hip Knee Foot & Ankle.

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Physical Examination Lower Extremity

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  1. Physical ExaminationLower Extremity Sohail Bajammal, MBChB, MSc, FRCS(C) November 4, 2008

  2. Objectives • Fundamentals of Diagnosis • Principles of Physical Examination • Principles of MSK Physical Examination • MSK Physical Examination Approach: • Hip • Knee • Foot & Ankle

  3. Fundamentals of Diagnosis • Have a list of D/D as you read the CC • VITAMIN 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

  4. Principles of Physical Exam • Permission • Pre-amble • Privacy • Politeness • Passionate • Pacing

  5. Principles of MSK Exam • Do not forget the patient • General exam, Vital signs • Two sides: right and left • Two joints: above and below • Two surfaces: front and back

  6. Approach to MSK ExamAny Lower Extremity Joint • General & Gait • Look, Feel & Move • Special Tests • Neurovascular Examination

  7. General • Well or ill-looking • Cachectic • Vital signs: febrile, hemodynamic stability

  8. Gait • Antalgic gait: painful, short stance phase • Trendelenburg (abductor lurch) gait: weak abductors • Waddling gait: bilateral weak abductors, bilateral DDH • Steppage gait: foot drop • Toe-walking • In-toeing vs out-toeing • Others: ataxic, scissoring, etc.

  9. Hip

  10. Hip - Look • Principles: • Enough exposure • Compare both sides • Examine joint above (back) and joint below • Look for: • Leg length discrepancy: blocks vs. tape • Alignment & Asymmetry (wasting) • Swelling, Skin changes (erythema), Scars

  11. Hip - Feel • Principles: • Start from non-painful area • Feel for warmth, swelling, tenderness • Sites: • From the front: ASIS, pubic tubercle • From the side: GT, iliotibial band • From the back: SI joint, PSIS

  12. Examination of a Mass “6 Students and 3 Teachers go for CAMPFIRE” • Site, Size, Shape, Surface, Skin, Scar • Tenderness, Temperature, Transillumination • Consistency • Attachment • Mobility • Pulsation • Fluctuation • Irreducibility • Regional lymph nodes • Edge

  13. Hip - Move • Principles: • Active then passive • Feel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation • ? Do the motor neurological exam now • Movements: • Flexion & Extension • Abduction & Adduction • IR & ER in flexion & extension

  14. Hip – Move (Motor)

  15. Hip – Special Tests • Trendelenburg test: for abductor strength • Thomas test: for hip flexion contracture • Ober’s test: for iliotibial band tightness • Patrick’s (FABER) test: for SI joint • Labral tear test

  16. Knee

  17. Knee - Look • Principles: • Enough exposure • Compare both sides • Examine joint above (hip) and joint below • Look for: • Leg length discrepancy • Alignment (varus, valgus, Q-angle) • Asymmetry (wasting) • Swelling, Skin changes (erythema), Scars

  18. Knee - Feel • Principles: • Start from non-painful area • Feel for warmth, swelling, effusion, tenderness • Do not forget the back of the knee • Sites: • Patella: margins and surfaces, quadriceps & patellar tendon & its insertion, bursae • Ligaments, tendons, & ITB attachment • Joint line: medial & lateral • Effusion: milking test, balloon test, ballotment

  19. Knee - Move • Principles: • Active then passive • Feel for crepitus, excessive movement (laxity), limited movement (contracture, locked knee), painful limitation • ? Do the motor neurological exam now • Movements: • Extension: quadriceps by femoral nerve • Flexion: hamstrings by sciatic nerve

  20. Knee – Special Tests • Patellar tests: • Patellar apprehension test • Patellofemoral grind test • Meniscal tests: • McMurray test • Apley’s test • Ligaments tests: ACL, PCL, MCL, LCL, PLC

  21. Knee – Ligaments Special Tests • ACL: Lachman’s, 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

  22. Foot & Ankle

  23. Foot & Ankle - Look • Principles: • Enough exposure, Compare both sides • Examine joint above & below • In hindfoot, midfoot & forefoot, look for: • Leg length discrepancy • Alignment: • Ankle: valgus or varus, • Foot: pes planus or cavus, • Big toe: hallux valgus or varus • Toes: claw, hammer, mallet • Asymmetry (wasting) • Swelling, Skin changes (erythema), Scars

  24. Toes Claw Toes Hammer Toe Mallet Toe

  25. Foot & Ankle - Feel • Principles: • Start from non-painful area • Feel for warmth, swelling, effusion, tenderness • Sites: • Bones: malleoli, bones of the hindfoot, midfoot and forefoot • Ankle joint • Tendons: Achilles, posterior tibial, peroneal • Interdigital neuroma

  26. Foot & Ankle - Move • Principles: • Active then passive • Feel for crepitus, excessive movement (laxity), limited movement (contracture), painful limitation • ? Do the motor neurological exam now • Movements: • Ankle: dorsiflexion & plantarflexion • Subtalar joint: inversion & eversion • Forefoot: abduction & adduction • Toes: extension & flexion

  27. Foot & Ankle – Move (Motor)

  28. Foot & Ankle – Special Tests • Tendons: • Achilles Tendon: Thompson test • Posterior Tibial Tendon: Heel raise test • Instability: • Anterior drawer test • Inversion stress test • Peroneal tendon instability test • Morton’s test: Mulder’s click

  29. Neurovascular Examination

  30. Neurological Examination • If suspecting peripheral pathology, test motor & sensory for all peripheral nerves • If suspecting spine pathology: • Dermatome sensation, myotome power testing & deep tendon reflexes

  31. Peripheral Nerves of Lower Extremities

  32. Sensation

  33. Dermatomes & Myotomes

  34. Vascular Examination • Inspection: • Pallor • Hair distribution • Palpation: • Feel pulses: dorsalis pedis, posterior tibial, popliteal, femoral • Temperature • Capillary refill • Sensation • Special Tests: • Compartments check • Ankle-Brachial Index

  35. References US$ 65 US$ 47

  36. Questions

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