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Physical Examination Lower Extremity

Physical Examination Lower Extremity. Sohail Bajammal, MBChB, MSc, FRCS(C) November 4, 2008. 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.

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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. 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

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

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

  5. Gait • Antalgic gait: painful, short stance phase • Trendelenburg (abductor lurch) gait: weak abductors • Steppage gait: foot drop • Others: ataxic, scissoring, etc.

  6. Hip

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

  8. Hip - Feel • Principles: • Start from non-painful area • Feel for warmth, swelling, tenderness

  9. 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

  10. Knee

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

  12. 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

  13. 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

  14. Foot & Ankle

  15. 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

  16. 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

  17. 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

  18. Foot & Ankle – Move (Motor)

  19. 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

  20. Neurovascular Examination

  21. 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

  22. Peripheral Nerves of Lower Extremities

  23. Sensation

  24. Dermatomes & Myotomes

  25. 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

  26. References US$ 65 US$ 47

  27. Questions

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