IB CSL ORTHO

IB CSL ORTHO

P/E LL
Dr PKY Chiu

Ortho

Fri 04-10-02
PRINCIPLES

Sequence

Look: deformity, scar, gait
Feel: tenderness, location (site of path), temp (inflam), crepitation (hyaline cartilage damaged; sandpaper rubbing, eg. OA)
Move

ROM

Active: ask Pt to perform himself, do not touch Pt

Passive: only if AROM not full

Resisted: test m power, grading 0-5

1^st doctor: bedside: usually only do passive (AROM if suspect neuro problem)
2^nd doctor: do active 1^st b/c Pt will stop if painful – then gently do passive + watch for facial expression of pain (if pain – STOP – report "ROM limited by pain")
If contracted jt capsule: AROM = PROM
If muscle weakness/ neuro prob: PROM > AROM (jt capsule normal)

Unaffected side first

For comparison – eg. Elderly, usually only 160 deg for shoulder abduction \ one side 155 deg but not affected that much (cf. normal young person)
Affected side may be painful \ examining unaffected side first shows Pt what you’re going to do on affected side \ ¯ uncertainty

ABNORMAL GAIT – "LIMP"

Best observed when Pt leaves clinic

Ask Pt to walk for you: wastes time/ unnatural gait
Entry into clinic: Pt may exaggerate gait (eg. To obtain sick leave certificate)

Types of gait

Antalgic: (most common abnormal gait) supporting limb takes 3x BW during stance \ pain – shortened stance phase on affected side; stand front/ side of Pt ® compare stance phases of L + R
Trendelenburg: weak hip abductor (gluteus medius); pelvis drops in the unsupported or the non-wt-bearing side; may shift trunk to wt-bearing side; Trendelenburg gait is dynamic test of hip abductor (cf. Trendelenburg test = static test of hip abductor)
Limb length inequality: Dx of exclusion, measure limb length

HIP

LOOK

Adequate exposure, front/ lat views
Scar (surgery/ TB sinuses)
M wasting

FEEL

Pt point to painful site
Palpate for tenderness: greater trochanter (eg. Trochanteric bursitis), ASIS, hip joint (slightly medial to femoral pulse)
Hip is deep-seated \ difficult to palpate
Need to rule out other pathology (1) AS ® sacroiliitis (2) Hernia ® dull ache in groin perceived as hip pain (3) Groin LN

MOVE

SUPINE ® Thomas, Flexion, Ab/adduction, Length

Thomas Test: flexion contracture/ fixed flexion deformity of hip (eg. Test L hip) ® eliminates hyperlordosis of lumbar spine assoc with flexion contracture

Hand under lumbar spine
Flex unaffected (R) side fully ® lumbar lordosis obliterated?
Check L hip for uncorrectable flexion posture

If LL flat, no flexion contracture, if yes…

Keep R hip flexed (Pt to hold own knee/ Dr hold
Can push down L leg flat?

Note: observation of flexion not enough b/c flexion contracture £ 30-40 deg not detectable (pelvis rotates – hyperlordosis of lumbar spine – to mask contracture)

Flexion

Check flexion of affected side
Note: flexion of unaffected side already checked in Thomas test

Ab/Adduction

Stabilise pelvis: (1) Forearm across ASIS’s (2) Hold contralateral hip (3) Hang contralateral leg off bed
Make sure observed movt occur at hip and not pelvis
Test AROM then PROM
Sequentially or simultaneously (balanced movt)
Adduction (1) Move leg over resting leg – some flexion involved (2) Move leg under raised leg – more accurate

Leg length inequality

Apparent: pelvic obliquity, hip contracture, scoliosis (no actual shortening)

® LL parallel to each other (functional position, no need to correct pelvis)

® Xiphisternum/ umbilicus to base of each medial malleoli

True: actual shortening

® Pelvis squared

® LL in corresponding positions (eg. If one side knee flexion deformity, other side placed the same)

® ASIS to each medial malleolus

Note: deformities of both sides (eg. Windswept deformity: one side adducted, one side abducted) -rare
If NO TAPE MEASURE: knees 90 degrees flexed (feet lined up, use your hand) – view (1) Tibial shortening: end of bed (2) Femoral shortening: head of bed [cannot be performed if ab/adduction flexion contracture]

Nelaton’s line: to distinguish between shortening below greater trochanter (ie. Femur) and above greater trochanter (ie. Hip) – measure distance from ASIS to greater trochanter, if one side shorter then hip path present
Reporting: report discrepancy (NOT actual measurements)

PRONE ® Rotation, Extension, Lumbar palpation

When Pt turns over, remember which is the affected side!

Rotation

Test in anatomical position \ better to test prone with hip neutral, knee 90 degrees and lower leg as level (cf. supine with hip and knee flexed)

Stabilise pelvis: hand on sacrum
Sequential or simultaneous

Extension

Stabilise pelvis: hand on sacrum
Ask Pt to extend each hip in turn (sequential) or simultaneous (balanced)
Note: hip extension less important than flexion (¯ use in ADL)

Lumbar palpation

Palpate lumbar spine for tenderness (refer pain to hip)

STANDING ® Trendelenburg test

Weakness of hip abductor (eg. Test L hip)
Pt stand on L foot (R leg bent 90 at knee – do not flex hip)
Observe pelvis (-ve test if R hip same ht/ lower than L hip; +ve if R hip drops lower than L hip = L hip abductor weak)
Upper trunk may lurch to L (wt-bearing) side (keep balance)

Shoulders even?
Observe: best from back (1) Iliac crest (2) Dimples

KNEE

LOOK

Scar (surgical/ TB sinuses)
M wasting
Swelling
Deformity (genu valgum/ varum)
Mass (Baker’s cyst)

FEEL

Point to painful site
Palpate for tenderness (medial/ lateral jt lines, retropatellar)
Crepitus
Effusions (patellar tap, bulge test, fluid displacement test, cross-fluctuation)

Patellar tap test: Pt supine; left hand compresses suprapatellar pouch forcing any fluid therein into joint cavity proper (a). Use tips of R-hand fingers to pushing sharply downwards on the patella (b). If +ve ® feel the patella clunk against the femoral condyles

Bulge test: run opened fingers firmly up medial side of affected knee a few times. Then, run opened fingers down lateral side of joint once while watching medial side of joint. If +ve ® see skin bulge (from fluid being pushed back into that area

Fluctuation test: place palm of cupped left hand over suprapatellar pouch. Place thumb and index finger of right hand on either side of patella at level of the joint line. Alternately, press down with your left hand and squeeze thumb and index finger of your right hand together. +ve ® feel hydraulic impulse as fluid reaches palm of left hand or thumb and index finger of right hand

Spongy feel: place cupped left hand over the suprapatellar pouch and thumb and index finger of your right hand on either side of patella at level of joint line. Press firmly down on suprapatellar pouch with palm of left hand to drive any fluid that is resting there into the joint cavity proper. While maintaining the pressure with left hand, squeeze thumb and index finger of right hand together. If +ve ® sensation obtained is "spongy feel", rather than a "bony hard" feel

MOVE

Supine on cough
Flexion/ Extension

AROM then PROM (unaffected side first)
Body habitus (thin flexion > obese)
Extension lag: extension not full AROM, but ROM with PROM (quadriceps weakness)
Flexion contracture: cannot be corrected with PROM
Note: If Pt has extension only to 90 deg, but then can to 120 with PROM, then this Pt has 30 deg extension lag + 30 deg flexion contracture

KNEE INJURY

Important structures (1) Collateral lig med/ lat (2) ACL/ PCL (3) Menisci med/ lat
Pt to relax

PCL

90 deg: feet on bed; posterior sag?

90-90 Test: knee + hip at 90 deg; posterior sag?

Posterior Drawer Test: if suspect PCL injury (rare; usu in MVA)

Must rule out PCL injury before proceeding to ACL testing (if PCL injury, knee may start anterior drawer from abnormal translocation to back, giving false impression of anterior translocation of tibia)

ACL ® most commonly injured

Anterior Drawer Test (AP/ saggital instability)

Pt supine, knees bent 90 deg
Sit on Pt’s feet (or use elbows)
Pt fully relax
Draw proximal tibia of unaffected knee fwd with both hands (index fingers rest/ feel relaxation of hamstrings; thumb over tip tibia)
Anterior translocation? If yes, +ve test
Repeat affected side

Lachman Test (AP/ saggital instability)

Pt supine, knees bent 20
Useful in acute injury (may hurt to flex to 90 for Anterior Drawer)
Pt relaxed
One hand distal thigh; other pulls proximal leg forward

Pivot Shift Test (anterolateral rotatory instability "all-or-none" result)

Not done in acute injury (chronic only)
ACL @ "pivot" of knee
Knee extended
Hold sole of foot ® internal rotation, then valgus (lateral) stress (just below knee) [tibia can sublux out]
Slowly flex knee – reduction @ 40 deg flexion? (due to m pull + bony geometry)

MENISCI

McMurray’s Test

Watch Pt’s face for pain

Fingers over lateral jt line (ie. Thumb and index on either side of patella) / hand over jt ® "clicks" (torn meniscus flaps in and out of position)
Original description: tear in posterior horn medial meniscus
Present form: knee fully flexed – apply alternating varu-valgus stress + int/ext rotation to knee while gradually extending knee

COLLATERAL LIGAMENTS

Varus/ Valgus Stress Tests

With knee (1) Extended (2) 30 degrees flexion – relaxes posterior structures
Stabilise foot (1) Axilla (2) Hold ankle
Varus: toward midline; stress lateral collateral lig
Valgus: away from midline: stress medial collateral lig

FOOT & ANKLE

LOOK

Fore-foot

Hallux valgus: angulation of the great toe toward the other toes
Hallux varus: angulation of the great toe away from the other toes
Lesser toe deformities

Mid-foot

Pes planus: flat foot
Pes cavus: claw foot

Hind-foot

Varus: bent inwards; towards midline
Valgus: bent outwards; away from midline

Others: callosities, shoes

FEEL ® exact site of tenderness

MOVE

Ankle (1) Dorsi/ plantarflexion (2) Pt walk on heels/ tip-toes
Subtalar jt (1) Inversion/ eversion