(16) Musculoskeletal Flashcards

Question

bone strength depends on:

Answer 1

bone quality, bone | density, and overall bone size.

Answer 2

DEXA measurement of bone density at the femoral neck

Answer 3

1. Inspect for joint symmetry, alignment, bony deformities, and swelling 2. Inspect and palpate surrounding tissues for skin changes, nodules, muscle atrophy, tenderness 3. Assess range of motion and maneuvers to test joint function and stability and the integrity of ligaments, tendons, bursae, especially if pain or trauma 4. Assess any areas of inflammation, especially tenderness, swelling, warmth, redness Your examination should be systematic. Include inspection, palpation of bony structures and related joint and soft tissue structures, assessment of range of motion, and special maneuvers to test specific movements. Recall that the anatomical shape of each joint determines its range of motion.

Answer 4

● During inspection, look for symmetry of involvement. Is the change in joints symmetric on both sides of the body, or is the change only in one or two joints? Note any deformities or malalignment of bones or joints. ● Use inspection and palpation to assess the surrounding tissues, noting skin changes, subcutaneous nodules, and muscle atrophy. Note any crepitus, an audible or palpable crunching during movement of tendons or ligaments over bone or areas of cartilage loss. This may occur in joints without pain but is more significant when associated with symptoms or signs. ● Test range of motion and maneuvers (described for each joint) to demonstrate limitations in range of motion or joint instability from excess mobility of joint ligaments, called ligamentous laxity. ● Finally, test muscle strength to aid in the assessment of joint function (for these techniques, see Chapter 17, pp. 743–748).

Answer 5

● Swelling. Palpable swelling may involve: (1) the synovial membrane, which can feel boggy or doughy; (2) effusion from excess synovial fluid within the joint space; or (3) soft tissue structures, such as bursae, tendons, and tendon sheaths. ● Warmth. Use the backs of your fingers to compare the involved joint with its unaffected contralateral joint, or with nearby tissues if both joints are involved. ● Redness. Redness of the overlying skin is the least common sign of inflammation near the joints and is usually seen in more superficial joints like fingers, toes, and knees. ● Pain or tenderness. Try to identify the specific anatomic structure that is tender.

Answer 6

``` Overview, Bony Structures, and Joints. The temporomandibular joint (TMJ) is the most active joint in the body, opening and closing up to 2,000 times a day (Figs. 16-10 and 16-11). It is formed by the fossa and articular tubercle of the temporal bone and the condyle of the mandible. It lies midway between the external acoustic meatus and the zygomatic arch. A fibrocartilaginous disc cushions the action of the condyle of the mandible against the synovial membrane and capsule of the articulating surfaces of the temporal bone. Therefore, it is a condylar synovial joint. Muscle Groups and Additional Structures. The principal muscles opening the mouth are the external pterygoids (Fig. 16-12). Closing the mouth are the muscles innervated by cranial nerve V, the trigeminal nerve— the masseter, the temporalis, and the internal pterygoids ```

Answer 7

rounded bulge approximately | 0.5 cm anterior to the external auditory meatus.

Answer 8

Inspect the face for symmetry. Inspect the TMJ for swelling or redness. Swelling may appear as a rounded bulge approximately 0.5 cm anterior to the external auditory meatus. To locate and palpate the joint, place the tips of your index fingers just in front of the tragus of each ear and ask the patient to open his or her mouth (Fig. 16-13). The fingertips should drop into the joint spaces as the mouth opens. Check for smooth range of motion; note any swelling or tenderness. Snapping or clicking may be felt or heard in normal people. Palpate the muscles of mastication: ■ The masseters, externally at the angle of the mandible ■ The temporal muscles, externally during clenching and relaxation of the jaw ■ The pterygoid muscles, internally between the tonsillar pillars at the mandible

Answer 9

The TMJ has glide and hinge motions in its upper and lower portions, respectively. Grinding or chewing consists primarily of gliding movements in the upper compartments. Range of motion is threefold: ask the patient to demonstrate opening and closing, protrusion and retraction (by jutting the mandible forward), and lateral, or sideto- side, motion. Normally, as the mouth is opened wide, three fingers can be inserted between the incisors. During normal protrusion of the jaw, the bottom teeth can be placed in front of the upper teeth.

Answer 10

The glenohumeral joint of the shoulder is distinguished by wideranging movement in all directions. This joint is largely uninhibited by bony structures. The humeral head contacts less than one third of the surface area of the glenoid fossa and essentially dangles from the scapula, attached by the joint capsule, the intra-articular capsular ligaments, the glenoid labrum, and a meshwork of muscles and tendons. The shoulder derives its mobility from a complex interconnected structure of three joints, three large bones, and three principal muscle groups, often referred to as the shoulder girdle. These structures are viewed as dynamic stabilizers, which are capable of movement, or static stabilizers, which are incapable of movement. ■ Dynamic stabilizers: These consist of the SITS muscles of the rotator cuff (Supraspinatus, Infraspinatus, Teres minor, and Subscapularis), which move the humerus and compress and stabilize the humeral head within the glenoid cavity. ■ Static stabilizers: These are the bony structures of the shoulder girdle, the labrum, the articular capsule, and the glenohumeral ligaments. The labrum is a fibrocartilaginous ring that surrounds the glenoid and deepens its socket, providing greater stability to the humeral head. The joint capsule is strengthened by tendons of the rotator cuff and glenohumeral ligaments, adding to joint stability

Answer 11

The bony structures of the shoulder include the humerus, the clavicle, and the scapula (Fig. 16-14). The scapula is anchored to the axial skeleton only by the sternoclavicular joint and inserting muscles, often called the scapulothoracic articulation because it is not a true joint. Identify the manubrium, the sternoclavicular joint, and the clavicle. Also identify the tip of the acromion, the greater tubercle of the humerus, and the coracoid process, which are important landmarks of shoulder anatomy

Answer 12

The glenohumeral joint. In this joint, the head of the humerus articulates with the shallow glenoid fossa of the scapula. This joint is deeply situated and normally not palpable. It is a ball-and-socket joint, allowing the arm its wide arc of movement—flexion, extension, abduction (movement away from the trunk), adduction (movement toward the trunk), rotation, and circumduction. ■ The sternoclavicular joint. The convex medial end of the clavicle articulates with the concave hollow in the upper sternum. ■ The acromioclavicular joint. The lateral end of the clavicle articulates with the acromion process of the scapula.

Answer 13

The Scapulohumeral Group. This group extends from the scapula to the humerus and includes the muscles inserting directly on the humerus, namely the SITS muscles of the rotator cuff: ■ Supraspinatus—runs above the glenohumeral joint; inserts on the greater tubercle ■ Infraspinatus and teres minor—cross the glenohumeral joint posteriorly; insert on the greater tubercle ■ Subscapularis (not illustrated)—originates on the anterior surface of the scapula and crosses the joint anteriorly; inserts on the lesser tubercle The scapulohumeral group rotates the shoulder laterally (the rotator cuff ) and depresses and rotates the head of the humerus (Fig. 16-15). See pp. 653–654 for discussion of rotator cuff injuries. The Axioscapular Group. This group attaches the scapula to the trunk and includes the trapezius, rhomboids, serratus anterior, and levator scapulae (Fig. 16-15). These muscles rotate the scapula and pull the shoulder posteriorly. The Axiohumeral Group. This group attaches the humerus to the trunk and includes the pectoralis major and minor and the latissimus dorsi (Fig. 16-16). These muscles rotate the shoulder internally. The biceps and triceps, which connect the scapula to the bones of the forearm, are also involved in shoulder movement, especially forward flexion (biceps) and extension (triceps).

Answer 14

Also important to shoulder movement are the articular capsule and bursae. Surrounding the glenohumeral joint is a fibrous articular capsule formed by the tendon insertions of the rotator cuff and other capsular structures. The loose fit of the capsule allows the shoulder bones to separate, and contributes to the shoulder’s wide range of movement. The capsule is lined by a synovial membrane with two outpouchings—the subscapular bursa and the synovial sheath of the tendon of the long head of the biceps. To locate the biceps tendon, rotate your arm externally and find the tendinous cord that runs just medial to the greater tubercle (Fig. 16-17). Roll it under your fingers. This is the tendon of the long head of the biceps. It runs in the bicipital groove between the greater and lesser tubercles. The principal bursa of the shoulder is the subacromial bursa, positioned between the acromion and the head of the humerus and overlying the supraspinatus tendon. Abduction of the shoulder compresses this bursa. Normally, the supraspinatus tendon and the subacromial bursa are not palpable. However, if the bursal surfaces are inflamed (subacromial bursitis), there may be tenderness just below the tip of the acromion, pain with abduction and rotation, and loss of smooth movement

Answer 15

Inspect the shoulder and shoulder girdle anteriorly, then the scapulae and related muscles posteriorly. Note any swelling, deformity, muscle atrophy or fasciculations (fine tremors of the muscles), or abnormal positioning. Look for swelling of the joint capsule anteriorly or a bulge in the subacromial bursa under the deltoid muscle. Survey the entire upper extremity for color change, skin alteration, or unusual bony contours.

Answer 16

Begin by palpating the bony contours and structures of the shoulder, then palpate any area of pain. ■ Beginning medially, at the sternoclavicular joint, trace the clavicle laterally with your fingers. ■ From behind, follow the bony spine of the scapula laterally and upward until it becomes the acromion (A), the summit of the shoulder (Fig. 16-18). Its upper surface is rough and slightly convex. Identify the anterior tip of the acromion. ■ With your index finger on top of the acromion, just behind its tip, press medially with your thumb to find the slightly elevated ridge that marks the distal end of the clavicle at the acromioclavicular joint (shown by the arrow). Move your thumb medially and down a short step to the next bony prominence, the coracoid process (B) of the scapula. ■ With your thumb on the coracoid process, allow your fingers to fall on and grasp the lateral aspect of the humerus to palpate the greater tubercle (C), where the SITS muscles insert. Next, to palpate the biceps tendon in the intertubercular bicipital groove, keep your thumb on the coracoid process and your fingers on the lateral aspect of the humerus (Fig. 16-19). Remove your index finger and place it halfway between the coracoid process and the greater tubercle on the anterior surface of the arm. As you check for tendon tenderness, rolling the tendon under the fingertips may be helpful. You can also rotate the glenohumeral joint externally, locate the muscle distally near the elbow, and track the muscle and its tendon proximally into the intertubercular groove. ■ To examine the subacromial and subdeltoid bursae and the SITS muscles, first passively extend the humerus by lifting the elbow posteriorly, which rotates these structures so that they are anterior to the acromion. Palpate carefully over the subacromial and subdeltoid bursae (Figs. 16-20 and 16-21). The underlying palpable SITS muscles are: Supraspinatus—directly under the acromion ■ Infraspinatus—posterior to supraspinatus ■ Teres minor—posterior and inferior to the supraspinatus ■ Subscapularis—inserts anteriorly and is not palpable ■ The fibrous articular capsule and the broad flat tendons of the rotator cuff are so closely associated that they must be examined simultaneously. Swelling in the capsule and synovial membrane is often best detected by looking down on the shoulder from above. Palpate the capsule and synovial membrane beneath the anterior and posterior acromion to check for injury or arthritis

Answer 17

(1) Flexion Principal Muscles Affecting Movement Anterior deltoid, pectoralis major (clavicular head), coracobrachialis, biceps brachii Patient Instructions “Raise your arms in front of you and overhead.” ``` (2) Extension Principal Muscles Affecting Movement Latissimus dorsi, teres major, posterior deltoid, triceps brachii (long head) Patient Instructions “Raise your arms behind you.” ``` ``` (3) Abduction Principal Muscles Affecting Movement Supraspinatus, middle deltoid, serratus anterior (via upward rotation of the scapula) Patient Instructions “Raise your arms out to the side and overhead.” ``` ``` (4) Adduction Principal Muscles Affecting Movement Pectoralis major, coracobrachialis, latissimus dorsi, teres major, subscapularis Patient Instructions “Cross your arm in front of your body.” ``` ``` (5) Internal Rotation Principal Muscles Affecting Movement Subscapularis, anterior deltoid, pectoralis major, teres major, latissimus dorsi Patient Instructions “Place one hand behind your back and touch your shoulder blade.” Identify the highest midline spinous process the patient is able to reach ``` ``` (6) External Rotation Principal Muscles Affecting Movement Infraspinatus, teres minor, posterior deltoid Patient Instructions “Raise your arm to shoulder level; bend your elbow and rotate your forearm toward the ceiling.” OR “Place one hand behind your neck or head as if you are brushing your hair.” ```

Answer 18

Acromiocalvicular Joint - Crossover or crossed body adduction test. Adduct the patient’s arm across the chest. Overall Shoulder Rotation - Apley scratch test. Ask the patient to touch the opposite scapula using the two motions shown below. Tests abduction and external rotation. Tests adduction and internal rotation. ``` Rotator Cuff: Pain Provocation Tests - Painful arc test. Fully adduct the patient’s arm from 0° to 180°. Neer impingement sign. Press on the scapula to prevent scapular motion with one hand, and raise the patient’s arm with the other. This compresses the greater tuberosity of the humerus against the acromion. Hawkins impingement sign. Flex the patient’s shoulder and elbow to 90° with the palm facing down. Then, with one hand on the forearm and one on the arm, rotate the arm internally. This compresses the greater tuberosity against the supraspinatus tendon and coracoacromial ligament. ``` ``` Strength Tests: External rotation lag test. With the patient’s arm flexed to 90° with palm up, rotate the arm into full external rotation Internal rotation lag test. Ask the patient to place the dorsum of the hand on the low back with the elbow flexed to 90°. Then you lift the hand off the back, which further internally rotates the shoulder. Ask the patient to keep the hand in this position. 90º flexion Drop-arm test. Ask the patient to fully abduct the arm to shoulder level, up to 90°, and lower it slowly. Note that abduction above shoulder level, from 90° to 120°, reflects action of the deltoid muscle. ``` ``` Composite Tests: External rotation resistance test. Ask the patient to adduct and flex the arm to 90°, with the thumbs turned up. Stabilize the elbow with one hand and apply pressure proximal to the patient’s wrist as the patient presses the wrist outward in external rotation. Empty can test. Elevate the arms to 90° and internally rotate the arms with the thumbs pointing down, as if emptying a can. Ask the patient to resist as you place downward pressure on the arms ```

Answer 19

Pain provocation test: painful arc test (subacromial bursa and rotator cuff). This test has a positive LR of 3.7, which is the highest of all the rotator cuff maneuvers. It also has the best negative LR, 0.36, for ruling out rotator cuff disorders. Other common pain provocation tests are the Neer and Hawkins tests, also included in the box on next page, although their positive LRs are <2, so they are less diagnostic Strength tests: internal rotation lag test (subscapularis), external rotation lag test (supraspinatus and infraspinatus), and drop arm test (supraspinatus). These tests have positive LRs of 7.2, 5.6, and 3.3, respectively. ■ Composite test: external rotation resistance test (infraspinatus). This test has a positive LR of 2.6. Another common composite test is the empty can test.

Answer 20

The elbow helps position the hand in space and stabilizes the lever action of the forearm. The elbow joint is formed by the humerus and the two bones of the forearm, the radius and the ulna (Fig. 16-22). Identify the medial and lateral epicondyles of the humerus and the olecranon process of the ulna. These bones have three articulations: the humeroulnar joint, the radiohumeral joint, and the radioulnar joint. All three share a large common articular cavity and an extensive synovial lining.

Answer 21

Muscles traversing the elbow include the biceps and brachioradialis (flexion), the brachialis, the triceps (extension), the pronator teres (pronation), and the supinator (supination). Note the location of the olecranon bursa between the olecranon process and the skin (Fig. 16-23). The bursa is not normally palpable but swells and becomes tender when inflamed. The ulnar nerve runs posteriorly in the ulnar groove between the medial epicondyle and the olecranon process. The radial nerve is adjacent to the lateral epicondyle. On the ventral forearm, the median nerve is just medial to the brachial artery in the antecubital fossa.

Answer 22

Support the patient’s forearm with your opposite hand so that the elbow is flexed to about 70°. Identify the medial and lateral epicondyles and the olecranon process of the ulna. Inspect the contours of the elbow, including the extensor surface of the ulna and the olecranon process. Note any nodules or swelling.

Answer 23

Palpate the olecranon process and press over the epicondyles for tenderness (Fig. 16-24). Palpate the grooves between the epicondyles and the olecranon process, where the synovium is most easily examined. Normally the synovium and olecranon bursae are not palpable. The sensitive ulnar nerve can be palpated posteriorly between the olecranon process and the medial epicondyle. Note any displacement of the olecranon process (Figs. 16-25 and 16-26).

Answer 24

Flexion:Biceps brachii, brachialis, brachioradialis PI: "Bend your elbow" Extension: Triceps brachii, anconeus PI: "straighten your elbow" Supination: Biceps brachii, supinator PI: “Turn your palms up, as if carrying a bowl of soup.” Pronation: Pronator teres, pronator quadratus PI: “Turn your palms down.”

Answer 25

The wrist includes the distal radius and ulna and eight small carpal bones (Fig. 16-28). At the wrist, identify the bony tips of the radius and the ulna. Identify the carpal bones distal to the wrist joint, each of the five metacarpals, and the proximal, middle, and distal phalanges. Note that the thumb has only two phalanges.

Answer 26

``` Wrist joints. The wrist joints include the radiocarpal or wrist joint, the distal radioulnar joint, and the intercarpal joints (Fig. 16-29). The joint capsule, articular disc, and synovial membrane of the wrist join the radius to the ulna and to the proximal carpal bones. On the dorsum of the wrist, locate the groove of the radiocarpal joint. This joint provides most of the flexion and extension at the wrist because the ulna does not articulate directly with the carpal bones. ■ Hand joints. The joints of the hand include the metacarpophalangeal joints (MCPs), the proximal interphalangeal joints (PIPs), and the distal interphalangeal joints (DIPs). Flex the hand and find the groove marking the MCP joint of each finger (Fig. 16-30). It is distal to the knuckle and is best felt on either side of the extensor tendon ```

Answer 27

Wrist flexion arises from the two carpal muscles, located on the radial and ulnar surfaces. Two radial and one ulnar muscle provide wrist extension. Supination and pronation are powered by muscle contraction in the forearm. The thumb is powered by three muscles that form the thenar eminence and provide flexion, abduction, and opposition. The muscles of extension are at the base of the thumb along the radial margin. Movement in the digits depends on action of the flexor and extensor tendons of muscles in the forearm and wrist. The intrinsic muscles of the hand attaching to the metacarpal bones are involved in flexion (lumbricals), abduction (dorsal interossei), and adduction (palmar interossei) of the fingers.

Answer 28

``` Soft tissue structures, especially tendons and tendon sheaths, are especially important to movement of the wrist and hand. Six extensor tendons and two flexor tendons pass across the wrist and hand to insert on the fingers. Through much of their course these tendons travel in tunnel-like sheaths, generally palpable only when swollen or inflamed. Be familiar with the structures of the carpal tunnel, a channel beneath the palmar surface of the wrist and proximal hand (Fig. 16-31). The channel contains the sheath and flexor tendons of the forearm muscles and the median nerve. Holding the tendons and tendon sheath in place is a transverse ligament, the flexor retinaculum. The median nerve lies between the flexor retinaculum and the tendon sheath. The median nerve provides sensation to the palm and the palmar surface of most of the thumb, the second and third digits, and half of the fourth digit. It also innervates the thumb muscles of flexion, abduction, and opposition. ```

Answer 29

Inspect the position of the hands in motion for smooth natural movement. When the fingers are relaxed they should be slightly flexed; the fingernail edges should be in parallel

Answer 30

Inspect the position of the hands in motion for smooth natural movement. When the fingers are relaxed they should be slightly flexed; the fingernail edges should be in parallel Inspect the palmar and dorsal surfaces of the wrist and hand carefully for swelling over the joints or signs of trauma. Note any deformities of the wrist, hand, or finger bones, as well as any angulation. Observe the contours of the palm, namely the thenar and hypothenar eminences. Note any thickening of the flexor tendons or flexion contractures in the fingers.

Answer 31

At the wrist, palpate the distal radius and ulna on the lateral and medial surfaces (Fig. 16-32). Palpate the groove of each wrist joint with your thumbs on the dorsum of the wrist, your fingers beneath it. Note any swelling, bogginess, or tenderness Palpate the radial styloid bone and the anatomic snuffbox, a hollowed depression just distal to the radial styloid process formed by the abductor and extensor muscles of the thumb (Fig. 16-33). The “snuffbox” is more visible with lateral extension of the thumb away from the hand (abduction). Palpate the eight carpal bones lying distal to the wrist joint, and then each of the five metacarpals and the proximal, middle, and distal phalanges (Fig. 16-34). Palpate any other area where you suspect an abnormality. Compress the MCP joints by squeezing the hand from each side between the thumb and fingers. Alternatively, use your thumb to palpate each MCP joint just distal to and on each side of the extensor tendons as your index finger feels the head of the metacarpal in the palm. Note any swelling, bogginess, or tenderness. Now examine the fingers and thumb. Palpate the medial and lateral aspects of each PIP joint between your thumb and index finger, again checking for swelling, bogginess, bony enlargement, or tenderness. Using the same techniques, examine the DIP joints (Fig. 16-36). In any area of swelling or inflammation, palpate along the tendons inserting on the thumb and fingers.

Answer 32

Flexion: Flexor carpi radialis, flexor carpi ulnaris “With palms down, point your fingers toward the floor.” ``` Extension: Extensor carpi ulnaris, extensor carpi radialis longus, extensor carpi radialis brevis “With palms down, point your fingers toward the ceiling.” ``` Adduction (radial deviation): Flexor carpi ulnaris “With palms down, bring your fingers toward the midline.” Abduction (ulnar deviation): Flexor carpi radialis “With palms down, bring your fingers away from the midline.”

Answer 33

Maneuvers for assessing conditions at the wrist are listed on the next page. For complaints of nocturnal hand or arm numbness (paresthesias), dropping objects, inability to twist lids off jars, aching at the wrist or even the forearm, and numbness of the first three digits, test for carpal tunnel syndrome, the most common entrapment neuropathy, involving compression of the median nerve. Learn the distribution of the median, radial, and ulnar nerve innervations of the wrist and hand (Figs. 16-39 and 16-40). Remember to assess more proximal causes of wrist and hand pain arising from cervical radiculopathy. Ulnar nerve Median nerve Radial nerve F I G U R E 1 6 - 3 9 . Dorsal surface. Radial nerve Ulnar nerve Median nerve F I G U R E 1 6 - 4 0 . Volar surface. Forceful repetitive handwork with wrist flexion such as keyboarding or mail sorting, vibration, cold environments, wrist anatomy, pregnancy, RA, diabetes, and hypothyroidism are risk factors for carpal tunnel syndrome. You can test sensation as follows: ■ Pulp of the index finger—median nerve ■ Pulp of the fifth finger—ulnar nerve ■ Dorsal web space of the thumb and index finger—radial nerve Hand Grip. Test hand grip strength by asking the patient to grasp your second and third fingers (Fig. 16-41). This tests function of wrist joints, the finger flexors, and the intrinsic muscles and joints of the hand EXAMINATION OF SPECIFIC JOINTS Thumb Movement. To test thumb function, ask the patient to grasp the thumb against the palm and then move the wrist toward the midline in ulnar deviation (sometimes called the Finkelstein test), as shown in Figure 16-42. Carpal Tunnel Syndrome—Thumb Abduction, Tinel Test, and Phalen Test for Median Nerve Compression. To test thumb abduction, ask the patient to raise the thumb straight up as you apply downward resistance (Fig. 16-43). Test Tinel sign by tapping lightly over the course of the median nerve in the carpal tunnel as shown in Figure 16-44. To test Phalen sign, ask the patient to hold the wrists in flexion for 60 seconds with the elbows fully extended (Fig. 16-45). Alternatively, ask the patient to press the backs of both hands together to form right angles. These maneuvers compress the median nerve.

Answer 34

Assess flexion, extension, abduction, and adduction of the fingers. ■ Flexion and extension (Fig. 16-46). For flexion, to test the lumbricals and finger flexor muscles, ask the patient to “Make a tight fist with each hand, thumb across the knuckles.” For extension, to test the finger extensor muscles, ask the patient to “Extend and spread the fingers.” At the MCPs, the fingers may extend beyond the neutral position. Test the flexion and extension of the PIP and DIP joints (lumbrical muscles). The fingers should open and close easily. ■ Abduction and adduction (Fig. 16-47). Ask the patient to spread the fingers apart (abduction from dorsal interossei) and back together (adduction from palmar interossei). Check for smooth, coordinated movement.

Answer 35

At the thumb, assess flexion, extension, abduction, adduction, and opposition (Figs. 16-48 to 16-51). Each of these movements is powered by a related muscle of the thumb Ask the patient to move the thumb across the palm and touch the base of the fifth finger to test flexion, and then to move the thumb back across the palm and away from the fingers to test extension. Next, ask the patient to place the fingers and thumb in the neutral position with the palm up, then have the patient move the thumb anteriorly away from the palm to assess abduction and back down for adduction. To test opposition, or movements of the thumb across the palm, ask the patient to touch the thumb to each of the other fingertips. A full examination of the wrist and hand involves detailed testing of muscle strength and sensation,

Answer 36

The vertebral column, or spine, is the central supporting structure of the trunk and back. The concave curves of the cervical and lumbar spine and the convex curves of the thoracic and sacrococcygeal spine help distribute upper body weight to the pelvis and lower extremities and cushion the concussive impact of walking or running. The complex mechanics of the back reflect the coordinated action of: ■ The vertebrae and intervertebral discs ■ An interconnecting system of ligaments between anterior vertebrae and posterior vertebrae, ligaments between the spinous processes, and ligaments between the lamina of two adjacent vertebrae ■ Large superficial muscles, deeper intrinsic muscles, and muscles of the abdominal wall

Answer 37

``` The vertebral column contains 24 vertebrae stacked on the sacrum and coccyx. A typical vertebra contains sites for joint articulations, weight bearing, and muscle attachments, as well as foramina for the spinal nerve roots and peripheral nerves. Anteriorly, the vertebral body supports weight bearing. The posterior vertebral arch encloses the spinal cord. Review the location of the vertebral processes and foramina, with particular attention to: ■ The spinous process projecting posteriorly in the midline and the two transverse processes at the junction of the pedicle and the lamina. Muscles attach at these processes. ■ The articular processes—two on each side of the vertebra, one facing up and one facing down, at the junction of the pedicles and laminae, often called articular facets. ■ The vertebral foramen, which encloses the spinal cord, the intervertebral foramen, formed by the inferior and superior articulating process of adjacent vertebrae, creating a channel for the spinal nerve roots; and in the cervical vertebrae, the transverse foramen for the vertebral artery The proximity of the spinal cord and spinal nerve roots to their bony vertebral casing and the intervertebral discs makes them especially vulnerable to disc herniation, impingement from degenerative changes in the vertebrae and facets, and trauma. ```

Answer 38

The spine has slightly movable cartilaginous joints between the vertebral bodies and between the articular facets. Between the vertebral bodies are the intervertebral discs, each consisting of a soft mucoid central core, the nucleus pulposus, rimmed by the tough fibrous tissue of the annulus fibrosis. The intervertebral discs cushion movement between vertebrae and allow the vertebral column to curve, flex, and bend. The flexibility of the spine is largely determined by the angle of the articular facet joints relative to the plane of the vertebral body, and varies at different levels of the spine. Note that the vertebral column angles sharply posterior at the lumbosacral junction and becomes immovable. The mechanical stress at this angulation contributes to the risk for disc herniation and subluxation, or slippage (spondylolisthesis), of L5 on S1.

Answer 39

``` The trapezius and latissimus dorsi form the large outer layer of muscles attaching to each side of the spine (Fig. 16-52). They overlie two deeper muscle layers—a layer attaching to the head, neck, and spinous processes (splenius capitis, splenius cervicis, and sacrospinalis) and a layer of smaller intrinsic muscles between vertebrae. Muscles attaching to the anterior surface of the vertebrae, including the psoas muscle and muscles of the abdominal wall, assist with flexion. Muscles moving the neck and lower vertebral column are summarized in the table on p. 670. ```

Answer 40

Inspect the patient’s posture when entering the room, including the position of both the neck and trunk. Assess the patient for erect position of the head, neck, and back; for smooth, coordinated neck movement; and for ease of gait. Drape or gown the patient to expose the entire back for complete inspection. If possible, the patient should be upright in the natural standing position, with feet together and arms at the sides. The head should be midline in the same plane as the sacrum, and the shoulders and pelvis should be level. Viewing the patient from behind, identify the following (Fig. 16-53): ■ Spinous processes, usually more prominent at C7 and T1 and more evident on forward flexion ■ Paravertebral muscles on either side of the midline ■ Iliac crests ■ Posterior superior iliac spines, usually marked by skin dimples. A line drawn above the posterior iliac crests crosses the spinous process of L4. Inspect the patient from the side and from behind. Evaluate the spinal curvatures and the features in the display on the next page.

Answer 41

From a sitting or standing position, palpate the spinous processes of each vertebra with your thumb. In the neck, palpate the facet joints that lie between the cervical vertebrae 1 to 2 cm lateral to the spinous processes of C2 to C7. These joints lie deep to the trapezius muscle and may not be palpable unless the neck muscles are relaxed. In the lower lumbar area, palpate carefully for vertebral “step-offs” to see if one spinous process seems unusually prominent (or recessed) in relation to the one above it. Identify any tenderness. Palpate over the sacroiliac joint, often identified by the dimple overlying the posterior superior iliac spine. You may wish to percuss the spine for tenderness by thumping, but not too roughly, with the ulnar surface of your fist. Inspect and palpate the paravertebral muscles for tenderness and spasm. Muscles in spasm feel firm and knotted and may be visible. With the patient’s hip flexed and the patient lying on the opposite side, palpate the sciatic nerve, the largest nerve in the body, consisting of nerve roots from L4, L5, S1, S2, and S3 (Fig. 16-54). The sciatic nerve lies midway between the greater trochanter and the ischial tuberosity as it runs through the sciatic notch. It is difficult to palpate in most patients. Palpate for tenderness in any other areas suggested by the patient’s symptoms. Check for pain radiation into the buttocks, perineum, or legs. Assess all low back pain for possible cauda equina compression, the most serious cause of pain, due to risk of limb paralysis or bladder/bowel dysfunction

Answer 42

1. Flexion - Sternocleidomastoid, scalene, prevertebral muscles “Bring your chin to your chest.” 2. Extension - Splenius capitis and cervicis, small intrinsic neck muscles “Look up at the ceiling.” 3. Rotation - Sternocleidomastoid, small intrinsic neck muscles “Look over one shoulder, and then the other.” 4. Lateral Bending - Scalenes and small intrinsic neck muscles “Bring your ear to your shoulder.”

Answer 43

``` Flexion - Psoas major, psoas minor, quadratus lumborum; abdominal muscles attaching to the anterior vertebrae, such as the internal and external obliques and rectus abdominis “Bend forward and try to touch your toes.” Note the smoothness and symmetry of movement, the range of motion, and the curve in the lumbar area. As flexion proceeds, the lumbar concavity should flatten out ``` ``` 2. Extension - Deep intrinsic muscles of the back, such as the erector spinae and transversospinalis groups “Bend back as far as possible.” Support the patient by placing your hand on the posterior superior iliac spine, with your fingers pointing toward the midline ``` ``` 3. Rotation - Abdominal muscles, intrinsic muscles of the back “Rotate from side to side.” Stabilize the patient’s pelvis by placing one hand on the patient’s hip and the other on the opposite shoulder. Then rotate the trunk by pulling the shoulder anteriorly and then the hip posteriorly. Repeat these maneuvers for the opposite side. ``` ``` 4. Lateral Bending - Abdominal muscles, intrinsic muscles of the back “Bend to the side from the waist.” Stabilize the patient’s pelvis by placing your hand on the patient’s hip. Repeat for the opposite side ```

Answer 44

The hip joint is deeply embedded in the pelvis and is notable for its strength, stability, and wide range of motion. The stability of the hip joint, essential for weight bearing, arises from the deep fit of the head of the femur into the acetabulum, its strong fibrous articular capsule, and the powerful muscles crossing the joint and inserting below the femoral head, providing leverage for movement of the femur.

Answer 45

rope-like bundles of collagen fibrils that connect bone to bone

Answer 46

collagen fibers connecting muscle to bone

Answer 47

pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures

Answer 48

The hip joint lies below the middle third of the inguinal ligament but in a deeper plane. It is a ball-and-socket joint; note how the rounded head of the femur articulates with the cup-like cavity of the acetabulum. Because of its overlying muscles and depth, the hip joint is not readily palpable. Review the bones of the pelvis—the acetabulum, the ilium, and the ischium—and the connection inferiorly at the symphysis pubis and posteriorly with the sacroiliac bone. On the anterior surface of the hip, locate the following bony structures (Fig. 16-56): ■ The iliac crest at the level of L4 ■ The iliac tubercle ■ The anterior superior iliac spine ■ The greater trochanter ■ The pubic tubercle On the posterior surface of the hip, locate the following (Fig. 16-57): ■ The posterior superior iliac spine ■ The greater trochanter ■ The ischial tuberosity ■ The sacroiliac joint Note that you can locate S2 by envisioning an imaginary line across the posterior superior iliac spines

Answer 49

Four powerful muscle groups move the hip. Picture these groups as you examine patients, and remember that to move the femur or any bone in a given direction, the muscle must cross the joint line. The flexor group lies anteriorly and flexes the thigh (Fig. 16-58). The primary hip flexor is the iliopsoas, extending from above the iliac crest to the lesser trochanter. The extensor group lies posteriorly and extends the thigh (Fig. 16-59). The gluteus maximus is the primary extensor of the hip. It forms a band crossing from its origin along the medial pelvis to its insertion below the trochanter The adductor group is medial and swings the thigh toward the body (Fig. 16-60). The muscles in this group arise from the rami of the pubis and ischium and insert on the posteromedial aspect of the femur. The abductor group is lateral, extending from the iliac crest to the greater trochanter, and moves the thigh away from the body (Fig. 16-61). This group includes the gluteus medius and minimus. These muscles help stabilize the pelvis during the stance phase of gait

Answer 50

A strong, dense articular capsule, extending from the acetabulum to the femoral neck, encases and strengthens the hip joint. The capsule is reinforced by three overlying ligaments and lined with synovial membrane. There are three principal bursae at the hip. Anterior to the joint is the psoas (also termed iliopectineal or iliopsoas) bursa, overlying the articular capsule and the psoas muscle. Find the bony prominence lateral to the hip joint—the greater trochanter of the femur. The large multilocular trochanteric bursa lies on its posterior surface. The ischial (or ischiogluteal) bursa, not always present, lies under the ischial tuberosity, and accommodates the weight of the sitting position. Note its proximity to the sciatic nerve, as shown on p. 679.

Answer 51

Inspection of the hip begins with careful observation of the patient’s gait when entering the room. Observe the two phases of gait: 1. Stance—when the foot is on the ground and bears weight (60% of the walking cycle) (Fig. 16-62) 2. Swing—when the foot moves forward and does not bear weight (40% of the cycle) Inspect the gait for the width of the base, the shift of the pelvis, and flexion of the knee (Fig. 16-63). The width of the base should be 2 to 4 inches from heel to heel. Normal gait has a smooth, continuous rhythm, achieved in part by contraction of the abductors of the weight-bearing limb. Abductor contraction stabilizes the pelvis and helps maintain balance, raising the opposite hip. The knee should be flexed throughout the stance phase, except when the heel strikes the ground to counteract motion at the ankle. Inspect the lumbar portion of the spine for the degree of lordosis and, with the patient supine, assess the length of the legs for symmetry. (To measure leg length, see Special Techniques, p. 694.) Inspect the anterior and posterior surfaces of the hip for any areas of muscle atrophy or bruising. The joint is too deeply situated to detect swelling.

Answer 52

● Identify the iliac crest at the upper margin of the pelvis at the level of L4. ● Follow the downward anterior curve and locate the iliac tubercle, marking the widest point of the crest, and continue tracking downward to the anterior– superior iliac spine. ● Place your thumbs on the anterior–superior spines and move your fingers downward and laterally from the iliac tubercles to the greater trochanter of the femur. ● Then move your thumbs medially and obliquely to the pubic tubercle, which lies at the same level as the greater trochanter.

Answer 53

● Palpate the posterior–superior iliac spine directly underneath the visible dimples just above the buttocks. ● Placing your left thumb and index finger over the posterior superior iliac spine, next locate the greater trochanter laterally with your fingers at the level of the gluteal fold, and place your thumb medially on the ischial tuberosity. The sacroiliac joint is not always palpable but may be tender. Note that an imaginary

Answer 54

With the patient supine, ask the patient to place the heel of the leg being examined on the opposite knee. Then palpate along the inguinal ligament, which extends from the anterior–superior iliac spine to the pubic tubercle (Fig. 16-64). The femoral nerve, artery, and vein bisect the overlying inguinal ligament; lymph nodes lie medially. The mnemonic NAVEL may help you remember the lateralto- medial sequence of Nerve–Artery–Vein–Empty space–Lymph node. Anterior or inguinal pain, typically deep within the hip joint and radiating to the knee, points to intra-articular pathology; pain radiating to the buttocks or posterior trochanteric region points to extra-articular causes.75

Answer 55

If the hip is painful, palpate the (psoas) bursa, below the inguinal ligament but on a deeper plane. With the patient resting on one side and the hip flexed and internally rotated, palpate the trochanteric bursa lying over the greater trochanter (Fig. 16-65). Normally, the ischiogluteal bursa, over the ischial tuberosity, is not palpable unless inflamed (Fig. 16-66).

Answer 56

1. Flexion - Iliopsoas “Bend your knee to your chest and pull it against your abdomen.” ``` 2. Extension (actually hyperextension) - Gluteus maximus “Lie face down, then bend your knee and lift it up.” OR “Lying flat, move your lower leg away from the midline and down over the side of the table.” ``` 3. Abduction - Gluteus medius and minimus “Lying flat, move your lower leg away from the midline.” ``` 4. Adduction - Adductor brevis, adductor longus, adductor magnus, pectineus, gracilis “Lying flat, bend your knee and move your lower leg toward the midline.” ``` ``` 5. External Rotation - Internal and external obturators, quadratus femoris, superior and inferior gemelli “Lying flat, bend your knee and turn your lower leg and foot across the midline.” ``` 6. Internal Rotation - Iliopsoas “Lying flat, bend your knee and turn your lower leg and foot away from the midline.”

Answer 57

Often, the examiner must assist the patient with movements of the hip, so further detail is provided below for flexion, abduction, adduction, and external and internal rotation. Meta-analyses suggest that no single test discriminates specific hip pathology.75,77,78 ■ Flexion. With the patient supine, place your hand under the patient’s lumbar spine. Ask the patient to bend each knee in turn up to the chest and pull it firmly against the abdomen (Fig. 16-67). Note that the hip can flex further when the knee is flexed because the hamstrings are relaxed. When the back touches your hand, indicating normal flattening of the lumbar lordosis, further flexion must arise from the hip joint itself As the thigh is held against the abdomen, inspect the degree of flexion at the hip and knee. Normally, the anterior portion of the thigh can almost touch the chest wall. Note whether the opposite thigh remains fully extended, resting on the table. ■ Extension. With the patient lying face down, extend the thigh toward you in a posterior direction. Alternatively, carefully position the supine patient near the edge of the table and extend the leg posteriorly. ■ Abduction. Stabilize the pelvis by pressing down on the opposite anterior– superior iliac spine with one hand. With the other hand, grasp the ankle and abduct the extended leg until you feel the iliac spine move (Fig. 16-69). This movement marks the limit of hip abduction Adduction. With the patient supine, stabilize the pelvis, hold one ankle, and move the leg medially across the body and over the opposite extremity (Fig. 16-70). External and internal rotation. Flex the leg to 90° at hip and knee, stabilize the thigh with one hand, grasp the ankle with the other, and swing the lower leg—medially for external rotation at the hip, and laterally for internal rotation (Fig. 16-71). Although confusing at first, it is the motion of the head of the femur in the acetabulum that identifies these movements

Answer 58

The knee joint is the largest joint in the body. It is a hinge joint involving three bones: the femur, the tibia, and the patella (or knee cap), with three articular surfaces, two between the femur and the tibia and one between the femur and the patella. Note how the two rounded condyles of the femur rest on the relatively flat tibial plateau. There is no inherent stability in the knee joint itself, making it dependent on four ligaments to hold its articulating femur and tibia in place. This feature, in addition to the lever action of the femur on the tibia and the lack of padding from overlying fat or muscle, makes the knee highly vulnerable to injury.

Answer 59

``` Learn the bony landmarks in and around the knee. These will guide your examination of this complicated joint (Fig. 16-72). ■ On the medial surface, identify the adductor tubercle, the medial epicondyle of the femur, and the medial condyle of the tibia. ■ On the anterior surface, identify the patella, which rests on the anterior articulating surface of the femur midway between the epicondyles, embedded in the tendon of the quadriceps muscle. This tendon continues below the knee joint as the patellar tendon, which inserts distally on the tibial tuberosity. ■ On the lateral surface, find the lateral epicondyle of the femur, the lateral condyle of the tibia, and the head of the fibula ```

Answer 60

Two condylar tibiofemoral joints are formed by the convex curves of the medial and lateral condyles of the femur as they articulate with the concave condyles of the tibia. The third articular surface is the patellofemoral joint. The patella slides on the groove of the anterior aspect of the distal femur, called the trochlear groove, during flexion and extension of the knee.

Answer 61

Powerful muscles move and support the knee. The quadriceps femoris extends the knee, covering the anterior, medial, and lateral aspects of the thigh (Figs. 16-73 and 16-74). The hamstring muscles lie on the posterior aspect of the thigh and flex the knee

Answer 62

The menisci and two important pairs of ligaments, the collaterals and the cruciates, are crucial to stability of the knee. Learn the location of these structures from the illustrations on p. 682 and below (Fig. 16-75). ■ The medial and lateral menisci cushion the action of the femur on the tibia. These crescent-shaped fibrocartilaginous discs add a cup-like surface to the otherwise flat tibial plateau. ■ The medial collateral ligament (MCL), not easily palpable, is a broad, flat ligament connecting the medial femoral epicondyle to the medial condyle of the tibia. The medial portion of the MCL also attaches to the medial meniscus. ■ The lateral collateral ligament (LCL) connects the lateral femoral epicondyle and the head of the fibula. The MCL and LCL provide medial and lateral stability to the knee joint. ■ The ACL crosses obliquely from the anterior medial tibia to the lateral femoral condyle, preventing the tibia from sliding forward on the femur. ■ The posterior cruciate ligament (PCL) crosses from the posterior tibia and lateral meniscus to the medial femoral condyle, preventing the tibia from slipping backward on the femur. Although the ACL and PCL lie within the knee joint so are not palpable, they are nonetheless crucial to the anteroposterior stability of the knee.

Answer 63

Inspect the concavities that are usually evident adjacent and superior to each side of the patella, known as the “negative infrapatellar space” (Fig. 16-76). Occupying these areas is the synovial cavity of the knee, one of the largest joint cavities in the body. This cavity includes an extension 6 cm above the upper border of the patella, lying upward and deep to the quadriceps muscle, called the suprapatellar pouch. The joint cavity covers the anterior, medial, and lateral surfaces of the knee, as well as the condyles of the femur and tibia posteriorly. Although the synovium is not normally palpable, these areas may become swollen and tender when the joint is inflamed or injured

Answer 64

Several bursae lie near the knee. The prepatellar bursa lies between the patella and the overlying skin. The anserine bursa lies 1 to 2 cm below the knee joint on the medial surface, proximal and medial to the attachments of the medial hamstring muscles on the proximal tibia. It cannot be palpated due to these overlying tendons. Now identify the large semimembranosus bursa that communicates with the joint cavity, also on the posterior and medial surfaces of the knee.

Answer 65

Learn to examine “the seven structures of the knee”: the medial and lateral menisci, the LCL and MCL, the ACL and PCL, and the patellar tendon. The ACL and PCL are not palpable but are tested by specific maneuvers. Palpation and maneuvers of these structures are especially helpful in primary care diagnosis. Inspection. Inspect the gait for a smooth rhythmic flow as the patient enters the room. The knee should be extended at heel strike and flexed at all other phases of swing and stance. Check the alignment and contours of the knees. Observe any atrophy of the quadriceps muscles. Inspect for any loss of the normal hollows around the patella, a sign of swelling in the knee joint and suprapatellar pouch; note any other swelling in or around the knee.

Answer 66

Ask the patient to sit on the edge of the examining table with the knees in flexion. In this position, bony landmarks are more visible, and the muscles, tendons, and ligaments are more relaxed, making them easier to palpate. Pay special attention to any areas of tenderness. Pain is a common complaint in knee problems, and localizing the structure causing pain is important for accurate evaluation.

Answer 67

Palpate the tibiofemoral joint. Facing the knee, place your thumbs in the soft tissue depressions on either side of the patellar tendon. Identify the groove of the tibiofemoral joint. Note that the inferior pole of the patella lies at the tibiofemoral joint line. As you press your thumbs downward, you can feel the edge of the tibial plateau. Follow it medially, then laterally, until you are stopped by the converging femur and tibia. By moving your thumbs upward toward the midline to the top of the patella, you can follow the articulating surface of the femur and identify the margins of the joint. Note any irregular bony ridges along the joint margins.

Answer 68

Palpate the medial meniscus. Press on the medial soft tissue depression along the upper edge of the tibial plateau with the tibia slightly internally rotated. Place the knee in slight flexion and palpate the lateral meniscus along the lateral joint line

Answer 69

Palpate the medial and lateral joint compartments of the tibiofemoral joint with the knee flexed on the examining table to approximately 90°. Pay special attention to any areas of pain or tenderness. ■ Medial compartment (Fig. 16-77). Medially, move your thumbs upward to palpate the medial femoral condyle. The adductor tubercle is posterior to the medial femoral condyle. Move your thumbs downward to palpate the medial tibial plateau. Also medially, palpate along the joint line and identify the MCL, which connects the medial epicondyle of the femur to the medial condyle and superior medial surface of the tibia. Palpate along this broad, flat ligament from its origin to insertion ■ Lateral compartment. Lateral to the patellar tendon, move your thumbs upward to palpate the lateral femoral condyle and downward to palpate the lateral tibial plateau. When the knee is flexed, the femoral epicondyles are lateral to the femoral condyles. ■ Also on the lateral surface, ask the patient to cross one leg so that the ankle rests on the opposite knee and find the LCL, a firm cord that runs from the lateral femoral epicondyle to the head of the fibula.

Answer 70

Palpate the patellofemoral compartment. Locate the patella and trace the patellar tendon distally until you palpate the tibial tuberosity. Ask the patient to extend the knee to make sure the patellar tendon is intact. With the patient supine and the knee extended, compress the patella against the underlying femur, and gently move it medially and laterally, assessing for crepitus and pain. Ask the patient to tighten the quadriceps as the patella moves distally in the trochlear groove. Check for a smooth sliding motion (the patellofemoral grinding test).

Answer 71

Palpate for any thickening or swelling in the suprapatellar pouch and along the margins of the patella (Fig. 16-78). Start 10 cm above the superior border of the patella, well above the pouch, and feel the soft tissues between your thumb and fingers. Move your hand distally in progressive steps, trying to identify the pouch. Continue your palpation along the sides of the patella. Note any tenderness or increased warmth. Check three other bursae for bogginess or swelling. Palpate the prepatellar bursa. Palpate over the anserine bursa on the posteromedial side of the knee between the MCL and the tendons inserting on the medial tibial and plateau. On the posterior surface, with the leg extended, check the medial aspect of the popliteal fossa.

Answer 72

Learn to apply three tests for detecting fluid in the knee joint: the bulge sign, the balloon sign, and balloting the patella. ■ The bulge sign (for minor effusions). With the knee extended, place the left hand above the knee and apply pressure on the suprapatellar pouch, displacing or “milking” fluid downward (Fig. 16-80). Stroke downward on the medial aspect of the knee and apply pressure to force fluid into the lateral area (Fig. 16-81). Tap the knee just behind the lateral margin of the patella with the right hand (Fig. 16-82). ■ The balloon sign (for major effusions). Place the thumb and index finger of your right hand on each side of the patella; with the left hand, compress the suprapatellar pouch against the femur (Fig. 16-83). Palpate for fluid ejected or “ballooning” into the spaces next to the patella under your right thumb and index finger ■ Balloting the patella (for major effusions). To assess large effusions, you can also compress the suprapatellar pouch and “ballotte” or push the patella sharply against the femur (Fig. 16-84). Watch for fluid returning to the suprapatellar pouch.

Answer 73

Palpate the gastrocnemius and soleus muscles on the posterior lower leg. Their common tendon, the Achilles, is palpable from about the lower third of the calf to its insertion on the calcaneus. To test the integrity of the Achilles tendon, place the patient prone with the knee and ankle flexed at 90°, or alternatively, ask the patient to kneel on a chair. Squeeze the calf and watch for plantar flexion at the ankle.

Answer 74

``` 1. Flexion - Hamstring group: biceps femoris, semitendinosus, and semimembranosus “Bend or flex your knee.” OR “Squat down to the floor.” ``` ``` 2. Extension - Quadriceps: rectus femoris, vastus medialis, lateralis, and intermedius “Straighten your leg.” OR “After you squat down to the floor, stand up.” ``` 3. Internal Rotation - Sartorius, gracilis, semitendinosus, semimembranosus “While sitting, swing your lower leg toward the midline.” 4. External Rotation - Biceps femoris “While sitting, swing your lower leg away from the midline.”

Answer 75

``` 1. Medial Meniscus and Lateral Meniscus: McMurray Test. With the patient supine, grasp the heel and flex the knee. Cup your other hand over the knee joint with fingers and thumb along the medial joint line. From the heel, externally rotate the lower leg, then push on the lateral side to apply a valgus stress on the medial side of the joint. At the same time, slowly extend the lower leg in external rotation. The same maneuver with internal rotation of the foot stresses the lateral meniscus. If a click is felt or heard at the joint line during flexion and extension of the knee, or if tenderness is noted along the joint line, further assess the meniscus for a posterior tear. ``` ``` 2. Medial Collateral Ligament (MCL): Abduction (or Valgus) Stress Test. With the patient supine and the knee slightly flexed, move the thigh about 30° laterally to the side of the table. Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle. Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side (valgus stress). ``` ``` 3. Lateral Collateral Ligament (LCL): Adduction (or Varus) Stress Test. With the thigh and knee in the same position, change your position so that you can place one hand against the medial surface of the knee and the other around the lateral ankle. Push laterally against the knee and pull medially at the ankle to open the knee joint on the lateral side (varus stress). ``` ``` 4. Anterior Cruciate Legament (ACL): Anterior Drawer Sign. With the patient supine, hips flexed and knees flexed to 90° and feet flat on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings. Draw the tibia forward and observe if it slides forward (like a drawer) from under the femur. Compare the degree of forward movement with that of the opposite knee. Lachman Test. Place the knee in 15° of flexion and external rotation. Grasp the distal femur on the lateral side with one hand and the proximal tibia on the medial side with the other. With the thumb of the tibial hand on the joint line, simultaneously pull the tibia forward and the femur back. Estimate the degree of forward excursion. ``` ``` 5. Posterior Cruciate Ligament (PCL): Posterior Drawer Sign. Position the patient and place your hands in the positions described for the anterior drawer test. Push the tibia posteriorly and observe the degree of backward movement in the femur. ```

Answer 76

The total weight of the body is transmitted through the ankle to the foot. The ankle and foot must balance the body and absorb the impact of the heel strike and gait. Despite thick padding along the toes, sole, and heel and stabilizing ligaments at the ankles, the ankle and foot are frequent sites of sprain and bony injury.

Answer 77

The ankle is a hinge joint formed by the tibia, the fibula, and the talus. The tibia and fibula act as a mortise, stabilizing the joint while bracing the talus like an inverted cup The principal joints of the ankle are the tibiotalar joint, between the tibia and the talus, and the subtalar (talocalcaneal) joint (Fig. 16-85). Note the principal landmarks of the ankle: the medial malleolus, the bony prominence at the distal end of the tibia, and the lateral malleolus, at the distal end of the fibula. Lodged under the talus and jutting posteriorly is the calcaneus, or heel bone. An imaginary line, the longitudinal arch, spans the foot, extending from the calcaneus of the hind foot along the tarsal bones of the midfoot (see cuneiform, navicular, and cuboid bones in Fig. 16-86) to the forefoot metatarsals and toes. The heads of the metatarsals are palpable in the ball of the foot. In the forefoot, identify the metatarsophalangeal joints, proximal to the webs of the toes, and the PIP and DIP joints of the toes.

Answer 78

Movement at the ankle (tibiotalar) joint is limited to dorsiflexion and plantar flexion. Plantar flexion is powered by the gastrocnemius, the posterior tibial muscle, and the toe flexors. Their tendons run behind the malleoli. The dorsiflexors include the anterior tibial muscle and the toe extensors. They lie prominently on the anterior surface, or dorsum, of the ankle, anterior to the malleoli. Ligaments extend from each malleolus onto the foot. ■ Medially, the triangle-shaped deltoid ligament fans out from the inferior surface of the medial malleolus to the talus and proximal tarsal bones, protecting against stress from eversion (heel bows outward). ■ Laterally, the three ligaments are less substantial, with higher risk for injury: the anterior talofibular ligament, most at risk in injury from inversion (heel bows inward) injuries; the calcaneofibular ligament; and the posterior talofibular ligament (Fig. 16-86). The strong Achilles tendon attaches the gastrocnemius and soleus muscles to the posterior calcaneus. The plantar fascia inserts on the medial tubercle of the calcaneus.

Answer 79

Observe all surfaces of the ankles and feet, noting any deformities, nodules, swelling, calluses, or corns

Answer 80

With your thumbs, palpate the anterior aspect of each ankle joint, noting any bogginess, swelling, or tenderness (Fig. 16-87). Feel along the Achilles tendon for nodules and tenderness. Palpate the heel, especially the posterior and inferior calcaneus, and the plantar fascia for tenderness. Bone spurs are common on the calcaneus. Palpate for tenderness over the medial and lateral ankle ligaments and the medial and lateral malleolus, especially in cases of trauma. In trauma, the distal tip of the tibia and fibula should also be palpated. Palpate the metatarsophalangeal (MTP) joints for tenderness (Fig. 16-88). Compress the forefoot between the thumb and fingers. Exert pressure just proximal to the heads of the first and fifth metatarsals. Palpate the heads of the five metatarsals and the grooves between them with your thumb and index finger (Fig. 16-89). Place your thumb on the dorsum of the foot and your index finger on the plantar surface.

Answer 81

1. Ankle Flexion (Plantar Flexion): Gastrocnemius, soleus, plantaris, tibialis posterior “Point your foot toward the floor.” ``` 2. Ankle Extension (Dorsiflexion): Tibialis anterior, extensor digitorum longus, and extensor hallucis longus “Point your foot toward the ceiling.” ``` 3. Inversion: Tibialis posterior and anterior “Bend your heel inward.” 4. Eversion: Peroneus longus and brevis “Bend your heel outward.”

Answer 82

``` ■ The ankle (tibiotalar) joint. Dorsiflex and plantar flex the foot at the ankle. ■ The subtalar (talocalcaneal) joint. Stabilize the ankle with one hand, grasp the heel with the other, and invert and evert the foot by turning the heel inward then outward (Figs. 16-90 and 16-91). ■ The transverse tarsal joint. Stabilize the heel and invert and evert the forefoot ■ The metatarsophalangeal joints. Move the proximal phalanx of each toe up and down. ```

Answer 83

To measure leg length, the patient should be relaxed in the supine position and symmetrically aligned with legs extended. With a tape, measure the distance between the anterior superior iliac spine and the medial malleolus (Fig. 16-94). The tape should cross the knee on its medial side.

Answer 84

Use a goniometer to measure range of motion in degrees. In Figures 16-95 and 16-96, the red lines show the range of the patient’s range of motion, and the black lines show the normal range. Observations may be described in several ways. The numbers in parentheses show abbreviated descriptions.