Examination of Lower Limb

Question 1

Think of

Answer 1

1. Neurological defect
2. Muscular dystrophy
3. Skeletal defect
   • Joint
   • Knock knee/ bow leg
4. Hemihypertrophy
5. Skin rash

Question 2

Examination of Lower limbs

Answer 2

Ask pt to undress, note the use of nappy by child of inappropriate age

1) Inspection
• Skin - rash, scar, trophic change, vasomotor change
• Muscles - wasting, hypertrophy, fasiculations
• Joint - inflammatory change
• Bone - deformity
• Asymmetry in size or length

2) Movement
• No movement –> Do neurological examination
• Movement ++ –> Stand up and note any deformity
• • Look for specific gait
• • Do Romberg’s test & Heel toe walking
• • Elicit related neurological sign

3) Examination of Lower limb
• Feel skin temperature, pheripheral pulses
• Joint: Note the ROM, ? Crepitus, feel for signs of inflammation
• Neurological: Sensory; motor and coordination

4) If indicated,
• Abdominal exam - bladder and kidney
• Anus exam - anal reflex, pendulous?
• Spine: Scar, hairy patch, mass

5) For small baby,
• Pull baby up via the axilla –> scissoring of LL –> Spastic diplegia

Question 3

Unequal leg length - Steps in examination

Answer 3

1. Compare the length of both sides after levelling the pelvis –> determine if above / below knee shortening
2. Measure the true & apparent lengths
   • Measure the thigh & leg lengths for both sides
3. For above knee shortening: Level the pelvis then –> Draw a line between anterior superior iliac spine & ischial tuberosity; normally, greater trochanter should be below this line. If the reverse, shortening is due to pathology at hip/ femoral neck
4. Examine the possible cause for the length discrepancy
   a) Small side abnormal
   • Hemiatrophy: Congenital; Vascular; Disuse (UMN / LMN lesion); Destructive lesion of bone

b) Big side abnormal
• Hemiatrophy: Congenital; Vascular; bone lesion –> Stimulate growth

c) Joint pathology
• Congenital dislocation of hip
–> Do neurological , vascular, bone & joint examination

Question 4

Pes Cavus - Steps in examination

Answer 4

1. Look
   • Hypertrophy - DM Dsytrophy - (Gower’s sign +ve; Waddling gait +ve)

• Atrophy
• • Symmetrical - CMT (Sensory loss)
• • Asymmetrical - Polio ( Sensory intact)

2. Examine tone, jerk, plantar reflex and spine
   • LMN signs - Polio
   • UMN signs - CP (Spastic gait)
   • No jerk but up-going plantar reflex - Fredreich’s ataxia ( Ataxic gait)

Question 5

Dermatome of Lower Limbs

Answer 5

1. Groin (L1)
2. Anterior thigh (L2)
3. Knee (L3)
4. Leg - medial (L4); Lateral (L5)
5. Foot - Big toe (L5); Little toe (S1)
6. Planter - medial (L5); Lateral (S1)
7. Back of thigh (S2)
8. Perineum (S3, S4)

Question 6

Myotome

Answer 6

1. Hip
   • Flexion (L2, L3)
   • Extension (L4, L5)
2. Knee
   • Extension (L3, L4)
   • Flexion (L5,S2)

3. Ankle 
•  Plantar flexion (S1, S2)
•  Dorsiflexion (L4, L5)
•  Inversion (L4)
•  Eversion (L5, S1)

If asymmetry of leg size is found
1. Confirm by measurement

2. Local examination
   • Oedematous
   • Neurofibroma
   • Increase blood flow –> hot flush
3. Examine upper limb & face for similar asymmetry
4. Face:
   • Coarse feature, big tongue, fissure at ear lobe, triangular face, fish-like mouth
   • Eye - Aniridia
5. Abdomen: Mass - Wilm’s tumour
6. Growth parameters - decrease in Russel Silver Syndrome
7. Skin: Hypopigmented lesion