Hip and Knee Q and A's Gindl Flashcards
Positive Fabere Patricks Test
-What does it indicate?
Acetabular hip pain, and or lack of motion
-Indicates hip joint pathology
What is part 3 of Fabere Patrick’s Test?
Dr. stabilizes the opposite ASIS and presses down on the femur to bring the hip into extension
What is the most common hip pathology in the elderly?
DJD causing arthritic pain
What are the 2 most common hip joint pathologies in the very young?
Legg-Calve-Perthes Disease
Slipped Capital Femoral Epiphysis
What is the most common cause of hip pain?
Subluxation
Positive Hibb’s Test
-What does it indicate?
Pain upon internal rotation at the hip
-Hip joint pathology
Positive Thomas Test
-What does it indicate?
Elevation of the straight leg (hip flexion on the side of the straight leg)
-Contracture of the hip flexors
A positive Thomas Test most commonly involves contracture of what hip flexor?
Iliopsoas
Positive Trendelenberg Test
-What does it indicate?
Weakness on the standing leg side (gluteus medius) while the raised leg side drops forward and down
-Deterioration/weakness of the pelvic stabilizer muscles (extensors or abductors)
How to check for fluid motion of the hip
Perform part 1 of Fabere Patricks Test. With the knee bent and the hip flexed press the femur in to the acetabulum. Feel for spinginess (end fell with bounce) vs. a hard end feel with the loss of motion.
Indications that Hip Traction is needed?
Loss of motion with Hibb’s or Fabere Patrick’s Tests or hip telescoping; Sharp or dull pain at the hip
Osteoarthritis
What is the most important thing about setting your contact for Hip Traction?
Triple Flexion (hip, knee, and pelvis each flexed to 90 degrees) is performed in order to place the Dr’s forearm under the ischial tuberosity. Dr. will stand opposite and inferior while reaching with the superior arm to place the posterior aspect of the forearm under the ischial tuberosity. The fingers of the Dr’s contact hand reach laterally, out from under the patient’s pelvis.
How to carefully keep your forearm away from the patient’s privates or pubis during hip traction?
Explain what you are about to do before you do it! Make sure that the doctor stance is inferior and that triple flexion is used to place the contact point under the ischial tuberosity. The Dr’s contact arm is at an oblique I-S angle with the fingers pointed laterally out from under the pelvis.
What do you do after setting your contact point for hip traction?
Bring the foot and leg down at an oblique angle until the thigh is tight against your forearm
How do you know that the hip joint is tractioning open during hip traction?
Two possibilities:
1) Visualize the hip joint
2) Dr places their forearm along the patient’s femur with the fingers palpating over the greater trochanter. The Dr’s elbow will squeeze the lateral aspect of the femur medially to open up the hip joint whoch the fingers should be able to feel
What is the most common tear of the knee ligaments?
1st = medial menisci
2nd = MCL
3rd = ACL
Positive anterior drawer sign
-What does it indicate?
Excessive motion P-A or increase in pain
-ACL tear
How do you stabilize for Anterior Drawer Sign?
Stabilize the patient’s anterior foot with your posterior thigh while the patient’s knee is flexed
Loss of motion on the Anterior Draw Sign indicates what knee subluxation?
Tibia P
What test would you run if you suspected a false negative on anterior draw sign?
Lachman’s
What test would you run after Anterior Draw Sign to verify a ACL damage and laxity?
Lachman’s
Positive Posterior Draw Sign
-What does it indicate?
Excessive motion A-P or increase in pain
-PCL tear. Not as common as ACL tear. Can perform Sag Sign to double check.
Positive Lachman’s Test
-What does it indicate?
Excessive motion P-A or increase in pain
-ACL tear
What is the orthopedic test of choice for the ACL?
Lachman’s
Why is Lachman’s preferred over anterior draw sign for ACL testing?
The greater angle of flexion (>90 degrees) does not stretch the quadriceps as much, and the condyles are not as deeply seated into the menisci
Positive Sag Sign
-What does it indicate?
The tibia sags posterior in relationship to the femur
-PCL tear
When should Sag Sign be performed?
Whenever you have a positive Anterior Draw Sign. If the PCL is torn and the tibia sags posterior it will appear and feel like it moves excessively P-A due to the laxity
Positive Apley’s Distraction
-What does it indicate?
Pain upon distraction
-Collateral ligament damage on the side of pain
What if pain decreases on Apley’s distraction what test would you run?
Apley’s compression suspecting a meniscal tear
Is Apley’s Distraction a subjective or objective test?
Subjective
Positive Valgus Stress test
-What does it indicate?
Increased pain and or excessive movement at the medial joint space (pushing from lateral to medial)
-Indicates MCL tear
What other test could you run to verify a positive Valgus stress test?
Apley’s Distraction with pain on the medial side
Is it normal to have a little bit of movement during Valgus stress test?
Yes. If there is no motion think Tibia AM, if there is excessive motion think MCL tear
What would be indicated if the pain was exacerbated during the Valgus stress test?
A partial MCL tear
What would be indicated if the pain remained the same during the valgus stress test?
A complete tear of the MCL
What other ligaments might be torn if the MCL is torn?
The medial meniscus and maybe the ACL
What would be indicated if there was no motion on the valgus stress test?
May be due to the tibia having rotated anterior on the medial side. This would pull the medial ligaments tight that attach to the femur. Thus restricting motion from lateral to medial
Positive Varus Stress Test
-What does it indicate?
Increased pain and or excessive movement at the lateral joint space
-LCL tear
Should you compare varus to valgus stress on the same knee?
NO! The two don’t always have the same laxity. Compare right knee varus to left knee varus and right knee valgus to left knee valgus.
What would be indicated if there was no motion on the Varus Stress test?
May be Tibia AL. This would pull the lateral ligaments tight that attach to the femur. Thus restricting motion from medial to lateral
What other test would you rin to verify a positive varus stress test?
Apley’s Distraction for the LCL damage
Positive Apley’s Compression
-What does it indicate?
Pain upon compression
-Meniscal damage on the side of pain
What if pain decreases on Apley’s Compression what test would you run?
Apley’s Distraction suspecting a collateral ligament tear
What test would you perform to verify pain on the medial side with Apley’s Compression?
McMurray’s Test
Is Apley’s Compression a subjective or objective test?
Subjective
Positive McMurray’s Test
-What does it indicate?
Palpable or audible click upon performing the procedure
-Medial meniscal tear on the side of pain. Most likely a horizontal/bucket handle tear
Describe the order of procedure for McMurray’s
Patient is supine, hip and knee are flexed to 90 degrees. Dr. palpates the medial knee joint, externally rotates the foot and applies a medial stress (varus) while extending the leg for medial meniscus (do the opposite for the lateral meniscus)
Is this test subjective of objective?
Objective. Pain is not a positive finding for this test
What might pain alone (no click) indicate in McMurray’s?
Possibly an:
- MCL tear
- Medial meniscus tear
- ACL tear
- Tibia AM
What orthopedic tests should be run if McMurray’s has pain only?
- Valgus Stress Test
- Apley’s Compression
- Apley’s Distraction
- Anterior Draw Sign
- Lachman’s
What is the most common cause of a joint mouse in the knee?
Medial Meniscus tear
Positive Bounce Home Test
-What does it indicate?
Hard end feel, the knee doesn’t bounce on extension
-A joint mouse. The joint mouse can be swelling, guarding of the hamstrings, torn meniscus, scar tissue, etc.
Positive Patellar Apprehension Test
-What does it indicate?
Patient has a look of apprehension. Look at the patient’s face
-A propensity for the patella to dislocate
In what direction is pressure applied for the Patellar Apprehension Test?
Press M-L against the medial border of the patella, then L-M against the lateral border of the patella.
What is the most common direction for patellar dislocation?
Superior and Lateral due to the pull of the quadriceps muscle
Positive Femoral Grinding Test
-What does it indicate?
Pain or crepitus during the test
-In the pediatric population the positive would indicate chrondromalacia patella. In the adult population it would indicate DJD, osteochondritis of the patella, patellar fracture or plica
What is the direction of pull for the patella femoral grind test?
With the Dr’s index finger and thumb finger at “10 and 2” on the patella utilize S-I pressure. Try very hard to NOT get A-P pressure on the patella. It is actually more humane (less painful) if the Dr takes the “10 and 2” position then asks the patient to life their foot off of the table. With the Dr’s thumbs holding the “10 and 2” position, when the patient raises their foot it contract the quadriceps and raises the patella superior
Visualization of the Knee with Tibia AM
Anterior tubercle of the tibia will be slightly lateral to the lower pole of the patella. The patient may also exhibit toe-out foot flare.
Visualization of the knee for Tibia AL
The anterior tubercle of the tibia will be slightly medial to the lower pole of the patella. The patient may also exhibit a toe-in foot flare.
Visualization of the knee with patella dislocation
The patient’s leg will most likely be flexed and the patella will be found lateral and superior to its normal position. With the patella on the lateral side of the lef the quadriceps will act as flexors instead of extensors
Fluid motion of the knee with Fibula AL
With the patient’s leg extended one hand of the Dr will palpate over the head of the fibula, the other hand will passively dorsiflex and plantar flex the foot. This will take the head of the fibula through a passive ROM. Look for restriction in the motion of the head of the fibula. To directly test the motion at the head of the fibula, the patient’s knee is slightly flexed. Then the Dr takes hold of the head of fibula with their thumb and finger. The Dr will attempt to move the head of the fibula A-P and P-A. This will determine not only a loss in motion but where the fibular head is restricted a little anterior or posterior too.
Fluid motion of the knee for Tibia AM
Perform valgus stress test. If there is no motion, it is due to the tibia having rotated anterior on the medial side. This pulls the medial ligaments tight that attach to the femir. This restricting motion from lateral to medial.
Fluid motion of the knee for Tibia AL
Perform varus stress test. If there is no motion it is due to the tibia having rotated anterior on the lateral side. This pulls the lateral ligaments right that attach to the femur. Thus restricting motion from medial to lateral.
Fluid motion of the knee for Tibia P
Loss of fluid motion on anterior drawer (pulling P-A)
Fluid motion of the knee for patella
Dr. will perform patellar apprehension test and feel for loss of motion L-M and M-L
What is the move of choice for any knee involvement and why?
Knee Traction Prone becaus you can palpate the joint at the same time.
What is the move of choice when there is limited flexion of the knee?
Knee Traction Limited Flexion
Knee Traction is most effective for knee subluxation?
Tibia P
Best post check for Knee Traction?
Test the fluid motion that was reduced on the pre-check
Which knee traction is the move of choice?
Prone, you can palpate the joint space during the procedure.
Knee traction can be used for what subluxations and pathologies?
Tibia P
Tibia AM
Tibia AL
OA
RA
Other arthritides
Fixation of the knee
-Maybe swelling of the knee
Indications of Tibia P
Aching behind the knee and/or below the patella at the anterior aspect of the knee. Patient may complain of difficulty going up or down statis. ROM decreased in the ability to fully flex the knee (the anterior ligaments pull tight restricting flexion), loss of fluid motion on anterior draw sign (pulls tibia P-A)
What is the first thing to do for Tibia P?
Have the patient (in the prone position) turn their head to the side to avoid catching the face/chin on the table when thrusting
What orthopedic test checks for Tibia P fluid motion?
Anterior Draw Sign
What is patient placement for Tibia P?
Prone with the knee flexed to less than 90 degrees
What is the LOC for tibia P?
P-A
Where is the pain point for Tibia P?
Pain in the back of the knee
What are some pathologies that might cause pain in the back of the knee?
Tibia P
Baker’s Cyst
Aneurysm in the popliteal fossa
Arthritis
What is the over all move of choice for Tibia P?
The knee traction prone is the move of choice due to the doctor being able to palpate the knee joint during the maneuver.
Describe the CP for Tibia P
Hand over hand (do not interlock fingers, it’s detrimental to your joints)
What would be a contraindication for the Tibia P thrusting move?
Varicosities
Thrombus
Baker’s cyst
Why does a varicosity occur?
Incompetent valves in the veins that let the blood pool
What can be done for varicosities?
Pregnant women
2nd MC group to have varicosities?
Middle aged older men
Indications of a Tibia AM
Pain point over the medial (slightly anterior) aspect of the joint space; relative toe-out (check the pelvis for an IN ilium). Loss of motion on Valgus stress test. Visually the anterior tubercle is slightly lateral to the inferior pole of the patella
What is the procedure for Tibia AM after the Dr. takes the contact?
Traction S-I, slightly flex the knee, then thrust with CH to bring the knee to full extension (femur on the table and the tibia off of the table)
Where should the femur be when the leg is in full extension for the Tibia AM adjustment?
On the table for stabilization
What is the stabilization for Tibia AM?
3 parts:
1) Femur on the table upon full extension
2) Lateral hand under the tibia (pre-stressing the tibia to de-rotate it)
3) Patients ankle between the Dr’s knees
With a Tibia AM, where is the tibial tuberosity (medial or lateral) compared to the inferior tip of the patella?
Slightly lateral
What is the LOD for Tibia AL?
Straight A-P, NOT L-M. With the SCP lateral to the anterior tubercle it will help to derotate the tibia
What is the best post-check for tibia AL?
Fluid motion done by performing the Varus Stress Test
Indications of Fibula L
Pain over the fibular head, sometimes at the distal end of the fibula,
- Pain in ankle dorsiflexion, inversion, or eversion.
- Swelling over the joint space
- Loss of fluid motion
- Might have a case history of an inversion sprain of the ankle, a blow (P-A or A-P on the lateral side of the leg) or unknown cause.
What is patient placement for Fibula L?
Supine, leg in full extension, between the Dr’s knees and NOT flexed
What is the CP for fibula L?
8 or #11, whichever is most comfortable for the Dr (NOT #9)
What is important for the LOD for Fibula L?
It must be straight L-M
2 most commonly mussed items on Fibula L during a practical?
Not having a straight L-M LOD, or not keeping the knee in full extension
What is the best post check for Fibula L?
Fluid motion
What protects the knee joint during the Fibula L thrust?
Having the knee in full extension and the SH across the medial aspect of the knee joint
Is Knee Traction Supine the preferred move for knee traction?
NO!
-Prone is preferred because with Supine you can’t palpate the joint space opening
What are limiting factors for Knee Traction Supine?
Patient tolerance or visualize the joint opening
What are the limiting factors for Knee Traction Prone?
Patient tolerance and visualizing the joint space opening up
-Make sure when performing this on the practical that you are looking at the joint space
What is the best way to post check for Knee Traction Prone?
Keep the patient in the prone position and try the fluid motion check that was reduced on the pre-check
What is the CP for Knee Traction Prone?
Thumb web
How might you modify Knee Traction Prone if it was a big patient and the Dr has small hands?
You can use a padded object as a fulcrum like a rolled up towel
What are the motions in order for Knee Traction Limited Flexion?
Flex the patients knee to tolerance, Traction S-I, Release, Bring knee into more flexion.
-Repeat until patient tolerance or no more motion is gained that visit.
DO NOT perform traction and flexion together you might entrap a joint mouse
Why don’t we traction, flex and then release during Knee Traction Limited Flexion?
It may entrap a joint mouse or meniscus (OUCH) and the patient will go into spasm
Best post check for Knee Traction Limited Flexion?
Increase ROM
Would you expect more, less, or the same ROM 24 hours after the knee traction limited flexion adjustment?
15% more movement once the patient begins using it after traction
Indications for Patellar Traction
Patella is dislocated. The patient is unable to extend their knee due to the quadriceps acting as flexors with the patella off center
-Visually the patella is usually lateral and superior to the knee joint
How would the patient present if they needed Patellar traction?
They would have a case history of impact on the patella causing pain
- Knee would be flexed
- Visually the patella would not be midline
What are 4 post checks for Patellar Traction?
1) Visually the patella is back to midline
2) X-ray to check for Fracture
3) Significant decrease in pain
4) Patient is not able to extend their leg
What procedures would you NOT use as post checks for Patellar Traction?
Due to hypermobility of the patella, you would NOT use:
- Fluid motion
- Patellar Apprehnesion Test
- Patella Femoral Grinding Test
