L11: Spine & LE Flashcards

Question

**Knee: Inspection** What are you inspecting for?

Answer 1

* Alignment and contour of the knees * Atrophy * Swelling * Patellar tracking * Obvious deformity

Answer 2

Size and symmetry Swelling/edema Venous pattern Texture of the skin Distribution of hair

Answer 3

* Palpation of landmarks: * Quadriceps tendon * Patella * Patellar tendon * Medial & lateral joint lines * Tibial tuberosity

Answer 4

* Palpate for fullness or masses (cyst, aneurysm, lymphadenopathy) * Popliteal pulse * Knee should be flexed * May need to press deeply

Answer 5

* Tibia/fibula * Musculature * Calf tenderness * Swelling * Palpable “cord” (suggestive of thrombosed vein) * Achilles tendon

Answer 6

* **Flexion:** bend knee * **Extension:** extend knee * Strength Testing of the Knee * Examine separately and compare * Flexion: * Knees bent * Hand on thigh and ankle * “Don’t let me pull your foot (away from the table)” * Extension: * Knees bent * Hand on thigh and ankle * “Push my hand away from the table with your foot”

Answer 7

**Genus Varum** – "bow-legged" **Genu Valgum** – "knock-kneed"

Answer 8

* **Baker’s Cyst (Popliteal Cyst)** * A synovial fluid cyst located in the popliteal space * Palpable as fluctuant fullness * May be painful or result in calf swelling if they leak fluid or rupture * Extend the knee to palpate a Baker’s cyst

Answer 9

* Usually due to atherosclerotic vascular disease * The most common aneurysm of the peripheral vascular system. * Bilateral over 50% of the time. * Males \>\>females, \> 65 years old. * Dx: pulsatile swelling behind the knee

Answer 10

1. Patient supine 2. Extend knee to relax quads 3. Displace patella medially and laterally **Positive:** Displacement \< 1⁄4 or patella (tightness of retinaculum) or \> 3⁄4 of patella width (hypermobility)

Answer 11

1. Knee flexed 30° 2. Apply medial pressure to displace patella laterally 3. Observe for apprehension **Positive:** Patient has sensation of instability (“knee giving out”) and guards or demonstrates apprehension indicating hypermobility or patellofemoral instability

Answer 12

1. Knee flexion of 45-90° 2. Slowly extend the knee 3. Observe patellar tracking **Positive:** Lateral tracking of the patella when approaching terminal extension indicating hypermobility or instability of the patella

Answer 13

1. Patient supine with leg in extension 2. Sweep downward with one hand “milking” the fluid toward the patella 3. Apply infrapatellar pressure to each side observing for a bulge or alternatively, stroke medial side upwards followed but the lateral side downwards **Positive:** medial bulge appreciated with presence of effusion

Answer 14

1. Patient supine 2. Leg fully extended 3. Compress suprapatellar pouch 4. Press patella toward the femur 5. Oscillate for motion and observe for fluid return to suprapatellar pouch **Positive:** Fluid present beneath the patella

Answer 15

**Valgus Stress Test (MCL)** 1. Patient supine 2. Stabilize at lateral joint line, medial ankle 3. Apply lateral to medial force at joint line while restricting axial rotation 4. Complete exam at 0 and 30 degrees of flexion **Positive:** pain or medial joint space laxity

Answer 16

**Varus Stress Test (LCL)** 1. Patient supine 2. Stabilize at medial joint line, lateral ankle 3. Apply medial to lateral force at joint line while restricting axial rotation 4. Complete exam at 0 and 30 degrees of flexion **Positive:** pain or lateral joint space laxity

Answer 17

1. Patient supine 2. Flex hips and knees to 90° 3. Stabilize foot flat on table 4. Thumbs on medial and lateral joint line with fingers on hamstring insertions 5. Pull tibia back checking for excessive posterior movement **Positive:** posterior translation without firm endpoint

Answer 18

**Posterior Sag Sign: PCL** * Note the amount of posterior sag relative to the other leg * The anterior tibial surface normally lies 1 cm anterior to the femoral surface * This is checked in both extension & 90° of flexion with both internal & external rotation

Answer 19

**Lachman (ACL)** 1. Patient in supine position 2. Kneeflexionto20-30° 3. Stabilize the distal femur with one hand while attempting to displace tibia anteriorly with the other hand **Positive:** anterior translation without firm endpoint

Answer 20

**Anterior Drawer (ACL)** 1. Patient supine 2. Flex hips and knees to 90° 3. Stabilize foot flat on table 4. Thumbs on medial and lateral joint line with fingers on hamstring insertions 5. Pull tibia forward checking for excessive forward movement **Positive:** anterior translation without firm endpoint

Answer 21

**Pivot-Shift (Pivot) Test** Assesses for instability associated with ACL injury 1. Flex hip to 20-30 degrees with knee extended 2. Hip should be slightly abducted to relax the IT band allowing rotation of the tibia 3. Internal rotation of the lower leg with valgus stress 4. Slowly flex and then extend the knee looking for subluxation

Answer 22

**McMurray Test** * Start with flexed knee: grasp heel with one hand & joint line of knee with thumb and index finger. * Medial meniscus * **_Externally rotate at heel_**, flex maximally, then slowly extend the knee while providing (**_valgus_**) stress to knee * Lateral meniscus * **_Internally rotate at the heel_**, flex maximally, then slowly extend the knee while providing (**_varus_**) stress to knee

Answer 23

**Apley Grind (Distraction and Compression) Test** * _Meniscus_ Assessment: * Patient prone * Knee flexed 90° * Stabilize thigh with examiner’s knee * Provide longitudinal distraction while gripping the ankle * Apply downward force to foot and rotate internally and externally * **Positive:** Pain/clicking with compression indicates possible meniscus injury which should resolve with distraction. * \*Pain with distraction testing may indicate ligament injury

Answer 24

* Ankle: * Weight-bearing joint * Absorb impact of the gait * Hinge joint * Tibiotalar joint. * Subtalar (talocalcaneal)

Answer 25

* Tarsal/metatarsal joint * PIP/DIP joint

Answer 26

* Deformities * Nodules or other masses * Swelling * Callus * Nails

Answer 27

**Neuropathic Ulcer** associated with diabetic neuropathy

Answer 28

* Palpation of landmarks: * Achilles tendon * Medial and lateral malleoli * Calcaneus * Metatarsals * MTP and IP joints * Press downward with thumb for a few seconds: * Dorsum of foot, behind medial malleolus, or on shins * Grade from 0 to 4+ edema * May indicate how high edemarises up leg

Answer 29

* **Dorsalis pedis pulse** * Dorsum of the foot * Approximately over the 1st-2nd metatarsals * **Posterior tibial pulse** * Behind and slightly below medial malleolus

Answer 30

Grade the amplitude of the pulse: * 0, Absent, unable to palpate * 1+, Diminished, weaker than expected * 2+, Brisk, normal * 3+, Increasing * 4+, Bounding

Answer 31

* Flexion of the toes: * Bend the toes * “curl your toes under” * Extension of the toes: * Straighten the toes * “lift your toes up”

Answer 32

* Dorsiflexion: * Put hand on top of foot * “Bend your foot up against my resistance” * Plantar flexion: * Put hand under ball of patient’s foot * “Push down against my hand, like foot on the accelerator”

Answer 33

1. Patient supine or seated 2. Stabilize the distal tibia with one hand 3. Grasp the calcaneus and pull anteriorly **Positive:** laxity associated with lateral collateral ligaments (anterior talofibular ligament ) instability

Answer 34

**Thompson Test: Achilles Tear** 1. Patient prone or can kneel on stool 2. Squeezecalf 3. Observeforplantarflexion **Positive:** No plantar flexion response with squeeze

Answer 35

* Expose the entire back * Note patient’s posture with feet aligned and together with arms hanging at the sides * Is head erect? * Are shoulders & pelvis level? * Inspect from the side * Evaluate spinal curvature * Assess cervical and lumbar concavity and thoracic convexity

Answer 36

* **Inspection** * Cervical concavity * Thoracic convexity * Lumbar concavity * **Palpation** * Spinous processes * May also do this during flexion of the spine * Paravertebral muscles – Tenderness * Spasm * Palpate sciatic nerve * Palpate sacroiliac joint

Answer 37

* ROM of the neck * Completed during the neck exam * ROM of the spine (thoracic & lumbar) * Flexion * Extension * Rotation * Lateral bending * Hunch the back **_Spine ROM_** * _Flexion_ * Bend forward and touch toes * Evaluate for scoliosis * May palpate along the spinous processes during this maneuver. * _Extension_ * Bend backwards * Stabilize the patient * Hands on hips standing to the side * _Rotation_ * Rotate the trunk posteriorly * Stabilize the patient * Hands on hip or shoulders * _Lateral Bending_ * Lean to each side as far as possible * Act like picking up a suitcase * Stabilize the patient * _Hunch the back_ * Assess for spinal curvature

Answer 38

Standing Examination and **Adams Forward Bend Test** * Inspect from several angles and with patient bending forward * Always evaluate for potential limb length discrepancy to determine if apparent discrepancy is from spine or if a true LLD is causing curvature.

Answer 39

Inspecting for limb length discrepancy Comparing medial malleolus (measurement to ASIS)

Answer 40

* Specialized test for lumbosacral radiculopathy and/or sciatic neuropathy * Most sensitive for L5-S1 * Passive ROM while supine with knees extended * Dorsiflexion of the ankle may further increase the pain response * Positive test: radiating pain in affected limb * Note degrees of elevation * *\*Also called Lasègue's Test (Sign)*

Answer 41

**Seated SLR Test (“flip sign”)** 1. Patient seated with hands on the table. 2. Passively extend knee **Positive sign:** Patient will “flip back” due to pain.