Lower Extremity Flashcards
Anatomy of the lower extremity
SEE DIAGRAM
Normal planes of movement of each of the lower extremity joints. Degrees of range of motion
Hip: Flexion: 115 degrees Extension: 0 degrees Hyperextension: 30 degrees Abduction: 50 degrees Adduction: 30 degrees Internal rotation: 30 degrees External rotation: 50 degrees
Knee:
Flexion: 135 degrees
Extension: 0 degrees
Hyperextension: 10 degrees
Ankle: Plantar flexion: 50 degrees Dorsiflexion: 20 degrees Inversion: 30 degrees Eversion: 20 degrees
Great Toe: Hinge joint
Flexion: 30 degrees
Extension: 0 degrees
Hyperextension: 50 degrees
Appropriate exam techniques and sequence of exam for lower extremity
Inspection
Palpation
-Leg, Knee, Ankle, Foot
Deep tendon reflexes of the lower extremity and the spinal nerve associated with each
Patellar Reflex (L4) – obtain with a relaxed, flexed knee – strike the soft tissue distal to the patella with pointy side of reflex hammer Achilles Reflex (S1) – obtain with a slightly stretched tendon by dorsiflexing the foot – strike the soft tissue superior to the calcaneus with pointy side of reflex hammer Note any ankle clonus – involuntary repetitive and variably sustained reflex response elicited by manually stretching the tendon.
Thompson or Simmonds test
Place patient in prone position (or with anterior legs bent 90 degrees on chair) and squeeze the calf muscle of the affected leg. If foot does not plantar flex, the test is positive.
Associated condition: Achilles tendon rupture
Patellar ballottement
Knee extended, apply downward pressure on the supra patellar pouch with the web or thumb and forefinger of one hand, then push the patella sharply downward against the femur with a finger of your other hand. Release pressure and if patella ‘floats’ effusion is present.
Associated condition: presence of excess fluid or effusion of the knee
Anterior/posterior drawer sign
Patient lies supine with flexed knees 45 - 90 degrees. Draw tibia forward, forcing the tibia to slide forward to the femur, then back. Movement greater than 5 mm in either direction is unexpected.
Associated condition: Instability of the anterior and posterior cruciate ligaments.
True/apparent leg length
True: measure from anterior superior iliac spin to the radial malleolus of the ankle, crossing the knee on the medial side
Apparent: measure from umbilicus to medial malleolus
Associated condition: differing leg or circumference of legs.
Homan sign
Flex patients knee slightly, dorsiflex the foot. Calf pain = (+); absence does not preclude venous thrombosis
Associated condition: DVT/ thrombosis
Ortolani/Barlow test
o Barlow maneuver: Use a small amount of force. Test one hip at a time. With infant supine, flex the hip and knee to 90 degrees. Adduct the thigh and gently push downward on the femur. A positive sign is indicated when you hear a clunk or the sensation is felt as the femoral head dislocates from the acetabulum.
o Ortolani maneuver: With infant in the same position as the barlow test, slowly abduct the thigh while maintaining pressure. Listening for the femur to move back into the acetabulum.
Associated condition: Hip dislocation or development dysplasia
Patellar bulge sign
With knee extended, milk the medial and lateral aspects of the knee upward. Observe for a bulge of fluid to return to the space.
Associated condition: Excess fluid in the knee
Apprehension test
Patient should lie supine on the table with legs relaxed. Press against the medial side of the patella with thumb. Watch the patients face. If the patella begins to move or dislocate the patients face will show distress.
Associated condition: Patellar dislocation and subluxation
McMurray test
Have patient lie supine on table, with legs extended in neutral position. With one hand grab the heel and flex the leg. Place the other hand at the knee joint and begin to rotate the leg internally and externally. Feel for any tenderness, palpable or audible “clicking” may indicate a tear.
Associated condition: Medial meniscus tear
Apley distraction/ grinding test
Distraction:
Maintain the same position as the Apley grinding test. Apply traction to the leg while rotating the tibia internally and externally. This reduces tension on the menisci and puts pressure on the ligaments. If there is a tear the patient will experience pain.
Associated condition: Ligamentous injury
Grinding:
Have patient lie prone with leg flexed to 90 degrees.
Stabilize the back of the thigh. Lean hard on the heel to compress the medial and lateral menisci between the femur and tibia. Rotate the tibia internally and externally. If this elicits pain there is probably a meniscus tear.
Associated Condition: Torn meniscus
Patellofemoral grinding test
Patient will lie supine with legs relaxed in neutral position. Push the patella distally into the trochlear groove, then have patient flex their quadriceps. Palpate and offer resistance to the patella as it moves under your fingers. If there is roughness of the articulating surfaces you will feel crepitus. It should normally be smooth. If the test is positive the patient will usually complain of pain.
Associated condition: Rough articulating surfaces of the patella and the trochlear groove of the femur. (pain when climbing stairs)
