O&T: Lower Limb Flashcards
P/E of Hip
Always normal side first
Look:
1. Scar: Surgical / Pitting scar (from drainage site e.g. TB)
2. Mass: Hernia, Bone / Soft tissue tumours
3. Muscle wasting: **Quadriceps, **Gluteus, **Hamstring (by disuse atrophy e.g. arthritis) —> measure girth of thigh
4. Position / Deformity
- Hip fracture —> shortened + externally rotated + abducted
- Hip posterior dislocation —> shortened + internally rotated + adducted
5. **Gait
- Antalgic gait
- Short limb gait
- Trendelenburg gait
Feel (front —> side —> back —> groin —> proximal femur):
1. Tenderness (***Always look at patient’s face!!!)
2. Mass
Move:
1. Flexion + Extension —> Thomas test —> Fixed flexion deformity (FFD) of Hip
2. Abduction + Adduction (stabilise pelvis by placing forearm over ASIS)
3. External + Internal rotation (prone / supine position) (***stabilise pelvis also)
- prone: hip + knee extended
- supine: hip + knee flexed (90o-90o)
Special tests:
1. ***Leg length discrepancy (LLD)
- Block test
- Apparent + True leg length
- Galeazzi test
- Bryant’s triangle
2. Muscle wasting measurement
Feel (Palpation) of Hip
Look at patient’s face for tenderness
1. Mid-inguinal point (same position as Femoral pulse)
2. Greater trochanter
3. Proximal femur
Thomas test
Test for Fixed flexion deformity of Hip (FFD)
- Passive extension of hip (Push down knee while whole leg extended)
- if corrected —> not FFD
- lumbar spine become hyperlordotic (compensation through rotate pelvis + lumbar spine) —> FFD - Active flexion of hip (Correct lumbar hyperlordosis —> put a hand underneath lower back to ensure lordosis obliterated)
- first check normal hip **active + **passive flexion angle
- then check abnormal hip
—> ask patient to keep normal hip maximally flexed —> lock pelvis in flexed position (lumbar lordosis should be obliterated —> no need put hand underneath now)
—> try extend hip —> abnormal hip will be raised (扯左上去) —> cannot lie down leg even when push down on knee (i.e. full extension) (fixed flexion)
—> try flex hip —> abnormal hip also cannot be flexed
—> FFD (extend又唔得, flex又唔得)
Leg length discrepancy (LLD)
***Block test
- in standing position, ASIS same level —> look at height of block placed under shortened limb
Apparent LLD:
- affect **function of patient (vs True LLD)
- cause: **Pelvic obliquity (i.e. tilted pelvis)
—> **Supra-pelvic (e.g. scoliosis)
—> **Infra-pelvic (e.g. hip adduction contracture)
- distance from ***umbilicus / xiphisternum to medial malleoli (do NOT square pelvis, just lie in comfortable position)
True LLD:
- shortening of limb
- causes: **Osteoarthritis, **AVN with collapsed hip, **Tibial fracture shortening
- distance from **ASIS to medial malleoli (need to **square pelvis)
- **Galeazzi test (determine which level is shortened: tibia / femur / both)
- **Bryant’s triangle (determine whether the shortening is above / below trochanter if **femur is short)
Galeazzi test
Flex hip 45o + flex knee 90o + both feet on same level
—> look from side / leg / head to compare height of knee
Lower knee level when looking from feet side —> Short tibia
Lower knee level when looking from head side (or Knee more proximal when looking from side) —> Short femur
Bryant’s triangle
Determine whether the shortening is above / below trochanter if ***femur is short
3 points:
1. ASIS (place thumb)
2. Greater trochanter (place index finger)
3. Junction of 2 perpendiculars (Vertical line from ASIS, horizontal line from Greater trochanter) (place middle finger)
—> Measure distance from point 2 to point 3
—> Compare both sides (if shorter —> indicate ***supratrochanteric shortening i.e. hip joint problem instead of shaft problem)
Gait
- Antalgic gait
- shortened stance phase (time on ground) due to pain - Trendelenburg gait / test
- weakness of hip abductors (Gluteus medius)
- hold the patient from front (kneel + hold both ASIS) —> single leg stance (testing side) —> drop of pelvis in contralateral side + truncal shift towards ipsilateral side (to compensate for drop of pelvis) + pushing down examiner’s arm by patient on ipsilateral side to maintain balance - Short limb gait (Leg length discrepancy)
- level of shoulder (dipping)
- level of pelvis (dropping)
- level of knee
- ***compensatory movements of lower limbs
—> Longer limb: “steppage” (hip + knee flexion), circumduction (to clear leg from ground in swing phase)
—> Shorter limb: knee extension, “tip-toeing” (ankle plantar flexion)
P/E of Knee
Look:
1. Scar (make sure observe all angles (including **back of knee))
2. Mass: Popliteal cyst, Dislocated patella, Bone / Soft tissue tumour etc.
3. Muscle wasting: **Quadriceps, Gluteus, Hamstring (by disuse atrophy e.g. arthritis) —> measure girth of thigh
4. Position / Deformity: Flexion contracture, **Varus / Valgus
5. **Gait
- Antalgic gait
- Short limb gait
(X Trendelenburg gait)
Feel:
1. Tenderness
2. Mass
Move:
1. Extensor + Flexion (Active vs Passive)
- Difference between active extension + passive extension —> Extensor lag (indicate Quadriceps weakness)
- Active extension cannot be corrected by passive extension —> Flexion contracture
Special tests:
1. Effusion
- **Fluid shift test (mild) (squeeze all fluid out —> replace back —> note any bulging of parapatellar gutter (luet上去, luet翻落黎))
- **Patella tap test (moderate) (squeeze all fluid from suprapatellar pouch into patellofemoral joint —> floating sensation of patellar against anterior femoral condyle)
- Fluctuance test (gross) (press down on either side of patella —> feel bouncing of fluid underneath)
- ACL + PCL laxity
- **Lachman test
- **Drawer’s test
- **Pivot shift test (ACL deficiency)
—> fully extend knee —> **internally rotate tibia —> **valgus force on knee —> **flex knee gradually —> patella jumping - Collateral ligaments
- **Valgus stress test (MCL)
- **Varus stress test (LCL)
—> fully extend knee + slightly flex knee (10-20o) (relax posterior joint capsule) - Meniscus injury (***McMurray test)
Palpation of knee
3 compartments:
1. **Medial tibiofemoral joint
2. **Lateral tibiofemoral joint
3. ***Patellofemoral joint
Palpate sequence:
- Tibial tuberosity / Patellar tendon
—> **Medial tibiofemoral joint (medial tibial plateau + medial femoral condyle)
—> Medial side of **Patellofemoral joint
—> ***MCL (Medial femoral epicondyle down to Medial tibial plateau / anteriorly to Proximal anterior tibia)
—> back to Tibial tuberosity / Patellar tendon
—> **Lateral tibiofemoral joint (lateral tibial plateau + lateral femoral condyle)
—> Lateral side of **Patellofemoral joint
—> **Fibula head
—> **LCL (Lateral femoral epicondyle to Fibula head)
(—> ***Gerdy’s tubercle (lateral tubercle of tibia, where iliotibial tract inserts, peroneal nerve runs near to it (fracture —> foot drop))
ROM of knee
Normal extension of knee: 0o (some people can hyperextend knee beyond 0o)
- Extensor lag
- Extension deficit that can be corrected passively (i.e. passive extension > active extension)
- Indicate underlying quadriceps weakness - Flexion contracture
- Fixed flexion deformity that cannot be corrected passively
Lachman test
CANNOT tell ACL / PCL deficiency (only know there is AP laxity)
One hand grip thigh (not move), One hand grip proximal tibia
—> flex knee 10-20o (to relax posterior joint capsule)
—> rock tibia anteriorly + posteriorly against femur
(From SpC O/T: Most sensitive but not specific vs Pivot shift test: Most specific)
Drawer’s test
Differentiate ACL vs PCL deficiency
Flex both knee 90o
—> Observe from side of table / Hold both ankles up —> PCL deficiency: posterior sagging of tibia (normally tibial tuberosity should be anterior to patella)
(From SpC O/T: Always do posterior sagging first to exclude PCL deficiency before doing Anterior drawer’s test, tibia returning from posteriorly translated position to neutral position will give rise to false impression that there is anterior translation)
—> Sit on patient’s feet
—> grab proximal tibia with both hands, thumbs on both sides of tibial tuberosity, index fingers feeling ***hamstring tendon (if hamstring tense / contracted by patient —> mask AP laxity)
—> Anterior drawer’s test: Pull knee (asymptomatic side first (get a feel of normal laxity)) —> ACL deficiency: anterior displacement of tibia
—> Posterior drawer’s test: Push knee —> PCL deficiency: posterior displacement of tibia
MBBS level: 90% exam on ligamentous laxity is ACL deficiency
McMurray test
- Flex knee (one hand grab knee: thumb on lateral knee joint line, index finger on medial knee joint line + other hand grab ankle)
—> **external (posterior medial meniscus) + **internal rotation (posterior lateral meniscus) of tibia (grind meniscus against femoral condyle)
—> Clung / Pain: +ve - Externally / Internally rotate tibia
—> **valgus stress on knee (grinding **lateral meniscus between lateral tibia plateau and lateral femoral condyle)
—> **varus stress on knee (grinding **medial meniscus between medial tibia plateau and medial femoral condyle)
—> Clung / Pain: +ve - Slowly extend knee (when tibia is externally rotated + in valgus + flexed)
—> test **posterior (when flexed) + **anterior meniscus (when extended)
—> Clung / Pain: +ve
