O&T - Upper and Lower limb

Question 1

Define measurement for apparent and true leg lengths

Answer 1

Apparent leg length: Umbilicus to medial malleolus (can be skewed by bad posture, deformity)

True leg length: ASIS to medial malleolus
Make sure the pelvis is square

Question 2

Test for true leg length measurement?

Follow-up test for femur shortness?

Answer 2

Galeazzi Test

• Hip flex 45, Knee flex 90
• Inspection for tibia length and femur length

Bryant’s triangle test
- Measure distances between ASIS, Greater trochanter and junction of 2 perpendiculars

Question 3

Define test for flexion contracture at hip.

Procedure

Answer 3

Thomas test

1) Place hand under lumbar spine space
2) Flex hip until lumbar lordosis is obliterated
3) Increase hip flexion and maintain, inspect for flexion contracture of opposite knee
4) Press on opposite knee to eliminate flexion contracture: Cannot eliminate = FIXED FLEXION CONTRACTURE

Question 4

Define positive Trendelenburg sign

Answer 4

Drop of pelvis when lifting leg opposite to weak gluteus medius (hip abductor weakness)

e. g. left sided Trendelenburg gait:
- Abductor weakness on left causes right side pelvic drop
- Compensate by leaning to the left during mid- stance so leg can clear ground

Question 5

Scars lateral or midline to patella.

Causes?

Answer 5

Lateral = Arthroscopy knee surgery 
Midline = Knee joint replacement surgery

Question 6

2 leg curvature deformities in OA.

Which is more prevalent?

Answer 6

Genu varus (bow leg) - 90%
Genu valgus (knock-knee) - 10%

Question 7

3 indications for patella tap

Answer 7

Test for knee effusion:

• Hemarthrosis from ACL injury
• Infective and septic knee joint
• Chronic infection exacerbated by OA

Question 8

Procedure for patella tap test

Answer 8

1) Slide hand down thigh, push down over the suprapatellar pouch, force effusion behind the patella
2) Exert firm pressure at upper pole of patella
3) Use index and middle finger of the other hand to push patella down
4) POSITIVE = Bouncing of patella

Question 9

Progression of knee OA pain? Which location affected first?

Answer 9

Pain at medial joint line first
» Pain at lateral joint line
» Patella-femoral compartment pain last

Question 10

2 tests for patella effusion

Answer 10

Bulge test

Patella tap/ ballottement test

Question 11

Describe knee bulge test

Answer 11

1) Using 2 finger to mild down fluid from above the knee and maintain pressure
2) Use other hand to empty medial compartment of fluid
3) Then stroke the contralateral side

4) Observe any bulging of medial knee
Bulging = positive for effusion

Question 12

Causes of fixed flexion contracture at knee?

Answer 12

• Osteophyte cause mechanical block
• Hamstring muscle injury/ contracture
• Prolonged inactivity

Question 13

Test for knee integrity/ ACL injury?

Procedure?

Answer 13

Anterior Drawer Test

1) Hip flex 45, Knee flex 90
2) Index fingers on hamstring, thumb on patella
3) Pull tibia towards you
3) Feel end-point of tugging of ACL

POSITIVE TEST = large anterior movement of tibia with no resistance = ACL injury/ subluxation

Question 14

Test for PCL injury?

Answer 14

1) Alignment of patella and tibial tuberosity
Normal = Tibial tuberosity is in front of patella edge
Abnormal = Tibial tuberosity is level or behind patella edge

2) Posterior drawer test
Same technique as Anterior drawer test but push tibia away form you
Normal: Step-off between medial femoral condyle and medial tibial plateau is maintained

Question 15

Test for meniscal tears?

Answer 15

McMurray Test

1) Flex knee, Internally and externally rotate tibia on femur, check movement
2) Externally rotate leg, place valgus stress on knee
3) Slowly extend the knee

POSITIVE = Click sound when extending externally rotated and valgus leg = torn medial meniscus

Question 16

Difference between flexion contracture and extensor lag

Answer 16

Flexion contracture = deformity that cannot be corrected passively

Extensor lag = Extension deficit that can be corrected passively = quadricep weakness

Question 17

Symptoms of limb length discrepancy

Answer 17

Long limb: Steppage (hip and knee flexion) + Circumduction

Short limb: Knee extension + tiptoeing/ ankle plantarflexion

Question 18

Dermatomes and myotomes

Answer 18

Refer to diagrams in lectures

Question 19

Nerve palsies

Answer 19

Refer to MSS lectures

Question 20

Pain on loading, relieved by rest
Joint stiffness
Deformity
Swelling

Most likely MSS condition?

Answer 20

OA

Question 21

Pain at base of thumb 
Occurs with gripping and pinching 
Clicking sound with certain movement 
Swan neck deformity 
Tender over volar and radial aspect of thumb base 

Most likely MSS condition?
Further investigation?

Answer 21

Carpometacarpal joint arthritis

Grinding sign positive

Question 22

Pain on shoulder when arm is abducted past 90 degrees

Most likely MSS condition?

Answer 22

Impingement syndrome

Greater tuberosity of humerus compresses rotator cuff against acromion, causing pain and limited ROM

Question 23

2 tests for Shoulder Impingement syndrome?

Answer 23

Hawkin’s and Neer’s test

Question 24

Insidious onset, decreasing active and passive ROM of shoulder
Pain and tenderness at rotator cuff
Stiff fingers

Most likely MSS condition?

Answer 24

Frozen shoulder

Question 25

Pain when lifting objects with palm facing down

Most likely MSS condition?

Answer 25

Tennis elbow: Lateral epicondylitis

Question 26

Pain when lifting objects with grip perpendicular to ground

Most likely MSS condition?

Answer 26

Golder’s elbow: medial epicondylitis

Question 27

D/dx of medial or lateral epicondylitis

Answer 27

Fracture 
Osteoarthritis 
Radial nerve impingement 
Elbow joint synovitis 
Triceps tendonitis

Question 28

Chronic/ sudden swelling of elbow
Sizeable mass at tip of ulna
Tenderness upon palpation
Pain

Most likely MSS condition?
D/dx?

Answer 28

Olecranon bursitis

D/dx:

• Gout
• Rheumatoid arthritis
• Synovial cyst of elbow joint
• Fracture

Question 29

Isolated pain upon extension and abduction of thumb against resistance
Local tenderness at radial styloid
No pain on wrist movement

Most likely MSS condition?
Further test to confirm?

Answer 29

De Quervain’s disease

Finkelstein test: Place patient’s thumb into hand, hold finger, Ulnar deviate the wrist

Question 30

Burning, tingling, or itching numbness in palm and thumb, index and middle fingers

Weakness in your hand and trouble holding things
Shock-like feelings that move into your fingers
Tingling that moves up into your arm

Most likely MSS condition?

Answer 30

Carpal tunnel syndrome, compression of median nerve

Question 31

Finger stiffness, particularly in the morning

A popping or clicking sensation as you move your finger

Tenderness or a bump (nodule) in the palm at the base of the affected finger

Finger catching or locking in a bent position, which suddenly pops straight

Finger locked in a bent position, which you are unable to straighten

Most likely MSS condition?
Treatment?

Answer 31

Trigger finger
Prolonged irritation of the tendon sheath

Steroid injection