Alternative to the Thomas test N. I f your uppet bow and proximal forearm O d - the Fig. Now wi th your other h, nd and forearm.
However, it can only be done in patients who can stand without much discomfort, despite hip pathology. I cm, 1. Palpate and note the level of both the ASlS. Confirm that both the ASfS are in the same hori zontal plane by placing a mea uring tape j oining both. When the extended hip is rotated there is spasmodic contraction of muscles around the hip joint and abdominal muscles.
This indicates active disease. May be found in TB Hip. Other Tests for supratrochanteric shortening 1 For bi lateral supratroc? Here N elaton'. Also note that when there i s bil ateral supratrochant ri c hortening, both the line. I I N 11 ther line jorning the tip '- or both t 1c reale r Lr c 1a nt cr. The examiner rotate the hip medially and laterally by holding the leg with one hand while palpating the trochanter with the other hand fig.
The angle made with the ve11ical and the long axis of the tibia is the femoral an tever ion see fig. Test for psoas abscess.. Patient presenting with groin pam and h, story O ig. Lastly drop perpendiculars joining ,. Only test which does not involve a pathological ipsilateral hip, which may give false positive result. Standing on the "affected' side of the patient place one hand on the opposite ASIS and iliac crest, and the opposite hand on the medial aspect of the flexed knee see fig.
Repeat the procedure for the opposite limb standing on the opposite side. Pain and I or restriction of downward motion of the flexed knee suggests SI pathology. The patient will complain of pain in lower back region when there is a sacro iliac pathology. Now maximally flex the hip and knee of the normal side with one hand and with your other hand apply a extension force on the affected sides thigh.
The patient will complain of pain in sacrollllac pathology. This pro- duces pain on the affected side SI joint. It is similar to the femoral nerve stretch test.
GAIT Gai t i the pnrticular manner or tyle of walking incl uding rhythm, cadence and speed. It involve a cyclic lo. B C Fig. If hortening i due to infratrochante1ic cause then opposite side hemipelvis will rise in stance pha e. The shoulder swings and lurches downward on the affected side, and the opposite side hemipelvi sags down when bearing weight.
In normal gait, cad nee i about 11 5 steps per minute. It is about 80 metre per minute in a normal gait. In a normal gait, the ri ght tep length i. Weight of a si ngle lower hmb ts a m.
Legg, Calve and Perthes had described this disease independently in Pathology May be divided into 3 stages. Thus it ap- pears thicker - which 1s seen 1n X-ray as larger joint space of hip Fig. Revascularization, repair reossification : This leads to - a Appositional new bone deposition on the avascular trabeculae.
This is visualized in X-rays as increased den- sity of the femoral head or epiphyses. Cystic changes of the metaphyses is also seen due to sprouting metaphyseal vessels.
Some dead trabe- culae are resorbed and replaced by fibrous tissue which in X-rays show as fragmen- tation. Distortion and remodelling : The ultimate fate , and thu. Your case? When present. Rarely knee pain may be a c. Trendelenburg si gn 1s pos1t1ve. So my provi- sional diagnosis is Perthes disease. So beware. So, in this case be sure to first examine, confirm and record the main points i.
Wasting: Must be measured in comparison to the other side. Anterior hip point : Location ; look at the face of patient while palpating for tenderness to note painful grimace. Roll-test : To note muscle spasm [Or gently abduct the affected sides thigh and palpate the adductor to note taut adductor muscles.
Thomas test : For fixed flexion deformity. Demonstrate abduction and internal rotation : In both extension and flexion of hip. If there is fixed adduction de m1ty interpretation of the result will be erroneous How will you manage the case? X-ray : - Pelvis with both hips : AP for comparison with other hip. Lateral view of the affected hip. MRI of hip is very useful for early de- tection of subluxation of the femora l he ad. It is a lso useful to show is- chaemia , articular cartilage status , ef- fusion , infarction, revascu lri zation.
Tc 99 bone scan : Shows decreased upt a k e , especially at the anter o - supero-lateral area of the head. See page Useful for early detection of ischaernia. What are the differential diagnosis? Transient non-specific synovitis Irritable hip - common after viral or subclinical infec- tions : Bone scan will differentiate.
Early TB Hip : Here all movements are restricted , especial ly at the extreme last part of the movement arc. Also ESR is increased. Mantoux test is often very high and rare ly normal. Low grade septic arthritis: Will have fever and other systemic features with high count in TLC , and increased polymorphs and very high ESR.
Monoarticular juvenile rheumatoid arthritis. Rarely Sickle-cell anaemia, Cretinism, Gaucher's disease. What are the principles of management of Perthes Disease? Universally acceptable guidelines for treatment is not available.
More or less acceptable and a logical protocol is based on the principle to ensure that, when the disease is completely healed the femoral head is spherical, so as to prevent secondary degenerative arthritis of the hip in adult life. For others regular 3 monthly follow-up with x-rays is. Containment may be consided if the femoral 1 head can be contained without hinged abduction.
For hinged abduction do valgus osteotomy. Containment can be done i Conservatively by - a Broomstick plaster. Ce vic. What will you suggest for this case? Varus subtrochanteric derotation oste O t. G , subluxa. What are the cli11irnl H ead-at-Ri!. Female ex 5 2- When the patient is obese, overweight.
When the patient' age is on the higher ide. I life. Wort ror Caterall lV , best for Caterall L. Type I Lat. Type II Lat. Type Ill Lat. Small lateral viable part with head-within-head sign , and metaphyseal changes resulting in the broadening of neck.
Type Ill 4. Type IV Lat. Epiphyses dense,. AP sclerotic , flattened. Group A has the best prognosis, group B the worst. Class I- Normal hip join! What; s S s ectoraJ sign? F l 22 which represents the distal margin of metaphys1s that 1s rarefied ig. Note - Lateral subluxation of head. What is Gearstick sign? Wh e n th is occurs observed that , when the hip is in exten sion , hip abduction is limited by impi nge m ent b etween the greater trochanter and the ilium , but wh en the hip is fl exed there is full abduc tion b ecause th e greater trochanter moves posteriorly.
Trochanteric advancement ope ration is indica te d he re. What is the role of arthrodiatasis in Perthes disease? It is a new method of treatment of Perthes disease which means arti c ul ate d distraction.
The advantages of distra xin,BI that it does not change th e anatomy of the pr? It produces abduction of the pathological hip thus ensuring better containment. Sometimes, without investiga- tion reports , even the exam iners can be unsure about the correct diagnosis.
Aetiology Starting point Fig. Acetabular roof. Metaphyseal region Babcock's triangle. Greater trochanter. Synovial membrane Rarely. Of the femoral head and acetabulum takes place. All moveme. Part due to muscle spasm. FIAdl r. Resu ting 1n wan ermg acetabulum. E mpl : Rabi Barik. Y , of lower soc1. On e amination the patient has antalgic gait. There is wasting of the thigh muscles and the affected lower limb has the attitude of flexion , adduction and internal rotation.
Antenor hip point is tender sometimes bi-trochanteric compression test is also positive. The adductor muscles are in spasm. There is fixed flexion deformity of There is supratrochanteric true shortening of T rendelenburg's sign positive. What are the points in favour of your diagnosis? From history : say only the positives. From examination : a Typical attitude of flexion-adduction- internal rotation.
Radiological stage Ill. When awake , the periarticular muscles are in spasm Th. P may e found. Femoral triangle; posterior m d. Iea st resistence. Affected h. Chest : PA view. Synovial biopsy may be confirmatory. Perthes disease , sub-acute septic arthritis, transient synovitis AVN of femoral head, juvenile rheumatoid arthritis monoarticular variety , traumatic cause like central dislocation of hip.
How will you treat the case? DOTS programme is being used in several centres in India, see page Traction of the affected limb is given to - 1.
Correct the deformity. Counter muscle spasm. Ensure forced bedrest. After about 3 to 4 weeks , when pain has subsided , hip mobilization exercises a re started Within the ongoing traction. After 4 to 6 months , patient may be allowed to walk w ith weight relieving callipers.
Unprotected weight bearing may be allowed after 9 to 12 months. They are. Ab-Extern al rotation posture by the pat! If the ,cc. A lso sec Page Arthroplasty i. Mu t be ure thal the pati ent i. Many urgeon's prefer to w ait for yea r , w hile.
What is the position of hip in which arthrodesis is done '? If th ere is ava c ul ar necrosi s of the head, i t mig ht appea r im i - lar to Perthes disease in X- ra ys.
O ccas ion- ally there may be Coxa Breva small -s i zed femoral hea d , mortar - and-pestle ac - Fig. Note - Coxa magna. What is the usual outcom e of tubercular arthdtis? Fibrous ankylosis B ony ankylo is is the outcome of untreated septi c arthritis. However , in caries spine u ually bony ankyl osis happen. Intra articular - e. Cobra pl ate arthrode i. Extra articular - e. B rittain's i schio-femora l arthrodesi , Albee's ilia-femoral arthrodes is.
In what conditions arthrodesis is contraindicated? When the contralateral hip, lumbar spine and ipsilateral knee i deranged. When there is acti ve infection. It i s better to wai t for al least 6- 12 month after disease healing. Always done after sk eletal maturity.
What can you do? In non-union fracture neck of femur , commonly there is absorption of the femora l neck, usually seen 1n I. Other risk factors for fracture neck femur : Alcoholism , diabetes , osteomalacia, cystic- tumors like GCT in the femoral neck, stroke due to disuse and post-radiation therapy. Occasionally it is a blow to the greater trochanter or sudden extreme external rotation of thf: limb. However, in young people more se- vere injury or trauma is often the cause, because there is no weakening of bone due to osteoporosis.
What is your diagnosis? Example : Mrs. Since then she has been bedridden and unable the nee weight. The attitude is of fl exion, sia t' on and external rotation of the limb, and there 1s wasting of the th igh and gluteal muscles. Note : Expect interruptions, questions and be ready to demonstrate the following - 1. Nutrition and wasting - don't forget obesity is also malnourishment. Tenderness - don't forget to look at patient's face, while demonstrating tenderness.
Indirect 3. All movements and all measurements including Bryant's triangle. What are the probable reasons for non- union of fracture neck of femur? In displaced fractures, vascularity is compromised. Know everything about the detailed blood supply to head and neck of femur.
See Fig. Synovial fluid prevents clotting of fracture haematoma , which is th e initial step of any fracture healing. See page There is tamponade effect within the. Shearing force acting across the fracture line tends to displace the fracture. How will you confirm your diagnosis? How can you classify neck femur fractures?
Anatomical classification Fig. S The higher the angle , poorer the prognosis. What are the complications of this fracture? Avascular necrosis of the femoral head, Type II and early secondary osteoarthritis. Type I Type Ill 3. Since physiological age of the patient is more than 65 years and the patient has a sedentary lifestyele with functi onal requirements of only activities of daily living AOL , and it is also an old displaced fracture , I would plan a hemiarthroplasty operation with Bipolar prosthesis.
When there i o. Some Old physwlog1cal age above 60 to 65 yea1s , but leading a sedentary life tyle, pe rforming only Produces shorte ning.
What is Singh 's index? Singh's index is usefull to asses osteoporosis by noting the trabeculae in proximal femur, seen in AP view X-rays. Primary Secondary A. Idiopathic A. Endocrinal Hyperparathyroidism, Hy.
Drug : Steroids, Anticonvulsant etc. Others eg. At around 4th decade 01 life, osteoclastic activity starts increasing with resultant bone loss of about 1? So there is constant decrease of the peak bone mass which was achieved in I e Pt 3rd decade, which is further accelerated in females after menopause. Therefore, commonly malunitedtrochanteric fractures are given as a long case. In the young , road accidents or other such severe high-velocity trauma is the cause. When lesser trochanter is fractured and displaced, the frac- ture becomes inherently unstable and difficult to manage.
So examine, and if you say, be ready to demonstrate. What is your case? What is the summary of the case? Bijonbala Das , 70 year old female patient, had a fall She has been bedridden since then and taken s0 d Fig. So my provisional di -. Normal Name some causes of coxa vara. Congenital coxa vara. Acquired : a Sequele of Perthes disease. Coxa vara Coxa valga h Paget's disease. What do you mean by coxa vara?
How would you manage this case? Then considering her age of 70 years, and the complain of groin and back pain, I would Fig. Note - Coxa Vara. If even after that the patient 15 dissatisfied , then a corrective subtrochanteric valgus osteotomy may be considered. Operative fixation with dynamic hiP,. Traction H wever, 1 0 there is minimal or no coxa vara. Since th e hip joint is inh erently very stab le , viol ent injuries like road traffic accidents are needed to dislocate a hip.
Urgent and immediate treatment is required for acute hip dislocation because the complica- tion rate increases with the time elapsed since injury. It is an emergency. Other varieties include anterior dislocation see fig. Majority of dislocations are associated with fracture of the rim of acetabulum. These cases are then called fracture dislocations. Sometimes the injury is missed, especially when there are other associated injuries, like fracture shaft of femur, or the patient is unconscious.
So , X-ray of pelvis with both hips should be done in all cases of fracture shaft femur and vice versa. Common mechanism of injury for posterior dislocation is , when after a collision the person s in the front seat of a car is thrown against the dashboard dashboard in- jury where the knee strikes with the hip and knee in flexed position , and there- fore the femoral head dislocates posteriorly.
What ts t e summ. Shahid Jabil , 2 year O. Don g limb Subsequently he was attended by t? After about. On examination, T here is true supra-trochanteric short- e ning of 4 cm.
Trendelenburg sign is positive if the pa- tient can s tand and b ear we ight on the left lower limb. So my provisional diagnosis is this is a case of neglected , untreated, posterior dis- location of left hip of 4 months duration.
This may be a chief complain. It happens due to sciatic nerve injury during initial trauma. A neuro- logical examination should always be done in- cluding power, reflex , sensation of both lower limbs, and sciatic nerve palsy must be in- cluded in your diagnosis when found. What are the complications of hip dislo- cation? Early complications - 1. Sciatic nerve palsy : Usually neuropraxia. It is an Note - Adduction deformity.
Irreducible dislocation : By closed manipulation. This happens when there is an associated fracture of the acetabulum and the bone fragment impedes reduction. Late complications - 1. Avascular necrosis of femoral head : Incidence increases with each hour of delay in reduction, so hip dislocation is an emergency.
Generally, clinical features of AVN appear after 1 to 2 years. Myositis ossifications : Uncommon. Osteoarthritis : Of the hip. MR I to note AVN 1h0n put the patient in heavy skeletal traction in abduction for 3 to 4 weeks w ith se rial portable X-rays to note the descent of femoral head. Then there is no question of examining gait or examination in standing or sitting posture. But it is always better to start by mentioning gait.
Inspection 1. Shape, symmetry, transverse furrows. Direct - over spinous process. Rotatory - twist side of spinous process. Indicates early anterior pathology 3. Thrust - gentle thumping.
Kibler test : pinched skin ove r the paraspinal muscles will be less mobile when moved longitudinally. Movements, measurements are of academic interest and will be discussed later, but you must measure wasting.
Normally the finger-to-floor distance is 7 cm or less Fig. Request the patient to bend forward and note the increase in distance between the above points. Normally it is 3 cm or more. Then request the patient to bend forward with extended knees and note the change in the distance. Normally it is 5 cm or more. Note the angle which is formed with the vertical axis. In facet joint arthropathy it may be painful and restricted [Fig.
Standing behind the patient and looking from above note tha angle between the plane of pelvis and a imaginary line joining the shoulders. Neurological examination done mainly with the patient in supine position 1.
Higher functions : Consciousness , alertness , orientation , speech. Hypotonia occurs in lower motor neurone lesions, cerebellar disease, tabes dorsalis and sensory neuropathies. Difficult to appreciate in obese 7 It 1s also important to detect whether a patient has come out of spinal shock.
For finger tips about 2mm separation and for pulp of toes about 1cm of separation can be recognised. In cervical cord compression, passive flexion and extension of neck sometime produce electric shock like feelings of the extremities. Stabilize the pelvis with one hand and hold the leg with flexed knee with your other hand.
Now extend the hip. If there is femoral nerve rool. Stop further movement when the patient complains of pain and note the angle between the leg and the horizontal. Scanned by CamScanner If pain. Exaggerated deep tendon reflex. Surroun ,ng osis of the subcutaneous tissue that may extend wade 3. Extremely difficult to ea.
Most c ommon si te s are the lungs and lymph nodes and then comes skeletal or osteoarticular TB. Sometimes caries spine is also called tuberculous spondylitis. In the spine, infection sometimes passes via the Batson's venous plexus. So in TB, involvement of the adjacent joint occurs rapidly. Septic arthritis resulting from pyogenic osteomyelitis is less common. This is due to destruction of the vertebral end-plates. Initial focus in spine after haematogenous spread is at four sites Fig.
Pedicle, transverse pro; cess, lamina, spinous process. Th 95 are rare. A s infection spreads there is hype ine. Cold abscess m ay also present as a psoas abscess see page and page What is your diagnosis? What is Fig. Note - Loss of disc space. Example : Mr. He found ditticulty in wearing shoes and then walking with any slipper type of footwear and later climbing stairs. He had been suffering from back pain, which was more severe at night, tor the last 4 months.
On enquiring , he gave history of con- Slncting girdle-type sensation near the groin level and that, initially he had pain radiating to both lower limbs, which increased with coughing , sneezing and jolting.
Active move ess over e O9 ver. Or What i th dlff r nc b rw 11 1, pl , eJcte. In extension t e - The lower limb has attitude of hip and kn Plantar fl. It involves both the pyramid 1 trapyramrdal tracts, and occurs late ,n the course of the disease. When bufbocave,nosus ,efle and anal reflex are present, it indicates intact sa.
It 1s called reflex or automatic bladder. When these re. Cold abscess is a non-pyogenrc abscess formed due to tuberculo us infection, and consists of tubercular debns , caseous matenal , serum , WBC's and occasional TB bacilli.
Since there is no 'rubor', 'dolor', 'color' and other signs of inflammation of pyogenic infection so-called "hot abscess " rt is called cold abscess. Where ould you search for cold abscess in a patient of TB spine? I would search in the paravertebral areas, lumbar "Petit's triangle", iliac fossae , femoral triangle, buttocks , thighs and the popliteal fossa. Besides it may cause psoas abscess, if the lesion is at, or below T 12 level.
If the lesion is in upper thoracic or cervical verte- brae, then neck, axilla , retropharyngeal space, anterior and lateral chest walls should also be searched. What is called early onset paraplegia and Fig.
What is tebral area. Seddon 's classification? Appears within the first 2 years of 1. Usually due to compression from in- 2. Usually due to sequestrum, internal flammatory oedema , TB granulation gibbus, spinal canal stenosis, vertebral tissue, caseous material, cold ab - deformity.
Prognosis is better. During healing, what 15 e order of recovery? M otor f unctions. I s ciurnsY are affected f,rst, and the first symptoms are twrtchrng of muse e , is gait, bris k jerks with extensor plantar response , ankle and knee clonus. Then sensory affected. Joint position sense and vibration sense is last to be affected. E xte nsor plantar response takes pos, ion. First there is.
What are the types of gibbus? How is gibbus formed? Common is external gibbus which is of 3 types. Knuckle gibbus : One spin ous process is prominent on palpation because one verte- bra co ll apses e. Angular gib bus : 2 o r 3 vertebrae involved e. Round gibbus : 3 o r more vertebrae involved e. Internal gibbus : Rare variety. Seen in late onset TB paraplegia. What are the landmarks of spinous process palpation? How do you establish the exact level of the palpated spinous process clinically?
C1 - Most prom inent spinous process at the base of the neck. D1 - Level of the inferi or angle of scapula. Li - Level of the highest point of iliac crest. S2 - Level of the posterior superior iliac spine dimple of venus [Fig. Disc spaces are usua y. I s11y an d controversra. Not routinely don e. X-ray : X-ray of spine, centering the sus- pected affected area known by tender- ness, girdle-sensation, motor-level, etc.
Look for : a In Lateral view - Inter verte- bral disc space decrease, or even fusion of adjascent vertebrae Fig. MRI : Costly Is the investigation of choice, as it shows cord compression, canal steno- sis, cold abscess, condition of disc and bone, etc. Cold abscess if present, should be drained after 3 weeks of chemotherapy, by aspiration and instillation of streptomycin. Besides this, care of the bladder and pressure sore has to be taken.
What are the areas where bedsores can occur? Sacrum, ischial tuberosities, scapula , occiput, greater-trochanter, heel, lateral and medial malleoli of ankle, olecranon, and over tibial and femoral condyles lateral and medial. How would you take care of the bladder function? Persistent in-dwelling catheter should be discouraged as it leads to infection.
If patient has incontinence, condom catheter is used. From below upwards Ll -- All sacral and coccygeal segment.
T11 -- L4 and L3 segment. T1o-- L2 and L1 segment. Tg -- T How will you clinically diagnose it? From a ny vertebrae T, to L. For c lin ica l di agnos is see page How will Jou tak e care of pressure sores? First en ure that the bed sheet ne not crumpled and has n o w rinkl es. The patient s hould always avoid pressure on bony promi - andnces for Io ng periods,. W a ter- bed, or ai r-cushion mattress, 1f thick.
A s for th e existent sore, s lou g h. This happe ns more c. He nce incrc:. Can be a rrested w ith o pe rauve spin al fusion. U Mild - Patient aware. Paralysi in extension. Stage Clinico-radiological features Usual duration.
Severe kyphos Humpback. IV, V - diagnosis is clear on conventional X-ray. CT scan and MRI would show advanced changes , however, these are unnecessary except for difficult sites Kumar, When the patient is unable to stand, squat, or walk, inform the examiner beforehand.
Then comment on any scar, sinus, skin condition, ulceration or venous prominence. Liga- ments may be stretched also due to chronic synov1t1s e. In PPRP fixed equinus deformity is usually associated. Recurvatum of knee in moderate degrees is actually helpful, because it stabilizes the knee which has weak quadriceps i.
Finally, standing behind the patient, note, compare and comment on any swelling see ;, page , scar, sinus, skin condition , ulceration , or venous prominence. Look for any abnormal prominence at the hamstring insertion i. Finally request the patient to stand up and then enquire about any pain during squatting or getting up may be osteoarthritis , see page Note and mention , that ability to squat normally, with both lower limbs symmetrical, which indicates full range of knee flexion.
Next, in the swing phase note, compare and comment on the free-swing of the leg, or the absence of it may be due to patella-femoral pain. Finally in the stance phase, observe and comment on whether there is full knee extension or any hyperextension , and whether the knee "buckles" due to instability.
Then slide the back of your fingers downwards from the thigh , over the knee and onto the legs of both the lower limbs to note, compare and comment on the "temperature gradient". Normally the tem- perature decreases from superior to inferior. Next palpate the fibular head for biceps femoris insertional tendinopathy, or injury to the superior tibio- fibular ligament.
Then palpate the patella tenderness Fig 1. Don't forget to look at the patient's face. Finally note retropatellar tenderness, found in retropatellar cartilage damage by the following 3 tests. Then ask the patient to contract or "tense" the quadriceps. This will cause pain. When the patient complains of pain during the procedure, the test is positive at that angle s of flexi on.
Don't Fig 1. Then with your other hand , glide the patella in the intercondylar groove from medial to lateral and then from superior to inferior. Look at the patient's face and note tenderness. Fig 1. Then an t e knee extended, push the retropatellar facet see fig 1. Th is shou ld be th e medial joint line, so mark it. Confirm by passively flexing and extending the kn ee wh ile palpating the joint lin e.
Repeat the procedure along the antero-lateral surface to find the lateral joint line, and mark it. Then using th e pulps of your thumbs , palpate circumferencially along the joint line, from anterior to posterior. Remember th at synovial thickening may also be palpated over the insertion of vastus medialis , which feels "boggy" or "doughy" see page Bulge test : It can be done with the patient standing , with the knee extended.
Place your thumb and index finger on th e medial and lateral parapatellar fossae, and firmly compress the medial fossa so as to empty it. Then sharply press the lateral parapatellar fosa. The medial fossa will refill with a "ri pple" see fig 1. Patellar Holl ow test : Normally, when the knee is grad ually flexed , a hollow appears , and then disappears just latera l to the patellar ten- don.
In the presence of intraarticular fluid , when compared to the opposite knee , the refilling of the hollow, occu rs at a lesser angle of flexion. Patellar Tap : With the knee extended , compress the suprapatellar bulge with your thumb and other fingers placed on both sides so as to empty it, and push the fluid down- wards under the patella. Now, with the tip of the index and middle finger of your other hand , sharply tap the centre of the patella see fig.
This demonstrates a positive patellar tap test. This test is ineffective when there is excessive fluid causing "tight and tensed" swelling. Cross Fluctuation : Cannot be done in very tense effusion. Now alternatively squeeze the suprapatellar bulge and the infrapatellar fossae to feel the transmitted "fluid impulse" across the joint see fig 1.
Anterior soft tissue swellings may be prepatellar bursa see page infrapatel lar bursa see page , or suprapatellar bursa. Posteriorly they may be Morant Baker cyst see page , semimembranosus bursa see page or popliteal aneurism see page Medially they may be pes-anserine bursa always about fingers below the joint line , me- dial meniscal cyst, or a torn part of the medial meniscus.
With the knee in extension grasp the edges of patella in pincer made of thumb and middle finger and try to lift up the patella. Normally this is possible. In synovial thickening, the fingers slip-off the patella edges. The fingertips of both hands are pressed in the middle of the popliteal fossa i. It may be palpated in prone position with knee partly flexed. Full extension 1s the neutral or zero position wh en the thigh and leg are compl etely aligned.
Zero position can be noted wi th the patient supine on a. If there is a gap, apply downward pressure over the patella with one hand, while lifting up the leg a few inches from the bed with your other hand by grasping the leg just above the ankle passive - see fig.
Remember that. If full extension is im- possible even "passively" then it is fixed-flex- ion-deformity FFD. Full extension can also be examined in the sitting position , with the legs Fig 1.
Now abduct see fig. Re- peat the procedure on the other knee. Then alternatively rotate the leg medially and laterally see fig. Repeat the procedure for the opposite knee. Note, compare and com ment. Other structures that contribute to stability are the quadriceps mainly vastus media- lis , the hamstrings, the joint capsule and the medial and lateral menisci. When it happens during climbing stairs - PCL may be torn, and when it happens during climbing downstairs - ACL may be torn.
Some commonly per- formed and popular tests are described in this chapter. Lachman Test : Th is test has a very high sensitivity , but it is difficult to perform in patients who are fat or very muscular.
For muscular or fat. Look tor any subl uxation anteriorly and wh ether there is a tendency for medial rotation. When medial rotation occurs it is a positive "Lachman sign". Now repeat the procedure on the opposite knee. Anterior Drawer Test : First do the sag sign , see fig. This sta- bilizes the leg , while the weight of the patient's trunk stabilizes the thigh. Now firmly grasp the upper leg wih both your hands, keeping the thumbs anteriorly and the fingers posteriorly see fig.
Then alterntively apply force so as to "push-and-pull" the leg, and look for any subluxation. Next, repeat the test on the opposite knee. With the patient supine and leg extended, stand on the affected side of the patient. With your opposite hand grasp the ankle and medially rotate the leg see fig. Then, apply valgus stress by forcefully abducting the leg which may cause anterior subluxation and gradually start flexing the knee.
Remember reduction is due to the pull of the ilio-tibial band 1TB. Interestingly, often the patient confirms that there was the same feeling of sudden "giving-way" and later "stabilization".
Single foot hopping test : If the patient can perform single foot hopping, then op r tive ACL reconstruction may not be indicated, except for atheletes or active sportspersons. Bend low an d bnng down your eye line to. Posterior Drawer Test : Already discussed- posterior drawer sign see page Now, grasp and support the femoral condyles from below, with your hand which is towards the head of the patient. Using your opposite hand grasp the patients leg just above the ankle.
Similarly apply varus stress i. Repeat the procedure on the opposite limb , standing on the other side of the patient. So medial meniscal injury is more common than lateral meniscal injuries. Just as a positive test is not always pathognomic, a negative test does not rule out a meniscal tear. Palpation of a torn meniscus at the joint line, or tenderness at the joint line should make you suspicious. Remember, the test may also be positive in osteoarthritis of knee.
A combination of history, palpation and special tests for menisci should reasonably place meniscal injury in the list of differential diagnosis. If the patient complains of pain it suggests medial meniscal lesion. Interestingly the degree of flexion where the. When the same procedure is done to bring the knee from go 0 flexion to full extension i. Apley's Grinding Test : With the patient prone, hold the ankle and lift the leg to flex the knee to go 0 with one hand.
With one of your knee stabilize the posterior thigh by pressing onto it. Then request the patient to twist the body to one side and then to the other side, 3 times producing rotational force in the knee. If there is meniscal lesion, there will be pain at the medial or lateral joint line and a feeling of "locking". It is an use ful tes t to note the ti ghtn e s a nd th e deg ree of te ns ion of th e lateral and medial parapat e llar retin acu lum. Norma l patellar excursion is half the breadth of patell a or 1 quadrant.
With th e patien t supine. Using your L thumb and index finger gra. Repea t the procedure for th e L knee standing on the L side of the patient. Co mpari tiv ely, when exces ivc mobility is noticed, the sa me procedure is repeated with the quadriceps tensed, by requ sti ng the patient to lift the lower limb about 8"- 12" off the bed.
Excessive lateral mobility sugge t lax medial patellofemoral ligament MPFL and incompetence of the medial retinaculum v ice-versa for excessive medi al mobility , and thus increa ed risk for habitual di slocation of patella. This test is positive fo r recurrent di slocation of patella and rarely for hab itual dislocation of patella see page Offers a user-friendly reference in a compact, pocket-sized format for on-the-go consultation.
Provides unique illustrations that present clear guidance on how to perform an orthopaedic examination and treat a full range of fractures. Answers clinical questions with remarkable clarity and brevity. Includes expanded information, including coverage of additional instabilities and operative fracture treatment. Features improved illustrations to include fracture-site labeling. Foot and ankle orthopedics is the fastest developing orthopedic subspecialty in the Asia-Pacific region and the Handbook of Foot and Ankle Orthopedics is designed to be an indispensable guide for all general as well as specialist orthopedicians.
The handbook covers a wide range of topics, including the general rules of foot and ankle examination, their investigation, rationale of prescription of foot and ankle orthotics, various malunions, management of foot and ankle trauma, diagnosis, and the management of common foot and ankle infections.
It also explains the art of arthrodesis in a concise yet comprehensive manner. Its content is organized in a pointwise format, supported by algorithms, tables, illustrations and real clinical pictures for easy and quick reference by orthopedic surgeons.
The chapters are contributed by internationally-renowned authors with years of clinical experience. Salient features Comprehensive knowledge of all common and complex foot and ankle problems encountered in general orthopedic practice.
Clear goals and principles of management along with treatment solutions in keeping with the resources available in developing countries. A simple approach to diagnosis and differential diagnosis of problems. Special 'Tips and Tricks' section summarizing the important points at various places within and at the end of chapters. Author : Kenneth Egol,Kenneth J. This practical handbook covers the diagnosis and management of fractures in adults and children.
Section 1 also covers Multiple Trauma, Gunshot Wounds, pathologic and periprosthetic fractures, and orthopedic analgesia. The new edition will be in full color and will include a new chapter on the basic science of fracture healing, as well as a new section on intraoperative Imaging. Features: Bulleted format allows quick access and easy reading Consistent format for targeted reading Covers adult and pediatric fractures Covers fractures in all anatomic areas Heavily illustrated PortableIn Full color New chapter: Basic Science of Fracture Healing New Section: Intraoperative Imaging.
The text is comprehensive, updated and fully revised as per the present day requirements in the subject of orthopedics. In this edition ofbook cases on malunited distal radius fracture, intertrochanteric fracture, cut tendon injuries, carpal tunnel syndrome are included. The book has 12 chapters.
The first chapter deals with how to approach for history taking and examination in orthopaedic patient.
Chapter two and three provides a comprehensive description of examination of hip and knee joints respectively. With its unique combination of classic Netter artwork, exam photos and videos, and rigorous evidence-based approach, Netter's Orthopaedic Clinical Examination, 3rd Edition, helps you get the most clinically significant information from every orthopaedic examination.
This new edition, by Drs. Joshua Cleland, Shane Koppenhaver, and Jonathan Su, allows you to quickly review the reliability and diagnostic utility of musculoskeletal physical exams and make it easier to incorporate evidence into your clinical decision making. Extremely user-friendly and well organized, this unique text walks you through the anatomy and clinical exam, then critically reviews all literature for given diagnostic tests.
A tabular format provides quick access to test reliability and diagnostic utility, study quality, anatomy and biomechanics, and summary recommendations for applying evidence in practice. Evidence-based approach helps you focus on the effectiveness of the clinical tests available and review recent studies quickly to determine which test will best predict a specific diagnosis. The Orthopaedic Clinical Handbook is a pocket guide for students in any orthopedic course, including physicians, physical therapists and assistants, chiropractors, and athletic trainers.
This useful resource is organized in a manner that is helpful for both students and clinicians. Suggestions for evaluation, post surgical rehab protocols, and evidence-based parameters for mod. Author : Marc F. Now in vibrant full color, Manual of Orthopaedics, Eighth Edition, provides the must-know information you need to diagnose and treat musculoskeletal injuries and diseases with confidence.
This quick-reference manual has been completely updated and revised to include content particularly valuable for orthopaedic physician assistants, while retaining key information for orthopaedic residents and nurse practitioners, primary care physicians, and orthopaedic providers in all practice environments.
Author : Charles E. DeCamp,Susan L. Piermattei, Gretchen L. Flo, Charles E. Author : Joseph J. Cipriano,Warren T. Jahn,Mark E. Author : Hai V. Author : Jon C. Jon C. Thompson presents the latest data in thoroughly updated diagnostic and treatment algorithms for all conditions while preserving the popular at-a-glance table format from the previous edition.
For a fast, memorable review of orthopaedic anatomy, this is a must-have. Maintains the popular at-a-glance table format that makes finding essential information quick and convenient.
Contains useful clinical information on disorders, trauma, history, physical exam, radiology, surgical approaches, and minor procedures in every chapter.
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