-O02 LLAss09-10. Flashcards
What muscles medially rotate the hip?
Gluteus medius and minimus (anterior fibres)
Tensor fascia latae
Adductor magnus
Pectineus
What muscles laterally rotate the hip?
Gluteus maximus Quadratus femoris Sartorius Obturator internus Iliopsoas Piriformis Obturator externus Gluteus medius and minimus
What muscles flex the hip?
Iliopsoas Tensor fascia latae Pectineus Adductor longus Adductor brevis Gracilis Rectus femoris Sartorius
What muscles abduct the hip?
Gluteus medius Tensor fascia latae Gluteus maximus Gluteus minimus Piriformis Obturator internus
What muscles adduct the hip?
Adductor magnus Adductor longus Adductor brevis Gluteus maximus Gracilis Pectineus Quadratus femoris Obturator externus Semitendinosus
What muscles extend the hip?
Gluteus maximus Gluteus medius Gluteus minimus Adductor magnus Piriformis Semimembranous Semitendinosus Biceps femoris
What muscles flex the knee?
Biceps femoris Semimembranosus Semitendinosus Gracilis Sartorius Popliteus Gastrocnemius
What muscles extend the knee?
Tensor fascia latae, quadriceps femoris (rectus femoris, vastus intermedius, vastus medialis, vastus lateralis)
What muscles medially rotate the knee?
Semimembranosus Semitendinosus Gracilis Sartorius Popliteus
What muscles laterally rotate the knee?
Biceps femoris
Tensor fascia latae
What muscles plantar flex the foot?
Peroneus longus Peroneus brevis Tibialis posterior Flexor digitorum longus Ticeps surae
What muscles dorsiflex the foot?
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
What muscles evert the foot?
Peroneus longus
Peroneus brevis
Extensor digitorum longus
What muscles invert the foot?
Triceps surae Tibialis posterior Flexor hallucis longus Flexor digitorum longus Tibialis anterior
What are the principles of patient assessment?
Seek consent
Maintain patients dignity
Explain to the patient what you are doing
Ensure the patients comfort at all times
Carry out assessment in a systematic fashion
Test the uninvolved side first (if only one side involved)
Be aware if non verbal communication throughout procedure i.e. facial expressions
Double check measurements and read scales carefully
Record measurements accurately
What are the 3 steps to patient assessment?
Look
Feel
Move
What is included in the look section of the assessment?
Visual inspection of the condition of the lower limbs Skin Hair Lld Atrophy Swelling Scars Callosities Nails/toes General body alignment Upper limb condition
What should be checked about a patients skin?
Condition of skin
Any redness abrasions or lesions
Note location and size of any deformity
Watch out for shiny areas or discolouration as this may indicate an underlying problem
What does redness of the skin indicate?
Increased blood flow or inflammation
What should be assessed about a patients hair condition?
Presence of hair
Symmetry of growth on both lower legs
What could cause absent or thinner hair?
Poor circulation or nerve supply
What could lack of hair be due to?
Sock wear
May be symmetrical
Use of prosthesis or orthosis
How would you check lld?
With patient lying down observe any lld
Pelvis should be level with hips knees and ankles flat on the bed and each joint at the same level
If a patient has a true lld this may not be possible
You should therefore attempt to position each joint as level as possible
If patient cannot straighten one of the joints on the table this may be indicative of a joint contracture or spasticity
Where is true lld measured?
Asis to medial malleolus
Where is apparent lld measured?
Xyphoid process to medial malleolus
What may be observed with a patient lying supine and hips and knees flexed?
Left shortened tibia
True lld
How do you check for atrophy?
Observe the shape of the leg
In particular checking for symmetry of shape and size of both legs
Check to see if there is any obvious muscle wasting
You should expect to visually identify the main muscle groups:quadriceps femoris, hamstrings, and gastrocnemius and observe their shape and bulk
Describe how you can check for swelling?
Observe the shape of the legs
You should expect to see a normal profile
Comparison of both legs is useful
However swelling may often affect both lower legs and may suggest circulatory problems
If swelling is accompanies by redness, pain and heat this is indicative of any inflammatory response
Describe what to look for with scars?
Note the location and description of any scars
Ascertain from the patient the reason for scarring
If it is from surgery you should ask the patient the aims of the surgery and if it was successful
Recent scars tend to be red, whereas older scars are white
Take note of the amount of scarring
Excessive thickened scar tissue us referred to as hypertrophic scarring
Describe the process of checking callosities?
Observe the lower leg for any thickened, hardened skin
This is most likely to be seen on the sole of the foot but may also be seen in other areas: the dorsal surface of toes if shoes are too tight, or areas where the prosthesis or orthosis is causing excess pressure
Describe the location and size of the callosity
Describe the process of checking nails/toes?
Check the condition of the toes and nails: colour, thickness, shape and texture
Fungal infections are one of the most common problems seen: the nail may be thickened and discoloured
It may then become fragile, soft and crumbly
However remember that not every thickened discoloured nail is infected. Other reasons may be psoriais or eczema
Where else might thickened course and irregular nails be seen?
Ischaemic foot
What type of nail may suggest deficiency of oxygen to major organs- heart and lungs?
Clubbing nails which grow around the tip of fingers or toes
What should you look for with general body alignment?
In standing lying supine and sitting, observe the trunk and the major joints of the lower limb in the sagittal coronal and transverse planes
For looking at general body alignment what should be viewed in the coronal plane?
The nose, xiphoid process and umbilicus should be in a straight line
The anterior superior iliac spines should be at the same level
What should be viewed about general body alignment in the sagittal plane?
The tip of the ear, the tip of the acromion process, the high point of the iliac crest and the anterior aspect of the lateral malleolus should be in line. In the spine observe for the normal cervical and lumbar lordoses (inward curvatures) and the thoracic kyphosis (outward curvatures)
What should be looked at for general body alignment in the transverse plane?
Observe the degree of toe in or toe out
Normal toe out is between 5-18degrees measures from the line of progression
It increases as a child grows to adulthood
The patella should be facing straight ahead
If there is excessive toe in or toe out or the patella is not facing directly forward further examination is required to determine if the rotational deformity comes from one of the joints or from one of the long bones such as the femur or tibia
What is tibial torsion?
The degree of rotation of the tibia along it’s long axis
To check tibial torsion angle the patient lies prone and the patient’s knees are flexed to 90degrees
Ensuring that the subtalar joint has been placed in the neutral position, the examiner observes the angle between the line of progression and the degree of toe out
If it is greater than normal toe out this is external tibial torsion
If it is less, this is internal tibial rotation
What should be observed about upper limb condition in the look section?
A full upper limb assessment is not carried out
However the condition of the upper limb should be observed
The patient should be asked if they have problems in relation to donning and doffing a device, or footwear for example
If questioning the patient highlights any problems this may warrant further investigation and assessment
Observe for major problems such as congenital abnormalities, limb absence, fixed deformities and muscle atrophy
What should be done before commencing the feel part of the assessment?
Find out if the patient has any pain
Causing or increasing pain experienced by the patient during the assessment may result in the rapport that you have built up with the patient being lost
What is important about pain in the feel part of the assessment?
Be aware of any pain throughout assessment
If any movements or tests elicit pain you should stop doing these
Question patient with regards to nature and intensity of pain
Observe the patient for any visual signs of discomfort
What should you take note of regarding pain in the feel section?
The location
History: when did the pain begin? Did a particular activity cause the pain? Has it happened before?
A description: stabbing, burning, crushing, itching
Intensity: constant, mild, severe, moderate
Timing: at what times does the pain exist? Is it constant? What exacerbates/relieves the pain?
What may cause discomfort or pain?
Scarring
It is useful to feel if the scar is mobile and without pain, or adherent(sticks to the underlying tissues). Adherent scars are often painful.
What is included in the feel section?
Pain Sensation Swelling Temperature Capillary return Vascularity Proprioception Extremity shortening
What types of sensation are there?
Normal
Anaesthesia
Hyperthesia
What should be check about sensation in the feel section?
Using light touch you should check all areas of the leg for adequate sensation
Begin distally at the feet and then move proximally
Use a monofilament for this
Before commencing the assessment with the monofilament demonstrate its use on your hand then the patients hand
Pay particular attention to areas you may have already identified as problematic eg scarred areas that may indicate surgical intervention
However do not test over areas where there is a callus
Describe using a monofilament
The patient is instructed to close their eyes and to tell you when he can feel the monofilament touching
The monofilament is applied at right angles to the area being tested
It is applied until it bends and the position is maintained for 1-2seconds
If the patient is able to identify this in several places, it is likely that they have normal sensation
The monofilament allows more quantitive testing as it will bend to form a ‘C’ shape under a fixed amount of pressure, usually 10g.
The monofilament should be applied at 90degrees to the surface of the skin and will bend when sufficient pressure is applied
Timing and location should be randomised to avoid the patient guessing as to where and when you are testing
Describe anasthesia
Sensory loss in areas where the patient cannot feel the filament
Describe hyperthesia
An abnormal increased sensitivity to sensory stimuli
If the patient has hyperthesia they may find this test uncomfortable as it often affects the pain as well as the touch receptirs
What should be noted on discovery of hyperthesia or anasthesia?
The location of areas affected
What is swelling?
An abnormal enlargement of a part of the body
Could be the result of bone thickening, synovial membrane thickening or fluid accumulation around a joint
What is oedema?
Sometimes used to describe swelling
But this refers specifically to an excess of fluid in the interstitial tissues (the space between cells).
Oedema should only be used if it is pitting
How do you check for pitting oedema?
Use your thumb and apply pressure over a specific area of the lower leg
When the thumb is removed and the skin remains indented and does not return to its original shape this indicates pitting oedema
