Examining joints Flashcards
1
Q
What causes a waddling gait (Trendelenburg gait)?
A
- loss of hip abductor function / weak gluteus medius
2
Q
What causes an antalgic gait (painful limp)?
A
- caused by any painful condition (patient tries to offload the painful limb by quickening and shortening the weight-bearing stance phase of the gait cycle)
3
Q
What causes a short-leg gait (dipping off shoulder on affected side)?
A
- any condition causing significant leg discrepancy
4
Q
What causes a high-stepping gait (knee is flexed and foot is lifted high to avoid foot dragging on floor)?
A
- nerve palsy (peroneal or sciatic)
- sometimes called foot drop
5
Q
What causes a stiff knee gait (knee cleared of floor by swinging out away from the body)?
A
- fusion of knee
6
Q
What are the main steps to an examination?
A
- LOOK: check for swelling, muscle wasting, scars, erythema, and deformity
- FEEL: palpate the joint, noting any effusions, tenderness, and heat
- MOVE: demonstrate joint movement actively and passively
- SPECIAL TESTS
- note: also examine joints above and below
7
Q
Lower limb dermatomes…
A
Reflexes tested…
- knee: L3-L4
- ankle: L5-S1
- plantar
8
Q
Upper limb dermatomes…
A
Reflexes tested…
- biceps: C5-C6
- triceps: C7
- brachioradialis: C6-C7
9
Q
Vertebral column diagram…
A
10
Q
Testing lower-limb muscle function (myotomes)…
A
Nerve roots tested : muscle action
- L1, L2 : hip flexion (iliopsoas)
- L3 : knee flexion (quadriceps)
- L4 : ankle dorsiflexion (tibialis anterior)
- L5 : great toe extension (extensor hallucis longus)
- S1 : ankle plantar flexion (soleus/gastrocnemius)
11
Q
Testing upper-limb muscle function (myotomes)…
A
Nerve roots tested : muscle action
- C5 : shoulder abduction
- C6, C7 : shoulder adduction
- C5, C6 : elbow flexion
- C7, C8 : elbow extension
- C6, C7 : wrist flexion / extension
- C7, C8 : MCP/IP flexion/extension
- T1 : MCP abduction/adduction
12
Q
How do you measure true-leg length in a hip examination?
A
- measure both limbs from ASIS (anterior-superior iliac spine) to medial malleolus and compare the values
- (note: apparent leg length is belly button to medial malleolus)
13
Q
What does tenderness over the greater trochanter indicate?
A
- trochanteric bursitis
14
Q
What movements are tested in a hip examination?
A
- hip flexion / extension
- hip abduction / adduction
- hip internal / external rotation
15
Q
What special tests are carried out in a hip examination?
A
- Thomas’ test (test for fixed flexion deformity): patient positioned supine, opposite hip is flexed fully, lordosis is felt, if extended hip lifts off couch then positive test
- Trendelenburg test (test for weak hip abductors / weak gluteus medius): patient holds onto your hands and lifts leg off ground, if hip tilts down then positive test for opposite leg
16
Q
What are you looking for in an examination of the knee?
A
- quadriceps wasting (measure thigh circumference)
- note any effusions, scars, erythema, or evidence of psoriasis
- varus/valgus deformities
17
Q
Why do we palpate the posterior aspect of the knee in a knee examination?
A
- a Baker’s cyst or bursa may be present
18
Q
What movements are tested in a knee examination?
A
- knee flexion/extension (feel for patella crepitus)
- note any fixed flexion or hyperextension of the knee
19
Q
What special tests are carried out in a knee examination?
A
- patellar tap test (test for effusion): fluid pushed from suprapatellar pouch, if patellar bounces then +ve
- swipe test (test for effusion): more sensitive to smaller effusions
- anterior/posterior draw test (ACL/PCL)
- (posterior sag: tibia falls posteriorly if PCL ruptured)
- lateral/medial collateral ligaments
20
Q
What are you looking for in an ankle/foot examination?
A
- erythema, swelling, scars
- any evidence of psoriatic changes to nails and skin
- note: synovitis of ankle usually produces diffuse swelling (lateral and medial malleoli contours not clear)
- flat feet (Pes planus): can cause valgus deformity of the heel
- hallux valgus: deformity of great toe (abducted at MTP joint)
21
Q
What movements are tested in an ankle/foot examination?
A
- inversion/eversion (subtalar joint)
- plantar flexion and dorsiflexion: midtarsal joint
- inversion/eversion: midtarsal joint (stabilise heel and move foot)
- movements of MTP, PIP, and DIP joints should also be tested
22
Q
What special test is performed in an ankle/foot examination?
A
- squeeze patient’s calf to check for Achilles tendon rupture
- +ve test: foot does not plantar flex
23
Q
What are you looking for in a spinal examination?
A
- patient’s posture: check for cervical lordosis, thoracic kyphosis, and lumbar lordosis
- muscle wasting, asymmetry, scoliosis (scoliosis more clearly seen when patient bends over)
24
Q
What are we feeling in a spinal examination?
A
- spinous processes
- paraspinal muscles
- sacroiliac joints
25
What movements do we do for cervical spine examination?
- cervical spine flexion/extension
- cervical spine lateral flexion
- cervical spine rotation
26
What movements do we do for thoracolumbar examination?
- thoracolumbar flexion/extension
- thoracolumbar lateral flexion
- thoracolumbar rotation
27
What special test do we perform in a spinal examination (tests for nerve root irritation/radiculopathy)?
- straight-leg raise
- with patient supine, elevate affected leg passively (keeping it straight)
- next step is to bend the knee (this will relieve tension on the nerve so symptoms should go away)
- if pain radiates to foot then positive test (indicated nerve radiculopathy, eg. sciatica)
28
What do we look for in a shoulder examination?
- patient's posture and any asymmetry
- muscle wasting: can be due to nerve pathology, rotator cuff tendinopathy, or chronic disuse
- any swelling, scars, erythema
29
What do we palpate in a shoulder examination?
- palpate sternoclavicular, acromioclavicular, glenohumeral joints, and clavicle
- feel joint temperature
- any tenderness in surrounding muscles
30
What movements do we assess in a shoulder examination?
- shoulder flexion/extension
- shoulder abduction/adduction
- shoulder internal/external rotation
- (note: hands on head with elbows back tests shoulder flexion, abduction, and external rotation)
- (note: hands behind back on thoracic area tests shoulder extension, adduction, and internal rotation)
31
What does loss of passive shoulder extension and abduction?
- adhesive capsulitis (frozen shoulder)
- note: frozen shoulder is an unknown disease (thought to be inflammation of the synovium within the shoulder joint which causes stiffness)
32
What does scapular winging indicate in a shoulder examination?
- scapula winging is a common sign of serratus anterior dysfunction, caused by damage to the long thoracic nerve
33
Serratus anterior and long thoracic nerve diagram...
34
What 4 muscles make up the rotator cuff?
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
35
What is the 'painful arc' in a shoulder examination?
- shoulder abduction (between 60 and 120 degrees)
- pain indicates supraspinatus impingement
36
How do you test the rotator cuff muscles?
- supraspinatus: empty can test (Jobe's test)
- subscapularis: resisted internal rotation
- infraspinatus / teres minor: resisted external rotation
37
What does the scarf test in shoulder examination test?
- acromioclavicular joint injury
38
The elbow consists of two articulations, one provides elbow flexion/extension, the other allows wrist rotation of the wrist through 180 degrees, what are they?
- first is between humerus, radius, and ulna
- second is the superior radioulnar joint
39
What are you looking for in an elbow examination?
- scars, swelling, erythema, muscle wasting
- rheumatoid nodules, psoriatic plaques, olecranon bursitis
40
What are you feeling in an elbow examination?
- olecranon process, radial head, ulnar head
- medial epicondyle tenderness: golfer's elbow
- lateral epicondyle tenderness: tennis elbow
41
What movements are assessed in an elbow examination?
- elbow flexion/extension
- pronation/supination (palm down, palm up respectively)
- note: also check for hyperextension
42
How do you test for tennis elbow and golfer's elbow?
- resisted wrist extension pain: tennis elbow
- resisted wrist flexion pain: golfer's elbow
- (note; tenderness over lateral epicondyle is tennis elbow, tenderness over medial epicondyle is golfer's elbow)
43
What are you looking for in a hand/wrist examination?
- skin: psoriasis, nodules, scleroderma (skin tightening)
- nails: pitting, onycholysis (psoriatic changes), splinter haemorrhages in vasculitis
- joints: deformity/swelling, OA (DIP/PIP joints affected), RA (PIP/MCP joints affected)
- muscles: thenar wasting (suggests carpal tunnel syndrome), hypothenar wasting (suggests cubital tunnel syndrome), dorsal interossei wasting (seen in RA)
44
What do we assess in the feel aspect of a wrist/hand examination?
- palpate wrist joint, MCP, PIP, DIP joints
- MCP squeeze
- palpate anatomical snuff box
- check sensation of radial, median, and ulnar nerve distributions
45
What movements do we assess in a hand/wrist examination?
- wrist flexion/extension (prayer sign and opposite respectively)
- finger flexion/extension (ask patient to make a fist)
- finger abduction/adduction
46
How do you put tension on the radial, median, and ulnar nerves to test function?
- radial: wrist/finger extension against resistance
- median: thumb abduction against resistance
- ulnar: finger abduction against resistance
47
What special tests are performed in a hand/wrist examination?
- Tinel's test: tap on wrist over carpal tunnel
- Phalen's test: hold wrist flexion for 60 seconds
- assess power grip
- assess pincer grip
- assess picking up a small object
48
What peripheral pulses can you palpate in the upper limb?
- radial pulse
- ulnar pulse
49
What peripheral pulses can you palpate in the lower limb?
- dorsalis pedis
- posterior tibial
50
What is the terrible triad?
- ACL (anterior cruciate ligament)
- MCL (medial collateral ligament)
- meniscus
51
Does being hypermobile affect knee replacement surgery?
- yes
- often the surgery will make the joint more stable but will cause more pain for the patient
52
What does localised weakness suggest and what does generalised weakness suggest?
- localised: peripheral nerve lesion
- generalised: systemic cause
53
What muscle is responsible for hip flexion?
- iliopsoas
54
what muscle is responsible for knee flexion?
- quadriceps
55
What muscle is responsible for ankle dorsiflexion?
- tibialis anterior
56
What muscle is responsible for great toe extension?
- extensor hallucis longus
57
What is a common way for true hip pain to present in a patient?
- true hip pain is often felt in the groin and may radiate to the knee on movement
58
Depuytren's contracture...
- thickening of the connective tissue in the hand (often forming nodules)
59
What is De Quervain's tenosynovitis?
- De Quervain syndrome is mucoid degeneration of two tendons that control movement of the thumb and their tendon sheath
- this results in pain and tenderness on the lateral (radial) aspect of the wrist
60
What is Finklestein's test?
- test for De Quervain's tenosynovitis
- examiner ulnar deviates the hand/wrist and pain will be felt on the radial side of the hand/wrist
