how to examine knee and hip the orthopaedic way

1. Lower limb examination
An introductory lecture

2. STANDARD APPROACH
LOOK
FEEL
MOVE
SPECIAL TESTS

3. Regional approach
• Hip
• Knee
• Foot (diabetic)

4. HIP
LOOK

5. • Gait…
In hip: short limb gait
trendelenburg gait
antalgic gait
• Scars, sinuses, skin changes, deformities

6. • Trendelenburg test
Standing on affected leg: pelvis falls to unaffected
side, body swerves to affected side to compensate

7. FEEL

8. • Temperature
• Joint palpation (tenderness)
–GT
–ASIS
– Joint line
– Pubic symphisis

9. MOVE

10. • Flexion: 0 – 140
– Thomas test
100
Right Thomas test positive

11. • Abduction: 0 – 45
• Adduction: 0 – 30
• Internal rotate: 0 – 40
• External rotate: 0 – 50

12. SPECIAL TESTS

13. Limb length measurement
• To determine site of shortening
• Start with galeazzi test

14. • Then proceed with Bryant’ triangle

15. • Measure apparent length:
–Umbilicus to medial malleolus
• Measure true length:
–ASIS to medial malleolus

16. Summary hip
+ Trendelenburg test
• Look
• Feel
• Move
• Special test
+ Thomas test
+ LLD measurement

17. KNEE
LOOK

18. • Gait patterns: antalgic, lateral thrust
• Front, side, back:
– Deformities, swellings, wasting, sinus,
scars, skin changes

19. • Sit at side of table:
– Assess patella tracking (inverted J)
– Measure Q – angle
• ♂ - 14 ♀ - 17

20. FEEL

21. • Temperature
• Effusion assessment
– Cross fluctuation – large
– Patella tap – medium
– Bulge test – little
– Hollow test – minimal

22. • Joint line tenderness
– may suggest meniscus involvement

23. MOVE

24. • Flexion: active, passive
• Extension: active, passive

25. SPECIAL TESTS

26. Aims
• To determine internal knee
structures integrity
• To assess patellofemoral joint
stability

27. Knee integrity
• Posterior sagging sign – PCL

28. • Drawer’s test – anterior and posterior
• Lachman’s test – ACL

29. • Varus and valgus test – MCL, LCL
• McMurray test – ?
Done in 0 and
30 degrees

30. PFJ assessment
• Palpate the patella and its
undersurface – tenderness
• Patella apprehension test

31. Summary knee
• Look
• Feel
• Move
• Special test
+ patella tracking, Q angle
+ effusion assessment
+ internal knee integrity
+ PFJ assessment

32. FOOT (DIABETIC)
• Vasculopathy
• Immunopathy
• Neuropathy
– Motor
– Sensory
– Autonomic

33. LOOK

34. • Wounds, ulcer, gangrene
• Deformities

35. • Immunopathy – cellulitis features
• Vasculopathy – loss of hair
• Neuropathy
– Motor – claw toes,
callosities
– Autonomic – dry skin

36. FEEL

37. • Immunopathy – warmth, tender
• Vasculopathy – pulses, cold
peripheries, CRT

38. MOVE

39. • Ankle – active and passive
• Tightness of tendon Achilles
– Due to glycolisation products
deposition

40. SPECIAL TESTS

41. • Neuropathy
– Sensory – glove and stocking
– Monofilament – assess protective
sensation
• Ankle-brachio systolic index (ABSI) –
0.8 – 1.0 ratio

42. King’s classification
• Stage 1 – normal foot
• Stage 2 – foot at risk
• Stage 3 – ulcerated foot
• Stage 4 – infected foot
• Stage 5 – necrotic foot
• Stage 6 – major amputation

43. Summary foot (diabetic)
• Aim to detect features of:
– Vasculopathy
–Immunopathy
– Neuropathy
• Classify the foot (King’s)

44. THANK YOU