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Knee Exam

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861. True Leg Length Discrepancy

malleolus Interpretation Leg Length Discrepancy if difference between sides IV. Exam: Evaluate tibia and femur lengths Position Patient lies supine s flexed at 90 degrees and feet flat on table Interpretation One knee higher than other: Tibia longer One knee projects further anteriorly: femur longer V. Management: True Limb Length Discrepancy >1.5 cm Shoe lift or prosthetic conversion Surgical intervention Epiphysiodesis of long leg Long leg shortening or short leg lengthening VI. Complications (...) True Leg Length Discrepancy Aka: True Leg Length Discrepancy , Leg Length Discrepancy , Limb Length Discrepancy , Leg Length Inequality From Related Chapters II. Causes Idiopathic unilateral hyperplasia or hypoplasia injury Infection Asymmetric paralysis Poliomyelitis Mass induced growth Tumor Post- hypervascularity III. Exam: Fixed point to fixed point testing Position Patient lies supine with legs in neutral position Measurement (compare both sides) Anterior superior iliac spine to medial

2015 FP Notebook

862. Umbilical Cord Prolapse

brim and presenting part IV. Risk factors Multiparity Prematurity Macrosomia Polyhydramnios High V. Signs Ill-fitting or non-engaged presenting part Prolapsed visualized in vagina or at vulva palpated on pelvic exam on May follow VI. Management: General Emergent only if imminent Deliver as if fetus has died Check for cord pulsations Check for fetal heart sounds to assess heart activity Pre-hospital cord prolapse noted at home by patient Patient assumes deep knee-chest position Emergent transport (...) to hospital VII. Management: Temporizing measures to relieve cord pressure Adjust maternal position to reduce cord pressure Raise foot of the bed (Trendelenburg's Position) Sims' position Mother in left lateral decubitus position Genu-pectoral position Mother in knee-chest position Vaginal retrograde pressure applied to presenting part Hand in vagina elevates presenting part Mother should stop pushing with 0.25 mg SC Consider filling with 500-700 cc Saline Minimize handling of the cord Do not attempt

2015 FP Notebook

863. Occiput Posterior

. Signs: Digital cervical exam Asymmetric cervical dilation Persistant anterior lip Palpation of fetal head Fetal anterior most palpable Follow sagittal to posterior Posterior , lambdoid with be posterior VII. Complications Extended episiotomy or perineal VIII. Management Spontaneous Delivery (anticipate in 45% of cases) Maternal position changes (unclear efficacy) Any position in which mother curls forward from hips Hands and knees Squatting Manual rotation during vaginal exam See Vacuum Delivery

2015 FP Notebook

864. Ankle External Rotation Test

Ankle External Rotation Test Aka: Ankle External Rotation Test , Syndesmotic Stress Test II. Indications Suspected of the ankle III. Technique Patient sits on exam table with knee flexed over edge of table Examiner stabilizes leg proximal to ankle Examiner uses other hand to grasp plantar foot and dorsiflex Rotate foot externally relative to tibia IV. Interpretation Pain on external rotation suggests Images: Related links to external sites (from Bing) These images are a random sampling from a Bing

2015 FP Notebook

865. NIH Stroke Scale

Scale II. Precautions NIH Stroke Scale has imperfect interrater reliability (i.e. different scores by different providers) NIH Stroke Scale may be low despite severe, disabling symptoms and signs (e.g. in posterior CVA) Facial droop may be subtle Consider counting visible teeth on each side for comparison When a patient is too weak overall to perform a particular exam element Default to a lower score (as if patient could perform that element) Obviously this does not apply to a focal weakness (...) degrees for 5 seconds No drift: 0 Drifts (within 5 seconds): 1 Unable to get to and maintain full limb elevation: 2 Unable to move against gravity (limb falls): 3 No movement: 4 Coordination or limb (0-2 points) Testing: , Heel-knee-shin Absent: 0 Present in one limb: 1 Present in both limbs: 2 Sensory (0-2 points) Test: Pin prick to face, arm, trunk, and legs Normal: 0 Mild to moderate sensory loss (reduced, dull): 1 Severe or total sensory loss (unaware of touch): 2 or Best Language (0-3 points

2015 FP Notebook

866. Epiphyseal Fracture

supply and high risk of growth failure (especially femur or tibia) May result in focal fusion of bone and joint deformity Salter V Rare (<1% of Epiphyseal Fractures) requiring severe (e.g. fall from height) Crushing of physis, most commonly in knee or ankle Early XRay negative (similar to Type I in this regard) Subsequent xrays demonstrate callous formation and delayed bone growth Diagnose clinically based on point tenderness Splint with orthopedic follow-up Poor prognosis Salter VI (Rang) Portion (...) of sheared off Penetrating injuries Rare VII. Exam Joint line and tenderness Joint instability ( ) Compare with opposite limb Bony deformity VIII. Precautions: Red Flags suggestive of Physeal Injury Point tenderness over a (regardless of xray findings) Inability to bear weight Ligamentous sprain or instability in a child (commonly associated with underlying Grade 3-4 physeal ) with rotation and supination is a risk for Tillaux , esp ages 12-15 (high risk injury) IX. Imaging XRay First-line study in all

2015 FP Notebook

867. Flexible Flatfoot

Weight bearing: Normal medial arch disappears Heels everted Forefoot pronated and abducted Non-Weight bearing Feet appear normal With heel inverted Passive ankle dorsiflexion limited Results from tight heel cord Infant findings hidden by fat infant foot Noticed when child begins standing VI. Associated conditions Hyperextension of fingers, elbows, and knees of and ligamentous laxity Flexible Flatfoot may be due to tight heel cord in Mild Congenital tightness heal cord Stiff, painful (unusual (...) deformities improve spontaneously with age Associated with tightening of ligaments Symptoms rarely occur in children and adults Abnormally high arch responsible for most XI. Patient Resources Hughston Sports Medicine Foundation XII. References Hoppenfeld (1976) Exam. Spine Extremities, p.159-60,223 Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "Flexible Flatfoot." Click on the image (or right click) to open the source website in a new

2015 FP Notebook

868. First Metatarsophalangeal Joint Injection

. Technique Images Patient position Supine position with knee flexed over towel roll in neutral position against exam table Slightly plantar flex great toe Landmarks Mark dorsum of first metatarsophalangeal joint (MTP) Consider ethyl chloride spray prior to needle insertion Sterilize local skin with betadine or hibiclens Insert needle into skin at MTP on dorsal surface Angle needle 60 degrees distally Insert needle into joint (relatively shallow depth) Aspirate before injection Aspiration pointers Apply (...) negative pressure on syringe Back and forth motion for 5 seconds Release negative pressure before exiting skin Avoids blood in sample (obscures crystal exam) Spray quickly onto slide and apply cover slip Send for polarized crystal exam at CLIA approved lab VI. Follow-up Instructions No stress to foot for 2 weeks after injection Examine again in 3 weeks post-injection VII. References Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term

2015 FP Notebook

869. Slipped Capital Femoral Epiphysis

% of cases Pain may be referrred to knee May present primarily as knee or distal thigh pain in 15-25% of cases IX. Signs Compare exam to opposite side (except in bilateral SCFE) Hip held in abduction and external rotation Obligatory external rotation (Drehmann Sign) or of the effective leg Patient externally rotates hip when the hip is actively flexed to 90 degrees Markedly limited internal rotation (most predictive finding) Hip abduction and hip flexion are also limited X. Imaging AP with Frog-Leg

2015 FP Notebook

870. Femoral Anteversion

. ) or Severe functional at age > 8 (0.1% of cases) Femoral Anteversion >50 degrees Internal rotation >80 degrees X. Complications ( ) No known association with hip or knee Does not significantly affect or walking XI. Course Spontaneously resolves to normal range in 80% of cases by age years Unlikely to resolve after age 8 years Compensatory lateral tibial torsion may occur XII. Patient Resources Hughston Sports Medicine Foundation XIII. References Pediatric Database Homepage by Alan Gandy, MD Hoppenfeld (...) (1976) Physical Exam, Appleton-Lange Bates (1991) Physical Exam, Lippincott Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "Femoral Anteversion." Click on the image (or right click) to open the source website in a new browser window. Related Studies (from Trip Database) Ontology: Congenital anteversion of femur (C0265616) Concepts Congenital Abnormality ( T019 ) SnomedCT 1239002 English Cong anteversion femoral neck , femoral

2015 FP Notebook

871. PCL Sulcus Test

II. Indications Assessment for III. See Also IV. Technique Patient Position Patient sits with knees flexed at 90 degrees Legs hanging freely over edge of exam table Examiner Palpate area between tibial plateau and femur Normally space is minimal Tibia and femur are well approximated Images V. Interpretation: Positive Test Suggests PCL Rupture Space widened with sulcus between tibia and femur Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search

2015 FP Notebook

872. Ober Test

Adduction II. Indication Evaluation III. Technique Patient lies on side, unaffected side down Examiner places one hand on ankle and the other on the lateral hip over the iliac crest Step 1: Tensor fasciae latae test With the hip and knee both extended, allow the hip to adduct toward the table with gravity Step 2: Gluteus medius test With the hip extended at 0 degrees, flex the knee to 45-90 degrees Step 3: Gluteus maximus test Patient rotates upper torso with both s against the exam table Flex the hip (...) and allow the leg to fall over the side of the table Extend the leg at the knee IV. Interpretation Positive test if patient unable to undergo Passive Hip Adduction past the midline Causes External Findings suggestive of IT Band Syndrome Difficult adduction of affected knee Lateral on attempted adduction V. References Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "Ober Test." Click on the image (or right click) to open the source

2015 FP Notebook

873. Ballottable Patella Sign

click present as strikes the trochlea No joint effusion (normal): no click palpated V. References Bates (1991) Physical Exam, Lippincott Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "Ballottable Patella Sign." Click on the image (or right click) to open the source website in a new browser window. Related Studies (from Trip Database) Ontology: Patellar tap (C0231756) Concepts Sign or Symptom ( T184 ) SnomedCT 56020001 Dutch (...) zwevende patella French Rotule flottante German tanzende Patella Italian Rotula fluttuante Portuguese Rótula flutuante Spanish Rótula flotante , percusión rotuliana , percusión rotuliana (hallazgo) , rótula flotante , clic rotuliano , peloteo rotuliano (hallazgo) , peloteo rotuliano , chasquido rotuliano Japanese 膝蓋跳動 , シツガイチョウドウ English knee patella ballottement , patellar ballottement (physical finding) , patellar ballottement , floating patella , patellar tapping , patellar tap , Floating patella

2015 FP Notebook

874. Ortolani Test

Gently abduct the hip while applying upward force Push upward with greater trochanter (away form bed) Push toward bed and laterally with thumb at knee Also assess for reduced in abduction Abduction less than 60 degrees OR Abduction more than 20 degrees difference between sides VII. Findings: Signs of dislocation Hip Clunk felt on exam Occurs when femoral head relocates in acetabulum Suggests Distinguish from a hip click Benign finding VIII. References Images: Related links to external sites (from

2015 FP Notebook

875. Fulcrum Test

Suspected III. Technique Patient position Patient sits on exam table with knee extended Examiner position Place one hand under sitting patient's femur Other hand placed over knee Maneuver Apply firm pressure upward on femur Apply firm pressure downward on knee IV. Interpretation Exquisite pain suggests Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "Fulcrum Test." Click on the image (or right click) to open the source website

2015 FP Notebook

876. Meningeal Irritation

Patient cannot flex neck to place chin on chest Unreliable in age under 18 months due to underdeveloped neck musculature V. Exam: Spinal Rigidity Erector spinae muscle spasm limits spine movement (rigid arched back) may occur VI. Exam: Kernig's Signs Technique Patient supine Flex both hip and knee to 90 degrees Hold hip immobile and extend knee Positive Test suggesting Meningeal Irritation Resistance to knee extension Pain in hamstrings VII. Exam: Brudzinski's Sign Technique Patient supine Immobilize (...) Aka: Meningeal Irritation , Brudzinski's Sign , Kernig's Sign , Spinal Rigidity , Nuchal Rigidity II. Causes Intracranial causes (esp. Posterior fossa tumor) Meningismus Extracranial Causes Retropharyngeal or cervical (especially young children) or Upper lobe III. Efficacy: Meningeal signs Do not rely on these signs due to low efficacy Kernig's Sign and Brudzinski's Sign : 5% : 95% Nuchal Rigidity : 30% : 68% References IV. Exam: Nuchal Rigidity Involuntary muscle spasm limits passive neck flexion

2015 FP Notebook

877. Jaundice in Newborns

of Head and neck : 6 mg/dl Trunk to : 9 mg/dl Trunk to knees: 12 mg/dl s and s: 15 mg/dl Hands and Feet: >15 mg/dl V. Differential Diagnosis See VI. Labs: Bilirubin See Transcutaneous Bili Meter Accurate in white infants Overestimates in black infants Do not use to monitor infants on VII. Labs: Secondary Cause See for additional evaluation VIII. Evaluation: Jaudice Monitoring before hospital discharge Visually inspect skin with s (at least every 8 hours) Visual inspection alone has low (misses cases (...) that appears excessive (e.g. below nipple line) Neonatal Jaundice that is difficult to assess on exam Do not rely solely on appearance of as a screening indication (misses cases of severe ) IX. Evaluation: Jaundice Monitoring after hospital discharge Based on age Discharge before 24 hours old: Reevaluate by 72 hours old Discharge before 48 hours old: Reevaluate by 96 hours old Discharge before 72 hours old: Reevaluate by 120 hours old Based on risk factors See s Number of risk factors dictates timing

2015 FP Notebook

878. Sarcoidosis

(first 6 months) Duration: weeks to 3 months Common joints involved Onset in ankles Spreads to knees Involves other joints Proximal interphalangeal joint Metacarpophalangeal joint Spares axial skeleton Associated with No XRay changes Late joint disease (onset after 6 months) Common joints involved s s Proximal interphalangeal joints Associated with chronic cutaneous Sarcoidosis XRay changes (see below) VIII. Signs: Skin changes (Lupus Pernio) Initial Characteristics Papular lesions (most common (...) to every 12 months if stable No follow-up if off therapy and stable for 3 years Stage II to IV Sarcoidosis Start with evaluations every 3-6 months Continue visits indefinately s Ophthalmology exam annually XXIII. Prognosis Overall mortality: 1-5% Cause of death in U.S.: or CHF Factors suggestive of worse prognosis Onset after age 40 years Black race Chronic Specific higher risk organ involvement Neurologic involvement Skin involvement (Lupus Pernio) Cardiac involvement Eye involvement (Chronic ) Renal

2015 FP Notebook

879. Acute Lymphocytic Leukemia

or fluorescence in situ hybridization analysis) IX. Management: Acute Remission-Induction Vincristine Daunorubicin or L-asparaginase CNS Prophylaxis (prevents Leukemic ) Whole Brain Radiation (18 to 24-Gy) Intrathecal Maintenance for 2-3 years 6-Mercaptopurine X. Management: Surveillance of survivors treated with Chemotherapy and radiation Initial surveillance Year 1 Monthly Physical Exam and (CBC) Every 2 month s until normal or as indicated as indicated Year 2 Every 3 month physical exam (with testicular (...) exam) and Year 3 (and after) Every 6 month physical exam (with testicular exam) and Routine periodic exams Dental care Annual lab testing with differential Obtain for up to 10 years following last treatment Comprehensive metabolic panel Includes serum electrolytes, , , and s Hepatitis testing (one time screening) testing (if treated before 1993) (if treated before 1972) Other tests as indicated Respiratory symptoms ing Hearing changes Cardiac symptoms (e.g. CHF) Repeat testing every 3-5 years

2015 FP Notebook

880. Deep Vein Thrombosis

year III. Risk Factors See (includes s) See IV. Signs Clinical exam is unreliable for DVT Homans' Sign (no predictive value) Homans' Sign: Relaxed foot abnormally plantar flexed Pseudo-Homans': Pain on passive dorsiflexion of foot Other unreliable signs Tenderness Distal extremity edema Palpable cord V. Differential Diagnosis See Extremity (Pseudo-thrombosis) VI. Diagnosis Step 1: Assess See If moderate to high probability, goto step 3 Step 2: Low Probability for DVT Obtain Negative : Excludes DVT (...) ) Reduced with below knee graded Encourage 30 minute walk per day ( ) Painful, white leg following ileo-femoral deep vein obstruction Painful, cyanotic, edematous leg following ileo-femoral deep and superficial vein obstruction (capillary obstruction) results if not promptly managed XIII. Precautions Idiopathic DVT associated with undiagnosed malignancy Initiate evaluation for underlying malignancy in the first month of unprovoked DVT Directed history and physical Consider , , , PSA of malignancy

2015 FP Notebook

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