1 – Introduction, gait cycle, symptoms in orthopaedic disorders

11. Gait and limping

Gait
- Has two phases
- Stance phase – lasts from the moment the heel touches the ground until the foot lifts off the ground
  - Heel strike
  - Rolling
  - Lift-off
- Swing phase – lasts from the moment of lift-off until the heel touches the ground
  - Acceleration
  - Swing-through
  - Deceleration
- What to assess in a patient’s gait
  - The character
  - The step length
  - The width
  - Whether there is limping
  - Whether the pelvis remains level during walking
  - Whether the shoulders remain level during walking
Limping
- = the movement of the lower limbs is no longer symmetrical, or the phases of the two lower limbs differ
- Potential causes of limping
  - Limb length discrepancy (discrepancy gait)
    - Normal 1 – 1,5 cm
  - Contractures (range of movement restrictions) or ankylosis (contracture gait)
  - Muscle atrophy/weakness or paralysis (paralytic gait)
  - Pain (antalgic gait)
  - Joint instability
- Discrepancy gait
  - Causes lateral pelvic tilt
  - Due to discrepancies in limb length
- Antalgic gait
  - Patient limps to avoid pain
  - The stance phase on the painful side or limb is shortened
- Paralytic gait
  - Due to muscle weakness or paralysis
  - Trendelenburg limping
    - A special form of paralytic gait
    - Due to weakness of gluteus medius, often due to superior gluteal nerve lesion
    - Pelvis tilts toward the contralateral side during the stance phase
- Contracture gait
  - Due to contractures in muscle, skin, or joints

15. Ultrasound imaging in orthopaedics

Used to investigate soft tissues
- Tendons
- Muscles
- Ligaments
- etc.
Can be used for functional and dynamic examination
- I.e., muscle movement can be detected
Used for examination of
- Soft tissue cysts
- Tendons
- Soft tissue tumours
Can also be used therapeutically
- Used in physiotherapy
- US provides heat, etc. to deep tissues
- Speeds up healing of muscles, tendons, ligaments, etc.

27. Joint movements, contractures, ankylosis, measurement methods in orthopaedics

Joint movements
- The passive movements of the affected/painful joint and the contralateral joint should be examined for contractures (range of motion), pain and crepitation
- Joints should physiologically not extend beyond 0° – if so, it’s called hyperextension
- If the examination of the joint movements is limited by pain they should be re-examined during anaesthesia before the surgery
Contractures
- = decrease of range of motion of a certain movement
- Any joint can experience contracture in any movement
- If a knee cannot be flexed as much as much as normal, the patient has a knee extension contracture
  - The knee motion stops in extension, before it reaches complete flexion
- If an elbow cannot be extended as much as normal, the patient has an elbow flexure contracture
  - The elbow motion stops in flexion, before it reaches complete extension
- General causes
  - Scarring of the skin
  - Muscle paralysis or constriction
    - Neuromuscular diseases, like Heine-Medin disease or infantile cerebral paresis
  - Changes in the joint and capsule
    - Very common in osteoarthritis, developmental dysplasia of the hip
    - Can be due to inflammation, trauma or repeated surgeries
- Thomas test
  - A test which tests for hip flexion contracture
  - Patient is supine on table
  - Passively flex the hip and knee of the unaffected leg
  - Positive test: The patient will reflexively lift the thigh of the other, affected leg
  - Negative test: The affected leg remains on the table
Increased range of motion of joints
- Opposite of contracture
- Often a symptom of a connective tissue disease like Marfan
Ankylosis
- = Total loss of joint motion due to bony or fibrous jusion
- Causes
  - Ankylosing spondylitis (Bechterev disease)
  - Psoriatic arthritis
  - Rheumatoid arthritis
  - Postoperative arthrofibrosis
Limb length discrepancy
- Measurement
  - Performed with limbs in extension and parallel position
  - Measured between easily palpable bony surfaces, or easily visible structure
  - For upper limbs: length between acromion and styloid process of radius
  - For lower limbs: length between anterior iliac spine OR umbilicus, and the medial malleolus
  - Length must always be compared between limbs
- Is best measured by x-ray or CT
- Normal length discrepancy: 1,0 – 1,5 cm
- Causes
  - Idiopathic
  - Osteoarthritis
  - Tumour
  - Trauma
  - Developmental dysplasia of the hip
- Clinical features
  - Limping
  - Lower back pain
  - Scoliosis
- Treatment
  - Orthopaedic shoes – see topic 55
  - Limb equalization – see topic 25

50. Joint motions, measurement of muscle strength

Joint motions
- Shoulder
  - Abduction 90 degrees
    - Elevation another 90 degrees
  - Flexion 90 degrees
    - Elevation another 90 degrees
  - Internal rotation 90 degrees
  - External rotation 50 degrees
- Elbow
  - Flexion 150 degrees
  - Extension 10 degrees
  - Supination 90 degrees
  - Pronation 90 degrees
- Wrist
  - Palmarflexion 50 degrees
  - Dorsiflexion 40 degrees
  - Ulnar deviation 30 degrees
  - Radial deviation 30 degrees
- Hip
  - Flexion 130 degrees
  - Abduction 30 degrees (when standing)
  - Adduction 30 degrees (when standing)
  - Internal rotation 40 degrees (when flexed)
  - External rotation 30 degrees (when flexed)
- Knee
  - Flexion 130 degrees
  - Extension 10 degrees
  - Slight internal and external rotation in flexed position
- Ankle
  - Dorsiflexion 30 degrees
  - Palmarflexion 40 degrees
  - Eversion, inversion
  - Pronation, supination
Measurement of muscle strength
- Determined by physical examination or EMG
- Scale:
  - 5 – Normal strength (full function even against great resistance)
  - 4 – Muscle function only against limited resistance
  - 3 – Muscle function against the action of gravity
  - 2 – Muscle function only in the absence of gravity
  - 1 – Only muscle fibrillation is visible
  - 0 – Total paralysis