Direct - over spinous process. Rotatory - twist side of spinous process. Indicates early anterior pathology 3. Thrust - gentle thumping. Kibler test : pinched skin ove r the paraspinal muscles will be less mobile when moved longitudinally.
Movements, measurements are of academic interest and will be discussed later, but you must measure wasting. Normally the finger-to-floor distance is 7 cm or less Fig. Request the patient to bend forward and note the increase in distance between the above points.
Normally it is 3 cm or more. Then request the patient to bend forward with extended knees and note the change in the distance. Normally it is 5 cm or more. Note the angle which is formed with the vertical axis. In facet joint arthropathy it may be painful and restricted [Fig.
Standing behind the patient and looking from above note tha angle between the plane of pelvis and a imaginary line joining the shoulders. Neurological examination done mainly with the patient in supine position 1. Higher functions : Consciousness , alertness , orientation , speech. Hypotonia occurs in lower motor neurone lesions, cerebellar disease, tabes dorsalis and sensory neuropathies.
Difficult to appreciate in obese 7 It 1s also important to detect whether a patient has come out of spinal shock.
For finger tips about 2mm separation and for pulp of toes about 1cm of separation can be recognised. In cervical cord compression, passive flexion and extension of neck sometime produce electric shock like feelings of the extremities. Stabilize the pelvis with one hand and hold the leg with flexed knee with your other hand. Now extend the hip. If there is femoral nerve rool. Stop further movement when the patient complains of pain and note the angle between the leg and the horizontal.
Scanned by CamScanner If pain. Exaggerated deep tendon reflex. Surroun ,ng osis of the subcutaneous tissue that may extend wade 3. Extremely difficult to ea. Most c ommon si te s are the lungs and lymph nodes and then comes skeletal or osteoarticular TB. Sometimes caries spine is also called tuberculous spondylitis. In the spine, infection sometimes passes via the Batson's venous plexus. So in TB, involvement of the adjacent joint occurs rapidly. Septic arthritis resulting from pyogenic osteomyelitis is less common.
This is due to destruction of the vertebral end-plates. Initial focus in spine after haematogenous spread is at four sites Fig. Pedicle, transverse pro; cess, lamina, spinous process. Th 95 are rare. A s infection spreads there is hype ine. Cold abscess m ay also present as a psoas abscess see page and page What is your diagnosis?
What is Fig. Note - Loss of disc space. Example : Mr. He found ditticulty in wearing shoes and then walking with any slipper type of footwear and later climbing stairs. He had been suffering from back pain, which was more severe at night, tor the last 4 months. On enquiring , he gave history of con- Slncting girdle-type sensation near the groin level and that, initially he had pain radiating to both lower limbs, which increased with coughing , sneezing and jolting.
Active move ess over e O9 ver. Or What i th dlff r nc b rw 11 1, pl , eJcte. In extension t e - The lower limb has attitude of hip and kn Plantar fl.
It involves both the pyramid 1 trapyramrdal tracts, and occurs late ,n the course of the disease. When bufbocave,nosus ,efle and anal reflex are present, it indicates intact sa.
It 1s called reflex or automatic bladder. When these re. Cold abscess is a non-pyogenrc abscess formed due to tuberculo us infection, and consists of tubercular debns , caseous matenal , serum , WBC's and occasional TB bacilli.
Since there is no 'rubor', 'dolor', 'color' and other signs of inflammation of pyogenic infection so-called "hot abscess " rt is called cold abscess. Where ould you search for cold abscess in a patient of TB spine? I would search in the paravertebral areas, lumbar "Petit's triangle", iliac fossae , femoral triangle, buttocks , thighs and the popliteal fossa. Besides it may cause psoas abscess, if the lesion is at, or below T 12 level. If the lesion is in upper thoracic or cervical verte- brae, then neck, axilla , retropharyngeal space, anterior and lateral chest walls should also be searched.
What is called early onset paraplegia and Fig. What is tebral area. Seddon 's classification? Appears within the first 2 years of 1. Usually due to compression from in- 2. Usually due to sequestrum, internal flammatory oedema , TB granulation gibbus, spinal canal stenosis, vertebral tissue, caseous material, cold ab - deformity.
Prognosis is better. During healing, what 15 e order of recovery? M otor f unctions. I s ciurnsY are affected f,rst, and the first symptoms are twrtchrng of muse e , is gait, bris k jerks with extensor plantar response , ankle and knee clonus.
Then sensory affected. Joint position sense and vibration sense is last to be affected. E xte nsor plantar response takes pos, ion. First there is. What are the types of gibbus?
How is gibbus formed? Common is external gibbus which is of 3 types. Knuckle gibbus : One spin ous process is prominent on palpation because one verte- bra co ll apses e.
Angular gib bus : 2 o r 3 vertebrae involved e. Round gibbus : 3 o r more vertebrae involved e. Internal gibbus : Rare variety. Seen in late onset TB paraplegia. What are the landmarks of spinous process palpation? How do you establish the exact level of the palpated spinous process clinically? C1 - Most prom inent spinous process at the base of the neck. D1 - Level of the inferi or angle of scapula.
Li - Level of the highest point of iliac crest. S2 - Level of the posterior superior iliac spine dimple of venus [Fig. Disc spaces are usua y. I s11y an d controversra. Not routinely don e. X-ray : X-ray of spine, centering the sus- pected affected area known by tender- ness, girdle-sensation, motor-level, etc.
Look for : a In Lateral view - Inter verte- bral disc space decrease, or even fusion of adjascent vertebrae Fig. MRI : Costly Is the investigation of choice, as it shows cord compression, canal steno- sis, cold abscess, condition of disc and bone, etc. Cold abscess if present, should be drained after 3 weeks of chemotherapy, by aspiration and instillation of streptomycin. Besides this, care of the bladder and pressure sore has to be taken. What are the areas where bedsores can occur? Sacrum, ischial tuberosities, scapula , occiput, greater-trochanter, heel, lateral and medial malleoli of ankle, olecranon, and over tibial and femoral condyles lateral and medial.
How would you take care of the bladder function? Persistent in-dwelling catheter should be discouraged as it leads to infection. If patient has incontinence, condom catheter is used. From below upwards Ll -- All sacral and coccygeal segment. T11 -- L4 and L3 segment. T1o-- L2 and L1 segment.
Tg -- T How will you clinically diagnose it? From a ny vertebrae T, to L. For c lin ica l di agnos is see page How will Jou tak e care of pressure sores? First en ure that the bed sheet ne not crumpled and has n o w rinkl es. The patient s hould always avoid pressure on bony promi - andnces for Io ng periods,.
W a ter- bed, or ai r-cushion mattress, 1f thick. A s for th e existent sore, s lou g h. This happe ns more c. He nce incrc:. Can be a rrested w ith o pe rauve spin al fusion. U Mild - Patient aware. Paralysi in extension. Stage Clinico-radiological features Usual duration.
Severe kyphos Humpback. IV, V - diagnosis is clear on conventional X-ray. CT scan and MRI would show advanced changes , however, these are unnecessary except for difficult sites Kumar, When the patient is unable to stand, squat, or walk, inform the examiner beforehand. Then comment on any scar, sinus, skin condition, ulceration or venous prominence. Liga- ments may be stretched also due to chronic synov1t1s e. In PPRP fixed equinus deformity is usually associated.
Recurvatum of knee in moderate degrees is actually helpful, because it stabilizes the knee which has weak quadriceps i. Finally, standing behind the patient, note, compare and comment on any swelling see ;, page , scar, sinus, skin condition , ulceration , or venous prominence. Look for any abnormal prominence at the hamstring insertion i. Finally request the patient to stand up and then enquire about any pain during squatting or getting up may be osteoarthritis , see page Note and mention , that ability to squat normally, with both lower limbs symmetrical, which indicates full range of knee flexion.
Next, in the swing phase note, compare and comment on the free-swing of the leg, or the absence of it may be due to patella-femoral pain. Finally in the stance phase, observe and comment on whether there is full knee extension or any hyperextension , and whether the knee "buckles" due to instability. Then slide the back of your fingers downwards from the thigh , over the knee and onto the legs of both the lower limbs to note, compare and comment on the "temperature gradient".
Normally the tem- perature decreases from superior to inferior. Next palpate the fibular head for biceps femoris insertional tendinopathy, or injury to the superior tibio- fibular ligament.
Then palpate the patella tenderness Fig 1. Don't forget to look at the patient's face. Finally note retropatellar tenderness, found in retropatellar cartilage damage by the following 3 tests. Then ask the patient to contract or "tense" the quadriceps. This will cause pain.
When the patient complains of pain during the procedure, the test is positive at that angle s of flexi on. Don't Fig 1. Then with your other hand , glide the patella in the intercondylar groove from medial to lateral and then from superior to inferior. Look at the patient's face and note tenderness. Fig 1. Then an t e knee extended, push the retropatellar facet see fig 1. Th is shou ld be th e medial joint line, so mark it. Confirm by passively flexing and extending the kn ee wh ile palpating the joint lin e.
Repeat the procedure along the antero-lateral surface to find the lateral joint line, and mark it. Then using th e pulps of your thumbs , palpate circumferencially along the joint line, from anterior to posterior.
Remember th at synovial thickening may also be palpated over the insertion of vastus medialis , which feels "boggy" or "doughy" see page Bulge test : It can be done with the patient standing , with the knee extended. Place your thumb and index finger on th e medial and lateral parapatellar fossae, and firmly compress the medial fossa so as to empty it.
Then sharply press the lateral parapatellar fosa. The medial fossa will refill with a "ri pple" see fig 1. Patellar Holl ow test : Normally, when the knee is grad ually flexed , a hollow appears , and then disappears just latera l to the patellar ten- don. In the presence of intraarticular fluid , when compared to the opposite knee , the refilling of the hollow, occu rs at a lesser angle of flexion.
Patellar Tap : With the knee extended , compress the suprapatellar bulge with your thumb and other fingers placed on both sides so as to empty it, and push the fluid down- wards under the patella. Now, with the tip of the index and middle finger of your other hand , sharply tap the centre of the patella see fig. This demonstrates a positive patellar tap test. This test is ineffective when there is excessive fluid causing "tight and tensed" swelling.
Cross Fluctuation : Cannot be done in very tense effusion. Now alternatively squeeze the suprapatellar bulge and the infrapatellar fossae to feel the transmitted "fluid impulse" across the joint see fig 1.
Anterior soft tissue swellings may be prepatellar bursa see page infrapatel lar bursa see page , or suprapatellar bursa.
Posteriorly they may be Morant Baker cyst see page , semimembranosus bursa see page or popliteal aneurism see page Medially they may be pes-anserine bursa always about fingers below the joint line , me- dial meniscal cyst, or a torn part of the medial meniscus.
With the knee in extension grasp the edges of patella in pincer made of thumb and middle finger and try to lift up the patella. Normally this is possible. In synovial thickening, the fingers slip-off the patella edges. The fingertips of both hands are pressed in the middle of the popliteal fossa i. It may be palpated in prone position with knee partly flexed.
Full extension 1s the neutral or zero position wh en the thigh and leg are compl etely aligned. Zero position can be noted wi th the patient supine on a.
If there is a gap, apply downward pressure over the patella with one hand, while lifting up the leg a few inches from the bed with your other hand by grasping the leg just above the ankle passive - see fig.
Remember that. If full extension is im- possible even "passively" then it is fixed-flex- ion-deformity FFD. Full extension can also be examined in the sitting position , with the legs Fig 1. Now abduct see fig. Re- peat the procedure on the other knee. Then alternatively rotate the leg medially and laterally see fig.
Repeat the procedure for the opposite knee. Note, compare and com ment. Other structures that contribute to stability are the quadriceps mainly vastus media- lis , the hamstrings, the joint capsule and the medial and lateral menisci. When it happens during climbing stairs - PCL may be torn, and when it happens during climbing downstairs - ACL may be torn.
Some commonly per- formed and popular tests are described in this chapter. Lachman Test : Th is test has a very high sensitivity , but it is difficult to perform in patients who are fat or very muscular. For muscular or fat. Look tor any subl uxation anteriorly and wh ether there is a tendency for medial rotation. When medial rotation occurs it is a positive "Lachman sign". Now repeat the procedure on the opposite knee. Anterior Drawer Test : First do the sag sign , see fig. This sta- bilizes the leg , while the weight of the patient's trunk stabilizes the thigh.
Now firmly grasp the upper leg wih both your hands, keeping the thumbs anteriorly and the fingers posteriorly see fig. Then alterntively apply force so as to "push-and-pull" the leg, and look for any subluxation. Next, repeat the test on the opposite knee. With the patient supine and leg extended, stand on the affected side of the patient. With your opposite hand grasp the ankle and medially rotate the leg see fig. Then, apply valgus stress by forcefully abducting the leg which may cause anterior subluxation and gradually start flexing the knee.
Remember reduction is due to the pull of the ilio-tibial band 1TB. Interestingly, often the patient confirms that there was the same feeling of sudden "giving-way" and later "stabilization". Single foot hopping test : If the patient can perform single foot hopping, then op r tive ACL reconstruction may not be indicated, except for atheletes or active sportspersons.
Bend low an d bnng down your eye line to. Posterior Drawer Test : Already discussed- posterior drawer sign see page Now, grasp and support the femoral condyles from below, with your hand which is towards the head of the patient. Using your opposite hand grasp the patients leg just above the ankle. Similarly apply varus stress i. Repeat the procedure on the opposite limb , standing on the other side of the patient. So medial meniscal injury is more common than lateral meniscal injuries.
Just as a positive test is not always pathognomic, a negative test does not rule out a meniscal tear. Palpation of a torn meniscus at the joint line, or tenderness at the joint line should make you suspicious.
Remember, the test may also be positive in osteoarthritis of knee. A combination of history, palpation and special tests for menisci should reasonably place meniscal injury in the list of differential diagnosis. If the patient complains of pain it suggests medial meniscal lesion. Interestingly the degree of flexion where the.
When the same procedure is done to bring the knee from go 0 flexion to full extension i. Apley's Grinding Test : With the patient prone, hold the ankle and lift the leg to flex the knee to go 0 with one hand. With one of your knee stabilize the posterior thigh by pressing onto it. Then request the patient to twist the body to one side and then to the other side, 3 times producing rotational force in the knee.
If there is meniscal lesion, there will be pain at the medial or lateral joint line and a feeling of "locking". It is an use ful tes t to note the ti ghtn e s a nd th e deg ree of te ns ion of th e lateral and medial parapat e llar retin acu lum. Norma l patellar excursion is half the breadth of patell a or 1 quadrant.
With th e patien t supine. Using your L thumb and index finger gra. Repea t the procedure for th e L knee standing on the L side of the patient. Co mpari tiv ely, when exces ivc mobility is noticed, the sa me procedure is repeated with the quadriceps tensed, by requ sti ng the patient to lift the lower limb about 8"- 12" off the bed.
Excessive lateral mobility sugge t lax medial patellofemoral ligament MPFL and incompetence of the medial retinaculum v ice-versa for excessive medi al mobility , and thus increa ed risk for habitual di slocation of patella. This test is positive fo r recurrent di slocation of patella and rarely for hab itual dislocation of patella see page With the patient supin e, stand on the R side of the patient. Using your L hand, place your fingers on th e lateral femoral condyle and the thumb on the medial margin of the pateUa see fig.
With your R hand grasp the lower leg and gradually tart flexing the knee, simultaneously applyi ng laterally directed pres- sure with your L thumb , trying to forcefully dislocate the patella laterally. Look towards the face of the patient. Reque t the patient to li e ideways on the unaffected side with the hips and knees flexed to obliterate lumbar lordo-i. Then tanding behind th patient extend the hip and knee of the affected limb maximally and try to addu t the hip e fig.
In ITB contracturc, adduction will be restricted. In severn 1TB contracture the limb will not touch the table and remain suspended sec fi g. The patient will complai n of pain at so me point, where you hould stop extension, and externally rotate the tibi a. If the pain i retie ed, then Wil on test i positive. Remember th at the investigation of choice is MRI. Patients have a varus thrust gait. Hip knee ankle angle : The angle formed by the mechanical axes of femur and tibia. A change in mechanical medial proximal t1b1al ang e s1gn1 ,es and proximal t1b1a 1 Join 11ne.
At fi rst sight, the most striking feature often is the prominence of the medial femoral condyle. This is a case of UR sided habitual dislocation of patella in a What are the types of patellar dislocation? It may be secondary to quadriceps contracture. Causes 1. Soft tissue factors : a Lateral side - Fig.
Factors causing increased Q angle : a When tibial tuberosity is more laterally placed. History : There may be history of trau ma. Crossing of large multiquasiparticle magnetic-rotation bands in Bi more. Sharp change-over from compound nuclear fission to quasifission more.
Measurement of giant dipole resonance width at low temperature: A new experimental perspective more. The systematic evolution of the giant dipole resonance GDR width in the temperature region of 0. The temperatures have been precisely determined by simultaneously extracting the vital level density parameter from the neutron evaporation spectrum and the angular momentum from gamma multiplicity filter using a realistic approach.
The systematic trend of the data seems to disagree with the thermal shape fluctuation model TSFM. Publication Name: Physics Letters B. Simultaneous optimisation of three different distributions the relative energy of 8Be like pairs, the root mean square energy deviation and the radial projection of symmetric Dalitz plot derived from the experimental data with those generated from the Monte Carlo simulated event sets, have been done to arrive at a consistent estimation of the contributions of various direct decay modes.
Properties of the alpha cluster states of [sup ]Po from elastic scattering of alpha particles from [sup ]Pb more. The same complex potential is used to calculate the alpha width of Po from the principle of The same complex potential is used to calculate the alpha width of Po from the principle of detailed balance.
The alpha width of the ground state can be reproduced to within a factor of 3 of the experimental value. Cluster state formation viz. It was observed that there is It has formed partnerships and alliances with leading distributors and various organizations worldwide. Academic Publishers also provides a variety of services to individuals and organizations worldwide. Have a requirement?
Get Best Price. Although written mainly for the undergraduates, the post-graduate trainees will also find it very handy and useful before the practical. Contact Seller Ask for best deal. Get Latest Price Request a quote. Kolkata, West Bengal. View Mobile Number.
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