Capítulo 2: CONCEPTOS DE ANÁLISIS FOTOGRÁFICO
2.2. El encuadre
2.2.3. Distancias focales y diafragma de los objetivos
“Mr/Ms.., now balance yourself on one leg. Start with the right
one….Close your eyes… Thank you, open your eyes.. Now, repeat on the left leg… close your eyes.. Thank you.”
To the examiner“Balance is normal.” 6- True & Apparent leg length:
Set the pelvis horizontally; place the legs 15-20 cm apart. True: Measure each leg from anterior superior iliac spine to medial maleolus. Apparent: same but from umbilicus.
“Mr/Ms.., now I want to measure your legs’ length… stand straight with your feet 15-20 cm apart and level your pelvis horizontally… let me see.. okay, let me measure.”
To the examiner“Legs’ lengths are symmetrical.”
2.Palpation:
“Mr/Ms .., Let me feel your hips, will you please lie down here flat on your back.”
Anterior aspect: 1- Iliac crests, anterior superior iliac spine, symphasis pubis. 2- Inguinal ligament, femoral triangle.
3- Hip joint, and. greater trochanter & trochantric bursa. 4- muscles.
5- Crepitation: place your fingers over the femoral head (lateral to femoral artery below inguinal ligament), then roll the relaxed leg medially & laterally (internal & external rotation).
“Mr./Ms.., relax your leg, I’m going to roll it in and out.” Femoral, popliteal, posterior tibial, and dorsalis pedis pulses.
Posterior aspect: “Now roll over on your stomach, let me feel your hips from the back.”
1- Iliac crests, posterior superior iliac spine. 2- Ischial tuberosity, greater trochanter.
3- Sacroiliac, lumbosacral, and sacrococcygeal joints.
To the examiner“There is / is no warmth, effusion, bony, soft tissue or joint tenderness. No crepitus. The skin is normal in thickness, soft, normal moisture. No muscular fasciculation. Distal pulses are present.”
Range of Motion: Patient still prone.
- Extension (10-150): “Mr./Ms.., will you please move this leg up to the
maximum….. Any pain?” If yes; “How does it feel like?.. From a scale of 1 to 10 where 1 is the mildest and to is the worst, how would you
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Musculoskeletal Examination: …Cont.
“Mr./Ms.., now let me move it the same way, please relax it.” Passive movement.
“Mr./Ms.., now I’ll do it again, but this time don’t let me do move it. I want to check your strength.” Power assessment.
“Now turn back on your back………….” COVER THE PATIENT
- Flexion (110-1200
): Knee also flexed.
“Mr/Ms.., now bend both your hip and knee.”
- Abduction (30-500): Place your hand on the opposite superior iliac spine to
fix the pelvis
“Now, I’ll hold your other hip. Please move your leg on the stretcher away from midline.”
- Adduction (300
):
“Now, bring it back and cross it over the other leg as far as you can.” - Rotation: With both hip and knee flexed. Move the foot in (external) and out
(internal) with both hip and knee fixed in position. - External (40-600): Moving the foot INWARD
“Mr/Ms.., now bend both your hip and knee 900…. Now move your
foot inward without moving the knee.” - Internal (30-400
): Moving the foot OUTWARD. “Now, move it outward.”
Passive: “Now let me move your leg in the same way to feel it, relax it.”
To the examiner“Active and passive range of motion is normal. End feel is normal tissue stretch.”
3.Power Assessment/Isometric Movements:
Patient is still supine. “Mr/Ms.., now, I’m going to check your power, okay.. I’m going to do the same movements you just did but don’t let me move you, resist me.” Do flexion, abduction, adduction, and internal and external rotation.Extension already done.
To the examiner“Normal muscle power, no weakness.”
5.Special tests:
Patient is still supine.1- Patrick’s Test (Faber or Figure-Four Test): on the affected leg.
“Now, place your right/left foot on the other leg knee…. I’ll bring your knee down to the stretcher.” Positive if the leg cannot be brought on stretcher parallel to the other leg.
Causes: 1. Hip or sacroiliac joint problem.
The Physical Examination Interview: Musculoskeletal Examination
Musculoskeletal Examination: …Cont.
To the examiner“Negative / Positive Patrick’s Test.”
2- Thomas Test: for fixed hip flexion contracture (most common hip
deformity).
Place your hand under his lumbar spine to obliterate the free space (lordosis).
Ask the patient to bend the leg and hold it against his abdomen. “Mr/Ms.., I’m going to put my hand under your lower spine…. Bend your right/left leg and hold it against your abdomen.” Elevation of the opposite thigh, Positive Thomas Test, suggests fixed hip flexion contracture of that hip (the elevated one not the one flexed against the abdomen).
To the examiner“Negative / Positive Thomas Test.”
3- Infants: Ortolani Test: for congenital hip dislocation. Infant supine with
both hips and knees flexed. Place your hands with the thumbs on the inner thighs & fingertips over the thigh muscles. Abduct each knee until it touches the table. If dislocated: an audible & palpable ‘chunk’ will be produced as the femoral head reenters the acetabulum.
6.Sensations and Reflexes:
- Sensation: L5: Foot dorsum. S2: Medial posterior thigh.
“Mr/Ms ..,I’m going to feel your skin with this cotton on several points on your leg. I want you to say ‘yes’ when you feel it just like this, okay. Let us start, close your eyes.”
Never ask the patient if he/she is feeling the touch every time you touch the skin so he wont know if you are touching or not.
To the examiner“Sensation screen is normal.”
- Reflexes:
“Mr/Ms .., now, I’ll check your reflexes. I’m going to strike this hammer gently on some points near your leg joints, Okay?” Patellar tendon reflex (Knee jerk) L2 - 4:
“Mr/Ms., I’ll start here on your right knee(Set the leg, strike, and watch twice).Now the other one.”
To the examiner“Patellar tendon reflex is normal/ diminished/ increased.”
Achilles tendon reflex (Ankle jerk) S1 - 2:
“Mr/Ms .., now your ankle. …. (Set the foot, strike, and watch twice).Now the other one….”
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The Physical Examination Interview: Musculoskeletal Examination