Functional tests
Grifka test
Evaluates the degree of inversion of the foot (flat feet).
Methodology . After passive dorsiflexion of the toes, the doctor presses with his fingers from the plantar side on the heads of the patient's metatarsal bones, causing compression in the metatarsophalangeal joints.
Grade . This test corresponds to the loads that occur during walking in the metatarsophalangeal joints and causes pain in the affected toe. In bunion feet this is often painful, whereas plantar compression alone does not cause pain.
Strunsky test
Provocative test to evaluate metatarsalgia.
Methodology . The patient is positioned on the table so that his feet hang over the edge of the table. Having tightly squeezed the first toes of the patient’s feet with the first and second fingers of his hands, and also grasping the remaining toes of the patient’s feet, the doctor performs maximum plantar flexion in the metatarsophalangeal joints.
Grade . In patients with existing chronic metatarsophalangeal joint pathology with metatarsalgia, this test significantly increases symptoms as a result of increased pressure on the metatarsophalangeal joints. Subsequent palpation of the metatarsophalangeal joints can identify the affected joint.
Finger displacement test
Used to assess instability of the metatarsophalangeal joints.
Methodology . Fixing the middle part of the forefoot with one hand, the doctor grasps the distal part of the proximal phalanx with the other hand and moves it alternately posteriorly and in the plantar direction relative to the head of the metatarsal bone.
Grade . Pain during movement in the metatarsophalangeal joint, accompanied by symptoms of instability, confirms the increasing deformation of the finger, leading to a functional claw-shaped deformity of the finger during walking with a load. Progression of this instability leads to a permanent claw deformity of the toe, in which the metatarsophalangeal joint is fixed in a dorsiflexed position.
If there is a dislocation in the metatarsophalangeal joint, then it is impossible to eliminate it in this test. The result is metatarsalgia with the development of plantar calluses.
Mulder click test
Used to diagnose interdigital neuroma (Morton's neuroma).
Methodology . The doctor grasps the patient's forefoot with his fingers in a "claw" manner and squeezes it. This causes the metatarsal heads to move closer to each other.
Grade . In the presence of an interdigital neuroma, pain and sometimes paresthesia occurs, radiating to adjacent fingers. Occasionally, a small fibroid-like hard mass may be palpated between the toes and may become dislodged, sometimes with an audible click as the forefoot is compressed. Morton's neuroma is shaped like a fusiform bulb and develops in the plantar nerve. Painful interdigital neuromas usually develop in the second or third interdigital space; Neuromas in the first or fourth spaces are rare.
Gaenslen maneuver
Allows you to evaluate pain in the forefoot.
Methodology . The doctor fixes the heads of the patient's metatarsal bones in one plane, holding them between the fingers of the hand on the plantar side and the first finger of this hand, located on the back of the foot. With the other hand, folded in a “claw” shape, the doctor grasps the patient’s toes, applying medial and lateral compression to the forefoot from the metatarsal heads of the first and fifth toes.
Grade . This "claw" compression of the forefoot causes pain between the metatarsal heads, often with sharp, episodic pain radiating to nearby toes in the presence of Morton's neuroma (painful interdigital neuroma). It also often causes pain when there is significant hallux valgus when there is irritation of the joint capsule.
Metatarsal Tapping Test
Provocative test to determine metatarsalgia
Methodology . The patient lies on his back with his feet hanging over the edge of the table. The physician slightly hyperextends the patient's toes with one hand and taps the metatarsal heads or metatarsophalangeal joints with a hammer with the other hand.
Grade . In patients with metatarsalgia due to chronic irritation of the metatarsophalangeal joints, effleurage causes an increase in metatarsalgia symptoms. Pain during tapping that occurs between the metatarsal heads (primarily the third and fourth, with sharp pain radiating to adjacent toes) is characteristic of Morton's neuroma (see Mulder click test)
Questioning the patient
If the patient is unconscious, it is necessary to find out, if possible, the circumstances and mechanism of injury from the persons accompanying him. If the patient is conscious, his complaints may indicate the main source of pain and often the segment of damage. Anamnesis plays a very important role. It is necessary to find out the time, place and circumstances of the injury. If the first two factors are of interest to legal authorities, then the mechanism of injury can suggest a diagnosis or refute it. For example, if a victim is hit on the back with a stick, the processes and arch of the vertebra may be broken, but not the body. If the victim claims that the foot has turned outward, then a Dupuytren's type of ankle fracture is possible, but not a Malgaigne's fracture. Anamnesis data is entered into the medical history even in cases where the doctor doubts their veracity (the patient is intoxicated by alcohol or drugs, is aggravating, etc.), in all cases of description of the anamnesis, a reservation should be made: “Recorded from the patient’s words,” “ according to relatives”, “according to ambulance workers”, etc.
Achilles tendon
Thompson compression test (Achilles tendon compression test)
Methodology . The patient lies on his stomach. His feet hang over the edge of the table. The doctor grasps the muscles of the upper third of the affected leg with one hand and squeezes them tightly.
Grade . Normally, compression of the calf muscles causes rapid passive plantar flexion of the foot. The absence of this plantar flexion indicates an Achilles tendon rupture. In patients with a partial Achilles tendon rupture, this test is not always conclusive and depends on the extent of the rupture. Patients with a torn Achilles tendon cannot stand on their toes, especially on the injured limb, and the Achilles reflex will be absent.
Note. This test can also be performed with the patient lying prone with the leg flexed to 90° at the knee. In this position, the doctor covers the muscles of the upper third of the leg with both hands and squeezes it tightly. Loss of plantar flexion is a symptom of an Achilles tendon rupture (Simmond test).
Hoffa's sign
Allows you to diagnose old rupture of the Achilles tendon.
Methodology . The patient lies on his stomach with his feet hanging over the edge of the table. The therapist passively performs dorsiflexion (dorsiflexion) of both feet.
Grade . In the presence of an old rupture of the Achilles tendon, the tension of the Achilles tendon decreases, and the affected foot may achieve greater dorsiflexion compared to the healthy one. The patient is then asked to stand on his toes, alternately on each leg. On the limb where there is a rupture of the Achilles tendon, the patient will not be able to stand up as suggested.
Achilles tendon tapping test
Allows you to diagnose Achilles tendon rupture.
Methodology . The patient lies on his stomach with his legs bent to 90° at the knee joints. The doctor taps the Achilles tendon in its distal third with a neurological hammer.
Grade . Increased pain and decreased plantar flexion (Achilles reflex) are symptoms of an Achilles tendon rupture. In the absence of the Achilles reflex, a differential diagnosis with neurological changes must be made.
Foot elasticity test
Evaluates the rigidity or elasticity of persistent flatfoot deformity (clubfoot).
Methodology . Planovalgus deformity (clubfoot) is characterized by an increase in the valgus position of the heel and flattening of the medial longitudinal arch (flatfoot or flat foot - pes planus). The feet are examined from the side and back with patients standing in a normal position, and then at the toes.
Grade . In the presence of a rigid planovalgus deformity, the valgus position of the heel and flattening of the medial longitudinal axis are preserved when the patient stands on his toes. With elastic planovalgus deformity, standing on the toes leads to varus of the heel, thereby compensating for the valgus deformity, and the medial longitudinal arch reappears.
Forefoot adduction test
Used to evaluate and differentiate between rigidity and elasticity of the foot adduction.
Methodology . The child lies on his back. The physician grasps the foot of the affected limb with one hand and tries to eliminate adduction of the foot by pressing on the medial edge of the forefoot with the first finger of the other hand.
Grade . If this manipulation easily eliminates foot adduction, then the deformity can correct itself spontaneously. A deformity that cannot be corrected is rigid.
Congenital deformity, which can be corrected manually, requires careful timely treatment using corrective plaster casts.
Examination of the patient
The examination begins from the moment the patient enters the emergency room or trauma room. If the patient moves independently, it is necessary to pay attention to his gait, how he sits down, takes off his clothes, his facial expressions and protective movements. It is better to carry out further examination with the victim completely exposed, and if this is not necessary, then you can limit yourself to examining half of the body, and the limbs are examined symmetrically for comparison. With this method of examination, it is possible to identify gentle postures of the patient, deformations of body segments due to edema, hematomas or bone damage, an increase or disappearance of the physiological curves of the spine, muscle tension, and unnatural positions of the limbs during dislocations. Sometimes deviations of the limb or its segment outward or inward are visible. In the first case, an angle opens outward; This deformity is called valgus. If the segment deviates inward, the angle will also be open, but inward, and the deformity is called varus.
Ankle joint
Lateral and medial ankle stability test
Allows assessment of damage to the lateral ligaments of the ankle joint.
Methodology . The patient lies on his back. The physician secures the lower limb behind the ankles with one hand. With the other hand, he grasps the lateral part of the midfoot and performs supination, trying to widen the joint space of the ankle joint on the lateral side. To evaluate the medial ligaments, the physician grasps the medial side of the midfoot and pronates, attempting to widen the medial joint space.
Grade . Injury to one of these ligaments results in instability and increased opening of the medial or lateral joint space. Increased supination may result from injury to the anterior talofibular and calcaneofibular ligaments. Increased pronation can occur when the deltoid ligament is damaged. Supination rotational injury is the most common mechanism of ankle injury and almost invariably involves the anterior talofibular ligament. Children usually have a greater range of motion in the ankle joint and this should not be misdiagnosed as ligament damage.
Comparison of both feet during examination is mandatory. Stress radiographs are necessary to document ligamentous injury, especially in the ankle.
Drawer test
Used to assess ankle stability.
Methodology . The patient lies on his back. The doctor fixes the patient's lower leg with one hand from behind and covers the midfoot with the other hand. The doctor moves the foot posteriorly at the ankle joint, against the force of the hand fixing the lower leg. In the second stage, the doctor covers the lower leg from the front and the heel from the back. Then the foot moves forward against the force of the hand fixing the lower leg.
Grade . A comparative examination of both limbs is performed. A rupture of the lateral collateral ligament of the ankle results in increased mobility of the foot at the ankle joint; rupture of the anterior ligaments leads to increased anterior mobility, and rupture of the posterior ligaments leads to posterior displacement.
Heel compression test
Indicates the presence of a stress fracture of the calcaneus.
Methodology . The physician performs symmetrical compression of the patient's heel between the thenars of his palms.
Grade . When a stress fracture is present, the patient experiences intense pain in the heel. Stress fractures mainly occur in patients with severe osteoporosis. Patients with such fractures develop a certain gait due to pain, often walking without putting any weight on the heel at all. The heel area itself may be swollen and painful on palpation. Heel compression rarely causes significant pain in patients with other conditions, such as subcalcaneal bursitis.
Tinel symptom
Indicates the presence of tarsal tunnel syndrome.
Methodology . The patient lies on his stomach, the leg is bent to 90° at the knee joint. The doctor performs percussion with a neurological hammer behind the inner malleolus in the projection of the tibial nerve.
Grade . Pain and discomfort in the plantar part of the foot confirms tarsal tunnel syndrome. This disease is a chronic neuropathy located behind the medial malleolus under the retinaculum of the flexor tendons. The nerve can be palpated behind the medial malleolus and palpation usually causes pain. The progression of neuropathy leads to sensory disturbances in the zone of innervation of the plantar nerve and atrophy of the plantar muscles.
Introduction
The correct method of examining the victim is the basis for making a diagnosis and timely treatment. Examination of a patient with injury or its consequences consists of a survey (complaints and history of injury), examination, palpation, percussion, auscultation, determining the range of motion in the joints, measuring the length of the limbs, determining muscle strength and limb functions, and only after that they resort to choosing additional research methods: laboratory, x-ray, ultrasound, etc.
Measuring the length and circumference of limbs
Measurement of the length and circumference of the limbs is performed on both the damaged and healthy limb. The obtained data are compared, which gives an idea of the degree of anatomical and functional disorders. When taking measurements, the patient must be positioned correctly: pay attention to the pelvis so that it is not skewed, and the line connecting the anterosuperior spines must be perpendicular to the midsagittal plane of the body. There are true, or anatomical, and functional limb lengths.
On the upper limb, the anatomical length is determined by measuring from the greater tubercle of the humerus to the olecranon and from the olecranon to the styloid process of the ulna; functional length - from the acromial process of the scapula to the end of the phalanx of the third finger. The anatomical length of the lower limb is determined from the greater trochanter of the femur to the lateral malleolus, the functional length is determined from the superior anterior iliac spine of the pelvis to the medial malleolus.
The circumference of the limb segments is measured in symmetrical places at the same distance from the identifying bony protrusions. For example, the thigh circumference in the middle third is measured 15-20 cm above the upper pole of the patella.
Laboratory research
♦ Clinical tests
Clinical studies primarily mean general blood, urine and stool tests. This is the minimum laboratory testing, without which it is impossible for the victim to undergo full-fledged therapy, much less perform surgery without the risk of serious complications or even death.
♦ Blood test
A blood test is carried out by counting the number of erythrocytes, leukocytes and determining the leukocyte formula, hemoglobin content, color index, hematocrit, ESR. If surgical intervention is proposed, there is a suspicion of ongoing interstitial or intracavitary bleeding, the study is supplemented by counting platelets, reticulocytes, determining the clotting time and duration of bleeding.
We give approximate normal indicators of the listed research parameters in an adult. Why exemplary? Yes, because they fluctuate depending on age, gender, sometimes time of day and place of residence of the subject. We present the average norms for the Central zone of Russia without taking into account the extreme climatic regions of the Far North, Northeast, and South.
- Red blood cell count: men - 4.0-5.5x1012/l; women - 3.6-5.0x1012/l.
- Leukocyte count: 4.0-4.8x1012/l.
- Hematocrit (the ratio of the volumes of red blood cells and circulating blood plasma): men - 0.380-0.480; women - 0.330-0.450.
- Platelet count: 180-320x109/l.
- The normal number of reticulocytes (young forms of red blood cells) in circulating blood is from 0.2 to 1%, i.e. 30-70x109/l.
- The duration of bleeding (according to Duke) is 2-3 minutes.
- Blood clotting time (according to Sukharev): beginning - from 30 s to 2 min; end - from 3 to 5 minutes.
- Leukocyte formula is the percentage of different leukocytes in a blood smear. The study is practically nonspecific, but very important, as it serves as an indicator of the severity of the patient’s condition.
♦ Urine examination
The quantity, color, transparency, density are determined (the norm is 1.008-1.025, fluctuates throughout the day). pH - 4.5-8.0. Tests for protein, glucose, and bilirubin must be negative.
In case of injuries, a test for the presence of blood in the urine. A positive reaction indicates damage to the genitourinary organs and urinary tract. In case of severe injuries, oliguria and anuria indicate the severity of the patient’s condition and become poor prognostic signs.
♦ Biochemical studies
If we consider biochemical research in traumatology in detail, it will result in a voluminous work of hundreds of typewritten pages. The purpose of the traumatology manual is not to describe the technique and features of all biochemical studies, but to once again remind orthopedic traumatologists of the importance of this branch of medicine in the diagnosis of injuries and diseases, but most importantly, to focus attention on the need for such studies in seriously ill patients, and this is primarily first of all, victims with multiple and combined injuries of the musculoskeletal system.
Without biochemical studies, it is impossible to control and regulate water-salt balance, acid-base, colloid-osmotic balance, determine the condition and functionality of vital organs: liver, kidneys, pancreas, etc. Only constant monitoring of biochemical studies and drug correction of identified changes can bring a patient with polytrauma back to life.
♦ Biopsy
A biopsy is used to obtain a preliminary histological diagnosis. It can be puncture, aspiration and open, depending on the time of material collection - preliminary and urgent (at the time of surgery).
• A puncture biopsy is used for lesions that are difficult to access for open biopsy or when there is a suspicion of a formation that is more easily diagnosed with a puncture. To carry it out, special syringes with special needles are used, with which, at the time of puncture, a column of material is taken for examination.
• A more reliable method of biopsy is aspiration, when access to the object of study is provided using a trocar, and aspiration contributes to a more extensive removal of tissue for research.
• The most accurate picture of the morphology of pathological tissue is provided by an open biopsy. It must be performed as a serious operation (usually under general anesthesia) in compliance with all the rules of asepsis and antisepsis. The soft tissue incision is made small, but sufficient for visual identification of pathological or suspicious tissues and sampling of the desired areas for subsequent examination. More often, an open biopsy is prescribed for tumor processes in inpatients at the time of surgery (urgent biopsy).
Instrumental studies
♦ X-ray examination
From the moment of their appearance to the present day, X-ray research methods have played a leading role in diagnosis, studying the dynamics of consolidation and resolving injuries of the musculoskeletal system. Almost half of the total working time of any radiology department is devoted to this work. It is clear that in any trauma clinic, X-ray diagnostics rightfully occupies the main place among other methods for recognizing fractures, dislocations and their complications.
It would seem that what could be simpler than diagnosing skeletal damage using an x-ray? But only an amateur, who is far from understanding how damage to a segment of the musculoskeletal system is diagnosed, can think so. In order for the doctor’s conclusion to be accurate, he must have a good knowledge of the x-ray anatomy and physiology of the skeleton, its age-related characteristics, starting from the formation of the child’s skeleton and ending with senile changes. The doctor reading the x-ray should be aware of the standard ways of positioning the patient during the examination and the possible distortions of the image if they are inaccurate. In addition, we should not forget about the so-called radiological findings: features of skeletal development, unstable bones, anomalies, dysplasias and rare or simply chronic sluggish diseases. Here is a small list of knowledge necessary to make a diagnosis with the simplest examination - radiography.
And yet, one of the main conditions for correct diagnosis is a thorough clinical examination of the patient in general and the site of injury in particular. Diagnostic clinical and radiological observation is considered the most complete if the orthopedic traumatologist himself masters reading radiographs, and does not base his conclusions only on the data of the written report of the radiologist.
Radiological science does not stand still: a large number of new studies have appeared, so the range of medical knowledge must constantly expand. In the last quarter century, new diagnostic imaging techniques such as ultrasound (ultrasonography), scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI) have become widespread.
♦ Computed X-ray tomography
Computed X-ray tomography is a method of layer-by-layer visualization of organs and tissues in an axial projection. During the examination, a narrow beam of X-rays “looks” through the patient’s body around the circumference at the level of the outermost opposite layer. Passing through the shadows, it is partially absorbed, then it is recorded by sensors, where it is converted into an electrical signal. A variety of electrical signals, carrying information about the X-ray image, are transformed into analog digital form and transmitted to a computer. Based on the digital code, the computer processor builds a density image of the layer under study, visible on the display screen. The method allows you to clearly identify the structure of bone matter, determine bone density, perform measurements, study the condition of soft tissues, articular cartilage, walls of the spinal canal, and construct a three-dimensional image of the skeleton.
♦ Magnetic resonance imaging
Magnetic resonance imaging is the visualization of thin layers of tissue in the human body in any plane. The method is based on the ability of hydrogen nuclei (protons) located in the tissues of the body to respond to the influence of a stable magnetic field and an alternating radio frequency wave. During the examination, the patient is placed in a diagnostic magnet tunnel, which also contains an installation for directing a radio signal to the layer under study. The radio frequency pulse leads to resonant excitation of protons and their deviation from the axis of rotation by 90° or 180°. At the end of the pulse, proton relaxation occurs, accompanied by the release of energy in the form of an MP signal. After this, the hydrogen nuclei return to their original position. The energy of relaxed hydrogen nuclei is recorded, converted into a digital code, and then it is sent to powerful computers, where it is used to reconstruct the image. The most powerful MP signal is characteristic of soft tissues. MP tomograms perfectly display muscles, fat layers, cartilage, blood vessels, bone and spinal cord, intervertebral discs, and periosteum. Bone tissue does not produce an MP signal.
♦ Osteoscintigraphy
Osteoscintigraphy is radionuclide visualization of the skeleton. The study is carried out using osteotropic radiopharmaceuticals (RPs) administered intravenously. Their inclusion in bone tissue reflects the state of blood flow in the bone and the intensity of metabolic processes in it. Gamma radiation from a radioactive tag is recorded by a gamma camera and converted into a visible image. The moving table of the gamma camera allows you to visualize the distribution of radiopharmaceuticals throughout the skeleton. Normally, there is a relatively uniform and symmetrical accumulation of radiopharmaceuticals in the skeleton. With tumor metastases, “hot spots” are identified. Hyperfixation of radiopharmaceuticals is observed in the area of fracture, with osteomyelitis, arthritis, and primary malignant bone tumors. A local decrease in radiopharmaceutical concentration is observed in aseptic bone necrosis.
♦ Ultrasound scanning
Ultrasound scanning (ultrasound, sonography) - layer-by-layer visualization of organs and tissues using ultrasound machines. The method is based on the use of ultrasonic waves with a frequency above 20 kHz. They penetrate well through tissue and are capable of being partially reflected from the boundaries of two media with different densities. The reflected echo signal serves to form an image on the display screen. The method is most informative when studying soft tissues. The examination reveals tendon ruptures, joint effusion, proliferative changes in the synovial membrane, synovial cysts, soft tissue abscesses and hematomas, and soft tissue foreign bodies.
Determination of muscle strength
Muscle strength is determined by the method of action and reaction, i.e. the patient is asked to perform the movement characteristic of the joint and, counteracting the examiner’s hand, the muscle tension is determined. Muscle strength is assessed using a 5-point system:
- 5 points - muscles of a healthy limb;
- 4 points - slight muscle atrophy, but the strength allows you to overcome the mass of the limb segment and the obstacle created by the researcher’s hand, but the resistance is weaker than on a healthy limb;
- 3 points - moderate muscle atrophy with active overcoming the mass of the segment, but without resistance;
- 2 points - severe atrophy, muscles contract with difficulty when the action of the mass of the segment is excluded;
- 1 point - severe muscle atrophy, no contractions.
Palpation
Palpation plays an important (if not decisive) role in making a trauma diagnosis. With its help, you can determine the point of greatest pain, the presence of a hematoma, fluid in the joint cavity, bone deformation, its pathological mobility, and crepitus. Palpation reveals a reliable sign of a fracture - a symptom of axial load. It is checked by squeezing a long tubular bone or a segment of limb bones along the longitudinal axis. This causes pain at the fracture site. By palpation, you can determine the violation of the external landmarks of the bones that form the joints. For example, in a flexed elbow joint, lines drawn through the external and internal epicondyles of the shoulder and through the apex of the olecranon form an equilateral triangle.