Physical Examination Orthopedi

151
Physical Examination Orthopedic

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Physical Examination Orthopedi

Transcript of Physical Examination Orthopedi

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Physical Examination Orthopedic

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Cervical

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Inspeksi

• Posisi kepala tegak lurus gerakan terkoordinasi

• Yang harus diperhatikan luka, jejas, perubahan warna

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Palpasi

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• Hyoid bone : meraba dengan dua jari garis tengah – lateral – posterior ( meminta pasien untuk menelan) teraba tulang hyoid

• Thyroid cartilage : garis tengah – kebawah ( akan teraba kartilago thyroid yang ukuranya kecil). Adam’s Apple

• First cricoid ring: letak lebih rendah dari tulang rawan tiroid

• Carotid tubercle : lateral, 1 inch dari dari first cricoid ring . Ukuran: kecil dan berada di garis tengah, didalam otot

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Move

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Muscle test

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Neurolgic examination

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Extensor carpi radialis longus,Extensor carpi radialiis brevisExtensor carpi ulnaris

Refleks tes: brachioradialis reflex

Sensation tes: lateral forearm (N.musculocutaneus)

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Muscle test: Triceps (N.Radiali) extensionWirst flexor 1.Flexor carpi radialis2.Flexor carpi ulnarisFinger extensor 1. Extensor digitorum communis2. Extensor digiti imdicis3. Extensor digiti minimi

Reflex test: triceps reflex

Sensation test: middle finger

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Muscle tes: finger flexus 1.Flexor digitorum superficialis2.Flexor digitorum profunidis

Sensation testRing and little fingers and forearm’s ulnar side

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Sensory Evaluation by cervical dermatoms

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Motor dermatomes Examination

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Reflexes

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Clinical Evaluation

Inspection• Posture• Movement Pattern

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• Palpation: Thoracic Spine• Position: Supine, prone, seated– Spinous Processes– Supraspinous Ligaments:

• Fills space between the spinous processes– Costovertebral Junction:

• Articulation between ribs and thoracic vertebrae– Only palpable on slender individuals

– Trapezius:• Origin to insertion• Rhomboids and levator scapulae lie deep to middle/upper traps

– Paravertebral Muscles– Scapular Muscles

Clinical Evaluation

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• 1 – Spinous Processes• 2 – Supraspinous

Ligaments• 3 – Costovertebral

Junction• 4 – Trapezius• 5 – Paravertebral

Muscles• 6 – Scapular Muscles

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Clinical Evaluation

C7

T1

T2

T3

T4

T5

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ROM TestMotion Normal Value Normal End Peel

Flexion 20-40 degrees Tissue stretch

Extension15-30 degrees Tissue stretch or bony

block

Lateral Flexion 25-30 degrees Tissue stretch

Rotation 5-20 degrees Tissue stretch

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Clinical Evaluation

• Resistive Range of Motion:– Flexion:• Patient position – supine with knees flexed and feet

flat on table• Stabilization – pelvis• Resistance – applied to the superior sternum as

patient lifts the scapulae off the table• Muscles tested – rectus abdominis, internal oblique,

external oblique

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Clinical Evaluation

• Resisted Range of Motion:– Extension:• Patient position – prone with arms interlocked behind

the head• Stabilization – lower lumbar region• Resistance – applied to upper thoracic spine as patient

lifts head, chest, and arms off table• Muscles tested – iliocostalis lumborum, iliocostalis

thoracis, longissimus thoracis, spinalis thoracis, semispinalis thoracis, rotators, latissimus dorsi

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Clinical Evaluation

• Resisted Range of Motion:– Rotation:• Patient position – supine (hands interlocked behind

head)• Stabilization – opposite ASIS• Resistance – anterior aspect of shoulder as it is

rotated off the table• Muscles tested – internal oblique, external oblique

(opposite side), rotators

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Thoracic Rotation

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Passive Rotation

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Resisted rotation

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Dural test

• Lhermitte sign

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Neurological Examination

• Beevor’s sign• Cremasteric reflex (in men)• Oppenheim’s sign

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Clinical Evaluation

• Beevor’s Sign:– Test for thoracic nerve inhibition

• Patient performs an abdominal curl-up from hook-lying position• Normal Findings: abdominal muscles receive concurrent

innervation from T5-T12 nerve roots (umbilicus does not move)• Positive Test: umbilicus is pulled toward the head

– Characteristic of spinal cord injury between T6 and T10 levels» Upper abdominal muscles (rectus abdominis) are intact at the

top of the abdomen but weak at the lower portion, patient is asked to do a sit up – only the upper muscles contract (umbilicus pulled toward the head)

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Physical examination of the spine

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Inspection

• Gait • Skin – color, scar, nevus, café au lait• Any swelling – Lipoma, cold abscess • Muscle wasting• Deformity - Scoliosis• Abnormal growth hair

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Inspection

• Laterally:– Spinal curves– Kyphosis– Lordosis

• Anterior: – Abnormal posture– Are the shoulder and pelvis in alignment?– Asymmetry of upper body muscles

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Feel

• Local rise in temperature• Any swelling, fluctuation • Palpate all spinous process – are they in

alignment?• Palpate sacroiliac joint – any tenderness?• Palpate paraspinal muscles – any

tenderness/spasm?

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Move

• Lumbar lateral flexion• Lumbar extension• Lumbar flexion place two finger on lumbar

spine distance between two finger should increase during flexion

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Pemeriksaan Neurologi

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Neurologic level T12, L1, L2, L3

• Muscle testingIliopsoas : T12, L1, L2, L3, L4

• Sensation testing

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Neurologic level L2, L3, L4

• Muscle testingQuadriceps : L2, L3, L4, n. femoralHip adductor group : L2, L3, L4, n. obturator

• Sensation testing

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Neurologic level L4

• Muscle testingTibialis anterior : L4, n. peroneal profunda

• Reflex testing : refleks patella• Sensation testing : medial of the leg

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Neurologic level L5

• Muscle testingExtensor hallucis longus : L5, n. peroneal profundaGluteus medius : L5, n. gluteal superiorExtensor digitorum longus and brevis : L5, n. peroneal profunda

• Reflex testing : (-)• Sensation testing : lateral leg and dorsum manus

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Neurologic level S1

• Muscle testingPeroneus longus and brevis : S1, n. peroneal superficialGluteus maximus : S1, n. gluteal inferior

• Reflex testing : refleks achiles • Sensation testing : lateral malleolus, lateral

side andplantar surface of the foot

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Neurologic level S2, S3, S4

• Refleks abdominal superficial• Refleks kremaster superficial• Refleks anal superficial• Oppenheim test

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Special test

• Test to stretch spinal cord/sciatic nerve• Test to increase intrathecal pressure• Test to rock the sacroiliac joint• Neurologic segmental innervations test

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Test to stretch spinal cord/sciatic nerve

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Test to increase intrathecal pressure

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Test to rock the sacroiliac joint

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Neurologic segmental innervations test

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Shoulder physical examination

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Examination

• LOOK

• FEEL

• MOVE

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Special tests

• Rotator cuff.• Instability• AC joint.• Impingement syndrome.• Biceps• SLAP• Thoracic outlet Syndrome

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Conditions

• Instability• Subacromial impingement• Rotator cuff rupture• SLAP Lesions– Superior labral anterior-posterior

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Rotator cuff

• ROTATOR CUFF INTEGRITY:– Active ROM + strength of:• Supraspinatus• Infraspinatus.• Subscapularis• Teres minor

– Lag signs.

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Rotator cuff integrity

Subscapularis

Lift-off TestBelly Press Test

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Rotator cuff integrity

Supraspinatus

Jobe test

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Rotator cuff integrity

Infraspinatus

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Rotator cuff integrity

Teres minor

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Rotator cuff integrity

Lag signs

Drop sign

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Rotator cuff integrity

Lag signs

External Rotation Lag Sign

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Rotator cuff integrity

Lag signs

Lift-off Test (Lag Sign)

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IMPINGEMENT TESTS

Neer’s impingement sign .

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IMPINGEMENT TESTS

Internal Rotation Resistance Stress Test

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IMPINGEMENT TESTS

Hawkin’s impingement test.

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IMPINGEMENT TESTS

Empty Can Test

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LAXITY TESTS

Sulcus sign

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TRANSLATION TESTS

Anterior and posterior drawAnterior and posterior draw

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INSTABILITY TESTS

Apprehension Test

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INSTABILITY TESTS

Relocation test Release test

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INSTABILITY TESTS

The Crank Test

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SLAP

O’Brien’s Active Compression Test

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SLAP

The pain provocation testSupination Pronation

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SLAP

Compression / rotation test

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SLAP

The biceps load test

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AC joint

Scarf test

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Biceps

Speed test

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Special Tests - Instability

• Sulcus sign

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Elbow and hand wrist examination

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• Explain to the patient• Ask about any pain the patient may have• Put the patient’s hand on a pillow, position

patient appropriately

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Look Dorsum•Any scars? Trauma? Previous surgery?•Any nodes?•Any nail changes? Pitting, onycholysis, psoriasis•Any deformity?

Plantar•Any scars? Swelling? Skin colour? Any deformity?•Thenar/hypothenar wasting – carpal tunnel syndrome•Dupytrons contracture – alcohol liver disease, diabetes

Elbows•Any nodules?

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Feel

Elbow•Palpate elbow/arm for nodules

Palm•Palpate thenar / hypothenar•Temperature - warm joints in inflamatory•Palmar thickening•Check pulse – radial pulse and ulnar pulse

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Palpate joints of the hand & wrist – Assess for tenderness / irregularities / warmth•Wrist•MCP joint (metatarsophalangeal joint)•PIP joint (proximal interphalangeal joint)•DIP joint (distal interphalangeal joint)

•MCP squeeze – often tender in RA / other inflammatory arthropathies •Anatomical snuffbox – tenderness may suggest scaphoid fracture

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Sensation

• Median nerve – thenar eminence• Ulnar nerve – hypothenar eminence• Radial nerve – first dorsal web space

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Move • Assess each of the following movements

passively first, feeling for crepitus & noting any pain. Then carry out active movements (patient does the movements independently).

• Wrist extension – “put palms of your hands together & extend wrists fully” – ROM 90º

• Wrist flexion – “put backs of your hands together & flex wrists fully” – ROM 90º

• Finger flexion – “make a fist”• Finger extension – “open your fist & splay your

fingers”

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Assess each of the movements of the elbow joint actively & passively:•Elbow flexion – 145º•Elbow extension – 0º•Pronation – 70º•Supination – 85º

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Motor assessment•Ask the patient to carry out the following movements against resistance.•This is a screening test to quickly assess the 3 major nerves of hand.•Wrist / finger extension (against resistance) – radial nerve •Finger abduction (against resistance) – index finger – ulnar nerve•Thumb abduction (against resistance) – median nerve

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Function•Power grip – “squeeze my fingers with your hands”•Pincer grip – “place your thumb & index finger together & don’t let me separate them”•Pick up small object – “can you pick up this small coin?”

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Special Test• Medial epicondylitis – a.k.a. “Golfers Elbow”• Ask the patient to actively flex the wrist whilst the

elbow is flexed.• Localised pain over the medial epicondyle suggests a

diagnosis of medial epicondylitis.• • Lateral epicondylitis – a.k.a. “Tennis Elbow”• Ask the patient to actively extend the wrist whilst the

elbow is flexed.• Localised pain over the lateral epicondyle suggests a

diagnosis of lateral epicondylitis.

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Hip Examination

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LOOK

• Scar• Swelling• Compare and measure the

disntance from the anterior superior iliac spine to the medial malleolus on each side.

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Feel

• Skin temperature • The anterior superior iliac

spines (ASIS) • Ischial spines • Greater trochanter

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Movement • Flexion

– Flexi hip and knee of affected side and note ROM (120°)

• Extension – ROM (20 °)

• Abduction – Stabilise pelvis and hold ankle with other hand . Abduct and note (45 °)

• Adduction – As above and note ROM (30 °)

• Interna rotation – ROM (45 °)

• External rotation – ROM (60 °)

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Special tests

• Trendelenburg test • Thomas test

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The Apprehension test – Thomas’ test for flexion deformity of the hip

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The Apprehension test – Trendelenburg’s test for instability of the hip

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Knee, Foot and AnkleExamination

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Knee

• Knee is the largest joint in the body• It is ginglymus (modified hinge) joint, provide

fairly wide ROM• Knee is not protected by layers of fat or

muscle, so it has high incidence of injury

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Inspection

Scar Swelling Bone deformities Muscle atrophy Masses Evidence of local

trauma Abrasions Contusions Lacerations

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Palpation• Temperat

ure• Bone

palpation• Soft tissue

palpation– Anterior– Medial– Lateral– Posterior

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Anterior Cruciate LigamentPosterior Cruciate Ligament

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Range of Motion

• Flexion• Extention• Internal rotation• External rotation

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Neurologic Examination

• Extention– Quadriceps• Femoral nerve, L2, L3, L4

• Flexion• Hamstring

• Reflex• Sensoric

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McMurray Test

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Apley’s Compression

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“Bounce Home” Test

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Ballotable Patella

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Foot and Ankle

• Kaki dan pergelangan kaki menahan tekanan beban berat tubuh kita saat kita melakukan semua aktivitas sehari-hari. Tekanan ini terjadi terus menerus. Saat kita berjalan di permukaan yang tidak rata, kaki menyerap gerakan ini, dan menambah tekanan lebih lanjut pada berbagai sendi di kaki

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• Satu hal yang sangat penting dari kaki adalah bahwa cedera atau kelainan pada satu sendi dengan cepat dapat menyebabkan cedera sendi lainnya yang ada di sekitarnya karena kedekatan dan keterkaitannya. Oleh karena itu, diagnosis yang cepat dan pengelolaan yang tepat penting untuk mencapai hasil yang diinginkan.

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• Penyebab utama sakit kaki kronis adalah degeneratif atau muncul dari cedera sebelumnya.

Masalah degeneratif yang menyakitkan dapat mempengaruhi sendi kaki, atau tendon atau fasia (jaringan lunak). Beberapa diagnosis umum diantaranya adalah plantar fasciitis (nyeri tumit), hallux valgus (jempol bengkok), collapsed arches (tapak rata) pada orang dewasa, osteoartritis sendi kecil atau pergelangan kaki.

Cedera pada kaki dan pergelangan kaki dapat timbul karena olahraga atau aktivitas sehari-hari. Patah tulang tak terlihat dapat terjadi atau jaringan lunak menjadi rusak. Jaringan lunak ini merujuk pada ligamen dan fasia yang mengikat tulang, atau tendon yang menggerakkan tulang. Jaringan ini dapat tertarik, robek, atau bergeser.

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Foot

• Inspeksi– Lihat bentuk kaki dan sepatu– Deformitas– Oedem unilateral atau bilateral– Trauma– Kulit ( jaringan parut?memar?

eritema?, sendi ( bengkak?effusi?), otot ( lemah?), tumit (berkulit tebal), diantara jari kaki (ulkus?) , kuku (psoriasis), permukaan ekstensor tungkai bawah ( plak psoriasis, nodul rheumatoid, tophus pada gout

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• Palpasi– Palpasi tulang dan sendi, tendon (medial ankle),

lateral ligament complex( lateral ankle), tendon Achilles

– Jaringan plantar : tebal, lembut, fibromatosis– Nyeri tekan– Benjolan– Pulsasi a.dorsalis pedis, a. tibialis posterior– Temperatur (ankle, midfoot, toes)

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• Move– Ankle motion (dorsofleksi dan plantarfleksi)– Subtalar motion (inversi dan eversi)– Midtarsal motion ( forefoot adduction dan

forefoot abduction)– Toe motion ( fleksi dan ekstensi)

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• Talar Tilt Test adalah tes ligamen yang menilaikeutuhan ligamen pergelangan kaki lateral, terutama ligamentum calcaneofibular.

• Manuver: pasien dalam posisi duduk, dengan lutut ditekuk dan kaki mereka dalam posisi netral atau sedikit dorsofleksi. stabilkan tibia distal dengan satu tangan sambil menerapkan kekuatan inversi ke kaki. Temuan positif: Temuan positif termasuk sakit di pergelangan kaki atau meningkatkan kelemahan sendi. Tergantung pada posisi pergelangan kaki, nyeri mungkin dialami di kedua ligamentum calcaneofibular atau talofibular ligamen anterior.

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Mekanisme umum pada cedera pergelangan kaki meliputi:

• 1. Inversi – (yang paling sering) terjadi setelah melangkah salah dan pergelangan kaki yang bergulir ke arah inversi. Ini akan melukai ligamen lateral pergelangan kaki jika dikombinasikan dengan plantar fleksi-bisa melukai tendon peroneal.

• 2. Eversi - dapat melukai ligamen medial pergelangan kaki (deltoid ligamen). Dikombinasikan eversi dan rotasi eksternal dapat terkilir tendon peroneal.

• 3. Eksternal rotasi - dapat melukai syndesmosis pergelangan kaki (tibiofibular• ligamen).• 4. Dorsiflexion - dorsofleksi yang mendadak setelah melompat dapat melukai

Achilles. Dorsofleksi sangat kuat di bagian pergelangan kaki juga bisa melukai syndesmosis pergelangan kaki.

• 5. Plantar-fleksi - yang disebabkan oleh kontraksi kuat gastro-soleus, bisa merobek

• tendon achilles yang. Memaksakan kaki ke plantar fleksi secara ekstrim dapat menyebabkan terkilirnya sendi pergelangan kaki

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Lokasi nyeri

• 1. Lateral — anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, peroneal tendon, lateral malleolus.

• 2. Medial — deltoid ligament, tibialis posterior tendon, medial malleolus.

• 3. Posterior — achilles tendon, OS trigonum. • 4. Anterior — talus, tibiotalar joint.

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PEMERIKSAAN Pergelangan kaki• Dilakukan pada dua sisi untuk membandingkan perbedaannya. • Inspeksi• Memeriksa dan membandingkan kedua pergelangan kaki

sepenuhnya dari depan, samping dan dari belakang. Melihat bentuk asimetri serta deformitas, pembengkakan atau ecchymosis. harus melihat pola pemakaian sepatu

• Palpasi • Meraba kaki bagian bawah, pergelangan kaki dan kaki berikut ini

bidang kelembutan: 1. kaki bagian bawah: fibula, membran interoseus, kompartemen anterior ,garis sendi pergelangan kaki anterior 2. pergelangan kaki tengah : maleolus medial, ligament deltoid,tendon tibialis posterior . 3. pergelangan kaki Lateral : maleolus lateral, anterior talofibular ligamentum (ATFL), ligamen calcaneofibular (CFL), posterior ligamen talofibular (ATFL), peroneal tendon (Gambar 62). 4. pergelangan kaki bawah: tendon Achilles , kalkaneus. 5. kaki : proksimal 5 th metatarsal , navicular

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• Range of Motion• Gerakan pergelangan kaki pertama harus dinilai

secara aktif dan kemudian pasif, membandingkan kedua pergelangan kaki untuk mencari asimetri.

• Periksa adanya keterbatasan gerakan atau nyeri . • 1. dorsofleksi biasanya sekitar 20 ° (Gambar 63) • 2. Plantar fleksi sekitar 50 ° • 3. Inversi sekitar 30 °• 4. Eversi sekitar 10 °

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• Pengujian kekuatan Periksa kelemahan otot dan / atau nyeri. Hal ini dilakukan oleh menahan gerakan pergelangan .

• 1. resisted dorsofleksi (tibialis anterior). • 2. resisted plantar fleksi-(gastroc, longus peroneus,

tibialis posterior).• 3. resisted eversi (peroneal longus dan brevis). • 4. resisted inversi (tibialis posterior, tibialis

anterior)

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• Tes khusus• Berbagai tes dapat dilakukan pada pergelangan kaki untuk menilai integritas ligamen pergelangan

kaki dan• tendon. Ketika melakukan tes ini, memeriksa adanya kelemahan dan / atau nyeri.• 1. Anterior drawer test - dilakukan dengan menstabilkan kaki bagian bawah dengan satu tangan

sementara melengkungkan• tumit dengan yang lain, kemudian menarik ke depan pada kalkaneus / talus kompleks• Kelemahan dibandingkan dengan sisi yang tidak terlibat menunjukkan lateral yang ligamen pecah.• 2. Talar tilt test - yang dilakukan adalah menstabilkan kaki bagian bawah dengan satu tangan

sementara bekamelengkungkan • tumit dengan yang lain, membalikan sendi pergelangan kaki. Kelemahan inversi dibandingkan

dengan tidak terlibat• sisi menunjukkan robeknya ligamen lateral, sementara rasa sakit dengan manuver ini menunjukkan• cedera ligamen.• 3. Squeeze test- dilakukan dengan menekan tibia dan fibula proksimal bersama sambil

menanyakan apakah ada rasa sakit dibagian distal pada pergelangan kaki Nyeri di pergelangan kaki menunjukkan cedera yang tibiofibular

• ligamen (syndesmosis keseleo). pemutaran Pasif pada pergelangan kaki ke rotasi eksternal juga• memperburuk rasa sakit dari cedera syndesmosis

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• Uji Thompson - dilakukan dengan meremas di dasar otot betis dan mencari plantar fleksi pergelangan kaki. Kurangnya plantar fleksi menunjukkan secara lengkap adanya tendon Achilles yang pecah.