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Edited by L M Merriman and W Turner. London: Churchill Livingstone, 2002, £39.99, pp 502, hardcover. ISBN 0443071128
The presentation and layout of the book is very nice and appealing. The content covers a broad range of lower limb disorders and stresses the importance of a thorough clinical examination to provide a correct clinical diagnosis. Important laboratory and other investigations that are essential are well outlined.
The book is targeted mainly at general practitioners, dermatologists, and podiatrists, although it could also be helpful for other physicians who treat problems related to the lower limb. With a broad base, it introduces the views of a variety of specialties. It is easy to read and grasp. This could be particularly beneficial to students as well as other paramedical staff. The first few pages have a coloured atlas mainly covering dermatology and vascular problems.
With the wide range of areas covered, this is not the book for a specialist seeking comprehensive details in that particular field. There are a number of arguable citations where the authors have tried to explain complicated details in a simplified way, which may confuse the reader. I pick out a few examples from the orthopaedic chapter to illustrate this.
p 184, Drawer test: “More than 2–3 cm displacement of the tibia is considered abnormal and may be painful”
My comment: before drawing any conclusion of what is abnormal or not, it must be stressed that the examiner must make a comparison with the other knee. In a general joint lax person, even a 2–3 cm translation may be found in a “normal” patient without knee injury. A positive anterior drawer test is defined as an increased translation of the tibia compared with the contralateral knee (if uninjured) with no firm end point! Furthermore, the start position should be neutral. Thus, a rupture of the posterior cruciate ligament causes a posterior sagging of a few centimetres from the start. When the examiner performs the anterior drawer test, he/she may feel that there is an increased laxity corresponding to a rupture of the anterior cruciate ligament, but in that case there is a firm end point. Finally, if the test is painful for the patient, this is not a sign of ligament injury at all but rather indicates other injuries to the joint.
Lachmann test: “If there is displacement of the tibia this is indicative of a weak anterior cruciate ligament”
My comment: a positive Lachmann test indicates the absence of a ruptured anterior cruciate ligament, with high sensitivity and specificity. A weakened or partially ruptured ligament will per definition not have a positive Lachmann test.
p 185, Apleys compression test: “A noisy and painful response suggests meniscus damage”
My comment: the Apleys compression rotation test, if positive—that is, causing pain for the patient—indicates that there is mechanical damage causing impingement in the knee which could be due to injuries to the cartilage, osteoarthritis, loose bodies, or meniscal damage. Before such specific diagnoses are made, further information should be gathered such as the presence of an effusion of the knee and subjective symptoms of locking, pseudo-locking, clicking, or crunching.
p 188, Talocrural joint
Compared with the knee chapter, where a number of clinical tests are presented with illustrations, the authors do not demonstrate the as commonly used clinical tests for ligament insufficiency of the ankle. As an example, the anterior drawer (anterior talofibular ligament rupture) and the talar tilt tests (calcaneofibular ligament rupture) should be the first tests a medical student learns because inversion ankle sprains, affecting these ligaments, are among the most common injuries in sport and daily activities.
The chapter entitled “Stability” (p 188) refers in my view to tests of “laxity”. The chapter is confusing in the sense that it does not mention that functional instability of the ankle is a subjective feeling reported by the patient, whereas the examiner can objectively find laxity by clinical tests. It also says directly after the title “Stability” that the ligaments can be stressed and any tenderness noted. This is even more confusing in the context of stability of a joint, as a ruptured ligament causes increased laxity with no firm end point and possibly recurrent instability for the patient, but not tenderness unless it is an acute injury or partial injury where the laxity tests are normal. If pain or tenderness is the main symptoms in a chronic case, underlying damage to talar dome cartilage or soft tissues causing synovitis should be considered.
Even though these details may sound very critical from an orthopaedic specialist point of view, reflecting weaknesses of this book for specialists, the book is still an excellent edition, with up to date knowledge of the assessment of the lower limb, well worth recommending for students, podiatrists, and other people working with patients with lower limb disorders.
Evidence basis 15/20
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