1. بسم الله الرحمن الرحيم

8. SYMPTOMS
PAIN
STIFFNESS
DEFORMITY
SWELLING
LIMPING

9. Normal Knee – Anterior, Extended

10. Surface Anatomy - Anterior, Extended*
Patella
Indented
Hollow
Appears hollow on either side of patella
There is a slight indentation above the patella
A small amount of fluid will make these hollow-appearing areas disappear. Larger effusions are most conspicuous as a fullness proximal to the patella.

11. Normal Knee – Anterior, Flexed

12. Surface Anatomy - Anterior, Flexed
Patella
Tibial
Tuberosity
Head Of
Fibula

13. Lateral and Medial Patellar Facets
Palpation – Anterior*
Patella:
Lateral and Medial Patellar Facets
Superior
And
Inferior
Patellar Facets
*Assess for tenderness, edema, warmth
**Palpate the insertion of the patellar tendon on tibial tubercle in adolescents (location of pain in Osgood-Schlatter syndrome in adolescents)
Medial Fat
Pat
Lateral Fat Pad
Patellar Tendon**

14. Surface Anatomy - Medial
Patella
Tibial
Tuberosity
Medial
Femoral
Condyle
Joint
Line
Medial
Tibial
Condyle

15. Palpation - Medial Medial Collateral Ligament (MCL)* Pes anserine
bursa**
Medial joint
line
*Assess for tenderness along entire course of ligament from origin on medial femoral condyle to insertion on proximal tibia.
**Pes anserine bursa is about 3 finger widths inferior to the medial joint line and contains the insertion site for the sartorius, gracilis, and semitendinosis muscles

16. Surface Anatomy – Lateral
Patella
Quadriceps
Tibial
Tuberosity
Head Of
Fibula

17. Palpation – Lateral* Lateral Collateral Ligament (LCL)** Lateral joint
line
* The LCL and joint line are more easily palpated with the knee in 90 degrees of flexion.
** LCL originates on lateral femoral epicondyle and inserts on fibular head

18. How to Start IPEEP INTRODUCE. PERMISSION. EXPLANTION. EXPOSURE.
POSITION.

19. The Apley System All joint examinations follow this system: Look Feel
Move : Active then Passive
Special Tests
Radiograpgy.

20. LOCAL EXAMINATION OF THE THIGH AND KNEE

21. Inspection (LOOK) Bone contours and alignment Soft-tissue contours
Colour and texture of skin
Scars or sinuses

25. Instability - Example Patellar dislocation

28. diffuse swelling of the knee can
arise only from three fundamental
causes:
I) thickening of bone;
2) fluid within the joint;
and
3) thickening of the synovial membrane

29. Distinction between effusions of blood, serous fluid, and pus is
made
partly from the history,
partly from the clinical examination.

30. (haemarthrosis) An
effusion of blood appears within an hour or two of an
injury and rapidly becomes tense.

31. clear fluid An effusion develops
slowly (twelve to twenty-four hours) and is never so tense as a blood.
An effusion of pus is associated with general illness and

32. Palpation (FEEL) Skin temperature Bone contours Soft-tissue contours
Local tenderness

37. Measurement of thigh girth
Comparative measurements at precisely
the same level In each limb.
(Note particularly the bulk of the quadriceps muscle)

38. Movements (active and passive)
against normal knee for comparison)

39. ? Pain on movement
? Crepitation on movement

40. Flexion.
patients can flex enough to bring the heel in contact with the buttock.
The range of the sound knee must be taken as the normal for the individual.

44. Extension
It is wrong to accept 0 degrees as the start in point of movement:
therefore the range on the sound side must be taken as the yardstick of

45. Power
(tested against resistance of examiner)
Flexion
Extension

46. Stability Medial ligament Lateral ligament Anterior cruciate ligament
Posterior cruciate ligament

47. Tests for stability

48. Testing the medial and lateral ligaments.

49. Collateral Ligament Assessment
*Position patient supine on table with thigh resting on edge of exam table and foot supported by examiner
Knee in 30 degrees of flexion – WHY? Increased laxity of medial side of knee in extension may indicate additional damage to posterior structures (posterior joint capsule & PCL)
Patient and Examiner
Position*

50. Valgus Stress Test for MCL*
*VALGUS (MCL) stress
Proximal hand on lateral aspect of knee holds and stabilizes thigh
Distal hand directs ankle laterally
Attempt to open knee joint on medial side
Estimate the medial joint space and evaluate the stiffness of motion. Positive test = Significant gap in medial aspect of knee with valgus stress = MCL injury.
Laxity is graded on a 1 to 4 scale: 1+, 5mm of medial joint space opening with a firm but abnormal endpoint; 2+, 10mm medial opening with a soft endpoint; 3+ (15mm) and 4+ (20mm) may be indicative of an associated cruciate ligament injury and must be carefully examined.
Note Direction Of Forces

51. Varus Stress Test for LCL*
*VARUS (LCL) Stress
Supine position, with knee at 20 to 30 degrees of flexion and thigh supported.
Stabilize medial aspect of knee and push ankle medially, trying to open knee joint on lateral side
Disruption of LCL is indicated by difference in degree of lateral knee tautness with varus stress. Compare affected knee to uninjured side
Note direction of forces

52. Rotation tests (McMurray)
(Of value mainly when a torn
meniscus is suspected)

55. The maneuver is carried
out by repeatedly
I) flexing the knee, first fully but in succeeding tests progressively less fully
then
2) rotating the tibia upon the femur, first laterally but in further tests medially;
and finally
3) extending the knee while the rotation of the tibia is still
maintained.

56. A loud click,
distinct from the normal patellar click and usually associated with pain,
suggests a tag tear (not a 'bucket-handle‘ tear) of a meniscus.

57. Testing the anterior and posterior cruciate ligaments.

58. Anterior Drawer Test for ACL
Physician Position & Movements*
Patient Position
*Patient Position
Supine
Flex hip of affected knee to 45 degrees
Bend knee to 90 degrees
Patient's foot planted firmly on examination table
Physician position:
Sitting on dorsum of foot, place both hands behind knee
Once hamstrings relaxed, try to displace proximal leg anteriorly
Anterior drawer test is LESS SENSITIVE for ACL damage than Lachman’s Maneuver
Note direction of forces

59. Posterior Drawer Testing- PCL*
*Patient Position
Supine
Affected knee at 90 degrees of flexion
Determine ‘neutral’ position by comparing resting position with unaffected knee
Physician Position & Movements
Patient's foot placed between examiner's legs while the palms of the hands are used to push the tibia posteriorly.
Tester directs pressure backward upon proximal tibia, similar to Anterior Drawer Testing
Interpretation of test:
Posterior instability - PCL injury indicated by increased posterior tibial translation
Confusion - trying to distinguish abnormal translation of tibia on femur - from excessive ACL or PCL laxity
Note direction of forces

61. Stance and gait

62. EXAMINATION OF POTENTIAL EXTRINSIC SOURCES OF THIGH OR KNEE SYMPTOMS
This is important if a satisfactory explanation for the symptoms is not found on local examination.
The investigation should include:
I) the spine.
2) the hip.

63. GENERAL EXAMINATION General survey of other parts of the body.
The local symptoms may be only one manifestation of a widespread disease.

64. CLASSIFICATION OF DISORDERS OF THE THIGH AND KNEE DISORDERS OF THE THIGH

65. INFECTIONS Acute osteomyelitis Chronic osteomyelitis
Syphilitic infection

67. TUMOURS
Benign bone tumors
Malignant bone tumors

69. ARTICULAR DISORDERS OF THE KNEE
ARTHRITIS
Pyogenic arthritis
Rheumatoid arthritis
Tuberculous arthritis
Osteoarthritis
Haemophilic arthritis
Neuropathic arthritis
Chondromalacia of the patella

73. MECHANICAL DISORDERS Tears of the menisci Cysts of the menisci
Discoid lateral meniscus
Osteochondritis dissecans
Intra-articular loose bodies
Recurrent dislocation of the patella
Habitual dislocation of the patella

74. Patellar dislocation

76. EXTRA-ARTICULAR DISORDERS IN THE REGION OF THE KNEE
DEFORMITIES
Genu varum
Genu valgum

78. INJURIES
Rupture of the quadriceps apparatus
OsgoodSchlatter's disease

84. CYSTIC SWELLINGS
Prepatellar bursitis
Popliteal cysts

86. POST-TRA UMA TIC OSSIFICATION
Pellegrini-Stieda's disease of the medial femoral
condyle