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Kathy Rainsbury February 2008

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1 Kathy Rainsbury February 2008
Knee Examination Kathy Rainsbury February 2008

2 How to diagnose a knee complaint - HISTORY
1) Patient’s age + sex 2) Does the knee swell? 3) Is there a mechanical problem?

3 Age + sex Age Group Males Females 0-12 Discoid lateral meniscus 12-18
Osteochondritis dissecans Osgood-Schlatter’s 1st patella dislocation 18-30 Longitudinal meniscal tears Recurrent dislocation patella Chondromalacia patellae Fat pad injury 30-50 Rheumatoid arthritis 40-55 Degenerative meniscus lesions 45+ Osteoarthritis

4 Swelling? Effusion Absence of effusion
presence of pathology which must be investigated XS synovial (inflammatory) fluid/ blood/ pus Absence of effusion Does not exclude pathology, but less likely. Long-standing meniscus lesions/ OA

5 Mechanical problem? Hx of initial injury ‘mechanism’ Knee ‘give way’?
Degree + direction + incapacity Knee ‘give way’? Going down stairs/ jumping : cruciate ligament Twisting/ walking/ uneven ground: meniscus Knee ‘locks’? NEVER locks in full extension Full flexion but limited extension – FB + meniscal (‘click’) Pain When? Localise?

6 Investigations Examine other joints (? Rheumatoid/ psoriasis + other inflammatory arthropathies) Aspiration + culture of fluid Bloods Xray joint (? use) CXR (if ? TB) MRI EUA Arthroscopy                                                                

7 Examination Look Measure Feel Move

8 Surface anatomy Hollows at side of patella ligament in flexed knee lie over joint line.

9 Surface anatomy 2 - Joint line 10 1 5
Nb suprapatellar bursa communicates with knee joint proper – therefore can milk fluid down in fluid displacement test - Joint line 5

10 Inspection (ant. + post.)
Symmetry Swelling/ bruising/ scars/ rash/ deformity/ wasting/ bursae (Heat) Patella position – quads/ extensor apparatus intact? Swelling – - Localised (bursitis/ meniscal cysts) – image carpenters knee (or parson’s knee to pray)– infrapatellar bursitis - suprapatellar bursitis ‘housemaid’s knee’ -confined to synovial cavity (effusion, haemarthrosis, pyarthrosis/ SOL) - generalised (infection/ tumour/ major injury) Bruising – soft tissues, not normally with meniscal linjuries Rash – psoriasis Wasting – pain/ instability/infection/RA Bursae – in popliteal region, cystic swelling – most commonly semi-membranous bursa Feel heat with back of hand Hand under knee – press leg against hand - ? Quads function ok SLR – to check extensor apparatus with knees hanging over edge of couch

11 Measure Quads circumference
If concerned muscle wasting – 18cm above joint line

12 Palpate Effusion – patellar tap Fluid displacement Tenderness
Bend knee – joint line Collateral ligaments Tibial tubercle Femoral condyles Evacuate supra-patellar pouch 15cm above knee Click on patella tap – effusion (NB tense effusion – negative) Localised tenderness along joint line commonest in meniscus, collateral ligament + fat pad injuries –seen in OA/ Pre-menstrual fluid retention (cured by fat pad excision) Tibial tuberosity – osgood schlatters (10-16y.os, usually settles with epiphyseal closure) / acute avulsion patella ligament Femoral condyles – osteochondritis dissecans, esp medial condyle. – teenage males, impingement of fem condyle against tibial spines/ cruciate ligs – AVN.

13 Move Active + passive Extension – 0 deg (? Hyperextension)
Flexion – 135 deg Extension – springy block – bucket handle meniscus tear - Rigid block – arthritic (fixed flexion deformity) Hyperextension – Ehlers danlos syndrome, Charcot’s disease + polio (rare), girls esp. – high patella, chondromalacia patellae, recurrent dislocation, sometime tears ant. Cruciate, medial meniscus or medial ligament. Ballet + high-heels – retard upper tibial epiphyseal growth.

14 Move - instability 1) Valgus stress test (+ve if medial lig torn)
2) Varus stress test ( +ve lat lig torn) 3) Anterior Drawer test (+ve if ant cruciate torn) Or Lachman test 4) Posterior Drawer test (+ve if post cruciate torn)

15 Instability - rotatory
MacIntosh test / pivot shift test (difficult if patient not under anaesthesia) MacIntosh – fully extend knee, hold foot in internal rotation, apply valgus stress, gradually flex knee, will jerk at 30 deg as tibial condyle reduces - if rotatory instability. – seen in ACL rupture, anterolateral displacement tibia then on further flexion, shifts back as ITB goes from extensor to flexor.

16 Menisci Feel for clicks, listen for crepitus
McMurrays test – medial + lateral menisci (or Apley’s grind test) Medial McMurray’s – leg flexed, foot EXTERNALLY rotated, hip aBducted, - clicks + grating felt while leg smoothly extended Lateral McMurray’s – lef flexed, foot INTERNALLY rotated, hip abducted – as above. Meniscal injuries – meniscal tears in young adult, degenerative lesions in middle age Meniscal cysts – firm on palpation joint line, tender on deep pressure – usually lateral side.

17 And finally… Gait Genu varum ‘varus my pig?’ Genu valgus varus valgus


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