Knee and hip examinations Flashcards
Hip exam-introduction
Wash hands
Chaperone
Hip exam: look
General inspection
Anterior, lateral and posterior inspection of hips (get pt to turn)
Gait
Inspect while pt on bed
Hip exam: Feel
Temperature
Hip joint palpation (greater trochanter)-painful in trochanteric bursitis
Leg length assessment
Hip exam: Move
Active movement:
–> Hip flexion (normal ROM 120 degrees)
–> Hip extension (normal ROM 180 degrees: flat on bed)
Passive movement
–> Flexion (120)
–> Internal rotation (flex to 90, then laterally rotate foot)
–> External rotation (flex to 90, then medially rotate foot)
–> Abduction: stabilise contralateral iliac crest and abduct until pelvis begins to tilt
–> Adduction: stabilise contralateral iliac crest, adduct until pelvis begins to tilt
–> Extension: prone position, place hand on ipsilateral pelvis
Hip exam: Special tests
Thomas’s test
Trendelenburg’s test
Thomas’s test
-Assess for fixed flexion deformity (inability to fully extend leg)
- Put hand under lumbar sign to prevent compensation by increasing lumbar lordosis
- Passively flex unaffected hip
- Repeat on other side
Abnormal if affected hip rises off bed
Shouldn’t be performed with hip replacement due to risk of dislocation
Trendelenberg’s test
-Ask pt to put their hands on your hands
-Lift same leg off floor
-Observe for pelvic tilt
If pelvis tilts on side of raised leg, this suggests contralateral abductor weakness
HIp: To complete examination:
Neurovascular examination of both lower limbs.
Examination of the joints above and below (lumbar spine and knee joint).
Further imaging if indicated (e.g. X-ray and MRI).
Hip exam general inspection findings
Body habitus (osteoarthritis)
Scars
Wasting (disuse atrophy secondary to joint pathology/LMN lesion)
Walking aids
Hip exam: Leg length assessment
-To distinguish between true leg length discrepancy and apparent (e.g. due to pelvic tilt)
-Apparent leg length: Measure from umbilicus to tip of medial malleolus each side
-True leg length: Asis to tip of medial malleolus
Hip exam closer inspection of hip findings
Swelling, bruising, scars, quadriceps wasting
Leg length discrepancy (congenital/aquired-fracture, surgery, joint disease)
Pelvic tilt (hip abductor weakness)
Hip: Gait
ROM (reduced in joint disease)
Trendelenberg (gluteal nerve weakness)
Wadding gait (muscular dystrophy)
HIp: Trendelenberg gait
As the pelvis sags towards the unaffected side, the trunk lurches towards the opposite side in an effort to maintain balance.
OA vs RA symptoms
The symptom of joint stiffness can be used to differentiate non-inflammatory arthropathies such as osteoarthritis from inflammatory arthropathies such as rheumatoid arthritis.
In inflammatory arthropathies, joint stiffness improves with activity and stiffness typically lasts longer than 30 minutes in the morning
XR findings OA
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
Osteoarthritis on XR
Osteophytes
Joint space narrowing
Subchondral sclerosis
Subchondral cysts
Mx OA
Conservative
-Weight loss
-Physiotherapy
-Hydrotherapy
Medical
-WHO pain ladder
Surgical
-Discuss options re: THR
-Comorbidities, shx, send for preassessment
Knee: Look
General inspection
Anterior inspection
Lateral inspection
Posterior inspection
Gait
Inspection with pt on bed
Knee: Feel
Temperature
Measurement of muscle bulk
Palpation of extended knee: Patellar, medial and lateral joint lines
Assess for effusion: patellar tap, sweep
Palpation of flexed knee (popliteal fossa and joint line easier to feel): Patellar, medial and lateral joint lines, tibial tubersoity, fibular head, popliteal fossa
Knee: Move
Straight leg raise
Active movement: flexion, extension
Passive movement: Flexion, extension
Special tests knee
-Posterior sag sign
-Anterior and Posterior drawer test
-Medial and lateral collateral ligament assessment
Offer:
-Lachman’s test
-Mcmurray’s test
-patellar apprehension test
Patellar apprehension test
-Patellar always dislocates laterall
-Push patellar laterally: if anxious/in pain, positive
Knee: general inspection findings
Same as hip: Body habitus, walking aids, scars, prescriptions, wasting
Knee: anterior inspection findings
Patellar position (dislocation/subluxation)
Psoriasis plaques (psoriatic arthritis)
Valgus deformity: tibia turned outwards in relation to femur, knees ‘knocking’ together
Varus deformity: tibia turned inwards, bowlegged appearance
Quadriceps wasting
Knee: lateral inspection findings
Extension abnormalities: knee hyperextension-cruciate ligament injury.
Flexion abnormalities: fixed flexion deformity
Knee: posterior inspection findings
Popliteal swelling
Knee: palpation of patellar
Patellar
1. Palpate medial and lateral border of patellar, stabilising one side and palpating with fingertips
–> tenderness: patellofemoral arthritis
–> tensing of muscles on mobilising patellar may suggest recent dislocation
2. Palpate patellar tendon for signs of tendonitis/rupture
Knee: measurement of quadriceps bulk
20cm above tibial tuberosity
Mcmurray’s
Check meniscal tear. Positive sign is pain
Medial: -Flex and externally rotate knee, slowly extend
Lateral: -Flex and internally rotate knee, before slowly extending
Knee: further tests/investigations
Further assessments and investigations to suggest may include:
Neurovascular examination of both lower limbs
Examination of the joints above and below (e.g. ankle and hip)
Bloods: FBC, U + E, CRP, Urate
Further imaging if indicated (e.g. X-ray AP and lateral and MRI)
Clinical features of a varus deformity
Can be physiological (up to 2 years old) or pathological
Bony deformity: the tibia is turned inward in relation to the femur
Abnormal gait: limp with in-toeing (feet are pointed towards the midline)
Lower limb pain: due to abnormal stress placed on the ligaments, joints, and muscles
Clinical features osgood schlatter’s disease and age affected
Typically affects males aged 10 to 15
Tender bony elevation of the tibial tuberosity
Pain exacerbated by activity and relieved by rest
Clinical features patellar dislocation
Intense pain
Swelling over the knee joint
May be associated with a “pop” or the knee “giving way” at time of dislocation
Haemarthrosis (bleeding into the knee joint cavity)
Describe the posterior sag sign and its clinical relevance
The posterior cruciate ligament (PCL) is responsible for preventing backward displacement of the tibia or forward sliding of the femur.
As a result, if the PCL is ruptured the tibia can sag posteriorly in relation to the femur and this is what is known as the posterior sag sign.
Significance of posterior drawer test
Significant movement may suggest posterior cruciate ligament laxity or rupture.
Describe the role of the medial collateral ligament (MCL) and a common mechanism of injury
The primary function of the MCL is to stabilise the knee by resisting valgus forces that would push the knee medially.
Injury of the MCL typically occurs secondary to excessive valgus force when the knee is partially flexed (e.g. a direct blow to the lateral aspect of the knee joint).
Describe the role of the lateral collateral ligament (LCL) of the knee and a common mechanism of injury
The primary function of the LCL is to stabilise the knee by resisting varus forces that would push the knee medially.
Injury of the LCL typically occurs secondary to excessive varus force (e.g. a direct blow to the medial aspect of the knee joint).
Name three causes of leg-length discrepancy in children
Congenital causes include:
-Congenital femoral deficiency
-Fibular hemimelia (shortened or missing fibula)
-Tibia hemimelia
Acquired causes are often secondary to joint pathologies, such as:
-Perthes
-Developmental dysplasia of the hip
-Slipped capital femoral epiphysis
Describe the anatomy and role of the posterior cruciate ligament (PCL)
LAMP: lateral acl, medial pcl
The PCL originates from the lateral edge of the medial femoral condyle and attaches in the posterior region of the intercondylar area.
Its primary purpose is to stabilise the knee joint by preventing posterior tibial subluxation (i.e. prevent posterior displacement of the tibia relative to the femur).
Describe the anatomy and role of the anterior cruciate ligament (ACL)
LAMP: lateral ACL, medial PCL
The ACL originates from medial wall lateral femoral condyle and inserts in the anterior region of the intercondylar area of the tibia.
Its primary purpose is to stabilise the knee joint by preventing anterior tibial subluxation (i.e. prevent anterior displacement of the tibia relative to the femur).
Describe the typical clinical features of a meniscal tear
Typical clinical features of a meniscal tear include:
Acute knee pain immediately following knee trauma
Popping, catching, locking of the knee
Knee joint swelling/effusion
List five causes of knee joint effusion
Ligament rupture: cruciate ligament, collateral ligaments
Septic arthritis
Inflammatory arthritis: rheumatoid arthritis, reactive arthritis
Gout
Osteoarthritis
Meniscal injury
Knee: soft tissue injury differentials
Primary differential plus:
-Or other soft tissue injury such as meniscus, pcl/acl and collaterals
What is RICE
Rest
Ice
Compression-e.g. knee brace
Elevation
