Knee Examination Flashcards
Introduction
Wash hands, PPE
Introduction - Hello, I’m An Nakamura a 3rd year medical student
Patient ID, DOB - Can I confirm your name and DOB
Explanation - I’d like to examine your knee. I’ll look at, feel, move your knee and ask you to do some small tasks. I’d like you to stand for the first half and lie on the couch for the latter part. I’d also like you to remove your trousers but you can keep your underwear on. Will this be ok?
Questions
-Do you have any questions?
-Any pain or stiffness in your knees?
Inspection
-general
Surroundings
- walking aids
- prescriptions
- orthotics
Patient
- habitus - increased mechanical load (OA)
- scars - past surgery, trauma
- wasting muscles - disuse atrophy, LMN
Inspection of knee
-what are we looking for
Ant inspection
- scars - past trauma, arthroscopy port site
- bruising - trauma, hemarthrosis (AC, clotting issues)
- swelling - effusion, inflammatory joints, hemarthrosis
- psoriatic plaques - ext surfaces (increased risk of PsA)
- patella position - dislocation, subluxation
- valgus/varus
- quad bulk - reduced from LMN, disuse atrophy
Lat inspection
- hyperextension - cruciate injury
- fixed flexion - contractures from trauma, inflammation, neuro
Post inspection
- scars - past trauma, surgery
- wasting - LMN, disuse atrophy
- popliteal swelling - Baker’s, popliteal aneurysm if pulsatile
Gait assessment
-what are we looking for
Abnormalities in gait and turning
ROI - reduced in chronic joint issues (inflammatory/OA)
Antalgic - pain or joint instability
Leg length difference - joint issues
Height of steps - high steppage (peroneal nerve palsy)
Palpation of knees
-what are we assessing for
Ask patient to lie on couch
Temperature - hot => septic/inflammatory?
Palpation of extended knee
Patella ligaments and tendon
-tendonitis, rupture
Medial, lateral joint lines
-fracture, meniscal injury, collateral ligament injury
Palpation of flexed knee
Patella ligaments - tendonitis, upture
Patella - medial, lateral border by stabilising one side and palpating other
-tender - injury, arthritis?
Medial, lateral joint lines
-fracture, meniscal injury, collateral injury
Tibial tuberosity
-tender - Osgood Schlatter
Fibular head
-tender - fracture
Popliteal fossa (thumbs on TT, curl fingers into fossa)
-cyst, aneurysm
Effusion tests
Effusion - ligament rupture, SA, IA, OA
Patellar tap - moderate effusion
-milk fluid from suprapatellar pouch into space behind patella
-stabilise patella and press down onto femur
Positive - tap felt when patella hits femur
Bulge test - small effusion
-gently stroke up medial patella => stroke down lateral patella
Positive - fluid bulge on medial
Movement of knees
-active and passive
Active extension of leg - straighten your leg and left your foot off the bed (5deg hyper normal)
-quad/patellar tendon rupture cannot due this
Passive extension of leg - let me take the weight of your leg (ext it further)
Active flexion of knee - bend your knee as far as it will go, one at a time
Passive flexion of knee - push leg further
Passive extension - straighten leg, feel crepitus
Note
- crepitus - OA
- ROM
- discomfort
Ligament tests - cruciates
- how would you do this
- what are you assessing for
Post sag - compare height of TT when knees flexed => lax PCL
Ant drawer - ACL test
-sit on patient’s foot to anchor lower leg, ask patient to relax leg
-thumbs on TT, fingers behind knee joint, pull ant
Positive - significant forward movement => lax/ruptured ACL
Post drawer - PCL
-push post
Positive => lax/ruptured PCL
OFFER
Lachmann - ACL
-flex knee to 30deg
-dom hand T over TT, fingers around calf => pull tibia forwards
-nondom hand, hold thigh => stabilise femur
Positive - significant ant mv =>lax/ruptured ACL
Ligament tests - collaterals
- how would you do this
- what are you assessing for?
Valgus stress - MCL
-flex knee to 20deg
-place hand on lateral thigh => apply valgus strain and palpate medial knee joint line
Positive - palpable gap
Varus stress - LCL
-place hand on medial thigh => apply varus strain and palpate lateral knee joint line
Positive - palpable gap
Menisci tests
-how would you do this
-what are you assessing for?
NOT EXPECTED IN OSCEs
McMurray - MM
-max passive flexion
-hold knee with thumb on medial and fingers on lateral joint lines
-hold sole with other hand
-slowly turn hand holding knee by applying outward pressure
-at the same time, slowly ext rotate foot and ext knee
Positive - click, discomfort => MM tear
-McMurray - LM
-same as before but slowly turn hand holding knee by applying inward pressure whilst int rotating foot and ext knee
Positive - click, discomfort => LM tear
Further investigations
Bedside
Hx
LL neuro exam
Joint exam of hip and ankle
Imaging
Xray, MRI
