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Phase 2b Sheffield Medicine > Knee Examination > Flashcards

Knee Examination Flashcards

1
Q

What should you do before starting a knee exam?

A

● Adequately expose the patient’s legs, provide blanket if necessary.
● Position the patient standing for the initial inspection of the lower limbs.
● Ask the patient if they have any pain before proceeding with the clinical examination.

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2
Q

What clinical signs may be observed during a general inspection of the patient during a hip exam?

A

● Body habitus
● Scars
● Wasting of muscles

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3
Q

What may obesity be suggestive of when performing a general inspection during a knee exam?

A

● Obesity is a significant risk factor for joint pathology due to increased mechanical load (e.g. osteoarthritis).

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4
Q

What may scars be suggestive of when performing a general inspection during a knee exam?

A

● May provide clues regarding previous lower limb surgery.

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5
Q

What may muscle wasting be suggestive of when performing a general inspection during a knee exam?

A

● Suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.

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6
Q

What objects of equipment may be seen around the patient when performing a general inspection in a knee exam?

A

● Walking aids: the ability to walk can be impacted by a wide range of knee, hip and ankle pathology.
● Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications (e.g. analgesia).

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7
Q

What clinical signs would you make note of when performing the anterior inspection during a knee exam?

A

● Scars
● Bruising
● Swelling
● Psoriasis plaques
● Patellar position
● Valgus deformity of the knee
● Varus deformity of the knee

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8
Q

What would scars be suggestive of on anterior inspection during a knee exam?

A

● Note the location of scars as they may provide clues as to the patient’s previous surgical history (e.g. arthroscopy port entry sites) or indicate previous joint trauma.

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9
Q

What would bruising be suggestive of on an anterior inspection during a knee exam?

A

● Suggestive of recent trauma or spontaneous haemarthrosis (e.g. patients on anticoagulants or with clotting disorders such as haemophilia).

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10
Q

What would swelling be suggestive of on an anterior inspection during a knee exam?

A

● Note any evidence of asymmetry in the size of the knee joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis, haemarthrosis).

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11
Q

What would psoriasis plaques be suggestive of on an anterior inspection during a knee exam?

A

● Typically present over extensor surfaces and important to note due to the increased risk of psoriatic arthritis.

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12
Q

What would patellar deviation be suggestive of on an anterior inspection during a knee exam?

A

● The patella is normally located over the center of the knee joint and any deviation from this central position may indicate patellar dislocation or subluxation (i.e. partial dislocation).

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13
Q

What is Valgus deformity of the knee?

A

● The tibia is turned outward in relation to the femur, resulting in the knees ‘knocking’ together.

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14
Q

What is Varus deformity of the knee?

A

● The tibia is turned inward in relation to the femur, resulting in a bowlegged appearance.

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15
Q

What would quadriceps wasting be suggestive of on anterior inspection of the knee?

A

● Asymmetry in the bulk of the quadriceps muscles may be due to disuse atrophy or a lower motor neuron lesion.

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16
Q

How would you get the patient to move so you are able to inspect all 4 views of the patient at the knee and lower limb, during a knee exam?

A

● Ask the patient to stand and turn in 90° increments as you inspect the knee joints from each angle for evidence of pathology.

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17
Q

What clinical signs may you observe on lateral inspection during a knee exam?

A

● Extension abnormalities
● Flexion abnormalities

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18
Q

What would extension abnormalities be suggestive of when performing a lateral inspection during a knee exam?

A

● Knee hyperextension can occur secondary to cruciate ligament injury.

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19
Q

What would flexion abnormalities be suggestive of when performing a lateral inspection during a knee exam?

A

● Fixed flexion deformity at the knee joint may suggest the presence of contractures secondary to previous trauma, inflammatory conditions or neurological disease.

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20
Q

What clinical signs may you observe on posterior inspection during a knee exam?

A

● Scars
● Muscle wasting
● Popliteal swelling

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21
Q

What would popliteal swelling be suggestive of when performing a posterior inspection during a hip exam?

A

● Possible causes include a Baker’s cyst or popliteal aneurysm (typically pulsatile).

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22
Q

What may you note about a patients gait cycle during a knee exam?

A

● Note any abnormalities of the gait cycle (e.g. abnormalities in toe-off or heel strike).

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23
Q

What may you note about range of movement during gait observation in a knee exam?

A

● Often reduced in the context of chronic joint pathology (e.g. osteoarthritis, inflammatory arthritis).

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24
Q

What may limping suggest when assessing a patients gait during a knee exam?

A

● May suggest joint pain (i.e. antalgic gait), weakness or joint instability (e.g. ligamentous injury).

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25
Q

What may you note about leg length when observing a patients gait during a hip exam?

A

● Note any discrepancy which may be the cause or the result of joint pathology.

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26
Q

What may you observe when a patient turns when observing gait in a knee exam?

A

● Patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.

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27
Q

What may you observe about the height of steps when observing gait during a knee exam?

A

● High-stepping gait is associated with foot drop, which can be caused by peroneal nerve palsy (e.g. trauma, surgery).

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28
Q

What is the next step in a knee exam after observing the patients gait?

A

● Inspection with the patient on the bed
● Ask the patient to lay down on the clinical examination couch, with the headrest positioned at a 45° angle for the next part of the assessment.

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29
Q

How would you assess for temperature at the knee joint during a knee exam?

A

● Simultaneously assess and compare knee joint temperature using the back of your hands.

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30
Q

What would increased temperature of a joint indicate during a knee exam?

A

● Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic arthritis, inflammatory arthritis, gout or pseudogout.

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31
Q

How would you measure the quadriceps muscles to assess for muscle wasting?

A

● To measure the circumference of the leg in the region of the quadriceps place a measuring tape around each leg at a point approximately 20cm above the tibial tuberosity.

● Record the circumference of each leg and compare to see if there is a significant difference indicative of quadriceps wasting.

32
Q

What structures in the knee should be palpated when the knee is extended during a knee exam?

A

● Patella
● Medial and lateral joint lines

33
Q

How would you palpate the structures of the extended knee during a knee exam?

A

● With the patient’s leg straight and relaxed, systematically palpate the joint lines and surrounding structures of each knee joint.

34
Q

Describe how would you palpate the patellar with an extended in a knee exam?

A
  1. Assess the medial and lateral border of the patella for tenderness by stabilising one side of the patella and palpating the other with a fingertip
  2. Palpate the patellar ligament for tenderness suggestive of tendonitis or rupture.
35
Q

What may tenderness suggest when palpating the patellar of an extended knee during a knee exam?

A

● Tenderness may represent injury or patellofemoral arthritis.

36
Q

What may apprehensiveness and tension in the muscles suggest when palpating an extended knee during a knee exam?

A

● If the patient appears apprehensive, developing tension in the muscles of the leg as you begin to mobilise the patella (typically in the lateral direction), it may suggest a history of recurrent patellar dislocation which the patient is anticipating
● This can be formally assessed using the patellar apprehension test.

37
Q

Describe how you would palpate the medial and lateral joint lines with an extended knee during a knee exam?

A
  1. Palpate the medial and lateral joint lines of the knee including the collateral ligaments for evidence of tenderness.
  2. Palpate the quadriceps tendon for tenderness suggestive of tendonitis or rupture.
38
Q

What would tenderness suggest when palpating the medial and lateral joint lines of an extended knee during a knee exam?

A

● Fracture
● Meniscal injury (e.g. meniscal tear)
● Collateral ligament injury (e.g. rupture)

39
Q

What can joint effusion in the knee be a clinic sign of?

A

● Ligament rupture (e.g. anterior cruciate ligament)
● Septic arthritis
● Inflammatory arthritis
● Osteoarthritis

40
Q

What can a patellar tap be used for during a knee exam?

A

● The patellar tap test can be used to screen for the presence of a moderate-to-large knee joint effusion.

41
Q

Describe how you would perform a patellar tap during a knee exam?

A
  1. With the patient’s knee fully extended, empty the suprapatellar pouch by sliding your left hand down the thigh to the upper border of the patella.
  2. Keep your left hand in position and use your right hand to press downwards on the patella with your fingertips.
  3. If there is fluid present you will feel a distinct tap as the patella bumps against the femur.
42
Q

What can the sweep test be used for during a knee exam?

A

● The sweep test can be useful to identify small joint effusions that may not be obvious using the patellar tap method.

43
Q

Describe how you would perform a sweep test during a knee exam?

A
  1. Position the patient supine with the leg relaxed and knee extended.
  2. Empty the suprapatellar pouch by sliding your left hand down the thigh to the upper border of the patella.
  3. Stroke the medial side of the knee joint to move any excess fluid across to the lateral side of the joint.
  4. Now stroke the lateral side of the knee joint which will cause any excess fluid to move back across to the emptied medial side of the knee joint. This causes the appearance of a bulge or ripple on the medial side of the joint indicating the presence of effusion.
44
Q

When you have performed all extended knee what is the next step in a knee exam?

A

● With the patient’s knee flexed at 90° repeat the same process of palpation as you did when the knee was extended.
● Joint lines and the popliteal fossa are often easier to assess with the knee flexed.

45
Q

What landmarks should be palpated again when the knee is flexed?

A

● Patella
● Medial and lateral joint lines
● Tibial tuberosity and the head of the fibula
● Popliteal fossa

46
Q

What is the next step in a knee exam after palpation?

A

● The knee joint of each leg should be assessed and compared.
● If the patient is known to have an issue with a particular leg, you should assess the ‘normal’’ leg first for comparison

47
Q

What is active movement?

A

● Active movement refers to a movement performed independently by the patient.

48
Q

What active movements of the knee joint should you get the patient to perform in a knee exam?

A

● Active knee flexion
● Active knee extension

49
Q

How would you instruct a patient to perform active knee flexion during a knee exam?

A

● Ask the patient to flex their knee as far as they are comfortably able to – “Move your heel as close to your bottom as you can manage.”

50
Q

How would you instruct a patient to extension during a knee exam?

A

● Ask the patient to extend their knee, so that their leg is flat on the bed – “Straighten your leg out so that it is flat on the bed.”

51
Q

What would the normal range of motion be for active knee flexion and active knee extension during a knee exam?

A

● 0-140° (flexion)
● Should be able to lie the leg flat (180°)

52
Q

What is passive movement?

A

● Passive movement refers to a movement of the patient, controlled by the examiner. ● This involves the patient relaxing and allowing you to move the joint freely to assess the full range of joint movement.

53
Q

What two passive movements should be performed on the knee joint during a knee exam?

A

● Passive knee flexion
● Passive knee extension

54
Q

Describe how you should perform passive knee flexion and what a normal range of motion would be, during a knee exam?

A

● Whilst supporting the patient’s leg, flex the knee as far as you are able, making sure to observe for signs of discomfort.
● 0-140°

55
Q

Describe how you would perform passive knee extension and what the normal range of motion would be, during a knee exam?

A

● If the patient is able to lay their legs flat on the bed, they are already demonstrating a normal range of movement for knee extension.

56
Q

Describe how you should assess for knee hyperextension during a knee exam?

A
  1. On the leg being assessed, hold above the ankle joint and gently lift the leg upwards.
  2. Inspect the knee joint for evidence of hyperextension, with less than 10° being considered normal. Excessive knee hyperextension may suggest pathology affecting the integrity of the knee joint’s ligaments.
57
Q

What sign should an examiner be aware of before commencing a cruciate ligament assessment?

A

● Posterior sag sign
● To screen for the posterior sag sign make sure the patient is relaxed and ask them to flex their knee to 90º with their foot placed flat on the bed.
● Inspect the lateral aspect of the knee joint for evidence of posterior sag.

58
Q

Why is it important to identify a posterior sag sign before commencing with a cruciate ligament assessment?

A

● A posterior cruciate ligament tear can result in a false positive anterior drawer sign.
● This is because an anterior movement of the tibia will occur during the anterior drawer test due to the tibia moving from a posteriorly subluxed position back to its neutral position.
● This relocation of the tibia to its neutral position may then be misinterpreted as excessive anterior movement secondary to anterior cruciate ligament laxity or rupture.

59
Q

What is the anterior drawer test used for in a knee exam?

A

● The anterior drawer test is used to assess the integrity of the anterior cruciate ligament.

60
Q

Describe how you would perform an anterior drawer test during a knee exam?

A
  1. Position the patient supine on the clinical examination couch with their knee flexed to 90º.
  2. Wrap your hands around the proximal tibia with your fingers around the back of the knee joint.
  3. Rest your forearm down the patient’s lower leg to fix its position.
  4. Position your thumbs over the tibial tuberosity.
  5. Ask the patient to keep their legs as relaxed as tense hamstrings can mask pathology.
  6. Pull the tibia anteriorly and feel for any anterior movement of the tibia on the femur. With healthy cruciate ligaments, there should be little or no movement noted. Significant movement may suggest anterior cruciate ligament laxity or rupture.
61
Q

Describe how you would perform a posterior drawer test in a knee exam?

A
  1. Position the patient supine on the clinical examination couch with their knee flexed to 90º.
  2. Wrap your hands around the proximal tibia with your fingers around the back of the knee joint.
  3. Rest your forearm down the patient’s lower leg to fix its position.
  4. Position your thumbs over the tibial tuberosity.
  5. Ask the patient to keep their legs as relaxed as tense hamstrings can mask pathology.
  6. Push the tibia posteriorly and feel for any posterior movement of the tibia on the femur. With healthy cruciate ligaments, there should be little or no movement noted. Significant posterior movement may suggest posterior cruciate ligament laxity or rupture.
62
Q

What is Lachman’s test?

A

● Lachman’s test is an alternative test assessing for laxity or rupture of the anterior cruciate ligament (ACL)

63
Q

Describe how you would perform Lachman’s test during a knee exam?

A
  1. Flex the patient’s knee to 30°.
  2. Hold the lower leg with your dominant hand with your thumb on the tibial tuberosity and your fingers over the calf.
  3. With the non-dominant hand, hold the thigh just above the patella.
  4. Use the dominant hand to pull the tibia forwards on the femur while the other hand stabilises the femur.
64
Q

What two movements should be performed when assessing the collateral ligaments during a knee exam?

A

● Lateral collateral ligament assessment (varus stress test)
● Medial collateral ligament assessment (valgus stress test)

65
Q

What is the purpose of a lateral collateral ligament assessment (varus stress test) in a knee exam?

A

● The lateral collateral ligament (LCL) assessment involves the application of a varus force to assess the integrity of the LCL of the knee joint.

66
Q

Describe how you would perform a lateral collateral ligament assessment (virus stress test during a knee exam?

A
  1. Extend the patient’s knee fully so that the leg is straight.
  2. Hold the patient’s ankle between your right elbow and side.
  3. Position your right palm over the medial aspect of the knee.
  4. Position your left palm a little lower down over the lateral aspect of the lower limb, with your fingers reaching upwards to palpate the lateral knee joint line.
  5. Push steadily outward with your right palm whilst pushing inwards with the left palm.
  6. Whilst performing this manoeuvre, palpate the lateral knee joint line with the fingers of your left hand.

*These instructions are for examining the right knee, use the opposite hands if assessing the left knee.

67
Q

What would a normal and abnormal finding be in a Lateral collateral ligament assessment (varus stress test) during a knee exam?

A

● With healthy collateral ligaments, there should be no abduction or adduction possible.
● If there is LCL laxity or rupture your fingers should be able to feel a palpable gap caused by the lateral aspect of the joint opening up secondary to the varus force being applied.

68
Q

What is the purpose of a Medial collateral ligament assessment (valgus stress test) during a knee exam?

A

● The medial collateral ligament (MCL) assessment involves the application of a valgus force to assess the integrity of the MCL of the knee joint.

69
Q

Describe how you would perform a medial collateral ligament assessment (valgus stress test during a knee exam?

A
  1. Extend the patient’s knee fully so that the leg is straight.
  2. Hold the patient’s ankle between your right elbow and side.
  3. Position your left palm over the lateral aspect of the knee.
  4. Position your right palm a little lower down over the medial aspect of the lower limb, with your fingers reaching upwards to palpate the medial knee joint line.
  5. Push steadily inward with your left hand whilst pushing outwards with the right hand.
  6. Whilst performing this manoeuvre, palpate the medial knee joint line with the fingers of your right hand.

*These instructions are for examining the right knee, use the opposite hands if assessing the left knee.

70
Q

What would a normal and abnormal finding be in a Medial collateral ligament assessment (valgus stress test) during a knee exam?

A

● With healthy collateral ligaments, there should be no abduction or adduction possible.
● If there is MCL laxity or rupture your fingers should be able to feel a palpable gap caused by the medial aspect of the joint opening up secondary to the valgus force being applied.

71
Q

If the collateral ligaments are stable after a varus and valgus stress test, what further test can be performed during a knee exam?

A

● If after assessment the knee appears stable you can further assess the collateral ligaments by repeating this test with the knee flexed at 30°.
● At this position, the cruciate ligament is not taught so minor collateral ligament laxity can be more easily detected.

72
Q

How would you perform McMurray’s test for the medial meniscus during a knee exam?

A
  1. With the patient supine on the clinical examination couch, passively flex the knee being assessed as far as is possible.
  2. Hold the patient’s right knee with your left hand, with your thumb over the medial aspect and fingers over the lateral aspect of the joint lines.
  3. Hold the patient’s right foot by the sole using your right hand.
  4. Create valgus stress on the knee joint with your left hand by applying outward pressure as if trying to abduct the leg at the hip whilst fixating and externally rotating the foot. At the same time slowly extend the knee joint.

*These instructions are for examining the right knee, use the opposite hands if assessing the left knee.

73
Q

What would a positive result be for a McMurrary’s test for the medial meniscus in a knee exam?

A

● The presence of a click and discomfort is suggestive of a medial meniscal tear.

74
Q

How would you perform a McMurray’s test for the lateral meniscus during a knee exam?

A
  1. With the patient supine on the clinical examination couch, passively flex the knee being assessed as far as is possible.
  2. Hold the patient’s right knee with your left hand, with your thumb over the medial aspect and fingers over the lateral aspect of the joint lines.
  3. Hold the patient’s right foot by the sole using your right hand.
  4. Create varus stress on the knee joint with your left hand by applying inward pressure as if trying to adduct the leg at the hip whilst fixating and internally rotating the foot. At the same time slowly extend the knee joint.

*These instructions are for examining the right knee, use the opposite hands if assessing the left knee.

75
Q

What would a positive result be for a McMurray’s test for the lateral meniscus during a knee exam?

A

● The presence of a click and discomfort is suggestive of a lateral meniscal tear.

76
Q

What further assessments and investigations could be performed after completion of a knee exam?

A

● Neurovascular examination of both lower limbs.
● Examination of the joints above and below (e.g. ankle and hip).
● Further imaging if indicated (e.g. X-ray and MRI).

Phase 2b Sheffield Medicine (17 decks)

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