Knee examination - questions from quiz Flashcards
for adequate inspection during the knee examination what level of exposure is required ?
Patients lower limbs must be exposed up to at least the mid-thigh level
why do you require the patient to expose their lower limb up to mid thigh level to adequately exammine the knee ?
due to the suprapatelar pouch - the superior part of the knee joint capsule - extends up beyond the superior pole of the patella.
what are you looking for (anteriorly and posteriorly) when the patient is standing up?
You will inspect the knee joint; comparing it to the contralateral side looking for:
Anteriorly - Quadricep muscle bulk, Limb alignment: Genu valgus or varus
Posteriorly - Swelling in the popliteal fossa, Hamstring muscle bulk
as part of the knee examination do you do an extensive gait assessment if the patient is able to weight bear or not ?
No - just a brief examination of their gait.
what things are you expected to comment on with regards to a patients walking/gait ?
Sitting to standing: Is the patient able to do this easily, was it difficult or did they need help?
Walking aids: Does the patient use one (and what is it) or are they independently mobile?
Pace: Does the patient walk at a normal pace or are they slow? This is separate from whether they have a limp, as you may have a limp but also be able to walk very quickly!
Gait: Does the patient have a limp? Is it an antalgic (pain relieving) gait? Does the hip or knee look stiff? Is it shuffling or wide based (unlikely to be orthopaedic related but is important in assessment of function)?
what do you look for when inspecting the knee?(6)
- Erythema
- Scars (traumatic or from surgery)
- Generalised swelling in the soft tissues around the joint
- Bruising
- Skin changes - such as eczema or psoriasis
- Effusion
Generalised swelling: inflammation (oedema) is spread throughout the skin and subdermal tissues and is NOT within the knee joint itself. Usually caused by cellulitis.
Effusion: is an accumulation of fluid within a joint. This swelling is centred on the knee joint itself; the surrounding soft tissues are normal.
Scars: Gives clues about previous injuries or surgeries.
Erythema: A sign of infection in the soft tissues, usually associated with cellulitis but often not seen with joint infections (septic arthritis).
Skin changes: This might relate to their underlying diagnosis (such as psoriatic arthritis) or be relevant to potential surgery (there are increased rates of post-op infection if the patient has inflammatory skin conditions such as eczema). Does the patient have atrophic skin or vascular changes to the limb?
Bruising: particularly relevant if paitent presents after an episode of trauma
There is a large swelling of the knee joint. The swelling obeys the boundaries of the knee capsule and you decide this is an effusion within the joint, not a generalised swelling of the surrounding soft tissues. What clinical test do you do?
Patellar tap test
There is no visible swelling in the patient’s knee; it looks normal compared to the other side. What clinical test do you do?
Medial gutter sweep
Describe the medial gutter sweep test
Firstly, the fluid is collected into the lateral gutter by pushing it in there with firm sweeping motions of your hand/fingertips. Then it is moved around, all together, into the medial gutter with the reciprocal firm sweeping movement of the back of your hand.
When is the patellar tap test positive?
This test is positive when you can feel the patellar bobbing up and down on the fluid underneath it, rather than sitting in the firm trochlear grove as normal.
Match each of the following conditions or injuries to the type of fluid that would collect in the knee joint:
- Gout
- A tibial plateau fracture (a fracture of the proximal tibia, communicating with the knee joint)
- An ACL rupture
- Septic arthritis (infection of the knee joint)
- Osteoarthritis
- An acute meniscal tear
- Crystal enriched synovial fluid
- Lipohaemarthrosis (blood and fat)
- Haemarthrosis
- Pus
- Synovial fluid
- Crystal enriched synovial fluid
- Lipohaemarthrosis (blood and fat)
- Haemarthosis
- Pus
- Synovial fluid
- Synovial fluid
Both degenerative conditions of the knee AND an acute meniscal tear cause reactive effusions within the knee joint and this is simply an increase of the normal amount of synovial fluid.
Crystal arthropathies such as gout result in a crystal-rich effusion of the joint
Fractures will cause bleeding from the bone marrow into the joint - this causes an accumulation of blood AND fat in the joint.
Vascular structures, including the ACL, will bleed when they rupture leading to a haemarthrosis. The effusion tends to occur very quickly.
Infection within a joint is referred to as a septic arthritis and this fluid is pus.
what does palpation for patellofemoral crepitations test for ?
Patello-femoral arthritis
What does the patellar grind test, test for ?
Patello-femoral arthritis
What does the patellar apprehension test, test for ?
Patellar instability (previous subluxation or dislocation)
If the patient has generalised joint line tenderness, typical of osteoarthritic changes with degenerative meniscal tears, you should perform a Steinmann’s test. T/F?
False
Steinmann’s test should only be performed in patient’s in whom you suspect an acute meniscal tear. This would be suggested by a patient’s young age (acute tears are v rare after 40), a history of a twisting injury and the presence of focal tenderness on one joint line on palpation.
In the absence of these factors, do NOT perform a Steinmann’s test.
