Knee OSCE Exam

Question 1

What are the first 3 things you should do on introduction to the examination?

Answer 1

Wash hands
Introduce yourself
Confirm pt details (name/DOB)

Question 2

How should you explain the knee examination to the patient?

Answer 2

“Today I need to examine your knee joint. This will involve looking, feeling & moving the joint.”

Question 3

How would you check the pt’s understanding & gain consent?

Answer 3

“Does everything I’ve said make sense?”

“Are you happy for me to examine your knee joint?”

Question 4

How would you like to position your pt?

Answer 4

Expose pt’s legs: ideally pt should be wearing shorts.

Position the pt standing upright.

Question 5

What crucial question should you ask before beginning the examination?

Answer 5

Ask the pt if they currently have any pain.

Question 6

What are the 3 main components to a knee examination?

Answer 6

Look
Feel
Move

Question 7

What 2 things are you looking for when you first look at your pt’s knees?

Answer 7

• Gait

- Inspect the knees (anteriorly & posteriorly)

Question 8

What are you looking for in the pt’s gait?

Answer 8

• Is the pt demonstrating a normal heel strike / toe off gait?
• Is each step of normal height (increased stepping seen in foot drop)
• Is the gait smooth & symmetrical?
• Any obvious abnormalities? (antalgia / waddling / broad based)

Question 9

When inspecting the knees, what are you looking for on the anterior aspect?

Answer 9

• Scars: previous surgery / trauma
• Swellings: effusions / inflammatory arthopathy / septic arthritis / gout
• Asymmetry / Leg length discrepancy
• Valgus or varus deformity
• Quadriceps wasting: suggests chronic inflammation / reduced mobility

Question 10

When inspecting the knees, what are you looking for on the posterior aspect?

Answer 10

• Scars
• Asymmetry
• Popliteal swellings: Baker’s cyst / popliteal aneurysm

Question 11

When you move onto the ‘feel’ part of the examination, how would you like to assess the pt?

Answer 11

Ask pt to lay on the bed.

Question 12

What 2 things should you do first when feeling the knee joint?

Answer 12

• Assess temperature: increased temp mays suggest inflammation / infection
• Palpate the quadriceps tendon: whilst leg extended (tenderness suggests synovitis)

Question 13

You need to palpate the knee joint. How would you like to position the knee?

Answer 13

Knee flexed at 90o.

Question 14

On palpation of the knee joint, which areas need to be palpated?

Answer 14

• Patella: palpate borders for tenderness / effusion
• Tibial tuberosity: tenderness -> ? Osgood Schlatter disease
• Head of the fibula: irregularities / tenderness
• Tibial & femoral joint lines: irregularities / tenderness
• Collateral ligaments: both medial & lateral
• Popliteal fossa: feel for any obvious collection of fluid (eg. a Baker’s cyst).

Question 15

Where should you measure the quadriceps circumference?

Answer 15

20cm above tibial tuberosity.

Compare legs.

Question 16

You need to conduct a patellar tap. What will this detect?

Answer 16

Can detect larger effusions.

Question 17

Describe how you’d conduct a patellar tap.

Answer 17

1. Empty the suprapatellar pouch by sliding your left hand down the thigh to the patella.
2. Keep your L hand in position & use your R hand to press downward on the patella with your fingertips.
3. If fluid is present, you will feel as distinct tap as the patella bumps against the femur.

Question 18

You need to conduct a sweep test. What does this detect?

Answer 18

Sweep test is useful for detecting small effusions.

Question 19

Describe how you’d conduct a sweep test.

Answer 19

1. Empty the suprapatellar pouch with one hand whilst also emptying the medial side of the joint using an upwards wiping motion.
2. Now release your hands and do a similar wiping motion downwards on the lateral side of the joint.
3. Watch for a bulge or ripple on the medial side of the joint.
4. The appearance of a bulge or ripple on the medial side of the joint suggests the presence of an effusion.

Question 20

What are the 2 types of movement you should be assessing?

Answer 20

Active: pt performs mvt. Observe for a restricted range of movement & signs of discomfort.

Passive: pt relaxes & allows you to move the joint freely. Feel for crepitus as you move the joint. Observe any restriction of movement.

Question 21

What 2 movements should you assess on active movement?

Answer 21

• Knee flexion: “Move your heel as close to your bottom as you can manage.” Normal ROM: 0 - 140o
• Knee extension: “Straighten your leg out as best as you are able to.”

Question 22

What movements should you assess on passive movement?

Answer 22

Knee flexion & extension

Hyperextension: elevate both legs by the heels: note any hyperextension (<10o is normal).

Question 23

What are the 2 ‘special tests’ required for knee examination?

Answer 23

1. Anterior / Posterior drawer test

2. Collateral ligament testing (Lateral collateral ligament & medial collateral ligament)

Question 24

Describe how you’d carry out the Anterior / Posterior drawer test.

Answer 24

1. Flex pt’s knee to 90o.
2. Inspect for evidence of posterior sag, as this can give a false positive anterior drawer sign.
3. Wrap your hands around the proximal tibia with your fingers around the back of the knee.
4. Rest your forearm down the pt’s lower leg to fix its position.
5. Position thumbs over the tibial tuberosity.
6. Ask pt to keep their legs as relaxed as possible.
7. Pull the tibia anteriorly: significant mvt suggests ANTERIOR cruciate laxity / rupture
8. Push the tibia posteriorly: significant movement suggests POSTERIOR cruciate laxity / rupture.

Question 25

A patient has healthy cruciate ligaments. What would you find on the Anterior / Posterior drawer test?

Answer 25

There should be little or no movement noted.

Question 26

You want to assess the Lateral Collateral Ligament. Describe how you’d do this.

Answer 26

1. Extend the pt’s knee fully.
2. Hold the pt’s ankle between your elbow & side,
3. Place your R hand along the medial aspect of the knee.
4. Place your L hand on the lower limb (calf or ankle).
5. Push steadily outward with your R hand whilst applying an opposite force with the L.

Question 27

If the LCL is damaged, what would you find?

Answer 27

Your hand should detect the lateral aspect of the joint opening up.

Question 28

You want to assess the Medial Collateral Ligament. Describe how you’d do this.

Answer 28

1. Extend the pt’s knee fully.
2. Hold the pt’s ankle between your elbow & side.
3. Place your R hand along the lateral aspect of the knee.
4. Place your L hand on the lower limb (eg. calf or ankle)
5. Push steadily inward with your R hand whilst applying an opposite force with the L.

Question 29

If the MCL is damaged, what would you find?

Answer 29

Your hand should detect the medial aspect of the joint opening up.

Question 30

If the knee appears stable, how might you further assess the collateral ligaments?

Answer 30

Repeat all tests, but with the knee flexed at 30o.
At this position, the cruciate ligaments are not taught, so minor collateral ligament laxity can be more easily detected.

Question 31

Your pt has very healthy collateral ligaments. What would you find on examination?

Answer 31

There should be no abduction or adduction possible.

If abduction/adduction is possible, it suggests laxity / rupture of the corresponding collateral ligament.

Question 32

What 3 steps should you take to complete the examination?

Answer 32

Thank the pt
Wash your hands
Summarise your findings

Question 33

What further assessments / investigations may be required?

Answer 33

• Neurovascular examination of both lower limbs
• Examination of the joint above and below (ankle & hip)
• Further imaging if indicated (X-ray / MRI)