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Knee examination

Clinical examination notes based on TU/KU curriculum of MBBS in nepal. Hope this will be very much helpful in step wise approach to you people especially during exam time.

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Knee examination

  1. 1. Knee Examination Prepared by: Sunil Baniya Student, NAIHS-COM, sanobharyang, ktm, Nepal 1Knee Examination/ Sunil Baniya
  2. 2. Complaints:  Pain  Swelling  Stiffness  Deformity  Locking  Giving away  Limp  Loss of function 2Knee Examination/ Sunil Baniya
  3. 3. Patient is examined in 3 positions: 1. Standing 2. Sitting 3. Lying supine in bed, prone A. LOOK 1. Gait: ◦ Antalgic gait ◦ Hand to knee gait in quadricep weakness 3Knee Examination/ Sunil Baniya
  4. 4. 2. Patient standing: Front ◦ Knee alignment for deformity - Varus (bow leg) - Valgus ( knock knee) - Windswept deformity ◦ Patellar rotation (to one side) ◦ Foot rotation ◦ Any scars (arthroscopic scars) ◦ Wasting of quadriceps Figs A to C: Varus/valgus knee/windswept deformity 4Knee Examination/ Sunil Baniya
  5. 5. ◦ Swelling around knee (diffuse) = Horse shoe shaped swelling ◦ Localized swelling around knee - Ganglion - Meniscal cyst - Tumors Side ◦ see only lateral swelling ◦ Ask patient to push knee back & see any - Flexion deformity - Recurvatum of knee 5Knee Examination/ Sunil Baniya
  6. 6. ◦ By looking from front and side triple deformity of knee - Flexion - Posterior subluxation - External rotation of tibia Can be made out. Back ◦ Look in popliteal area for any obvious swelling - Baker’s cyst - Gastrocnemius- semimembranosus bursa - Popliteal artery aneurysm - Lymphadenopathy - Soft tissue tumors 6Knee Examination/ Sunil Baniya
  7. 7. ◦ Wasting of hamstring and calf muscles 2. Patient sitting: ◦ Knee flexed at 90°, look for position of patella - High riding patella = patella alta - Low riding patella = patella baja 3. Patient lying supine on bed: B. FEEL a. Temperature: proximal to distal 7Knee Examination/ Sunil Baniya
  8. 8. b. Tenderness: ◦ For soft tissue and bony tenderness ◦ Knee flexed at 90°, examined for - Tenderness along the medial & lateral joint line ◦ Knee extremely flexed - Tenderness over medial femoral condyle just medial to patellar lig (osteoarthritis dessicans of medial femoral epicondyle) Knee Examination/ Sunil Baniya 8
  9. 9.  Knee extended: - Tibial tuberosity - femoral condyle - Tibial condyle - Suprapatellar pouch - Retropatellar area (by gliding movement of patella between thumb and index finger on medial and lateral facets, try to palpate undersurface of patella) - Patellar tendon - Pes anserinus (medial proximal part of tibia) - Attachement site of collateral ligaments Fig : Feeling for tenderness (a) This is the best position for eliciting tenderness around the knee. (b) By pushing the patella to one or other side of the midline one can feel under its edge 9Knee Examination/ Sunil Baniya
  10. 10. c. Synovial thickening: ◦ Knee at extension ◦ Grasp patella in a picer made of thumb and middle finger, pull toward - Pulled quite firmly: normal synovial membrane - Slip off: thickened synovial membrane d. Distal pulsation: ◦ Dorsalis pedis artery ◦ Posterior tibial artery 10Knee Examination/ Sunil Baniya
  11. 11. C. MOVE ◦ First active movement and ◦ then passive movement ◦ Normal Range of Motion: - Flexion : 0 – 135/140° - Extension : 0 – 5° (hyperextension) - Adduction : 0 – 5° - Abduction : 0 – 5° - Internal rotation : 5 – 7° or ˂10° - External rotation : 5 – 7° or ˂10° 11Knee Examination/ Sunil Baniya
  12. 12. D. MEASURE a. For position of patella: ◦ Flex knee at 30° ◦ Measure height of patella (H) & length of patellar tendon (L) ◦ Findings: - L= H : normal - L ˃H : patella alta - L ˂H : patella baja 12Knee Examination/ Sunil Baniya
  13. 13. b. Q-angle: ◦ Patient sitting on edge of couch ◦ Leg full extension ◦ 2 lines - ASIS to centre of patella - Centre of patella to tibial tuberosity ◦ Measure angle (normally 14° in male & 17° in female) ◦ Increase in angle : valgus deformity (predisposing factor for chondromalacia) 13Knee Examination/ Sunil Baniya
  14. 14. c. Girth of Quadriceps femoris: ◦ Measure 15 – 20 cm above the margin of base of patella SPECIAL TESTS: 1. For joint effusion a. Cross fluctuation test b. Patellar tap c. Bulge test d. Juxta patellar hollow test Fig : Quadriceps wasting is common in all types of joint derangement; it can be accurately assessed by measuring the thigh girth at a fixed distance above the joint line of each knee and comparing the two sides. 14Knee Examination/ Sunil Baniya
  15. 15. 2. For stability of joint: a. For cruciate ligaments i) Anterior cruciate ligamnent (ACL)  Anterior drawer test  Lachman’s test ii) Posterior cruciate ligament (PCL)  Posterior drawer test  Sag test iii) Complex ligament injury  Pivot shift test 15Knee Examination/ Sunil Baniya
  16. 16. b. For collateral ligaments: i) Varus valgus stress test (in flexion) ii) Varus valgus stress test (in extension) iii) Appley’s distraction test c. For meniscal injury: i) Mcmurray’s test ii) Thassaly’s test iii) Appley’s grinding test 16Knee Examination/ Sunil Baniya
  17. 17. Cross fluctuation test:  Grading of effusion: - Mild - Moderate - Moderate to severe  Method: - Applicable only if there is a sizable joint effusion (large joint effusion) - left hand is used to compress - and empty the suprapatellar pouch while the right hand straddles the front of the joint below the patella - by squeezing with each hand alternately - Finding: a fluid impulse is transmitted across the joint 17Knee Examination/ Sunil Baniya
  18. 18. Patellar tap: ◦ Method: - The suprapatellar pouch is compressed with the left hand to squeeze any fluid from the pouch into the joint - With the other hand the patella is then tapped sharply backwards onto the femoral condyles - Finding : In a positive test the patella can be felt striking the femur and bouncing off again (a type of ballottement). Fig : Testing for intraarticular fluid – Patellar tap test. 18Knee Examination/ Sunil Baniya
  19. 19. The Bulge test: ◦ Method: - useful method of testing very little fluid in the joint - - squeezing any fluid out of the suprapatellar pouch - medial compartment emptied by pressing on the medial aspect of the joint - that hand then lifted away - and the lateral side is sharply compressed - Finding: a distinct ripple is seen on the flattened medial surface as fluid is shunted across. Fig : Doing the bulge test: (a)compress the suprapatellar pouch (b) empty the medial compartment (c) push fluid back from the lateral compartment and watch for the bulge on the medial side 19Knee Examination/ Sunil Baniya
  20. 20. Juxta patellar hollow test: ◦ Method: - both knees bent gradually and observed from below - a hollow appears lateral to the patellar ligament - disappears on further flexion - Finding: if fluid in the joint, hollow fills quickly and disappears at a lesser angle of flexion, or may not be seen at all Fig : Testing for intraarticular Fluid: the juxtapatellar hollow, which disappears in flexion if there is fluid in the knee. 20Knee Examination/ Sunil Baniya
  21. 21. Anterior & Posterior drawer test: ◦ Method: Finding : Excessive anterior movement (a positive anterior drawer sign) denotes anterior cruciate laxity; & excessive posterior movement (a positive posterior drawer sign) signifies posterior cruciate laxity. 21Knee Examination/ Sunil Baniya
  22. 22. Lachman test: ◦ Method: - More sensitive than drawer test - knee flexed at 20 degrees - with one hand grasping the lower thigh and the other the upper part of the leg - the joint surfaces are shifted backwards and forwards upon each other - Finding : If the knee is stable, there should be no gliding. Fig : Lachman test 22Knee Examination/ Sunil Baniya
  23. 23. Sag test: ◦ Method: - Bend both knees to 90 degrees - Look tangentially from side for posterior sag of upper tibia - Importance: indicates posterior cruciate ligament rupture. Fig: Posterior sag in PCL insufficiency 23Knee Examination/ Sunil Baniya
  24. 24. Macintosh's Pivot Shift Test: ◦ Method: - supine with one hand holding the upper tibia and other hand on the heel - knee in full extension, internally rotate and apply valgus force - Finding: sublux the tibia in anterolateral instability - From extension maintaining the valgus—internal rotation force flex the knee - At about 30° flexion, tibia reduces back with a clunk (action of iliotibial band) Fig : Pivot shift test 24Knee Examination/ Sunil Baniya
  25. 25. Varus valgus stress test (in flexion):  side to side stability  Patient supine  20° – 30° knee flexion (relaxes posterior capsule and cruciate ligament) & put pillow under it  Apply adduction force (varus) & abduction force (valgus) alternatively  Finding : Feel opening of joint line at lateral side & medial side, and complain of pain Fig : (a) by gripping the foot close to your body and guiding the knee alternately towards valgus and varus (b) by gripping the femoral condyles (provided your hand is big enough) and then forcing the leg alternately into valgus and varus 25Knee Examination/ Sunil Baniya
  26. 26. Varus valgus stress test (in extension): ◦ Method: - In full extension - Leg in axilla - Apply varus/valgus force alternatively - Pain or opening of joint - Findings: - collateral ligament injury - Posterior capsular ligament - Cruciate ligament tear Fig : Varus stress test 26Knee Examination/ Sunil Baniya
  27. 27. Apley’s grinding test: ◦ Method: - Prone - Knee bent at 90 - Compression + medially rotate leg = if pain, lesion in lateral meniscus - Compression + laterally rotate leg = if pain, lesion in medial meniscus Fig : Apley’s grinding test 27Knee Examination/ Sunil Baniya
  28. 28. Apley’s distraction test: ◦ Method: - Prone - Knee bent at 90 - Pulled knee - Medial rotation = for lateral collateral ligament - Lateral rotation = for medial collateral ligament Fig : Apley’s distraction test 28Knee Examination/ Sunil Baniya
  29. 29. McMurray’s test: ◦ Method: - Done only when full flexion is possible - Flexion + external rotation + varus force/adduction force - Gradually extended - Pain or click felt over medial aspect of joint line at certain angle - Finding: tear of medial meniscus ( more part tear, more flexed position - Similoarly for lateral meniscus, flexion but internal rotation & valgus/abduction force Fig : McMurray’s test 29Knee Examination/ Sunil Baniya
  30. 30. Thessaly test: ◦ Method: - Support - Ask to satnd on affected leg and flexion at 20 - Ask to twist body 3 times each side alternatively - Medial joint line pain = medial meniscus tear - Lateral joint line pain = Lateral meniscus tear 30Knee Examination/ Sunil Baniya
  31. 31. THANK YOU 31Knee Examination/ Sunil Baniya
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Clinical examination notes based on TU/KU curriculum of MBBS in nepal. Hope this will be very much helpful in step wise approach to you people especially during exam time.

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