9_Knee.pdf

Mr Georgios Arealis, MD, PhD, FRCS -Consultant Trauma & Orthopaedic Surgeon Shoulder & Upper Limb Specialist East Kent Hospitals University NHS Foundation Trust - Visiting Professor, Faculty of Medicine, Health and Social Care Canterbury Christchurch University -Honorary Researcher, School Of Engine...

Mr Georgios Arealis, MD, PhD, FRCS -Consultant Trauma & Orthopaedic Surgeon Shoulder & Upper Limb Specialist East Kent Hospitals University NHS Foundation Trust - Visiting Professor, Faculty of Medicine, Health and Social Care Canterbury Christchurch University -Honorary Researcher, School Of Engineering and Digital Arts University Of Kent - Clinical tutor Clinical and Educational Supervisor, Stage 3, Year 5 medical students, King's College London - Clinical tutor, Sutgical group, Kent and Medway Medical School Knee STRUCTURE INTRODUCTION Look Feel Move Function Special Tests Neurology THANK THE PATIENT COMPLETE EXAMINATION PRESENT EXAMINATION FINDINGS Introduction (WIPE) Wash hands, Intro, ?Patient (DOB, Name), Explain/ consent Expose lower limb, undress to underwear Respect privacy, ask for chaperone General inspection, including walking aids around bedside Body habitus: high BMI risk factor to OA and failed surgery Inspection when standing– Front, back, side Scars LOOK Previous surgery or trauma Color Red: infection/ inflammation Bruising: recent trauma/ heamarthrosis if on anticoagulation Psoriasis plaques Swelling Effusion knee Popliteal swelling Muscle wasting Deformity valgus vs. varus Hyper extension, fixed flexion Position of patella Scars Baker's cyst Popliteal aneurysm Loss of quadriceps bulk after ACL surgery Congenital valgus knee Hypermobility Varus knee OA Fixed flexion Patella dislocation FEEL Temperature: assess and compare Muscle bulk Increased+(swelling and loss ROM) = arthritis: septic or inflammatory inc. gout/ pseudogout place a measuring tape around each leg at a point approximately 20cm above the tibial tuberosity Effusion Patellar tap test – for large quantities of fluid: Apply pressure on the proximal side of the knee in an effort to squeeze the fluid out of the suprapatellar pouch, maintain the pressure on the suprapatellar pouch; with other hand place counterpressure and use your index to tap down the patella. A positive test is when the patella can be felt to move down through the fluid and rebound on the femur and a palpable ‘click’ is felt. Sweep test – for smaller quantities: stroke medial upwards and towards the suprapatellar bursa 2 -3 times in a sweeping then stroke downwards lateral just superior to the supra-patellar bursa towards the lateral joint line. If the test tests positive you’ll detect a small wave or bulge on the medial aspect of the knee, just inferior to the patella within a few seconds. Palpate knee surface anatomy – tenderness, both extended and flexed Palpation of the knee: extended and flexed Patella Lateral ligaments 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), patella instability Superior – inferior Tendinopathy If gap is felt= tear Pain at the tibial tuberosity = Osgood Schlatter Medial and lateral joint lines and above below Pain at joint line = OA or meniscal injury Above or below ? collateral ligament injury or tendinitis – medial hamstrings / lateral ITB Popliteal fossa With your thumbs placed on the tibial tuberosity, curl your fingers into the popliteal fossa and palpate for evidence of a swelling which may indicate the presence of a popliteal cyst (often referred to as a Baker’s cyst). A pulsatile mass in the popliteal fossa may represent a popliteal aneurysm. MOVE Gait Ask the patient to walk away and turn back Active & Passive Compare sides MOVE Normal range of movement: (0 to +10) to (135 to 140°) Functional range of movement can be less but at least 90 is essential for daily life More than 10 deg hyperextenstion can be sign of pathology: hyperlaxity or ligament injury GAIT Antalgic Trendelenburg Gait High stepping gait is associated with foot drop, which can be caused by peroneal nerve palsy: trauma, surgery, spinal disease Gait cycle The gait cycle has 2 phases, only 2 instances have double support: STANCE PHASE Heel-strike: initial contact of the heel with the floor= Double Support - Foot flat: weight is transferred onto this leg. - Mid-stance: the weight is aligned and balanced on this leg. - Heel-off: the heel lifts off the floor as the foot rises but the toes remain in contact with the floor. Pre- Swing: only tip of toes on the floor= Double Support SWING PHASE - Toe-off: as the foot continues to rise the toes lift off the floor. - Mid-Swing: the foot swings forward - Terminal-Swing comes back into contact with the floor with a heel strike (and the gait cycle repeats). Anterior and posterior cruciate ligament tests ACL Anterior drawer test Lachman’s test PCL Posterior sag sign Posterior drawer test Lateral ligament tests Lateral collateral ligament assessment (varus stress test) Medial collateral ligament assessment (valgus stress test) Further collateral ligament assessment Menisci test SPECIAL TESTS McMurray’s test Patellofemoral joint test Apprehension test Chondromalacia/ Clarke's Sign / Patellar Grind Test Cruciate ligaments of the knee The cruciate ligaments of the knee include the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). The ACL originates from deep within the notch of the distal femur and inserts in the anterior region of the intercondylar area of the tibia. Its primary purpose is to stabilise the knee joint by preventing anterior tibial subluxation (i.e. prevent anterior displacement of the tibia relative to the femur). ACL injury (i.e. rupture) typically occurs when a patient lands on a leg and then quickly pivots in the opposite direction resulting in a valgus twisting injury (e.g. in football). The PCL originates from the lateral edge of the medial femoral condyle and attaches in the posterior region of the intercondylar area. Its primary purpose is to stabilise the knee joint by preventing posterior tibial subluxation (i.e. prevent posterior displacement of the tibia relative to the femur). PCL injury typically occurs secondary to hyperflexion of the knee joint (e.g. a fall onto a flexed knee). The ACL and PCL cross over each other, forming a cross shape (the Latin translation of cruciate is “cross-shaped”). Posterior sag sign flex their knee to 90º Foot placed flat on the bed Inspect the lateral aspect of the knee joint for evidence of posterior sag. ! Identify this sign before proceeding to anterior drawer test! = face positive Anterior drawer test The anterior drawer test is used to assess the integrity of the anterior cruciate ligament. Position the patient supine on the clinical examination couch with their knee flexed to 90º. Wrap your hands around the proximal tibia with your fingers around the back of the knee joint. Rest your forearm down the patient’s lower leg to fix its position. Position your thumbs over the tibial tuberosity. Ask the patient to keep their legs as relaxed as tense hamstrings can mask pathology. 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. Posterior drawer test Same position as anterior drawer but push backwards Movement  PCL tear Lachman’s test Lachman’s test is an alternative test assessing for laxity or rupture of the anterior cruciate ligament (ACL). This test is rarely required in an OSCE scenario, with the anterior drawer test being the preferred method of ACL assessment. Flex the patient’s knee to 30°. Hold the lower leg with your dominant hand with your thumb on the tibial tuberosity and your fingers over the calf. With the non-dominant hand, hold the thigh just above the patella. Use the dominant hand to pull the tibia forwards on the femur while the other hand stabilises the femur. Significant anterior movement of the tibia on the femur suggests ACL laxity or rupture. Lateral and medial ligament tests Start with the knee extended and the try at 30 degrees of flexion Hold the patient’s ankle one hand and rotate out tibia Place the other hand either medial or lateral – opposite to the ligament tested and apply valgus = MCL or varus= LCL force Pain or obvious laxity means the test is positive Compare both sides Repeat at 30 degrees of flexion to identify more subtle laxity McMurray’s test Patient supine Hold the foot with one hand and place the other above the knee Put pressure with the hand above the knee Flex maximally the knee (>90) Slowly start to extend and: - internally rotate and apply valgus pressure to examine the lateral meniscus - externally rotate and apply varus pressure to examine the medial meniscus The presence of a click and discomfort is suggestive of a meniscal tear. Chondromalacia/ Clarke's Sign / Patellar Grind Test Patient supine or sitting with the involved knee extended. Places the web space of hand just superior to the patella while applying pressure. The patient is instructed to gently and gradually contract the quadriceps muscle. A positive sign on this test is pain in the patellofemoral joint Apprehension test Position supine or sitting position Flex knee 30 degrees The quadriceps should be relaxed to allow passive movements of the patella. Using the thumb of both hands press on the medial side of the patient's patella. Positive if it produces pain and apprehension. The patient may reach for the clinician hands or attempt to straighten his/her knee in an attempt to pull the patella back to the relative normal position. Extensor MechanismActive Straight Leg Raise Test 1. The test is performed with the patient in a supine position with legs straight and feet 20cm apart. 2. The test is performed after the verbal instruction: "Try to raise your legs, one after the other, above the table for 20cm without bending the knee." Complete the examination Complete with joint above and below and neurological examination (= similar to spine) and vascular examination Thank the patient Dispose of PPE appropriately and wash your hands Present your findings Imaging and tests Common Pathologies Traumatic – – – – Fracture Patellar Dislocation Ligament tear Meniscal Tear Arthritic= similar to hip – OA – RA Red, Hot, Swollen, Painful – Septic Arthritis = similar to hip, can use the Kocher’s – Gout / Pseudo Gout Paediatric: Osgood-Schlatter’s Disease Osgood-Schlatter’s Disease Temporary condition involving pain and swelling at tibial tubercle When there is too much stress on the patellar tendon, it pulls on the bone and growth plate at the tibial tubercle, causing the pain and swelling that come with Osgood Schlatter’s disease.