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Examination of knee joint

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Clinical examination of knee joint (orthopedics posting)
I do not own this file. Courtesy to Dr Madhusudhan, BBH Orthopaedics

Publicado en: Salud y medicina
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Examination of knee joint

  1. 1.     Page1 EXAMINATION OF KNEE JOINT Chief complaints: – Any Swellings, Deformity, Pain disability / locking/ giving away. H/o presenting illness:- elaborate on his chief complaints and add 2 sub headings ADL: - ability to walk , run , sit cross leg, use bicycle etc. Negative H/O: – multiple joint pain (Rheumatoid), constitutional symptoms (TB / Septic). Pain in gr toe (gout), night cries (TB),/ trauma, /fever,/ bleeding diathesis./ ho of exposure( gonorrhea, reiters),diarrhea(reactive, IBS,) Local Examination:- Gait;- look for antalgic, knock knee, crossleg, Attitude; – Supine or standing ;- Look for level of ASIS, level of patella Hip/knee/ankle position(eg;- pt in supine position hip is in extension,knee is in 45deg of flexion, ankle in equinus of 5 deg , toe in neutral position). Deformity;- Look for FFD, Varus and Valgus deformity, Angular deformity.   Pearls –what determines deformity‐ In paralytic conditions‐the overpowering muscles determines  the deformity,   In non paralytic conditions‐Innate tendency of postural fixity  in possible position of walking that  determines the deformity.  INSPECTION:- Antrly ;- ASIS – is it at samelevel, Is there a varus valgus angulation at knee(Comment on varus / valgus – Outward or Inward deviation of knee joint.check in sitting and standing position,) Is there wasting of quadriceps muscle . Swelling ;-size, shape, extent, surface margins.(use the word swelling in tumor , eg, exostoses cases only) Look for fullness in knee it supra patella fossa, para patellar fossa (eg in effusion and synuvitis its full). look for Visible scars or sinuses. Laterally :-look for Prominence of head of fibula, normal contours – any scars / sinuses, cyst of lat meniscus. Posteriorly:– contour of thigh, supra popliteal slope, popliteal fossa.
  2. 2.     Page2 PALPATION:- Temperature - local rise in temp, Tenderness- superficial and deep ,(supfl tenderness seen in cellulitis, deep tenderness is seen in osteomyelitis, tumor, impingement s, bursitis) 1. Structures surrounding the knee- MCL / LCL/bursa/synovial thickening. 2. Bony components - femur – Patella(feel for articular and nonarticular surfaces) - Tibia 3. Joint line – look for tenderness medially( msc tear) or laterally( lsc tear ) or underneath patella (osteochondritis) 4. Fluctuation and patellar tap– in cases of effusion Mild effusion– should be looked in standing position –because the effusion settles in knee , milk suprapatellar pouch and do patellar tap Moderate effusion – Cross fluctuation test and Patellar tap. Severe effusion – Patellar tap – not possible bcos massive tense effusion, ( also in FFD of knee joint and dislocation of patella we cannot elicit patellar tap) MOVEMENTS :- look for active and passive, is it associated with pain, locking , Crepitus, and contracture, FFD. Movements Degree Muscles Nerve Flexion 0-120 Biceps, ST,SM L45S123 Extension 0 quadriceps L234 Look for quadriceps lag-(normally no lag , in quadriceps weakness , and patellectomies there is a lag of about 15 to 30 degress) MEASUREMENTS:- 1. Linear – Apparent Length, True length, Segmental measurements 2. Circumferential –thigh and calf circumference DEFORMITY ASSESMENT :- 1. Q angle ;– 120 – 150 , look for Varus angle, Valgus angle 2. Intermalleolar distance <5cm – important in genu valgus deformity. 3. Inter condylar distance ;- 1 cm or 1 finger should pass between the condlyles.(for genu varus deformity) 4. Tibia torsion and femoral anti version( checked by rotational profile of staheli ie thigh foot angle/medial and lateral hip rotation in extension/transmalleolar axis ) 5. Valgus / varus disappears on flexion? (if varus or valgus disappears on flexion the deformity is in the femur and if it persists its in tibia.) . Spl. Tests: - kindly read in standard text books about all these tests , by heart and apply these tests wherever necessary.
  3. 3.     Page3 1. Varus & valgus stress tests 2. Lachman’s test– done with 150 knee flexion – Sensitive than drawers test, done in acute injuries of knee joint with pain . 3. Drawers test- done in neutral and 15deg IR and ER Anterior drawers– 6 – 8 mm translation than opp knee (for AM bundle ) Posterior drawers – Neutral , 15deg IR / ER,(for PL bundle) 4. Mc. Murrays test – for meniscal injuries --- for MSC tear ,pls do –AB+ER at the knee and then-FLEX TO EXTN-look for pain through the movement, (pain when fully flexed –post horn involved, mid flexion –middle horn, terminal extension pain- antr horn is involved) similarly AD+IR at the knee and then FLEXION TO EXTN –look for pain implies lsc tear, Also Look for terminal flexion implies posterior horn tear, terminal extension is painful in anterior horn tear in either meniscus, ok 5. Childress test- deep squat and walk –implies meniscus tear 6. Apley’s – grinding / distraction test 7. Wilsons – FL+ IR 8. Fair banks / Apprehension test:- Manually push the patella laterally- Pt. winces with pain. 9. Pivotal shift 10. Slocum test : For ACL and PM Complex injuries. 11. Elys test (rectus femoris contracture prove – flex knee – Hip and drop it it hangs mid air) 12. Patellar tracking (inverted J sign). Exam of others joints and thorough Neurovascular (motor, sensory, reflexes, and distal pulses and lymph node examination . DIAGNOSIS  :‐  ANATOMICAL –what is involved bone,joint  or internal structures in the knee  joint                      PATHOLOGICAL‐   it can be synovitis, arthritis, or menisci or ligament instabilities . INVESTIGATIONS;- 1)LABORATORY ; Hb , wbc , Tc, Dc, Esr, CRP, RA Factor, 2)RADIOLOGICAL ;- plain x ray of knee joint in AP &LAT views 3)SPECIAL INVESTIGATIONS;-1 MRI, (in meniscal/ ligamentous injuries and instability)          
  4. 4.     Page4 SELF NOTES