بسم الله الرحمن الرحيم

SYMPTOMS PAIN STIFFNESS DEFORMITY SWELLING LIMPING

Normal Knee – Anterior, Extended

Surface Anatomy - Anterior, Extended* Patella Indented Hollow Appears hollow on either side of patella There is a slight indentation above the patella A small amount of fluid will make these hollow-appearing areas disappear. Larger effusions are most conspicuous as a fullness proximal to the patella.

Normal Knee – Anterior, Flexed

Surface Anatomy - Anterior, Flexed Patella Tibial Tuberosity Head Of Fibula

Lateral and Medial Patellar Facets Palpation – Anterior* Patella: Lateral and Medial Patellar Facets Superior And Inferior Patellar Facets *Assess for tenderness, edema, warmth **Palpate the insertion of the patellar tendon on tibial tubercle in adolescents (location of pain in Osgood-Schlatter syndrome in adolescents) Medial Fat Pat Lateral Fat Pad Patellar Tendon**

Surface Anatomy - Medial Patella Tibial Tuberosity Medial Femoral Condyle Joint Line Medial Tibial Condyle

Palpation - Medial Medial Collateral Ligament (MCL)* Pes anserine bursa** Medial joint line *Assess for tenderness along entire course of ligament from origin on medial femoral condyle to insertion on proximal tibia. **Pes anserine bursa is about 3 finger widths inferior to the medial joint line and contains the insertion site for the sartorius, gracilis, and semitendinosis muscles

Surface Anatomy – Lateral Patella Quadriceps Tibial Tuberosity Head Of Fibula

Palpation – Lateral* Lateral Collateral Ligament (LCL)** Lateral joint line * The LCL and joint line are more easily palpated with the knee in 90 degrees of flexion. ** LCL originates on lateral femoral epicondyle and inserts on fibular head

How to Start IPEEP INTRODUCE. PERMISSION. EXPLANTION. EXPOSURE. POSITION.

The Apley System All joint examinations follow this system: Look Feel Move : Active then Passive Special Tests Radiograpgy.

LOCAL EXAMINATION OF THE THIGH AND KNEE

Inspection (LOOK) Bone contours and alignment Soft-tissue contours Colour and texture of skin Scars or sinuses

Instability - Example Patellar dislocation http://www.carletonsportsmed.com/Libraria_medicus/PF_patella_dislocation.JPG

diffuse swelling of the knee can arise only from three fundamental causes: I) thickening of bone; 2) fluid within the joint; and 3) thickening of the synovial membrane

Distinction between effusions of blood, serous fluid, and pus is made partly from the history, partly from the clinical examination.

(haemarthrosis) An effusion of blood appears within an hour or two of an injury and rapidly becomes tense.

clear fluid An effusion develops slowly (twelve to twenty-four hours) and is never so tense as a blood. An effusion of pus is associated with general illness and

Palpation (FEEL) Skin temperature Bone contours Soft-tissue contours Local tenderness

Measurement of thigh girth Comparative measurements at precisely the same level In each limb. (Note particularly the bulk of the quadriceps muscle)

Movements (active and passive) against normal knee for comparison)

? Pain on movement ? Crepitation on movement

Flexion. patients can flex enough to bring the heel in contact with the buttock. The range of the sound knee must be taken as the normal for the individual.

Extension It is wrong to accept 0 degrees as the start in point of movement: therefore the range on the sound side must be taken as the yardstick of

Power (tested against resistance of examiner) Flexion Extension

Stability Medial ligament Lateral ligament Anterior cruciate ligament Posterior cruciate ligament

Tests for stability

Testing the medial and lateral ligaments.

Collateral Ligament Assessment *Position patient supine on table with thigh resting on edge of exam table and foot supported by examiner Knee in 30 degrees of flexion – WHY? Increased laxity of medial side of knee in extension may indicate additional damage to posterior structures (posterior joint capsule & PCL) Patient and Examiner Position*

Valgus Stress Test for MCL* *VALGUS (MCL) stress Proximal hand on lateral aspect of knee holds and stabilizes thigh Distal hand directs ankle laterally Attempt to open knee joint on medial side Estimate the medial joint space and evaluate the stiffness of motion. Positive test = Significant gap in medial aspect of knee with valgus stress = MCL injury. Laxity is graded on a 1 to 4 scale: 1+, 5mm of medial joint space opening with a firm but abnormal endpoint; 2+, 10mm medial opening with a soft endpoint; 3+ (15mm) and 4+ (20mm) may be indicative of an associated cruciate ligament injury and must be carefully examined. Note Direction Of Forces

Varus Stress Test for LCL* *VARUS (LCL) Stress Supine position, with knee at 20 to 30 degrees of flexion and thigh supported. Stabilize medial aspect of knee and push ankle medially, trying to open knee joint on lateral side Disruption of LCL is indicated by difference in degree of lateral knee tautness with varus stress. Compare affected knee to uninjured side Note direction of forces

Rotation tests (McMurray) (Of value mainly when a torn meniscus is suspected)

The maneuver is carried out by repeatedly I) flexing the knee, first fully but in succeeding tests progressively less fully then 2) rotating the tibia upon the femur, first laterally but in further tests medially; and finally 3) extending the knee while the rotation of the tibia is still maintained.

A loud click, distinct from the normal patellar click and usually associated with pain, suggests a tag tear (not a 'bucket-handle‘ tear) of a meniscus.

Testing the anterior and posterior cruciate ligaments.

Anterior Drawer Test for ACL Physician Position & Movements* Patient Position *Patient Position Supine Flex hip of affected knee to 45 degrees Bend knee to 90 degrees Patient's foot planted firmly on examination table Physician position: Sitting on dorsum of foot, place both hands behind knee Once hamstrings relaxed, try to displace proximal leg anteriorly Anterior drawer test is LESS SENSITIVE for ACL damage than Lachman’s Maneuver Note direction of forces

Posterior Drawer Testing- PCL* *Patient Position Supine Affected knee at 90 degrees of flexion Determine ‘neutral’ position by comparing resting position with unaffected knee Physician Position & Movements Patient's foot placed between examiner's legs while the palms of the hands are used to push the tibia posteriorly. Tester directs pressure backward upon proximal tibia, similar to Anterior Drawer Testing Interpretation of test: Posterior instability - PCL injury indicated by increased posterior tibial translation Confusion - trying to distinguish abnormal translation of tibia on femur - from excessive ACL or PCL laxity Note direction of forces

Stance and gait

EXAMINATION OF POTENTIAL EXTRINSIC SOURCES OF THIGH OR KNEE SYMPTOMS This is important if a satisfactory explanation for the symptoms is not found on local examination. The investigation should include: I) the spine. 2) the hip.

GENERAL EXAMINATION General survey of other parts of the body. The local symptoms may be only one manifestation of a widespread disease.

CLASSIFICATION OF DISORDERS OF THE THIGH AND KNEE DISORDERS OF THE THIGH

INFECTIONS Acute osteomyelitis Chronic osteomyelitis Syphilitic infection

TUMOURS Benign bone tumors Malignant bone tumors

ARTICULAR DISORDERS OF THE KNEE ARTHRITIS Pyogenic arthritis Rheumatoid arthritis Tuberculous arthritis Osteoarthritis Haemophilic arthritis Neuropathic arthritis Chondromalacia of the patella

MECHANICAL DISORDERS Tears of the menisci Cysts of the menisci Discoid lateral meniscus Osteochondritis dissecans Intra-articular loose bodies Recurrent dislocation of the patella Habitual dislocation of the patella

Patellar dislocation http://www.carletonsportsmed.com/Libraria_medicus/PF_patella_dislocation.JPG

EXTRA-ARTICULAR DISORDERS IN THE REGION OF THE KNEE DEFORMITIES Genu varum Genu valgum

INJURIES Rupture of the quadriceps apparatus OsgoodSchlatter's disease

CYSTIC SWELLINGS Prepatellar bursitis Popliteal cysts

POST-TRA UMA TIC OSSIFICATION Pellegrini-Stieda's disease of the medial femoral condyle