KNEE JOINT examination

 

KNEE JOINT examination

Look

(inspection)

Feel

(palpation)

Move

Measure / special tests

Standing

  1. GAIT
  2. Skin (scar – sinus)
  3. Subcutaneous (swelling)
  4. Muscle (Quadriceps wasting)
  5. Bone (deformity): Genu varus, Valgus or recurvatum
Supine

Temperature

Tenderness

Bony promenents

  • Tibial plateau
  • Femoral Condyles
  • Patellar Griding test

Soft tissue

  • Medial and Lateral Collateral Ligaments
  • Patellar Ligament

Effusion

Patellar Tap

Fluid Shift

Fluctuation test

Flexion and extension

(0-140)

Active (1st)

Passive

Against resistance

Full range vs. limited rang

Painful vs. painless

KNEE STABILITY

  • Extension mechanism (Active SLR test)
  • Medial collateral ligament (stress valgus test)
  • Lateral collateral ligament (stress varus test)
  • PCL (posterior sag – posterior drawer test)
  • ACL (anterior drawer test – Lachmann test)
  • menisci (Mac Murry test)

MEASURE

Quadriceps wasting 15 cm above patella

Examination of joint above and joint below

Examination of sensory and motor innervations

Examination of peripheral circulation

HIP JOINT examination

 

HIP JOINT examination

Standing (gait)

  • Trendelenburg gait
  • Antalgic gait

Look

(inspection)

Feel

(palpation)

Move

Measure / special tests

  1. from back & sides :
    1. skin
    2. subcutaneous
    3. muscle (gluteal wasting)
  2. from back: bones pelvic tilt, iliac crests & PSIS and compensatory scoliosis of spin (ADDuction deformity)
  3. from side: exaggerated lumber lordosis flexion deformity
(gentle and rapid)

  • Temperature
  • Tenderness
  • Hip joint gently from front
  • trochanteric area Bursitis

Supine

Repeat palpation

Supine

Active & Passive (fix the pelvis and compare with the other side)

Thomas test fixed flexion deformity

Flexion  from 0 to 140

Extension from 0 to 10

Abduction from 0 to 45

Adduction from 0 to 30

External rotation from 0 to 40

Internal rotation from 0 to 40

Against resistance

Full range vs. limited range

Painful vs. painless

Trendelenburg test defective ABDuctor mechanism

(SSS) Sound Side Sages

MEASURE

  • REAL length

from ASIS to medial malleolus for shorting of femur or tibia

Galleazzia sign

Bryant’s test

  • APPARENT length

from Xiphisternum to medial malleolus

short side with normal real length –> ADDuction deformity

Examination of joint above and joint below

Examination of sensory and motor innervations

Examination of peripheral circulation

 

NOTE

Galleazzia sign [shortening in the femur or tibia] Flex the hip to 45º and knee in 90º Any shortening in the femur or tibia

Bryant’s test  Determines whether the shortening in the supra-trochanteric or infra-trochanteric.  Is the perpendicular distance from the line drawn from the ASIS This gives Supratrochanteric distance. It is a comparative test [compare with the contralateal side]

Lumbar spine examination

 

Lumbar spine examination

Standing (gait)

  • High steppage (foot drop)
  • Half-shut knife

Look

(inspection)

Feel

(palpation)

Move

Measure / special tests

  1. Skin (scar – sinus)
  2. Subcutaneous (swelling)
  3. Muscle (wasting – spasm)
  4. Bone (deformity)
  • from beck scoliosis
  • from side lumber lordidsos – dorsal kyphosis
(gentle and rapid)

  • Temperature
  • Tenderness
  • Erector spinae muscle
  • Tender segment
Active (1st)

  • Forward flexion5cm from the ground
  • Extension10-30˚ (support the patient)
  • Lateral flexion30˚ or touching knees
  • Rotation while sitting

Passive

Against resistance

Full range vs. limited range

Painful vs. painless

Supine

  1. Straight leg raising (crossed straight raising)
  2. Sciatic stretch test
  3. Neurological examination
    1. Sensation (dermatomes)
    2. Power (myotomes)
    3. Reflexes (kneeL2,3&4 – ankleS1)

Prone

  1. Femoral stretch test
  2. Tender segment

Examination of joint above and joint below

Examination of sensory and motor innervations

Complete comprehensive examination of Dermatomes, Myotomes and Reflexes

Exclude CAUDA EQUINE lesion

    1. incontinence
    2. tone of sphincter and sensation of saddle area

Examination of peripheral circulation

Screen Shot 2016-06-19 at 1.30.44 PM
Dermatomes.. Myotomes..

JOINT examination

 

JOINT examination

Standing (gait) supine prone
General plan for examination of bones and joints of a limb

Look

(inspection)

Feel

(palpation)

Move

Measure / special tests

  1. Skin (scar – sinus)
  2. Subcutaneous (swelling)
  3. Muscle (wasting – spasm)
  4. Bone (deformity)
Temperature

Tenderness

Soft tissue related

Active

Passive

Against resistance

Full range vs. limited rang

Painful vs. painless

Measure Length and Girth

Examination of joint above and joint below

Examination of sensory and motor innervations

Examination of peripheral circulation

General plan for examination of extremities

Standing (gait) ->  supine ->  prone

Look

(inspection)

Feel

(palpation)

Move

Measure / special tests

  1. Skin (scar – sinus)
  2. Subcutaneous (swelling)
  3. Muscle (wasting – spasm)
  4. Bone (deformity)
Temperature

Tenderness

Soft tissue related

Active (1st)

Passive

Against resistance

Full range vs. limited rang

Painful vs. painless

Examination of peripheral circulation

 

Examination for Fractures and dislocation

Look

‘inspection’

Feel

‘palpation’

Move

Measure

Skin

Ecchymosis

Edema

Skin

Tenderness

Edema

Loss of function

Abnormal mobility

Crepitus

Shape

Swelling

Deformity

Postural alternation

Shape

Swelling (as any swelling)

Deformity

Examination of sensory and motor innervations

Examination of peripheral circulation

Investigation

Labs

  1. Rheumatic profile (ESR – CRP – rheumatoid factor – antinuclear antibody – Uric Acid)
  2. Inflammatory profile (CBC – TLC total and differential – ESR – CRP)
  3. Baseline renal and liver function test (if NSAID being considered)

Radiological

  1. X-ray (2 views – 2 joints)
  2. CT (better in trauma than MRI)
  3. MRI (better in soft tissue assessment)
X-ray features of osteoarthritis (LOSS)
  1. Loss of joint space
  2. Osteophyte formation
  3. Subchondral sclerosis
  4. Subchondral cysts
Management

Non-surgical option

  1. Lifestyle modification / rest
  2. Physiotherapy
  3. Analgesics

Surgery

  1. Failure of conservative management
  2. After optimization and assessment of the patient general condition and fitness for surgery
  3. In any rheumatoid patient you have to exclude atlanto-axial sublaxation by cervical spine X-ray
Plain X-ray
2 views
2 joints Above and below
2 limbs In children
2 injuries To exclude common association
2 occasions As in scaphoid fracture
How to describe a fracture? (theoretical)
  • Definition
  • Aetiology
    • General incidence
    • Age
    • Sex
    • Possible cause
  • Pathology
    • Bone
    • Site
    • Extent
      • Complete
      • Incomplete
    • Fracture line
      • Transverse
      • Oblique
      • Comminuted
      • Avulsion
      • Epiphyseal separation
      • Displacement
      • Lateral displacement
      • Angulation
      • Over-riding
      • Rotation
      • Distraction
      • Depression
      • Impaction
    • Stability
      • Stable
      • Unstable
    • Skin damage
      • Simple (closed) fracture
      • Compound (open) fracture
    • Special feature
  • Healing
    • 3 weeks is the least time and if in
      • Child
      • Upper limb
      • Spiral or simple fracture
    • ×2 if any of them changed
    • ×2 for consolidation
  • Complication
    • General
    • Local
What is the plan of management?

General and Local

Reduce

Hold

Rehabilitate

Closed reduction by:

  • Gravity
  • Manipulation
  • Traction

Open reduction

External fixation by:

  • Plasters of Paris
  • Traction
  • External skeletal fixators

Internal fixation

How to describe a bony lesions (e.g. tumors)? (theoretical)
  • Skeletal maturation
  • Bone
  • Region
  • Nature of lesion
  • Special feature
  • Effect on
    • Medullary canal
    • Epiphysial cartilage
    • Articular cartilage
    • Joint
    • Surrounding bone
    • Cortex
    • Periosteum
    • Outside
  • Diagnosis
    • Swelling
    • Pain
    • Pathological fracture
    • Growth affection
    • Joint movement
    • Complication
      • Spread