Orthopedic Medicine knee Examination Dr Youssef Nauf MD

Orthopedic Medicine knee Examination Dr. Youssef Nauf MD, SNBGM, NNBGM, MSUGP, SNBFM Sr. Consultant Family Medicine. PHCC Asst. Prof, Weill Cornell Medicine - Qatar Core-Faculty Residency Training Program HMC/PHCC - Qatar With special interest of Orthopedic Medicine & Orthopedic Manual Therapy

Topics to be covered Background Facts Anatomy and movement Stability History of complaint/pain Mechanism of injury Videos for anatomy, exam cases Exam on pat Matching game Conclusion & Recommendation Questions

Well-known phrases that includes the word 'knee' Knee-high to a grasshopper Is a way of describing someone who is small in height.

known phrases that includes the word 'knee' Knee-jerk reaction Describes a sudden, unexpected and automatic response to something, and originates from the knee's involuntary movement when rapped sharply with something.

Known phrases that includes the word 'knee' The bee's knees Derives from bees, due to them carrying their precious pollen back to their hives in the sacks on their knees. It means of the utmost quality

Brainstorming questions • What are the cushions of the knee? • What are the most injured structure of the knee? • What is a more common name for pre-patellar bursitis?

Background • The knee joint is the most complex joint in the body. • Biggest body weight bearing joint in the body. • Healthy knee is essential for a normal daily activity. • Can be hurt and cause invalidity and affect individuals welfare. • Very common cause for surgery visit. • Cost the society billions of Riyals each year. • Healthy life style and Preventive cautions can reduce its incidence.

Fact • 10. 4 millions visits because of knee problems in united states • 27 millions of knee OA in USA • There are 650. 000 TKR in 2010 (95% because of OA) • 4. 5 millions with knee replacement now • Knee injuries constitute only about 15% of all sports injuries but are 50% of visits to sports doctors, indicating that when they happen, they are usually significant.

Fact • 75% of surgeries are because of ACL and Meniscal injury • ACL injury has an annual incidence of more than 200, 000 cases with ~100, 000 of these knees reconstructed annually • ACL injury is most prevalent (1 in 1, 750 persons) in patients 15 -45 years of age

Fact Knee injuries are common in all sports: • 42% basketball players • 29%. . . dancers • 43%. . . football • 31%. . . gymnasts • 38%. . . runners • 67%. . . skiers • 46%. . . soccer • 24%. . . tennis

Knee Examination

Type of the joint The knee joint is the most complex joint in the body. What is the name of this type of joint? q. Condylar or q. Hinge joint

Knee stability comes from three elements ØThe geometry of the bones themselves/ menisci ØCollateral and Cruciate ligaments/capsule ØThe muscle groups. If any of these are deficient due to bad lifestyle, injury or due to inadequate rehabilitation, a person will tend to have ongoing problems/disability. In an adult knee, the ACL prevents forward movement of the tibia. It also provides roughly 90% of stability in the knee joint.

Knee anatomy Ant. view

Knee anatomy Ant. view

Knee anatomy Post. view

Knee anatomy Med. View

Knee anatomy Lat. view

Please note q q Always get a permission before you expose and examine the pat Always explain the patient what you are doing

General approach • • • Introduce your self Start soft General questions Create friendly environment Identify patient culture An idea about the patient personality Penetrate social history Chronic diseases and previous surgeries Chronic medications Joint problems Other relevant factors

Patients complaints Sound history penetration is always the most important part of , your consultation Ø Show your understanding and respect to patient complaint Ø Give time and listen carefully Ø Ask the patient about possible cause/diagnosis of his/her problem Ø Explain how you will examine the patient Ø Explain what you are doing during the examination and observe the patient facial expression Ø Talk clearly and give clear Dx or DDx. Ø Involve the patient actively in the treatment plan Ø Explain and summarize the agreed treatment plan Ø Put a follow up plan and determine the future appointments Ø

General Inspection Ø A lot of information you can get if you bring the patient from the waiting area by your self Ø Expose well “one joint above and one joint below” Ø Inspect well and look from all direction Ø Lying down, sitting, standing Ø Gate, “Stance and swinging phases” Ø Smoothness of Movement & turning Ø Putting on and taking off Cloths

Local Inspection • • Skin Marks Sign of inflammations Muscles/atrophy Posture/alignment Any limb shortness Any deformity Compare

Palpation • • • Firm/soft pressure Muscles Landmarks, ligaments Joint lines Sign of inflammation (temp, tenderness and effusion) • • Patellar undersurface Bursae Popliteal fossa Iliotibial band

Movement • Active and Passive movement • Crepitus and End-feel • Functional and power assessment “Resisted movement” • Compare • Normal range variation • Goniometer

Special tests 1. Patellar Apprehension test 2. Patellar compression test 3. Anterior and Posterior drawer tests 4. Lachman’s test 5. Stress vulgus and varus test 6. Pivot shift test! 7. Mc. Murray test 8. Thessaly test! 9. Apley's compression test 10. Ober’s test

Special tests Patellar compression test Patellar Apprehension test

Special tests Anterior and posterior cruciate ligament Anterior and Posterior drawer test Lachman test Pivot shift test

Special tests Medial and collateral ligaments Stress vulgus and varus test

Special tests Menisci Mc. Murray test! Apple's compression test Thessaly test

Special tests Iliotibial band Ober’s test

Vascular testing • Popliteal fossa • Foot

Muscle Power assessment • • Hip flexion L 1 -3 Hip extension S 1 -2 Knee flexion L 5 -S 2 Knee extension L 2 -4 Ankle dorsiflexion. L 4 -5 Ankle plantar flexion S 1 -2 Great toe dorsiflexion L 5 -S 1

Tendon reflexes • Patellar L 2 -4 • Achilles S 1 -2

Sensation • L 1 • L 2 • L 3 • L 4 • L 5 • S 1

Back to brainstorming questions

What are the cushions of the knee? • The knee relies on 12 muscles at least to perform its function. • It has the most well developed cartilages in the body, the menisci, between the femur and the tibia • It has the thickest cartilage covering the back of the kneecap.

What is a more common name for pre-patellar bursitis? • Housemaid's knee. • Acute Bursitis is usually relieved by R. I. C. E (Rest, Ice, Compression, Elevation), anti inflammatory. • Chronic Bursitis is treated by avoiding further damage (using knee-pads or not kneeling at all), aspirating some of the fluid from the bursa or, in extreme cases, removal of the bursa by surgery.

What are the most injured structure of the knee? • Medial structures • Lateral structures • Posterior structures • Anterior Structure • Inner structure • Injuries to medial structures are more common than injuries to lateral structures since you are more likely to be hit from the side, a valgus force

Videos about the knee • Video here:

Case • 72 years old man visits your surgery for bilateral knee pain • Your approach • History • Exam • Other

Case • 30 year old male/female comes to the surgery complaining about knee pain. • Your approach • History • Exam • Other • Examination Findings • Obviously finding it painful to walk on his right knee. • Obviously swollen knee with generalised decreased range of movement • No tenderness to palpation of joint line • Anterior draw test positive

case • Basket ball player with knee pain during game playing • Your approach • History • Exam • Other

case • 15 years old boy with anterior knee pain • Your approach • History • Exam • Others

Matching game

Matching game

Thanks Questions