clinical aSSeSSment

hiStory
Pain is the most common symptom. In
infl ammatory or degenerative disorders it
is usually diffuse gradual in onset with
osteoarthritis but typically sudden and severe
with gout or infection. In mechanical disorders
(especially after injury) it is usually localized:
think of a torn meniscus or ligament; it helps if
the patient can point to the painful spot.
Swelling, too, may be diffuse or localized. When
diffuse, it is suggestive of fl uid within the joint
or synovial thickening. If there was an injury,
ask whether the swelling appeared immediately
(sug gest ing a haemarthrosis) or gradually
(typical of a torn meniscus). Chronic diffuse
swelling is characteris tic of arthritis or synovitis.
Intermittent swelling suggests an old meniscal
tear or a loose body.
A soft, well-defi ned, localized swelling either
in front of or behind the knee may be due to
an infl amed bursa.
A fi rm, fi xed swelling along the lateral joint
line is typical of a meniscal cyst; a loose body
in the joint is also fi rm but it tends to move
around on pressure.
A bony hard swelling at the distal end of
the femur or the proximal end of the tibia is
more sinister: x-ray examination may reveal
a tumour.
Stiffness is also a common complaint. Ask
whether it fl uctuates and when it feels worse
or better. Early morning stiffness suggests an
infl ammatory disorder; stiffness after periods of
inactivity is typical of osteoarthritis.
Locking is different from stiffness. The joint
is not really locked in the sense that it cannot
move at all. One minute it moves perfectly
well and the next it can still fl ex as before
but it cannot extend fully; something has got
jammed between the articular surfaces (usually
a torn meniscus or a loose body). Unlocking
is even more suggestive: the obstructing object
has shifted and the joint can now move freely
again.
Do not be misled by pseudolocking, when
movement is suddenly stopped by pain or the
fear of impending pain.

Deformity, especially if it is of recent onset, is

quickly noticed. It may be unilateral or bilateral:
valgus or varus, fi xed fl exion or hyperextension.
Knock-knees and bandy-legs are common in
children and usually correct spontaneously as
the child grows.
Giving way can be due to muscle weakness, but
more often it is caused by a mechanical disorder
The Knee
266
such as a torn meniscus or a faulty patellar
extensor mechanism.
Loss of function manifests as difficulty in standing
up from a low chair, a progressively diminishing
walking distance, inability to run and difficulty
going up and down steps.

Pain in the knee

Check the hip as well it could be referred
pain.

Signs with the patient standing

Uncover the lower limbs from groin to toe and
position the patient with both feet pointing
forward and slightly apart. Getting the patient to
stand upright unmasks deformities better than with
the patient lying down. Look at the overall shape
and alignment of the limb: is there an asymmetry;
are the muscles wasted; do the limbs appear to be
bow-legged (genu varum) or knock-kneed (genu
valgum)? Remember it is often easier to pick up
subtle changes of alignment looking from behind
the patient than from the front.
Then ask the patient to walk. Is there a limp
and, if so, is it because the knee does not move
freely as it swings through or because it does not
straighten well when planted on the ground? Is
there an irregular rhythm with the patient trying
to diminish weightbearing on one or other side?
If the history suggests a possible meniscal injury,
the Thessaly test is useful. The patient is instructed
to stand with the affected knee flexed to 20 degrees
and the foot placed flat on the ground, taking his
or her full weight on that leg (the examiner can
support the patient for balance). The patient is
then asked to twist his or her body first to one side
and then to the other three times (thus exerting
a rotational force in the knee with each turn),
while still keeping the knee flexed at 20 degrees.

Patients with meniscal tears experience medial or

lateral joint line pain and may feel that the knee
is locking.
Signs with the patient sitting
With the patient sitting on the edge of the
examination couch look at the position of the
patella: is it seated centrally or is it shifted to one
side? Does it appear higher (patella alta) or lower
(patella baja / infera) than usual? Ask the patient to
straighten each knee in turn. Note the movement
of the patella. Does it glide upwards in a smooth
manner or does it momentarily veer sideways
(maltracking or patellar instability)?
Signs with the patient lying
supine
Always compare the two sides; subtle differences
are easier to detect by comparing the abnormal
with the normal side.
Look
Is there any asymmetry? Are there tell-tale scars
from previous injuries or operations? Is there muscle
wasting? Always confirm the visual impression by
measuring the girth of the thigh at a fixed point
above each knee. Is there swelling and is it diffuse
or localized? Is there bruising that may help localize
the injury?
20.1 Examination standing (a) Look at the general shape and posture, first from in front and then
from behind.
Normally the knees are in slight valgus. (b) Varus deformity (osteoarthritis). (c) Valgus deformity
(rheumatoid arthritis).
(a) (b) (c)

Clinical assessment
267

Feel
Run the back of your hand down each limb from
the thigh and across the knee. Does the knee feel
warmer on one side, suggesting inflammation?
Now bend the patients knee to about 70 degrees
and sit on the edge of the couch facing the knee.
Feel the bony contours around the joint, the
attachments of ligaments and tendons, and the
joint line. Note where there is tenderness.
Synovial thickening is best diagnosed as follows.
Grasp the patella between the thumb and middle
finger and try to lift it off the femoral groove:
normally it can be gripped quite firmly but if the
synovium is thickened, your fingers simply slip off
the edges of the patella.
The patellofemoral joint can be felt only at its

medial and lateral edges. Straighten the patients knee

and push the patella first towards the medial and then
towards the lateral side, feeling with the fingers of your
other hand for tenderness along the undersurface of
the bone. Rubbing the patella against the femoral
trochlea may also elicit pain. A more sensitive test
is to press gently against the proximal edge of the
patella and ask the patient to contract the quadriceps
muscles: as the patella is dragged forcefully along the
front of the femur the patient may wince with pain
a feature that is often encountered in patellofemoral
chondromalacia or osteoarthritis.
Move
Ask the patient to bend and straighten the knee
fully. Note the range of movement. Repeat the
motion while placing a hand over the front of the
knee; crepitus is felt as a grating sensation between
the patella and femur a sign of patellofemoral
degeneration. Finally check if passively moving the
knee alters the range.
The patellar apprehension test is a useful way
of detecting unstable patellar movement. While
passively flexing the patients knee slowly, use your
thumb to press the patella laterally: if the patient
becomes increasingly anxious and resistant to
further movement, it suggests that he or she has
20.2 Examination with the patient supine Swelling may involve either the whole joint, as in (a), a
patient with
synovitis of the right knee, or may be due to a localized lesion, as in (b), a patient with a large loose
body slipping
around in the joint. Quadriceps wasting is common in all types of joint derangement; it can be
accurately assessed by
(c) measuring the thigh girth at a fixed distance above the joint line of each knee and comparing the
two sides.
(a) (b) (c)

1
5
63
2
4

20.3 Feeling for tenderness (a) This is the best position for eliciting tenderness around the knee.
(b) Landmarks
are: 1, quadriceps tendon; 2, edge of patella; 3, medial collateral ligament; 4, the joint line; 5, lateral
collateral
ligament; 6, patellar ligament. (c) By pushing the patella to one or other side of the midline one can
feel under its
edge.
(a) (b) (c)

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268

either experienced a previous patellar dislocation

of subluxation or fears an impending subluxation
because of patellar instability.

Tests for intra-articular fluid

Cross-fluctuation

This test is applicable only if there is a sizable

joint effusion. The left hand is used to compress
and empty the suprapatellar pouch while the right
hand straddles the front of the joint below the
patella; by squeezing with each hand alternately, a
fluid impulse is transmitted across the joint.
The patellar tap

The suprapatellar pouch is compressed with the left

hand to squeeze any fluid from the pouch into the
joint. With the other hand the patella is then tapped
sharply backwards onto the femoral condyles. In a
positive test the patella can be felt striking the femur
and bouncing off again (a type of ballottement).
The bulge test

This is a useful method of testing when there is very

little fluid in the joint, though it takes some practice
to get it right! After squeezing any fluid out of the
suprapatellar pouch, the medial compartment is
emptied by pressing on the medial aspect of the
joint; that hand is then lifted away and the lateral
side is sharply compressed a distinct ripple is seen
on the flattened medial surface as fluid is shunted
across.
The juxtapatellar hollow

If both knees are bent gradually and observed

from below, a hollow appears lateral to the patellar
ligament and disappears on further flexion; if there
is fluid in the joint, this hollow fills quickly and
disappears at a lesser angle of flexion, or it may not
be seen at all.
Tests for ligamentous stability
Collateral ligaments

The medial and lateral ligaments are tested by

stressing the knee into valgus and varus: this is best
done by tucking the patients foot under your arm
and holding the extended knee firmly with one hand
on each side of the joint; the leg is then angulated
alternately towards abduction and adduction.
The test is performed at full extension and again
at 30 degrees of flexion. There is normally some
mediolateral movement at 30 degrees, but if this is
excessive (compared to the normal side) it suggests
a torn or stretched collateral ligament. Sideways
movement in full extension is always abnormal; this
may be due either to torn or stretched ligaments
and capsule, or to loss of articular cartilage or bone
on one side of the knee which allows the affected

compartment to collapse.
Cruciate ligaments

Routine examination for cruciate ligament stability

involves testing for abnormal gliding movements
in the anteroposterior (sagittal) plane. With the
patients knees flexed 90 degrees and the feet
resting on the couch, the upper tibia is inspected
from the side; if its upper end has dropped back,
or can be gently pushed back, this indicates a tear
of the posterior cruciate ligament (the sag sign).
With the knee in the same position, the foot is
anchored by the examiner sitting on it (provided
this does not cause pain); then, using both hands,
the upper end of the tibia is grasped firmly and
rocked backwards and forwards to see if there is any
anteroposterior glide (the drawer test). Excessive
anterior movement (a positive anterior drawer
sign) denotes anterior cruciate laxity; excessive
posterior movement (a positive posterior drawer
sign) signifies posterior cruciate laxity.

20.4 Movement The knee should move from full extension (a) through a range of 150 degrees to full
flexion (b).
Small degrees of flexion deformity (loss of full extension) can be detected by placing the hands under
the knees while
the patient forces the legs down on the couch (c); if your hand can be extracted more easily on one
side than the
other, this indicates loss of the final few degrees of complete extension.
(a) (b) (c)

Clinical assessment
269

20.5 Testing for intraarticular

fluid (a) The
juxtapatellar hollow, which
disappears in flexion if there is
fluid in the knee. (b) Patellar
tap test. (ce) Doing the bulge
test: compress the
suprapatellar pouch (c); empty
the medial compartment (d);
push fluid back from the lateral
compartment and watch for the
bulge on the medial side (e).
(a) (b)
(c) (d) (e)

20.6 Testing for

instability There are two
ways of testing the collateral
ligaments (side-to-side
stability): (a) by gripping the
foot close to your body and
guiding the knee alternately
towards valgus and varus;
(b) by gripping the femoral
condyles (provided your hand
is big enough) and then
forcing the leg alternately into

valgus and varus. (c) In this

case there was gross instability
on the lateral side, allowing
the knee to be pulled into
marked varus. Cruciate
ligament instability can be
assessed by either the drawer
test (d) or the Lachman test (e)
as described in the text.
(a) (b) (c)
(d) (e)

More sensitive is the Lachman test, but this

is difficult if the patient has big thighs (or the
examiner has small hands). The patients knee is
flexed 20 degrees; with one hand grasping the lower
thigh and the other the upper part of the leg, the
joint surfaces are shifted backwards and forwards
upon each other. If the knee is stable, there should
be no gliding.
Rotatory instability

If multiple ligaments and the capsule are torn,

the knee can become unstable to rotatory forces.
The Knee
270
Special clinical tests have been developed to detect
these abnormalities; the best known is the pivot
shift test. The patient lies supine with the lower
limb completely relaxed. The examiner lifts the
leg with the knee held in full extension and the
tibia internally rotated. This produces a position of
slight rotational subluxation if the lateral collateral,
anterior cruciate and part of the posterolateral
capsule are torn (see Chapter 32). A valgus force
is then applied to the lateral side of the joint as the
knee is flexed; a sudden posterior movement of the
tibia is seen and felt as the joint is fully re-located.
The test is sometimes quite painful.
Signs with the patient lying
prone
Scars or lumps in the popliteal fossa are noted. If
there is a swelling, is it in the midline (most likely
a bulging capsule) or to one side (possibly a bursa)?
The soft tissues are carefully palpated. If there is a
lump, where does it originate? Does it pulsate? Can
it be emptied into the joint?
The joint line is located about a fingers breadth
below the flexion crease. A semimembranous bursa is
usually just above the joint line, a Bakers cyst below it.
Apleys test (also called the grinding test) is
sometimes helpful. The knee is flexed to 90 degrees
and rotated while a compression force is applied;

this may reproduce symptoms if a meniscus is torn.

Rotation is then repeated while the leg is pulled
upwards with the surgeons knee holding the thigh
flat on the couch; this, the distraction test, produces
increased pain only if there is ligament damage.
Table 20.1
Three causes of:
Acute swelling Chronic swelling
Synovitis Rheumatoid arthritis
Haemarthrosis Osteoarthritis
Septic arthritis Tuberculosis
Giving way
Torn meniscus
Torn ligaments
Unstable patella

Imaging
X-rays

Anteroposterior and lateral views are routine; it

is often useful also to obtain tangential (skyline)
patellofemoral views and intercondylar (or tunnel)
views. The skyline view gives additional information
on how the patella lies within the femoral groove
and may reveal poor tracking of this sesamoid
bone; the tunnel view reveals the articular portions
of the medial and lateral femoral condyles where
osteoarticular lesions (osteochondritis dissecans)
may exist.
The anteroposterior view should always be taken
with the patient standing: unless the femorotibial
compartment is loaded, narrowing of the articular
space may be missed.
20.7 X-rays Anteroposterior views should always be taken with the patient standing. (a,b) Images
obtained with the
patient lying on the x-ray couch show only slight narrowing of the medial joint space on each side; but
with
weightbearing (c,d) it is clear that the changes are much more marked than at first thought.
(a) (b) (c) (d)

Swellings around the knee

271

Magnetic resonance imaging (MRI)

MRI has evolved to become the standard imaging

method for diagnosing and grading the severity of
many intra-articular and extra-articular problems.
It is able to detect meniscal tears, ligament and
capsular injuries, osteoarticular fractures and both
benign and malignant tumours.
Arthroscopy
Arthroscopy is useful: (1) to establish or refine the
accuracy of diagnosis (e.g. biopsies can be taken);
(2) to help in deciding a treatment strategy or to plan
the operative approach; (3) to record the progress

of a knee disorder; and (4) to perform certain

operative procedures, particularly for meniscal tears
and ligament reconstructions. Arthroscopy is not
a substitute for clinical examination and imaging;
a detailed history, meticulous assessment of the
physical signs and careful scrutiny of imaging are
indispensable preliminaries and remain the sheet
anchor of diagnosis.

Swellings around the knee

A common complaint is of swelling either of
the entire joint or asymmetrically on one or other
aspect of the joint. The following conditions
should be considered.
Acute swelling of the entire
joint
Traumatic synovitis

Any moderately severe injury (including a torn or

trapped meniscus or a torn cruciate ligament) can
precipitate a reactive synovitis, but typically the
swelling appears only after several hours.

20.8 MRI A series of sagittal T1-weighted images proceeding from medial to lateral show the normal
appearances
of: (a,b) the medial meniscus; (c) the posterior cruciate ligament; (d) the somewhat fan-shaped
anterior cruciate
ligament; and (e,f) the lateral meniscus.
(a) (b) (c)
(d) (e) (f)

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272

Post-traumatic haemarthrosis

Tense swelling immediately after injury means

blood in the joint. The knee is painful and it feels
warm, tense and tender. Movements are restricted.
X-rays are essential to see if there is a fracture; if
there is not, then suspect a tear of the anterior
cruciate ligament.
Non-traumatic haemarthrosis

In patients with clotting disorders, the knee is a

common site for acute bleeds. If the appropriate
clotting factor is available, the joint should be
aspirated and splinted. Bleeds can also occur from
tears to vascular lesions in the knee (e.g. pigmented

Latar Belakang
Dislokasi adalah keadaan di mana tulang- tulang yang membentuk sendi tidak
lagi berhubungan secara anatomis (tulang lepas dari kesatuan sendi) Dislokasi ini
dapat hanya komponen tulangnya saja

yang bergeser atau terlepasnya seluruh komponen tulang dari tempat yangseharusnya
(dari mangkuk sendi.. Oleh karenafungsi tulang yang sangat penting bagi tubuh kita,
maka telah semestinyatulang harus di jaga agar terhindar dari trauma atau benturan
yang dapatmengakibatkan terjadinya patah tulang atau dislokasi tulang.Dislokasi
terjadi saat ligarnen rnamberikan jalan sedemikian rupasehingga tulang berpindah
dari posisinya yang normal di dalam sendi.Dislokasi dapat disebabkan oleh faktor
penyakit atau trauma karenadapatan (acquired) atau karena sejak lahir (kongenital)
Dislokasi patella biasanya terjadi kea rah lateral , berupa dislokasi akut,
dislokasi rekuren dan dislokasi habitual. Dislokasi habitual lebih jarang di
temukan dan biasanya terjadi pada anak-anak dan penyebab utamanya
adalah pemendekan otot kuadrisep terutama komponen vastus lateralis yang
dapat bersifat kongenital atau akibat injeksi berkali-kali ke dalam otot.

BAB IITINJAUAN PUSTAKA2 . 1

D e f i n i s i
Dislokasi adalah keadaan dimana tulang-tulang yang membentuk sendi tidak
lagi b e r h u b u n g a n s e c a r a a n a t o m i s ( t u l a n g l e p a s d a r i s e n d i ) . A t a u d
i s l o k a s i a d a l a h s u a t u keadaan keluarnya (bercerainya) kepala sendi dari
mangkuknya. Dislokasi merupakansuatu kedaruratan yang membutuhkan
pertolongan segera. Bila terjadi patah tulang didekat sendi atau mengenai
sendi disertai luksasi sendi yang disebut fraktur dislokasi. Dislokasi adalah
terlepasnya kompresi jaringan tulang dari kesatuan sendi. Dislokasi inidapat hanya
komponen tulangnya saja yang bergeser atau terlepasnya seluruh komponentulang
dari tempat yang seharusnya (dari mangkuk sendi)