The Knee

physical examination

by RYS

Symptoms
• Pain
– Diffuse – localized
Somebody Help my knee ??

• Swelling
– Immediate – Some hours

• • • •

Stiffness Locking Deformity Limp

knee

Observation
• Anterior view,standing
– Normally tibia has a slight valgus
• Genu varum until about 18-19 months • Genu valgum until about 3-4 years

– Patella should symetrical and level
• Squinting patella

– Deformity

:

• Valgus or knock knee
– Normal intermaleolar less than 6cm

• Varus or bowlegs
– Normal intercondyler less than 8 cm

• Analyze gait
Look knee at – Heelstrike – Swingphase fully extended? flexion?

• Swelling
– Intracapsuler ?
• generalized

– Extracapsuler ?
• localized

• Lateral view, standing
– Genu recurvatum (hiperextended knee) – Patella displace
• High (alta) • Lower (baja)

• Posterior view, standing
– Similar to those in anterior – Baker’s cyst

• Anterior and lateral view, sitting
– Knee flexed 90 degree, feet dangling free – Patella face forward and on distal end femur – Displaced patella
• Frog’s eyes patella alta with lateral displaced

– Note tibial torsion
• Medial associated with genu varum
– Pigeon toed foot deformity

• Lateral for genu valgum

Feel
• Warmth, intraarticular fluid • Anterior
– Quadriceps
• wasting
Prepatellar bursa

– Infrapatellar tendon • Insertion into tibial tubercle – Prepatellar bursa Pes anserine bursa
• Housemaid knee

– Pes anserinus bursa
Deep infrapatellar bursa Superficial infrapatellar bursa

• Medial
– Medial meniscus
• Tenderness If detached due tears coronay ligament

– Medial collateral ligament
• Move medially and posterior • Position resistance against knee flexion

Medial meniscus

– Sartorius,gracillis,and semitendinosus muscle

• Lateral
– Lateral meniscus – Lateral collateral ligament – Common peroneal nerve

Lateral meniscus

• Posterior
– – – – Popliteal fossa Posterior tibial nerve Popliteal vein,artery Gastrocnemius muscle

Move
• Active
– – – – Flexion (0°-135°) Extension ( 0-15°) Internal rotation (10°) External rotation ( 10°)

Passive

Joint stability
• Ligament
Collateral ligaments
• Medial collateral ligament
– Tes – Tes : abduction( VALGUS STRESS ) test : adduction ( VARUS STRESS ) test

• Lateral collateral ligament

Anatomy
Anterior cruciatum ligament Posterior cruciatum ligament

Medial collateral ligament

Lateral collateral ligament

Cruciatum ligaments
• Anterior cruciatum ligament
DRAWER TEST – Tes : ANTERIOR DRAWER TEST – Positive (+) there is forward movement tibia • Posterior cruciatum ligaments – Tes : POSTERIOR DRAWER TEST – Positive (+) reverse anterior • LACHMAN test – Knee flexed 20 degree – Positive(+) soft end feel forward tibia slope (-) LACHMAN test – Knee flexed 90° hip 45 °

Special test
• Meniscus injury
– Mc Murray test
• Loose tag induced palpable and audible click

– Apley’s compresion distraction test
• Grinding reproduces symptoms from meniscus torn • Distraction from ligament damage

Mc Murray test

Apley’s test

Test for swelling
• Patellar tap test( ballotable patella )
– Positive(+) Ballotement +

• Cross fluctuation test
– Positive(+)Fluid impulse transmitted across the joint

• Bulge test
– Positive(+) Distinct ripple seen

• Patellar hollow test
– Normal : hollow +

Neurologic
• Muscle
– Extension
• Primary extensor
– Quadriceps ,femoral nerve L234

– Flexion
• Primary flexor
– Hamstring » Semimembranosus, sciathic L5 » Semitendinosus, sciathic L5 » Biceps femoris, sciathic S1

• Sensation

L4 L3 L2 S2

• Reflexes
– Patellar reflexs, L234

Healthy Knee Joint ?
May Be….

Terima Kasih

Uluwatu Beach Sunset view Bali

Ronny Sutanto

Other special test
• Patellofemoral angle ( Q angle )
– – – – Angle between Q muscle and patellar tendon. Normally 13° -18° <13° patella alta or chondromalacia patella >18° chondromalacia patella,sublux patella, genu valgum,lateral tibial torsion. – If knee full extended normal 8-10°

• Apprehension test
– For dislocation patella – Knee flexed 30°, slowly passive move patella laterally – Positive if patient become apprehension

Observation
• Anterior view,standing
– Normally tibia has a slight valgus
• Genu varum until about 18-19 months • Genu valgum until about 3-4 years

– Patella should symetrical and level
• Squinting patella

– Deformity

:

• Valgus or knock knee
– Normal intermaleolar less than 6cm

• Varus or bowlegs

Tibiofemoral shaft angle normal 6º

– Normal intercondyler less than 8 cm

Gravity Drawer test ( posterior sag sign )

Feel
Patient sit on the edge of examining table knee flexed 90 degree relaxed,non weigthbearing.

• Medial aspect
– – – – Medial tibial plateau Tibial tubercle Medial femoral condyle Adductor tubercle

• Lateral aspect
– Lateral tibial plateau – Lateral tubercle

– – – – –

Lateral tibial plateau Lateral tubercle Lateral femoral condyle Lateral femoral epicondyle Head of the fibula

• Trochlear groove and patella
– Patella fixed in trochlear groove in flexion and mobile in extension.

• Anterior and lateral view, sitting
– Excessive tibial torsion
-Chondromalacia patella -Patellofemoral instability -Fat pad entrapment

Osgood sclatter disease

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