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Knee Examination for Medical Student OSCE

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1. Inspection

   1. Gait – limp, restriction of movement

   2. Pt standing:

      1. Posture: alignment of shoulder, hips, patella

      2. Skin: colour, sinuses, (arthroscopic) scars

      3. Joint: popliteal fossa: Baker’s Cyst

      4. Position: neutral, valgus (knock knee), vagus (distal part of leg deviated to midline), varus (bow leg), fixed flexion deformity, recurvatum (hyperextension)

      5. Muscle wasting

      6. Redness / other skin changes associated with psoriasis

   3. Lying on couch: (SPAM-J)

      1. Skin: as above

      2. Position: held in flexion can indicate inflammation

      3. Alignment: patellar and tibial

      4. Muscle: fasciculations (LMN)

      5. Joints: effusions, rheumatoid nodules, psoriatic plaques

2. Palpation

   1. Quadriceps: bulk and strength

   2. Skin: warmth – active arthritis or infection

   3. Thickening of synovium – palpable either side of the patella, and in suprapatellar pouch: warm, rubbery, boggy mass

   4. Crepitus

   5. Joint line (with knee flexed 30?)

   6. Tenderness over insertions of contralateral ligaments, tendon insertions, bursas

   7. Effusions

      1. Cross fluctuation

      2. Patella tap test

      3. Bulge test: stroke fluid from medial border of patella up to suprapatellar pouch. With other hand compress suprapatellar pouch. Any fluid then forced into lateral gutter.

Then press on lateral gutter, forcing any fluid back medially. This fluctuation is visible with small effusions, and the pressure change is palpable (but not visible) with large effusions

1. Move: how far? Pain?

   1. Active

      1. Quadriceps lag: ask pt to perform straight leg raise; dragging heel on couch = +ve for quadriceps weakness

   2. Passive

      1. Heel to <3cm from buttock

      2. Lift heel off bed: hyperextension of knee? Normal = <10?

2. Special tests

   1. Collateral ligaments

      1. Medial cruciate ligament: pt supine, hip slightly abducted, knee flexed 30?. Place lower leg under your right arm, and steady with right hand. Place left hand over lateral knee. Abduct knee until pain produced over medial compartment. Repeat with straight leg: if now negative, MCL damaged, but if positive in both positions, both the MCL and medial capsular ligaments are damaged.

      2. Lateral cruciate ligament: change over hands, and apply adduction stress to knee.

   2. Cruciate ligaments

      1. Anterior draw test: anterior cruciate ligament. Knee flexed 90?, sit on foot. Grasp upper calf with thumbs on tibial tubercle, check for relaxed hamstrings, jerk leg.

      2. Posterior draw test: posterior cruciate ligament deficiency. Again, knee flexed 90?, sit on foot. Jerk tibia backwards, compare each knee.

   3. Meniscus tests

      1. Medial meniscus tear suspected: externally rotate and abduct lower leg. Maintain this position, and extend knee. +ve test: painful click

      2. Lateral meniscus tear suspected: internally rotate lower leg. Extend knee, while palpating over joint line.

3. Further investigations

   1. Examine for any distal neurovascular deficits

   2. Check for peripheral pulses – Dorsalis pedis and posterior tibial

   3. Sensation

   4. Proprioception

   5. Would also like to perform a hip and ankle examination.

4. Differential diagnosis

   1. Osteoarthritis of knee

   2. Baker’s cyst

About the Author

by: Admin
Total views: 0
Word Count: 873
Date: Fri, 22 Jan 2010 Time: 4:03 PM
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