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Lecture 6: 05/02/2023 Presented by: Abhisekh Chatterjee Musculoskeletal Examination SURGICAL SOCIETY JUNIOR ANATOMY SERIES | CPA LECTURE SERIESContents Quick recap of knee anatomy Basics of the exam • Look • Feel • Move • Special Tests Practice Questions for viva • Radiographic images • Presentation of certain pathologies S U R G S O C J A S | C P A L E C T U R E S E R I E S This is Sally Sally is a 24-year-old graduate medical student who is in hospital for a knee issue. Your registrar on placement tells you that she’s got signs, so you should conduct a musculoskeletal examination on her. Have you got the skills necessary to pick up on the signs? S U R G S O C J A S | C P A L E C T U R E S E R I E S Structure of the Examination Positioning and Exposure Look Feel Move Special Tests Viva S U R G S O C J A S | C P A L E C T U R E S E R I E S Quick Recap of Knee Anatomy Bones and ligaments Muscles Neurovasculature S U R G S O C J A S | C P A L E C T U R E S E R I E SBones of the Knee The knee joint is formed by three bones: • Femur • Tibia • Patella Also present is the Fibula Important ligaments: • Collateral ligaments (medial and lateral) • Cruciate ligaments (anterior and posterior) S U R G S O C J A S | C P A L E C T U R E S E R I E SMuscles of the knee The relevant muscles of the knee joint are: • Quadriceps (4 muscles) • Semitendinosus • Semimembranosus • Gastrocnemius • Popliteus muscle Important tendon is the patellar tendon S U R G S O C J A S | C P A L E C T U R E S E R I E SMuscles of the knee The relevant muscles of the knee joint are: • Quadriceps (4 muscles) • Semitendinosus • Semimembranosus • Gastrocnemius • Popliteus muscle Important tendon is the patellar tendon S U R G S O C J A S | C P A L E C T U R E S E R I E SNeurovasculature of the Knee Relevant Nerves: • Tibial Nerve • Common fibular (peroneal) nerve Relevant artery: • Popliteal artery Other vasculature: • Popliteal vein S U R G S O C J A S | C P A L E C T U R E S E R I E S What type of bone is the patella? Which nerve near to the fibula is at risk of Sesamoid damage? Common peroneal/fibular nerve Name all four quadriceps heads. What ligament prevents the tibia from sliding backwards? Rectus femoris, Vastus lateralis, Vastus, intermedius, Vastus medialis Posterior cruciate ligament What important artery passes through the popliteal fossa, and is the deepest structure? Popliteal artery S U R G S O C J A S | C P A L E C T U R E S E R I E S Position and Exposure Position Exposure S U R G S O C J A S | C P A L E C T U R E S E R I E SPosition Lying on the couch. Patient will likely be positioned at 45 degrees. S U R G S O C J A S | C P A L E C T U R E S E R I E SExposure Need to be able to see knee joint and quadriceps and calf muscles. The patient will likely be wearing shorts. S U R G S O C J A S | C P A L E C T U R E S E R I E S Look Scars Muscle Wasting Knee Deformities S U R G S O C J A S | C P A L E C T U R E S E R I E S Scars Looking Pay attention! THINK: what is the difference Genu valgum Muscle Wasting between valgus and varus? What pathology (that you know of) can cause muscle wasting? What can you see by looking at the knee? Genu varum Swelling S U R G S O C J A S | C P A L E R I E S E S ES U R G S O C J A S | C P A L E C T U R E S E R I E S You don’t need to know about Q angles S U R G S O C J A S | C P A L E C T R I E S E Feel Joint Lines Bones Fat spaces S U R G S O C J A S | C P A L E C T U R E S E R I E S We can break up ‘Feeling’ into a few respective parts: Temperature: Feeling • Using the back of your hand, and doing both legs at the Gel your hands! same time • Assess temperature at the patella, above the patella, below the patella. Palpation • Using your fingers, think logically, and follow the steps: • Around the patella • Medial Joint Line • Lateral Joint Line • Tibial Tuberosity and Head of Fibula • Popliteal fossa Swelling in the popliteal fossa is indicative of a Baker’s cyst. S U R G S O C J A S | C P R I E S T U R E S E Effusions: • Sweep method – Small effusions Feeling • Tap method – Large effusions An effusion is excess synovial fluid, and can be caused by arthritisor structures.he internal knee What is a positive sign for an effusion in each of these tests? S U R G S O C J A S | C P AR I E ST U R E S ES U R G S O C J A S | C P A L E C T U R E S E R I E S What is the correct exposure for a On which side do you sweep upwards when musculoskeletal examination of the knee? performing the Sweep Test for small effusions? Enough to see the knee joint, quadriceps and Medial side calf muscles What the medical term for knock-kneed? Genu valgum S U R G S O C J A S | C P A L E C T U R E S E R I E S Move Active Passive S U R G S O C J A S | C P A L E C T U R E S E R I E SActive Movement • Look for • Pain on movement – the Flexion patient’s face! • Hamstring muscles (biceps femoris, • Range of movement – reduced semitendinosus, semimembranosus ROM or pain can be due to gracilis*) damage to the knee, pain, arthritis, and a host of other Extension conditions • Extensor apparatus (quadriceps muscles, quadriceps tendon, patellar tendon, tibial tuberosity) S U R G S O C J A S | C P A L E C T U R E S E R I E SPassive • Patient must be relaxed Movement • Flex and extend their legs • Look for hyperextension. This is where you lift their leg without bending the knee at all, and look for Your turn. hyperextension at the knee joint. • Up to 10 degrees is normal only if bilateral S U R G S O C J A S | C P A L E C T U R E S E R I E SS U R G S O C J A S | C P A L E C T U R E S E R I E S Where must the practitioner’s hand be placed What is the normal range of motion for the when assessing hyperextension? knee? At the ankle (hold the achilles tendon) 0 to about 140 degrees (lower range of -10 degrees normal if bilateral) Arthritis will cause an increased or decreased range of motion? Decreased S U R G S O C J A S | C P A L E C T U R E S E R I E S Special T ests Anterior Draw and Medial and Lateral Posterior Sag Collateral Ligaments S U R G S O C J A S | C P A L E C T U R E S E R I E SPosterior Sag Knees flexed Feet flat on the couch Look from the side Normal Posterior sag Posterior Sag Sign indicates the presence of a posterior cruciate ligament tear. Think about the way that the PCL holds the tibia – why does it sag posteriorly? S U R G S O C J A S | C P A R I E S U R E S EAnterior Draw Knees flexed Feet flat on the couch Thumbs on tibial tuberosity and fingers reaching into popliteal fossa Normal Anterior Draw Pull gently A Positive Anterior Draw indicates the presence of an anterior cruciate ligament tear - BUT A Positive Anterior Draw in the presence of a positive posterior sag sign is CLINICALLY INCONCLUSIVE. Why? Question: What is the difference between the Anterior Draw test and the Lachman test? S U R G S O C J A S | C P A L ER I E SR E S ECollateral Ligaments Knees slightly flexed Place hands above and below sidesnee on medial and lateral Gently apply valgus and varus stress Opening of the Medial and Lateral Joint line is NOT normal Opening of the medial joint line suggests damage to the medial collateral ligament Opening of the lateral joint line suggests damage to the lateral collateral ligament S U R G S O C J A S | C P A L ER I E SR E S E When providing a varus stress to the knee, which ligament is being tested? In what position must the patient’s legs be when looking for Posterior Sag Sign? Lateral Collateral Ligament Feet flat on the couch, knees bent at 90 degrees Where are the thumbs of the physician placed when performing the Anterior Draw Test? On the tibial tuberosity S U R G S O C J A S | C P A L E C T U R E S E R I E S Viva Questions Radiographic Images Presentations of Pathologies S U R G S O C J A S | C P A L E C T U R E S E R I E SBasics of What will an X-ray allow us to see? Bones imaging What will an MRI allow us to see? the knee Bones Usually get an MRI of theCartilage Ligaments Vessels Fat S U R G S O C J A S R I E S L E C T U R E S EBasics of imaging the knee X-ray is standard. patient is standing. May be for investigation of OA Need to be able to: • Name the bones • Identify fractures → look at outline • Identify displacement/abnormal spaces S U R G S O C J A S | C P A R I E S U R E S EBasics of imaging the knee MRI allows us to see the soft tissues Need to be able to: Need to be able to: • Name the bones • Name the ligaments • Name the muscles • Name the menisci S U R G S O C J A S | C PR I E SC T U R E S ELeft knee Top tip: look at the fibula Which knee is this? S U R G S O C J A S | C P A L E C T UR I E SEKnee replacement What surgical intervention has been performed? S U R G S O C J A S | C P AR I E ST U R E S EMedial meniscus Top tip: look at the fibula to decide whether medial or lateral Name the structure. S U R G S O C J A S | C P A L E C R I E S S E(Torn ACL gives positive) Anterior Draw Top tip: Anterior/Posterior refer to the attachments of the not femurligaments on the TIBIA What test will be positive if the following structure is torn? S U R G S O C J A S | C P A L E C R I E S S EGastrocnemius Top tip: Gastrocnemius attaches to the femur, not the tibia Name the structure. S U R G S O C J A S | C P A L E CR I E SE S ELateral collateral ligament Top tip: look at the fibula to decide whether medial or lateral Name the structure. S U R G S O C J A S | C P R I E S T U R E S E(This vessel arises from) Femoral Artery Name the vessel from which this vessel arises S U R G S O C J A S | C P AR I E ST U R E S ES U R G S O C J A S | C P A L E C T U R E S E R I E SFemur Top tip: the patella is located at the level of the femur, not the tibia Name the bone. S U R G S O C J A S | C P A L E C T UR I E SES U R G S O C J A S | C P A L E C T U R E S E R I E SPosterior Sag Name the pathology shown here. S U R G S O C J A S | C PR I E SC T U R E S E 1. Pain worse on movement Osteoarthritis 2. History of trauma to the knee 3. X-ray shows joint space narrowing and osteophytes What pathology does this patient have? S U R G S O CR I E S| C P A L E C T U R E S ESeptic arthritis 1.Knee tender and feels hot 2.Positive T ap test Possible differentials: 3.Reduced range of motion • Reactive arthritis • Rheumatoid arthritis flare up What pathology must you first suspect in this patient? S U R G S O C J A S | C P A R I E S U R E S E 1.Open Medial Joint Line Sports 2.Positive Anterior Draw Common in: 3.Pain on passive flexion • Footballers • Rugby players Name one type of activity that typically damage these structures? S U R G S O C J A S | C P AR I E ST U R E S EBONUS Why have these structures been damaged together? S U R G S O C JR I E SC P A L E C T U R E S E Medial Collateral Ligament closely connected to Medial Meniscus S U R G S O C J A S | C P A L E C T U R E S E R I E SLast top If you are unsure about the answer to a viva question, be vague. tips If they require more specificity they will prompt you. You can always ask them to repeat a question. But only do so when you finish the exam. Start practicing… TODAY. S U R G S O C J A S | R I E S E C T U R E S E Abhisekh Chatterjee ac2420@ic.ac.uk JAS Leads CPA Lead: Mohamad Abou-Eid (ma2219@ic.ac.uk) Phase 1a Lead: Sree Kanakala (sk1821@ic.ac.uk) Phase 1b Lead: Ananya Jain (aj620@ic.ac.uk)