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Lecture 6: 06/03/2022 Presented by:Chelsea A. Stubbs Musculoskeletal Examination S URGICAL S O CIETY J UN IO R AN ATO M Y S ERIES | CPA L ECTU R E S ER I ESContents 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 GJ A C P A L E CS E R I E S This is Sally Sally is a 24-year-oldgraduate medical student who is in hospitalfor a knee issue. Your registraron placementtells youthat she’s got signs, so you shouldconduct a musculoskeletalexaminationon her. Have you got the skills necessaryto pick up on the signs? S U R G SJ A S C P A L E C TS E R I E S Structure of the Examination Positioning and Exposure Look Feel Move Special Tests Viva S U R G J A S C P A L E C S E R I E S Quick Recap of Knee Anatomy Bonesand ligaments Muscles Neurovasculature S U R G J A SC P A L E C 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 J A SC P A L E CS 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 J A C P A L 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 GJ A C P A L E S E R I E S Whattype of bone is the patella? Which nerve near to the fibulais atriskof Sesamoid damage? Common peronealnerve Name all fourquadricepsmuscles. Whatligamentpreventsthe tibia fromsliding Rectusfemoris, Vastuslateralis,Vastus, backwards? Posteriorcruciateligament intermedius,Vastusmedialis Whatimportantarterypassesthrough the poplitealfossa? Poplitealartery S U R G SJ A S C P A L E C TS E R I E S Position and Exposure Position Exposure S U R G J A S C P A L E C S E R I E SPosition Lying on the couch. Patientwill likely be positioned at45 degrees. S U R GJ A SC P A L E CS E R I E SExposure Need tobe able tosee kneejointand quadriceps and calf muscles. The patientwill likely be wearing shorts. S U R G J A C P A L E CS E R I E S Look Scars Muscle Wasting Knee Deformities S U R G J A SC P A L E C S E R I E S Scars Looking Pay attention! Genu valgum Muscle Wasting What can you see bylooking at the knee? Genu varum Swelling S U R G J A SC P A L E S E UR 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 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 U R E S E R I E S Feel Joint Lines Bones Fat spaces S U R G J A S C P A L E C S E R I E S Feel for temperaturefirst.Assessabove and below the jointline Feeling Gel yourhands! We feel in 6 differentareas: • Around thepatella • Medial Joint Line • Lateral Joint Line • Tibial Tuberosity • Head of Fibula • Popliteal fossa Effusions: • Sweepmethod – Small effusions • Tapmethod – Large effusions S U R G J A SC P A L E S E UR 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 Whatis the correctexposurefora On which side do you sweep upwardswhen musculoskeletalexaminationof the knee? performingthe Sweep Testforsmalleffusions? Enoughto see the knee joint,quadricepsand Medialside calfmuscles Whatthe medicalterm forknock-kneed? Genu valgum S U R G S J A S C P A L E C TS E R I E S Move Active Passive S U R GJ A SC P A L E S E R I E S • Lookfor Active Movement • Pain on movement Flexion • Range of movement • Hamstringmuscles(biceps femoris, semitendinosus,semimembranosus gracilis*) Extension • Extensorapparatus (quadriceps muscles,quadriceps tendon,patellar tendon,tibial tuberosity) S U R GJ A C P A L E S E R I E SPassive • Patient must be relaxed Movement • Flex and extend their legs • Lookfor hyperextension. Up to 10 degrees is normal only if bilateral Yourturn. S U R J AC P A L ES 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 Wheremustthe practitioner’shand be placed Whatis the normalrange of motionforthe when assessinghyperextension? knee? At the ankle(holdthe achillestendon) 0 to about140 degrees(lower rangeof -10 degrees normalif bilateral) Arthritiswillcause an increasedor decreased range of motion? Decreased S U R G S J A S C P A L E C T S E R I E S Special T ests AnteriorDraw and Medialand Lateral PosteriorSag Collateral Ligaments S U R GJ A SC P A L E S E R I E SPosterior Sag Knees flexed Feet flat onthe couch Look from the side Normal Posteriorsag PosteriorSag Sign indicates thepresenceof a posterior cruciate ligament tear S U R G J A C P A L E CS EUR I E SAnterior Draw Knees flexed Feet flat onthe couch Thumbsontibialtuberosityand fingersreachingintopopliteal fossa Normal AnteriorDraw Pullgently A Positive Anterior Draw indicates the presence of an anterior cruciate ligament tear BUT APositive Anterior Draw inthe presence ofa positiveposteriorsag signis CLINICALLY INCONCLUSIVE S U R GJ A SC P A L E CS EU R I E SCollateral Ligaments Knees slightlyflexed Place handsaboveandbelow the knee on medialandlateral sides Gentlyapplyvalgusand varus stress Opening of the Medial and LateralJoint line is NOT normal collateralligamentialjointline suggestsdamagetothe medial Opening of the lateraljointline suggestsdamageto the lateral collateralligament S U R G J A SC P A L E CS EU R I E S When providinga varusstressto the knee, In whatpositionmustthe patient’slegs be which ligamentis beingtested? when lookingfor PosteriorSagSign? LateralCollateralLigament Feet flat onthe couch,knees bentat 90 degrees Whereare the thumbsof the physicianplaced when performingthe AnteriorDraw Test? On the tibialtuberosity S U R G S J A S C P A L E C T S E R I E S Viva Questions RadiographicImages Presentationsof Pathologies S U R G J A S C P A L E CS E R I E S What will an X-ray allow us to see? Basics of Bones imaging What will an MRI allow us to see? the knee Bones Usuallyget anMRI of the kneCartilage Ligaments Vessels Fat S U R J AC P A L ES ER I E SBasics of imaging the knee X-rayis standard. patientis standing.Maybe for investigationof OA Need to be able to: • Name the bones • Identify fractures → look at outline • Identify displacement/abnormal spaces S U R GJ A C P A L E S E R I E SBasics of imaging the knee MRI allowsusto 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 GJ A C P A L ES ETR I E SLeft knee Toptip: lookatthe fibula Which knee is this? S U R G SJ A S C P A L E C TS ER R I E SKnee replacement What surgical intervention has been performed? S U R GJ A C P A L ES ETR I E SMedial meniscus Toptip: lookatthe fibulato decidewhether medialorlateral Name the structure. S U R GJ A C P A L E S E R I E S(Torn ACL givespositive) Anterior Draw Toptip: Anterior/Posteriorrefer to the attachmentsofthe cruciateligamentson the TIBIA not femur What test will be positive if the following structure is torn? S U R G J A C P A L E CS EUR I E SGastrocnemius Toptip: Gastrocnemiusattaches to the femur, not the tibia Name the structure. S U R G SJ A SC P A L E C TS ER ER I E SLateral collateral ligament decidewhether medialorlateral Name the structure. S U R GJ A C P A L ES ETR I E S(Thisvessel arises from) Femoral Artery Name the vessel from which this vessel arises S U R GJ A SC P A L 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 SFemur Toptip: the patellaislocatedat the levelof the femur, not the tibia Name the bone. S U R G J A S C P A L E CS EU RR 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 SPosterior Sag Name the pathology shown here. S U R GJ A C P A L E S E R I E S 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 J AC P A L ES ETR I E S 1.Knee tender and feels hot Septic arthritis 2.Positive T ap test Possibledifferentials: • Reactivearthritis 3.Reduced range of motion • Rheumatoidarthritisflareup What pathology must you first suspect in this patient? S U R GJ A C P A L E S E R I E S 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 GJ A C P A L E S E R I E SBONUS Why have these structures been damaged together? S U R J A C P A L ES ETR I E S 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 ES 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 GJ A C P A L ES ETR I E SChelsea A. Stubbs cs1119@ic.ac.uk