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Examination of Hip & Knee by Mr Douglas Pearman



Examination of right hip and knee in trauma and orthopaedics by Mr Doug Pearman

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Uh Hi, fella. Can you hear me there? Uh confirm if you can have Ian. Fantastic guys. Uh Welcome along to the teaching. I don't know how many of you there are. Um, how many people do we have uh to be off for great stuff? Uh ok, let's get started. Uh We only have so long to deliver this one. So uh eight people in the drawing room. Bloody hell, excellent. So, er, today's session is uh about hip and knee examination and the purpose of this session, er, is that uh what we want to do is to not just talk about uh what you do in an osk for hips and knees cos actually, that's not really relevant when it comes to doing sho based uh hip and knee examination. Er, the relevant thing is that uh given you can't do one of those osk examinations on a, a fractured hip, er, and you can't really, er, assess er, much about a hot acute knee, er, that's just had a sporting injury, uh trying to make the presentation as relevant to the bits and pieces that you need to do in the hospital either on your a and a acute on call or during your ward reviews. Um So hopefully that will be relevant. Uh What I can't do is I can't hear any of you. So it may be a little bit taxing to uh to hear what you're giving us responses cos hopefully we're gonna be doing interactive stuff. Uh Somebody said, can I record the session? Uh and the ulcer is uh I'm not sure. So uh I'm not sure about the technicalities of recording the session, I'm afraid. Um And sharing caught on the screen, not sure. Um So I can hide that away. Uh Turn off microphone, turn on camera, stop presenting more options. Uh I can't see an option to record the session, I'm afraid. Uh So uh if somebody can excellent, please do record it. Otherwise we'll just crack on. So uh let's go back to this. Uh Let's try this one over here. Five. Yeah, there we go on the spot. OK. So uh the things we're gonna talk through, first of all, we'll talk through uh the purpose which we've gone, gone again. Uh Then anatomy of the knee and the hip, uh some common differential diagnoses, uh general examination tips, some examination stuff of the knee and examination stuff of the hip. So, first of all, uh brief anatomy summary here. So uh uh what we've got here is uh an ap in the later view of the knee. Uh the features I want you to think about are that, er, on both the medial and lateral side of the knee, we've got the er collateral ligaments, er, and er, within the joint capsule, we have the ACL and the PCL, er, the ACL resists anterior translation of the tibia on the femur, on the PCL, er uh oppositely uh it uh prevents posterior translation of the tibia on the femur. Uh The patella is uh held in place by the quadriceps muscles, uh the quadriceps tendon uh and the patella tendon which attaches onto the er the tubercle, uh hip wise. Uh the answers that I want you to look at on this uh hip diagram are just to, just to see that the, the, the hip is relatively. Um So, so that you have various structures which uh which um insert into the greater tranter. So you've got the uh gluteus minimus um at various of the tendons that can insert in there uh over which there is a bursa. So that can be an important feature. Um And in terms of the proximal femur anatomy, just be reminded where the head is. You've got a neck of the femur, you've got two trach cancers of the femur. Uh And then you have the uh the uh the, the diaphyseal portion of the femur. So, differential diagnoses I want you to have in your head when you're doing examinations. Er So, er here are things that you may face on the ward. So I want you to think about uh uh about uh wounds that you're gonna be seeing. I want you to be thinking about compartment syndrome, er DVT, er, and acute hot swollen joints. I think those are things that you may be called to uh to see as inpatients. Uh In addition, uh I uh I think in the A&E department you're more likely to, to encounter these sporting knees where somebody's had an accident on some kind of playing field. Um And in that context, you want, want to be thinking about uh injuries to those ligaments we've talked about as well as meniscal injuries uh and patellar dislocations. Um You may see bursitis, you may see knee dislocations which is a diagnosis not to miss and you may see fractures uh within those acute hot swollen joints. Uh You want to be thinking uh uh top of your differential list to rule out iss knee, but it's much more common to have calcium pyrophosphate crystals, gouty crystals. An old person on anticoagulant who's got a he arthrosis in the knee or a flare of oa um uh within the hip. Uh naturally, the most common er admission for fracture that we have is uh proximal femur fractures. So that's extracapsular, intracapsular, subtrochanteric. Um We also want to be thinking uh when we see patients in the A&E setting about dislocations, uh again, about flares of osteoarthritis, uh which can happen in the hip as well. Uh We want to be thinking about septic hip, which is rare but uh possible uh pain over the greatest cancer uh which can be caused by a series of different uh uh different um anatomical causes. Uh And we may want to have tumor in our differentials too. Um with inpatients around the hip, you may see wound breakdown when you've got a leaky hip wound or a dessing hip wound. And then in the pediatric A&E department, we may see limping Children. So, uh, it's a little bit challenging without the old two way interaction. Um, because I can't really get you guys to give answers to this. So, what I'm gonna say is if you're listening, I'd like you to speak to each other for 30 seconds. Er, and try and think first of all, uh, if you have to think about seven steps to every orthopedic examination, uh, can you list what those seven steps would be? I'd like you to have a chat with each other for 30 seconds and I'd like you to type it into the messaging box on this med app. So, seven steps to orthopedic examination. What are they help? Ok. Uh, nobody's typed into the box. Er, can you type in some of your answers into the chat box, please? For uh uh examples of the seven steps of examination in orthopedics? Yeah. No. Ok. Oh, here we go. History. No, history is not part of the examination. So look, field, move special tests. Excellent. That's four. so look inspection. Yeah, that's good. So that's four of them. Look, feel, move special tests. Um, any other? So that's four out of seven. what are the other three? Yeah. Are we gonna examine any, any of the joints? Which joints are we, are we gonna examine, if we're examining all the joints, person's got a painful knee above and below and then there's one more, er, which, er, one of the consultants picks up it's above below and also the contralateral side. Uh So, yeah, that's good joints above and below. Er, the other things we want to be thinking about are uh we want to think about functional movements. Uh and what are we gonna be checking distally uh from the joints of injury? Excellent neurovascular stasis. Fantastic. Right. That's it. Boom. So look, palpate move active, then passive joint above, below comparison with contralateral side. Distal neurovascular stasis, exactly pulses, er, and, er, whether they can move, uh whether they, they've got sensation intact, functional movements. So, for hips and knees, this is essentially gait. Um and uh then special tests. So, special tests we might want to think about, might be valgus or various stress tests on the knee, uh might be quite relevant, er, for yourselves. Um, think about the Lachman's or anterior draw or posterior sag, which, which is really just an inspection, er, and then around the hip when we're thinking about uh special tests, uh you might want to do the thomas test to check for a, a fixed selection deformity, um, uh perhaps less commonly, er, a fat ear test, flexion adduction and internal rotation to check for so irritation. Er, and you may want to palpate the si joint. In addition for your examination orthopedically, I've got three further pleas with the patients that you see. Number one of these is, uh, think about screening examination in trauma cases. We're quite lucky here in the A&E at worthy that not many injuries are missed by the A&E team. But uh and it's something I'm not always very good at. Uh we should, when we're seeing a patient with a hip fracture or with uh with, with a knee injury, we should just make sure they can move the other leg, they can move their arms. Uh so that there's no great distracting injury uh that we're examining primarily for where we miss something else that's going on. Cos I know occasionally things do get missed an examination also use your pen. So uh you will have a pen with you. Uh Whenever you're examining a patient with a knee or a hip injury, uh I'd recommend use your marker pen to draw on the dorsalis pedis pulse if you can feel it. Um And if you have cellulitic spread, cos the patient that you're seeing for the hip or knee trouble has got cellulitis, uh uh mark around the outside of that cellulitis and time and date it uh because it will help people when they're examining in the future and it makes your photos of the injury look better. Uh finally document your examination findings. So, ok, examination wise, when we think about uh knees, uh this is what the documentation of the examination finding would er reflect. So a knee can flex from naught degrees to about 100 and 40 or 100 and 50 degrees. Um and so it can be helpful when you're talking about a fixed flexion deformity to write it in the context of 10 to 90 degrees. Er, is the patient's range of motion in this arthritic knee. Uh, it's worth remembering that the knee is close packed at naught degrees when it's in fully extended, er, position. Uh and it's loose packed ie the tension inside the capsule, the pressure inside the capsule is at its lowest, at about 25 degrees of flexion that's relevant in examination because uh patients with uh uh effusion inside the knee and particularly in aseptic arthritis where they've got a very inflamed effusion inside the knee, uh will not want to move it away from that 25 degree of flexion position. Um, hip wise, we talk about the range of motion uh as a range of flexion and a range of extension. So people may be able to flex up to 100 and 20 degrees. If they are, uh, if they're really flexible, it might be 100 and 40 or even more. Uh an extension might be 30 or 40 degrees of flexion. So you have those two different ways of describing the movement. You've got uh flexion range and extension range in the hip. Uh uh normal patients will have about 45 degrees of internal and external rotation of the hip. Although many of the elderly patients that we see will of course not have that because they have some degree of arthritis, uh arthritis uh notably is more likely to affect internal. So I haven't got time for a quick examination video. Uh Will it even work? Let's try. Hopefully, you can hear it to relax as much as possible during the test with one hand, grab onto the lower leg just above the ankle joint. And the other hand is used to fixate the femur then slightly externally rotate the tibia and perform passive abduction in the knee joint. And thus putting stress on the medial collateral ligament. You are looking for excessive gapping on the medial side and the reproduction of pain consequently, perform the same test with the knee in 20 to 30 degrees of flexion. Again, you're looking for excessive capping on the medial side and the reproduction of pain. Take a look at this table which lists all of the fine. So uh briefly, that was your uh that was your valgus stress test of the knee. Uh The relevance of the valgus stress test of the knee uh is that uh it can help us identify if there's an N TL uh tear. Uh and what's helpful in these sporting injuries is valgus stress test, uh will be pronouncedly painful if they have an NCL tear. Er, and in the context of a medial meniscal tear alone, uh actually, the valgus stress test may not be quite so painful. So it can be a useful distinguishing test as well. Uh The opposite of the va stress test can obviously be done for a various stress test to test the la er the lateral cola ligament. Uh The other test that I would think about is the Lachman's test to perform this test. Have your patient in the spine line position and bring your patient's test leg into 30 degrees of flexion, fixate the femur with your outer hand, bring the tibia into slight external rotation and then try to translate the tibia anteriorly. This test is positive if you experience a soft or mushy and feel or if the anterior translation of the tibia in the injured leg is at least three millimeters greater compared to the uninjured leg. Please keep in mind that your test results in a chronic situation will always be more valid than in an acute situation. The reason for this is that swelling and muscle spasm in an acute situation will have a negative influence on your test results. Ok, guys, this was the Lachman test. I hope this video is helpful to you if great stuff. So, uh, the reason I've presented the Lachman's test there and you can also do this by placing your knee underneath the distal femur. Er, is that, that's a helpful test, uh, where the knee is slightly flexed, er, in about that 20 degree position, er, for assessing whether you can translate, uh, the tibia on the femur, er, and that's a helpful test for ACL er, rupture. Uh, again, in the er acute setting, it may not be quite so helpful because the pain, the, the knee may be so painful and so inflamed, it may be difficult to do. Er, but these are two good tests to know how to do well. So, uh then in general examination as well, cos this is relevant to both knees and hips. Uh I'd recommend have a think about some of the common things that we're gonna see around the wounds that we're examining. So think about stitch abscess, which is where a knot at the end of the uh vitral suture, usually inside the wound, which will have about three or four layers because it's a knot causes a greater tissue reaction in the patients than does just a single filament of the, of the suture. And therefore, the patients can get an area of inflammation that can turn into a small localized abscess. Uh think about erythema around wounds, think about serous or particularly leak of pus because ser leak can be caused by low albumin or hyper or coagulopathy, uh, equally uh, pus. Uh, but it's unlikely for pus to be caused by anything other than an infection. Look for dehiscence, which is where the wounds coming apart. And think about, is there any suture or click? Uh Are there any other clips remaining in this wound that I'm examining that should have come out by now, uh, with knee and hip wounds be less concerned by bruising and swelling. So I've got some pictures here. So, uh uh I'm sure you can see among yourselves what these are, call that out on the room. Uh I can't hear you but I'm sure you can call out what you can see there. Likewise here. Uh What can you see here? This is an area of localized swelling at one end of a, a wound. Similarly, here, we've got a small area of localized erythema at one end of a, of a wound where the rest of it looks quite well healed. Similarly here that this is a wound that has opened up in part. So this is a dehiscence. Uh What's the notable feature you can see here in this er POSTOP total knee replacement at uh 11 days down the line. Uh And if it were 17 days down the line, what else would you be concerned by in this wound? Suspect what you're saying is erythema and the eclipse are still in situ. Uh And this is just on the one on the hip. So, erythema of this nature is something that definitely wants to raise an alarm in us. Uh This is the kind of bruising or swelling that actually might be quite common with uh postoperative patients, uh particularly if they're coagulopathic. So, knee examination, uh uh so uh we'll just go through a few of these. So uh compartment syndrome wise in the leg uh when you were examining a, a leg and you're thinking, I saw one of these on the wall the other day actually, uh in, in recovery uh where we had, it was in a forearm, uh it was painful, it was a cast in situ. Uh The pain couldn't be controlled by ketamine. Uh It was exacerbated by passive stretch of the chat uh fingers, er, and the hand was very swollen. It was really, uh it was really ticking all the boxes for uh a compartment syndrome. We released the cast and it got better. So those are the things I want you to think about in compartment syndrome and if you can palpate them, palpate those posterior compartments and see if you can, er, if it's hard and tense because it shouldn't be like that. Uh It shouldn't be hard and tense when you palpate those compartments. Er, a feature in the history is that the patient may report pain that's both worsening and it's beyond the site of where the injury was. Er, and that may be more telling for compartment in. Don't forget to do the passive stretch test, uh flexion or extension. Er, and it may give you some guidance as to which compartment is painful. Uh If they can point to it when you're moving the foot DVT wise, think about swelling of the limb, uh unilateral pitting edema, er, superficial, er er phlebitis, er, and shiny skin. Er some of these are on the er the wells score. Of course, if the patient's got pleuritic pain as well, when they take a deep breath, that may be relevant in your DVT exam, er, for pe now, acutely hot and swollen joint. Uh my slides got a little bit mushy here. Uh But uh when you get called to the ward about an acutely hot and swollen joint, uh I want you to think about what position is the joint held in. Firstly, if the, if the person on the end of the phone or the person, uh or the patients can move their joint through a range of naught to 100 and 10 degrees, you're probably less concerned about a septic intra articular pathology. It's not impossible, but it makes it less likely that that's what they're gonna be having. In fact, it may be extra articular if they've got a uh such a good range of motion. Um, uh you want to think about, is the patient unwell or are they just in pain? Um, uh, so you can look at their observations uh, and consider if there are any other joints affected cos that may point to either a localized pathology or something systemic that's going on. Uh, in the bottom left picture here. Uh, we've got a picture of a patient with osteoarthritis. And if they had a hot and painful knee, you might look at that right knee and the bottom right left image and think, well, that's inva that knee, uh, that suggests to me may, maybe this patient's already got preexisting arthritis. Could this be an osteoarthritic flare uh in the top right picture here. Uh Or in fact, what have we got in the, in the two top pictures? We've got areas of cellulitis around the the knee, particularly in the top left picture. So when you're examining a hot and swollen knee, you definitely want to be looking for cellulitis and thinking, uh uh I don't want to, uh I don't want to get this infection that's in the skin uh to penetrate into the joints. So, uh certainly when you're examining for cellulitis, you're drawing your line around the cellulitis, uh do not put a needle through cellulitis into a native joint. Uh You may also want to think about whether there are scars in situ over the knee. Uh because if there's metal work in situ, er then you'll need to uh do any kind of joint aspirate, er, will need to be performed in theater rather than being done on the wall. Yeah. Perfect. Um Of course, there are various features that of the history that may be relevant uh particularly if there's a a background of gout C CPPD or some form of anticoagulant in in situ. So the middle image we have here is I think a patient with hemophilia. Uh but we do get this in the elderly patients who are on Apixaban as well. The top right picture in this image represents septic arthritis where there's both the painful joints and there's overlying uh inflammation too. Uh So when we think about the acute sporting knee, so this is the patient who's been taken off the field. Uh you want to be thinking about uh differentiating diagnoses if you can or trying to rule things out. So first of all, think about the patella, er is the patella in the right place, is it central over the knee or is the patella uh off to one side and dislocated? Uh because then you have your diagnosis straight away, uh look at the er er look above and below the patella. So think about is there a gap here uh in the distal quadriceps tendon or in the patellar tendon? Er and then you can palpate it in there too. It may not even be desperately painful where you palpate it. Uh but you may be able to feel a gap if there's been a tendon rupture. Uh You uh also think about uh doing a straight leg raise test on these patients. Uh, sometimes with an innocuous soft tissue injury just because it's painful. They may not be able to straight leg raise and we may need to bring them back to clinic to assess for that. But if they, uh if you've got a high suspicion that the extensor mechanism is ruptured, we need to be ordering additional imaging, uh MRI ultrasound, et cetera to confirm the diagnosis directly from A&E we don't need to wait for the two weeks until they're seen you in clinic. Uh, a key feature of this is that straight leg raise or being able to actively extend the knee, uh means that they can extend the knee beyond 45 degrees. Er, so, er, er, just because they can extend it to 15 degrees. So from 90 to 75 that kind of extension can be controlled by the retinacular fibers of the knee. Uh So there are some parts of the extension mechanism which bypass the quadriceps tendon and the patella. So, don't be fooled by that when you're assessing for knee extension. Uh if the patient wants, you put a cricket pad splint on them and you're thinking, oh, maybe this patient's just got some form of ligamentous injury if you're stabilizing the knee in extension, uh and the patient still cannot weight, bear on it, then, uh then uh uh you'll, you'll certainly want to rule out a fracture and if you can't see it on the X ray you'll need to uh ensure you've got some CT imaging if they can't weight, bear on that, on that limb. Uh And don't forget dislocation er in the top right image here, we've got an example of a dislocated knee in the middle image on the right. We've got uh a PCL rupture. Um So you don't want to miss dislocation because there, you're definitely gonna need to assess the distal pulses and get cc angiography. Uh So, two more diagnoses to go, I think uh bursitis. Uh So this is superficial swelling. Uh uh you may get a fluctuance, it may be infected. Um but they should probably still have a fairly good range of motion of the knee. Uh And it's an important distinction to be able to make between an intra articular pathology and an extra articular pathology. Uh You'll be wanting to look for a punctum uh because there may be penetrating injury that may have caused an infection. Um And certainly the history may tell you, er if they have a job that involves kneeling down or something similar uh and the knee fractures and dislocations in A&E. Um So, although these can happen in the high energy trauma, patient, motorbike accident, rugby injury, whatever, uh they can also happen innocuously in, in a morbidly obese patient where uh just through twisting their knee slightly, uh a ligament can rupture uh due to the high mechanical load on it and you can end up with a uh a knee dislocation. So, uh think carefully about that when you're examining morbidly obese patients check for those distal pulses, uh ensure the components are soft in a dislocation patients. Um uh and if there's an open fracture or a puncture wound, they'll need a major trauma center. Uh fine. So I think what I'm gonna do there, we're at time. I know Zain has got a further teaching session that he wants to run now. Uh, so I'm gonna wind things up there. We may have to do hip at a second time. Um, er, but, er, I'd like you to just consider this case example as you close. Uh, and, uh, and then if you can provide some feedback, that would be really helpful. Yeah. Yeah. So this is a, a 30 year old male rugby player tackled from the side and then he was caught squashed in the rock that ensued. He's got a right, painful swollen knee, uh, no previous surgery, no allergies, no regular medication, uh, and lives a fairly unremarkable lifestyle with 20 units of alcohol a week. Uh, think about how you'd examine this to ensure that you identify the correct pathology. Um, uh, great. So, uh, that's it for today. Thanks very much for attending. Uh, see you next time.