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But actually it's more complex than that and, and often, um, the examination, um, and the history taking, um, er, is, is very telling of what's actually going inside the knee because it's a, it's a fairly superficial joint, you can actually feel what's going on and if you perform the test uh properly and you do take the correct history, then often, um, you know what you're going to find on the investigation such as MRI or X ray. Um, so your, your history and your examination gives you most of the information you need. Um, the anatomy is very important for, for that precise reason, you need to understand where everything is that you're feeling. And for the, you know, if you just focus on getting through examinations as in your, uh osk, the examiner who's observing you, um, I've examined for osk and it, it's very easy to tell when somebody examined the knee before, uh, versus somebody who hasn't. So I highly encourage you guys, I know a lot of you come to the ROH for your orthopedic block, highly encourage you go and sit with one of the, um, uh, knee surgeons in the, in in the clinic and examine in front of them or watch them examine, um, or, or w watch them examine the patient and you'll pick up so much from just observing four or five patients. I promise you that's all you need. And then go away, examine on each other and then come back again and, you know, just refining your technique. I think, I think the key is really turning up to clinics and actually um put your hand on the patient because that practice they, the, the real feel that you get, you, you can't replicate that on, in books or even me talking to you through a screen today. Um So you really need to, it's, it's a very hands on specialty and you need to put your hand on the patient to, to, to really get a feel for it. Um The common knee conditions that I'm gonna be covering are ligamentous injuries, meniscal tears, arthritis, er will cover some of the patella frontal problems. Er, and I think that in, in its entirety should be enough to um you know, give you a, a good foundation. Um You'll see some time uh reminders at the top, ignore those dates for me to know. Um If, if I'm er, spending too long on a slide. So, uh so that's uh that's just a note for me. Um in terms of anatomy, um often you, you, you think of knee as an articulation between the tibia and the femur, but actually there's more to it, it's more complex. You know, you've got the patella in front so that forms the patellofemoral articulation. And then you've got the tibiofemoral articulation. But there is a, a third one which is the um uh the, the proximal er tibiofibular er joint, which believe it or not is a joint, there's not much movement there but it, it does exist um and the tibial er tibiofemoral um articulation is further then divided into medial and lateral compartments, which we're going to talk about in a second. You know, meniscus wise, there is a medial and lateral meniscus. Um We'll go through that in a minute. Um muscles wise, the only ones I really want you to focus on initially is the quadriceps and hamstrings. And we'll talk about the importance of that later. Um key ligaments. We know ACL and PCL very well. We know the M CL, which is the media collateral ligament and then the lateral collateral ligament. There are many other ligaments in the knee and some of them have been more recently described. So without going into the nitty gritty of it, just remember all of those ligaments and the importance of it will come on to later, it's um synovial joint. Um and there are some bursa associated with the patella um which you know, you you you do see patients coming in with swelling outside of the knee joint, which is often to do with the bursa um referred to as bursitis. I'm not gonna dwell on it too much, but just know that there are bursa around the knee and then finally, the importance of neurovascular structures. Um I've mentioned pop artery there, there are others, we'll talk about it. Um So this is just a schematic of what you see. And as I said, the patellofemoral joint is um part of the knee joint and it's important to consider it as part of your examination. As you can see, there is another joint between the proximal tibia and fibula. Um um The main thing to er say on this slide is that the patella is a desmoid bone, which means that it is covered um uh with a uh with a tendon on either side of it. So, um you've got the quadriceps tendon approximately and then distally you have the patella tendon. Um and this together with the patella forms, what we call the extensor mechanism of the knee pivotal for uh the function of the knee. And um as you can see the, the quadriceps are coming er and merging onto the patella um forming this sort of insertion point which is the quadriceps tendon, um know your anatomy. Uh This is probably the first thing that you get asked about if you come to theaters, if only if you are interested in orthopedics. Um or even if you come to clinic. And the reason is that, and that is key to understanding what's going on when something goes wrong, you need to understand how it's meant to be in a physiological state. Um, and this is another schematic showing you the medial or lateral meniscus, which er, or menisci rather. Um, these are squidgy bits between the knee and that's basically what they are, but the function is far more complex. So they don't just provide a bit of cushioning between the two bones. They're actually acting to also provide a more of a, a socket for the knee. If you think of it as a ball and uh the tibia is a flat surface, if the menisci weren't there, then you'll have a lot of contact pressure in this area. And therefore, if you remember your basic physics, uh force equals pressure signs area, surface area. So if the surface area is small, there's a lot more force going through the joint and you get um er wear off the joint much quicker and develop arthritis, the meniscus sort of forms a dish and gives it uh a larger surface area as you can see here. So, rather than the articulations just happening here, it happens across the joint like that. So it distributes the forces much better and therefore gives you um less forces going through the joint. Um There are other features too, it provides some stability to the joint. Um It, it does provide some cushioning. Um although that is questioned. Um and um and it is key to the function of the, of the knee joint without a meniscus, people develop arthritis much quicker. So for any of you, if you know somebody or yourself have had a meniscal injury, you'll know the surgeon will talk about um the need for preserving the meniscus. Um in terms of um insuring longevity of the joint, if the meniscus is torn and it's not repaired, uh patients are, are, are, are at risk of developing arthritis much earlier than they would otherwise, another schematic just showing uh the relationship between the quadriceps and the hamstrings. Remember both of these cross the joint. And so this is important in understanding the um the function of what happens when a hamstring contracts, you get flexion at the knee joint. And um it is not just a simple hinge joint actually as the hamstring muscles contract. And if you just, I don't know if you can see my screen or my camera, but um if you imagine my right hand as the femur and tibia on the left side as the knee flexes, it's not just this motion cos if that motion happened, eventually, the femur would fall off the back. The femur rotates on top of the at tia. And this is known as the rollback mechanism of the knee key to um uh smooth movement and um and function of the joint. Um Finally talking about the cruciate ligaments, which I think most of us learn to do the anterior draw and posterior draw test very early on when we're learning these examinations. Um it's important to provide the um ap stability in the knee. Um as the knee rotates, um the ACL functions to stop the uh tibia from uh subluxing forwards. Uh whereas the PCL functions to stop it from subluxing backwards. Um So the easiest way to remember is anterior stops, anterior subluxation of the tibia and posterior cruciate ligament stops posterior subluxation. Um without them again, um apart aside from the instability, symptoms that patients complain of, um uh it's also believed that it contributes to um uh wearing out of the joint as well as um have causing other injuries within the knee joint as it's unstable. You get meniscal tears and other um cartilage injuries if you don't have an intact men um uh ACL or PCL. So, um that's enough with the bone. Um and the er articulations, um actually, the key structures in the knee lie behind the knee joint and that is the um popliteal artery, the popliteal vein and the tibial nerve, which of course is a branch of the sciatic nerve. So this is just looking at the knee from the back, you've got both your medial and the lateral head of the gastroc muscles, gastrocnemius muscles. And as you can see, the neurovascular bundle is very closely related uh to the back of the knee. And therefore, um if somebody comes in with a knee dislocation these structures are at risk. Um, and you must always examine the neurovascular status of the lower limb. Uh, if you're ever examining somebody with a knee injury, critical, critical people lose their limbs over this if it's not examined and documented properly. And so, um getting the habit of doing a neurovascular examination, um it's as simple as feeling for the arterial pulse uh in the thesis pedis and the er, er, poster tibial and then asking them to um er move their ankle and their toes. I'm not gonna go into the details of neurovascular examination with you, something that you need to examine and practice in your for oss, but just remember that this is a key part of the examination. So uh common presentations, um I thought we'd spend a little bit of time talking about trauma related um uh problems and uh the main ones I've already mentioned are ACL tear, meniscal tear collateral ligament injuries. It could be simple as a sprain, which is just a bit of uh injury uh to the, to the um ligament all the way to rupture. Uh which of course makes the knee joint quite unstable and then fractures which we're not gonna dwell on too much. Um but uh the commonest fractures around the knee joint would be to do with the tibial plateau ie the tibial condyle, the medial and the lateral condyles. Um and then we'll talk a little bit about arthritis. So, degenerative causes of knee pain, um and then overuse uh uh syndromes. So, um people who um uh complain of anterior knee pain, uh can often have a uh pain coming from the patellofemoral joint or coming from the iliotibial band. And that is the um er structure on the, on the lateral aspect of the knee, uh which can sometimes get irritated um due to overuse um primarily managed by the physiotherapist. But as surgeons or as doctors, in fact, we need to be able to diagnose it and uh usher the patient correctly towards uh the right management. Um in your surgical serve, you also need to include inflammatory causes. I've already mentioned bursitis, tendonitis is another um cause. So patella tendonitis is a, is a, is a uh relatively common presentation um within inflammatory. You can probably also uh talk about things like um uh uh rheumatoid arthritis. Um although that has a degenerative flavor to it, to it as well. Uh and then finally infective and uh within that, um we we know that infection in the joint is and an orthopedic emergency. And the reason for that is that when there is pus inside the joint, it is not very well tolerated by the cartilage. So you must act quickly to diagnose it and then refer the patient appropriately to an orthopedic surgeon who can then do a, a wash out of the knee joint or any joint for that matter um to get rid of the pus as quickly as possible because that improves the um recovery of the joint and, and prevents any long term um uh problems that they may develop if you don't get rid of the pus, cos, the pus is not well tolerated by um joints. Um And so in terms of your history taking, you're gonna start off with a presenting complaint. Uh The, the main thing to mention there is regardless of which joint you're focusing on the, the structure remains the same. You ask about the pain where it is when it came on, what it feels like, where does it go? How bad is it? And how long has it been there? Have you done anything to improve and make it worse? Simple as that, those six questions should be on the tip of your tongue if you're walking into an orthopedic consultation or even uh osk you for that matter, focusing on the knee itself. Um You wanna ask about medial knee pain. Um for example, um and if, if that is um um uh present, then um you wanna also ask about any um uh associated um site. So for example, medial knee pain and then medial joint pain, two are different entities when you come to examine them. Uh But from your history, you want to try and clarify which areas are painful and whether it's only one side of the knee or it's both sides of the knee, um swelling, um the, you wanna understand when the swelling came on. Um And how long it took for it to go down. These are important um things in the history because as a surgeon, it gives you a clue as to um what structures may be injured, whether there may be a possibility po possible underlying fracture or not. Um And um the, the, the old dogma that immediate swelling after trauma is more suggestive of ligamentous injury and delayed swelling suggests more of a meniscal injury because the meniscus is not very vascularized. That is probably historic. Um because these days we do get MRI S for most patients who come in with this problem. And so we don't rely just on that sign, but it is still a useful thing to show and examination, for example, your in your os station um who is not an orthopedic surgeon and you, you know, just a general um uh a general surgeon or, or, or a GP for, for example, um because it, it is still in the textbooks. And from that point of view, I think it's still relevant to ask that question. And then you wanna talk about whether there is any mechanical symptoms. So mechanical symptoms is a, a term that we use to describe instability and locking. Those are two different facets. So instability is the act of their walking and their knee gives way. Um And often patients describe my knee, just my leg just gave way underneath me and that's the way to ask it. You don't, you, you don't ask the patient, do you have any instability because they will know what that means? So, ask them when you're walking, does your knee ever give way or does your leg give way beneath you? Um And what happens? Do you, do you fall to the ground or are you able to um are you able to just carry on walking? Because that gives you some clue as to how unstable the knee might be. Um So that's instability locking is when, well, it, it, it is what it says on the tin, it, the knee locks as it's going through its range of motion. So they're walking and suddenly the knee knocks locks in flexion and they're unable to straighten it. That gives us a clue that there might be something going on with the meniscus. There's a meniscal tear and that's getting engaged as they're going into flexion and extension. These are important um criteria for when we're deciding about whether to offer somebody surgery or not. Um And the presence of mechanical symptoms are an important positive or negative finding in the history. So if the patient says that don't have mechanical symptoms, that's an important thing to document. And also uh uh mention in your summary at the end of a of a presentation if you were presenting to your senior colleague. Um So I imagine mechanical symptoms on there again, but essentially, it's the same thing, um, stiffness. So that's the, um, uh, that, that's, that's again a common symptom, especially if they've got pain, um, often is subconscious. Uh, the knees, uh, the, the muscles go into spasm and sometimes, um, if it's severe arthritis, they'll actually have physical stiffness. Um, ie, the, the, the, the joint is not as well lubricated as you'd expect. And therefore you get, um, stiffness in the, in, in, in the joint, um, fine function limitation important for any history taking, but most important for orthopedics and even more so in knees because it, it tells you what your next step is gonna be in terms of management. So you wanna ask them, does this get in the way of you walking, climbing stairs squatting? What is it that you're unable to do? And often these patients are young who've had a sporting injury. So we want to find out what level of sports they play at, whether they have intentions to go back to it and how quickly, um and then just a little bit exploration of on of the trauma history itself. So if they do come in with having injured their knee, what was the mechanism? Um The words you can use are twisting or whether there was a direct blow or whether they fell, um Was there a AAA popping sound? They heard? I mean, this is not something that informs my management, but patients often described that they had a twisting injury that heard a popping sound and that normally indicates ACL injury. Um, and were you able to wait right after that or did you have to be carried off the pitch or, you know, carried away from wherever you were by a stretcher or somebody, um, holding on to you? Um, and that's important because it tells you about severity of injury and it gives you some idea of, um, what it structures may be er involved. Finally, in your um focused history taking, you want to ask a few questions about their medical history. So, have they had any previous injuries to that knee or any surgeries? Any history of inflammatory joint conditions? I mentioned rheumatoid arthritis because that may well be um the cause for their stiffness or pain. And if it is rheuma rheumatoid, if it, if it is a rheumatoid patient, the management is slightly different to somebody with a bar or osteoarthritis. Um because you want to make sure that their uh medical treatment is, is optimized prior to dwelling on any, uh uh prior to proceeding with any, any surgical treatment. Um and then you want to know about any systemic symptoms. So I mentioned septic arthritis to you. They often prevent with fevers occasionally and this is rare but cancers of the bone do exist. Um And so weight loss is an important thing to check, especially if it's, you've got a young person presenting to you with knee pain with no history of trauma and there's an insidious onset of pain which has been worsening over the last few months. You want to find out about any fevers, weight loss because you may well be looking at oncological cause for it. Um Finally, social history. So, um occupational demands, I've already mentioned they may have a sporting um uh career. There may be um uh somebody who works in the construction industry and has um has to put their knee through a lot of, um, uh, motion or weight on a daily basis. Um, there may be a, a doctor and, and, and, and they have to be on their feet quite a lot during their shift. These are all things that things that factor into how we're going to manage them so, very important to gauge that from the history. Um, I won't dwell on sporting activities anymore and then finally, lifestyle factors. So obesity is very important. You don't need to ask that question. You can call the patient in front of you, you can tell. Um, uh, but uh, other things like smoking and alcohol may give you a clue about, um, what sort of, um, uh, so, so particularly if you talk about alcohol excess, what sort of compliance you may get from that patient. And, um, may also, um, sometimes give you a clue about um, the, er, mechanism of injury because clearly someone who's intoxicated may not remember or, um, er, be aware at the time of what sort of forces have gone through their knee. So it's an important thing to factor in. Um, sorry, sorry to interrupt. Um, Jamie's raised a specific question in the chat. She's, um, iliotibial band was mentioned. She's wondering if you could explain the course of, uh, ITBS for her. Absolutely. So, it's common after, uh, knee replacement surgery. Um, and, and that is because the demands that go through the knee joint change after a knee replacement and sometimes it can be because the, um, the alignment of the joint has changed. So, an iliotibial band, uh for, for this particular patient that they were born with and had the whole of their life, um, is now being put through more forces. So it ITB is um uh a uh lateral based structure. It attaches onto the dys tubercle on the proximal tibia. Uh I'm afraid I don't have a picture to show you, but perhaps we could, I don't think I have a picture of the lateral aspect of the knee, unfortunately. Yeah. So ger cubicle is located down here and the ITB comes and attaches down here. So it, it crosses the knee joint. Um, and so any valgus forces, er, sorry, any various forces that are put on the knee joint would put the ITB at, uh, at, at, at risk and cause it to stretch. And so the management usually tends to be with physiotherapy, um, essentially, um, giving them stretching exercises to try and, uh, um, uh, lengthen the ITB. So it's, it's not as contracted and also, um, in some cases, uh, sterile injections are tried. I hope that answers the question. It's probably not one to worry too much about at your stage. Um, it's more a specialist area. I mentioned it because it is commonly seen after total knee replacement patients come in with pain over the lateral aspect of the knee. Um, and, and I do commonly see in clinic, but probably at your stage, it's not not to dwell on too much. I have the answer to the question. OK. Um Back to the history. So uh we talked about lifestyle factors. Um Now examination, now the orthopedic mantra for any examination is look, feel, move and then special tests. Unfortunately, because of the setting we're in at the moment, I can't show you the full examination in detail, but I'm gonna try and use some props to, to help us make sure the patients are properly undressed and they're comfortable before you lay your hand on the knee. Um You wanna start with looking, inspecting their gait, whether they're showing any signs of antalgia gait or limping gait. Um When they stand, ask them to stand with their patella facing forwards, so their feet facing forwards, patella, facing forwards and then look at the alignment of the lower limbs are their knees in what we call various position? Are you bow legged or are they in valgus position. Are you knock knees? Um And you wanna be able to describe that because it has uh implications on um what could be the underlying pathology and how it's going to be managed. And then you look for swelling, if there's an effusion, ie swelling inside the knee joint, or there is generalized swelling in the limb, which could be suggestive of infection if there's any muscle wasting. So somebody who's had a chronic disuse of their muscle due to an injury that happened six months ago, their quadriceps may well be very weak. And so we often put these patients through a course of physiotherapy before we offer them surgery in order to get their muscles into a good enough position. Um and then on the skin, inspect for any scars, um bruising redness and deformity, which we've already mentioned. So, the, the, these are um a couple of pictures trying to demonstrate the surface anatomy. I've already mentioned to you, the quadriceps at the front hamstrings at the back. Remember, they're both crossing the, the knee joint, the medial joint line is here. It's a bit more distal than what you might expect. And so I encourage you if you're able to feel your knee right now to try and feel your lateral joint line. And often if you ask someone to, to point it, they end up pointing over this area here, which is the um uh the, the, the femoral condyle, the, the joint actually is much lower down. Um And so um get used to feeling the joint line. Um and this is looking at the medial side. So the pes entering, which is where the hamstrings come and attach is located on the medial side, on the lateral side is the it band that we talked about. It band syndrome. And that's where um uh it's, it's sort of the ITB which is the iliotibial band comes and attaches onto here laterally. Um And that's a lateral joint line. Um The rest is as it says on there. So get used to palpating um the joint line of the knee, it's very important and it shows when somebody's done it before versus somebody who's doing it for the first time in their oy. Um when you're feeling, you wanna feel for temperature compared to the opposite side, feel for any localized tenderness over the medial collateral ligament um or the lateral collateral ligament. Um and then palpate along the patella. Remember, patella is also part of the joint. So as you're feeling the medial and lateral joint line, you wanna go all the way around the patella. There are some important ligaments that attach from the patella and they can be uh tender if tho those ligaments have been injured. Um Now, effusion testing, there's a lot of uh talk about and I think as medical students, um you guys get quite hung up on uh how to do these. Um it's it's, it's simple. If there is a large effusion inside the knee joint, you'll be able to feel it by a patella tap. So essentially you're just bouncing the patella up and down, pushing it against the, the femur and you can, if there's a large effusion there, the patella bounces rather than just sitting on the femur. If there isn't. If so, if that test is negative, then you can proceed to doing a sweep test. There's no point doing a sweep test and then doing a patella tap test. If you know what I mean, cos a sweep test is for a small effusion. So clearly, if there is a um large effusion, you will just do a patella tap test. You don't need to worry about a sweep test. Um And in the sweep test, you were just milking the fluid all the way from the super patella pouch. And then um I normally put my um fingers up the lateral side of the knee and look for a bulge over the medial side. You can do it the other way around if that's what you prefer. Um But the whole idea is that you're looking for the synovial fluid to push the skin up and you can see it bulging a little bit. It's a very subtle thing. You have to do it a few times and do it on, proper, on, on real patients to who have an effusion to know what it feels like um and finally feeling the popliteal fossa, you sometimes feel baker cyst at the back. Um Historically, if you used to feel for the Popliteal pulse, I'm not sure it's a very comfortable thing to do in the osk situation and it's not a very easy pulse to feel. So, um, er, probably stay clear of that and finally, er, the range of motion. Um So you wanna ask the patient to completely extend their knee and that's zero degrees. Ok. So normal range of motion of the knee is from zero degrees, which is full extension to however far they can flex it. And in a young individual, in a young fit and active, non obese individual, they should be able to get to 100 and 4050 degrees. If they've got a lot of thigh mass, they may not get past uh 100 degrees. Um, in those patients that have a lock knee, they may not start at zero, they may start at 30 degrees. So when you're describing the range of motion, you say the range of motion is from 30 to whatever flexion they can do. Ok. And that's the most standardized way of describing knee range of motion. So, if they're able to extend fully, you say their range of motion is from zero to whatever flexion they can go to if they're not able to start at zero, whatever the starting point. If it's 2030 40 50 you say the range of motion is 52 whatever flexion. Oh, that's clear. Um And then you look for pain or creps as you're doing the range of motion, you do it more both passively and actively clearly. If they don't have much passive, uh much um uh active, then you'll have to do passive. But if they've got full active range of motion, then you don't need to do passive range of motion. Um, in terms of your special tests, um they're important in as far as they give you a lot of information about what to expect on further imaging and sometimes they um reduce the need for unnecessary investigations if you're able to do a test properly, um then you can save the, the NHS some money and also the patient some time and effort going through various investigations. Um For ACL, we do the anterior draw test for PCL, we do the posterior draw test. There are some other special tests described, I don't want you to go uh into the de details of that. It's probably more a postgraduate subject. Um in terms of M CL and LCL, you wanna apply valgus stress. So, IE the act of trying to open the medial side up with um uh when, when testing M CL and for LCL, the lateral collateral ligament, you want to apply a very stress. So the act of essentially er bringing the two ankles together and, and, and, and push, putting your hand in the middle of the knee in on the medial side of the knee. Again, these things are very difficult to talk about in this setting. You probably want to go and learn this by the bedside or in clinic. The best place to do the examination actually is when the patient is asleep in theater. So if you ever have the opportunity to go to the roh or any other or hospital, go to a knee knees list when the patient is asleep, examine them because that's when you can uh gauge most of most of these signs and not cause any pain to the patient. Finally mcmurray's test, Ali's test, I encourage you not to do either of these in your examinations, it causes pain. If they do have a meniscal tear and if they don't have a meniscal tear, it's useless. Um So um finally coming on to the common conditions and I'm gonna talk through each of these individually. We don't have a lot of time left. So I'll try and whizz through these very quickly. Um With ACL tears, I've already said they normally give you a history of twisting injury with hearing a pop or feeling a pop in the knee. They may have a positive anti draw test and the other one is Lachman's test again. Don't worry about this for your stage because Lachman's test requires a bit of practice and it's not something um that um you'll be able to um uh do very well in awake patients because often they use their muscles to control the knee. And so if they're awake and they're guarding their knee, you won't be able to uh get a Lachman test. So for your stage stick with anterior and posterior draw test as simple as that meniscal tears, twisting injury again. Um and often the swelling is delayed as I said, but this is less relevant these days. Um Books talk about mcmurray's test by all means offer to do it in the examination, but I encourage you not to do it. Uh And if your examiner is being mean to you and wants you to perform it, then know how to do it, but often not asked. And if I was the examiner, I would ask you to move on because it's, it's, it's not clinically um that useful um medial collateral ligament uh again, often pain on the medial side of the knee happens because of a, a lateral blow. So the knee opens up on the medial side. Um It's very unlikely you'll have a patient with um M CL injury coming to OSC examination. Um but just know that it exists and have a way of testing it, which is you apply valgus stress to test M CL and V stress to test LCL osteoarthritis. Finally is a um a condition we know very well. Um I've got an X ray here to go, go through some of the common findings of osteoarthritis. And if you come to an orthopedic knee clinic or any orthopedic clinic, the first thing you might get asked is what do you see on the X ray? Apart from describing that this is a uh an ap x-ray of the knee joint. Um the most pertinent findings that you you can see here is reduced joint space on the medial side of the knee, there are some subchondral uh cysts present which are part and parcel of the arthritic process. There are osteophytes, which is the active, the, the body producing extra b excess bone, which is useless, but it, it's a clue on X ray. Um and then subchondral sclerosis, which is this er um very visible um uh glowing er joint line which is again a part parcel of, of, of um of arthritis. Um So, so these are the four things you want to mention if somebody asks you to describe an arthritic knee or X ray. Um there are others but I wouldn't worry about those. So, septic arthritis is, as I said, an orthopedic emergency, you may have warmth and tenderness. Usually these patients can't wait be through the joint. They say I've, I've not been able to wait through my joint and that is a clue. Uh And if they, they usually have a large effusion, the knee is warm to feel they have no history of trauma and they may have fevers. If you do bloods, they may have raised uh inflammatory markers. So white cell count might be high CRP, might be high and all of these are tell tale signs. And as I say, this is an orthopedic emergency. You must refer this patient to an orthopedic surgeon as soon as possible. I'm not gonna talk about this cos I think it's probably beyond your level. So I'm gonna summarize quickly and that's a whistle stop tour through knees in 14 minutes. Um We've talked about the importance of structured history and examination for an accurate diagnosis. And the reason for being very slick at this is not just for your, for getting through your osk, but also because no matter which field you choose to go down, whether it's GP emergency medicine or indeed any surgical specialty, um being able to diagnose and refer um a patient onto the correct team, um is, is a critical part of being a doctor, especially a junior doctor. And so, um if you learn to do this well, very early on, it will send you in good, good uh position later on in your career. We recap the anatomy. We've talked about the um examination and I said that you must follow the orthoptic mantra of look, feel, move and then special tests um for every joint and get in the habit of doing it in that sequence and you, you won't miss things. I think that's all I have to say about knees. Um I will just quickly check if there are any questions and if there aren't any questions about knees, then perhaps we will carry on and move on to the next talk. Um, do we have any questions? Not in the chat? But if anyone wants to unmute and? Yeah. Ok. Nothing. All right. It's done with silence. Good. Well, let me, uh, carry on and then perhaps we'll, um, we'll generate a few more questions from the next, um, talk. Mm. Right. So, uh, foot and ankle again, we're gonna spend about 15 minutes on this, maybe 10 minutes. Um, we'll see how we get on, um, another important joint in the knee, in, in, in the body. The reason is it is the most, um, probably the most abused joint in the body. If you think about the fact that it's, er, er, weight bearing and, um, you, you, all your forces are going through it, um, is an imperative part of gait, locomotion and often, um, we neglect it because of poor footwear and I'm not gonna target ladies here. I think men are just as bad. Um, and, um, it's not very well understood by most, um, GPS. Um, or indeed, um, doctors at large. Um, we must be able to understand how to do a basic examination history taking and then, um, how to, um, not manage the uh, conditions but know where you're going to refer these patients to remember. Feet problems are also managed by podiatrists as well. As orthopedic surgeons. So um knowing where to send this patient is quite an important part of being a GP. Um or indeed, I in the emergency department. So as I mentioned, um a vital role in weight bearing balance and mobility, common pathologies are either trauma related, such as ankle sprains fractures, or they can be degenerative conditions such as arthritis. Um overuse syndromes are probably more common in foot and ankle than their own knee. So things like plantar fasciitis, achilles, tendinopathy, uh we're gonna talk about those later. So recognize them early and refer patients on appropriately so that they can um um they, they can get the right care and prevent long term complications, as I've said with knees. Um the previous uh picture shows you the the bony structures in the, in, in the foot and ankle uh which I encourage you to be very familiar with. Um But there are also remember soft tissue structures. So the tendons, the ligaments that pass around the foot and ankle, it is a very complex organ. And actually, um I put it to you that in some ways, it is more complicated than the hand um in the sense that there are multiple compartments inside the foot. Um and the mus uh so, so the musculature that's involved in providing the fine movements in the er in the foot are probably not as precise as the um as as the hand because of evolution. But um they do serve very important functions. Um er in terms of locomotion and um keeping your balance while you're walking for trauma, the commonest cause for ankle pain, after twisting your ankle. And this, you know, this may have happened to most of you um is, is, is an ankle sprain and that all that means is that you have stretched or injured. One of the ligaments around the ankle joint, the anterior tibia, talofibular ligament is perhaps the most commonly injured, but there are many others. I don't want you to dwell too much on the ligaments. Uh but just know that ankle sprains are common. And uh one of your primary um concerns when examining an ankle that's been injured. Um is to figure out whether you're dealing with a sprain or you're dealing with a fracture because clearly the management is is different. Um And the fractures can be around the ankle and it can be around the um the bones in the forefoot. So the metatarsals or it could be one of the bones of the hind foot. Uh either calcaneum or it could be anywhere in between the mid foot. So without going into the nitty gritty of it, just being able to differentiate between a sprain and a fracture is probably quite key clearly. The only way to do that is by getting an X ray. Um But we'll come on to talking about judicial use, use of x-rays in a minute and then coming on to degenerative and overuse conditions. So, plantar fasciitis is a condition that causes you heal pain again, very common in a general population. Um, patients often describe that when I wake up in the morning and put my foot down, I get sharp stinging pain on my heel, which tends to get better as the day goes on. That is very typical of plantar fasciitis. It is essentially overuse or um uh uh sort of um yeah, overuse or inflammation of the uh uh fascia on the plantar aspect of the foot, achilles tendinopathy is um a problem with the achilles tendon. Um So clearly, the pain will be at the back of the ankle. Um And often when you press there, the patient complains of tenderness as well. Um Again, worse with activity, clearly, anything where they have to do, push off very quickly will cause some pain because the forces go through the achilles tendon, hx valgus, otherwise known as bunions, very common in the general population. Um You just need to understand that it is an entity. Um You're not expected to know the management or the classification of these, but just understand that a bunion is otherwise known as Hallux valgus. So if you're looking at a photo describing deformities, call it hallux valgus. And what it is is if you think of uh the big toe um uh joint, it often tends to go uh laterally and point that way. Uh And, and that's the, the helix valgus, deformity, difficult to show you that on a hand. But, um, I wish I had a, uh, a foot model here to show you. But, um, if any of you, um, are wondering just Google bunions or, um, helix valgus and you know exactly what I mean, osteoarthritis, um, primarily affects the first metatarsophalangeal joint of the foot and goes hand in hand with the hallux valgus deformity, um, or it can affect the ankle joint. Other conditions which you may want to know about is something called a Morton's neuroma that often causes pain between the, um, the 2nd and 3rd or the 3rd and 4th toes. Um, I wouldn't worry about tarsal tunnel syndrome. Skip that history. I'm gonna spend four minutes on this. So, um, it's essentially a repetition of exactly what we've talked about in the last talk. Um, pain, swelling, stiffness, deformity. Er, that's different from, er, knees because deformity in foot and ankle is, uh, much more important than those mechanical symptoms that we talked about in the knee. So, er, the same history as knees, but maybe replace the mechanical side of things with deformity. Um, and then finally, you want to ask about any numbness or tingling, that's part of your neurovascular, um, uh, sort of assessment. Um, because remember people with diabetic feet often lose sensation in the, in the foot in a glove and stocking distribution. If anybody doesn't know what that is, please do ask um, um, and, um, and it's important to know if they have that because they may get injuries or, um, wounds to their foot, which get neglected because they were not able to feel pain in the normal way. And, and that can often turn, they can often turn into ulcerations and long term problems. People lose their feet over it. Um, in regards to the history, you want to find out about the mechanism, Uh, um, you know, whether it was an inversion injury or an aversion injury gives you some idea of which ligaments may be involved. Often when patients twist their ankle, they're not paying attention to how their ankle was twisted. They just say it was twisted. So, um, you can try and probe it, but often they just say ankle got twisted and they don't know whether it was inversion or inversion. So it's probably more in the textbooks in real life. It doesn't have much of an application and then immediate symptoms. Was there swelling? Was there bruising? Were they able to walk on it? Same questions as what we said before, if they're not able to walk after or, or put weight through the ankle after injuring it, that is probably more suggestive of a fracture. But we'll come on to more of the uh uh more telltale signs that you can use again. I won't dwell on it too much. But in terms of your history of presenting complaint and past medical history again, you want to find out if there's any inflammatory um arthritis in them or in family. Um gout clearly affects the first uh metatarsal pharyngeal joint of the big toe. Um And so that's an important one to ask about. And in terms of occupation, whether their job involves a lots of standing lifting. Um when it comes to examination, follow the same mantra look, feel, move and special test. When you're inspecting the foot, you want to look at it from the front and look for any obvious deformities. We mentioned the hallux valgus deformity being one of them. Then once you've looked at them from the front, you ask them to turn to face the wall or, or, or, or, or wherever you, you are face to face the other way. So you're looking at them side on and what you're looking at there in this profile is the medial longitudinal arch. Clearly, this patient doesn't have one. They've got what we call ap planus, a flat foot. Um These patients are at risk of developing certain problems in the foot. Um The opposite to this would be a, a pes pes cavus ie high arch and those patients are also just as uh um a as as, as likely uh to develop certain problems. So it's a bit of a goldilocks er phenomenon. It, it has to be just right. Um um and then you get them to walk. So ask them to uh to walk to the end of the room and observe how they're walking. Clearly, someone who's got a lot of arthritis or pain in their foot will not go through the, the normal, um, rhythm, er, that you and I might use when we're walking. So normally if you observe, uh, a pain free individual walking, they will firstly contact the floor with their heel and then the foot will become planted and then they will go through what's known as toe off. So they'll have this rhythm of walking. Somebody who's got either stiffness or, um, they've got, uh, pain might compensate by not going through the normal rhythm. So they might just have a sort of a, a stepping like AFA flat foot gate where they're sort of just planting their foot all the way like this rather than going through the normal motion. Ok. So that's something to pay attention to when you see them walking, um, feel for the temperature, warmth, swelling. Um And then if you're suspecting somebody to have overuse injuries such as the achilles tendon or the um, uh plantar fasciitis I mentioned before, then feel those pertinent points to see if they've got pain tenderness when you press on them. And again, another reason to be very sharp on your anatomy, um, so that you know what you're feeling, um what lies underneath, um, and what the pathology may be. Um Finally, you take them through uh a range of motion both actively and passively. So you ask them to move their ankle up and down, wiggle their toes and then you do it passively by moving each of the joint yourself. Um Special tests are probably not um that useful um at your stage, but um, the key ones to know about are um, firstly, um, if they've got um, uh laxity in the ankle, then um, or they've torn one of the ligaments, then there's something known as the anterior draw test, similar to the anterior jaw test in the, in, in the knee. Um That tells you about any ligamentous injury. Um and then achilles tendon rupture, if they have had an achilles tendon rupture, firstly, they won't bring this patient to your sy. But um if it was, it was a chronic rupture and it's never healed up, um then they may, and the way to test for that is by asking the patient to um er, stand on the side of a bed uh with or stand on their knees basically. And then you squeeze their calf. Um And if the achilles tendon is intact, then you get plantar flexion of the foot passively. Er, if the Ales Tenon is not intact, you get no movement and you compare it to the opposite side to check. Um We've talked about this already, so I'm not gonna dwell on it anymore. This slide is probably important. So this is talking about what's known as the Ottawa ankle foot and ankle rule. So, Ottawa, um, er, study was performed in, I think, 2012 or earlier than that. It was a randomized controlled trial, er, Multicentric. And they basically, er, looked at, um, a number of patients who came in with ankle injuries, um, and, and foot injuries and, um, their examination findings and how that translated to what they found on the x rays. So they came up with a few rules that you can um use to figure out which patient needs an x-ray and which patient you can be fairly certain has just got a sprain and you don't need to x-ray again within that as well. Um deciding whether they need a ankle X ray or they need a foot X ray. So um they've come up with this criteria, it's quite sensitive, but it's not specific ie if it, it will pick up. Um So if it's positive, your um uh you're, you're unlikely to miss um an ankle fracture, but just because it posi it's positive doesn't mean that you have an ankle fracture. So it's not very specific, but it is quite sensitive. Um And the way uh to do that is look for it is to divide the um the foot into uh different zones. So this is the malleolar zone ie behind the medial malleolus or the lateral malleolus and you palpate along that area. If they have tenderness in the malleolar area, in the presence of being unable to weight bear, um immediately or, and in A&E then they've earned themselves an X ray, an ankle x-ray because they've probably fractured the ankle. Um, for the foot again, you feel in these areas. So the mid foot zone and the base of the fifth metatarsal and if they've got tenderness in any of these areas, um and they're unable to weight bear and they've, and themselves a foot X ray. Um And so this tends to be a, a good tool to decide who needs an X ray in the emergency department setting or if you're indeed seeing them in the GP practice. So I'm gonna summarize quickly. We said we need to take a structured history and examination. Uh in order to get accurate diagnosis, we said that anatomy is key and practicing examinations. Um firstly on um each other to get your routine right, and then examining on patients to get the signs, um is, is key to mastering these skills. Um And I can't dwell on this enough practice, practice practice because when you walk into your Aussies, you want to look like you've done this before and you're very comfortable in how you examine your foot. For example, foot examination is performed with you s crouching on the foot or keeping the patient's foot on your leg. If you've not done a foot and ankle examination before, you wouldn't know that if you've not been to a clinic before, you wouldn't know that. So, um it becomes very obvious for the examiner if you've seen this being done by an orthopedic surgeon or not. Um, and you wanna practice because, um, even legends like this gentleman uh practices. And so, um, that your performance on the day, um, it doesn't suffer and, and that's really the key of this entire, um, next year or 18 months or however long you've got left, er, in med school. I would strongly recommend uh practicing examinations as much as you can because the moment you finish, you're expected to then um perform. Um, and so the longer you spend in clinics and uh uh and going to the ward or going to theaters now it will send you in better position when you uh come out on the other end. Um, and that's me. I hope it's been of some use to um, those attending. If there are any questions we go, we can go through them. Now, if you've put something in the chat, I will look for it. Yeah, brilliant. Thank you mister to, um, has anyone got any questions to round off any questions? If not, I had a question. Um, um, so to do with um, something like Pez Planus, how can that affect the biomechanics of like the joint above the knee? What are the signs um that you can see in a patient? Something has, has affected the mechanics of their joints? That's a good question. So, um Pas Planus um, is often a constitutional problem. It's not something that's just individualized to the foot. There are different categories. Um, you, uh, we, we, we talk about the adolescent perp planus, which is, um, something that, um, many of us are born with. Um, and there is some hereditary component to it which our patients present with very early on. So in their teenage years, they start to say, well, I don't like the foot, the, the look of my foot, um, often doesn't cause them pain, but they're just worried about the cosmic side of it. And then you have the acquired uh pus, which is what happens later on in life as you start to either loader an abnormal joint with an abnormal alignment or you overload a normal joint. So you start to develop arthritis as a result of it and the deformity is secondary to that. Um, so often these patients will have a valgus knee deformity. Um, and, and in keeping with that, they'll have a, um, a hallux valgus as well. Um, important to look out for it because it does mean that if you're trying to correct someone's deformity, you need to correct the proximal one first before you come to the foot. Uh clearly someone who's got a, um, a knock knee, er, regardless of what you do with the foot, it will go back into that position. Um, if, if the knee has not been corrected. So it's an important finding to pick up and comment on in your examination. So whenever you ask them to undress, that's why you ask them to undress from er, um, a waist downwards because you, you wanna be able to see the entire lower limb because it does affect the biomechanics and the management. Thank you. Any, any other questions at this point? No, a lot of thank you in the chat. Um, thank you so much answer to here. I think everyone would ever appreciated that was super relevant to us. Um especially year four and year five, it's almost guaranteed to have an orthopedic exam. So super relevant to us and um not a problem. It's a pleasure. Thank you for having me. Um I'm uh usually um uh currently at the hospital um but we do do some clinics and um theaters at the ro orthopedic hospital. So if um any of you interested in coming over observing or getting involved in surgeries or any projects or anything like that, first of all knows that you can get in touch with me. Um uh First of all, I'm happy for you to send out my number if if anybody's interested um or might share my email with them, er, so that um we can, we can arrange something. Uh but I highly encourage you to do that um in your last couple of years. Brilliant. Thank you so much guys for joining. Um Hope you enjoy the rest of the series. Thank you. Thank you. Thank you. Bye bye bye.