Knee and hip examinations

Question 1

Hip exam-introduction

Answer 1

Wash hands
Chaperone

Question 2

Hip exam: look

Answer 2

General inspection
Anterior, lateral and posterior inspection of hips (get pt to turn)
Gait
Inspect while pt on bed

Question 3

Hip exam: Feel

Answer 3

Temperature
Hip joint palpation (greater trochanter)-painful in trochanteric bursitis
Leg length assessment

Question 4

Hip exam: Move

Answer 4

Active movement:
–> Hip flexion (normal ROM 120 degrees)
–> Hip extension (normal ROM 180 degrees: flat on bed)
Passive movement
–> Flexion (120)
–> Internal rotation (flex to 90, then laterally rotate foot)
–> External rotation (flex to 90, then medially rotate foot)
–> Abduction: stabilise contralateral iliac crest and abduct until pelvis begins to tilt
–> Adduction: stabilise contralateral iliac crest, adduct until pelvis begins to tilt
–> Extension: prone position, place hand on ipsilateral pelvis

Question 5

Hip exam: Special tests

Answer 5

Thomas’s test
Trendelenburg’s test

Question 6

Thomas’s test

Answer 6

-Assess for fixed flexion deformity (inability to fully extend leg)

1. Put hand under lumbar sign to prevent compensation by increasing lumbar lordosis
2. Passively flex unaffected hip
3. Repeat on other side

Abnormal if affected hip rises off bed
Shouldn’t be performed with hip replacement due to risk of dislocation

Question 7

Trendelenberg’s test

Answer 7

-Ask pt to put their hands on your hands
-Lift same leg off floor
-Observe for pelvic tilt

If pelvis tilts on side of raised leg, this suggests contralateral abductor weakness

Question 8

HIp: To complete examination:

Answer 8

Neurovascular examination of both lower limbs.
Examination of the joints above and below (lumbar spine and knee joint).
Further imaging if indicated (e.g. X-ray and MRI).

Question 9

Hip exam general inspection findings

Answer 9

Body habitus (osteoarthritis)
Scars
Wasting (disuse atrophy secondary to joint pathology/LMN lesion)
Walking aids

Question 10

Hip exam: Leg length assessment

Answer 10

-To distinguish between true leg length discrepancy and apparent (e.g. due to pelvic tilt)
-Apparent leg length: Measure from umbilicus to tip of medial malleolus each side
-True leg length: Asis to tip of medial malleolus

Question 11

Hip exam closer inspection of hip findings

Answer 11

Swelling, bruising, scars, quadriceps wasting
Leg length discrepancy (congenital/aquired-fracture, surgery, joint disease)
Pelvic tilt (hip abductor weakness)

Question 12

Hip: Gait

Answer 12

ROM (reduced in joint disease)
Trendelenberg (gluteal nerve weakness)
Wadding gait (muscular dystrophy)

Question 13

HIp: Trendelenberg gait

Answer 13

As the pelvis sags towards the unaffected side, the trunk lurches towards the opposite side in an effort to maintain balance.

Question 14

OA vs RA symptoms

Answer 14

The symptom of joint stiffness can be used to differentiate non-inflammatory arthropathies such as osteoarthritis from inflammatory arthropathies such as rheumatoid arthritis.

In inflammatory arthropathies, joint stiffness improves with activity and stiffness typically lasts longer than 30 minutes in the morning

Question 15

XR findings OA

Answer 15

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

Question 16

Osteoarthritis on XR

Answer 16

Osteophytes
Joint space narrowing
Subchondral sclerosis
Subchondral cysts

Question 17

Mx OA

Answer 17

Conservative
-Weight loss
-Physiotherapy
-Hydrotherapy

Medical
-WHO pain ladder

Surgical
-Discuss options re: THR
-Comorbidities, shx, send for preassessment

Question 18

Knee: Look

Answer 18

General inspection
Anterior inspection
Lateral inspection
Posterior inspection
Gait
Inspection with pt on bed

Question 19

Knee: Feel

Answer 19

Temperature

Measurement of muscle bulk

Palpation of extended knee: Patellar, medial and lateral joint lines

Assess for effusion: patellar tap, sweep

Palpation of flexed knee (popliteal fossa and joint line easier to feel): Patellar, medial and lateral joint lines, tibial tubersoity, fibular head, popliteal fossa

Question 20

Knee: Move

Answer 20

Straight leg raise
Active movement: flexion, extension
Passive movement: Flexion, extension

Question 21

Special tests knee

Answer 21

-Posterior sag sign
-Anterior and Posterior drawer test
-Medial and lateral collateral ligament assessment

Offer:
-Lachman’s test
-Mcmurray’s test
-patellar apprehension test

Question 22

Patellar apprehension test

Answer 22

-Patellar always dislocates laterall
-Push patellar laterally: if anxious/in pain, positive

Question 23

Knee: general inspection findings

Answer 23

Same as hip: Body habitus, walking aids, scars, prescriptions, wasting

Question 24

Knee: anterior inspection findings

Answer 24

Patellar position (dislocation/subluxation)
Psoriasis plaques (psoriatic arthritis)
Valgus deformity: tibia turned outwards in relation to femur, knees ‘knocking’ together
Varus deformity: tibia turned inwards, bowlegged appearance
Quadriceps wasting

Question 25

Knee: lateral inspection findings

Answer 25

Extension abnormalities: knee hyperextension-cruciate ligament injury. Flexion abnormalities: fixed flexion deformity

Question 26

Knee: posterior inspection findings

Answer 26

Popliteal swelling

Question 27

Knee: palpation of patellar

Answer 27

Patellar 1. Palpate medial and lateral border of patellar, stabilising one side and palpating with fingertips --> tenderness: patellofemoral arthritis --> tensing of muscles on mobilising patellar may suggest recent dislocation 2. Palpate patellar tendon for signs of tendonitis/rupture

Question 28

Knee: measurement of quadriceps bulk

Answer 28

20cm above tibial tuberosity

Question 29

Mcmurray's

Answer 29

Check meniscal tear. Positive sign is pain Medial: -Flex and externally rotate knee, slowly extend Lateral: -Flex and internally rotate knee, before slowly extending

Question 30

Knee: further tests/investigations

Answer 30

Further assessments and investigations to suggest may include: Neurovascular examination of both lower limbs Examination of the joints above and below (e.g. ankle and hip) Bloods: FBC, U + E, CRP, Urate Further imaging if indicated (e.g. X-ray AP and lateral and MRI)

Question 31

Clinical features of a varus deformity

Answer 31

Can be physiological (up to 2 years old) or pathological Bony deformity: the tibia is turned inward in relation to the femur Abnormal gait: limp with in-toeing (feet are pointed towards the midline) Lower limb pain: due to abnormal stress placed on the ligaments, joints, and muscles

Question 32

Clinical features osgood schlatter's disease and age affected

Answer 32

Typically affects males aged 10 to 15 Tender bony elevation of the tibial tuberosity Pain exacerbated by activity and relieved by rest

Question 33

Clinical features patellar dislocation

Answer 33

Intense pain Swelling over the knee joint May be associated with a "pop" or the knee "giving way" at time of dislocation Haemarthrosis (bleeding into the knee joint cavity)

Question 34

Describe the posterior sag sign and its clinical relevance

Answer 34

The posterior cruciate ligament (PCL) is responsible for preventing backward displacement of the tibia or forward sliding of the femur. As a result, if the PCL is ruptured the tibia can sag posteriorly in relation to the femur and this is what is known as the posterior sag sign.

Question 35

Significance of posterior drawer test

Answer 35

Significant movement may suggest posterior cruciate ligament laxity or rupture.

Question 36

Describe the role of the medial collateral ligament (MCL) and a common mechanism of injury

Answer 36

The primary function of the MCL is to stabilise the knee by resisting valgus forces that would push the knee medially. Injury of the MCL typically occurs secondary to excessive valgus force when the knee is partially flexed (e.g. a direct blow to the lateral aspect of the knee joint).

Question 37

Describe the role of the lateral collateral ligament (LCL) of the knee and a common mechanism of injury

Answer 37

The primary function of the LCL is to stabilise the knee by resisting varus forces that would push the knee medially. Injury of the LCL typically occurs secondary to excessive varus force (e.g. a direct blow to the medial aspect of the knee joint).

Question 38

Name three causes of leg-length discrepancy in children

Answer 38

Congenital causes include: -Congenital femoral deficiency -Fibular hemimelia (shortened or missing fibula) -Tibia hemimelia Acquired causes are often secondary to joint pathologies, such as: -Perthes -Developmental dysplasia of the hip -Slipped capital femoral epiphysis

Question 39

Describe the anatomy and role of the posterior cruciate ligament (PCL)

Answer 39

LAMP: lateral acl, medial pcl The PCL originates from the lateral edge of the medial femoral condyle and attaches in the posterior region of the intercondylar area. Its primary purpose is to stabilise the knee joint by preventing posterior tibial subluxation (i.e. prevent posterior displacement of the tibia relative to the femur).

Question 40

Describe the anatomy and role of the anterior cruciate ligament (ACL)

Answer 40

LAMP: lateral ACL, medial PCL The ACL originates from medial wall lateral femoral condyle and inserts in the anterior region of the intercondylar area of the tibia. Its primary purpose is to stabilise the knee joint by preventing anterior tibial subluxation (i.e. prevent anterior displacement of the tibia relative to the femur).

Question 41

Describe the typical clinical features of a meniscal tear

Answer 41

Typical clinical features of a meniscal tear include: Acute knee pain immediately following knee trauma Popping, catching, locking of the knee Knee joint swelling/effusion

Question 42

List five causes of knee joint effusion

Answer 42

Ligament rupture: cruciate ligament, collateral ligaments Septic arthritis Inflammatory arthritis: rheumatoid arthritis, reactive arthritis Gout Osteoarthritis Meniscal injury

Question 43

Knee: soft tissue injury differentials

Answer 43

Primary differential plus: -Or other soft tissue injury such as meniscus, pcl/acl and collaterals

Question 44

What is RICE

Answer 44

Rest Ice Compression-e.g. knee brace Elevation