Dan Bertheau, NP, MPH

Orthopaedic Trauma Institute

SFGH/UCSF

NP/CNM/PAPROFESSIONAL PRACTICE GROUP

CITY & COUNTY OF SAN FRANCISCOAPRIL 21, 2011 CONFERENCE

Knee Examination

DISCLOSURE

I have no relevant financial disclosures related to topics in this lecture

KNEE EXAM- TOPICS

• Anatomy

• Three Typical Conditions

• History

• Physical Exam Tests

• Diagnostics

• Red Flag/Emergent/Urgent

• Referrals

• Physical Exam

KNEE ANATOMY

www.aclsolutions.com

KNEE ANATOMY

www.aclsolutions.com

THREE TYPICAL CONDITIONS

• DJD

• Ligament Injury (ACL- most common)

• Meniscus Injury

• Mechanism of Injury

• Duration

• Walking Tolerance (# blocks)

• Range of Motion (~0-140)

• Locking? (unable to fully extend- r/o Bucket Handle)

• Edema

• Neurovascular

• Sensation

• Motor

• Previous Treatment (success/failure)

• Assistive Devices

HISTORY

PAIN

• Anterior- Patella & Associated Soft Tissues

• Medial- Meniscus, OA

• Lateral- Iliotibial Band Friction, Meniscus, OA

• Posterior- Meniscus, Baker’s Cyst

KNEE DJD

LACHMAN- ACL

Snider, R.

ANTERIOR DRAWER- ACL

Snider, R.

MRI – NORMAL ACL – SAGITTAL VIEW

Helms, C. A.

MRI – ACL RUPTURE – SAGITTAL VIEW

VARUS STRESS- LCLVALGUS STRESS- MCL

www.aafp.org

POSTERIOR SAG- PCL

Snider, R.

MCMURRAY TEST- MENISCUS

MRI – MENISCAL TEAR – SAGITTAL VIEW

MENISCUS TEAR

www.leadingmd.com

X-RAY IMAGING

***WEIGHT BEARING***•AP

• Tibiofemoral Joint•LAT

• Patellofemoral Joint•Rosenberg (Bent Knee PA)

• Tibiofemoral Joint•Sunrise (Merchant, Axial)

• Patellofemoral Joint

MRI IMAGING

• Order Plain X-Rays First

• R/O Soft Tissue Injury

• Do Not Order In Patient With Known DJD

LAB

• CBC with Differential

• ESR

• CRP

RED FLAG/EMERGENT/URGENT

• Knee Dislocation

• Septic Knee

• Acute Fractures

• Bucket Handle Tear of Meniscus

REFERRAL- LESS THAN IDEAL

“knee pain”

REFERRAL- IDEAL

“64 year old male with several years of progressive right knee pain; less than 2 block walking tolerance for last 6 months; failed NSAIDs; started PT 3 months ago; Jan 2011 WB x-rays = arthritic changes; interested in op & non-op options”

PATIENT HANDOUTS

• PCP “Bridge” to Physical Therapy

• Online (in the future)

REFERENCES

• Atlas of Human Anatomy, 2nd Edition, Netter, Frank, 2003, Icon Learning Systems

• Essentials of Musculoskeletal Care, Snider, Robert K., Ed.,2003, American Academy of Orthopedic Surgeons

• Fundamentals of Skeletal Radiology, 2nd Ed., Helms, Clyde A., 1995, W. B. Saunders

• Orthopaedist’s Guide to Plain Film Imaging, Pavlov, H., Burke, M., Giesa, M., Seager, K.R., White, E.T.,1999, Thieme Medical Publishers

• Orthopedic Physical Assessment, 4th Ed., Magee, David J., 2002, Elsevier Sciences

• Physical Examination of the Spine & Extremities, Hoppenfeld, Stanley, 1976, Appleton-Century-Crofts

Thank You!