HANDS ON: Knee Evaluation J. Scott Delaney MD, FRCPC, FACEP, CSPQ

HANDS ON: Knee Evaluation J. Scott Delaney MD, FRCPC, FACEP, CSPQ

FACULTY DISCLOSURE Dr. Delaney has no affiliation with the manufacturer of any commercial product or provider of any commercial service discussed in this CME activity.

Objectives 1. Examine a knee for major ligamentous instability 2. Examine a knee for meniscal injury 3. Examine a knee for various overuse injuries 4. Understand the need for Xrays and other imaging modalities in the knee

3 Diagnoses Not To Miss Fracture Knee dislocation Extensor mechanism Rupture

Case 1 A 23 year old McGill student with no PMH presents with left knee pain after a twisting motion a few days earlier. She heard a pop and felt her knee move out of joint. She is limping and her knee appears swollen. She keeps her knee bent at 20-30 o of flexion. She doesn't look very relaxed as you prepare to exam her.

Case 1 Exam X-rays? Diagnosis Treatment Aspirate? Immobilization?

Exam

Lachman Test

Drawer Test

Knee Radiography Stiell I et al: JAMA, 1996 1096 patients validation of previously derived decision rule regarding radiography in acute knee injuries (less than 7 days) clinically important fractures only x-rays: left to the usual practice of the physician

Stiell I et al: JAMA, 1996 cont d Knee radiography if age 55 or more tenderness at head of fibula isolated tenderness of patella inability to flex to 90º inability to bear weight both immediately and in the ED ( 4 steps ) K = 0.77 Sens = 1.0 Spec = 0.49

Knee Radiography Trauma AP lateral oblique x 2 - tibial plateau # Subacute / Office AP lateral tunnel - intercondylar notch - tibial spines sunrise

Internal oblique External oblique

ACL tears

More common in women ACL tears

Treatment Analgesia +/- Aspiration R-I-C-E ( +/- weight bearing ) +/- NSAIDS? wait 24 hours if hemarthrosis suspected ROM / strengthening / functional rehab Maintain fitness Surgery

Knee Immobilization Avoid if possible As much ROM as possible Noyes F: CORR, 1977 immobilized primates (total body or leg) : 8 weeks decreased strength and histologic changes : - ACL - ligament-bone complex up to 12 months for ACL strength to return

Case 2 A 55 year old female who started cycling 4 months ago has been experiencing bilateral knee pain for a few weeks. She has recently increased her mileage. The knees hurt at the beginning of a workout, improve after 20 minutes, but then hurt again after her workout has finished. She never has any swelling in her knees.

Case 2 Exam X-rays? Diagnosis PFS, ITB, patellar tendonitis, etc., Treatment Return to exercise?

Analgesia R-I-C-E +/- NSAIDS ROM / strengthening Cross training Treatment Your heart is ahead of your muscle and tendons!! Sport specific changes Peddle clips, etc.

Valgus Stress Test

Varus Stress test

Abnormal Varus Stress test

Hands On Time!!

Knee Aspiration medial approach Identify midpoint of medial or lateral border of patella

Knee Aspiration medial approach Insert needle horizontally just under this point Aim towards area under centre of patella

Knee Aspiration suprapatellar Locate superior aspect of patella Draw horizontal line 1 finger-breadth above superior patellar margin.

Knee Aspiration suprapatellar Locate posterior edge of patella Draw vertical line parallel to it.

Knee Aspiration suprapatellar Insert needle at intersection of these lines with needle parallel to plane of bed (horizontal)

Knee Joint seated technique Knee flexed to 60-90 Locate tibial plateau and patellar tendon Aim just above tibial plateau (within joint space) and lateral or medial to patellar tendon Aim for centre of knee

Knee Joint seated technique Back to main