Knee Examination - Orthopaedic Knee OSCE - Medicine Explained - Clinical Skills - Dr Gill

Hello and welcome back to the channel. My name is Dr James Gill and you've joined us for another clinical skills video. Today we're going to be looking over the knee. The knee is a vitally important part of our kinetic chain formed for the ankle, the knee and the hip. If any of those three joints are affected then it's going to have a significant impact on a patient's mobility. So we need to be able to adequately assess all of those joints well and today we're going to do a deep dive on assessing the knee joint. So we've been joined by another medical student today and to start off our examination obviously we always want to make sure that we're appropriately gelling our hands. So my name is Dr James Gill and we've been asked to do an assessment of your knee today. Could you please confirm your name and date of birth? My name is Megan's brothers and my date of birth is 2nd February 1994. Thank you. So today what we're going to do is we're going to have a look at your knee, we're going to get you to do some movements and we're going to get you to lie on the couch and I'm going to assess your knee. That'll involve me putting my hands on your knees and getting you to move your legs around. Is that okay? Yeah. Super. So to start off could I get you to take your shoes off please and just stand in front and then turn to your left. Okay so here we're having a look at the back of the knee to see if we can see any signs of swelling here and then if you could turn all the way to face the opposite wall. So looking at the legs from behind we want to see if there's any evidence of a varus or valgus deformity colloquially referred to as being bow-legged or knock-kneed. We also need to assess the ankle and here we see a slight pronation or in-turning of the ankles which can result in a slight valgus deformity to the knees and if you could turn all the way to the opposite side and again checking the opposite knee to make sure there's nothing present behind. If we assess the shoes we can actually see we've got wear patterns on the outside and across the mid foot more so on the right side in keeping with what we've seen here. So if I could get you to walk forwards for me please and we're going to do five paces looking at a straightforward heel toe and then turn and come backwards please. Okay again we're seeing normal pace there, normal falls and no obvious issues. The five steps is very important because we need to go at least that far in order to engage with our normal gait pattern to see how somebody's walking. Thankfully there's no signs of a limp or abnormal gait here so we've not got anything to be too concerned about. So if I could get you to jump up on the bed for me if that's all right and then lie backwards. Okay and relax your legs down on the bed. So before we start do you have any problems with your knees at the moment? So looking over the knees I can see a couple of scars on the right knee and some bruises to the left but no obvious inflammation, no clear swellings or deformities. We also need to then assess for any wasting of the quads which we'd see with knee pain. Now when it comes to knee pain we can lose up to 20% power on the quads over weeks if we've got significant pains here hence why the knee assessment is so very important. We're going to measure 20 centimetres up from the tibial tuberosity and then we're going to measure around the thigh at that point. Okay so 43 centimetres there and we'll do the same again on the opposite side. So 20 centimetres up from the tibial tuberosity. I'm just going to go around and we've got a similar 43 centimetres on that side as well. So to start off with I'm just going to touch your legs if you don't mind to see if there's any heat to them. So as with all orthopaedics we're going to be comparing like with like so looking for symmetry and there's no heat above or below the knee and directly over the knees we've not got any temperature either. Now we can have problems with gait with what's called a leg length discrepancy so we need to assess how long the patient's legs are and there are two ways of assessing that. We have a true leg length and an apparent leg length. So with our true leg length we're going to find the patient's anterior superior spine and measure down toward the medial malleolus. So we've got 90 centimetres here and then we're going to if you could just lift up your shirt slightly so we can get to your umbilicus. Thank you. And we're going to do this from the centre down again showing 100 centimetres and we're going to do the same again on the opposite side. So from the anterior superior spine to the medial malleolus and again up to the umbilicus so we've got equal legs on both sides. So orthopaedics is based around the simple look feel and move protocols. So we've adequately assessed the patient in terms of their gait, in terms of looking at their standing position and the overall appearance of their legs. So now we need to assess the joints themselves in terms of seeing if there's a fusion and any pain. So I'm going to start off on the left leg checking for an effusion and pushing down and then tapping directly over the patella. We've got a little bit of lateral movement that's fine but we're checking to see if the patella moves up and down and taps on the femoral condyles. We're going to do the same again on the opposite side and tapping down so there's no problems there. As we're doing this we're trying to push any fluid under around the kneecap so that if there is an effusion there the kneecap will float up on that fluid and then when we press it with our thumbs we'll get a patella tap as that floating bone contacts with the femoral condyles. If there is no effusion we may get a movement of the patella laterally and medially but we're not going to get that click click which is seen as the patella moves down. So we're then going to do the same again. I'm going to sweep on the medial side of the knee so sweeping up on the medial side moving any fluid around and seeing if it's come to show with a bulge present also on that side of the knee. There's no problems there and we'll do the same again on this side sweeping up any fluid holding it and seeing if it comes around to give us a bulge sign which we haven't got. So we can be reassured here that there's no effusion to the patient's knee. We now need to have a look at the actual joint lines so I'm going to take your leg and put it at 90 degrees and I'm going to press around the knee. Tell me if there's any areas of pain or tenderness for this. So starting off at the tuberosity where the patella tendon inserts into the tibia we're moving up to the patella itself and then moving round up to the superior patella tendon and into the quadriceps making sure that there's no pain here. We're coming back down again and going around the joint line. As we're pressing around the joint line we were paying a lot of attention to see if there's any pain which may indicate a problem with the meniscus and then we're going to check over the lateral and collateral ligaments to see if we can find any obvious steps or pain. Finally we're going to press up inside the knee behind warning the patient this might feel uncomfortable. So I'm just going to put some direct pressure here tell me if there's any problems there. So behind the knee there I'm feeling to see if I can find a swelling that may be in keeping with a baker's cyst. Again symmetry is vitally important so we're going to do the same again on the opposite knee. Doing exactly the same again checking the tibial tuberosity up the patella tendon around the patella carry on up the tendon up the tendon into the quads back down along the joint line to the lateral and collateral ligaments and then checking up behind the knee. So again we've got a normal test here with no issues. So we now need to move the knee if you could take this knee and take it up to your chin please and then back down any problems with that and we'll do the same again with this knee up and back down any issues there. Super so to complete our movement I'm going to do the same but this time as I move the patient's knee I'm going to be feeling for any added sensations so any crepitus any crunching any clicks or any movement of the patella out of alignment. So I'm just going to move your legs please relax and allow me to do the movements. So pressing up and back down and there's no obvious crunches or clicks we've got a nice smooth movement there. I'm going to do the same again on the opposite side taking the knee and up and I'm feeling during this if there's any abnormal sensation. Crepitus will feel like glass rubbing against glass but thankfully we've got no problems here with that. Now we have already seen that there's no problems with the patella tendon in terms of palpation so I couldn't feel any steps and we seem to have had a good flexion of the knee but we can also assess if you just raise this leg up in a straight line for me we can also assess the continuity of the patella because we've got a positive a normal straight leg raise and the same again the opposite side please. If there was a problem with the patella when the patient tried to move their leg the patella is needed to transmit the force from the quads so as they attempted a straight leg that leg would dip down because the patella was not able to transmit that force through. Just relax down again for me and I'm just going to put my hands either side and push down into the bed please okay and relax and we've got a slight hyperextension there in the sense that you can close the gap on my fingers but nothing worrying with that. So having done our look feel and move we now need to do the special tests to assess the ligaments of the knee. So if you take your knee to 90 degrees please and just relax on the bed. So having a look at the knee I want to look from behind initially to see if there's a sag sign where the knee is actually slipping backwards suggesting that we've got a rupture of the posterior cruciate ligament. It's very important we've established whether or not there is a step here because when we do the anterior draw test if we pulled forwards with the PCL having gone we may have a false positive thinking that we're drawing the knee forwards whereas actually we're just returning it to its normal position. Thankfully that's not present so I want to do an anterior draw test. Sometimes you'll see clinicians set on the patient's bed and holding with their thumbs either side of the tibial tuberosity and pulling forwards. Personally I'm not a big fan of that from an infection control standpoint in terms of sitting on the patient's bed. You can do a similar by again taking the tibial tuberosity with both of your thumbs and bracing against your own arm to then pull forwards. I feel that that's a slightly more appropriate approach to this examination. So confirming that there's no sag sign there I'm going to brace against my arm, thumbs over the tibial tuberosity and I'm pulling forwards. So we've got a bit of a movement there but there's not a significant step coming off the knee. Relax down again for me and we'll do the same again on this side. So bringing the knee up, bracing against my forearm and pulling and we've got no issues there either. So when we do this draw test our thumbs are at the tibial tuberosity in case the knee actually comes forward in which case our thumbs would drop over the top of that step confirming that the anterior cruciate ligament had stretched or had potentially ruptured. So if you relax down please and we'll do the same on the opposite side. So bringing the leg up and I'm going to check to make sure there's no sag sign so the knee isn't slopping back and we don't have a step going backwards. I'm then going to put my finger, my thumbs at the tibial tuberosity bracing and pulling forwards. So we've got no step there again so we can be reassured that the anterior cruciate and the posterior cruciate ligaments are intact. We then need to check for the lateral and medial collateral. So I'm going to take the leg slightly bent and I'm going to be pushing with my left hand and pulling with my right trying to bend the knee out of alignment. I'm going to swap over and do the same again. So there's a small amount of movement there that will be normal particularly in a lady but if we got significant movement and it wasn't being pulled back we'd be worried about that. So to start off and being careful of the bruising I'm pushing with my left hand and pulling with my right trying to open the lateral collaterals. Okay so we've got a little bit of bounce but nothing major. I'm going to swap over and I'm now pulling with this hand and pushing with my right trying to open up the medial collaterals. So we've got no worrying features there. Now in some textbooks they'll discuss McMurray's test which is used for assessing if there's any damage to the meniscus. That would be where we take the lady's knee and twist and turn her foot as we extended it. Personally I dislike this test because there is a theoretical risk of damage to the meniscus. What we can do instead is get the patient to attempt to turn on their own foot. So if you stand up for me please and what I need you to do is steady yourself on the bed and with one foot on the floor just twist forwards and backwards. Okay so if you stabilise yourself on the bed and putting all your weight on your left foot for me and just spin side to side and if there's any pain with that then we would assume that there was damage to the meniscus we hadn't found earlier and if we could do the same on the opposite knee. So lift up and then spin again and we've got any pain at all with that and the patient's in control of their own body there and we're less likely to cause any significant harm. So the last thing I need to do is what's called an apprehension test. So what I'm going to do I'm going to push your patella sideways as if trying to literally push it off and I'm going to begin to bend your knee as we do so. If there's any problems any worries please stop us. Okay so just coming up so pressing over the super so no problems with that and we'll do the same again on this side and pushing the patella bending great. Okay so you didn't object to that that's fine thank you. So that completes our assessment and overview of the knee examination. I hope this has been useful for yourselves. Please drop us a comment down below and we'll see if we can cover any questions that you might have on assessing the knee and please obviously like the video because it tells YouTube that we're here. Thank you we'll see you in the next one. Take care.