Emergency Medicine Bite-Sized Basics
- Position with knees & thighs exposed
General Principles of Joint Exam
- Check if any pain, then look, feel, move, measure & compare with other side, & assess function.
- General inspection
- Obvious other joint disease
- Quadriceps wasting
- Skin – Scars, swelling
- Deformities – incl fixed flexion (look for gap under knees when lying down), valgus (e.g. RA) or varus (e.g. OA)
- Quadriceps bulk
- Warmth, swelling over knee
- Patellar tap for large effusion (compress suprapatellar bursa with other hand)
- Bulge sign for small effusion (compress suprapatellar bursa with one hand and run other hand up lat & medial sides of knee looking for fluid wave on opposite side)
- Joint line tenderness
- Popliteal pulse
- Popliteal Baker cyst
- Passive movements: Place a hand over the knee & note any crepitus & ROM.
- Flexion (135 deg)
- Extension (5 deg)
- Active flexion/extension of knee – look for subluxation of patella Ligament laxity:
- Med/lat collateral ligaments (≤5 deg). Stress at 30 deg.
- ACL (≤5-10 deg):
- Lachman: (95% sens, knee flexed ~30 deg, distal femur fixed & proximal tibia pulled anteriorly – intact ACL should stop with “firm endpoint”),
- Pivot shift (75%).
- Anterior draw (60%)
- PCL (≤5-10 deg):
- Posterior draw,
- Godfrey’s sign (affected tibia sags when supine if legs passively lifted into 90 deg flexion at hip & knee.)
- Bragard’s (point tenderness along jt line),
- McMurray’s test
- Patellar apprehension test if recurrent patella dislocation suspected:
- Push patella laterally whilst flexing knee. Stop if patient’s face shows apprehension (impending dislocation) Reposition patient prone
- Can perform Apley’s grind test (not sens/spec) in this position for meniscal tear (fix thigh, flex knee and rotate leg by pressing down & turning foot – clicking of pain make test positive)
- Ability to stand from sitting position with arms folded.