How To Examine an injured knee tests and Treatments used

How to examine the knee ( knee injury examinations)tests

How to examine a knee injury steps on how to check a knee for injuries, and what king of treatments surgeries are there available for an injured knee.

The patient should be positioned comfortably (in some cases may require analgesia) in private area so their dignity and privacy is maintained. Both knees should be exposed for better comparison

Look for common abnormalities of the knee (e.g. deformity, scars, signs of inflammation).

Palpate (feel) for heat, pain, tenderness and swelling.

Test for an effusion.

Method 1. The ‘Bulge’ test

Explained instructions on how to do the small effusion bulge test

(small effusions)

The patient is sitting on the examination couch, the examiner smooths his hand across the medial aspect of the knee watching for a bulge (refilling) in a lateral aspect of the knee joint. Repeat for the lateral aspect of the knee.

Method 2. The Patella tap or ‘Bounce’ test

How to do the Bounce test for large effusions instructions (large effusions)

The patient is sitting on the examination couch, the examiner empties the supra-patellar bursa with the non-dominant hand and attempts to ‘bounce’ the patella on the anterior joint by pushing down with two fingers.

how to assess active vs passive

Assess movement: active vs passive what should you check to determinede if its active or passive

First the joint should be checked in normal anatomical position. All the range of movement should be assessed ( fig CCC). Then active movements (patient moves unassisted) are checked vs. passive (the physician assists patient moving the joint).

Assessment of the stability of the knee joint.

important tips to remember before carrying out these knee test

It is important that the patient is relaxed. The test should not be performed if the patient is in pain.

Stressing the collateral ligaments
Stressing the collateral ligaments

‘Stressing the collateral ligaments.

MCL

Support the lateral aspect of the knee. Move the distal leg laterally. The idea is to try to ‘open up’ the joint- ‘stressing’ the ligament.

LCL - test
LCL - test

LCL

Repeat as for MCL but from medial aspect.

Anterior Draw test
Anterior Draw test

Anterior Draw test:

The anterior draw test is performed to assess the ACL. The role of ACL to prevent the femur from moving posteriorly on the tibia prevents hyperextension of the knee, as well as limiting medial rotation of the femur when the foot is plantarflexed and the leg is flexed.

The knee is flexed to approximately 80°. The muscles are palpated so their complete relaxation is achieved.

With the foot stabilized in plantarflexion position (achieved by gently sitting on the feet), a grip on the proximal tibia is applied.

Then an anterior gentle force is applied to the proximal tibia, pulling forward, assessing how much anteriorly the tibia can move under the fixed femur.               

This should be compared to compared the other knee.

Lachman Test
Lachman Test

Lachman Test

Lachman Test: Tests the ACL instability as Anterior Draw Test.

1. Patient lies on the couch with one hand the examiner secures and stabilizes the distal femur while the other firmly grasps around the proximal tibia, placing the patient's injured knee in about 20 degrees of flexion.

2. The patient's heel rests on the bed. The examiner's thumb is paced on the tibial tuberosity. A brisk anterior force is applied to the proximal end of tibia.

3.  The examiner pulls the patient’s tibia backward and forward. If the ACL is normal, the movement of the tibia will come to the endpoint and will feel firm. If the endpoint feels soft or mushy, a tear of ACL should be suspected.  

Posterior Drawer Test
Posterior Drawer Test

Posterior Drawer Test

Posterior Drawer Test for PCL

Similar to the Anterior Drawer Test but the tibia is pushed posteriorly. A positive test suggest that the PCL is torn and therefore allows the tibia to move posteriorly on the femur.

Assess the function

The patient is asked to stand and walk (see if the gait is normal).

Treatments Used Surgery on the knee

Arthroscopic surgery

During the knee surgery meniscal tears are repaired by sutures of the torn pieces. Knee arthroscopic surgery performed through small incisions in the skin within the knee joint area rather than cut open. A special instrument called arthroscope is used. It is guided by a light scope and attached to a monitor showing a picture of the inside of the joint. Two or three more incisions are made so needed instruments can be inserted depending on the type of problem.

Arthroscopic surgery is a procedure of choice for knee surgeries at the moment as there is usually: less pain following the procedure; less risk of complications; a shorter hospital stay (it is often done as a day-case procedure); a quicker recovery compare to the traditional surgery of a joint. There is a range of procedures for which arthroscopic surgery can be used for example repairing or taking out torn ligaments, removing inflamed synovium and damaged cartilage, as well as repairing meniscal tear.

Muscle Graft

Another surgical procedure for the injured knee is a semitendinosus-gracilis grafting where ruptured ACL is reconstructed by using a semitendinosus-gracilis graft. In this procedure the semitendinosus-gracilis tendons are added together and folded over to make a stronger graft to replace the ACL.

Many orthopaedic surgeons prefer repairing the ACL by using semitendinosus-gracilis graft rather than the patellar tendon graft as a removal of these muscles does not appear to have a clinical impact on the movement. It is thought that ‘the biceps femoris and semimembranosus muscles appear to compensate for reduced semitendinosus and gracilis function’ and the tendons regeneration is seen in most of the patients.

The numbers of studies were carried out to evaluate replacement of a torn ACL with semitendinosus-gracilis graft and compared this method to a bone-patellar tendon-bone autograft method. The results showed that the bone-patellar tendon-bone autograft method was better compared to the semitendinosus-gracilis graft method which gave four times more knee laxity and less strength of the knee flexor muscles, but overall patient satisfaction with the procedures was equal.

Rehabilitation program and knee braces

After an ACL injury the goal is to return the function and stability of the knee with the use of Rehabilitation program and knee braces so the patient can have their previous level of activity. Therefore a knee rehabilitation program is important. It includes different types of exercises e.g. strengthening and flexibility exercises, aerobic conditioning, and technique refinement. Using ACL knee braces has been proven to be beneficial as they allow the knee to bend and straighten while providing rotational support to the knee. ‘ACL braces also provide support to the inner (medial) and outer (lateral) aspects of the knee’.

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