THE KNEE

CHAPTER 20
CLINICAL ASSESSMENT
HISTORY
1-pain & referred pain
2-swelling
3-stiffness
4-locking & unlocking
5-giving way
6-deformity
7-loss of function
8-limping
Pain is the most common symptom.
DESCREPTION OF PAIN:
1- Inflammatory or degenerative disorders= diffuse
2- Mechanical disorders, injury = localized
3- Osteoarthritis= gradual in onset
4- Gout or infections = sudden and severe.
5- Nerve pain= sharp, burning, distribution of nerve
6- Bone pain= deep, localized
7- Vascular pain= diffuse, aching, poorly localized,
8- Muscle pain= dull , aching, poorly localized.
9- Neoplastic and Infectious= Constant, night pain
10-Check the hip = could be referred pain.
EXAMINATION
EXAMINATION
1-WITH THE PATINT UPRIGHT
EXAMINATIO
*TEST N
FOR INTRA-ARTICULAR FLUID(EFFUSION)
1-CROSS FLUCTUATION
2-PATELLAR TAP
3-THE BULGE TEST
4-THE PATELLAR HALLOW TEST
*patellar tests
1-friction test
2-aprehenssion test
 EXAMINATION
*TESTS FOR LIGAMENTS INSTABILITY
1-STRESS TEST
2-DRAWER TEST
3-LACHMAN TEST
 EXAMINATION

3-WITH THE PATIENT IN PRONE

*LOOK, FEEL &MOOVE
*APPLY’S TEST
INVESTIGATIONS
20.7 X-rays Anteroposterior views should always be taken with the
patient standing. (a,b) Images obtained with the patient lying on the
x-ray couch show only slight narrowing of the medial joint space on
each side; but with weight bearing (c,d) it is clear that the changes are
much more marked than at first thought.
 Arthroscopy Arthroscopic images of the interior of
the right knee from the lateral side, showing (a) a
normal medial meniscus and (b) a torn medial M.
 SWELLINGS
AROUND THE KNEE
ACUTE SWELLING OF THE KNEE
1-post trumatic hemarthrosis (fracture, tear of ACL).
2- nontrumatic hemarthrosis: clotting disorders, pigmented
villonodular synov.
3-acute septic arthritis:: Staphyloco.aureus, or adults
gonococcal infection.
4-trumatic synovitis (a torn or trapped meniscus or a torn
cruciate ligament)
5-aseptic non trumatic synovitis; gout or pseudogout, Reiter’s
disease.
CHRONIC SWELLINGS OF THE KNEE
1- Non-infective arthritis : osteoarthritis and rheumatoid
arthritis
2- Infective arthritis: tuberculosis
3-synovial disorders: synovial chondromatosis,pigmented
villonodular synovitis (PVNS)
SWELLINGS IN FRONT OF THE KNEE
1-prepatellar bursitis (housemaid’s knee)
2-infrapatellar bursitis (clergyman ‘s knee)
SWELLINGS AT THE BACK OF THE KNEE
1-semimembranosus bursa : at the medial side
2-popliteal cyst : rheumatoid or osteoarthritis,
tuberculous arthritis (Baker’s cyst).
3- popliteal aneurysm ; make sure that the popliteal
swelling is not an aneurysm
SWELLINGS AT THE SIDE OF THE KNEE
1-meniscal cyst; small, tense tender, at or just below the
lateral joint line.
2-calcification of the collateral ligament; calcific material is
extruded like toothpaste. Usually medial
3-bony swellings (exostosis or bone tumors)
20.10 Swellings around
the knee (a)
Infrapatellar
bursitis. (b) Osgood
Schlatter’s disease (see
also Figure 20.26). (c)
Swelling in the right
popliteal fossa and
upper calf, due to a
large joint effusion. In
this case the joint
capsule ruptured and
synovial fluid trickled
into the popliteal
space, as revealed in
the arthrogram (d)
SWELLINGS AROUND THE KNEE JOINT
DEFORMITIES
OF THE KNEE
PHYSIOLOGICAL BOW-LEGS AND KNOCK-KNEES
-Bow-legs in babies and knock-knees in 4 year olds.
- considered to be stages of normal development.
-In the occasional case where, by the age of 10 years, the
deformity is still marked (i.e. the intercondylar distance is
more than 6 cm or the intermalleolar distance more than 8
cm), operative correction is done by :hemi-epiphyseodesis

1- inserting a staple or small plate on the side of the physis

(the convex side of the deformity) that needs growth
restriction (hemi-epiphyseodesis).
2- When the deformity has been corrected, the staple or
plate is removed.
20.11 ‘Bow-legs’ and ‘knock-knees’ in children Two
sisters with natural self-correcting ‘deformities’ of
the knees. (a,b) Tamzin at 1½ and 2½ years; (c,d)
Jessy at 3 and 4½ years.
Pathological bow-legs and knock-knees in children
CF: 1- unilateral deformity is likely = pathological , Unilateral
deformities are from 1-rickets, 2-injury, 3-infection, or 4- inherent
growth disorder. Deformity is usually 2- progressive.
RX Operative correction by osteotomy should be deferred until near
the end of growth lest the deformity recur with further growth.
BLOUNT’S DISEASE is a progressive bow-legged deformity due to
abnormal growth of the posteromedial part of the proximal tibia. It
tends to affect children of black African descent more frequently than
others. Typically, and in the adolescent variety, the child is
overweight and walks with an outward thrust at the knee.
X-RAY, the proximal tibial epiphysis is flattened medially and the
adjacent metaphysis is beak shaped, & metaphyseo-diaphyseal angle
RX Spontaneous resolution is rare. Hemiepiphyseodesis may not
always work and correction by osteotomy is usually needed.
20.12 Pathological bow-legs (a) Child with healed rickets. (b) Growth deformity following a
fracture through the proximal tibial physis. (c) This deformity was due to a ‘slipped’ tibial
epiphysis in a child with an endocrine disorder. (d,e) Blount’s disease in a young boy who
developed progressive ‘bow-legs’ from the time he started walking. X-rays showed the
typical distortion of the tibial epiphysis. The deformity can be accurately assessed by
measuring the metaphyseo-diaphyseal angle: a line is drawn perpendicular to the long axis
of the tibia and another across the metaphyseal flare as shown on the x-ray; the acute
angle formed by these two lines should normally not exceed 11 degrees.
PATHOLOGICAL BOW-LEGS AND KNOCK-KNEES IN ADULTS
Angular deformities are common in adults (usually bow-legs
in men and knock-knees in women).Causes;
1-a sequel to a childhood problem,
2- asymmetrical cartilage or bone loss on one side of the
joint, e.g. in osteoarthritis, rheumatoid arthritis,
3-subchondral fractures or
4- Paget’s disease.

RX Provided the joint is stable, a corrective osteotomy

may be all that is required. However, a unilateral ligament
injury may also cause an unstable valgus or varus
deformity; this will call for ligament reconstruction. In some
cases partial or total joint replacement will be needed.
KNEE DEFORMITY IN ADULTS
LESIONS OF THE
MENISCI
MENISCAL TEARS
The menisci have three important roles:
■ Improving articular congruency and stability.
■ Controlling the complex rolling and gliding
■ Distributing load during weight bearing.
The medial meniscus 1-is less mobile, 2-more
liable to tearing.
Bucket-handle tear If the separated fragment
remains attached at the front and back. Locking ;
torn part jammed between femur and tibia,& block
the knee extending fully. Tear is anterior, posterior,
Horizontal , central or peripheral (outer third).
20.13 Torn medial meniscus (a) The meniscus is usually torn by a
twisting force with the knee bent and taking weight; the initial split (b)
may extend anteriorly (c), posteriorly (d) or both ways to create a
‘bucket handle’ tear (e).
CLINICAL FEATURES
young person, twisting injury, Pain, locking suggests a bucket-handle
tear , swelling, giving way. ‘unlock’ the knee.
On examination effusion, quadriceps wasted, tender joint line,
Flexion is full but extension is slightly limited.
1- McMurray’s test, a positive test is helpful but not pathognomonic
and a negative test does not exclude a tear. 2- Apley’s grinding test
.3-The Thessaly test,
IMAGING Plain x-rays are normal but MRI is a reliable method for
confirming the diagnosis, and may even reveal tears that are missed
by arthroscopy.
ARTHROSCOPY identify, & treat at the same time
TREATMENT
Nowadays arthroscopic surgery is preferable. For peripheral tears,
operative repair is feasible. In other cases, the displaced portion
should be cleanly excised. Postoperative physiotherapy is
an important part of the treatment.
Meniscal tears(special tests) (a)Thessaly
test(b)McMurray’stest(c)The grinding test
20.15 Meniscal tears (a) MRI is now the standard method of
diagnosing meniscal lesions. This image shows a horizontal tear of the
posterior horn of the medial meniscus. Most meniscal tears are
excised (b) but some tears at the periphery can be repaired
MENISCAL CYST
Ganglion- like mass firm (or tense) particularly
when the knee is extended, usually on lateral side,
after truma, pain.
RX when need can be decompressed or removed
arthroscopically; any meniscal lesion can be dealt
with at the same time.
20.16 Meniscal cyst (a) Typical appearance of a small,
firm swelling at or just below the joint line. (b) MRI showing
the cyst arising from the edge of the meniscus (arrow).
 OSTEOCHONDRITIS DISSECANS
separation of avascular fragment from condyles.
-mostly due to truma, & 80% on the lateral part of the medial
condyle. 25% is bilateral.
CF; male 15-20y, intermittent pain or swelling, giving way&
locking.
DX signs 1-tenderness localized to one condyle,
2-Wilson’s sign; (flexion 90`+ med rotation + gradual
extension = pain) (-ve in lat rotation).
-XR ; tunnel view(intercondylar)= rounded line or empty
lesion + loose body . MRI & radionuclide are +ve
RX; 1-stable lesion 6-12 months curtailed activity.
2-unstable;if small, remove +drilling the bed by arthroscope.
If large,>1cm,fixed in site with pins or Herbert screw.6w cast,
then exercise, wt bearing until XR is normal healing
-resent RX under study by cartilage graft.
OSTEOCHONDRITIS DISSECANS
 LOOSE BODY
Causes: inj, osteochondritis disecans, OA,
Charcot’s dis , synovial chondromatosis.
CF; asymtomatic, sudden locking (variable in
position from one attack to another),
swelling ,
XR; mostly are visible + the underlying disease.
RX; severe symptoms needs removal.
 TUBERCULOSIS
-Cf ; more in child than adults , pain, swelling , low
grade fever, wasting, warm knee, synovial
thickening, painful limited moves, Mantoux test
+ve , ESR high.
XR; periarticular osteoporosis, enlarged epiphysis
,joint space decrease& erosion.
DX; synovial biopsy to DDX from mono-articular RH
A, juvenile chronic arthritis.
RX; Anti TB for 3-6m,splint in active stage then
exercise . In severe case arthrodesis for adults(not
before complete growth),
 RHEOMATOID ARTHRITIS
CF; pain ,swelling, wasting,large effusion,
synovial thickening, instable joint, some loss
of moves ,
XR ; loss of joint space,,erosion,no
osteophytes, joint deformity.
RX; general RX+ splint+I A injection of steroid
or radiocolloid, arthroscopic synovectomy,
osteotomy in deformities, total knee
replacment .
 OSTEOARTHRITIS
-its one of the commonest site for OA, may be secondary to 1-
injury of art. cartig,2- meniscus tear,3- lig instability, 4-
bone deformity.
-In many cases no primary factor is found, which is usually
bilateral & associated with Heberden’s nodes (primary OA).
Commomly affects med compartment.
CF; >50y, overWt, bow leg, pain, stiff & hurts after rest or
sitting, swelling, locking or giving way, deformity, wasting,
not warmth, no synovial thickening, somewhat limited
moves with crepitus.
XR : decreased oint space(med comp), subchondral sclerosis &
cysts, osteophytes,s t calcifications.
RX ;conser. RX analgesic, exercise physiotherapy, less
activities
OP RX ; arthroscopic washouts & trimming, upper tibial valgus
osteotomy , replacement arthroplasty.
PATELLO-FEMORAL
DISORDERS
RECURRENT PATELLAR DISLOCATION
-15-20% of the cases is recurrent, st without strain due to:
1-general lig laxity 2-underdevelop Fem. condyles 3- patella
maldevelop 4-valgua deform 5-primary muscle defect.
Late complication is OA due to cartilage damage of PF joint.
CF; often bilateral, girls>boys, acute pain, knee is stuck in flexion,
the pat may fall, tender medial side, swelling, hemarthrosis,
apprehenssion test is +ve.
RX; If patella is still dislocated,reduction with push & extending the
knee, POP 2-3w, Quad m exercise for 3m & allow walk with
cruches.
OP RX ; indicated for 15% of pat suffer repeated & severe distress
of dislocations, Rx by repair & strengthening of the Patellofem.
lig+re-align the ext mechanism.
l
 PATELLAR PAIN SYNDROM (PATELLOFEMORAL OVERLOAD SYN)
(CHONDROMALACIA OF THE PATELLA)
-common in young active due to
1-mal-congreuent PF joint
2-malalignment of ext mechanism(weakness of vastus medlialis)
causing pat tilt.
CF; teenager girls, pain anteriorly, wasted Q M,apprehenssion test
+ve.
XR; skyline view show abnormal tilting or subluxating patella.
patella may look small or high, MRI & CT more helpful,
-arthroscopic DX = softening
DDX; other causes of anterior knee pain?
RX;-adgust activity and physiotherapy+ EX.
-Surgery in persist, Unstable patella (lateral release+…).
-Arthroscopic shaving drilling may success.
PATELLAR PAIN SYNDROME
Chondromalacia patellae
OSGOOD-SCHLATTERS DISEASE