OSCE - Knee Examination

The following videos I found very useful for the practice of knee examination.

The first video by Geeky Medics is very good. But the missed out the McMurray test for maniscus injury in their special test. In the second video the McMurray test is shown at 4:35

Introduction

Wash hands
Introduce yourself
Check patient details – name / DOB
Explain examination
Gain consent
Expose patients legs
Position – standing
Ask if patient has any pain anywhere before you begin and offer analgesics accordingly!

Look

Inspect around bed for aids & adaptations - walking stick /wheelchair /knee brace/ etc

Gait

Is the patient demonstrating a normal heel strike / toe off gait?
Is each step of normal height? – increased stepping height is noted in foot drop
Is the gait smooth & symmetrical?
Any obvious abnormalities? – antalgia /waddling /broad based /high stepping?

Inspection from front

Scars – previous surgery / trauma
Swellings - effusions / inflammatory arthropathy / septic arthritis / gout
Asymmetry / leg length differences 
Valgus or varus deformity
Quadriceps wasting – suggests chronic inflammation / reduced mobility

Inspection from the back

Popliteal swellings – Baker’s cyst / Popliteal aneurysm

.Feel

Ask patient to lay on bed
Assess temperature – ↑ temperature may suggest inflammation / infection
Palpate joint lines – irregularities / tenderness (ask patient to flex knee slightly)
Palpate collateral ligaments – either side of joint
Palpate patello-femoral joint
Measure quadriceps circumference & compare – 2.5cm above tibial tubercle

Sweep Test- (small effusion)

1. Empty the media joint recess using a wiping motion
2. This milks any fluid into the lateral joint recess
3. Now do a similar wiping motion to the lateral recess
4. Watch the medial recess
5. If fluid is present a bulge will appear on medial recess

Patella tap- (large effusion)

1. Use your palm to milk fluid from the anterior thigh towards the patella
2. Keep tight hold of the thigh just above the patella
3. With the other hand, press on the patella with two fingers
4. If fluid is present you will feel a distinct tap against the femur

Popliteal swellings- (bakers cyst)

1. Palpate the popliteal fossa with your finger tips
2. Feel for any obvious collection of fluid

Move

Perform flexion / extension both actively & passively (feeling for creptius)

Knee flexion – ask patient to move heel towards bottom – normal ROM 0-140º
Knee extension – ask patient to straighten leg out fully 
Hyperextension –  lift both legs by the feet - note any hyperextension (<10º is normal)

Special Tests

Anterior/Posterior Drawer Test

1. Flex patients knee to 90º
2. Rest your forearm down the patients lower leg to hold their lower leg still
3. Wrap your fingers around back of the knee using both hands
4. Position thumbs over the tibial tuberosity
5. Pull the tibia anteriorly  -  significant movement suggests anterior cruciate laxity /rupture
6. Push the tibia posteriorly  -  significant movement suggests posterior cruciate laxity /rupture
With healthy cruciate ligaments there should be little or no movement noted 

Collateral Ligaments

1. Extend the patients knee fully
2. Hold just above the patients knee with one hand
3. Hold the patients lower portion of the leg with the other hand
4. Attempt to bend the lower leg medially (lateral collateral ligament)
5. Attempt to bend the lower leg laterally (medial collateral ligament)..
With healthy collateral ligaments there should be no abduction or adduction possible

If abduction/adduction is possible, it suggests laxity / rupture of the corresponding collateral ligament

McMurray Test for Maniscus

Patient lies supine

Knee flexed to 45 degrees

Hip flexed to 45 degrees

Examiner braces lower leg

One hand holds ankle

Other hand holds knee

Medial meniscus assessment

Assess for pain on palpation

Palpate medial joint line with knee flexed

Assess for “click” suggesting meniscus relocation

Apply valgus stress to flexed knee

Externally rotate leg (toes point outward)

Slowly extend the knee while still in valgus

Lateral meniscus

Repeat above with varus stress and internal rotation

Positive Test suggests Meniscal Injury

“Click” heard or palpated on above manoeuvres

Joint line tenderness on palpation

To complete the examination

Thank the patient
Wash your hands
Summarise your findings

.Say you would…

Perform a full neurovascular examination of both limbs
Examine the joint above and below - ankle/ hip
Request an X-ray of the knee joint if pathology was suspected

Input from Geeky Medics

OSCE - Knee Examination