viernes, 24 de marzo de 2017

Examen de la articulación de la rodilla



Examination of the Knee Joint

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Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA
Dr. Ebraheim’s educational animated video illustrates the knee examination.
The immediate swelling is probably a large hemarthrosis. 
And if the patient stated they had a twisting injury and now they feel locking and catching which we call it mechanical symptoms and the patient gets some swelling later on then this is probably meniscal tear. 
The if the patient stated that they have pain with stairs and anterior knee pain and feel some crepitus then this is probably a patellar problem. 
If the patient said they have pain in the inside of the knee after a blow to the outside of the knee, that’s probably an MCL tear. 
If it is a dashboard injury or a fall with the foot plantar flexed then this is probably a posterior cruciate ligament ( I was texting you about itPCL) injury. 
Is a patient stated that they had a fall with the foot dorsiflexed then this is a patellar problem. 
Inspection:
Where are going to inspected the knee area for swelling, scars, ecchymosis, and muscle atrophy. 
We check the quadriceps on the right and left sides. 
Compare the condition of both quadriceps muscles to each other. 
Then ask the patient to stand and check the alignment. 
If they have varus bow legs, or valgus knock knees, 
Does the patient have a cavus foot, high arched foot, internal tibial torsion or flat foot?
That will increase the patellofemoral abnormality. 
After that we check the gait:
Check if a patient has quadriceps avoidance gait, which occurs with ACL injury. 
The patient will walk with slightly bent knee to avoid making the quadriceps work. 
Check if the patient has an anatalgic gait, which is a painful gait, it is done to lift the painful extremity quickly off the ground, it is usually caused by a hih or a knee pathology or from severe disc radiation symptoms. 
Make sure that the pain is not radiating from the spine so we ask the patient questions related to the spine. 
Straight leg raising test:
– the test is positive when the painful limb is elevated and that causes severe ciatica and radicular pain. 
Make sure you check the dorsiflexion and plantar flexion of the ankle and toes, specially the big toe. 
Chick the sensation in different dermatomes. 
Then don’t forget about the hip exam specially in children, they may have a slipped epiphysis so we need to check the internal and external rotation of the hip. 
Questions about the hip and hip Exam May detect hip pathology with pain radiating to the medial aspect of the knee. 
Range of motion:
The patient will be supine. 
Extension should be full. 
Election should be about 130°.
Compare to the other side. 
When you evaluate and compare flexion contracture on both sides you can do it supine or prone position. 
as every Orthopedic patient, you’ll also do distal neurovascular exam. 
the neurovascular exam will include the sensation, at the foot level. 
will examine the strength and the power of the muscles of the quadriceps, hamstrings, and gastrocnemius muscles. 
Don’t forget about the pulses. 
Especially in patient with knee dislocation or multiple ligamentous injury of the knee. 
You may get assistance from the ankle brachial index which should be at least 0.9.
Palpation:
palpation is usually done with the patient in the Supine position. 
The first thing I do is palpate the joint line tenderness in order to rule out a meniscal tear or arthritis. 
Then I palpate the anatomical landmarks around the knee, like the quadriceps tendon, patella and the distal pole of the patella, to see if the patient has Jumper’s knee. 
I palpate paid around the patellar tendon, tibial tubercle to rule out Osgood schlatter disease. 
Patella pathology, the most specific test is the patella apprehension test.
You put your fingers on the patella and then try to push the patella that’s really, if this causes pain and apprehension then the test is considered positive.
Evaluate patellar tracking, do full range of motion, to see if the patella will stay in the position or if it will sublux. 
Check the medial side tenderness over the medial patellofemoral ligament.
Check the patellar stability by moving the patella from side to side. 
Try to check the underside of the patella for any sign of arthritis or chondral lesion, both medially and laterally. 
Check for the hamstring muscle insertion for the as in pes anserine bursitis. 
pes anserine Bursa is located several fingers breadth below the level of the joint. 
The most important thing is not to miss him hemarthrosis or effusion in the knee joint, at that point I started looking for an ACL tear, meniscal injury, patellar dislocation or intra-articular fracture. 
Look for effusion check the suprapatellar pouch and around the knee for effusion or swelling. 
Try to push the fluid from one side to the other top to the bottom or vice versa, try to feel the fusion.
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