MS 1 knee 5

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MS 1 knee 5
2012-10-16 08:11:51
MS knee

MS 1 knee 5
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  1. anterior drawer test - what it tests, specificity
    primarily tests ACL, but lots of other elements give support - posterolateral capsule, posteromedial capsule, MCL, ITB, POL, arcuate-popliteus complex

    mod-high degree of specificity, so if test is neg we're confident pt has no tear
  2. anterior drawer test - how?
    • supine, knee in 90 degrees flexion
    • sit on pt's foot to keep in from sliding
    • thumbs (thenar eminences) on joint line on tibial plateaus
    • hands on ant tib plateau
    • fingers wrapped around tibial condyles
    • First, check alignment of tibia w fem condyles to make sure your starting point is neutral. Then lean back and see if there's much distraction.
  3. grading of movemnt for Lachman, ant drawer test, and I guess others
    • grade 1 = mild translation < 5 mm
    • grade 2 = mod instability 5-10 mm
    • grade 3 = "serious" >10 mm
  4. gold standard for checking the ACL and why
    • MRI
    • bc with all the supporting structures, a torn ACL might not be noticable in manual tests
  5. Lachman test - pt position? where you're pulling? specificity and sensitivity?
    • pt supine, knee 20-30 degrees flex (rest pt's knee on yours)
    • ER knee and pull tibia ant
    • high degree of spec and sens
  6. Lachman test - hand pos?
    • stability hand: ant distal femur pressing down toward table
    • (pt's knee resting on yours for 20-30 degrees flexion)
    • mob hand: around posterior proximal calf
    • DON'T just rotate the gastroc - grab the tibia with your thumb on the tibial plateau

    first rotate, then pull up
  7. posterior sag sign (aka gravity or Godfrey sign)
    • 1) look at rel btwn front of fem condyle and tibial plateau from ant view
    • 2) look from the side

    you're checking to see if the PCL is holding them together. If absent, the tibial will fall backwards
  8. posterior drawer test - tests what? how to do this?
    • tests ant fibers of PCL
    • same pos as ant drawer test, but now you're pushing post on the tibial crest, so no soft tissue issues
  9. warning if pt's PCL is shot
    be careful doing the ant drawer test. First you have to get the tibia into neutral position, else it'll start far post and will move a lot, so it'll seem like there's no ACL
  10. reverse Lachman
    • prone, flexed 20-30 degrees
    • now stabilize dorsal distal femur while the other hand on the ant prox tibia tries to glide posteriorly (no rot)
    • the pulling hand should approach the calf from the medial side (good pic in slides)
  11. 4 structures involved in restricting posterior instability, in order of importance
    • PCL
    • arcuate-popliteus complex
    • posterior oblique lig
    • ACL - bc it helps keep the two bones together, even if it does so in the opp dir
  12. important note on being polite about the drawer tests
    ask pt if you can sit on her foot before plopping your tush there
  13. ER "slocum test" test for what? - motion and 4 structures
    anteromedial rotary instability

    • MCL
    • POL
    • posteromedial capsule
    • ACL
  14. how to do ER slocum test
    same pos as ant drawer, but this time ER foot ~30 degrees first
  15. position where MCL is at max tautness?
    ER while you're pulling forward - this is done in the slocum test (anteromedial rotary instability test)
  16. slocum test w IR tests for what?  structures?
    • anterolateral instability
    • ACL
    • posterolateral capsule
    • arcuate-popliteus complex
    • LCL
    • ITB
  17. how to do the anterolateral instability test (this is a variety of the slocum test)
    knee flexed to 90, put foot into IR and sit on it to make the LCL taut, now pull upwards
  18. Lateral Pivot Shift test method
    • pt supine, flex hip to 20 degrees, abd to 30 to get space under and med to leg
    • hand: holding med or lat ankle
    • other hand: behind fibula (not on, lest you hit the nerve) over lateral gastroc
    • 1: put knee in IR
    • 2: apply valgus while holding knee in IR
    • 3: bring knee into 30-40 degrees flexion
    • If knee is unstable, the tibial plateau will subluc. The ITB will become a flexor to pull it back into alignment. The test is positive if you feel a click.
    • This test is supposed to duplicate the movement on a sports field when you tear your ACL
    • Good specificity when done right, but much variability in the test/so many dimensions to worry about
  19. lateral pivot shift tests these structures
    • ACL
    • posterolateral capsule
    • arcuate popliteus complex
    • LCL
    • ITB
    • (same as the slocum test done w IR)
  20. Hughston's posteromedial drawer test - tests for what? structures?
    posteromedial rotary instability

    • PCL
    • POL
    • MCL
    • semimembranosus muscle
    • posteromedial capsule
    • ACL
  21. Hughston's posteromedial drawer test - how?
    • supine, hip and knee in flexion
    • IR tibia
    • perform like the post drawer test
    • (this is the reverse of the slocum w IR)
  22. Hughston's posterolateral drawer test - structures?
    looks at posterolateral rotary instability

    • PCL
    • arcuate-popliteus lig
    • LCL
    • biceps femoris tendon
    • posterolateral capsule
    • ACL
  23. Hughston's posterolateral drawer test - how?
    • supine, knee and hip in flexion
    • do ER of tibia
    • press posteriorly on tibia
  24. signs of meniscal issues
    • tenderness along joint line (you can run your fingers along it, and pt can pinpoint exactly where it hurts/ where it's torn)
    • squat w feet in IR or ER
    • walk in a squat w toes out
  25. Duckwalk/Childress Sign
    squat w toes out and walk, and see if there's pain in knees - be careful to be rotating only at knee, not at hip
  26. pain when squatting w feet in IR indicates...
    problem in lateral meniscus
  27. pain when squatting w feet in ER indicates...
    pain in med meniscus
  28. McMurray test for meniscal issues - for med and lat
    • supine, hip and knee flexed
    • pair ER of tib w valgus of knee, and go from flex to ext
    • this taxes the med meniscus
    • pop and "ouch" means trouble

    repeat w IR and varus for med meniscus