<p begin="00:00:09.429" end="00:00:11.263" style="s2">- We're going to review the knee exam,</p>
<p begin="00:00:11.263" end="00:00:13.106" style="s2">but before we get started, there are a few</p>
<p begin="00:00:13.106" end="00:00:16.420" style="s2">important principles to be aware of.</p>
<p begin="00:00:16.420" end="00:00:18.967" style="s2">Some of the ultrasound settings need to be</p>
<p begin="00:00:18.967" end="00:00:21.396" style="s2">taken care of before we do the exam.</p>
<p begin="00:00:21.396" end="00:00:24.996" style="s2">Firstly, we look to see<br />that we have the machine</p>
<p begin="00:00:24.996" end="00:00:28.064" style="s2">set up for musculoskeletal.</p>
<p begin="00:00:28.064" end="00:00:30.413" style="s2">We do this by pressing the exam button</p>
<p begin="00:00:30.413" end="00:00:32.838" style="s2">on the machine, which will identify</p>
<p begin="00:00:32.838" end="00:00:35.806" style="s2">that we are in musculoskeletal mode.</p>
<p begin="00:00:35.806" end="00:00:39.566" style="s2">We will click select, and<br />we are ready to begin.</p>
<p begin="00:00:39.566" end="00:00:42.024" style="s2">I recommend using a linear transducer,</p>
<p begin="00:00:42.024" end="00:00:44.595" style="s2">which is between eight and 13 hertz.</p>
<p begin="00:00:44.595" end="00:00:46.425" style="s2">When using this transducer, it's important</p>
<p begin="00:00:46.425" end="00:00:47.965" style="s2">to stay with a consistent method,</p>
<p begin="00:00:47.965" end="00:00:49.331" style="s2">so that you're always confident</p>
<p begin="00:00:49.331" end="00:00:52.370" style="s2">of where you are when<br />you're scanning the patient.</p>
<p begin="00:00:52.370" end="00:00:55.384" style="s2">I recommend keeping the<br />notch of the transducer</p>
<p begin="00:00:55.384" end="00:00:59.336" style="s2">always in the superior aspect,<br />always pointing upwards</p>
<p begin="00:00:59.336" end="00:01:02.484" style="s2">toward the patients head,<br />as well as immediately</p>
<p begin="00:01:02.484" end="00:01:04.710" style="s2">toward the patient's body.</p>
<p begin="00:01:04.710" end="00:01:06.440" style="s2">You can correlate this with the machine,</p>
<p begin="00:01:06.440" end="00:01:09.597" style="s2">because there's a dot in<br />the upper left hand corner</p>
<p begin="00:01:09.597" end="00:01:11.343" style="s2">of the screen, which will orientate you</p>
<p begin="00:01:11.343" end="00:01:15.343" style="s2">as far as your scanning<br />or injection techniques.</p>
<p begin="00:01:37.566" end="00:01:40.015" style="s2">We're going to begin<br />scanning the right knee.</p>
<p begin="00:01:40.015" end="00:01:42.546" style="s2">I like to begin the scan by starting</p>
<p begin="00:01:42.546" end="00:01:45.722" style="s2">at the quadriceps tendon,<br />with the transducer</p>
<p begin="00:01:45.722" end="00:01:49.860" style="s2">with the notch facing<br />towards the patient, upwards,</p>
<p begin="00:01:49.860" end="00:01:52.338" style="s2">In a longitudinal plane.</p>
<p begin="00:01:52.338" end="00:01:54.671" style="s2">As my landmarks, I'm going to use</p>
<p begin="00:01:54.671" end="00:01:57.414" style="s2">so the bottom of the<br />transducer is touching the top</p>
<p begin="00:01:57.414" end="00:01:59.476" style="s2">of the patella tendon.</p>
<p begin="00:01:59.476" end="00:02:02.797" style="s2">I can clearly see the fibers<br />of the quadriceps tendon</p>
<p begin="00:02:02.797" end="00:02:06.797" style="s2">attaching on the patella<br />here at the distal end.</p>
<p begin="00:02:10.854" end="00:02:13.448" style="s2">It's important to maintain<br />contact on both ends</p>
<p begin="00:02:13.448" end="00:02:17.757" style="s2">of the transducer, to<br />get an accurate image.</p>
<p begin="00:02:17.757" end="00:02:20.725" style="s2">I'm going to scan up<br />and down the quadriceps</p>
<p begin="00:02:20.725" end="00:02:23.166" style="s2">to detect any abnormality.</p>
<p begin="00:02:23.166" end="00:02:26.755" style="s2">Clinically, if I suspected<br />a tear more approximately,</p>
<p begin="00:02:26.755" end="00:02:29.677" style="s2">I would examine further,<br />but for most purposes,</p>
<p begin="00:02:29.677" end="00:02:31.260" style="s2">this is sufficient.</p>
<p begin="00:02:39.323" end="00:02:40.645" style="s2">Next, we are going to take a look</p>
<p begin="00:02:40.645" end="00:02:42.922" style="s2">at the patient's cartilage, with the knee</p>
<p begin="00:02:42.922" end="00:02:45.368" style="s2">in the flex position.</p>
<p begin="00:02:45.368" end="00:02:48.440" style="s2">By holding the transducer<br />with the notch facing</p>
<p begin="00:02:48.440" end="00:02:50.963" style="s2">towards the patient,<br />in the medial position</p>
<p begin="00:02:50.963" end="00:02:54.385" style="s2">and placing the probe in cross section,</p>
<p begin="00:02:54.385" end="00:02:57.135" style="s2">just above the patient's patella.</p>
<p begin="00:02:59.037" end="00:03:01.789" style="s2">Here, I see a clear image of the patient's</p>
<p begin="00:03:01.789" end="00:03:04.517" style="s2">medial and lateral epicondyles,</p>
<p begin="00:03:04.517" end="00:03:07.758" style="s2">with cartilage shown in<br />the area of blackness.</p>
<p begin="00:03:07.758" end="00:03:10.524" style="s2">In demonstration of<br />arthritis or chondropenia,</p>
<p begin="00:03:10.524" end="00:03:13.675" style="s2">we can measure from the<br />center of the cartilage,</p>
<p begin="00:03:13.675" end="00:03:17.154" style="s2">as well as at the edge of each<br />epicondyle and compare them</p>
<p begin="00:03:17.154" end="00:03:20.829" style="s2">to standards to determine<br />the grade of osteoarthritis.</p>
<p begin="00:03:20.829" end="00:03:23.087" style="s2">By freezing the image, I can now measure</p>
<p begin="00:03:23.087" end="00:03:24.684" style="s2">the cartilage thickness.</p>
<p begin="00:03:24.684" end="00:03:27.999" style="s2">I press the caliper button<br />and I locate the center</p>
<p begin="00:03:27.999" end="00:03:31.895" style="s2">of the cartilage and I<br />can measure the distance</p>
<p begin="00:03:31.895" end="00:03:33.812" style="s2">of cartilage thickness.</p>
<p begin="00:03:37.059" end="00:03:39.941" style="s2">I can measure the cartilage<br />thickness at the point</p>
<p begin="00:03:39.941" end="00:03:44.108" style="s2">of each lateral condyle and<br />compare these to normal values.</p>

<p begin="00:00:09.494" end="00:00:13.392" style="s2">- Next we're going to review<br />injection of the knee.</p>
<p begin="00:00:13.392" end="00:00:15.580" style="s2">Before we get started,<br />keep in mind that this is</p>
<p begin="00:00:15.580" end="00:00:19.340" style="s2">just a demonstration, and<br />normally these are performed</p>
<p begin="00:00:19.340" end="00:00:23.355" style="s2">under sterile environments,<br />with Betadine, and prepping</p>
<p begin="00:00:23.355" end="00:00:26.802" style="s2">the area properly, this<br />is just an idea to show</p>
<p begin="00:00:26.802" end="00:00:30.027" style="s2">the physician exactly the<br />approach that we use in doing</p>
<p begin="00:00:30.027" end="00:00:34.505" style="s2">injections with the proper<br />needle placement and approach.</p>
<p begin="00:00:34.505" end="00:00:37.462" style="s2">The most common target that<br />physicians typically inject</p>
<p begin="00:00:37.462" end="00:00:41.272" style="s2">the knee joint, is the<br />Suprapatellar Recess, or Bursa.</p>
<p begin="00:00:41.272" end="00:00:44.087" style="s2">We begin by placing the<br />transducer in a longitudinal</p>
<p begin="00:00:44.087" end="00:00:47.631" style="s2">plane, with the end of<br />the transducer just above</p>
<p begin="00:00:47.631" end="00:00:49.473" style="s2">the patient's Patella.</p>
<p begin="00:00:49.473" end="00:00:52.791" style="s2">Next, in setup for the<br />injection, I'm going to rotate</p>
<p begin="00:00:52.791" end="00:00:56.958" style="s2">my transducer to cross-section,<br />and here we can visualize</p>
<p begin="00:00:59.526" end="00:01:02.712" style="s2">the physiologic fluid of<br />the Suprapatellar Recess,</p>
<p begin="00:01:02.712" end="00:01:06.699" style="s2">which is the band of<br />darkness above the Cortex.</p>
<p begin="00:01:06.699" end="00:01:10.039" style="s2">This will be the target<br />site of our knee injection.</p>
<p begin="00:01:10.039" end="00:01:12.960" style="s2">The proper landmarks associated<br />with a knee injection</p>
<p begin="00:01:12.960" end="00:01:16.617" style="s2">are palpating the Iliotibial<br />Band, which is a structure</p>
<p begin="00:01:16.617" end="00:01:19.439" style="s2">that runs down the Lateral<br />Thigh, and in between</p>
<p begin="00:01:19.439" end="00:01:22.164" style="s2">the Iliotibial band and<br />the Vastus Lateralis</p>
<p begin="00:01:22.164" end="00:01:23.803" style="s2">is the soft spot.</p>
<p begin="00:01:23.803" end="00:01:25.470" style="s2">Palpated right here.</p>
<p begin="00:01:26.716" end="00:01:31.148" style="s2">A needle as it's inserted<br />in this soft spot,</p>
<p begin="00:01:31.148" end="00:01:35.372" style="s2">between the Iliotibial Band<br />and the Vastus Lateralis,</p>
<p begin="00:01:35.372" end="00:01:40.017" style="s2">in a direction directly beneath<br />the center of the transducer</p>
<p begin="00:01:40.017" end="00:01:42.934" style="s2">to ensure an accurate localization.</p>
<p begin="00:01:48.114" end="00:01:51.772" style="s2">The needle will be guided<br />into the Suprapatellar Bursa,</p>
<p begin="00:01:51.772" end="00:01:55.102" style="s2">and Lidocaine is typically<br />injected to ensure proper</p>
<p begin="00:01:55.102" end="00:01:58.519" style="s2">location, and we'll see the Bursa expand.</p>
<p begin="00:02:08.897" end="00:02:12.506" style="s2">In addition to injections<br />of Cortisone or Lidocaine,</p>
<p begin="00:02:12.506" end="00:02:16.127" style="s2">or other medications, we<br />often aspirate the knee</p>
<p begin="00:02:16.127" end="00:02:18.056" style="s2">if there is a significant effusion</p>
<p begin="00:02:18.056" end="00:02:20.753" style="s2">of the Suprapatellar Recess.</p>
<p begin="00:02:20.753" end="00:02:24.832" style="s2">By doing this, we use the<br />same approach as the described</p>
<p begin="00:02:24.832" end="00:02:28.296" style="s2">injection technique,<br />however, initially we'll use</p>
<p begin="00:02:28.296" end="00:02:30.431" style="s2">an 18-gauge needle.</p>
<p begin="00:02:30.431" end="00:02:34.598" style="s2">Insert the Suprapatellar<br />Recess, and drain the fluid out.</p>