Anatomi_Lutut_dan_Pemeriksaan_Lutut.pptx

Anatomi lutut dan pemeriksaan pada lutut

1. Pendahuluan Anatomi Lutut dan Fokus pada Pemeriksaan Lutut Samuel Sembiring

2. Outline Pendahuluan Anatomy of the knee: Bone Anatomi Lutut: Suplai Darah dan Sistem Limfatik Anatomi Lutut: Saraf Anatomi Lutut: Otot Pemeriksaan Lutut: Riwayat Pemeriksaan Lutut: Pemeriksaan Fisik

3. Pendahuluan Lutut adalah sendi terbesar dalam tubuh Lutut pada dasarnya adalah sendi engsel yang memungkinkan fleksi dan ekstensi kaki. Other movements are also possible, though to a limited extent. The knee is critical to efficient bipedal movements like walking, running, and jumping. Muscular support is this joint's most important stabilizing factor, and proper conditioning and training can help prevent sports injuries. Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

4. Anatomi Lutut: Struktur The bones articulating at the knee are large and complex. The femur has a slight medial slant, while the tibia is nearly vertical. The patella  sesamoid bone—the largest in the body—occupying the anterior part of the knee. The surfaces articulating at the knee are the following: Lateral and medial condylar surfaces of the femur and tibia Anteroposterior articulation between the patella and femur Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Rohen JW, Yokochi C, Lütjen-Drecoll E. Anatomy: A photographic atlas. 8th ed. Erlangen: Wolters Kluwer; 2016.

5. Anatomi Lutut: Stabilisasi Stabilization of the knee: Quadriceps femoris Fibrous capsule Extracapsular ligaments Patellar ligament Fibullar collateral ligament or lataeral collateral ligament (LCL) Tibial collateral ligament or medial collateral ligament (MCL) Oblique popliteal ligament Arcuate popliteal ligament Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Rohen JW, Yokochi C, Lütjen-Drecoll E. Anatomy: A photographic atlas. 8th ed. Erlangen: Wolters Kluwer; 2016.

6. Anatomi Lutut: Stabilisasi Stabilization of the knee: Intraarticular ligaments Anterior cruciate ligament (ACL) Posterior cruciate ligament (PCL) Medial and lateral menisci Bursae Suprapatellar bursa Popliteus bursa Anserine bursa Gastrocnemius bursa Prepatellar bursa Deep and subcutaneous infrapatellar bursae Medial collateral ligament bursa Illiotibial bursa Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Rohen JW, Yokochi C, Lütjen-Drecoll E. Anatomy: A photographic atlas. 8th ed. Erlangen: Wolters Kluwer; 2016.

7. Anatomi Lutut: Suplai Darah dan Sistem Limfatik Blood supply Arteries “genicular anastomosis” Femoral artery Popliteal artery Anterior and posterior recurrent branches of the circumflex fibular and anterior tibial recurrent arteries Venous drainage Great saphenous vein Small saphenous vein Lymphatics Most lymph from the knee and leg drains into the popliteal lymph nodes in the popliteal fossa. The popliteal nodes and other knee and lower limb lymphatics empty into the deep inguinal and subinguinal nodes. Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

8. Anatomi Lutut: Saraf The structures of the knee and most knee extensors  femoral nerve (L1 to L3). The gracilis muscle  obturator nerve (L2 and L3)  crosses the knee superoinferiorly and flexes the leg The knee flexors in the posterior thigh compartment  sciatic nerve (L4 to S3)  branches into the tibial and common peroneal nerves. The tibial nerve  gastrocnemius  knee flexor in the posterior leg compartment. Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

9. Anatomi Lutut: Otot Knee extensors Knee extensors (mainly the quadriceps femoris) form the quadriceps tendon conjointly and are innervated by the femoral nerve. Knee extensors are the main muscular stabilizers of the knee joint Consisted of Rectus femoris Vastus lateralis Vastus medialis Vastus intermedius Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Rohen JW, Yokochi C, Lütjen-Drecoll E. Anatomy: A photographic atlas. 8th ed. Erlangen: Wolters Kluwer; 2016.

10. Anatomi Lutut: Otot Knee extensors Knee extensors (mainly the quadriceps femoris) form the quadriceps tendon conjointly and are innervated by the femoral nerve. Knee extensors are the main muscular stabilizers of the knee joint Consisted of Rectus femoris Vastus lateralis Vastus medialis Vastus intermedius Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Rohen JW, Yokochi C, Lütjen-Drecoll E. Anatomy: A photographic atlas. 8th ed. Erlangen: Wolters Kluwer; 2016.

11. Anatomi Lutut: Otot Knee flexors Consisted of Semitendinosus  the tibial division of the sciatic nerve Semimembranosus  the tibial division of the sciatic nerve Biceps femoris  the tibial (long head) and common peroneal (short head) divisions of the sciatic nerve Gracilis  the obturator nerve Gastrocnemius  the tibial nerve Popliteus  the tibial nerve The gracilus is a thigh adductor that flexes and medially rotates the knee. The popliteus unlocks and weekly flexes the knee. Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Rohen JW, Yokochi C, Lütjen-Drecoll E. Anatomy: A photographic atlas. 8th ed. Erlangen: Wolters Kluwer; 2016.

12. Anatomi Lutut: Otot Knee flexors Consisted of Semitendinosus  the tibial division of the sciatic nerve Semimembranosus  the tibial division of the sciatic nerve Biceps femoris  the tibial (long head) and common peroneal (short head) divisions of the sciatic nerve Gracilis  the obturator nerve Gastrocnemius  the tibial nerve Popliteus  the tibial nerve The gracilus is a thigh adductor that flexes and medially rotates the knee. The popliteus unlocks and weekly flexes the knee. Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Rohen JW, Yokochi C, Lütjen-Drecoll E. Anatomy: A photographic atlas. 8th ed. Erlangen: Wolters Kluwer; 2016.

13. Anatomi Lutut: Otot Knee flexors Consisted of Semitendinosus  the tibial division of the sciatic nerve Semimembranosus  the tibial division of the sciatic nerve Biceps femoris  the tibial (long head) and common peroneal (short head) divisions of the sciatic nerve Gracilis  the obturator nerve Gastrocnemius  the tibial nerve Popliteus  the tibial nerve The gracilus is a thigh adductor that flexes and medially rotates the knee. The popliteus unlocks and weekly flexes the knee. Gupton M, Imonugo O, Black AC< Launico MV, Terreberry RR. Anatomy, Bony Pelvis and Lower Limb, Knee. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Rohen JW, Yokochi C, Lütjen-Drecoll E. Anatomy: A photographic atlas. 8th ed. Erlangen: Wolters Kluwer; 2016.

14. Pemeriksaan Lutut: Riwayat Pain In inflammatory or degenerative disorders, it is usually diffuse – gradual in onset with osteoarthritis but typically sudden and severe with gout or infection. Swelling When diffuse, it is suggestive of fluid within the joint or synovial thickening. If there was an injury, ask whether the swelling appeared immediately (suggesting a haemarthrosis) or gradually (typical of a torn meniscus). Chronic diffuse swelling is characteristic of arthritis or synovitis. Intermittent swelling suggests an old meniscal tear or a loose body Stiffness Ask whether it fluctuates and when it feels worse or better. Early morning stiffness suggests an inflammatory disorder; stiffness after periods of inactivity is typical of osteoarthritis. Locking One minute it moves perfectly well and the next it can still flex as before but it cannot extend fully Something has got jammed between the articular surfaces (usually a torn meniscus or a loose body). Deformity It may be unilateral or bilateral: valgus or varus, fixed flexion or hyperextension. Knock-knees and bandy-legs are common in children and usually correct spontaneously Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

15. Pemeriksaan Lutut: Pemeriksaan Fisik Signs with the patient standing Uncover the lower limbs from groin to toe and position the patient with both feet pointing forward and slightly apart. Getting the patient to stand upright unmasks deformities better than with the patient lying down. Look at the overall shape and alignment of the limb: is there an asymmetry; are the muscles wasted; do the limbs appear to be bow-legged (genu varum) or knock-kneed (genu valgum)? Remember it is often easier to pick up subtle changes of alignment looking from behind the patient than from the front. Ask the patient to walk. Is there a limp and, if so, is it because the knee does not move freely as it swings through or because it does not straighten well when planted on the ground? Is there an irregular rhythm with the patient trying to diminish weightbearing on one or other side? Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

16. Pemeriksaan Lutut: Pemeriksaan Fisik Signs with the patient sitting With the patient sitting on the edge of the examination couch look at the position of the patella: is it seated centrally or is it shifted to one side? Does it appear higher (patella alta) or lower (patella baja / infera) than usual? Ask the patient to straighten each knee in turn. Note the movement of the patella. Does it glide upwards in a smooth manner or does it momentarily veer sideways (maltracking or patellar instability)? Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

17. Pemeriksaan Lutut: Pemeriksaan Fisik Signs with the patient lying supine Look Is there any asymmetry? Are there tell-tale scars from previous injuries or operations? Is there muscle wasting? Always confirm the visual impression by measuring the girth of the thigh at a fixed point above each knee. Is there swelling and is it diffuse or localized? Is there bruising that may help localize the injury? Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

18. Pemeriksaan Lutut: Pemeriksaan Fisik Feel Run the back of your hand down each limb from the thigh and across the knee. Does the knee feel warmer on one side, suggesting inflammation? Now bend the patient’s knee to about 70 degrees and sit on the edge of the couch facing the knee. Feel the bony contours around the joint, the attachments of ligaments and tendons, and the joint line. Note where there is tenderness. Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

19. Pemeriksaan Lutut: Pemeriksaan Fisik Feel Synovial thickening Grasp the patella between the thumb and middle finger and try to lift it off the femoral groove Normally it can be gripped quite firmly but if the synovium is thickened, your fingers simply slip off the edges of the patella. Patellofemoral joint Straightens and push the patella first towards the medial and then towards the lateral side, feeling with the fingers of your other hand for tenderness along the undersurface of the bone. Rubbing the patella against the femoral trochlea may also elicit pain. Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

20. Pemeriksaan Lutut: Pemeriksaan Fisik Move Ask the patient to bend and straighten the knee fully. Note the range of movement. Repeat the motion while placing a hand over the front of the knee; crepitus is felt as a grating sensation between the patella and femur – a sign of patellofemoral degeneration. Finally check if passively moving the knee alters the range. Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

21. Pemeriksaan Lutut: Pemeriksaan Fisik Move Patellar apprehension While passively flexing the patient’s knee slowly, use your thumb to press the patella laterally: if the patient becomes increasingly anxious and resistant to further movement, it suggests that he or she has either experienced a previous patellar dislocation of subluxation or fears an impending subluxation because of patellar instability. Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

22. Pemeriksaan Lutut: Pemeriksaan Fisik Tests for intra-articular fluid Cross fluctuation This test is applicable only if there is a sizable joint effusion. The left hand is used to compress and empty the suprapatellar pouch while the right hand straddles the front of the joint below the patella; by squeezing with each hand alternately, a fluid impulse is transmitted across the joint. Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

23. Pemeriksaan Lutut: Pemeriksaan Fisik Tests for intra-articular fluid The patellar tap The suprapatellar pouch is compressed with the left hand to squeeze any fluid from the pouch into the joint. With the other hand the patella is then tapped sharply backwards onto the femoral condyles. In a positive test the patella can be felt striking the femur and bouncing off again (a type of ballottement). Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

24. Pemeriksaan Lutut: Pemeriksaan Fisik Tests for intra-articular fluid The bulge test This is a useful method of testing when there is very little fluid in the joint, though it takes some practice to get it right! After squeezing any fluid out of the suprapatellar pouch, the medial compartment is emptied by pressing on the medial aspect of the joint; that hand is then lifted away and the lateral side is sharply compressed – a distinct ripple is seen on the flattened medial surface as fluid is shunted across. Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

25. Pemeriksaan Lutut: Pemeriksaan Fisik Tests for intra-articular fluid The juxtapatellar hollow If both knees are bent gradually and observed from below, a hollow appears lateral to the patellar ligament and disappears on further flexion; if there is fluid in the joint, this hollow fills quickly and disappears at a lesser angle of flexion, or it may not be seen at all. Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

26. Pemeriksaan Lutut: Pemeriksaan Fisik Tests for ligamentous stability Collateral ligaments Tuck the patient’s foot under your arm and holding the extended knee firmly with one hand on each side of the joint; the leg is then angulated alternately towards abduction and adduction. The test is performed at full extension and again at 30 degrees of flexion. (continued next slide) Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

27. Pemeriksaan Lutut: Pemeriksaan Fisik Tests for ligamentous stability Collateral ligaments There is normally some mediolateral movement at 30 degrees, but if this is excessive (compared to the normal side) it suggests a torn or stretched collateral ligament. Sideways movement in full extension is always abnormal; this may be due either to torn or stretched ligaments and capsule, or to loss of articular cartilage or bone on one side of the knee which allows the affected compartment to collapse Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

28. Pemeriksaan Lutut: Pemeriksaan Fisik Tests for ligamentous stability Cruciate ligaments Routine examination for cruciate ligament stability involves testing for abnormal gliding movements in the anteroposterior (sagittal) plane. With the patient’s knees flexed 90 degrees and the feet resting on the couch, the upper tibia is inspected from the side; if its upper end has dropped back, or can be gently pushed back, this indicates a tear of the posterior cruciate ligament (the ‘sag sign’). (continued next slide) Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

29. Pemeriksaan Lutut: Pemeriksaan Fisik Tests for ligamentous stability Cruciate ligaments With the knee in the same position, the foot is anchored by the examiner sitting on it (provided this does not cause pain); then, using both hands, the upper end of the tibia is grasped firmly and rocked backwards and forwards to see if there is any anteroposterior glide (the ‘drawer test’). Excessive anterior movement (a positive anterior drawer sign) denotes anterior cruciate laxity; excessive posterior movement (a positive posterior drawer sign) signifies posterior cruciate laxity. Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

30. Pemeriksaan Lutut: Pemeriksaan Fisik Tests for ligamentous stability Collateral ligaments More sensitive is the Lachman test, but this is difficult if the patient has big thighs (or the examiner has small hands). The patient’s knee is flexed 20 degrees; with one hand grasping the lower thigh and the other the upper part of the leg, the joint surfaces are shifted backwards and forwards upon each other. If the knee is stable, there should be no gliding. Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

31. Pemeriksaan Lutut: Pemeriksaan Fisik Tests for ligamentous stability Rotary stability If multiple ligaments and the capsule are torn, the knee can become unstable to rotatory forces. Special clinical tests have been developed to detect these abnormalities; the best known is the pivot shift test. The patient lies supine with the lower limb completely relaxed. The examiner lifts the leg with the knee held in full extension and the tibia internally rotated. This produces a position of slight rotational subluxation if the lateral collateral, anterior cruciate and part of the posterolateral capsule are torn A valgus force is then applied to the lateral side of the joint as the knee is flexed; a sudden posterior movement of the tibia is seen and felt as the joint is fully re-located. The test is sometimes quite painful. Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma. 4th ed. Florida: Taylor and Francis; 2014

32. Terima Kasih