Your patient has a positive bulge sign and a palpable click upon ballottement, which most likely indicate
a. a small effusion of his knee. c. a large effusion of his knee.
b. torn cartilage within the knee joint. d. torn ligaments of the knee.
C
For swelling in the suprapatellar pouch of the knee, the bulge sign confirms the presence of small amounts of fluid as you try to move the fluid from one side of the joint to the other. Firmly stroke up on the medial aspect of the knee two or three times to displace any fluid. Tap the lateral aspect. Watch the medial side in the hollow for a distinct bulge from a fluid wave. This is a positive bulge sign and indicates joint effusion. Ballottement is performed to detect large effusions in the knee. Use your left hand to compress the suprapatellar pouch to move any fluid into the knee joint. With your right hand, push the patella sharply against the femur. Feel for a click. Normally, there is no palpable click. However, if there is a large effusion in the knee, the presence of fluid between the femur and patella causes the patella to float on top of the femur. As the patella is pushed back, fluid is displaced, and a palpable click is felt when the patella hits the femur; therefore, the patient with a positive bulge sign and a palpable click upon ballottement most likely has a large effusion of the knee. A positive Apley's sign is suggestive of torn cartilage within the knee joint. This is indicated by limited movement of the knee joint or by audible clicks.
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