Diagnosis in orthopedics

هشام عبد الكريم القطانأستاذ مساعدجراحة العظام

Orthopaedics
Is concerned with: bone,joints,muscles ,tendons and nerves ,the skeletal system and all that makes it move.

describe

Write in details = introduction + pathological process + management All should have equal time

Diagnosis

You have to prove what it is Anatomically (what structure). Pathology (what is wrong). History. Examination. Special test. D.D. is only referred to incidental.

Differential diagnosis

What else could be and how would you exclude the other possibilities. by Examination , tests We have to thing of the causes in the following A.anatomical structure. B.the pathological conditions either (congenital,acquired).

Give an account

Comprehensive for each Incidence, pathology, etiology, symptoms and sign , treatment. Discuss Select the most important controversial aspect of the subject(compare and contrast).

References

Outline of orthopedics 14 edition 2010 adams’s.Apley's system of orthopedics & fracture.Essential orthopaedic and trauma 2009 (david j dandy).

Landmarks of surgery in the Nineteenth Century

Fundamental advances depend upon the development of other branches of science & industry. The first ,was introduction of anaesthesia (Crawford 1842) Ether.

Louis Pasteur (1822-1895),has fundamental research on bacteria.Joseph Lister (1867) introduce antiseptic surgical technique.Roentgens’ in (1895) discovered X-ray

To start orthopaedic surgery encompassed by general surgeon. Until after the first world war. In great Britain just before twentieth century each of

(Hugh Owen Thomas &Sir Robert Jones) . both they set the sound foundation of orthopaedic surgery that now we enjoys.

History. Examination. Diagnostic imaging Blood test

Synovial fluid analysis. Bone biopsy. Arthroscopy. Electrodiagnosis.

Carefully and patiently compiled ,the history can be every bit as informative as examination or laboratory test.



Patient give history e.g. Injury. pain. stiffness. Swelling .

Defomity. instability. Weakness . altered sensibilty and loss function.

Each symptom is need more detail
when it begin. suddenly or gradually. spontaneously or after some specific events. how it progressed. what make it better or what it make it worse.

Is the most common symptom in orthopaedics .Its precise location is important.Ask the patient to point it.Don’t forget pain might referred.might be boring .dramatic and bizarre .e.g.

Throbbing abcess Aching chronic arthritis Burning neuralgia Stabbing ruptured tendon


G1(mild) : can be easily ignored.G11 (moderate): pain cannt’be ignored,interfer with function and need rx from time to time.

G111 (severe): pain present most of the time ,demanding constant attention. G1V totally incapacitating


Pain arising in or near the skin is usually localized accurately. (it is due to inability of cerebral cortex to distinguish between sensory messages from embyrologically related site). E. g. sciatica.


Is much more vague ,often wide spread and accompanied by vasomotor and trophic abnormalities.



Generalized: and regularrly in early morning as in rheumatoid arthritis. Localized: for a particular joint.


Regular at early morning: as in R. A. OR Transient stiffness : on or two joints after periods of inactivity is typical of osteoarthritis.

Is aspecial variety of stiffness .it is the suddenly inability to complete one particular movement and it suggests a mechanical block

E.g. torn meniscus.

May be in soft tissue , the joint, or the bone .it occurred either


Rapidly as haematoma. Slowly as soft tissue inflammation, joint effusion.


Painful as acute inflammation, infection . Is it constant or continue to enlarge, or comes and goes.

Knock knee

Bow leg

Spinal curvature changes. Kyphosis. Scolosis. Lordosis.


Muscle weakness may be associated with any joint dysfunction, It may also suggest a more specific neurological disorder as e.g. poliomylites.


The patient complains that the joint ((( jumps out ))). Due to muscle weakness or ligamentous deficiency. Loose body.


Tingling or numbness signifies interference with nerve function ,as pressure from a neighbouring structure e.g. disc prolapse. Local ischaemia as in C.T.S in nerve entrapment. Or peripheral neuropathy.

e.g. patient say ‘I can't sit for long time rather than I have backache’.

It is very important e.g. history of twisted ankle many years ago may be the clue to the onset of O.A.

e.g. in musculoskeletal disorder.

Details about work ,travel ,recreation,home circumstances, and the level of support from family and friends.

General. Local examination of the affected parts.

Examination begins from the moment we set eyes on the patient. We should be observing his ,her appearance, posture ,gait . e.g. are they walking freely or do they use stick, any spinal curvature, short limb.

Gait consist of four parts.

Examples
High steppage gait (foot drop) Antalgic gait in pain. scissor gait. Shuffling gait Dipping gait. Waddling gait.

Examination of the affected parts

Patient must be suitably undressed. If one limb is affected ,both must be exposed to compare. We examine the good limb then the bad limb. We followed the system of (look, feel, move).

Examination

Look
Feel
Move
Look
Feel
Move

Look

Skin
Shape
Position

look

Skin scar,color,creases. Shape swelling ,wasting. Position in nerve lesion and the joint disease a limb assumes characteristic attitude.

Deformity

Deformity applied to either Person shortness stature Bone short bone. Joint joint may be held in an unusual position. (g.varum, lordosis, kyphosis)

Causes of bone deformity

Congenital pseudarthrosis.Bone softening , ricket.Dysplasia,exostosis.Plate injury.Fracture malunion.Pagets’ disease.

Causes of joint deformity

Skin contracture (burn).Fascial contracure (dupuytrens’).Muscle contracture (volkmanns’)Muscle imbalance.Joint instability (torn ligament).Joint destruction (arthritis).

2 introduction

Examination
Look
Feel
Move
Look
Feel
Move

Look

Skin
Shape
Position


look
Skin scar,color,creases. Shape swelling ,wasting. Position in nerve lesion and the joint disease a limb assumes characteristic attitude.

Deformity

Deformity applied to either Person shortness stature Bone short bone. Joint joint may be held in an unusual position. (g.varum, lordosis, kyphosis)

Causes of bone deformity

Congenital pseudarthrosis.Bone softening , ricket.Dysplasia,exostosis.Plate injury.Fracture malunion.Pagets’ disease.

Causes of joint deformity

Skin contracture (burn).Fascial contracure (dupuytrens’).Muscle contracture (volkmanns’)Muscle imbalance.Joint instability (torn ligament).Joint destruction (arthritis).

Feel

Skin
Soft tissue
Bone and joint


Skin temp,sensation. Soft tissue lump ,pulse. Bone and joints fluid,synovium. Tenderness precisely WHERE. E.G. bony lumps. (size, site, margins, consistency, tenderness, multiplicity).

Move

Active
Passive
Abnormal

Active ask the patient to move the joint. Passive by the examiner.

Normal movement
The range of joint movement is recorded in degrees starting from zero. Flexion-extension : sagittal plane. Adduction- abduction :coronal plane.

External –internal rotation: along the longitudinal axis.Pronation- supination: rotatory movement applied to foot and forearm.


The term stiffness covers a variety of limitation of movement . Types: 1. All movements absent. e.g. surgical fusion. (arthrodesis). pathological fusion (T.B.).
Joint stiffness



2. ALL MOVEMENT LIMITED
e.g. in O.A. there is active inflammation of synovium.

3.One or two movements limited

When movement in at least one direction is full and painless the cause is usually mechanical. e.g. torn meniscus.


If the symptoms include weakness or in coordination or changes in the sensibility. or if they point to any disorder of the neck or back. A complete neurological examination of the related part is mandatory.

Steps

General appearance . Claw hand, spastic of cerebral palsy, trophic skin changes, ulcer , muscle wasting.


Motor function:tone(( increase tone as in CVA))not confused with rigidity ((lead pipe….)) power ,reflexes.flaccidity ( as in polio.).

Testing muscle power(medical research council)

G0:no movement. G1:only a flicker of movement. G2:movement with gravity eliminated.

G3:mov. against gravity. G4:mov. With resistance. G5:normal movement

superficial.
Sensory function

Hyperasthesia (increased). Dysaesthesia (unpleasant). Hypoasthesia. (diminished). Anaesthesia. (loss).

Deep vibration test, position sense, sense of joint posture, sterognosis the ability to recognize shape and texture by feel alone.

Reflexes

The tendon reflexes are monosynaptic segmental reflexes that is the reflex pathway takes a short cut through the spinal cord at the segmental level.


Tendon reflex. Patellar tendon reflex. Achilles tendon reflex. Superficial reflexes. e.g. abdominal reflex. Deep reflexes. planter reflex. ( babinski sign).

Plain film radiography. Tomography. Computed tomography T. M .R. I . Diagnostic ultrasound. Radionuclide imaging.

X-ray examination is almost 100 years old .

Despite the remarkable technical advances of recent years, plain X-ray examination remains the most useful method of diagnostic imaging.

it provides information simultaneously on the .Size.Shape.Tissue density.Bone architecture. Which is usually suggest a diagnosis or at least a range of possible diagnosis.We should follow the principle of two in reading X –ray.


How to read an X-RAY
The process of reading x-ray films should be as methodical as clinical examination. Systematic study is the only safeguard against missing other important signs.

The sequence as start with identifying the part. particular view. Then patient : name . age. sex.

2.soft tissue study: unless examined early ,these are liable to be forgotten.

looks for muscular planes. bulging around joints as in rheumatoid arthritis. presence of calcification.

3.bones looks for deformity, irregularity. cortex for Periosteal surface (periosteal reaction). Endosteal surface. Trabecular structure.

density : increase in density (sclerosis) Decrease as in osteoporosis.

The joint

The radiographic joint consists of the articulating bones and the space between them.The space occupied with radiolucent cartilage.Looks for narrowing of this space, flattening, erosion, sclerosis………..


The contrast media used in Orthopaedics are mostly, Iodine-based liquids. (either oily iodides or water soluble ionic variety, e.g. metrizamide. Sinography. Arthrography. myelography.

Provides an image focused on a selected plane.

Produce cutting image through selected tissue planes but with much greater resolution. Is capable of recording bone and soft tissue outline in cross section. Disadvantage irradiation.

Relies upon radio frequency emission from atoms(proton) and molecules in tissues exposed to a static magnetic field. it is with better contrast resolution and more refined differentiation of tissues.

Fat , cancellous , marrow

Produced brightest images

Cortical bone ,ligament

appear black.

Intermediate(cartilage,muscle,spinal canal)

High frequency sound waves generated by transducer can penetrate several cm into the soft tissue and reflected back and they are registered a electrical signals and displayed as images on the screen. The equipment is simple and portable. It has harmless side effect. It is helpful for screening of DDH.

Photon emission by radionuclide taken up in specific tissue can be recorded to produce an image which reflect activity in that tissue or organ. The ideal isotope. 99m technetium methylene diphosphonate Gallium 67.


Hb , differential count,ESR,c-reactive protein, gama globulin. Rheumatoid factor . Tissue typing (HLA-AG)detected in the white blood cell and are used to characterize individual tissue types. E.g. HLA-B27 on chromosome 6 as in seronegative. Blood chemistry.



Arthrocentesis: done after e.g. injures . suspected infection . acute synovitis in adult. chronic synovitis .


Is often crucial means of making a diagnosis or distinguishing between local conditions that closely resemble one another. Might open (surgery) or closed (needle). e.g. in bone tumor diagnosis to confirm benign or malignant.


Is commonly performed for. Diagnostic Therapeutic reasons. Almost any joint can be reached,most usefully employed in . Knee. shoulder. wrist.


Nerve and muscle function can be studied by various electrical methods. Motor nerve conduction. Sensory nerve conduction. Electromyography.

NERVE CONDUCTION

Conduction velocity of the nerve could be measured between 2 points. e.g. velocity could be slowed as in nerve compression.(40-60 m\ s).

Treatments

METHODS OF NON-OPERATIVE TREATMENT

REST 

Since the days of H. O. Thomas , who, more than a century ago, emphasized its value in diseases of the spine and limbs, rest has been one of the mainstays of orthopaedic treatment. Complete rest demands recumbency in bed


SUPPORT 
. Examples in common use are spinal braces, cervical collars, wrist supports, walking calipers, knee and ankle orthoses, and devices to control drop foot

PHYSIOTHERAPY

These may be active, passive or a combination of the two.

Passive approaches involve a range of different techniques carried out on the patient by the therapist.

Active approaches require active involvement by the patient, either by exercising or changing behavior

passive intervention

Manual therapy Soft tissue techniques Traction Electrotherapy Ultrasound

Alternative therapies

Acupuncture

massage

LOCAL INJECTIONS 
Intraarticullar


Periarticular

drugs

Antibacterial and antibiotic Analgesics Sedatives Anti-inflammatory Hormone like drug Ant osteoporosis Specific drugs Cytotoxic drugs

MANIPULATION 

manipulation for correction of deformity manipulation to improve the range of movements at a stiff joint manipulation for relief of chronic pain in or about a joint, especially in the neck or spine

RADIOTHERAPY

Operative treatment
SYNOVECTOMY

OSTEOTOMY

ARTHROPLASTY

Bone GRAFTING OPERATIONS

TENDON GRAFTING OPERATIONS

TENDON TRANSFER OPERATIONS

EQUALISATION OF LEG LENGTH 
leg lengthening

leg shortening

arrest of epiphysial growth.

BONE FIXATION TECHNIQUES

AMPUTATION