Orthopedics

Deals with the skeletal system and all structures that makes it move; bone,

joint, muscle, tendons and nerves.

symptoms

• Pain: most common complain.– Throbbing; abscess.– Stabbing; cut tendon.– Aching ; arthritis.– Referred pain; e.g. knee pain with hip jt

problems, gluteal pain from lumbr spine,…

Symptoms • Stiffness; – Generalized early morning in rheumatoid arthritis,– Localized after immobilization in osteoarthritis.

• Swelling; – Sudden; eg hemarthrosis, – Gradual ; tumor. Infection.

• Deformity;– Sudden; eg elbow dislocation, – Gradual; eg knock knees of rickets

Heberden nodes

Knee Joint effusion

Lipoma

Genu varum and valgum

Symptoms

• Weakness; suggest neurological or muscle disorder.

• Instability (giving way); ligament laxity or rupture.

• Change in sensibility; tingling or numpness eg nerve root compression from prolapsed intrvertebal disc, median nerve entrapment in carpal tunnel syndrome, peripheral neuropathy in DM,…

Symptoms

• Loss of function; eg inability to climb stairs in knee OA, inability to comb hair in frozen shoulder,….

• Past history;– Ankle trauma; secondary OA.– Corticosteroid therapy; osteoporosis, – Chronic diarrhea; ankylosing sponylitis,…

Examination

• Generalized appearance, posture, and gait.• Undress the patient properly.• LOOK, FEEL, MOVE.

LOOK

• Skin; scars, color (eg red inflamed),• Shape; swelling, wasting, lump, deformity.• Position; eg fixed flexion of the knee,…

Skin; psoriatic arthritis

Bow leg deformity

Localized swelling of infrapatellar bursa

Skin ulcer of sarcoma

Finger gangrene; Raynaud’s disease

Feel

• Skin temperature,• Lump,• Effusion,• Tender points.

Move

• Active movement; range of motion (ROM), and power.

• Passive; ROM, crepitus.• Provocative tests; eg induce dislocation in

unstable joints.

Move

Joint stiffness

• All movements absent;– Ankylosis (pathological) eg fibrous ankylosis of TB.– Surgical (arthrodesis).

• All movements limited; eg post traumatic adhesions.

• Some movements limited; eg torn meniscus block full knee extension.

Joint laxity

• Normal in children.• 5% of people have persistent hypermobility

and are more susceptible to dislocation (eg shoulder and patella) and arthralgia.

Deformity

• Varus; part distal to the joint displaced toward the midline.

• Valgus; part distal to the joint displaced away from the midline.

• Kyphosis; increased posterior convexity of the spine.

• Scoliosis; lateral curvature of the spine.

Cubitus Varus

Arthrogriposis

Neurological examination• Appearance:– Abnormal posture; eg claw hand of ulnar nerve

injury.– Abnormal gait; foot drop of sciatic nerve injury.– Muscle wasting, trophic ulcers, shiny skin and hair

loss.• Tone and power.• Tendon reflexes.• Sensibility.

Claw hand of ulnar nerve injury

Diagnostic imaging• Plain film radiography; most useful diagnostic

imaging.• How to read an X-Ray:– The patient name, age, date, clinical summery.– Projection; eg AP and lateral.– Side; left or right.– Soft tissue:• Shape: swelling, wasting, effusion.• Density: calcification, FB,…

Bones

• Shape:– Deformity; eg bow legs.– Periosteal reaction; eg fracture, infection, tumor.– Cortex distruction; eg fracture, tumor.

• density:– Increased density; sclerosis.– Decreased density; oseoporosis.– Bone defects or cysts.

Bone cyst

Myositis ossificans

Joints

• Shape:– Decreased joint space and oseophytes in

osteoarthritis.– Dislocation or subluxation.

• Density: increased in chondrocalcinosis, loose bodies…

Calcification in knee jointsynovial

carcinoma

X-ray with contrast media

• Water soluble based iodine liquids.• Sinography in chronic discharging sinus.• Arthrography in joints.• Myelography in spinal disorders.

Arthrography of shoulder joint

C-T scan• Indications:– Segmental bone necrosis.– Depressed fracture in cancellous bone.– Small radiolucent lesion; eg oseoid osteoma.– Bone and soft tissue tumors.– Complex fractures of spine, pelvis, tarsal and

carpal bones.– 3-D reconstructed images.

• Disadvantage: high radiation exposure.

3-D C-T in fracture pelvic ilium

C-T of shoulder

MRI

• Reading of radiofrequency emissions from atoms and molecules of tissues exposed to static magnetic field.

• Indications:– Bone tumors; size and spread.– Spinal disorders; eg disc prolapse.– Cartilage and ligament. Eg meniscus and anterior

cruciate ligament injuries.

MRI of osteosarcoma

of femur

MRI

• Free of ionizing radiation.• Limitations:– Metallic foreign bodies and implants.– Overweight.– Fear of closed spaces.– Irritable patients and children.

Diagnostic ultrasound

• Advantages: simple, portable, applied anywhere, no side effects.

• Indications:– Cystic lesion, eg abscess, hematoma, aneurism.– DDH.– Rotator cuff tear.– Knee problems; eg ACL injury, meniscal tear,

synovial cysts….

Radionucleide imaging

• Technitium-99m (Tc 99m) for bone scanning.• Selectively concentrated in skeletal tissues.• Increased activity (hot spots) in inflammation,

infection, metastatic tumors, healing (stress) fractures.

• Decreased activity (cold spots) in ischemic necrosis (eg Perthe’s disease).

Radioisotope scan

Bone Meniral densitometry (BMD)

• Double Enrgy X-ray Absortiometry (DEXA) is the most reliable in measurement of osteoporosis

Blood tests• Leukocytosis: in infection, rheumatoid arthritis,

gout…• High ESR- acute and chronic inflammatory disorders

and injury, multiple myeloma.• C-reactive protein (an acute phase protein); in chronic

inflammatory arthritis.• Rheumatoid factor; negative in seronegatve arthritis

eg ankylosing spondylitis, reiter’s disease, psoriatic arthritis,…

• Tissue typing; eg HLA B27 on chromosome 6 In seronegative arthritis.

Synovial fluid analysis

• Indications:– Swelling after injury- hemarthrosis.– Suspected infection.– Gout and pseudogout.– Chronic synovitis- eg TB.

Bone biopsy

• Fine Needle Aspiration (FNA) or open biopsy.• For suspected tumors.• Primary or secondary.• Benign or malignant.

Arthroscopy

• Diagnostic- eg meniscal injury, cruciate ligament injury, biopsy.

• Therapeutic: eg menisectomy, repair of cruciate ligament, loose body removal.

Electrodiagnosis

• Nerve conduction study (NCS): – Measurement of velocity of nerve conduction;

normally 50-60 m/second.– Slowed in peripheral nerve damage or

compression.• Elecromyography (EMG):– For diagnosis myopathy or muscle denervation.