Pay attention to lectures because you will

not find time to study

It is not about getting marks, its about taking

care of humans

You will be asked about this responsibility

Orthopaedic Diagnosis
 Orthopaedics is concerned with motion:
bones, joints, muscles, tendons, and nerves
The skeletal system and all what makes it move
Ortho = ‫ قويم‬Paedic = ‫يمشي أو طفل‬
Translation to Arabic as ‫ جراحة العظام و المفاصل‬is
deficient.
Conditions affecting the structures
responsible for motion
Congenital and developmental abn.
Infection and inflammation
Arthritis and rheumatic disorders
Metabolic and endocrine disorders
Tumors and lesions that mimic them
Sensory disturbances and muscle
weakness
Injury and mechanical derangements
 Diagnosis
Identification of the disease
Pathological process, functional loss and
disability
Systemic gathering of information
Systematic but never mechanical
Patient first: person, mind, personality, job,
hobbies, family, home, .. All affected by
the disorder and its treatment.
 History
Taking history is misnomer; the patient tells a
story
Story may be maddeningly disorganized
History has to be structured and systematic
We record
An art that we should master
Key words: injury, pain, stiffness, swelling,
deformity, instability, weakness, altered
sensibility, and loss of function.
More details on each symptom
 Details
When it began
Sudden or gradual
Spontaneously or after a specific event
How it has changed or progressed
What makes it worse or better
While listening we consider if story fits some
pattern that we recognize
Pieces of large picture that gradually unfolds
 History/Symptoms/Pain
Most common symptom in orthopedics
Intensity: personal threshold differences
Type: throbbing, aching, burning, stabbing
Severity is subjective but pain is as bad as
it feels
The main value of estimating severity is to
assess the progress of the disorder or
the response to treatment.
 Pain/Grading System
Grade I (mild): pain that can easily be
ignored
Grade II (moderate) cannot be ignored,
interferes with function and needs
treatment from time to time
Grade III (severe): present most of the
time, demanding constant attention
Grade IV (excruciating): Totally
incapacitating pain
Ask patient to point to where it hurts
Yet don’t assume that the pathology is
where the patient points. There is referred
pain/ autonomic pain: can be very
deceptive
 Pain/ Referred
Deep structure pain as hip may be
referred to knee
Not due to sensory nerves but to cerebral
cortex inability to distinguish between
messages from embryologically related
sites
 Pain/ Autonomic
Autonomic nerves that accompany the
peripheral blood vessels: can be source of pain
e.g. after operation
More vague
Widespread
Accompanied by vasomotor and trophic
abnormalities
Real yet poorly understood and often doubted
The pattern is sought to be atypical or
inappropriate in regard to sensory nerve
supply to anatomical structures
 History/Symptoms/Stiffness
Generalized: R.A, A.Spondylitis
Localized: O.A (due to capsular fibrosis)
Painful movement vs. localized stiffness
Stiffness only assessed by examination
R.A: morning stiffness as cardinal
O.A: transient after period of inactivity
Locking: sudden inability to complete one
particular movement. Mechanical block
(meniscal tear)
 History/Symptoms/Swelling
Soft tissue, joint or bone: to patient they
are all the same
Followed an injury, rapid or slow, painful
Constant or comes and goes
Progressively enlarging (tumor)
History/Symptoms/Deformity
Round shoulders, spinal curvature, knock
knees, bow legs, flat feet
 Patient may say: crooked
 Some are variations of the normal: short
stature, wide hips
Some disappear spontaneously with
growth: flat feet (only dx after age of 5)
If progressive it may be serious
May lead to abnormal weight
distribution→ early OA
History/Symptoms/Weakness
Generalized: a feature of all chronic illness
True muscular weakness: neurological or
muscular disorder
Patients may say: limb is dead meaning it
is weak
Questions directed to which movements
are affected precisely
 History/Symptoms/Instability
Joint giving way: muscle weakness,
ligamentous deficiency from laxity or
rupture
History of injury and its precise nature
 History/Symptoms/change in
sensibility
Tingling or numbness: nerve dysfunction
due to pressure, ischemia, neuropathy
Establish its exact distribution: to assess
peripheral vs. root
What makes it worse or better
History/Symptoms/Loss of function
Upon the needs of the patient (depends on
the patient’s baseline of functioning)
Patient expressions vary
What can’t you do that you used to be able
to do?
 History/Past History
Ask specifically about childhood disorders,
old injury, periods of incapacity
Old twisted ankle: O.A
GIT diseases: A.spondylitis or O.P
R.A systemic S&S
Previous medications (antiepileptics,
steroids, insulin, anticoags→
osteoporosis)
Drugs or alcohols
 History/Family history
Inheritance or familial
 History/social background
work, travel, recreation, home
circumstances, level of support
Affect assessment of disability
A particular activity m.b responsible for the
entire condition
 Examination

NOT
INVISIBLE
BUT
UNNOTICED
 Examination
Always examine even if only to make the
patients feel properly attended to

Always examine so that it is a habit even if

diagnosis is obvious as in R.A hand or
acromegaly
 Examination
Begins from the moment we set eyes on
the patient
General appearance, posture, gait, stick,
pain, distinctive features, short limb,
characteristic facies, spinal curvature,
short limb, asymmetry, … endless
Structured examination: suitably
undressed, both sides to compare
Examine the good limb first (helps gain
trust esp. in children)
 Examination/system
Look
Feel
Move
To encourage the habit of systematic
thought
Sometimes we need to be flexible
 Examination/Look
Skin: scars, colour changes, shiny,
creases
Shape: swelling, wasting, lump, is a
normally straight bone bent?
Position: look at deformity in three
planes
In many joint disorders and most nerve
lesions the limb assumes a characteristic
posture
 Examination/Feel
Feeling is exploring not groping
aimlessly
Know your anatomy and you will
know where to feel for the
landmarks
Find the landmarks and you can
trace a diagnostic map in your
mind
 Examination/feel
Skin: warm or cold, moist or dry. Is sensation
normal?
Soft tissue: characteristics of lump. Are pulses
normal (pulsatile mass→ aneurysm)
Bone and joint: are outlines normal? Is the
synovium thickened? Is there excessive joint
fluid (effusion)?
Tenderness: keep your eyes on the patient’s
face. Try to localize any tenderness to particular
structure
 Examination/Move
Active, passive, abnormal or unstable
and provocative
 Active movement
Ask the patient to move without
your assistance.
Helps to assess: degree of
motion, pain, muscle power
 Passive movement
The examiner moves
Difference in the range of active or
passive movement – may be due to:
 Pain
 Nerve injury (drop foot)
 muscle weakness
Record range of motion: zero is the
natural or anatomical position of the joint
Goniometer, with practice by eye
Compare with asymptomatic side
 Passive movement
Don’t describe with terms as good, limited
and poor BUT always cite the range with
span (degrees)
Ex: knee flexion is from 0-140. zero
means straight
or 20-90 degrees: so patient can’t extend
knee fully
Feel for crepitus while moving
 Unstable movement
Out of normal plane of movement

M.b obvious as wobbly knee

Or needing specific manoeuvres to pick up

minor degrees of instability
 Provocative movement
Reproducing the patient’s symptoms by
applying a specific provocative movement
Subacromial impingement
 May be first sign of rotator cuff disease
 Evaluated via impingement tests (Neer, Hawkins, Jobe…etc)

Dislocation or subluxation
Apprehension test: elicits patient’s worries
anticipating results (performed by bringing
the arm in 90 degrees of abduction and
full external rotation and patient
experiences sense of instability)
 Terminology of movement
Flexion/extension: movements in the
sagittal` plane
Abduction/adduction: in the coronal plane:
away or towards the midline
External rotation/ internal rotation:
rotational around the longitudinal axis.
Strictly they should be called lateral and
medial rotation
 Terminology of motion
Pronation/supination: rotatory applied only to
movements of forearm and foot
Circumduction: composite movement made of
rhythmic sequence of all movements. Possible
only for ball and socket joints ( hip, shoulder)
Specialized movements: opposition of the
thumb, lateral flexion and rotation of the spine
and inversion and eversion of the foot.
 Joint stiffness
All movements absent: patient may
return good function that restriction goes
unnoticed unless examined
surgical fusion is called: arthrodesis
pathological fusion is called: ankylosis
as in acute suppurative arthritis, t.b:
fibrous ankylosis
 Joint stiffness
All movements limited: after severe
injury, movements limited by oedema and
bruising. Later adhesions and loss of
muscle extensibility
active inflammation: irritable joints
acute arthritis: spasm
O.A: capsule fibroses and
movements become increasingly restricted
but pain occurs at extremes of motion
 Joint stiffness
Some movements limited:
usually mechanical causes
torn or displaced meniscus may prevent
full extension of the knee but not flexion
bone deformity may alter the arc of
motion
 Joint Laxity
Children’s joints are more mobile
Athletes (gymnasts)
Persistent generalized joint hypermobility:
5% of normal inherited as dominant
hypermobile joints
not necessarily unstable but tendency to
recurrent dislocation.
tendency to arthralgias (joint pains)
no evidence to relate to O.A; only if joints
become unstable
not associated with any obvious disease
 Deformity
Bone or joint
Joint: faulty alignment or lack of mobility
Special terms:
Varus (O) and valgus (X):
varus: the part distal to the joint is
displaced towards the midline
valgus: away from it.
 Deformity
Kyphosis and lordosis:
• spine has a series of curvatures:
• convex posteriorly in the dorsal spine
(kyphosis)
• convex anteriorly in the cervical and lumbar
spine (Lordosis)
• loss of lordosis may occur due to muscle spasm
• Excessive curvatures constitutes
kyphotic or lordotic deformities or referred
to as hyperkyphosis and hyperlordosis.
 Deformity
Scoliosis: seen from behind, the normal spine is
straight. Any curvature in the coronal plane with
rotation is called scoliosis
Postural deformity: here the patient can if he
chooses to correct by voluntary effort: sciatic
scoliosis due to spasm of paravertebral
muscles
Structural deformity: permanent change in
anatomical structure that can’t be voluntarily
corrected. It is important to def. bet. Postural and
structural scoliosis as pos. is non progressive,
benign and needs no treatment and Str. Is
usually progressive and needs treatment
 Deformity
Fixed deformity: One particular movement
can’t be completed. It does NOT mean
that the joint is deformed and immobile.
If a knee can flex fully but can’t extend
fully it is said to have a “fixed flexion
deformity”
 Joint Deformity
Four basic causes of joint deformity:
1- contracture of the overlying soft tissue:
as in severe scarring across the flexor
aspect of a joint ( burn) or muscle fibrosis
or contracture
2- muscle imbalance: unbalanced muscle
weakness or spasticity will result in joint
deformity which will eventually be fixed.
(Polio and CP). Tendon rupture may
cause deformity
 Joint deformity
3- dislocation: if a joint is disarticulated it
can’t presume its normal position.

4- joint destruction: trauma, infection or

arthritis may destroy the joint and lead to
severe deformity.
 Bone deformity
Children: distorted growth due to genetic
abn., injury or disease.
 As in achondroplasia (genetic), physeal
fracture (trauma), rickets (vit. D dif)
In adults: malunion of a fracture, Paget’s
disease and bone tumours.
 Bony lumps
Due to faulty development, injury,
inflammation or tumour
X- ray examination is essential
Clinical features are highly informative
 Bony Lump/clinical features
Size: a large lump attached to bone or a
lump that is getting bigger is nearly always
a tumour
Site: a lump near a joint is most likely to
be a tumour. A lump in the shaft may be a
fracture callus, inflammatory new bone or
tumour
Margin: benign tumour has well-defined
margin; malignant tumours,
inflammatory lumps and callus have a
vague edge
 Bony Lump/clinical features
Consistency: benign tumour feels bony
hard; malignant often give the impression
that they can be indented
Tenderness: active inflammatory, recent
callus or a rapidly growing sarcoma
Multiplicity: multiple bony lumps are
uncommon> hereditary multiple exostosis
and in Ollier’s disease.
 Neurological examination
In neurosciences course
Examination in special situation
Methods described should be regarded as guide
not rigid rules
Ex: don’t try to a move a limb with suspected
fracture when an x-ray can provide the
answer. (causes pain and neurovascular/ soft
tissue damage)
Acute injuries
Disabled patients
Children
Resuscitation
You will learn much more by adopting methods
of play than by applying a rigid system of
examination.
Diagnostic Imaging

You are
treating
a patient
not an image
 Plain Film Radiology
Over 100 years old
Remains the most useful method of
diagnostic imaging
Size, shape, tissue density and bone
architecture – taken together suggest a
diagnosis or at least a possible range of
diagnosis
 The radiographic image
Attenuation of x-ray
Metal: intensely white
Bone: white to less extent
Soft tissue: varying shades of grey depending on
their density
Cartilage: little attenuation, as a dark area
between adjacent bone ends. This gap is
called the joint space. It is not a space at all; it
is a radiolucent zone filled with cartilage
Radiolucent as osteoporotic bone and fluid filled
bone cysts
 Radiographic image
Superimposed images: one bone
overlying another; as in femoral head
inside the acetabular socket.
different projections to
differentiate which bone is affected
bright image of metallic foreign
body
 How to read an x-Ray
Radiograph is more accurate name
In most cases at least two projections of
each part will be needed: Golden rule
Methodical process of interpretation
It is seductively easy to be led astray by
some flagrant anomaly
Systematic study is the only safeguard
Convenient sequence: patient, soft
tissue, bone, joint and diagnostic
associations.
 The patient
Make sure of the name and date

Clinical background: (write on request)

 The soft tissues
Unless examined early they are liable to
be forgotten
Shape: muscle planes are often visible:
may reveal wasting or swelling. Bulging
outlines around the hip may suggest a
joint effusion.
Soft tissue swelling around IPJs may the
first radiographic sign of R.A
 The soft tissue
Density: increased density in the soft
tissue follows calcification in a tendon, a
blood vessel, a haematoma or an abscess
Metal, wood, glass
The precise localization of foreign body
necessitates multiple views
Decreased density of soft tissue is due to
either fat( the most radiolucent tissue) or
to a gas
 The bones
Shape:
look at overall shape of the bone and how they
fit together
Identify the anatomical structures and study
each one carefully
 Ex: spine, pelvis
 Bent or unduly wide bones
 Localized deformity: cyst, excessive new bone
formation (tumour)
 Examine periosteal surface; periosteal new bone
formation: (infection, fracture, malignancy)
 Examine the cortex ( destruction (malignancy) or
fracture) and endosteum (sharp and clear or
excavated).
 The Bone
Density
Increased: sclerosis
Decreased: O.P, other tissue replacement
Trabecular structure: regular, vacant areas
 Altered trabeculation may be the only sign of a fracture
Focal defects with sharp margins are usually benign
Defects with fuzzy margins may signify infection or
malignancy
Those with moth eaten appearance are almost certainly
malignant
Vacant area in an image is not necessarily vacant in
reality: any tissue that is radiolucent looks dark so a
fibrous tumour may look like a cyst
 The joint
Articulating bones and the illusory space
between them
Film of synovial fluid plus radiolucent
articular cartilage that vary in thickness
from 1 mm or less in carpal joints to 6 mm
in the knee.
It looks much wider in children because
much of the epiphysis is still cartilaginous
and therefore radiolucent
 The joint
Shape
General orientation, congruity, compare if
necessary
Narrowing or asymmetry of the joint ‘space’ :
O.A
Joint destruction: interruption of subarticular
bone plates, radiolucent bone cysts or
periarticular erosions
Osteophytes: bony outgrowths from the joint
margins. Typical of O.A
 The Joint
Density
Chondrocalcinosis: calcification of the
cartilage or menisci (lines of increased
density within the articular space) -
pseudogout
Loose bodies: if radio-opaque : round or
irregular patches overlying the normal
structures.
 The Joint
Diagnostic associations
It is the pattern of abnormalities that counts
If you concentrate on feature that is suggestive,
look for others that are commonly associated
Ex: Narrowing of joint space + subarticular
cysts + osteophytes = O.A
Ex: Narrowing of joint space + O.P +
periarticular erosions = inflam. Arthritis
Ex: bone destruction + periosteal new bone
formation = infection or malignancy UPOW
The search for associated abnormalities or
clarification of some poorly observed
features in the plain film may call for
further examination by one of the other
imaging techniques.

RADIOLOGY COURSE
 BLOOD TESTS
Non specific blood tests:
* non specific blood abn. are common in bone and joint
disorders
* their results hinges with the clinical and x-ray findings.
- Hypochromic anaemia: R.A, NSAID
- Leucocytosis: infection. Mild in R.A, gout
- ESR: usually increased in acute and chronic
inflammatory disorders. Low grade infection may not
raise ESR . High ESR is mandatory to diagnose
myelomatosis (multiple myeloma)
- C-reactive protein: to monitor the progress and activity of
R.A and chronic infection
- Plasma gamma globulins: protein electrophoresis. In the
dx. of myelomatosis
 Rheumatoid factor tests
Not diagnostic of R.A
When negative: seronegative
Seronegative spondarthritidis:
- A.spondylitis
- Reiter’s disease
- psoriatic arthritis
 Tissue Typing
HLA antigens detected in WBCs
Seronegative arthritidis are closely
associated with the presence of HLA-B27
on chromosome 6
It is positive in about 8% of normal
Caucasians
So shouldn’t be regarded as specific