orthopedics deals with the skeletal system and all structures that makes it move; bone, joint,...
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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.