Presentation on theme: "Clinical and x-ray features frcatures. Diagnosis in orthopaedics HISTORY Pain; most common symptom; type (throbbing, aching, burning, stabbing); Severity(‘pain."— Presentation transcript:
Diagnosis in orthopaedics HISTORY Pain; most common symptom; type (throbbing, aching, burning, stabbing); Severity(‘pain grading’ 1-10); site of pain; referred pain (sciatica); autonomic pain
Stiffness in rheumatoid arthritis; ankylosing spondylitis; early morning stiffness; Locking and unlocking; Swelling in soft tissues, the joint or bone; follow an injury, appeared rapidly or slowly; it is painful; increasing in size.
Deformities ; named as round shoulders, spinal curvature, knock knees, bow legs and ﬂ at feet; normal veriations(e.g. Short stature or wide hips); others disappear spontaneously with growth (e.g. ﬂ at feet or bandy legs in an infant); progressive, like scoliosis in young childrens or if it affects only one side of the body
Weakness in all chronic illness; prolonged joint dysfunction; pure muscular weakness; Instability joint ‘gives way’; joint laxity, capsular or ligamentous de ﬁ ciency, internal derangement torn meniscus or a loose body in the joint
EXAMINATION general appearance, posture and gait; knock-knees; spinal curvature; short limb; paralysed limb; patient in pain
gait swing phase and stance (heal strike, midfoot and push off) painful hip, unstable knee or a foot-drop
suitably undressed; no mere rolling up of a trouser leg; both must be exposed for comparison traditional clinical
inspection, palpation, purcussionand auscultation replaced by look, feel, move
Look Shape and posture; overall posture; spine straight or unusually curved; shoulders level; limbs normally positioned; look for deformity in three planes and always compare Skin; colour, quality,bruising, wounds and ulceration, scars General survey; Attention is initially focussed on the symptomatic or most obviously abnormal area
Feel Know your anatomy and ﬁ nd the landmarks skin; warm or cold; moist or dry; sensation soft tissues; lump and its characteristics; pulses bones and joints; are the outlines normal; synovium thickened; excessive joint ﬂ uid Tenderness
Move Types active; passive; abnormal or unstable movement, and provocative movement. Active ; to move without your assistance; degree of mobility; painful or not Active movement is also used to assess muscle power Passive examiner who moves the joint in each anatomical plane;difference between the range of active and passive Range of movement; in degrees, starting from zero; for example, ‘knee ﬂ exion 0–140°; feel for crepitus
Unstable; unphysiological; joint is unstable Provocative impingement of the subacromial structures; apprehension test
fracture It represents failure of the bone to respond to a high impact, which can be direct or indirect. Associated injuries to the adjacent soft tissues (e.g. ligaments, tendons, etc.) are not uncommon
Mechanism of injury Although most fractures occur due to direct or indirect trauma, other mechanisms may be responsible in some special situations.
Direct injuries In these injuries, the forces are concentrated at one site and, therefore, the bone fails at the point of impact. Fractures occurring due to direct mechanisms are often comminuted and may be associated with signi ﬁ cant soft tissue injuries. A typical example is a comminuted tibial midshaft fracture sustained bya pedestrian due to direct impact from a speeding car.
Indirect mechanisms The force causing the fracture is applied at a distance in indirect mechanisms and therefore, associated damage to soft tissues may not be much. An intracapsular fracture of the femoral neck is a typical example of an injury with indirect mechanism.
Grading system of soft tissue injury in closed fractures. A, Grade 0—little or no soft tissue injury. B, Grade 1—superficial abrasion with local contusional damage to skin or muscle. C, Grade 2—deep contaminated abrasion with local contusional damage to skin and muscle. D, Grade 3—extensive contusion or crushing of skin or destruction of muscle
Classification of fractures A fracture is generally described in terms of displacement (e.g. undisplaced/minimally displaced/completely displaced) and pattern transverse/oblique/ spiral / comminuted, etc.). The fracture can be intra-articular or extra-articular depending upon the involvement of the adjacent joint.
Classification of fractures The most comprehensive and universally accepted system for classi ﬁ cation of long bone fractures is that proposed by the Association for the Study of Internal Fixation (ASIF), commonly referred to as AO (‘Arbeitsgemeinschaft f ¨ur Osteosynthesefragen’). Although it is important to understand the basic principles of this classi ﬁ cation system, minute details are not necessary.
Classification of fractures In the AO classi ﬁ cation, a number is assigned to each long bone (humerus = 1, radius or ulna = 2, femur = 3, tibia or ﬁ bula = 4) and each bone is subdivided into segments (proximal =1, middle =2 and distal =3, ankle = 4). Letters A, B and C are used to denote the level and pattern of fracture. For example, a completely displaced intracapsular fracture of the femoral neck may be denoted with an alphanumeric value of 31B3.3, where (in order)
Classification of fractures Bone Segment Type Group Subgroup 1234 123 ABC 184.108.40.206
X-RAY Con ﬁ rmation of the diagnosis is done with two radiographic views (anteroposterior and lateral) of the injured site and each ﬁ lm should include the joint above and below the fracture. Additional views may be necessary for some injuries. e.g. scaphoid fractures. A good quality radiograph should be able to clearly demonstrate the fracture details and status of the adjacent joint.
Advanced imaging is occasionally indicated. For example, CT Scanning of an unstable thoracolumbar spine fracture may provide further details about the injury.