Clinical and x-ray features frcatures Slide 2 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 Slide 3 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. Slide 4 Deformities ; named as round
shoulders, spinal curvature, knock knees, bow legs and at feet;
normal veriations(e.g. Short stature or wide hips); others
disappear spontaneously with growth (e.g. at feet or bandy legs in
an infant); progressive, like scoliosis in young childrens or if it
affects only one side of the body Slide 5 Weakness in all chronic
illness; prolonged joint dysfunction; pure muscular weakness;
Instability joint gives way; joint laxity, capsular or ligamentous
de ciency, internal derangement torn meniscus or a loose body in
the joint Slide 6 EXAMINATION general appearance, posture and gait;
knock-knees; spinal curvature; short limb; paralysed limb; patient
in pain Slide 7 gait swing phase and stance (heal strike, midfoot
and push off) painful hip, unstable knee or a foot-drop Slide 8
suitably undressed; no mere rolling up of a trouser leg; both must
be exposed for comparison traditional clinical Slide 9 inspection,
palpation, purcussionand auscultation replaced by look, feel, move
Slide 10 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 Slide 11 Look Scars an old operation
Sinuses Slide 12 Feel Know your anatomy and 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 uid Tenderness Slide 13 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 exion 0140; feel for crepitus Slide 14 Unstable;
unphysiological; joint is unstable Provocative impingement of the
subacromial structures; apprehension test Slide 15 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 Slide 16
Mechanism of injury Although most fractures occur due to direct or
indirect trauma, other mechanisms may be responsible in some
special situations. Slide 17 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
cant soft tissue injuries. A typical example is a comminuted tibial
midshaft fracture sustained bya pedestrian due to direct impact
from a speeding car. Slide 18 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. Slide 19 Grading system of soft
tissue injury in closed fractures. A, Grade 0little or no soft
tissue injury. B, Grade 1superficial abrasion with local
contusional damage to skin or muscle. C, Grade 2deep contaminated
abrasion with local contusional damage to skin and muscle. D, Grade
3extensive contusion or crushing of skin or destruction of muscle
Slide 20 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. Slide 21 Classification of fractures The most comprehensive
and universally accepted system for classi 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 cation
system, minute details are not necessary. Slide 22 Classification
of fractures In the AO classi cation, a number is assigned to each
long bone (humerus = 1, radius or ulna = 2, femur = 3, tibia or
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) Slide 23
Classification of fractures Bone Segment Type Group Subgroup 1234
123 ABC 123.1.2.3 Slide 24 X-RAY Con rmation of the diagnosis is
done with two radiographic views (anteroposterior and lateral) of
the injured site and each 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. Slide 25 Advanced imaging is occasionally
indicated. For example, CT Scanning of an unstable thoracolumbar
spine fracture may provide further details about the injury.
