Orthopaedic / orthopedic

A branch of surgery

which is concerned with the

preservation & restoration

of the function of the skeletal system.

Orthopaedics is concerned with bones joints muscles tendons & nerves .

Diagnosis

Diagnosis in orthopaedics as in all of medicine,

Is the identification of disease.

G.Bateson said “ Information consists of

differences that make a difference.”

Diagnosis

History ?

Examination ?

( LOOK FEEL & MOVE )

Investigation ?

Key for diagnonsis? 7 pairs 1. Congenital & Developmental 2. Infection & Inflammation 3. Arthritis & Rheumatic disorders 4. Metabolic dysfunction & Degeneration5. Tumours & Lesions 6. Neurological & Muscular7. Injury & mechanical derangement

This patient following road traffic accident had pain in neck and consulted her three times.On each occasion she was told the x-rays are normal . When strenuous effort was made to show the entire cervical spine a dislocationOf C6 and C7 could be seen at the very bottom of the film.

The anterior, posterior and spino laminar lines are use ful for identifying anterior translation on lateral radiograph of the neck. a- anterior b-posterior c- spino laminar.

Normal range of movements. In full flexion the chin normally touches the chest. In full extension the imaginary line joining the chin to the posterior occipital protuberance( the occipito mental line) forms an angle of at least 45 degree with horizontal line , and usually 60 degree in young people. Lateral flexion and rotation are equal in both directions.

A- Flexion

B-Extension

C-Rotation

D-Sideways tilt

F- Testing power in the shoulder elbow wrist, and fingers

Examination In this patient with signs of a prolapsed disc, flexion and tilting to the left are limited.

The examination may be broken down into six distinct steps:

1. Inspection 2. Palpation 3. Examination of movements 4. Conduction of special tests 5 Examination of radiographs 6. Arranging further investigations. It is not always necessary to keep strictly to this order or indeed to carry out all of these procedures.

INSPECTION Look carefully at the joint, paying particular attention to the following points: 1. Is there swelling? If so, is the swelling diffuse or localised? If it is confined to the joint it may be due to excess synovial fluid (effusion), blood within the joint cavity (haemarthrosis), or pus (pyarthrosis). Swelling extending beyond the confines of the joint may occur in major infections in a limb, tumours and problems of lymphatic and venous drainage. 2. Is there bruising? Is this due to trauma; or an abnormality of the vessels or the clotting mechanisms? 3. Is there any other discoloration, or oedema? 4. Is there muscle wasting? If so, is this due to inactiviw- from pain or incapacity, or from denervation? 5. Is there any alteration in shape or posture, or is there evidence of shortening? This will require careful examination to establish the cause.

2: PALPATION Sonic' of the points to note include the following:1. Is the joint warm? If so, note whether the temperature increase is diffuse or localised, always bearing in mind the false impression which may be caused' by the effects of local bandaging_ A diffuse increase in heat occurs when a substantial tissue mass is involved, and is seen most commonly in pvogenic and non-pyogenic inflammatory processes, vascular abnormalities and tumours. A localised increase in temperature generally pin-points an inflammatory process to an isolated structure.. 2. Is there tenderness? The causes of diffuse and localised tenderness are similar to the causes of increased joint temperature.

MOVEMENTS Estimation of the range of movements in the joint is an essential part of any orthopaedic examination. To assess any deviation from normal, the good side may be compared with the bad. Where this is not suitable (e.g. when both sides are involved), ranges.

Muscle power is usually graded on the Medical Research Council scale: Grade 0 — no movement Grade 1 — only a flicker of movement Grade 2 — movement with gravity eliminatedGrade 3 — movement against gravityGrade 4 — movement against resistanceGrade 5 — normal power It is important to recognize that muscle weakness may be due to muscle disease rather than nerve disease. In muscle disorders the weakness is usually symmetrical and sensation is normal.

4: CONDUCTION OF SPECIAL TESTS In the case of sensory testing, the MRC gradings may be used: SO— Absence of all modalities of sensation in the area exclusively supplied by the affected nerve.

S1— Recovery of deep pain sensation.

S2— Recovery of protective sensation (skin touch, pain and thermal sensation).

S3— Recovery of ability to recognise objects and texture; any residual cold sensitivity and hypersensitivity should now be minimal. In the case of the hand, recovery of two point discrimination to less than 8 mm.

S4— Normal sensation.

INVESTIGATIONSX-RAYS / RADIOGRAPHSDiagnostic ultrasound

Blood tests Routine blood testSpecific blood tests . Rheumatoid factor tests Rheumatoid factor (RA Factor) is an autoantibody (or antiglobulin) which is often present in patients with rheumatoid arthritis (RA). Tissue typing HLA antigens can be detected in white blood cells HLA-B27 this is frequently used as a confirmatory test in patients suspected of having ankylosing spondylitis Biochemistry Biochemical tests are essential in monitoring patients after any serious injury

5: EXAMINATION OF RADIOGRAPHS Check the following: 1. Are the bones of normal shape, size and contour, or are they thicker or thinner than normal, shorter or longer than usual or abnormally curved or angled? 2. At the joints themselves, are the bony components in correct alignment, or are they displaced or angled? 3. Is the bone texture normal? 4. Are there are any areas of new bone formation, such as exostoses or subperiosteal new bone formation, or is their evidence of bone destruction? 5. Is there any evidence of congenital abnormality, infection or inflammation, rheumatoid or osteoarthritis?

Specific tests . ArthrocentesisSynovial fluid analysis ArthroscopyBone ScanBone marrow aspiration and Bone biopsy

Arthroscopy. Methods for the examination of all the major joints have been developed, and allow direct visualisation of the articular surfaces, the joint capsule, many associated ligaments, and in the case of the knee, the menisci. At the same session, biopsy samples may be taken if required, and sometimes treatment procedures may be carried out.

FUNCTIONAL IMAGING TECHNIQUES Technetium bone scans. Bone scans may be performed after the injection of technetium tagged methylene diphosphonate (99Tcrn-methylene diphosphonate [MDP]). The facility is widely available, inexpensive and gives rapid results. In the trauma field, such scans may assist in the diagnosis of hairline fractures (e.g. of the scaphoid, shin or neck of femur). They may assist in gauging the age of a fracture, and in detecting avascular necrosis of bone. They are of value in the investigation of unexplained pain in the long bones and the spine, infections in bone and in the region of prostheses, and in assessing Sudeck's atrophy (complex regional pain syndrome).

Arthocentesis. Procedure where fluid is removed from a joint space or medication may be administered into the joint cavity for diagnostic or therapeutic purposes.

INDICATIONS: •To evaluate synovial fluid and determine whether the cause of effusion is from •Infectious (for culture sensitivity) , •rheumatic, •traumatic, •or crystal-induced etiology •To remove exudative fluid from a septic joint•To relieve pain in a grossly swollen joint (e.g., traumatic effusion)

CONTRAINDICATIONS:•Cellulitis or broken skin over the intended entry site for the injection or aspiration

•Anticogulant therapy that is not well controlled

•Septic effusion of a bursa or a periarticular structure

•Suspected bacteremia

•Joint prostheses (If infection is suspected, consider a referral to the orthopedist who placed the prosthesis, if at all possible)

Bone marrow aspiration and biopsy are now well-accepted procedures for evaluation both the cellularity of the marrow and the nature of the cells present. Although sternum is the traditional site for bone marrow aspiration preferred site is the posterior Iliac crest (the hip bone) because of ease and safety and the fact that the posterior Iliac crest is usually quite cellular.

Thank You

ALLAH HAFIZ,FEE AMAN ALLAH