Section 1 General Orthopaedics© ONAHAHNHH ea Nis Orthopaedic diagnosis Infection Rheumatic disorders Crystal deposition disorders Osteoarthritis Osteonecrosis and related disorders Metabolic and endocrine disorders Genetic disorders, skeletal dysplasias and malformations Tumours Neuromuscular disorders Peripheral nerve injuries Orthopaedic operations 133 167 201 229 2551 Information consists of differences that make a difference. Gregory Bateson Orthopaedics is concerned with bones, joints, muscles, tendons and nerves ~ the skeletal system and all that makes it move. Conditions that affect these structures fall into seven easily remembered pairs: |. Congenital and developmental abnormalities Infection and inflammation Arthritis and rheumatic disorders Metabolic and endocrine disorders ‘Tumours and lesions that mimic them . Sensory disturbance and muscle weakness Injury and mechanical derangement Diagnosis in orthopaedics, as in all of medicine, is the identification of disease. It begins from the very first ‘encounter with the patient and is gradually modified and fine-tuned until we have a picture, not only of a patho- logical process but also of the functional loss and the disability that goes with it. Understanding evolves from the systematic gathering of information from the history, the physical examination, tissue and organ imaging and special investigations. Systematic, but never mechani- cal; behind the enquiring head there should also be what D. H, Lawrence has called the intelligent heart, It must never be forgotten that the patient is also a person, with a mind and a personality, a job and hobbies, a family and a home; all have a bearing upon ~ and are in turn affected by ~ the disorder and its treatment. HISTORY Taking a history’ is a misnomer. The patient tells a story; it is we the listeners who construct a history. The story may be maddeningly disorganized; the history has to be systematic. Carefully and patiently compiled, it can be every bit as informative as examination or laboratory tesis. ‘As we record it, certain key words will inevitably stand out: injury, pain, stiffness, swelling, deformity, instabil- ity, weakness, altered sensibility and loss of finetion. Each symptom is pursued for more detail: we need to know when it began, whether suddenly or gradually, sponta- neously or after some specific event; how it has changed or progressed; what makes i worse; what makes it better. Orthopaedic diagnosi While listening, we consider if the story fits some pattern that we recognize ~ for we are already think- ing of a diagnosis. Every piece of information should be thought of as part of a larger picture which gradu- ally unfolds in our understanding, ‘Disease reveals itself in casual parentheses’, is the way Trotter described it. ‘SymProMs. Pain Pain is the most common symptom in orthopaedics. Itis described in terms that range from the most boring and bland to the impossibly dramatic and bizarre. The metaphors used tell us more about the patient's psyche than about the pathology; yet there are clearly differences, between the throbbing pain of an abscess and the aching, pain of chronic arthritis, between the ‘buming pain’ of neuralgia and the ‘stabbing pain’ of a ruptured tendon. Severity is even more subjective. High and low thresh- olds undoubtedly exist, but to the patient pain is as bad as it feels, and any system of pain grading’ must take this into account. The main value of estimating severity is in assessing the progress of the disorder or the response to treatment. The following is a simple and useful system: * Grade I (mild) Pain that can easily be ignored * Grade I (moderate) Pain that cannot be ignored, interferes with function and needs treatment from time to time. © Grade IM (severe) Pain that is present most of the time, demanding constant attention. * Grade IV (excruciating) Totally incapacitating pain. Patients are often vague about the site of pain. Yet its precise location is important, and in orthopaedics it is particularly useful to ask the patient to point to where it hurts; not merely to tell us, but actually to point. But don't assume that the site of pain is always the site of pathology; ‘referred’ pain and ‘autonomic’ pain can be very deceptive. Referred pon Pain arising in or near the skin is usually localized accurately. Pain arising in deep structures is ‘more diffuse and is sometimes of unexpected distribu- tion; thus, hip disease may manifest with pain in the ‘knee (50 might an obturator hernia). This is not because sensory nerves connect the two sites; it is due to inabil- ity ofthe cerebral cortex to distinguish between sensory