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SECTION 1

GENERAL ORTHOPAEDICS

ORTHOPAEDIC DIAGNOSIS

previous medication • FAMILY HISTORY dx in family help w diagnosis & counseling. Deformity Weakness Instability The patient may complain that the joint ‘gives way’ or ‘jumps out of place’. ‘What has the patient lost and what is he or she hoping to regain?’ . or they may simply not appreciate their relevance to the present complaint. work.HISTORY •Symptoms  Pain  The main value of estimating severity is in assessing the progress of the disorder or the response to treatment  Grade I (mild) Pain that can easily be ignored. demanding constant attention or treatment. interferes with function and needs attention or treatment from time to time  Grade III (severe) Pain that is present most of the time.  Grade IV (excruciating) Totally incapacitating pain. communicable disease • SOCIAL BACKGROUND habit (food. limitation of movement should never be assumed until verified by examination. drink. If this happens repeatedly Change in sensibility Loss of function ‘What can’t you do now that you used to be able to do?’  Stiffness  Patients often have difficulty in distinguishing localized stiffness from • PAST HITORY painful movement.  Grade II (moderate) Pain that cannot be ignored. smoke).  Swelling  It followed an injury  Appeared rapidly (haematoma/haemarthrosis)  Slowly (inflammation/joint effusion/infection/tumor)  Painful  Constant/comes and goes  Increasing in size? Patients often forget to mention previous illnesses or accidents.

bone & joints. soft tissue. provocative movement .Examination begin from the moment we set eyes on patient • Look  Shape & Posture  Skin colour. marking  General survey • Feel skin. tenderness • Move  Active movement  Passive mobility  Abnormal/unstable movement  Provocative movement reproducing the patient’s symptoms by applying a specific. quality.

Neurological exam weakness or incoordination or a change in sensibility. a complete neurological examination of the related part is mandatory •Appearance the claw hand of an ulnar nerve lesion. or the ‘waiter’s tip’ deformity of the arm in brachial plexus injury •Muscle tone spasticity/flaccidity •Power •Tendon reflex •Superficial reflex abdominal (T7–T12). drop wrist following radial nerve palsy. cremasteric (L1. 2) and anal (S4. 5) •Plantar reflex •Sensibility •Cortical & cerebellar function . or if they point to any disorder of the neck or back.

Physical variatons & deformity •Joint Laxity Generalized hypermobility is not usually associated with any obvious disease •Deformity  Varus and valgus Varus means that the part distal to the joint in question is displaced towards the median plane.  Kyphosis and lordosis excessive curvature  Scoliosis  Postural deformity correct voluntarily  Structural deformity cant be voluntarily corrected  ‘Fixed deformity’ . valgus away from it.

Causes such as osteomalacia. . ask about previous injuries. bone tumours and Paget’s disease should always be considered. Other causes include rickets.Cause of joint deformity •Contracture of the overlying skin severe scarring flexor aspect •Contracture of subcutaneous fascia •Muscle contracture fibrosis&contracture that cross jointfixed deformity •Muscle imbalance unbalance muscle weakness/spasticityjoint deformity (polio/CP) •Joint instability •Joint destruction Cause of bone deformity •Acquired deformities in children  fractures involving the physis (growth plate). malunited diaphyseal fractures and tumours •Acquired deformities of bone in adults  previous malunited fractures. endocrine disorders.

injury.inflam.tumor •Size large att to bone/getting bigger •Site near joint/in the shaft •Margin well-defined/vague •Consistency bony hard/can be indented •Tenderness •Multiplicity uncommon Joint stiffness •All movement absent •All movement limited •One or two movement limited .Bony lumps faulty dev.

Diagnostic imaging •Plain film radiography •Xray using contrast media • Sinography • Arthrography • Myelography •Plain tomography •Computed tomography (CT) •MRI •Diagnostic Ultrasound •Radionuclide imaging •Single photon emission tomography •Positron emission tomography •Bone mineral densitometry .

• Blood test • Non specific blood test • Rheumatoid factor tests • Tissue typing • Synovial fluid analysis • Bone biopsy • Diagnostic arthroscopy .

INFECTION .

•to restore continuity if there is a gap in the bone. •to eradicate avascular and necrotic tissue. •to identify the infecting organism and administer effective antibiotic treatment or chemotherapy.The principles of treatment are •to provide analgesia and general supportive measures. •to release pus as soon as it is detected •to stabilize the bone if it has fractured. •to rest the affected part. . and •to maintain soft-tissue and skin cover.

ACUTE HAEMATOGENOUS OSTEOMYELITIS Aetiology & Pathogenesis •Casual organism both adult & children  Staphylococcus aureus •Blood stream invasion (skin abrasion. most often in the proximal tibia or in the distal or proximal ends of the femur the peculiar arrangement of the blood vessels in that area  stasis. ureth. lower oxygen tension . inf umb cord. cath. arterial line) •In children  starts in the vascular metaphysis of a long bone.

recent history of infection Infant •<1 year. suppuration. reactive new bone formation  resolution&healing/intractable chronicity Clinical feature Children •>4 years. malaise & fever. severe pain. birth difficulty?. drowsy but irritable. umbilical art cath Adult •Common site thoracolumbar spine. fail to thrive. history of uro procedure followed mild fever&back ache . bone necrosis. he/she refused to use limb/to be handheld/touch.Pathology •Caharacteristic progression inflammation.

haemtom/pus) •Radionuclide scanning • Radioscintigraphy with Tc-HDP reveals increased activity in both the perfusion phase and the bone phase 99m •MRI .Diagnostic imaging •Plain xray • First weekno abnormality. 2nd weekfaint extracortical outline due to periosteal new bone formationperiosteal thickening more obvious + patchy rarefaction metaphysisragged feature of bone destruction appear •USG • Subperiosteal collection of fluid (cant dist.

assist with the initial choice of antibiotic •Sensitivity test •CRP  elevated within12-24 hours.Laboratory investigation Aspirate pus/fluid from the metaphyseal subperiosteal abcess. adjacent joint •Simple gram stainidentify type of infection. extraosseus soft tissue. ESR  24-48 hours after onset symptom •WBC rise .

treat w suit antibiotic in salmonella endemic • Gaucher’s disease .DIFFERENTIAL DIAGNOSIS • Cellulitis widespread redness. lymphangitis • Acute suppurative arthritis tenderness is diffuse. movement at joint abolished bcs muscle spasm • Streptococcal necrotizing myositis • Acute rheumatism • Sickle-cell crisis indistinguishable.

gentamicin • Children 6 mo-6y flucoxacillin+cefotaxime/cefuroxime • Older children&fit adult flucoxacillin&fucidic acid • Elderly&unfit patient flucoxaxcillin+2nd/3rd gen cephalosporin • Patient w sickle cell disease 3rd gen cephalosporin/ciprofloxacin • Heroin addict & immunocompromised 3rd gen cephalosporin/depend on result test • Patient risk for MRSA infection vancomycin+3rd gen cephalosporin .TREATMENT • Supportive treatment for pain & dehydration • Splintage of the affected part • App. Antimicrobial therapy • Neonate&infant up to 6 mo. Flucoxaxillin+cefotaxime/combination flucoxaxillin. benzylpenisillin.

• Surgical drainage • If antibiotic given in first 48 h usually no need drainage. • Clinical features does not improve within 36 hours starting treatment/earlier Complication •Epiphyseal damage & altered bone growth •Suppurative arthritis •Metastatic infection •Pathological fracture •Chronic osteomyelitis .

pain near larger joint for several weeks/months •May have limp •Slight swelling.SUBACUTE HAEMATOGENOUS OSTEOMYELITIS Pathology •In well-defined cavity in cancellous bone containing glairy seropurulent fluid (rarely pus)lined by acute&chronic inflamm cellsurrounding trabeculae thickenederode bony cortex Clinical features •Child/adolescent. local tenderness •Normal temperature .

round/oval radioluscent ‘cavity’ 1-2 cm diameter •‘cavity’ is surrounded by halo of sclerosis (Brodie’s abcess) .Imaging •Circumscribed.

Diagnosis •The diagnosis remains in doubt until a biopsy is performed •If fluid is encountered. it should be sent for bacteriological culture •The organism is always Staphylococcus aureus Treatment •Immobilization •Antibiotics flucoxacillin+fusidic acid (iv) 4-5 days  Oral for another 6w .

POST-TRAUMATIC OSTEOMYELITIS Clinical feature •Fever •Pain & swelling at fracture site •Wound inflamed •Seropurulent discharge •Blood test: inc. ESR . leukocytosis & elev. CRP.

Treatment •Essenceprophylaxis • Thorough cleansing & debridement of open fracture • The provision of drainageleaving wound open • Immobilization of fracture • Antibiotics flucoxacillin + benzylpencillin/sodium fusidate 6-hours for 48 hours. if contaminated + metronidazole for 4-5 days • Regular wound dressing & repeated excision of all dead & infected tissue .

CHRONIC OSTEOMYELITIS .