Ortho CP - FINAL (2nd Batch) PDF

Orthopedics- CP
Extra Articular Limb Pain
Limb Pain
Articular/Periarticular Non-Articular
Limb pain is one of the commonest causes of a visit by a patient to an orthopedic clinic or a GP clinic. Limb
pain can be articular, peri-articular or extra-articular (non-articular), former two being in and around the
joint respectively. The latter refers to the region between the two adjacent joints, both in the upper and
the lower limbs. The nature and the type of pain in the upper limb and the lower limb may vary slightly
because of the special functions each are subjected to (carrying objects by upper limb; weight bearing by
lower limb), but the causes can be grossly categorized and summarized into a few common ones. At times
the cause of a limb pain is benign, but it can be disabling or even life-threatening.
The articular/peri-articular pain and the causes are discussed in the separate cp: Joint Pain. Here we focus
on the extra-articular limb pain.
Limb Pain
Traumatic Non-Traumatic
Acute Repetitive
Overuse
Fractures
(Bursitis, Tendinitis,
(Open or closed)
Fascitis, Tenosynovitis)
Soft tissue injuries

(Muscles, tendons, Stress fractures
open injuries)
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Orthopedics- CP
Non-articular limb pain can be traumatic or non-traumatic. Trauma can be acute injury to the limb or a
repetitive trivial injury. Careful history should be taken regarding any acute traumatic events (fall from
height, Road Traffic Accident, sports injuries or physical assault) or type and nature of work leading to the
clue of overuse injury.
Clinical Clues
Ask About
Any history leading to trauma like fall from height, Road Traffic Accident (RTA) or physical assault,
suggesting fractures or injuries to the muscles, tendons or any internal degloving injuries
Initiation and duration of pain
The nature of work suggesting repetitive injury eg. Retrocalcaneal bursitis, Dequervains
tenosynovitis
Excessive walking, sports activities or a trek without prior warm-up exercises
Excessive tra ining activities in sportspersons, army cadets, policemen, security guards etc.
suggesting stress fractures
Relieving or aggravating factors
Site of pain
Nature of pain
Fever, anorexia suggestive of infection, malignancy
Trauma, trivial or major, suggestive of fracture
New or increased sport activity, suggestive of stress fracture, muscle injury, cramps
Any wounds, scratches, IM injections, iv infusions suggesting infection
Any drugs
Look For
Examination of both the limbs fully exposed
Compare with the contralateral limb whenever possible and look for wasting of muscles, mass or
any signs of inflammation, pus discharge
Any restriction of movements of the adjacent joints, active or passive or both
Gait abnormality especially antalgic gait
Investigations
TC, DC, ESR, CRP
X-ray
Diagnoses to consider:
Fracture: open or closed
Muscle strain
Muscle tears
Tendon injuries, ruptures
Open injuries of the extremities
Stress fractures
Pathological fractures
Tenosynovitis eg. De Quervains Disease, Intersection Syndrome, Trigger Digits
Bursitis eg. Retrocalcaneal Bursitis
Fascitis eg. Plantar Fascitis
Comments
Traumatic limb pain is to be discussed in a separate cp: Musculoskeletal Injuries and hence will not
be discussed in detail here
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Limb Pain
Traumatic Non-Traumatic
Infective Vascular Neurological Tumor
AOM Thrombophlebitis PIVD Bony
Arterial Spinal/Root Canal

COM Soft tissue
Insufficiency Stenosis
Soft Tissue
Infection
Spinal Cord
Eg. necrotising Varicose veins
Lesion
fasciitis, cellulitis,
abscess
Neurovascular
DVT
entrapment
Clinical Clues
Ask About
Site of pain
Nature of pain, relieving or aggravating factors suggesting arterial or neurological causes; eg.
Throbbing in abscess and acute osteomyelitis, ischemic in Arterial insufficiency, radiating and
shooting in PIVD or nerve entrapment etc.
History or fever, anorexia suggestive of infection, malignancy
History of infective lesion in the past, history of chronic discharge, history of pus drainage from
the limbs
Any wounds, scratches, IM injections, iv infusions suggesting infection
Prolonged iv infusions especially antibiotics suggesting thrombophlebitis
Any surgery or prolonged immobilization suggesting Deep Vein Thrombosis
Any drugs eg. Prolonged use of steroid or quinolones leading to spontaneous rupture of tendons
Any sensory abnormality eg. Tingling sensation or numbness of the distal portion of the limb
suggesting nerve entrapment
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Orthopedics- CP
Look For
Scar suggestive of previous surgery or trauma
Compare with the contralateral limb whenever possible and look for wasting of muscles, mass or
any signs of inflammation, pus discharge, change in skin colour or texture
Any mass and its characteristics suggestive of tumour
Any restriction of movements of the adjacent joints, active or passive or both
Gait abnormality especially antalgic gait
Large dilated veins especially tortuous in looks
Investigations
TC, DC, ESR, CRP
X-ray
Diagnoses to consider:
Fracture: open or closed
Muscle strain
Muscle tears
Tendon injuries, ruptures
Open injuries of the extremities
Stress fractures
Pathological fractures
Tenosynovitis eg. De Quervains Disease, Intersection Syndrome, Trigger Digits
Bursitis eg. Retrocalcaneal Bursitis
Fascitis eg. Plantar Fascitis
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Orthopedics- CP
Musculoskeletal Injury
Musculo-skeletal Injury
High Energy Low Energy
Fracture Dislocation Soft tissue Fracture Dislocation Soft tissue
Contusion,
New Dislocation Pathological Sprain Strain
laceration
Stress /
Old Subluxation Strain Contusion
fatigue
Fracture/
Union in good Sprain Insufficiency
dislocation
alignment
Malunion
Non-union
Delayed union
Musculoskeletal trauma is a process whereby energy imparted to the extremities (upper and lower, arms
and legs) and spine causes damage or injury to the affected tissues. Every injury has a specific personality
defined by the energy which has caused it and by the victim or host (age, health etc.) and his/her
reaction(s) (tissue damage). The extent of injury depends largely upon the dissipation of energy causing
the injury (the mechanism of injury) and the subsequent tissue damage(musculoskeletal and other organ
systems). In other words, in the management of a person who sustained trauma, the following three
separate components have to be taken into consideration all the time:
1. Energy
2. Host
3. Tissue damage
Kinetic energy = mass x velocity. Bigger objects moving with higher speed (car, bullet, are high energy)
will cause more damage than smaller and slower objects (lower energy) that have an impact with live
tissue. In this clinical presentation, the diagnosis of fractures / dislocations / joint injuries will be the
main concern. The complications of fracture and dislocations shall also be discussed, with special attention
to compartment syndrome and open fractures.
Injuries to the head, spine, and the spinal nerves will be considered in the clinical presentation head and
spinal injury. Polytrauma and Multiple trauma will be dealt with in the lecture
Shock/Polytrauma/Multiple Trauma.
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Orthopedics- CP
Musculoskeletal
injury
High energy Low energy
Clinical clues
Ask about:
o Mechanism of injury:
High Energy: driver or passenger, with/without seatbelt on; motorcycle rider with/without
helmet; hit as pedestrian, fall from higher than standing height etc.
Low Energy: standing height fall, minimal activity and/or repetitive stress activities marching
or running, overuse injuries etc.
Comments:
Fractures occurring at low energy should raise suspicion of stress/fatigue, insufficiency or pathological
fracture (see later in this CP)
Diagnoses to consider
High energy
Polytrauma. Patients have injuries of two or more organ systems (like cranio-cerebral, cardio-
vascular, respiratory, gastrointestinal, urogenital, musculoskeletal) and they are in serious medical
condition (like hemorrhagic shock, respiratory insufficiency, renal insufficiency) and with
potentially endangered life.
Multiple trauma usually there are two or more severe injuries within one organ system (e.g.
musculoskeletal: broken femur and tibia, humerus and so on).
Isolated severe injuries, fractures and fracture-dislocations (closed or open femoral or tibial
fractures, dislocated hip or knee joint, ankle or wrist fracture dislocation, amputation etc).
Morbidly obese patients with dislocated knee after standing height fall (their weight - mass makes
it high energy with potentially severe consequences like neurovascular injuries, amputations).
Major wounds or burns (depth and area).
Low energy
Bruises, contusions, sprains (stretched or ruptured ligaments of different joints) or strains
(stretched or ruptured tendons or muscles).
Minor wounds or burns.
Undisplaced or minimally displaced fractures (adults with normal bone structure and pediatric
fractures like: distal radius, radial head, forearm, elbow etc).
Stress fractures (foot fractures in soldiers, dancers, sportsperson; femoral neck fractures in
runners).
Dislocations or subluxations.
Overuse injuries (elbow pain in tennis or golf players; shoulder pain in pitchers and gymnasts).
Broken pathologically changed bones (in elderly population: distal radius, hip, proximal humerus,
spine).
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Orthopedics- CP
High energy
musculoskeletal
injury
Fracture Dislocation Soft tissue
Clinical clues
Ask about:
o Pain
o Diminished or limited function, suggestive of fracture and/or dislocation.
o Mechanism of injury:
High Energy
Low Energy
o Time of injury: within 4-6 hours:
o open wounds have to be surgically treated (cleaned, debrided - excised and closed or
covered) in order to prevent infections
o vascular injuries have to be repaired / reconstructed in order to avoid amputations
o tight compartments with increased pressures have to be released in order to avoid
irreversible damages, tissues necrosis and amputations
o dislocated joints have to be reduced (in order to preserve cartilage and avoid avascular
necrosis bone death; diminish pressure on neurovascular bundle)
o Functional capabilities before injury, ability to walk
o Previous injury causing deformity and limitation of motion of any joints
Look for
Primary survey: ABCDE
Vital signs
Swelling, contusions, discoloration
Deformities (swelling, funny unusual extremity positions)
Crepitations by trial of active or passive motion at fracture level (audible or palpable rubbing of
bone pieces against each other, always painful).
Presence of skin breakage wound and bleeding (arterial pulsatile bright red blood, or venous:
dark bluish, oozing blood) and whether are in vicinity of joint or broken bone; wounds in
communication with bone fragments (draining hematoma, open fractures i.e. open joint or bone
injury - high risk of infection, which is an orthopedic emergency)
Visible bone fragments, ruptured tendons and muscles, foreign material grass, pieces of clothing
etc in the wound.
Presence of arterial pulse and capillary refill distal to the injury; color and temperature of the skin
(diminished or absent in main vessel arterial injuries).
Ability to move and feel extremity distal to the injury level (spontaneously if comatose; on request
if cooperative) assessment of nerve or muscle injury.
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Orthopedics- CP
Tightness on palpation of compartments at/or distal to the level of injury; presence of pain out of
proportion (if cooperative) and increased by passive stretch of muscles going through
compartment in question (plantar flexion of toes for antero-lateral leg compartment).
Extent of disability
Mental status: patient could be fully cooperative or obtunded to comatose (no contact or
response possible).
If non-cooperative (intoxicated, agitated, somnolent, and comatose), identify others who could
provide information about the injury.
If patient is able to cooperate, determine movement and sensation in the upper and lower
extremities (neurological exam to determine whether spinal cord and main peripheral nerves are
intact). Also, look for spontaneous motion (or absence) of digits and toes, extremities distal to the
injury level (nerve damage, muscles damage) in non-cooperative patients.
Visually inspect and palpate all parts of the body from head to toe in order to establish the extent
of injuries (secondary survey).
Investigations
Definitive sign of fracture is provided by diagnostic imaging. Align, immobilize extremity and obtain
o X-ray in two planes of injured area and neighboring joints (AP and lateral)
o CT for complex joint injuries and most spine injuries(not routinely done)
o MRI for better evaluation of soft tissue injuries, joint injuries, spinal injuries and occult fractures
Lab tests hemoglobin, blood grouping for patients in shock; electrolytes, blood sugar level for
unconscious/comatose patients especially with unclear history etc.
Comments
o About 75% of patients who sustain trauma have injured extremities.
o The bones give mechanical strength and support to the extremities. The bones are connected via
joints (bone ends encapsulated in joint capsule and ligaments) that allow controlled motion.
Muscles are attached to the bones via tendons and some cross joints in different directions allowing
for motion through contraction or shortening of the muscle bellies. Muscle contractions are
controlled by nerves as is sensation of every part of the extremities. All tissues are nourished by
vessels (arterial, venous and lymphatic), and all of them work in harmony in order to have a normal,
functional extremity. Trauma could damage one or all these tissues and it is necessary to evaluate
each one separately.
o Any patient with trauma should first undergo primary survey with a strict trauma protocol, (ABCDE),
even before a complete history is obtained (a brief history either by the patient, bystanders or the
patients relatives who were present at the scene of the incident should commence the initiation of
resuscitation) so as to stabilize the patient first.
o In the Non-cooperative patient (child, intubated, comatose, intoxicated) get report from
paramedics, witnesses, family.
o Patients with high energy trauma could have multiple injuries (brain, chest, intra-abdominal,
extremities), and such severely injured patients are at risk for permanent disability or even death
(polytrauma). In order to get optimal care and maximize the possibility of improvement and
recovery, they require an organized, trained team approach.
o It is important to evaluate whether the patient is able to cooperate (level of consciousness) and
move and feel her/his extremities. Moreover, the patient need to be completely exposed (all
clothing is removed) and all parts of the body is visually inspected and palpated to ensure the
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Orthopedics- CP
absence of any other injury and confirm that the injury identified is indeed isolated. If possible,
obtaining and storing digital photos on presentation and during the course of treatment, might be
extremely helpful:
medically (for other members of the team to be able to evaluate covered wounds
and non-aligned, original presentation of the injuries) and
legally (family, patient, jury and lawyers will appreciate more the severity of
injuries and eventual less than perfect outcome if they had chance to see the
original damages).
o Secondary survey (each part of the body is examined, visually and palpated) has to be repeated later
(hours and days; when situation is less urgent and/or patient is able to be more cooperative),
preferably by different members of the team, in order to avoid the risks of missing other injuries.
One severe injury could be distracting and masking other, less severe injuries.
o From a medico-legal point of view, it is important to record the patients neurological status (if
attainable) prior to any diagnostic or therapeutic interventions.
o The age of the injured patient is very important. It is expected that most children who are victims of
injury are healthy. Their body is elastic, light, and mobile. If even light skeletal injury is sustained,
it is indicative of high impact injury. If the cause of injury is low energy mechanism, be aware that
child could have bone abnormalities, fragile bones like in osteogenesis imperfecta or some
underlying bone tumor. When dealing with minors, consent, for medico-legal reasons, must be
obtained from parents. Their musculoskeletal condition could be changing until growth ceases,
meaning that there is need for long term follow-up.
o In the adult population, the use of nicotine could hinder recovery (slow wound/bone healing,
increased risk of pulmonary problems). In addition, drugs and alcohol will significantly influence pain
treatment (need for more narcotics) and cooperation as well as general medical condition (liver and
nerve problems in alcoholics, immune status and possibility of HIV and hepatitis in drug abusers).
o Elderly patients have multiple medical problems, less healing potential and lower activity capacities
and needs than younger patients. They tend to sustain severe, potentially life threatening injuries
after low energy trauma (e.g., hip after fall from standing height) or even without trauma (e.g.,
osteoporosis of the spine or bones invaded by tumors). Their medical/ surgical care is complex.
o The occupation of the patient might also affect treatment (violin or guitar player will need a
different approach to the treatment of a small finger injury than security guard). Patients who are
hurt at work may require special attention and documentation.
o Women in childbearing age require pregnancy testing. The fetus could sustain injury as a result of
the trauma or diagnostic and therapeutic interventions (anesthesia, irradiation, medications etc).
o The mode of injury is very important, not only for determining the high or low energy trauma, but
also for proper documentation. The patients who have sustained road traffic accident, or who have
sustained injury as a result of fall from height might need proper documentation as regards to the
mode of injury for medicolegal purposes.
o Bone scans when looking for isolated (scaphoid, femoral neck fracture; they are strongly positive
after three days) or more often when looking for multiple occult fractures or infection.
o After studying diagnostic imaging results, determine whether there is a non-displaced or minimally
displaced fracture present, even without some or all symptoms and signs discussed above. Fractures
can be outside of the joint (shaft and metaphyseal area), inside of the joint (epiphyseal fractures) or
a combination thereof.
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Orthopedics- CP
Fractures
New Fracture Old Fracture
Union in good
Malunion Non-union Delayed Union
Alignment
Fracture is defined as the break in the continuity of bone caused by trauma which exceeds bone resistance
to mechanical load. Complete fractures divide the affected bone into two or more pieces, while partial
(incomplete) fractures do not extend contiguously through the cortex. An example of an incomplete
fracture is the "greenstick" fracture, in which the convex side of a long bone is disrupted, while the
concave surface remains intact; or femoral neck stress fracture just one side has broken cortex.
If a patient presents soon after injury, then any bone break sustained is an acute fracture; if the bone
break is presented to the physician late (weeks and months), then it is termed a chronic or old fracture.
However, the terms acute and chronic are arbitrary and no absolute time has been agreed upon to
distinguish between a fresh (acute) and an old (chronic) fracture. The knowledge of acute and chronic
fracture is important because of the treatment regimen and the modalities which differ greatly between
the two.
Clinical clues
Ask about:
o Mechanism (Mode) of injury
o Time of injury
o Course of treatment, if any (reduction attempts, immobilization, surgery)
o Function (motion and sensitivity)
Look for:
o Damaged soft tissue protective envelop (complete skin breakage, open wounds). Such breaks
provide openings for contamination of fracture or hematoma which could result in acute or chronic
infection. Such complications can significantly affect bone healing and final outcomes.
o Distal pulses for presence and quality in every injured extremity in order to prevent ischemia and
eventual loss of extremity.
o Tightness of osteo-fascial extremity compartments; to rule out increased intra-compartmental
pressure
o Damaged nerves (ability to move and feel)
o Deformity, pain during motion, tenderness, any movement at fracture sitesuggesting old fractures
o Scars, signs of drainage (infection)
o Function (inability to bear weight, pain at fracture level)
o Signs of muscles atrophy, joint contractures (stiffness)
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Orthopedics- CP
Investigations
o X-rays (AP and lateral), consider special views for hand, foot, shoulder, calcaneum, knee, scaphoid
o Intra-compartmental pressure monitoring
o CT (intra-articular fractures)
o MRI (occult fractures, soft tissues)
o Bone scan
Comments
o Absence of pulse in patient who is not in shock will need further evaluation by ultrasound,
angiography, or exploration
o Acute (Fresh) fractures are the result of relatively recent injury. Pain, swelling, deformity, limited
function is present as well as instability (motion) at level of injury (for unstable, displaced fractures).
o If fracture presents late (weeks or even months), all symptoms will be diminished and there is
possibility that motion is abolished (fracture in healing or healed). In case for needed reduction
(better alignment, rotation and length), it would be impossible to mobilize fragments without
surgery.
o Late presentation might be in form of united, non-union, delayed union or malunion.
United in good alignment normal healing
Malunion - healed in non-anatomical position
Non-united fracture (radiological and clinical diagnosis)
absence of healing in expected time for respectful localization, type of
fracture and age of the patient,
lack of at least three bridging cortices on two orthogonal x-rays views,
pain at non-union (chronic fracture) level at time of attempts of weight
bearing and/or
there is no progress of healing (radiological and clinical) in the last three
months of follow up.
Delayed union - slower than expected progress of healing but there is evidence of
fracture healing,
o All fractures will heal in favorable circumstances (adequate stability, preserved blood supply and
innervations, absence of bone destroying infection, normal hormonal and nutritional status) in
certain, expected time. Usual timing to bone healing is historically known and dependant on the age
of the patient, localization and fracture type:
o Younger patient will have faster healing (weeks) than older (months needed).
o Epiphyseal and metaphyseal fracture (joint and close to the joint) with a lot of cancellous, well
vascularized bone will heal faster than diaphyseal, mostly cortical bone with less abundant blood
supply.
o Simple, long spiral fracture (with two main fragments and broad fracture - contact surfaces) will heal
faster than transverse fracture (small contact area) or complex, multi-fragmentary fracture.
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Orthopedics- CP
Low energy
Fractures
Stress/Fatigue Insufficiency Pathological

Fracture Fracture Fracture
A stress or fatigue fracture occurs when abnormal stress is applied to bone with normal elastic
resistance. An "insufficiency fracture" is produced by normal or physiological stress applied to bone with
deficient elastic resistance e.g. osteoporosis, osteomalacia. Fatigue and insufficiency fractures occur
most frequently in the weight-bearing bones. Pathologic fractures are due to a localized loss of strength
in a bone from a disease process such as tumors (benign or malignant), bone cysts and infections.
Clinical clues
Ask about
o Age elderly (malignant tumors, metastases), younger people (benign bone cysts, osteosarcoma)
o Mechanism (Mode) of injury in minimal trauma and low level energy consider pathological
fracture.
o Recent weight loss
o Pain, variable in quality, sharp or dull, in the absence of preceding trauma or exercise or after trivial
trauma
o Acute pain, if any, resolving after 4 6 weeks, suggestive of stress fracture
o Diminished or limited function, suggestive of fracture.
o On occasion, history of minor trauma such as going over speed bumps.
o History of osteopenia (osteoporosis, osteogenesis imperfecta)
o History of hormonal problems (parathyroid, suprarenal)
o History of malignancy (metastases, multiple myeloma)
o Occupation or type/frequency/extent of exercise s/o stress or fatigue fracture.
o Any abrupt increase in the duration, intensity, or frequency of physical activity without adequate
periods of rest.
o Risk factors for osteoporosis
White race
Alcohol, cola, and/or tobacco use
Less weight-bearing exercise prior to exercise
Lower adult weight (lowest adult weight)
Medications eg. Glucocorticoid use
Use of depo-medroxyprogesterone acetate (DMPA) for contraception (DMPA
increased the risk for stress fracture in white women)
o Dietary history (vitamin D deficiency)
o Past history: general health, past medical history, current medications, occupation, and previous
injuries.
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Orthopedics- CP
Look for
o Deformity of the spine and the limbs suggesting osteoporosis or metastatic lesion
o Patient nutritional status (undernourished?)
o Muscle strains, joint sprains, nerve entrapment syndromes and compartment syndrome that share
some features with stress fractures.
o The most worrisome competing diagnoses are neoplasm and infection. (see clinical presentations
lumps and bumps, surgery)
Investigations
o X-rays (AP and lateral)
o Chest x-rays (metastases?)
o Bone scan (metastases, stress fractures, infections)
o CT (cortical involvement)
o MRI (soft tissue involvement, skipped intramedullary lesions, infection, tumor)
o Labs (ESR, CRP, metabolic panel)
Comments
o Stress fractures are due to loads that stress (either compress or stretch) a bone, but which would
not individually be expected to cause it to break. Stress fractures may be the result of a small
number of repetitions with a relatively large load (e.g., a military recruit marching for several miles
with a heavy backpack), a large number of repetitions with a usual load (e.g., an athlete training for
a long distance race), or some intermediate combination of increased load and number of
repetitions. If a fracture is caused by repetitive minor stress, like femoral neck fractures in runners
or metatarsal fracture in marching solders, then the injury is termed a stress fracture. Underlying
cause might be unrecognized bone metabolism deficiency (nutritional, hormonal etc.).
o If minimal trauma such as falling at the same level (standing height) or activity of daily living (like
lifting or pushing) causes bone discontinuity, consider both the level of energy as well as whether
pathological changes may be producing excessively fragile bones (osteopenia, bone tumors,
infection).
o Insidious onset of localized pain that is initially activity related and increases in severity with
increased activity is highly suggestive of stress fracture. Eventually the pain is present during less
strenuous activity and ultimately during rest. Occasionally, the patient experiences an abrupt
increase in pain at the site of milder chronic symptoms indicating that a repeatedly stressed area of
bone has finally fractured.
o Any repeated tensile or compressive stresses in a person who is not known to have an underlying
disease that would be expected to cause abnormal bone fragility is suggestive of stress fractures.
o Sites of possible fracture in order to assess risk of complications:
Second through fourth metatarsal shafts, posteromedial tibial shaft, proximal
humerus or humeral shaft, ribs, sacrum, and pubic rami are considered low risk.
Stress fractures of the superior side of the femoral neck (i.e., tension side),
patella, anterior cortex of the tibia (i.e., tension side), medial malleolus, talus,
navicular, fifth metatarsal base, great toe sesamoids, and the base of the second
metatarsal bone are considered to be at high risk for complications.
o mong runners, the Shin Splint Syndrome (Medial Tibial Stress Syndrome) is most common.
o There should be high suspicion of pathological fracture if trauma is minimal, pain is mild, fracture
edges on x-rays are not sharp and surrounding bone does not appear normal (like the rest of
neighboring bone tissue).
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Orthopedics- CP
o Stress Fractures
o Insufficiency fractures
o Pathological fractures
Tumors
Benign
Malignant
o Primary
o Secondary
Osteomyelitis
Pyogenic
Tubercular
Dislocation
High or low energy
Fracture-
Dislocation Subluxation
Dislocation
Dislocation is defined as the total loss of contact between the two joint surfaces. Partial loss of contact
between the two surfaces is termed Subluxation. When there is associated fracture in conjunction with
the loss of joint surfaces, the term is then called Fracture-Dislocation.
As in the case of fracture, the terms acute and chronic are arbitrary. When the dislocation presents within
hours of injury, it is called acute or fresh. In most cases acute dislocations are indication for immediate
relocation to relieve pain as well as to prevent avascular necrosis of the joint. The chronic or old
dislocations can be further classified into missed, neglected, habitual or recurrent.
Habitual - can be precipitated by certain movements around the joint. Doesnt involve trauma
and can be relocated by the patient themselves, e.g. patella or shoulder dislocation
Recurrent involves trauma but may be mild.
It is important to recognize and treat the dislocations immediately since the treatment of the old
dislocations could be far more complicated and the results unsatisfactory because of various factors
affecting the joint mobility.
Clinical clues
Ask about
Mechanism of injury
Timing of injury, pain and swelling
Ability to bear weight after injury
About similar problems in the past
Look for
Appearance of joint
Presence of wounds, draining hematoma or synovial - joint fluid
Ability to move and feel extremity at level of injury and distal to it
Color and temperature of the skin distal to the injury
Active and passive movement of the joint
Pulse, sensation and active motion distal to the joint
Presence of fluid into the joint
Deformity and loss of function of the joint, if any
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Orthopedics- CP
Investigations
X-rays, AP and lateral + special views
CT - in uncertain diagnosis just with x-rays or when intra-articular fractures present
Aspiration of joint fluid and instillation of local anesthetic
Joint stability testing (if pain control obtained)
Comments
There are special X-Ray views for certain joints e.g. Shoulder (axillary view), knee (skyline view for
patella), scaphoid view.
Joint injury can present acutely soon after trauma (immediately, hours or days), as an old injury
(after weeks), or as result of chronic repetitive injuries (months or years).
Bone ends of two neighboring bones are covered by cartilage, held together by their symmetrical
shape, secured by capsule, ligaments, and muscle tone, and innervated by local nerves. If trauma
exceeds joint resistance, it could result in:
o Sprain (stretching or tearing of ligaments and capsule), with some pain, swelling and
difficulties to bear weight. On stress x-rays (weight bearing or under specific load), joint
surfaces are still aligned well, parallel. On clinical exam joint appears to be stable although
testing the stability could be painful in acute setting (pain control necessary).
o Subluxation on x-ray exam (weight bearing or stress view) joint surfaces are apart (still in
some contact, but not parallel any more). On clinical stress exam joint is opening more
than opposite, uninjured joint. Underlying problem is partial or full tear of some or all
supporting structures (ligaments and capsule) or their chronic elongation (old or repetitive
injuries and healing).
o Dislocation - when there is complete separation of adjacent joint surfaces as result of
major disruptions, avulsions and tears of supporting structures. There could be additional
neuro-vascular injury as well.
o Fracture dislocation, besides joint asymmetry has additional intra-articular bony
fragments.
For joints to function properly (stable, without pain and with full range of motion, long lasting), it
is necessary to reestablish stability, alignment , congruity and motion:
o Non-operatively (by immobilization using static or dynamic splints, muscles strengthening,
anti-inflammatory and pain medications) or
o Surgically (repair and reconstructions).
o In cases of fracture-dislocation, all bone pieces have to be put together and articular
surfaces have to be restored back to anatomical shape as much as possible (to allow early
smooth range of motion and avoid cartilage damage). Also, the rest of the fractured
extremity needs to have good alignment in order to distribute weight evenly on the
articular surface and prevent posttraumatic arthritis.
Where there is a history of recurrent dislocation or dislocation after minimal trauma this suggests
a problem with either the anatomy of the joint surface or weakness of the capsule or supporting
ligaments. Consider hypermobility syndrome (quite common) or Ehlers Danlos syndrome.
Sprains
Subluxation
Dislocation
Fracture-Dislocation
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Orthopedics- CP
Soft Tissue
Injury
Contusion,
Strain Sprain
laceration, abrasion
Any injury to the tissues in the limbs other than the bone and the joints are commonly termed Soft Tissue
Injury. An off blow to the extremity results in a contusion. The injury to the muscles is termed strain.
Sprain is defined as the injury to the ligaments in a joint and is classified into three grades:
I, Only stretching of the ligaments without any loss of stability;
II, partial tear of the ligaments with partial loss of stability;
III,complete ligamentous disruption resulting in joint stability and probability of
subluxation/dislocation.
The primary treatment of any of the above conditions consists of RICE, R: Rest; I: Immobilization; C: Cold
compression; E: Elevation. Non-Steroidal Anti-Inflammatory Drugs are given in conjunction to relieve pain
as well as to reduce inflammation.
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Orthopedics- CP
JOINT PAIN
Joint pain
Monoarticular Polyarticular Periarticular
Inflammatory e.g.
Infection rheumatoid arthritis, Infection
psoriatic, enteropathic
Metabolic (gout, Degenerative e.g.

Rheumatological
pseudogout) osteoarthritis
Traumatic e.g. fractures,

haemarthrosis,
Trauma / repetitive injury
dislocations, ligamentous
/ degenerative
injury, osteochondral
injuries,etc
Others e.g. bleeding

disorder, degenerative,
Tumour
inflammatory, Avascular
necrosis, tumors, etc
Joint pain refers to the problems inside the joint proper (intra-articular) or problems in the tissues
surrounding the joint (periarticular). As in the extra-articular limb pain, the nature and the type of pain in
the upper limb and the lower limb may vary slightly because of the special functions each are subjected to
(carrying objects by upper limb; weight bearing by lower limb), but the causes can be grossly categorized
and summarized into a few common ones. Some causes of the joint pain can present as acute orthopedic
emergencies and should be treated immediately to prevent complications and preservation of proper joint
function.
One important area is to distinguish between joint pain alone (arthralgia) and joint pain associated with
swelling (arthritis). Arthritis is usually more significant than arthralgia.
Extra-articular limb pain and the causes are discussed in a separate cp. Here we focus on the intra and
peri-articular limb pain.
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Orthopedics- CP
Joint Pain
Monoarticular Polyarticular Periarticular
Joint pain can present as a problem in single joint (monoarticular), multiple joints (polyarticular) or around
the joint (periarticular). Polyarticular joint pain usually involves more than 5 joints. The term oligoarticular
is used when only 2~4 joints are involved. For ease, both the conditions are discussed here within
polyarticular joint pain. The problems arising in a single joint or multiple joints vary in underlying cause but
there can be some overlap.
Clinical Clues
Ask About
The joint(s) involved
If the pain is associated with swelling
Aggravating and /or relieving factors
Fever, anorexia suggestive of infection, malignancy
Morning stiffness and duration
History of trivial or significant trauma
Look For
Compare with the contra-lateral limb whenever possible and look for wasting of muscles, mass or
any signs of inflammation, pus discharge
Location of the swelling: intra-articular or peri-articular
Restriction of active and passive movements
Comments
At this point it is difficult to get to the diagnosis and should move further down to differentiate
the different causes of joint pain.
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Orthopedics- CP
Monoarticular
Metabolic and
Infective Traumatic Others
Endocrine
Bleeding
Septic Gout Fractures
Disorders
Acute/chronic
TB Pseudogout Dislocations
Syonvitis
Fungal Hemarthrosis Degenerative
Ligamentous Avascular
Others
Injury necrosis
Osteochondral
Tumour
Injuries
Inflammatory
Clinical Clues
Ask About
History of trauma or surgery
Site of pain
Time of onset
Whether or not the pain is migratory as in Rheumatic fever
Nature of pain, eg. Throbbing in septic arthritis and acute osteomyelitis, etc.
Severity of pain if refusing to weight bear or move that limb at all, highly suggestive of septic
arthritis.
Relieving and/or aggravating factors eg. High purine diet and gout, pain at terminal movements in
Osteoarthritis
History or fever, anorexia suggestive of infection, malignancy
History of infective lesion in the past, history of chronic discharge, history of pus drainage from
the limbs
Wounds, scratches, steroid injections suggesting infection
History of drugs intake eg. prolonged use of steroid leading to avascular necrosis
History of contact with TB patients
Bleeding from gums and nose or black stool suggestive of bleeding disorders
Family history of bleeding disorders
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Orthopedics- CP
Look For
General condition of the patient - toxic appearance s/o septic arthritis
Physical examination of the patient- lymph nodes, pallor, icterus, oedema, etc
Vital signs BP, pulse, temperature, respiratory rate
Scar suggestive of previous surgery or trauma
any signs of inflammation, pus discharge, change in skin colour or texture
Any mass and its characteristics suggestive of tumour
Range of motion of the joint, both active and passive
Gait abnormality especially stiff hip or stiff knee gait
Gouty tophi on fingers and earlobes
Investigations
TC, DC, ESR, CRP
Serum uric acid
Serum Calcium, phosphorus and alkaline phosphatase
Bleeding profile as needed
Joint aspirate for biochemistry, culture and crystal examination
Blood culture is suspect septic arthritis
X-ray
CT Scan, MRI and Bone Scan as indicated
Biopsy
Septic arthritis if associated with fever, painful movements and raised neutrophil count
TB arthritis in case of long standing joint infection not responding to antibiotics
Acute onset of joint pain especially the 1st Metatarsophalangeal joint should raise the suspicion of
gout
Acute onset of joint swelling with or without pain and signs of significant inflammation points
towards the diagnosis of bleeding disorders
People with history of prolonged steroid use or with chronic alcohol intake may present with joint
pain especially single or bilateral hip: Avascular necrosis of femoral head
Painful movements at extremes especially in elderly suggests Osteoarthritis
Comments
Traumatic joint pain is discussed in the cp on musculoskeletal injury
Inflammatory arthritis although mostly oligoarticular or polyarticular, may also present as
monoarticular joint pain and needs to be ruled out
Gouty arthritis can present as an acute monoarticular joint pain, swelling and other signs of acute
inflammation and need to be differentiated with acute septic arthritis. Sometimes joint aspiration
is needed for clinical diagnosis
Septic arthritis is an orthopedic emergency, the delay in treatment of which may lead to joint
cartilage destruction and loss of function
20
Orthopedics- CP
Polyarticular
Non-
Inflammatory Inflammatory
(Degenerative)
Rheumatoid Primary
arthritis Osteoarthritis
Sero Negative
Secondary
Spondylarthrop
Osteoarthritis
athy
Reactive
arthritis
Psoriatic
arthritis
Ethteropathic
arthritis
Juvenile
Idiopathic
Arthritis
Connective
Tissue Disorder
eg SLE
Oligoarticular or polyarticular joint pain can generally be classified as inflammatory or non-inflammatory.

The clinical history and examination are the key factors in reaching the preliminary diagnosis that can
further be supplemented by some investigative measures.
Clinical Clues
Ask About
Joints Involved
Time of onset
Relieving and/or aggravating factors eg. Morning stiffness > 30min in Inflammatory arthritis, pain
relieved by exercise s/o inflammatory arthritis (e.g. rheumatoid arthritis, ankylosing spondylitis), pain
relieved by rest and exacerbated by exercise s/o non-inflammatory arthritis
History or fever, anorexia, malaise suggestive of inflammatory arthritis
Pain on movements/ weight bearing
History of pervious trauma to the joint or other problems of the joint
History of GI symptoms suggestive of ulcerative colitis or Crohns disease or simply enteric fever
Changes in skin conditions suggestive of Psoriasis (e.g. pitting of nails, plaques on extensor surfaces)
History of associated chronic back pain or sacroiliac pain suggestive of spondylarthropathies
21
Orthopedics- CP
Look For
General appearance (obesity is a risk factor for osteoarthritis, anaemia, lymphnodes may be
present in rheumatoid arthritis, skin conditions e.g. psoriasis, malar rash of SLE)
Examination of both the limbs fully exposed, examine the back as well
Scar around the joint suggestive of previous surgery or trauma
any signs of inflammation, pus discharge, change in skin colour or texture, limb length discrepancy
Distribution of joint swelling
o typical patterns for rheumatoid arthritis MCP, PIP, wrists, elbows, knees, ankles, MT
heads (usually symmetrical pattern)
o typical pattern for osteoarthritis DIP, base of thumb, knees and hips
Swelling in the joint(s), synovial thickening
Deformity at the joint(s) eg. Typical swan neck deformity or buttonaire deformity of hand in RA,
genu varum in OA
Range of motion of the joints, both active and passive
Evidence of extra-articular features of disease e.g. rheumatoid nodules on extensor surfaces of
forearms, gouty tophi, skin rashes, pleural effusion (RA, SLE).
Investigations
TC, DC, Hb, ESR, CRP
Serum uric acid, albumin
Rheumatoid Factor, HLA-B27, Anti CCP antibodies etc as required and if available
Joint aspirate for biochemistry, culture, crystals
X-ray
Biopsy
Morning stiffness > 30 min with small joints bilateral involvement is suggestive of inflammatory
arthritis especially in adult females
Painful movements at extremes and a few minutes of morning stiffness especially in elderly
suggests Osteoarthritis
Comments
Inflammatory arthritis is usually the musculoskeletal manifestation of system diseases and hence a
holistic approach is needed for the treatment.
Inflammatory disorders may be identified by the presence of some or all of the four cardinal signs
of inflammation (erythema, warmth, pain, and swelling), by systemic symptoms (prolonged
morning stiffness, fatigue, fever, weight loss), or by laboratory evidence of inflammation (elevated
erythrocyte sedimentation rate or C-reactive protein level, thrombocytosis, anemia of chronic
disease, or hypoalbuminemia).
Articular stiffness is common in chronic musculoskeletal disorders. However, the chronology and
magnitude of stiffness may be diagnostically important. Morning stiffness related to inflammatory
disorders (such as RA) is precipitated by prolonged rest, often lasts several hours, and may
improve with activity and anti-inflammatory medications. By contrast, intermittent stiffness
associated with non-inflammatory conditions, such as osteoarthritis, is precipitated by brief
periods of rest, usually lasts less than 60 min, and is exacerbated by activity.
There may be significant overlap between the different conditions of the inflammatory arthritic
conditions. The chronic inflammatory conditions may also lead to or be associated with
osteoarthritis.
Inflammatory arthritis although mostly oligoarticular or polyarticular, may also present as
monoarticular joint pain and needs to be ruled out.
22
Orthopedics- CP
Polynodular osteoarthritis mimics the features of Rheumatoid Arthritis with subcutaneous

nodules and has to be ruled out before definitive treatment is commenced
Old age with pain on extremes of movements of weight bearing of lower limb joints, especially the
knee joint points towards degenerative arthritis often called the osteoarthrosis
Gouty arthritis may also present as oligo or polyarticular joint pain, swelling.
Septic arthritis may involve multiple joints especially in patients with sepsis and
immunodeficiency. It may be associated with multifocal abscess and osteomyelitis as well
Inflammatory arthritis can be immune-related [rheumatoid arthritis (RA), systemic lupus
erythematosus (SLE)], reactive (rheumatic fever, Reiter's syndrome), or idiopathic.
Noninflammatory disorders may be related to trauma (rotator cuff tear), ineffective repair
(osteoarthritis), cellular overgrowth (pigmented villonodular synovitis), or pain amplification
(fibromyalgia). They are often characterized by pain without swelling or warmth, the absence of
inflammatory or systemic features, little or no morning stiffness, and normal laboratory findings.
Periarticular
Traumatic/
Infective Rheumatological Repetitive/ Tumour
Degenerative
Superficial eg. soft

tissue infection Benign
around the joint
Deep
Malignant
eg. osteomyelitis
Periarticular pain can sometimes be confused with pain from intra-articular structures. The treatment and
prognosis of the two conditions could vary largely both regarding the technical aspects as well as
rehabilitation process. Hence it is very important to differentiate the cause.
Clinical Clues
Ask About
Joints Involved
Time of onset and duration
Relieving and/or aggravating factors
History or fever suggestive of infection
Pain on movements/ weight bearing
History of pervious trauma to the joint and soft tissues or other problems of the joint
Pain associated with fast growing mass, weight loss, anemia suggestive of malignancy
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Orthopedics- CP
Look For
General appearance
Examination of both the limbs fully exposed, examine the back as well
Scar around the joint suggestive of previous surgery or trauma
any signs of inflammation, pus discharge, change in skin colour or texture, limb length discrepancy
Swelling around the joint
Mass and the characteristics
Tenderness: superficial or bony
Range of motion of the joints, both active and passive
Investigations
TC, DC, Hb, ESR, CRP
Serum uric acid, albumin
Rheumatoid Factor, HLA-B27, Anti CCP antibodies etc as required and if available
Fluid aspirate for biochemistry, culture
X-ray
Biopsy
Acute onset of pain in the metaphyseal region associated with fever suggests soft tissue infection
or acute osteomyelitis
The recurrent bursal or tendinopathies, if associated with other rheumatological manifestation
suggests inflammatory conditions. If the condition is isolated, it may just be repetitive or
degenerative condition.
Benigh and Malignant tumors of the metaphyseal region
Comments
Acute osteomyelitis usually starts in the metaphyseal region. It may be confused with septic
arthritis in most of the cases, especially in a child where physical examination is not very easy. The
most valid differentiating physical examination is the bony tenderness in case of osteomyelitis and
extremely painful movement in case of septic arthritis. Both are orthopedic emergencies and have
to be treated at earliest.
Rheumatological conditions (immune system related problems) may manifest as bursal or
tendinous inflammation and have to be carefully evaluated, especially when associated with
polyarthralgia or back pain.
Hyperuricemia may precipitate crystal deposits in the bursa and present as non-infective bursitis.
Traumatic/repetitive conditions like bursitis, tendinitis, rotator cuff tears etc have been discussed
in separate CP and hence will not be discussed here in detail.
MRI may sometimes be very crucial in diagnosing conditions like malignant or benign tumour but
have to be sought for with care, especially because of the cost factor involved.
Biopsy is the ultimate diagnostic tool in case of all the above conditions and has to be done by an
experienced surgeon, especially when a malignancy is being suspected.
24
Orthopedics- CP
LOW BACK PAIN
Low Back Pain
Acute/Subacute
Chronic
< 6 weeks
Traumatic Atraumatic Local Referred
Spondylogenic Neurogenic Viscerogenic
Degenerative Inflammatory Vascular
Psychogenic
Low back pain, lumbalgia, lumbago is a common clinical condition that has many etiologies. Fortunately
the vast majorities of these lumbalgia episodes are self-limiting and resolve with minimal to no
intervention. Lumbalgia is largely divided into two broad categories of acute/subacute vs. chronic. An
important component in the evaluation of lumbalgia is this temporal phenomenon of whether the pain
has been present for less than or greater than six weeks. Another important characteristic of lumbalgia is
the paradoxical relationship seen in many patients wherein severe pain may be present without
radiographic corroboration and the converse wherein patients are asymptomatic but have significant
radiographic abnormalities. This signifies the importance of the history of each individuals lumbalgia to
determine its etiology and treatment.
25
Orthopedics- CP
Low Back Pain
Acute/Subacute Chronic
< 6 weeks > 6 weeks
Traumatic
Sprain/strain Atraumatic
Compression fracture
Herniated Nucleosus Pulposus
Low back pain is one of the most common diagnoses and is usually of an acute, subacute or chronic
nature. When low back pain has been present for less than six weeks this is termed acute or subacute
lumbalgia. When lumbalgia has been present for more than six weeks this falls into and is termed chronic
lumbalgia.
Clinical Clues
Ask about
How long has lumbalgia been present, < 6 weeks or > 6 weeks?
Whether any associated or antecedent trauma was involved with onset of lumbalgia; eg. Nature of
trauma, lifting of heavy weight etc.
Prior history of similar lumbalgia episodes.
Position of pain, radiation.
Any change in bowel and bladder control/habits.
Socio economic and occupational status.
Look for
Gait disturbance
Heel, tiptoe and tandem walking
Uncoordinated spinal rhythm (from sitting to standing and standing to sitting position).
Motor, sensory or deep tendon reflex abnormality.
Limb length discrepancy.
Investigations
Standing lumbar radiographs, AP and Lateral to evaluate for listhesis, kyphosis or scoliosis. If there
is any history of trauma, the x-ray should be done in lying position.
AP Pelvis X-Ray evaluate for leg length discrepancy, pelvic obliquity.
Comments
There is usually no need for routine X-Ray if there is no history of antecedent trauma and
symptoms present for < 6 weeks.
Evaluate X-Ray for evidence of fracture, listhesis, pelvic obliquity, kyphosis or scoliosis.
26
Orthopedics- CP
Most of the lumbalgia episodes with < 6 weeks duration are self-limited.
Herniated Nucleosus Pulposus(HNP), also termed Protrusion of Intervertebral Disc(PIVD), can be
the result of acute trauma, especially in a young adult with a history of sprained back or significant
flexion injury to the lower back.
Lower back pain as a result of fracture has been discussed in detail in the separate CP Spinal
Trauma.
Mechanical LBP, which is common in younger age group, is diagnosed when trauma and other
causes have been ruled out or when there is no evidence of significant clinical or radiological
findings. Mechanical LBP is associated mostly with mechanical works like washing clothes, carrying
loads sitting for long periods of time, works related to flexion and extension of the spine for a
prolonged time, etc.
Lumbar Sprain/Strain
Herniated Disk
Compression Fracture
Low Back Pain
Acute/Subacute Chronic
< 6 weeks > 6 weeks
Atraumatic
Infective
Traumatic HNP
Neoplastic
Others eg. Mechanical LBP
Clinical Clues
Ask about
History suggesting referred pain eg. Viscerogenic.
Recent illness, fevers, chills, weight loss, anorexia suggesting infection.
Change in bowel or bladder function, suggesting cauda equina compression.
History of TB or any contact to TB.
History of tumor or family history of malignancy.
27
Orthopedics- CP
Look for
Vital signs
Gait pattern, paraspinal muscle spasm or neurologic deficit
Spinal deformity
Examine rectal tone, voluntary sphincter control
Distant focus of infection eg Pulmonary TB or bacterial endocarditis.
Evidence of primary tumor eg. Prostate, breast, lung etc.
Investigations
CBC, ESR, CRP
Post void residual volume
Blood cultures
X-Ray, CT, and MRI with and without contrast studies as indicated.
Comments
Atraumatic acute or subacute lumbalgia is usually secondary to infection or tumor if laboratory
studies reveal evidence of inflammatory process such as elevated CBC, ESR and CRP.
Associated findings of cauda equina nerve compression findings of saddle anesthesia, bilateral
sciatica, decreased rectal tone, impaired voluntary sphincter control or Post Void Residual
Volume(PVR) > 100 cc urine indicate a probable surgical emergency for acute decompression.
MRI, although expensive, is an important and crucial tool in differentiating various atraumatic
conditions.
Bone scan can sometimes be used to detect subtle fractures, inflammatory conditions and
metastatic bone tumours.
It is also important to keep in mind that back pain may be referred from viscerogenic origin.
Tubercular spondilitis
Vertebral discitis
Epidural and /or spinal abscess
Vertebral metastases with epidural extension, canal compromise and spinal cord compression
UTI
Viscerogenic Causes: eg. Cholilithiasis, renal/ureteric calculi, Pelvic Inflammatory diseases,
Endometrosis, Tumors of the GI, Urinogenital Tracts etc.
28
Orthopedics- CP
Low Back Pain
Acute/Subacute
Chronic
< 6 weeks
Local Referred
Spondylogenic Neurogenic
Degenerative Inflammatory
Chronic lumbalgia is caused by factors within the spine (local) or outside of the spine (referred). Intrinsic
local causes are spondylogenic or neurogenic. Spondylogenic pain pertains to structures of the spinal
column and its associated structures. Pain may radiate down the limbs, usually not below the knee.
Neurogenic causes most commonly refers to tension, irritation or compression of lumbar nerve root(s)
with associated radicular unilateral or bilateral legs and paraspinal region and can radiate up to the ankle
or foot. Pain is frequently aggravated by certain activities and relieved by rest. The neurogenic pain may
be on the buttocks, thigh and leg depending on the level of the cord or nerve roots involved. Both the
spondylogenic and the neurogenic type of pain can occur at the same time, most often the former being
the cause and the latter being the more obvious effect (eg. Lumbar spinal canal stenosis).
Clinical Clues
Ask about
Whether pain is same, better or worsening over time
What activities precipitate pain or relieve it.
Whether sciatica relieved by sitting or standing, brought on by walking on flat surface or up hills,
or whether in proximal thighs or below knees.
Whether any recent or distant trauma was involved with onset of acute exacerbation of lumbalgia.
Prior history of similar lumbalgia episodes and their resolution
Changes in bowel or bladder function
History of tumor or family history of cancer
History of Pulmonary TB or distant infection
Look for
29
Orthopedics- CP
Gait pattern stooped over as seen in lumbar stenosis, paraspinal muscle spasm (possible hip or
knee arthritis) or neurologic deficit
Gait disturbance, heel, tiptoe and tandem
Spinal rhythm from sitting to standing and standing to sitting position.
Examine rectal tone, voluntary sphincter control, post void residual volume (PVR)
Motor, sensory or reflex testing abnormality. In particular evaluate for upper motor neuron tract
signs such as Babinski, clonus or paradoxical double-crush syndrome of tandem stenosis (lumbar
stenosis associated with cervical spinal cord stenosis).
Investigations
Standing lumbar radiographs, AP and Lateral.
Standing AP Pelvis XR evaluate for leg length discrepancy, pelvic obliquity, evaluate for listhesis,
kyphosis or scoliosis
CBC, ESR, CRP evaluate for indolent infection or occult malignancy.
DEXA(Dual Emission X-ray Absorpsiometry) for measuring bone density, CT, and MRI with and
without contrast studies
Comments
Acute cases may also progress into chronic condition
Evaluate X-Ray for evidence of fracture, listhesis, pelvic obliquity, kyphosis or scoliosis. If there is
preexisting deformity evaluate for changes comparing to prior radiographic studies.
Chronic Herniated Nucleosus Pulposus
Osteoporotic Compression Fracture
Vertebral metastases with epidural extension, canal compromise and spinal cord compression
Degenerative scoliosis
Lumbar stenosis
Cervical Stenosis
Spondylolisthesis
Spinal Tumors (Intradural or extradural)
Peripheral Neuropathies secondary to diabetes, chemotherapy, etc.
Spondylarthropathy
30
Orthopedics- CP
Low Back Pain
Acute/Subacute
Chronic
< 6 weeks
Local Referred
Viscerogenic
Vascular
Psychogenic
Not all causes of low back pain are attributable to the spine, nerves and associated structures. It is
possible for a patient to have viscerogenic origin (kidney, pelvic viscera, lesions of the lesser sac, and
retroperitoneal tumors); vascular origin (abdominal aortic aneurysm or peripheral vascular disease); or
psychogenic (depression, conversion disorders, others). The presentations of these non-spondylogenic
causes of lumbalgia are consistent enough to allow a systematic evaluation for these possible etiologies.
One important feature to this type of lumbalgia is that it is not aggravated by activity nor is it relieved by
rest.
Clinical Clues
Ask about
Whether pain is same, better or worsening over time
What activities precipitate pain or relieve it
Whether any recent or distant trauma was involved with onset of acute exacerbation of lumbalgia.
This is particularly important in patients with secondary gain, such as those seeking disability
status, workers compensation.
Prior history of similar lumbalgia episodes and their resolution
Any changes in bowel or bladder function
Any recent psychosocial stressors such as divorce, death, deployment to war, social unrest,
disaster or major accident etc
Associated comorbidities such as coronary artery disease, renal disorders, history of tumor
31
Orthopedics- CP
Look for
Neurologic exam
Gait pattern, guarding or neurologic deficit
Gait disturbance, heel, tiptoe and tandem
Motor, sensory or reflex testing abnormality. In particular evaluate for non-dermatomal findings,
normal findings when patient is distracted.
Abdominal examination for expansile mass eg AAA, pelvic or abdominal masses
Skin rashes eg Herpes Zoster
Peripheral Pulses
Investigations
Standing lumbar radiographs, AP and Lateral.
Review any studies performed of non-spine regions such as abdominal CT, renal ultrasound,
others.
Examine rectal tone, voluntary sphincter control, post void residual volume (PVR)
CT, MRI or other studies as indicated
Comments
Always consider atypical basis for radicular pain such as central nervous system tumor or similar
etiologies.
People with HLA-B27 gene are more likely to get spondylarthropathy group of diseases eg.
Ankylosing Spondilitis
Depression and psycosocial stresses may aggravate all the other causes of LBP
Red Flag Signs

1. Fever
2. Severe pain, especially night pain
3. Positive Straight Leg Raising Test
4. Positive Contralateral Straight Leg Raising Test
5. Saddle Anesthesia with loss of bowel and bladder control indicating cauda equine syndrome
6. Other systemic symptoms/signs eg. Hypotension, tachycardia, weight loss etc.
Abdominal aortic aneurysm (AAA)
Retroperitoneal tumors
Intraabdominal tumors
Kidney or Pelvic viscera disorders
Peripheral vascular disease
PID
UTI
Depression
Conversion Disorder
Peripheral Neuropathies secondary to diabetes, chemotherapy, etc.
32
Orthopedics- CP
Limb deformity
Limb deformity
Congenital Acquired
Upper limb Lower limb Joint Bone
Primary causes Secondary causes Fracture
Trauma
e.g. fracture, Muscle imbalance Infection
dislocation,
malunion
Contracture of
Tumour
Infection overlying tissues
Inflammatory Metabolic
arthritis
Degenerative
33
Orthopedics- CP
limb deformity
congenital acquired
A deformity, literally means, a major difference in the shape of a body part or organ compared to the
average shape of that part. The word deformity may be applied to a person, a bone or a joint. Shortness
of stature is a kind of deformity; it may be due to shortness of the limbs or of the trunk or both. We shall
discuss limb deformities in this CP.
Limb deformity is any deviation from the normal anatomy of a bone or joint of the limb. Limb deformity is
caused by disorders of bone, joint, soft tissues (muscles, subcutaneous tissues) and certain neuromuscular
disorders. Broadly, we can divide the etiology into two groups- congenital and acquired. Congenital limb
deformities means, deformities are present since birth or seen within a few years. Acquired means,
develops during the later part of the life.
Clinical clues:
Ask about:
Ask whether the deformity is present since birth or within a few years.
If present since birth or developed after few months or years, ask for
Family history of similar problem
During pregnancy: ask especially for
- Any medical problems or complications
- Any medications or procedure
- Exposure to the radiations
- Difficult labour
Maternal history: maternal age, history of diabetes, hypertension, multiple pregnancies,
smoking or alcoholic habits, etc
If present later in the life, ask for:
Spontaneous or traumatic
Limb involved-upper or lower, number of deformities, nature- whether progressive or
non-progressive
History of any medical problems- diabetes, hypertension, nutritional status
Treatment history
Comments:
Congenital limb deformities: Congenital limb deformities are due to some genetic abnormalities or
environmental variations or both. However, the exact cause is unknown. They may be obvious at
birth or seen a few years later. They may be so severe that the baby is still born or may be so
minor that it is not noticeable. These problems are more prevalent in diabetic mothers, multiple
pregnancies, older mothers and family history of similar congenital deformities. We can divide
limb deformities into two groups- upper and lower limbs for the easy description.
Acquired causes: The deformity is classified as an acquired limb deformity when it results from a
fracture, infection, arthritis, tumors, etc.
34
Orthopedics- CP
congenital
upper limb lower limb
Clinical clues:
Ask about:
Whether the deformity involved upper/lower limb or both
Unilateral or bilateral limbs involvement
Impairment in activity of daily living (ADL)
Uses of external appliances for walking or normal function
Any medical or surgical intervention
Family history- any similar problems or deformities in the family
Maternal history- maternal age, any medical problems, complications, medications, radiation
exposures, infections during pregnancy or difficult labour, etc
Look for:
Involvement of the limbs-whether upper or lower, unilateral or bilateral
Gait e.g. waddling gait, in case of bilateral developmental dysplasia of hip (childhood or
adolescents).
Extent of deformity
Functional disabilities activity of daily living
Whether the deformity involve the joint, bone or soft tissues (muscles, nerves)
Joint and ligamentous laxity
Neurological assessment of the limb motor and sensory examination
Mental status of the patient: some patient may have involvement of the CNS as a cause of limb
deformity
Other associated congenital anomalies.
Possibilities of medical or surgical intervention to correct the deformity to normalize the function
Investigations:
X-rays: do in at least two planes to have a clear picture of the deformities, sometimes special
views may be necessary to see the deformities.
CT/MRI scans: occasionally needed for the detail picture or analysis of the deformities. MRI is
more informative when we want to know about the involvement of the soft tissues including the
nervous tissues. CT scan is better to reveal the bony involvement.
Blood and urine analysis: especially when someone is planned for surgical management.
Comments:
Examples of congenital upper limb deformity:
Scapula lies more superiorly than it should in relation to the thoracic cage and is
hypoplastic with restricted scapulothoracic motion suggest the Sprengel deformity.
35
Orthopedics- CP
Unilateral or bilateral forearm defects with variable forearm rotation suggests the
congenital radioulnar synostosis.
Wrist deformity - Lower radius curves forwards (ventrally), carrying with it the carpus and
hand but leaving the lower ulna sticking out as a lump on the back of the wrist suggest
the Madelung deformity.
Infant born with the wrist in marked radial deviation radial club hand
Infant born with extra-thumb polydactyly
Infant born with fused middle and ring fingers syndactyly
Examples of congenital lower limb deformity:
Infant, breech delivered, with asymmetric thigh, gluteal folds and wide perineum,
dislocated hip joint suggest the congenital dislocation of hip, recently known as
developmental dysplasia of hip.
Infant with hyperextension deformity of the knee and could be quite grotesque
congenital dislocation of knee.
Infant or child presents with anterior bowing of the tibia of various severities congenital
pseudoarthrosis of tibia.
Infant born with the heel is in equinus, the entire hindfoot in varus and the mid- and
forefoot adducted and supinated suggest the clubfoot or congenital talipes equinovarus
(CTEV) deformity.
A congenital deformity produces not only flattening but an actual convexity of the sole of
the foot Rocker bottom flat foot or congenital vertical talus.
acquired
joint bone
primary causes secondary causes
Clinical clues:
Ask about:
Age and sex of the patient
Involved joint or bone
Age of onset, characteristics, duration of the deformity
Associated pain, fever, history of trauma
Restriction of movements, discharging sinuses, limping, etc
Functional disabilities, activity of daily living (ADL)
Other systemic involvement
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Orthopedics- CP
Look for:
Gait of the patient, when deformity involves the lower limbs
Site of the deformity- whether arising from the joint or bone or soft tissues
Involved limb/limbs upper or lower limb; part or joint/joints of the limbs
Extent of the limb deformities
Color and texture of the overlying skin especially when there is associated bony or soft tissues
swelling or lumps.
Presence of any scars or sinuses these may indicate the presence of chronic osteomyelitis or old
infection.
Position of the limbs/ joints for example, like cubitus varus, valgus, genu valgus or varus, flexion
deformities, etc should be looked for.
Measurement of the limbs - Shortening or lengthening of the deformed limbs
Symmetry or asymmetry of the deformities, when bilateral
Inspect other areas like thoracic cage, spine, skull etc.
The affected limb(s) should be palpated to evaluate degree of ligamentous laxity and the presence
of pain or swelling.
Associated bony or soft tissues swelling, its extent, tenderness, increased localized temperature
Distal neurovascular status of the involved limb
Comments:
Acquired causes: if a limb appears to be crooked, it is important to establish whether deformity is in the
bone or in the joint. A joint may be held in an unnatural position because of either joint pathologies or soft
tissues pathologies that cause joint deformity. If the deformity occurred in the joints itself, it called
primary, whereas other pathologies caused deformities of the joints that is called secondary.
primary
causes
inflammatory
trauma infection degenerative
arthritis
fracture/dislocation malunion
Clinical clues:
Ask about:
Involved joint/joints
Age of onset, characteristics, duration of the deformity
Whether the deformity is progressive or non-progressive
Associated pain, swelling, fever, history of trauma
Restriction of movements, discharging sinuses, limping, etc
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Orthopedics- CP
Functional disabilities, activity of daily living (ADL)

Other systemic involvement
Medical problems- diabetes, hypertension
Infection elsewhere, e.g. history of tuberculosis
Skin problems e.g. psorasis (psoriatic arthropathy), malar rash (s/o Systemic lupus erythematosis)
Use of immunosuppressive drugs
Treatment history
Family history
Look for:
Gait when the deformity involves the lower limbs
Number of deformed joints, of upper or lower limbs
Characteristic pattern of the deformities, e.g., cubitus varus, valgus after malunion of distal
humeral fractures, swan-neck deformity of rheumatoid arthritis, etc
Any evidence of trauma- new or old or surgery performed about the joint/joints
Features of inflammation about the joints/deformity redness, increased localized temperature,
tender, swelling and loss of function
Distal neurovascular status of the involved limbs, including reduced sensation in hands and feet
which can lead to neuropathic joints (e.g. leprosy, diabetes)
Movements of the involved joint/joints whether it is normal or restricted
Measurement of the limbs- lengthening or shortening of the limbs, symmetrical or asymmetrical
involvement in case of bilateral involvement
Other systemic examinations vertebral column deformity, respiratory, cardiovascular, central
nervous system, skin etc
Investigations:
Blood investigations: TC, DC, ESR, CRP, Rheumatoid factor, ASO titre (if s/o rheumatic fever), blood
culture, etc, these tests are helpful to diagnose infective, inflammatory causes of deformities of
the joints.
Synovial fluid analysis: especially helpful in infective and inflammatory causes
X-rays: it is the most useful investigation to define the deformity of the joints. At least two views
are essential, but sometime special views are required to clearly view the deformity.
CT or MRI scans: these are sometime necessary to study the extent of involvement.
Comments:
Primary causes can be sub-classified into different headings, viz. trauma, infection, inflammatory arthritis,
degenerative, etc.
Trauma: whether it is fresh (recent) or old, any dislocations, intra-articular fractures and
fracture-dislocation of the joints, can caused deformities of the joints. Any intra-articular
fractures or fracture-dislocations with malunion also presents with deformity of the joints.
Infection: infection of the joint is called infective arthritis. It can be caused by pyogenic,
tubercular, mycotic microrganisms, etc. The causal organism is usually Staphylococcus aureus,
however, in infants Haemophilus influenza, and occasional other organisms are Streptococcus,
E.coli and Proteus. Predisposing conditions are rheumatoid arthritis, chronic debilitating
disorders, intravenous drug abuse, immunosuppressive drug therapy and acquired
immunodeficiency syndrome (AIDS). A joint can become infected by
o Direct invasion through a penetrating wound, intra-articular injection or arthroscopy,
o Direct spread from an adjacent bone abscess, or
o Blood spread from a distant site.
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Orthopedics- CP
Infective arthritis initially causes muscles spasm around the joint and causes reversible flexion
deformities of the joints, but if untreated or complicated, then is converted into the fixed
deformities or even pathological dislocation of joints can happen. Septic arthritis causes bony
ankylosis whereas tubercular arthritis causes fibrous ankylosis. In children, there may be localized
deformity or shortening of the bone. In adults, partial destruction of the joint will result in
secondary osteoarthritis.
Inflammatory arthritis: acute inflammatory arthritides (e.g., reactive arthritis) seldom produce
deformity, but it is the chronic inflammatory arthritides, which causes deformity of the joints.
Chronic inflammatory arthritis includes rheumatoid arthritis, ankylosing spondylitis, juvenile
rheumatoid arthritis, etc.
Degenerative joint disorders: degeneration of the joints also causes deformity of the joint.
Osteoarthritis is the common example in this category. Actually, osteoarthritis is a misnomer,
because there is no sign of inflammation in this condition, so osteoarthrosis is the better
term. Degeneration of the joints could be primary or secondary to other causes. Primary is
idiopathic or age related degeneration of the articular cartilage of the joints, whereas
secondary could be due to infection, trauma, etc. of the joints.
Secondary
causes
Contracture of
Muscle
overlying soft
imbalance
tissues
Neuromuscular Burn
disorders contractures
Primary muscle Post-traumatic

disease contractures
Peripheral nerve Prolonged

disease immobilization
Central nervous
Muscle fibrosis
system disease
Tendon injury
Peripheral nerve
injury
Clinical clues:
Ask about:
Age at onset of deformity
Characteristic pattern of the deformity
History of injury Cut, lacerations involving tendons, peripheral nerves
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Orthopedics- CP
History of trauma with fractures of the joints or bones with prolonged immobilization
Recent surgical procedures, or the use of a tourniquet must be noted.
Burns
Any associated pain and swelling
Fever, sore throat, headache, neck stiffness (s/o encephalitis or meningitis which can lead to
neuromuscular disorders)
Muscle weakness that may be due to upper or lower motor neuron lesions (spastic versus flaccid
paralysis) but it may also be due to a primary muscle problem. The type and degree of weakness,
the rate of onset, whether it affects part of a limb, a whole limb, upper or lower limb, one side of
the body or both sides all these details should be enquired into and help to give an insight into
the aetiology.
Numbness and paraesthesiae - establish their exact distribution to help localize the anatomical
nature and level of the lesion accurately, and the rate of onset and the relationship to posture.
History of diabetes, poliomyelitis, stroke, syphilis (tabes dorsalis).
Non-orthopaedic problems should also be discussed. It can be particularly important to note
throw-away comments regarding problems such as headaches, dizziness, falls, feeding problems,
hearing difficulties or visual disturbances in addition to the more obvious complaints of cognitive
impairment, speech disorders or incontinence. Some symptoms will only be disclosed on direct
questioning as the patient may not consider them relevant; other symptoms, such as incontinence
or impotence, may be too embarrassing to mention.
Family history
Treatment history
When patient presents early during infancy ask about a history of prenatal toxemia,
haemorrhage, premature birth, difficult labour, foetal distress or kernicterus. These may arouse
suspicion towards cerebral palsy. Also ask for developmental milestones in cases of children.
Vaccination profile according to WHO in case of children (for polio and Jap Encephalitis especially)
Look for:
Neurological examination with particular attention should be paid to:
o patients mental state,
o natural posture,
o gait,
o Sense of balance,
o involuntary movements,
o Muscle wasting, muscle tone and power, reflexes, skin changes,
o Sensation e.g. in peripheral neuropathy
o Autonomic functions such as sphincter control, peripheral blood flow and sweating.
The back should always be carefully examined as it holds the key to many causes of neurological
disorder.
Extent of cut or lacerated wound of the limbs to assess the tendon or peripheral nerve injury
If there is associated burns of the limbs its site, duration, extent, depth, etc
Immobilization of the limbs/joints in plaster or braces
Characteristic patterns of the deformities, e.g. winging of scapula-seen in injury to long thoracic
nerve, wrist drop-seen in radial nerve palsy, claw hand-seen in ulnar nerve palsy, etc.
Contracture of the joints
Increased localized temperature and tenderness (s/o infection)
Distal neurovascular status of the limb
Range of movement of the joints- normal or restricted
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Orthopedics- CP
Investigations:
Blood investigations TC, DC, ESR, Hb%, RBS, Urea, Creatinine, Sodium, Potassium, Calcium,
Phosphorus, etc - these routine tests are usually done as pre-operative investigations rather than
to clinch the diagnosis.
Tests for syphilis e.g. VDRL and RPR
CSF analysis - in some cases of neuromuscular disorders, these are helpful.
Creatinine phosphokinase level helpful in certain neuromuscular disorders, e.g., muscular
dystrophy
Muscle biopsy required in certain neuromuscular disorders, e.g., Duchene muscular dystrophy
Radiology X-rays of the deformed limbs are routinely done to assess the bony involvement.
CT/MRI these are more sensitive tests to establish the lesions in the nervous system or soft
tissues, which are not easily figured out in the plain x-ray.
Neurophysiological studies - nerve conduction studies (NCS) and electromyography (EMG) these
are very helpful in the neuromuscular disorders and peripheral nerve injuries.
Comments:
Secondary causes: defined as pathologies other than joint itself, which cause deformities of the joint.
Mostly they include the soft tissues or neuromuscular causes. Secondary cause can be again sub-classified
under two headings, like muscle imbalance and contracture of overlying soft tissues.
Muscle imbalance:
Neuromuscular disorders:
A neuromuscular disease damages the neurons or nerve cells that send messages that control
voluntary muscles, leading to muscle weakness and atrophy. The patient may experience pain,
muscle cramps, twitching and mobility problems. Neuromuscular disease can affect the muscles,
the central nervous system, and the peripheral nervous system, which includes the arms and legs.
The deformity occurs due to imbalance in the muscular co-ordination, weakness or paralysis
secondary to different diseases of muscles or nervous system. Examples: cerebral palsy, stroke,
acute poliomyelitis, etc.
In unbalanced paralysis, one group of muscles is too weak to balance the pull of the antagonists.
At first this produces a deformity that can be corrected passively (dynamic deformity); over time
the active muscles and the soft tissues of the joints contract and the deformity becomes fixed or
structural.
In balanced paralysis, the joint assumes the position imposed on it by gravity and it may feel
floppy or flail.
In a dynamic deformity, rebalancing of the muscle forces may be possible with a tendon transfer.
If the deformity is fixed, soft-tissue releases, and possibly osteotomies, may be needed to correct
the deformity before rebalancing can be considered.
Paralysis occurring in childhood seriously affects growth. Bones are thinner and shorter than usual
and in the absence of normal mechanical stresses (imposed by normal muscle pull) bone
modelling can be defective (e.g. a valgus femoral neckshaft angle, which is often seen in
neuromuscular disorders).
Tendon injury:
Tendon injuries can also cause deformities of the limbs or digits. Acute tendon ruptures causes
temporary deformity, but if not treated in time, can lead to permanent deformity. Example:
rupture of distal insertion of long extensor tendon of the fingers can cause mallet deformity of the
finger.
If one of two adjacent joints changes direction, then the overlying long tendons will pull the other
joint into the opposite direction. The classical example is swan neck and boutonniere deformities
of fingers in rheumatoid arthritis.
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Orthopedics- CP
Peripheral nerve injuries:

Peripheral nerve injuries may occur because of trauma (eg, a blunt or penetrating wound, trauma) or
acute compression. It may result in demyelination or axonal degeneration. Clinically, both
demyelination and axonal degeneration result in disruption of the sensory and/or motor function of
the injured nerve. Injury to a motor nerve results in a loss of muscle function, and injury to a sensory
nerve results in a loss of sensation to the affected nerve's sensory distribution and/or neuromatous or
causalgia pain. The deformity of the limb occurs due to the imbalance in the muscular co-ordination as
one group of the muscle is paralyzed due to the injury to its motor nerve and other antagonistic muscle
group will pull the joint in its line of action. Examples are:
o Winging of scapula: A winged scapula is a condition in which the medial scapular blade, or
shoulder bone, protrudes from a persons back in an abnormal position due to paralysis of serratus
anterior muscle secondary to injury to the long thoracic nerve.
o Wrist drop: patient will be unable to extend the wrist joint due to the paralysis of the extensor
muscles of the forearm secondary to injury to the radial nerve.
o Claw hand deformity: hyperextension of the metacarpophalangeal joints and flexion of the distal
and proximal Interphalangeal (IP) joints of the fourth and fifth digits (ring and little finger)
secondary to injury to the ulnar nerve.
o Ape-like hand deformity: In this deformity, a person cannot move the thumb outside of the plane
of the palm. It is an inability to oppose the thumb and the limited abduction of the thumb. It is
caused by damage to the median nerve. The name ape hand deformity is misleading, as apes have
opposable thumbs.
Contracture:
Contractures are defined as an inability to perform full range of motion of a joint. Contractures can develop
in almost any muscle group. They result from a combination of possible factorslimb positioning, duration
of immobilization and muscle, soft tissue, and bony pathology.
Burn contracture:
Individuals with burn injuries are at risk for developing contractures. Patients with burns often are
immobilized, both globally, because of critical illness in the severely burned, and focally, as a result of
the burn itself because of pain, splinting, and positioning. Burns, by definition, damage the skin and
may involve damage to the underlying soft tissue, muscle, and bone. The deeper tissues may be
affected due to either involvement in the initial burn injury (e.g., electrical burns) or secondary to the
presence of a skin contracture over a prolonged period of many years, which leads to shortening of
musculotendinous units and neurovascular structures. The joints may be subluxated or dislocated, with
joint capsule and ligaments becoming tight in the direction of the contracture.
Post-traumatic contracture:
Post-traumatic contracture is due to fibrosis and thickening of the capsule and periarticular soft
tissues. Elbow, shoulder, knee joints are most commonly involved. The causes can be classified into
extrinsic (e.g. soft tissue contracture of heterotropic bone formation) intrinsic (e.g. intra-articular
adhesions and articular incongruity) or a combination of both.
Prolonged immobilization:
Prolonged immobilization leads to joint stiffness due to oedema, fibrosis of the capsule, the ligaments
and the muscles around the joint, or adhesions of the soft tissues to each other or to the underlying
bone. Moreover, if the joint has been held in a position where the ligaments are at their strongest, no
amount of exercise will afterwards succeed in stretching these tissues and restoring the lost movement
completely, leading to the deformity of the joints. Joint stiffness after a fracture commonly occurs in
the knee, elbow, shoulder and small joints of the hand.
Muscle fibrosis:
Muscular fibrosis is the excessive formation of fibrous bands of scar tissue in between muscle fibers.
The abnormal development of muscular fibrosis may cause muscle weakness, fatigue, and an inability
to perform simple daily activities. Skeletal muscle fibrosis may be a symptom of a muscle disorder.
Some people with Duchenne or Becker muscular dystrophy develop large amounts of fibrous tissue as
the healthy muscle tissue degrades. Lou Gehrigs disease, or amyotrophic lateral sclerosis (ALS), is a
disabling condition that causes the formation of large amounts of muscular fibrosis after denervation,
or separation of the nerve, and atrophy of skeletal muscle.
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Orthopedics- CP
bone
fracture tumors infection metabolic miscellaneous
physeal
malunion benign malignant
injury
primary secondary
Bone
Bones may become deformed for many reasons. These include congenital, posttraumatic (from
healing in a deformed position after a fracture, called malunion), tumors, infections, metabolic,
miscellaneous, etc. congenital causes shall discuss under congenital heading.
Bones may be deformed in four ways: angulation (a bend in the bone), rotation or torsion (a twist
in the bone), translation or displacement (a shift in the position of the bone after a fracture or
osteotomy), or limb length discrepancy (a difference in the length of a bone compared with the
other side).
Although each of the different types of bone deformities can exist on its own, it is very common to
see combinations of two or more of these deformity components together.
Clinical clues:
Ask about:
Age at onset of deformity
Whether upper or lower limb site in the limbs, e.g., arm, forearm, thigh, leg
Progressive or non-progressive deformity
History of trauma with fracture of long bones or physis in case of children recent or old, treated
or untreated
Associated with swelling or lump painful or painless, progressive or non-progressive
Fever associated with chills, rigor, evening rise of temperature, bone pain, swelling
Previous history of acute osteomyelitis whether treated partially or completely
History of bony tumors in the patient him/herself or family, e.g. osteochondromata
Discharging sinuses on the limb with pus discharge
Nutritional status of the patient
Socioeconomic status
History of diabetes, hypertension, hyperthyroidism, hyperparathyroidism and their treatment
history
Family history
Functional disabilities or activity of daily living
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Orthopedics- CP
Look for:
Gait in case of lower limb deformity
Involved limb upper or lower, deformity site, characteristics position
If there is a lump, where does it arise? Is it discrete or ill defined? Is it soft or hard, or pulsatile?
And is it tender? Swelling is sometimes diffuse, and the overlying skin warm and inflamed; it can
be difficult to distinguish a tumour from infection.
Nearby joint for an effusion and/or limitation of movement
The examination will focus on the symptomatic part, but it should include the area of lymphatic
drainage and, often, the pelvis, abdomen, chest and spine.
Previous scars or signs of trauma, operations
Discharging sinuses, skin color, excoriation
In children, bowlegs or knock-knees, enlargement of costochondral junctions, and wrists, ankles
etc, suggest the metabolic reason for the deformity rickets.
In elderly patients, bowing of the legs, kyphosis suggests Pagets disease
Distal neurovascular status of the deformed limb
Investigations:
Blood investigations: TC, DC, ESR, CRP, Blood culture and sensitivity when suspecting infection
Culture and sensitivity of the pus from the discharging sinus
Serum electrolytes (calcium, phosphorus, sodium, potassium), urea, creatinine, albumin, alkaline
phosphatase
Thyroid function test, serum parathyroid hormone level (PTH) especially in hyperthyroidism and
hyperparathyroidism.
X-rays of the limb - essential investigations to identify the nature and cause of deformity
CT/MRI - required to see the extent of the tumors, infections, when these are the causes of the
deformity
Bone scan help to differentiate between infection and tumors, and to see the metastases in
cases of malignant tumors, causing limb deformities.
Comments:
I. Trauma: Limb deformity may result from various traumatic sequelae. The most common cause is
fracture malunion, but in growing children, shortening and angulation secondary to physis injury is
also common.
Malunion:
o It is defined as when the fracture fragments have healed in a non-anatomical
position. In malunion, the bone may have healed at a bent angle (angulated),
may be rotated out of position, or the fractured ends may be overlapped causing
bone shortening.
o Whether the deformity is unsightly or not, it can impair function in several ways:
(1) An abnormal joint surface can cause irregular weight transfer and arthritis
of the joint, especially in the lower extremities,
(2) Rotation or angulation of the fragments can interfere with proper balance
or gait in the lower extremities or positioning of the upper extremities,
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Orthopedics- CP
(3) Overriding of fragments or bone loss can result in perceptible shortening;

and
(4) The movements of neighboring joints can be blocked.
o Malunions, by strict definition, commonly are the rule in the closed treatment of
fractures; however, they frequently are compatible with function. A malunited
fracture becomes surgically significant only when it impairs function. Malunions
generally are caused by either inaccurate reduction or ineffective immobilization
during healing. Most malunions could be prevented by skillful treatment of fresh
fractures; however, malunion sometimes occurs despite the most expert treatment.
Physeal injury:
o All long bones of a growing child consist of an epiphysis, physis, and metaphysis at
each end separated by the diaphysis.
o Physis is a Greek word (phyein) which means nature, or to generate, also called
growth plate. In English, it means something that grows or becomes. English medical
dictionaries designate the physis as the segment of bone responsible for growth in
length of the bone.
o Physeal injuries are a common and unique feature of children's bony injuries, in part
because the physis is structurally more susceptible to loads that would produce
metaphyseal or juxta-articular fractures in adults.
o Physeal injury may occur in a variety of ways in addition to trauma. These physeal
injuries sometimes present with complications like physeal arrest-partial or
complete, which might result in angular deformity, joint distortion, limb length
inequality, or combinations of these, depending on the location of the arrest, the
rate and extent of growth remaining in the physis involved, and the health of the
residual affected physis.
II. Tumors:
Tumor is an abnormal growth of tissue resulting from uncontrolled, progressive
multiplication of cells and serving no physiological function; also called neoplasm.
Tumors of the bones may cause bony deformities.
Tumors are graded into benign and malignant, depending on their cytological
characteristics as well as clinical behaviour, i.e. the likelihood of recurrence and spread
after surgical removal. Examples of benign bone tumors- osteochondroma, multiple
hereditary osteochondromata, giant cell tumor, chondroblastoma, etc.
Malignant bone tumors are again subdivided into primary and secondary malignant
tumors. The tumors that originate in the bone are classified to be primary and those that
originate elsewhere in the body other than the bones and metastasize to the bone are
secondary. Examples of primary malignant tumors- osteosarcoma, chondrosarcoma,
Ewings sarcoma; examples of secondary malignant tumors- tumors which originates at
other organs like the lungs, breasts and prostrate, spread to the bone.
Usually the tumors of the growing bone develop deformities. For example, multiple hereditary
osteochondromata of forearm causes deformities like relative shortening of the ulna, bowing
of the radius and/or ulna, increased ulnar tilt of the distal radial epiphysis, ulnar deviation of
the hand, progressive ulnarward translocation of the carpus, and subluxation/dislocation of
the proximal radial head. In addition to relative shortening and cosmetic displeasure, these
deformities commonly produce limited forearm rotation, limited wrist motion, and, when the
radial head dislocates, both elbow pain and loss of motion.
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Orthopedics- CP
III. Infection:
Infections of bone are one of the most common causes of deformities.
Tuberculosis and septic infections cause the largest number of deformities.
It is the sequelae or complications of chronic infections that cause deformities of the limb.
Acute infection seldom causes any deformity. Inflammation of the bone caused by an infective
organism is known as osteomyelitis.
It is classified as acute, subacute and chronic depending upon the duration and ongoing
pathology.
Acute osteomyelitis: duration less than 2 weeks
Subacute infection: duration 2-6 weeks
Chronic infection: duration > 6 weeks
The usual organisms of chronic osteomyelitis (and with time there is always a mixed infection)
are Staphylococcus aureus, Escherichia coli, Streptococcus pyogenes, Proteus mirabilis and
Pseudomonas aeruginosa. Sequestra (dead necrotic piece of bone), involucrum (new bone
formation around the sequestra), sinus formation and ultimately deformed limb are
characteristic features of chronic osteomyelitis.
IV. Metabolic & endocrine:
Metabolic and hormonal disorders may cause skeletal deformities. For example: rickets,
osteomalacia, hyperparathyroidism, and Paget's disease.
Metabolic bone disorders are associated with critical alterations in the regulation of bone
formation, bone resorption and distribution of minerals in bone. Calcium and phosphate are
the bone minerals.
Rickets & osteomalacia: these are different expressions of the same disease - inadequate
mineralization of bone. The most common cause is the deficiency of vitamin D.
o Rickets occurs in children whereas osteomalacia is in adults. In rickets, child may
present with bowlegs or knock knees, swollen joints and disturbed gait. Other bone
changes are deformity of the skull (cranitabes) and thickening of knees, ankles and
wrists from physeal overgrowth, enlargement of the costochondral junctions (rickety
rosary) and lateral indentation of the chest (Harrisons sulcus). They also lag in growth.
In severe rickets, there may be coxa vara, spinal curvature and long bone fractures.
o Osteomalacia has a much more insidious course. Limb deformities like knock knee or
bowlegs are mostly the existing deformities of the adolescent rickets. Patients usually
presents with bone pain, backache and muscle weakness for many years and there may
be vertebral collapse causes loss of height.
Pagets disease:
o Pagets disease is a disorder in which rapid and excessive bone breakdown and formation
lead to large, misshapen bones. As a normal part of keeping bones strong and healthy, the
body breaks down old bone and rebuilds new bone structure.
o In Pagets diseases, one or a few bones begin a fast turnover cycle. As a result, affected
bones are not built correctly, the bones become large but weak, and they break easily.
o Pagets disease affects men and women equally. It is rare in persons younger than 25
years and increases in frequency with increasing age. It is believed to develop in persons in
the fifth decade of life and is most commonly diagnosed in the sixth decade.
o Deformities are seen mainly in the lower limbs. The limb looks bent and feel thick, and the
skin is unduly warm hence the term osteitis deformans.
o In generalized Pagets disease, there may also be considerable kyphosis, so the patient
becomes shorter and ape-like, with bent legs and arms hanging in front of him.
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Orthopedics- CP
Spinal Injuries
spinal injuries
lumbosacral
cervical spine thoracic spine
spine
unstable
stable fractures fractures/fracture-
dislocation
neurologically neurologically neurologically neurologically

stable deficit deficit stable
complete
Incomplete
central cord
syndrome anterior cord
syndrome
posterior cord Brown-Sequard

syndrome syndrome
conus cauda equina

medullaris syndrome
syndrome
Spinal injuries carry a double threat: damage to the vertebral column and damage to the neural tissues.
While the full extent of the damage may be apparent from the moment of injury, there is always the fear
movement may cause or aggravate the neural lesion; hence the importance of establishing whether the
injury is stable or unstable and treating it as unstable until proven otherwise.
A stable injury is one in which the vertebral components will not be displaced by normal
movements; in a stable injury, if the neural elements are undamaged there is little risk of them
becoming damaged.
An unstable injury is one in which there is a significant risk of displacement and consequent
damage or further damage to the neural tissues.
View the spine as three distinct columns: anterior, middle, and posterior (Denis column concept).
1. Anterior column: composed of anterior half of the vertebral body, the anterior part of
intervertebral discs and the anterior longitudinal ligament.
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Orthopedics- CP
2. Middle column: composed of posterior half of the vertebral body, posterior part of intervertebral
disc and the posterior longitudinal ligament.
3. Posterior column: consisting of the pedicles, facet joints, posterior bony arch, interspinous and
supraspinous ligaments.
Stable fractures: examples are fractures of spinous processes, transverse processes, wedge compression
fractures, fractures involving only one column, etc.
Unstable fractures: All fractures involving the middle column and at least one other column and fracture
dislocation of the facet joints should be regarded as unstable. Examples are burst fracture, fracture
dislocation.
A high index of suspicion is essential; symptoms and signs may be minimal; the history is crucial. Every
patient with a blunt injury above the clavicle, a head injury or loss of consciousness should be considered
to have a cervical spine injury until proven otherwise. Every patient who is involved in a fall from a height
or a high-speed deceleration accident should similarly be considered to have a thoracolumbar injury. The
safe approach is to consider the presence of a vertebral column injury in all patients with multiple injuries.
Lesser injuries also should arouse suspicion if they are followed by pain in the neck, back, or neurological
symptoms in the limbs.
Clinical examination and management must go simultaneously with spinal injury patients, as many a times
patients present with multiple injuries. Always start with ABCDE of ATLS (Advanced Trauma Life Support)
protocol. Besides other systemic examinations, accurate and detailed neurological evaluation of patients
with spinal cord injuries is essential. Use of the American Spinal Injury Association (ASIA) impairment scale
is helpful in organizing this evaluation. The patient's mental status and the level of consciousness should
be determined quickly, including pupillary size and reaction. The Glasgow Coma Scale (GCS) is useful in
determining the level of consciousness. A detailed initial neurological examination, including sensory,
motor, and reflex function, is important in determining prognosis and treatment. The presence of an
incomplete or complete spinal cord injury must be determined and documented by meticulous
neurological examination.
Three types of shock may be encountered in patients with spinal injury:
1. Hypovolaemic shock is suggested by tachycardia, peripheral shutdown and, in later stages,
hypotension.
2. Neurogenic shock reflects loss of the sympathetic pathways in the spinal cord; the combination of
paralysis, warm and well-perfused peripheral areas, bradycardia and hypotension with a low
diastolic blood pressure suggests neurogenic shock.
3. Spinal shock occurs when the spinal cord fails temporarily following injury. Below the level of the
injury, the muscles are flaccid, the reflexes absent and sensation is lost. This rarely lasts for more
than 48 hours and during this period, it is difficult to tell whether the neurological lesion is
complete or incomplete. Some neurological improvement can occur as time passes.
ASIA IMPAIRMENT SCALE

A=complete No motor or sensory function is preserved in the sacral segments S4-S5
B=incomplete Sensory but not motor function is preserved below the neurological level and
includes the sacral segments S4-S5
C=incomplete Motor function is preserved below the neurological level, and more than half of key
muscles below the neurological level have a muscle grade less than 3
D=incomplete Motor function is preserved below the neurological level, and at least half of key
muscles below the neurological level have a muscle grade of 3 or more
E=normal motor and sensory function are normal
48
Orthopedics- CP
cervical spine
injuries
unstable
stable
fractures/fracture-
fractures
dislocation

intact deficit deficit intact
complete incomplete incomplete complete
central cord
syndrome
anterior cord
syndrome
posterior cord
syndrome
Brown-
Sequard
syndrome
49
Orthopedics- CP
cervical spine
injuries
unstable
dislocation

Cervical spine injuries:

Clinical clues
Ask about:
Mechanism of injury
o Road traffic accidents
o Fall from the height
o Sports injuries
o Gunshot injuries
o Physical assault etc
Time of injury
Headache, neck pain & shoulder pain
Presence and distribution of upper and/or lower extremity numbness, paresthesias, or weakness
Unable to move the upper and/or lower extremities
Bladder and bowel habits after the injury
Past medical history history of rheumatoid arthritis (increased risk atlantoaxial disruption)
Unconscious patients due to head injury ask the accompanied people, could be patients
relatives, police or volunteers.
History of alcohol intoxication or drug overdose
50
Orthopedics- CP
Look for:
ATLS (Advanced Trauma Life Support) Primary survey
A Airway
B breathing
C circulation
D Disability, includes (AVPU)
E Exposure
Mental status and level of consciousness whether conscious, semi-conscious or unconscious,
Glasgow coma scale
Semi-conscious or unconscious patients consider cervical spine injuries until and otherwise
proved by the radiological examination apply hard Philadelphia cervical collar.
Secondary survey head to toe examinations and systemic examination including vital signs
Any scalp lacerations, haematoma, facial lacerations, ear or nose bleeding or CSF leaking
suggestive of skull fractures
Deformity of cervical spine, bruises, abrasions around the neck
Tenderness on palpation of spinous processes
Feel for the defects in the inter-spinous regions
Evidence of intoxications drugs, alcohol
Neurologic examination includes assessment of sensation, motor function and reflexes to identify
objective signs of focal deficit, such as paraesthesia, weakness or decreased/absent deep tendon
reflexes.
If the patient has a neurologic deficit, pay special attention to
Rectal tone, sacral sensation, and bowel and bladder function in order to avoid missing
injuries to the conus medullaris and cauda equina, as well as documenting complete vs.
incomplete cord injury.
Priapism in male patients
Bulbocavernosus reflex & anal wink
Spinal shock
Investigations:
Radiological examination X-rays of Cervical spine anteroposterior and lateral views, but in
cases of acute trauma, only lateral view is done along with the chest and pelvis anteroposterior
views. It is essential that all 7 vertebral bodies are visualized on the X-Ray.
CT scan in doubtful cases, or when unstable fractures are suspected, it is most important to view
the clear picture of the fracture or fracture-dislocation.
MRI important diagnostic tool when neurological deficit is present as well, to view the cervical
spinal cord injury
51
Orthopedics- CP
Comments:
The cervical spinal column is extremely vulnerable to injury. The seven cervical vertebrae, whose
specific facet joint articulations allow movement in the planes of flexion, extension, lateral
bending, and rotation, have attached at the cephalic aspect the skull and its contents.
Injury occurs when forces applied to the head and neck result in loads that exceed the ability of
the supporting structures to dissipate energy.
Injuries of the cervical spine produce neurological damage in approximately 40% of patients.
Approximately 10% of traumatic cord injuries have no obvious radiographic evidence of vertebral
injury.
The most common site of fracture in the cervical spine is C2 (including the odontoid), which
accounts for roughly 24% of fractures. C3 is the least likely vertebra in the cervical spine to be
fractured. Dislocations occur most commonly at C5-C6 or C6-C7 and uncommonly at C7-T1 and the
atlanto-occipital complex.
Children (<12 years) and the elderly (>50 years) usually sustain injury to the upper cervical spine
(C1-C3); approximately 43% of injuries in patients older than 50 years involve the atlanto-axial
complex. Teens and young to middle-age adults (12-50 years old) usually sustain injury to the
lower spine (C6-T1).
In a patient unconscious from a head injury, a fractured cervical spine should be assumed (and
acted upon) until proved otherwise.
The normal anatomy of the cervical spine consists of 7 cervical vertebrae separated by
intervertebral disks and joined by a complex network of ligaments. These ligaments keep
individual bony elements behaving as a single unit.
The atlas (C1) and the axis (C2) differ markedly from other cervical vertebrae. The atlas has no
vertebral body; however, it is composed of a thick anterior arch with 2 prominent lateral masses
and a thin posterior arch. The axis contains the odontoid process that represents fused remnants
of the atlas body. The odontoid process is held in tight approximation to the posterior aspect of
the anterior arch of C1 by the transverse ligament, which stabilizes the atlantoaxial joint. Apical,
alar, and transverse ligaments provide further stabilization by allowing spinal column rotation; this
prevents posterior displacement of the dens in relation to the atlas.
Approximately every fifth severe cervical spine injury is associated with paralysis or at least a loss
of sensation. This is the result of compression or distortion damaging the spinal cord and the
exiting nerves. Compression damage can be a result of vertebrae being traumatically displaced in
relation to each other, fragments of bone shooting into the spinal canal and bleeding in the spinal
cord or the spinal column.
Typical deficits occur depending on the level damaged by these injuries.
Injuries to the upper cervical spine region can result in immediate respiratory and
circulatory arrest as the vitally important centers for breathing and circulation are found
in the near vicinity. These injuries often cause death unless resuscitation is started straight
away.
Injury to the spinal cord above the fourth cervical vertebra can also cause major problems
with breathing as the nerves for the diaphragm exit the vertebral column at this point.
Loss of nerve function can present as so-called complete or incomplete quadriplegia. A
complete quadriplegic syndrome at the cervical spine is not only characterized by the
complete loss of function in the arms and legs, it is also characterized by the complete loss
of sensation below the injured spinal level. This is usually associated with disturbances to
the autonomic nervous system that can affect the regulation of the circulation, bowel, and
the emptying of bladder and bowel.
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Orthopedics- CP
Classification of Cervical Spine Injuries: Cervical spine injuries are best classified according to several
mechanisms of injury.
Flexion injuries: Flexion Injuries cause compression of the anterior column and distraction of the
posterior column. This result in varying degrees of crush to the anterior aspect of the vertebral
body, and ligamentous disruption and widening of the posterior column (crushed in the front and
wide in the back). E.g. simple wedge fractures, flexion teardrop fractures, unilateral facet
dislocations
Extension Injuries: Extension injuries cause distraction of the anterior column and compression of
the posterior column. There is variable disruption and widening of the anterior ligaments and
varying degrees of crush of the posterior elements (wide in the front and crushed in the back).
Examples hangmans fracture, extension teardrop fractures, posterior atlantoaxial dislocation,
etc.
Axial Load Injuries: Axial load injuries cause compression of both the anterior, middle and
posterior columns. These are the result of forces from above (skull) or below (pelvis) that are
applied to the vertebral column in neutral position at the time of impact. Adjacent vertebral
bodies are forced against each other with overwhelming force. The resultant vectors cause the
vertebral body to shatter outward, resulting in a burst fracture.
Rotational Injuries: Rotational injuries cause varying degrees of rotation of the anterior, middle
and posterior columns, usually around a facet dislocation. This occurs when one of the facets acts
as a fulcrum, and rotation plus flexion allows the contralateral facet to dislocate. The superior
facet jumps above and anterior to the inferior facet. Thus the superior facet comes to rest in the
intervertebral foramen, resulting in a locked in position and a stable injury (even though the
posterior ligaments are somewhat disrupted).
Multiple or Complex Injuries: Common injuries associated with multiple or complex mechanisms
include odontoid fracture, fracture of the transverse process of C2 (lateral flexion), atlanto-
occipital dislocation (flexion or extension with a shearing component), and occipital condyle
fracture (vertical compression with lateral bending).
neurologically
deficit
complete incomplete
Brown-
central cord anterior cord posterior cord
Sequard
syndrome syndrome syndrome
syndrome
53
Orthopedics- CP
Clinical clues:
Ask about:
Mechanism of injury
Time of injury
Loss of consciousness, vomiting, seizures (features of head injury)
Weakness, numbness or paresthesias of the limbs or unable to move the limbs (upper and lower
limbs)
Bowel and bladder habits
Look for:
Neurologic examination includes assessment of sensation, motor function and reflexes to identify
objective signs of focal deficit, such as paraesthesia, weakness or decreased/absent deep tendon
reflexes.
Spinal shock
Sensory examinations:
Light touch,
Pinpricks (using a sterile needle), beginning at the head and neck and progressing distally,
to examine specific dermatome distributions. Important dermatome landmarks are the
nipple line (T4), xiphoid process (T7), umbilicus (T10), inguinal region (T12, L1), and
perineum and perianal region (S2, S3, and S4).
Temperature, vibration sensations
Motor examinations:
Upper extremities and lower extremities key muscle groups and their corresponding
nerve root levels that should be evaluated in a patient with spinal cord injury.
Key Muscle Groups Used in Motor Source Evaluation of Spinal Cord Injury
Level Muscle Group
C5 Elbow flexors (biceps, brachialis)
C6 Wrist extensors (extensor carpi radialis longus and brevis)
C7 Elbow extensors (triceps)
C8 Finger flexors (flexor digitorum profundus to the middle finger)
T1 Small finger abductors (abductor digiti minimi)
L2 Hip flexors (iliopsoas)
L3 Knee extensors (quadriceps)
L4 Ankle dorsiflexors (tibialis anterior)
L5 Long toe extensors (extensor hallucis longus)
S1 Ankle plantarflexors (gastrocnemius, soleus)
Bulbocavernosus reflex
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Orthopedics- CP
Anal wink reflex

Comments:
Most of the stable fractures do not have neurological deficit, it is the unstable fractures that
present with neurological deficits, which may be complete or incomplete.
In case of complete neurological deficit, the prognosis is poor, with no hope for recovery.
Incomplete spinal cord injury: Evidence of sacral sensory sparing suggests the incomplete
neurological deficit. During motor examination, it is important to differentiate between complete
and incomplete spinal cord injuries and pure nerve root lesions.
Spinal shock is a specific term that relates to the loss of all neurological activity below the level
of injury. This loss of neurological activity includes loss of motor, sensory, reflex and autonomic
function. Spinal shock is a short-term temporary physiologic disorganization of spinal cord
function that can start between 30-60 minutes following a spinal cord injury. Although spinal
shock generally resolves within 24 hours, it may last longer.
A positive bulbocavernosus reflex or return of the anal wink reflex indicates the end of spinal
shock. If no motor or sensory function below the level of injury can be documented when spinal
shock ends, a complete spinal cord injury is present, and the prognosis is poor for recovery of
distal motor or sensory function.
Incomplete spinal cord injury syndromes:
1. Central cord syndrome:
Most common
Consists of destruction of the central area of the spinal cord, including gray and
white matter
Mechanism hyperextension injury
Centrally located arm tracts in the cortical spinal area are the most severely
affected, and the leg tracts are affected to a lesser extent, that is why patients
have a quadriparesis involving the upper extremities to a greater degree than the
lower.
Sensory sparing varies, but usually sacral pinprick sensation is preserved.
2. Anterior cord syndrome:

Mechanism usually is caused by a hyperflexion injury in which bone or disc
fragments compress the anterior spinal artery and cord.
It is characterized by complete motor loss and loss of pain and temperature
discrimination below the level of injury.
The posterior columns are spared to varying degrees, resulting in preservation of
deep touch, position sense, and vibratory sensation.
Prognosis for significant recovery in this injury is poor.
3. Posterior cord syndrome:

Involves the dorsal columns of the spinal cord and produces loss of proprioception
vibrating sense, while preserving other sensory and motor functions.
This syndrome is rare and usually is caused by an extension injury.
55
Orthopedics- CP
4. Brown-Squard syndrome:
An injury to either half of the spinal cord and usually is the result of a unilateral
laminar or pedicle fracture, penetrating injury, or rotational injury resulting in a
subluxation.
It is characterized by motor weakness on the side of the lesion and the
contralateral loss of pain and temperature sensation.
Prognosis for recovery is good, with significant neurological improvement often
occurring.
thoracic spine
injuries
unstable
dislocation

incomplete complete incomplete complete
Thoracic spine injuries:

Clinical clues:
Ask about:
Mechanism of injury
o Road traffic accidents
o Fall from the height
o Sports injuries
o Gunshot injuries
o Physical assault etc
Time of injury
Upper or lower back pain
History from the witnesses in patients who present in semiconscious or unconscious states
Presence and distribution of upper and/or lower extremity numbness, paresthesias, or weakness
Unable to move the upper and/or lower extremities
Bladder and bowel habits after the injury
previous spine injury, prior neurologic deficit
History of alcohol intoxication or drug overdose
Other limbs pain, deformity, abdominal pain, etc (distracting injuries)
56
Orthopedics- CP
Look for:
Start with primary survey, ABCDE according to ATLS (Advanced trauma life support) protocol.
Level of consciousness and mental status according to GCS
Patient should be kept in spinal board, until the spinal injuries are ruled out.
Secondary survey, including vital signs.
Logroll the patient to examine the spine and look for:
Ecchymoses, abrasions, lacerations, or swelling;
Palpation of the spine for focal tenderness at the fracture site and reveal an obvious step
off between the spinous processes, crepitus, soft tissue defects, or other signs of mal-
alignment.
A comprehensive neurologic evaluation
Motor examination Upper extremities and lower extremities key muscle groups and
their corresponding nerve root levels. Grading of muscle power according to Medical
Research Council (MRC) scale, 0-5, where 0 is complete paralysis and 5 is normal with
variable degrees of weakness between 1-4 grades.
Sensory examination Light touch, Pinpricks, Temperature, vibration sensations, position
sensation.
Reflex tests of upper and lower extremities, including bulbocavernous reflex, anal wink,
anal tone. In upper extremity, look for biceps, triceps, and supinator reflexes. In lower
extremity, look for ankle, knee, and patellar reflexes.
Bladder and bowel habits whether retention or incontinence of urine.
Spinal shock
Grading of spinal injury according to the ASIA impairment scale.
Investigations:
Radiological examination X-rays of thoracic spine anteroposterior and lateral views.
MRI important diagnostic tool when neurological deficit is present as well, to view the thoracic
spinal cord injury
Comments:
Fracture of the thoracic spine is a break (fracture) of one or more of the 12 bones of the thoracic
spine (vertebrae T1 through T12) in the upper back.
The thoracic spine is the longest section of the spine, with smaller vertebrae, a smaller spinal
canal, and a less developed vascular system than the lumbar region. It is also the most stable
spinal section due to support from the ribs and ribcage; significant force is needed to injure
thoracic vertebrae.
Most thoracic spine fractures occur in the lower thoracic spine, with 60% to 70% of thoraco-
lumbar fractures occurring in the T12 to L2 region. The majority of these fractures (75% to 90%)
occur without spinal cord injury.
Major trauma is the most common cause of thoracic fractures, including motor vehicle accidents,
falls, sports injuries, and violence.
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Orthopedics- CP
Minor trauma can also cause a thoracic spine fracture in individuals who have a condition
associated with loss of bone mass (e.g., osteoporosis).
A thoracic fracture should be suspected in the setting of poly-trauma until proved otherwise,
especially when the patient may be distracted by injuries to other organ systems.
Patient must be stabilized properly in spinal board, until clear the spinal injuries by clinical and
radiological assessments.
Spinal shock comments as previously
There are various classification system for thoracic spine fractures, but the following four major
types of thoracic spine injury are described, based on the mechanism of injury:
1) Compression also termed wedge fractures, stable type of fracture, mostly without
neurological deficit. It is common in upper thoracic vertebrae. Usually caused by fall
from a height. Minor trauma can cause a thoracic spine fracture in individuals with
osteoporosis or a loss of bone mass. Most vertebral compression fractures are related
to osteoporosis, with up to 50% occurring without an accompanying trauma.
2) Burst entire vertebra is crushed, mostly unstable and associated with neurological
deficit. Common in lower thoracic and upper lumbar spine (also called thoraco-lumbar
junction). Usually caused by fall from a height.
3) Flexion-distraction Flexion-distraction fractures (seatbelt injury, lap belt injury,
Chance fracture) involve the separation (distraction) of the fractured vertebra, and are
caused by hyper-flexion during the traumatic event. Flexion-distraction fractures
rarely occur in the thoracic spine but can occur during a motor vehicle accident if the
seat belt is worn high and without a shoulder harness.
4) Fracture-dislocation Fracture-dislocations, in which vertebral fractures are found in
combination with displacement (dislocation) of adjacent vertebrae, are caused by
high-energy trauma. Fracture-dislocations are unstable and can cause complete
neurologic deficit (paraplegia) in 90% of individuals injured above T10 and in 60% of
individuals injured below the T10 vertebral level.
58
Orthopedics- CP
lumbosacral spine
injuries
unstable
dislocation

complete incomplete incomplete complete
Conus medullaris
syndrome
cauda equina
syndrome
Lumbar Spine injuries:

Clinical clues:
Ask about:
Mechanism of injury
Time of injury
Low back pain, wounds, deformity
Change in bowel and bladder habits after the injury retention or incontinence
Weakness, numbness & altered sensation in the lower limbs
Unable to move the lower limbs as a whole or any particular movements
History of associated loss of consciousness, vomiting or seizures
Look for:
Start with primary survey, ABCDE according to ATLS (Advanced trauma life support) protocol.
Level of consciousness and mental status according to GCS
Patient should be stabilized in spinal board, until spinal injury is ruled out clinically and
radiologically.
vital signs BP especially for hypotension, Pulse bradycardia/tachycardia, Respiratory rate,
oxygen saturation
Secondary survey look for chest or abdomen injuries, orthopaedic injuries including pelvis and
extremities fractures and head trauma.
Log roll the patient to examine the spine and look for:
59
Orthopedics- CP
Ecchymoses, abrasions, lacerations, or swelling;

Palpation of the spine for focal tenderness at the fracture site and reveal an obvious step
off between the spinous processes, crepitus, soft tissue defects, or other signs of mal-
alignment.
A comprehensive neurologic evaluation of the lower extremities
Motor examination key muscle groups and their corresponding nerve root levels.
Grading of muscle power is according to Medical Research Council (MRC) scale.
L2 Hip flexors (iliopsoas)
L3 Knee extensors (quadriceps)
L4 Ankle dorsiflexors (tibialis anterior)
L5 Long toe extensors (extensor hallucis longus)
S1 Ankle plantarflexors (gastrocnemius, soleus)
Sensory examination Light touch & pinpricks (using a sterile needle) to examine specific
dermatome distributions. Sensory dermatome of the lower limb:
L2 upper thigh
L3 around the knees
L4 medial aspect of the leg
L5 lateral aspect of the leg, medial side of the dorsum of the foot
S1 lateral aspect of the foot, the heel and most of the sole
S2 posterior aspect of the thigh
S3, S4, S5 concentric rings around the anus, the outermost of which is S3
Reflex tests lower extremities, including bulbocavernous reflex, anal wink, anal tone,
Babinski sign
Bladder and bowel habits whether retention or incontinence of urine.
Spinal shock
Grading of spinal injury is according to the ASIA impairment scale.
Per rectal examination in both sexes & vaginal examination in females as sacral fractures may be
associated with pelvic injuries.
Investigations:
Radiological examination X-rays of lumbosacral spine anteroposterior and lateral views.
MRI important diagnostic tool when neurological deficit is present.
60
Orthopedics- CP
Comments:
The lumbar spine consists of a mobile segment of 5 vertebrae, which are located between the
relatively immobile segments of the thoracic and sacral segments. The thoracic spine is stabilized
by the attached rib cage and intercostal musculature, whereas the sacral segments are fused,
providing a stable articulation with the ilium.
The lumbar spine is a complex 3-dimensional structure, capable of flexion, extension, lateral
bending, and rotation. The total range of motion is the result of a summation of the limited
movements that occur between the individual vertebrae. Strong muscles and ligaments are crucial
in supporting the bony structures and in the initiation and control of movements.
Thoracolumbar spine is the part of the vertebral column from the eleventh thoracic vertebra to
the second lumbar vertebra. Here the spinal curvature changes from kyphosis to lordosis and the
orientation of the facet joints changes from coronal to sagittal. This transitional zone may
experience substantial biomechanical stresses during traumatic incidents, which generally make it
more susceptible to fracture.
Fractures of the thoracolumbar vertebrae are more common than the lower lumbar and sacral
vertebrae.
Fractures of the thoracolumbar junction can produce a mixture of cord and root syndromes
caused by lesions of the conus medullaris and lumbar nerve roots. Complete damage of the conus
medullaris is manifested as no motor function or sensation below L1. Patients with complete
damage to the sacral portion of the cord have loss of control of bowel and bladder function and
sacral motor paralysis of the lower extremities with preservation of some movement of the hips
and knees and preserved knee jerks and sensation in the lumbar dermatomes.
Lower lumbar fractures may cause solitary or multiple root deficits. However, fracture-
dislocations, and burst fractures in the lumbar region can cause a cauda equina syndrome with
variable paraparesis, asymmetrical saddle anesthesia, radiating pain, and sphincter disturbances.
Patients with lumbosacral fractures present with severe pain, deformity, and neurologic deficits
related to compression of neural structures.
Sacral fractures and lumbosacral dislocation are rare spinal fractures. They frequently are
associated with pelvic fractures and often are overlooked. A high index of suspicion is necessary to
diagnose sacral fractures in patients with multiple trauma. These patients should be examined
carefully for sacral root dysfunction, suggested by decreased perianal sensation and rectal
sphincter disturbance. Decreased ankle jerk reflexes and absence of a bulbocavernosus reflex also
may suggest sacral root injury.
Stable and unstable injuries are classified according to the three-column concept as mentioned
earlier. When only one column or transverse, or spinous processes are fractured, it is considered
as stable injuries whereas if middle column with any other column is involved, then it is
considered as unstable injuries; examples are burst fracture, fracture dislocation.
Lumbar vertebrae fractures are also classified according to the mechanism of injury into
compression, burst, fracture-distraction, and fracture-dislocation. Sacral vertebrae fractures are
classified according to the anatomical location of fracture, e.g. fracture of sacral alar,
transforaminal fracture and fracture involving spinal canal.
The physical examination of a patient with an acute lumbosacral fracture usually is limited by
severe pain. In the spinal examination, inspect the overlying skin for abrasions or contusions. Pay
attention to general deviations from the normal spine curves. Muscle spasm from pain frequently
flattens the spine, whereas spinal fractures may cause a kyphotic or scoliotic deformity. In
addition, palpate the spine for areas of tenderness or fractured or displaced spinous processes.
61
Orthopedics- CP
Multiple traumatic injuries, spinal shock, or sedation can make the initial neurologic examination
difficult. Document any neurologic deficit according to the American Spinal Injury Association
(ASIA) Motor Index. In all conscious patients, perform a motor examination. Muscle strength and
weakness are graded from a strength of 5/5, considered normal, to a strength of 0/5, considered
paralysis.
In addition, a detailed neurologic evaluation should include evaluation of sensory level, posterior
column function, normal and abnormal reflexes, and examination of rectal tone and perianal
sensation. The cutaneous abdominal reflex, bulbocavernosus reflex, anal wink, and the presence
of the Babinski sign also should be noted and documented. Always include a rectal examination to
check for rectal tone and voluntary sphincter function.
Repeat the neurologic examination and document the findings at regular intervals to monitor for
improvement or deterioration in the patient's neurologic status over time.
Spinal shock can last 24-48 hours, suppressing all reflex activity below the level of the lesion. The
return of reflex activity (bulbocavernosus and anal reflexes) in the absence of any return of
sensation or motor function generally is a poor prognostic indicator. Some return of motor or
sensory function below the level of the lesion indicates the possibility of some return of useful
neurologic function.
Conus medullaris syndrome:
Injury of the sacral cord (conus) and lumbar nerve roots within the spinal canal
Usually results in areflexic bladder, bowel, and lower extremities.
Most of these injuries occur between T11 and L2 and result in flaccid paralysis in the
perineum and loss of all bladder and perianal muscle control.
The irreversible nature of this injury to the sacral segments is evidenced by the absence of
the bulbocavernosus reflex and the perianal wink.
Motor function in the lower extremities between L1 and L4 may be present if nerve root
sparing occurs.
Cauda equina syndrome:
Injury between the conus and the lumbosacral nerve roots within the spinal canal
Results in areflexic bladder, bowel, and lower limbs
With a complete cauda equina injury, all peripheral nerves to the bowel, bladder, perianal
area, and lower extremities are lost, and the bulbocavernosus reflex, anal wink, and all
reflex activity in the lower extremities are absent, indicating absence of any function in
the cauda equina.
The cauda equina functions as the peripheral nervous system, and there is a possibility of
return of function of the nerve rootlets if they have not been completely transected or
destroyed.
Most often, cauda equina syndrome manifests as a neurologically incomplete lesion.
62

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Orthopedics- CP

Extra Articular Limb Pain

Soft tissue injuries

Infective Vascular Neurological Tumor

AOM Thrombophlebitis PIVD Bony

Arterial Spinal/Root Canal

High Energy Low Energy

Fracture Dislocation Soft tissue Fracture Dislocation Soft tissue

High energy Low energy

Fracture Dislocation Soft tissue

New Fracture Old Fracture

Stress/Fatigue Insufficiency Pathological

Monoarticular Polyarticular Periarticular

Metabolic (gout, Degenerative e.g.

Traumatic e.g. fractures,

Others e.g. bleeding

Monoarticular Polyarticular Periarticular

Fungal Hemarthrosis Degenerative

Oligoarticular or polyarticular joint pain can generally be classified as inflammatory or non-inflammatory.

Polynodular osteoarthritis mimics the features of Rheumatoid Arthritis with subcutaneous

Superficial eg. soft

LOW BACK PAIN

Low Back Pain

Traumatic Atraumatic Local Referred

Spondylogenic Neurogenic Viscerogenic

Degenerative Inflammatory Vascular

Low Back Pain

Low Back Pain

Low Back Pain

Low Back Pain

Red Flag Signs

Upper limb Lower limb Joint Bone

Primary causes Secondary causes Fracture

upper limb lower limb

primary causes secondary causes

Functional disabilities, activity of daily living (ADL)

Primary muscle Post-traumatic

Peripheral nerve Prolonged

Peripheral nerve injuries:

fracture tumors infection metabolic miscellaneous

(3) Overriding of fragments or bone loss can result in perceptible shortening;

neurologically neurologically neurologically neurologically

posterior cord Brown-Sequard

conus cauda equina

ASIA IMPAIRMENT SCALE

neurologically neurologically neurologically neurologically

complete incomplete incomplete complete

neurologically neurologically neurologically neurologically

Cervical spine injuries:

Level Muscle Group

C5 Elbow flexors (biceps, brachialis)

C6 Wrist extensors (extensor carpi radialis longus and brevis)

C7 Elbow extensors (triceps)

C8 Finger flexors (flexor digitorum profundus to the middle finger)

T1 Small finger abductors (abductor digiti minimi)

L2 Hip flexors (iliopsoas)

L3 Knee extensors (quadriceps)

L4 Ankle dorsiflexors (tibialis anterior)

L5 Long toe extensors (extensor hallucis longus)

S1 Ankle plantarflexors (gastrocnemius, soleus)

Anal wink reflex

2. Anterior cord syndrome:

3. Posterior cord syndrome: