SECTION 1

GENERAL ORTHOPAEDICS

ORTHOPAEDIC DIAGNOSIS

HISTORY
Symptoms

Pain The main value of estimating severity is in assessing the progress of the
disorder or the response to treatment

Grade I (mild) Pain that can easily be ignored.

Grade II (moderate) Pain that cannot be ignored,

interferes with function and needs attention or
treatment from time to time

Grade III (severe) Pain that is present most of the

time, demanding constant attention or treatment.

Grade IV (excruciating) Totally incapacitating pain.

Deformity
Weakness Instability

The patient may complain

that the joint gives way or jumps out of place. If this happens
repeatedly

Change in sensibility
Loss of function What cant you do now that you
used to be able to do?

Stiffness Patients often have difficulty in distinguishing localized stiffness from PAST HITORY
painful movement; limitation of movement should never be assumed until verified by
examination.

Swelling

It followed an injury

Appeared rapidly (haematoma/haemarthrosis)

Slowly (inflammation/joint effusion/infection/tumor)

Painful

Constant/comes and goes

Increasing in size?

Patients often forget to mention previous illnesses or

accidents, or they may simply not appreciate their relevance to the present complaint,
previous medication

FAMILY HISTORY dx in family help w diagnosis & counseling,

communicable disease

SOCIAL BACKGROUND habit (food, drink, smoke), work,

What has the patient lost and what is he or she hoping to regain?

Examination begin from the moment we set eyes on patient

Look
Shape & Posture
Skin colour, quality, marking
General survey

Feel skin, soft tissue, bone & joints, tenderness

Move
Active movement
Passive mobility
Abnormal/unstable movement
Provocative movement reproducing the patients symptoms by applying a specific, provocative movement

Neurological exam weakness or incoordination or a change in sensibility, or if they point

to any disorder of the neck or back, a complete neurological examination of the related part is mandatory

Appearance the claw hand of an ulnar nerve lesion; drop wrist following radial nerve palsy; or
the waiters tip deformity of the arm in brachial plexus injury

Muscle tone spasticity/flaccidity

Power
Tendon reflex
Superficial reflex abdominal (T7T12), cremasteric (L1, 2) and anal (S4, 5)
Plantar reflex
Sensibility
Cortical & cerebellar function

Physical variatons & deformity

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

Cause of joint deformity

Contracture of the overlying skin severe scarring flexor aspect
Contracture of subcutaneous fascia
Muscle contracture fibrosis&contracture that cross jointfixed deformity
Muscle imbalance unbalance muscle weakness/spasticityjoint deformity (polio/CP)
Joint instability
Joint destruction

Cause of bone deformity

Acquired deformities in children fractures involving the physis (growth
plate); ask about previous injuries. Other causes include rickets, endocrine
disorders, malunited diaphyseal fractures and tumours
Acquired deformities of bone in adults previous malunited fractures.
Causes such as osteomalacia, bone tumours and Pagets disease should
always be considered.

Bony lumps faulty dev,injury,inflam,tumor

Size large att to bone/getting bigger
Site near joint/in the shaft
Margin well-defined/vague
Consistency bony hard/can be indented
Tenderness
Multiplicity uncommon

Joint stiffness
All movement absent
All movement limited
One or two movement
limited

Diagnostic imaging
Plain film radiography
Xray using contrast media
Sinography
Arthrography
Myelography

Plain tomography
Computed tomography (CT)
MRI
Diagnostic Ultrasound
Radionuclide imaging
Single photon emission tomography
Positron emission tomography
Bone mineral densitometry

 Blood test
Non specific blood test
Rheumatoid factor tests
Tissue typing

Synovial fluid analysis

Bone biopsy
Diagnostic arthroscopy

INFECTION

The principles of treatment are

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

ACUTE HAEMATOGENOUS OSTEOMYELITIS

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

Pathology
Caharacteristic progression inflammation, suppuration, bone necrosis, reactive new bone formation resolution&healing/intractable
chronicity

Clinical feature
Children
>4 years, severe pain, malaise & fever, he/she refused to use limb/to be
handheld/touch, recent history of infection
Infant
<1 year, fail to thrive, drowsy but irritable, birth difficulty?, umbilical art cath
Adult
Common site thoracolumbar spine, history of uro procedure followed mild
fever&back ache

Diagnostic imaging
Plain xray
First weekno abnormality, 2nd weekfaint extracortical outline due to periosteal
new bone formationperiosteal thickening more obvious + patchy rarefaction
metaphysisragged feature of bone destruction appear

USG
Subperiosteal collection of fluid (cant dist. haemtom/pus)

Radionuclide scanning
Radioscintigraphy with Tc-HDP reveals increased activity in both the perfusion
phase and the bone phase
99m

MRI

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

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

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

 Surgical drainage
If antibiotic given in first 48 h usually no need drainage.
Clinical features does not improve within 36 hours starting treatment/earlier

Complication
Epiphyseal damage & altered bone growth
Suppurative arthritis
Metastatic infection
Pathological fracture
Chronic osteomyelitis

SUBACUTE HAEMATOGENOUS
OSTEOMYELITIS
Pathology
In well-defined cavity in cancellous bone containing glairy seropurulent fluid
(rarely pus)lined by acute&chronic inflamm cellsurrounding trabeculae
thickenederode bony cortex

Clinical features
Child/adolescent, pain near larger joint for several weeks/months
May have limp
Slight swelling, local tenderness
Normal temperature

Imaging
Circumscribed, round/oval radioluscent cavity 1-2 cm diameter
cavity is surrounded by halo of sclerosis (Brodies abcess)

Diagnosis
The diagnosis remains in doubt until a biopsy is performed
If fluid is encountered, it should be sent for bacteriological culture
The organism is always Staphylococcus aureus

Treatment
Immobilization
Antibiotics flucoxacillin+fusidic acid (iv) 4-5 days Oral for another 6w

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

Treatment
Essenceprophylaxis
Thorough cleansing & debridement of open fracture
The provision of drainageleaving wound open
Immobilization of fracture
Antibiotics flucoxacillin + benzylpencillin/sodium fusidate 6-hours for 48 hours,
if contaminated + metronidazole for 4-5 days
Regular wound dressing & repeated excision of all dead & infected tissue

CHRONIC OSTEOMYELITIS