Examination of Bone and joint pathology

Dr.S.M.Muhammad Thahir Assistant Professor Saveetha medical college

The Basics
History Look Feel Move Special Tests

History taking
Name Age Sex Social status Occupation Chief complaints History of presenting illness Past History Family history Drug history

History
History of trauma Nature of symptoms Pain, instability, swelling Duration of symptoms History of arthropathy Gout, rheumatoid, psoriatic History of immunocompromise Steroids, diabetes

Age of the patient and site of the bone

Solitary cyst - Children Osteogenesis imperfecta - Children Acute osteomyelitis - Children Tuberculosis Any age, Pagets disease old age, All benign bone tumours Adolescent and young adults Osteoclastoma 20 to 30 yrs, Osteosarcoma 15 to 30 yrs, Multiple myeloma 30 to 50 yrs, Primary carcinoma young adults, Secondary carcinome old age.

Onset and progress

H/O Trauma

Acute onset High grade fever Osteomyelitis,

Short history of swelling with fast growth Malignant tumours.

Pain
Always associated with inflammation, Pain first and swelling later Malignant growth Osteosarcoma. Others painless swelling to start.

Duration
Very short duration Acute osteomyelitis, Chronic duration Benign bony swelling,

Relatively short duration Malignant swelling,

General examination
Anemia, cachexia and malnutrition Secondaries Toxic features ( Fever , malaise and tachycardia) Infection Lymphadenopathy Tuberculosis.

Local examination
Look Feel

Move
Measure Special test

Look
Scars of surgery Deformity Swelling Muscle wasting Skin changes erythema/psoriasis/eczema Bone/muscle contours Comparison to unaffected side

Benign Swelling

Malignant swelling

Chronic osteomyelitis

Feel
Temperature Tenderness Swelling Site Size/Shape Surface Edge Consistency Pulsation Effusion Bony prominences.

Move
Range of movement Active and Passive Stress tests

Shoulder Examination

History
Age 2nd & 3rd decades instability 4th & 5th decades impingement, frozen shoulder, inflammatory joint disease 6th decade onwards rotator cuff tears , degen joint disease Hand dominance Occupation

Pain ACJ pain usually well localised Neck pain, pain over trapezius or medial border of scapula usually cervical in origin Assoc pain in wrist or hand +/parasthesiae usually neurogenic Poorly localised pain from deltoid region usually subacromial and rotator cuff pathology

Pain Night pain often rotator cuff disease, glenohumeral arthritis and frozen shoulder Sudden onset excruciating pain is typical of reorptive phase of acute calcific tendonitis Pain occurring in part of the range of shoulder abduction is termed painful arc

Instability
Any history of trauma? Was shoulder dislocated? How many dislocations since then? Was dislocation spontaneous? If atraumatic dislocation is there history of joint laxity? Painless clicks in the shoulder are common and usually have no significance

Weakness
Following traumatic event - important to exclude brachial plexus injury May be due to pain (would examine with local anaesthetic joint examination in shoulder clinic)

Stiffness
Restriction of both passive and active movements Usually associated with frozen shoulder, osteoarthritis, rheumatoid arthritis, chronic dislocation and cuff tear

Examination

Inspection (Look)
Undressed to the waist (bra can stay on) Observe for difficulty getting undressed Scars Asymmetry or deformity of sternoclavicular joints Outline and contour of clavicles and ACJ compared

Inspection (Look)
Squaring off of the shoulder profile from anterior dislocation, deltoid wasting or erosive arthritis with medialisation of humeral head Bulk of pectoral and trapezius muscles should be compared Pop-Eye appearance of biceps might signify rupture of long head of biceps Winging of scapula caused by injury to long thoracic nerve

Palpation (Feel)
Start with sternoclavicular joint medially Move along clavicle to ACJ Tenderness over ACJ assoc with degen change (common and not nec. abnormal) and traumatic subluxation

Palpation (Feel)
Palpation lateral and inferior to coracoid assoc with inflammatory arthropathy or primary frozen shoulder Palpation should continue anterolaterally to intertubercular sulcus on humerus. Pain here may suggest biciptal tendonitis Palpation of posterior joint line, where pain is more typical of osteoarthritis

Movement
Assess cervical spine to see if neck movements recreate shoulder symptoms In full extension of C spine nose parallels the floor and in full flexion chin should rest on chest Lateral rotation approx 80o Lateral flexion 40o

Movement
Active and Passive range of movements of shoulder Forward elevation (0-170) Abduction (0-170) External rotation with abduction (0-90) Internal rotation (behind the back) Comparison with contralateral side

 Fixing the scapula Normal scapulothoracic to glenohumeral movement is usually 1:2 By fixing the scapula with thumb and finger try to quantify glenohumeral movement only 0-90o

Neurovascular assessment
Sensation dermatomes C4 toT2 Power around elbow, wrist and hand Shoulder power tested separately Test peripheral nerves, esp. Axillary nerve Biceps and triceps reflexes Radial pulses

Special Tests
Deltoid Arm in 90o abduction, neutral rotation With resistance deltoid can be felt to contract Supraspinatus empty cans test Subscapularis Push-off test Infraspinatus Swinging doors test

Empty Cans Test Supraspinatus

Push-off test Subscapularis

Swinging Doors Test Infraspinatus

 Painful arc/Impingement test

Internally rotated arm passively abducted in scapula plane (20-30 deg off coronal). Pain usually elicited in arc between 70-120o

Scarf test
ACJ injury

Anterior apprehension test

Arm externally rotated and shoulder abducted to 90 and elbow flexed. With gentle external pressure on back of humeral head, arm is externally rotated further

Anterior Apprehension Test

Hip examination

Hip Examination
Child with limp is an orthopaedic emergency Irritable hip is a diagnosis of exclusion

History
Pain Limp Stiffness Effect on daily activities i.e. putting on socks Previous surgery for adult/childhood disease Patients occupational and recreational demands

Pain
Pain in the groin or thigh is most likely a result of hip disease and radiates from the joint capsule and synovial lining Radiation to anterior, lateral and medial thigh an to the knee is also common Pain localised to gluteal region is often lumbrosacral in origin and may have assoc radicular signs Differentiation between hip and lumbrosacral pain is sometimes difficult on just examination

Pain
Pain due to arthritis is usually exacerbated by exercise and relieved by rest As OA progresses pain at rest becomes a more prominent feature Pain of septic arthritis is constant and unrelenting. It is associated with muscle spasm around hip It is present equally on weight-bearing and at rest. It is usually localised to groin and inner thigh.

Stiffness and Limp

Pts do not always complain of stiffness but will comment on which activities have become more difficult as a consequence ; stairs, cutting toenails etc Limping may be due to a variety of reasons Pain Limb length inequality Muscle wasting Bone/joint deformity

Snapping and clicking (adolescent and adult)

If painless does not require investigation If painful may suggest labral tear or iliotibial band snapping

General
Walking aids? Which hand? Limp? Is patient in obvious pain?

Inspection (Look)
Patient standing barefoot in underwear Muscle wasting Scars Posture (esp. Scoliosis) Ability to stand with feet flat on the ground Assessment of pelvic obliquity due to leg length inequality

 Trendelenberg test Test is negative if hips remain level when standing on one leg Test is positive if hip drops on the affected side ie. the hip abductor mechanism is weak and unable to hold the pelvis up Test is positive due to neurological lesion (spina bifida , superior gluteal n injury) or mechanical weakness (inefficent lever arm - congenital hip dislocation, coxa vara)

Gait (Look)
Antalgic gait Short-leg gait Trendelenberg gait

Palpation (Feel)
Patient supine and flat as tolerated Get pelvis square on the couch If cannot get pelvis square note fixed adductor or abductor deformity ?Palpate bony prominences ASIS Greater trochanter (trochanteric bursitis) Hip joint is too deep to assess for effusion or synovial thickening

Measurement of leg length Apparent limb length discrepancy - fixed adduction True limb length discrepancy - determine whether above or below knee

Movements
Active and passive range Flexion, extension, internal and external rotation Large range of variability in normal population Fix the pelvis with the hand to prevent tilting

 Flexion Patient supine Knee flexed Normal range 0 to 100-135 Fixed flexion deformity Thomas test A patient with a fixed flexion deformity at the hip will arch their back to compensate when lying flat

Positive Thomas test

 Abduction Stabilise the pelvis with hand on opposite ASIS Abduct affected leg away from the other Normal range is 0-45 degrees Assess power by abduction with hip in flexion which relaxes iliotibial band

 Adduction True adduction can only be measured if the contralateral hip is in abduction If it is in a neutral position then a degree of pelvic tilt will come into play as the affected leg crosses over the other As with abduction the pelvis must be stabilised Adductor power is tested by resisting adduction with the examining hand placed on the inner thigh will reveal adductor tendonitits

 Rotation Internal and external rotation with knee flexed Internal rotation 0-30o External rotation 0-40o Loss of rotation or pain is earliest sign of hip pathology

 Extension Best measured with the patient prone Maximum extension when pelvis begins to rotate Normal range 15-30o

Knee Examination

General
Patients age Occupation Sporting participation Duration of symptoms Exact nature of precipitating injury (twisting injury wearing studs, sudden haemarthrosis, gradual haearthrosis)

General
Swelling Pain (location anterior, medial lateral, infra-patellar, behind patella) Locking Instability, giving way Pain related to specific activities; walking only a few steps, running, twisting, squatting, kneeling

General
Acute Knee trauma with haemarthrosis should go to A&E and have plain films to exclude tibial plateau fractures Locked knee that cannot be straightened warrants acute referral Locking of the knee that can be unlocked warrants outpatient referral Knee instability, patella instability warrants outpatient referral Haemarthrosis secondary to warfarin is not drained as it will only reaccumulate

Swelling
Localised (meniscal cyst, Bakers cyst) or Generalised (haemarthrosis or effusion) Duration of swelling Whether swelling is increasing or resolving Is the swelling painful

Effusion or Haemarthrosis

Effusion or Haemarthrosis
Effusions occur secondary to an inflammatory process, most commonly a mechanical derangement eg. Meniscal tear or chondral injury There is usually a history of injury with the effusion developing over 24hrs Effusions also occur seconadry to inflammatory arthropathy (rheum or seroneg)

Locking
True locking Relatively rare Occurs when there is a loose body or meniscal tear which gets between the femoral condyle and tibial surface The patient lacks full extension but is able to flex the knee

Locking
Pseudo-Locking More common than true locking Pts with anterior knee pain secondary to patella maltracking Marked pain with a solidly locked knee Over several hours knee movement gradually returns Often provoked by bent knee activity; ging down stairs

Giving Way
True giving way is associated with ligamentous instability Eg. ACL instability; patient can run in straight line without problems, but when turning to change direction knee gives way followed by pain and swelling Buckling of the knee may occur with anterior knee pain and is assoc with pseudo locking . There is rarely an effusion

Examination

Inspection
Scars Skin changes, rashes Quadriceps wasting Limb alignment (valgus or varus deformity) Limb shortening Femoral torsion (anteversion) Tibial torsion Gait

Genu varus / valgus

Palpation (Feel)
With leg straight: Temperature Synovial thickening Effusion Balloting the patella Empty the lateral gutter and look for fluid wave in medial gutter

Palpation
Palpate knee while flexed to 90o Palpate along joint margins starting away from painful side Tenderness medially may indicate medial meniscal or medial collateral pathology Tenderness laterally may indicate lateral meniscus or lateral collateral pathology

Palpation
Patella tendon should be palpated in both extension and flexion and tendersness over its insertion in a teenager may signify Osgood-Schlatters disease Posterior aspect of the knee should be palpated for soft tissue masses in the politeal fossa eg. Bakers cyst, popliteal artery aneurysm

Medial joint line tenderness

Balloting patella

Emptying lateral gutter and observing fluid wave in medial gutter

Movement
Range of movement recorded Small degree of hyper-extension is normal Limit of flexion is how close heel gets to the buttock Typically -10 to 140 degrees Straight Leg Raise / Extensor mechanism

Special Tests
Stressing of medial and lateral collaterals Posterior sag and anterior draw

Lachmans test

Posterior sag

Anterior draw

Lachmans test

Special Tests
Meniscal tests McMurrays Test Appleys Grind Test

McMurrays Test