General plan for examination of extremities

Standing (gait) ->  supine ->  prone

Look

(inspection)

Feel

(palpation)

Move

Measure / special tests

  1. Skin (scar – sinus)
  2. Subcutaneous (swelling)
  3. Muscle (wasting – spasm)
  4. Bone (deformity)
Temperature

Tenderness

Soft tissue related

Active (1st)

Passive

Against resistance

Full range vs. limited rang

Painful vs. painless

Examination of peripheral circulation

 

Examination for Fractures and dislocation

Look

‘inspection’

Feel

‘palpation’

Move

Measure

Skin

Ecchymosis

Edema

Skin

Tenderness

Edema

Loss of function

Abnormal mobility

Crepitus

Shape

Swelling

Deformity

Postural alternation

Shape

Swelling (as any swelling)

Deformity

Examination of sensory and motor innervations

Examination of peripheral circulation

Investigation

Labs

  1. Rheumatic profile (ESR – CRP – rheumatoid factor – antinuclear antibody – Uric Acid)
  2. Inflammatory profile (CBC – TLC total and differential – ESR – CRP)
  3. Baseline renal and liver function test (if NSAID being considered)

Radiological

  1. X-ray (2 views – 2 joints)
  2. CT (better in trauma than MRI)
  3. MRI (better in soft tissue assessment)
X-ray features of osteoarthritis (LOSS)
  1. Loss of joint space
  2. Osteophyte formation
  3. Subchondral sclerosis
  4. Subchondral cysts
Management

Non-surgical option

  1. Lifestyle modification / rest
  2. Physiotherapy
  3. Analgesics

Surgery

  1. Failure of conservative management
  2. After optimization and assessment of the patient general condition and fitness for surgery
  3. In any rheumatoid patient you have to exclude atlanto-axial sublaxation by cervical spine X-ray
Plain X-ray
2 views
2 joints Above and below
2 limbs In children
2 injuries To exclude common association
2 occasions As in scaphoid fracture
How to describe a fracture? (theoretical)
  • Definition
  • Aetiology
    • General incidence
    • Age
    • Sex
    • Possible cause
  • Pathology
    • Bone
    • Site
    • Extent
      • Complete
      • Incomplete
    • Fracture line
      • Transverse
      • Oblique
      • Comminuted
      • Avulsion
      • Epiphyseal separation
      • Displacement
      • Lateral displacement
      • Angulation
      • Over-riding
      • Rotation
      • Distraction
      • Depression
      • Impaction
    • Stability
      • Stable
      • Unstable
    • Skin damage
      • Simple (closed) fracture
      • Compound (open) fracture
    • Special feature
  • Healing
    • 3 weeks is the least time and if in
      • Child
      • Upper limb
      • Spiral or simple fracture
    • ×2 if any of them changed
    • ×2 for consolidation
  • Complication
    • General
    • Local
What is the plan of management?

General and Local

Reduce

Hold

Rehabilitate

Closed reduction by:

  • Gravity
  • Manipulation
  • Traction

Open reduction

External fixation by:

  • Plasters of Paris
  • Traction
  • External skeletal fixators

Internal fixation

How to describe a bony lesions (e.g. tumors)? (theoretical)
  • Skeletal maturation
  • Bone
  • Region
  • Nature of lesion
  • Special feature
  • Effect on
    • Medullary canal
    • Epiphysial cartilage
    • Articular cartilage
    • Joint
    • Surrounding bone
    • Cortex
    • Periosteum
    • Outside
  • Diagnosis
    • Swelling
    • Pain
    • Pathological fracture
    • Growth affection
    • Joint movement
    • Complication
      • Spread