Clinical- Orthopedics discussion


Examine this pt. L.L.? (open Q) = Vascular + Orthopedic + Neurological + L.N.

Lumbar Spine

What is pathology of lumbar disc prolapse? Rupture nucleus pulposus & herniation through annulous fibrosus


Why inspection of SC swellings is important in spine case?
Multiple neurofibromatosis are neuromas from n.sheath that can compress n.roots → C/P similar to disc prolapse
Presented by multiple swellings & caffe au lait patches

How to level tender spinal segment? Line between liac crests at L4,L5
At level = L4-L5 disc & below = L5-S1 disc
If above = high lumbar disc L2-L3 or L3-L4(rare),
if even above (last rib)= lower dorsal disc (v.rare)

In pt. with scoliosis, How to differentiate spine pathology from lowerdown causes by inspection? By leveling iliac crests (detect pelvic tilt)
Put thumbs on level at iliac crests
If no pelvic tilt (iliac crests leveled) → spine pathology
If pelvic tilt (iliac crests not leveled) → lowerdown pathology (e.g, hip adductor deformity) → short limb → pelvic tilt same side & compensatory scoliosis other side) 

Scoliosis may be on same or other side of spine pathology

How to differentiate spine problem from hip problem by lumbar lordosis?
Spine → loss of lordosis (flattened) due to paravertebral ms spasm
Hip → hyperlordosis compensatory to fixed flexion deformity (or severe kyphosis)

What if calf wasting found during inspection of spine? May be reflex wasting
(confirm later by measurement (while supine))

Can calf wasting occur with knee pathology? Yes, as reflex wasting

What is difference between Sciatic list & scoliosis? Only X-ray finding
Sciatic list: is a one plane deformity (pedicles equal & lined up at both sides)
Scoliosis: is a 3D deformity (pedicles not equal & not lined up)


Types of abnormal gait you know?
Antalgic gait
Trendlenburg gait
High steppage gait in common peroneal nerve injury (common) or sciatic (rare)
High steppage gait in Hemiplegia
Shuffling gait in parkinsonism
limbing gait in short limb

- You can say abnormal gait if donot know type   ?????????

What are common gait abnormalities in spine?
Normal: most common
Half shut knife: keep nerve away from its root مطواة قرن غزال ½ مفتوحة 
High steppage gait: due to foot drop in L4,L5 disc prolapse (rare because emergency)

What are common gait abnormalities in hip problem? Trendlenburg or antalgic

What are common gait abnormalities in knee problems? antalgic


Comment on movement?
      full range mvt (……-….. degrees) & painless
or   limited mvt (……-….. degrees) due to pain
or   limited mvt (……-….. degrees) due to mechanical block (rare)

How to test for lat. rotation?
Rotation is performed at dorsal spine (thoracic vertebrae) & may be limited in acute disc prolapse
Sit down (to fix pelvis)
Range is normally 45 degrees

Why test for lat. rotation?
1-    check joint above (dorsal spine)
2-    may be limited in acute prolapse (by severe paravertebral ms spasm)


Value of SLR (straight leg raising test)?
1-    Active SLR = knee stability test for extensor mechanism (quadriceps muscle
      , quadriceps tendon, patella, patellar tendon & tibial tuberosity).
2-  Passive SLR (Lasegue test) = for sciatic stretch (L4,5, S1)

Passive SLR interpretation?
If pain below knee (e.g, calf muscle) → +ve
If pain above knee (hamstring) → -ve (may be due to spondyolitis or disc)

Site of pain (not imp)? Inside of leg= L4, outside of leg = L5, dorsum of leg = S1

What are sciatic nerve tests? SLR & sciatic stretch test

What is crossed leg raising test?
SLR of one side causes pain on other side below knee.
So stop test and 10 degrees below perform sciatic stretch test
Due to huge central disc (usually L4,5) with more prominence to one side
More sensitive test to spine than SLR

Is SLR specific to spine? NO, SLR may be +ve in spine or hip problems
                                          BUT, crossed leg raising test is specific to spine


What is main root affected in disc? The nerve below disc is the main root affected
L4-L5 disc → mainly L5
L5-S1 disc → mainly S1

What is full neurological exam.? SLR & neurological (sensory, motor & reflexes)

How to perform full neurological examination of LL?
1-    SLR test: part of neurological examination (to know side of disc compression)
2-    Sensory (Dermatome)
3-    Motor Power (Myotome)
4-    Reflexes

What to do if hyosthesia of L1? affected L1 = high disc or combined disc. → Test sensory level at umbilicus (T10),

Where is autonomus area of L5? 1st web space

How to test for knee reflex? L2,3,4 (mainly L3)
Flex &elevate knee with Lt hand and ankle just touch couch
Tap on patellar tendon & look at quadriceps ms      -may do clenching of teeth
Intact or absent
Compare both sides (may be absent bilaterally = normal)

How to test for ankle reflex?   S1
Ext. rotation leg & dorsiflexion of ankle (to stretch tendoachilis)
Tap on tendoachilis & look at calf ms                      -may do clenching of teeth
Intact or absent
Compare both sides (may be absent bilaterally normally)

How to interpret reflexes?
Bilat. Absent knee or ankle → Normal
Unilat. Absent reflex → root affection
Unilat. Exaggerated reflex → UMNL

What are characters of UMNL & LMNL?
UMNL: ms weakness, ↑ tone, hyperreflexia
LMNL: ms weakness, ↓ tone, hyporeflexia


When & how to perform femoral stretch test (Reverse Lesague test)?
If suspect high disc (L2-L3 or L3-L4)
Prone position & flex knee then extend hip
If pain infront thigh → +ve

How to suspect high lumbar disc?
Tenderness above iliac crests (above L4, 5)
Dermatome & Myotome affection at L2-L3 or L3-L5
Lost knee reflex                                                    
→ confirm by Femoral stretch test

Why examine joint above & below? For referred pain

Why neurovascular examination? For priority of ttt (PVD or neurological previous to orthopedic intervention) & differentiate spinal from vascular claudications

Table for low lumbar disc prolapse (common in exam)?

L4-L5 disc prolapse
L5-S1 disc prolapse
Main root
Med. leg (L4)
Lat. leg & 1st web space (L5)
Lat. leg & 1st web space (L5)
Sole (S1)
(Motor power)
Ankle dorsiflexion (L4)
Big toe dorsiflexion (L5)
Big toe dorsiflexion (L5)
Ankle plantar flexion (S1)
Ankle reflex (S1)

What are indications of urgent intervention in disc prolapse?
1-    foot drop
2-    cauda equine lesion (usually presented by retention)

What is urgency of cauda equine lesion?
Irreversible if no urgent intervention → retention early & incontinence later
Can present as isolated lesion

Diagnosis, D.D. & management

Diagnosis of spine case? (in spine & Knee we reach diagnosis by examination unlike hip diagnosis is hip problem needs X-ray) for example,
Rt Backpain with tender segment at L4-L5 level, sensory affection at level L4-L5 myotome affection at level L4-L5
→ nerve root L4,L5 affection due to acute disc prolapse

How to manage? (in investigations start by cheap & non-invasive)
Lab:  ESR, CRP, ASOT, Rheumatoid profile
X-ray: plain X-ray spine 2 views at least
CT: If suspect fracture (better 3D CT) 
MRI: If suspect pathology

What is TTT?
Conservative ttt: bed rest, analgesic (NSAIDs+SMR), lifestyle modif., physiotherapy
Surgery: if failed conservative ttt inform of Diskectomy +/- Laminectomy
                           (after general assessment for fitness to surgery)

D.D. Spine pathology?
Disc prolapse (most common)
Cong.: spondylolithiasis, spondylolysis
Traumatic: fracture, spondylolithiasis
Inflammatory: T.B. (rare)

What is common pathology involving different spine levels?
1-    lumbar area: disc prolapse
2-    Dorsal area: trauma
3-    Dorso-lumbar: T.B. or metastasis


What to do if examiner asked to examine Rt hip?
“ I should start examination by the normal (Lt) side”
Examiner will propably ask to stick to Rt side


Can you examine hip in supine position? Yes, if pt. cannot stand or examiner asked. but will skip: pelvic tilt & scoliosis by inspection, trendlenberg test, gait.

Scars? Lat.=lat. Exposure,                             Anterolat.=anterolat.exposure,
           posterolat.=posterolat. Exposure,       Iliac crest= donor site for bone graft
           2scars at knee joint line = arthroscopy
           2 scars at tibial tuberosity = skeletal traction to keep limb length
           Midline scar = total knee replacement

If Scar healed by 2ry intention.What does it mean? inf.

What is cause of pelvic tilt? Hip problem or limb shortening

What is cause of scoliosis in this case? Compensatory to pelvic tilt & to other side

What is compensatory scoliosis? scoliosis on opposite side of pelvic tilt

Cause of compensatory lumbar hyperlordosis?
1-    compensatory to fixed flexion deformity of hip
2-    compensatory to severe dorsal kyphosis

How to differentiate structural from scoliosis? By sitting down
1-    Compensatory scoliosis will be corrected
2-    Structural scoliosis will remain

What does compensatory scoliosis & Hyperlordosis mean? Long term pathology

Cause of compensatory lumbar hyperlordosis (exaggerated lordosis)?
1-    compensatory to fixed flexion deformity of hip
2-    compensatory to severe dorsal kyphosis

Wating of hip ms start by which part? Glutei then hamstring then quadriceps

What is cause of Severe Glutei wasting? T.B. (rare) usually with sinus back of hip


What are common gait abnormalities in hip problem? Trendlenberg or antalgic

What does trendlenburg test asseses?
Function of hip abductors (gluteus medius & minimus) on side pt. standing on, which supports elevated side (action paradox)           -SSS (sound side sags)

Why trendlenburg before gait? If +ve → Trendlenberg gait, if –ve →antalgic gait

What is meant by antalgic gait? Painful gait due to short stance phase of gait due to pain of knee or hip

Phases of gait?   Heel strike - stance (heel & toes on ground) – toe off - swing

Effect of weak hip abductors?
Unilateral → trendlenburg gait,
Bilateral → waddling gait


How to detect common hip deformities?
1-    Flexion deformity (weak extensors): by Thomas test
2-    Adductor deformity (weak abductors): by apparent length

What is Thomas test? Test for fixed flexion deformity (weak hip extensors)
Put hand behind pt. spine to feel obliteration of compensatory hyperlordosis (to fixed flexion deformity).
Flex one limb & notice flexion of other limb
If other hip flexed (elevated from couch) = +ve Thomas test (fixed flexion deformity due to weak hip extensors)

What is cause of bilat. FFD? Ankylosing spondyolitis (also there is kyphosis) (D.D. with disc prolapse)

How to differentiate FFD hip or knee? By knee extension
can extend knee = Hip FFD 
cannot extend knee = Knee FFD

How to test hip movement?
do passive only-
fix hip by Lt hand & elbow to avoid pelvic rotation

test for hip flexion? While knee flexed to relax hamstring

test for hip extensors? in prone position (do not test in side where FFD found)

Test for hip rotation? While hip 90° & knee 90° to relax all ligaments & muscles.


What is difference between true & apparent length?
True length: measure length of bones
Apparent length: measure length of bone & soft tissues

How to find ASIS? 1st bone from inguinal ligament

What if shortening in apparent length but normal true length? This means
Muscle deformity (usually adductor deformity → short limb)

What if shortening in apparent length & true length? This means
Bone shortening (true) → femur or tibia →if femur → supra- or infra-trochanteric

How to detect Femur vs Tibia shortening without measurement? Rough test
Knee to 90 degrees & heels together → limb in lower position is shorter

What does Supratrochanteric length include?
Head femur, neck femur & acetabulum

What are causes of supratrochanteric shortening?
Head femur (Fracture), neck femur (avascular necrosis) or acetabulum (Fracture)

What is ttt of short limb?
Heel raise, crouches or correction osteotomy (may be hidden if < 2cm)

Diagnosis, D.D. & management

Diagnosis of hip case? For example
painful limited movement (…., ….., ….), fixed flexion deformity by Thomas test, adductor deformity by difference between apparent & true length, & true shortening
→ Rt hip problem (for investigation)

D.D. hip problem?
1- cong.: slipped upper femoral epiphysis (SUFE), Cong.dislocation (CHD)
2- Tr.: Fracture acetabulum, head of femur, neck of femur
3- Inflammatory: Osteoarthritis (old pt.) or rheumatoid arthritis or T.B.
4- Neoplastic
5- avascular necrosis of femoral head (young)

How to manage?
Lab: ESR, CRP, HLA-B27
X-ray: plain X-ray hip
If suspect fracture → CT
If suspect pathology (ankylosing sponyolitis) → MRI

What is TTT? 
1- conservative ttt: bed rest, analgesic, lifestyle modification
2- Surgery: ………….(if failed conservative ttt) (after general assessment for fitness to surgery)

What are surgical options for osteoarthritis of hip?
Osteotomy – Arthroplasty (hip replacement) – Arthrodesis (=fix joint, rare now, used if contraindication to arthroplasty)

What are complications of THR (total hip replacement)?
How to prevent peri-operative DVT after THR?


What to do if examiner asked to examine Lt knee?
“ I should start examination by the normal (Rt) side”
Examiner will propably ask to stick to Lt side


Can you examine knee in supine position? Yes, if pt. cannot stand or examiner asked. but will skip: gait.

2 dimples on joint line: arthroscopy scars for 2 ports of arthroscope
Scar on tibial tuberosity: site of skeletal traction to keep limb length
Scar on iliac crest: donor site for bone graft

Cause of sinus ?  Inf. = Osteomyelitis O.M. or T.B. (rare).

Healed sinus? Healed SC inf.

Warmth? Inf. -Superficial= cellulites or -deep= O.M.

Swelling? Generalized = effusion  or localized = bursa (e.g, infrapatellar)

Discolouration ?  Hemoarthrosis (acute trauma).

Wasting of quadriceps starts by which part ? Vastus medialis.

Where to inspect for wasting? Vastus medialis (first muscle of quadr.gr to be wasted)

Knee deformity ? Genu varum =bow leg, Genu valgum=knock knee,
                               Genu recurvatum=hyperextended knee (due to lax ligaments).
                               Fixed flexion deformity=


What is common gait abnormalities in knee problems? Antalgic

What is meant by antalgic gait? Painful gait due to short stance phase of gait due to pain of knee or hip


What is cause of tenderness during examination? Usually meniscal inj.
Med.= usually med. meniscus inj., Lat. = usually lat. meniscus inj.
In young → Trauma
In old → Osteoarthritis (meniscus degeneration)

What are causes +ve grinding test (tender patella)?
Move patella on femur in 2 vertcal planes. If +ve =
Young → chondromalacia patella (rare)
Old → Patello-femoral Osteoarthritis (common)


Test for Movement start by? Active then passive to avoid eliciting tenderness

Why passive test? To complete range to differentiate limited range due to pain or mechanical block
if due to pain → stop
if due to mechanical block (e.g, myositis ossificans)→ try to complete range (rare)

What is tibial tuberosity? Part giving  attachment to patellar tendon

Patellar tap test?
For detection of moderate knee effusion
Lt hand press suprapatellar pouch
Rt hand firm continous pressure on patella (sharply) & notice ballotment

Stroke test (bulge test) (visible fluctuation)?
For detection of mild knee effusion
Empty medial side knee from below upwards
Swipe across lateral side & notice medial bulge

Cross fluctuation test of knee?
For detection of severe knee effusion
Lt hand press suprapatellar pouch
Rt thumb at side & rest of fingers on other press upwards & recieve fluctuation by Lt

How to differentiate knee effusion from pre-patellar bursa?
By contraction of quadriceps ms (knee extension)
If swelling ↑ → pre-patellar bursa (infront patella)
If swelling ↓ → effusion (communicate to joint)

What is cause of effusion? Sympathetic (2ry to cruciate lig. or meniscal Inj.)


Role of knee ligaments? Cruciate → prevent anterior-posterior displacement of tibia
                                         Collateral → prevent side displacement

How to examine extensor mechanism of knee? Active SLR test

What is value for active SLR?
Test for extensor mechanism of knee. if +ve → weak ext. mechanism (5components)
1-    quadriceps muscle
2-    quadriceps tendon
3-    patella
4-    patellar tendon
5-    tibial tuberosity

How to determine the affected part of extensor mechanism?
Feel the 5 components for defect or tenderness
If no defect or tenderness → weak ms

Why in stress valgus or varus knee at 0o then at 20o ? To abolish effect of ACL, PCL, postero- capsule of knee (knee locking mechanism)
At 0 degrees stability of med. joint is by med. collateral lig., ACL, postero-med. capsule. So, +ve → combined inj. = severe trauma
 At 0 degrees stability of lat. joint is by lat. collateral lig., PCL or ACL, postero-lat. capsule. So, +ve → combined inj. = severe trauma
At 20 degrees stability is by collateral lig. Only. So, +ve → isolated collat. lig. inj.

Posterior sag +ve. What does it mean? Complete PCL tear

Posterior sag –ve & posterior drawer +ve. What does it mean? Partial PCL tear

Why do posterior sag test before anterior drawer? To avoid false +ve ant. drawer

If  +ve drawer test does it mean ACL inj.? NO, have to compare with other side
If bilat. +ve → lax ACL
If unilat. +ve → torn ACL

Examine ACL? Start by post. Sag test
1-                                                                                                                                                                       post. Sag test: to avoid false +ve ant. drawer
2-                                                                                                                                                                       Ant. drawer test
3-                                                                                                                                                                       Lachman test              4- Pivot shift (idea)

Other tests for ACL? Lachman test (difficult than drawer test) & Pivot test (idea)
mild flexion of knee
examiner thigh below pt. knee
hand on femur to fix & hand on tibia to move (keep hands A-P near joint to control)
pull tibia up on femur
(Can be modified also to examine PCL)

McMurray test? For meniscal injury
If pain or feel click → +ve because detached tag of meniscus dislodge from trap site between femur & tibia

Is McMurray test specific to meniscal injury? No, +ve if synovial fold or loose body in joint

if  +ve McMurray test does it mean meniscal inj.? NO, have to compare with other side
If bilat. +ve → lax meniscus
If unilat. +ve → meniscal inj.


Measurement of quadriceps circumference. Why 15 cm above patella?
1- above suprapatellar pouch to avoid effusion
2- site of muscle bulk

Normal variation in thigh circumference? < 2 cm (but have to mention)

What to do for pt. with knee C/O? MRI or arthroscopy

Diagnosis, D.D. & management

D.D. Knee problems?
D.D. Knee Pain
Tr.: Cruciate lig. inj., Collat. lig. Inj. or meniscal inj.
Inflammation: Osteoarthritis, Rheumatoid arthritis or T.B. (rare)
Knee stability: weak extensor mechanism (5 components), Lig. Or meniscal inj.
Knee swellings: ant. knee or post. Knee (bursa or cyst or effusion)

D.D. Knee swelling?

Ant. knee: Pre-patellar bursa (Housemaid bursa), Infrapatellar bursa (Klegerman’s)    or Effusion
Post. Knee: Above j.line (Med.) → Semimembraosus bursa
Below j. line → Baker cyst (old & patho. As Rh.Arth. or T.B.)
 Popliteal cyst (Young & no patho.)
How to diagnose bursa? Fluctuation & Transillumination

What is TTT bursa? Conservative or Aspiration or Excision

How to manage?
Lab: ESR, CRP, HLA-B27
X-ray: plain X-ray knee
If suspect fracture → CT
If suspect pathology → MRI

What is TTT? 
1- conservative ttt: bed rest, analgesic, lifestyle modification
2- Surgery: ………….(if failed conservative ttt) (after general assessment for fitness to surgery)

What are surgical options for osteoarthritis of knee?
Osteotomy – Arthroplasty (hip replacement) – Arthrodesis (=fix joint, rare now, used if contraindication to arthroplasty)
Arthroscopic debridement & washout of meniscal debris & osteophytes

What are surgical options for Rh.Arthritis of knee?
Osteotomy – Arthroplasty
Arthroscopic synovectomy & debridement

What are complications of total knee replacement ?

What are X-ray findings in Osteo-Arthritis?
1-    peri-articular osteoprosis (in O-A osteosclerosis)
2-    narrow joint space 
3-    destruction & subluxation joint
no new bone formation (no osteophytes) unlike O-A

What are stages of Rh.Arthritis? Proliferative → Destructive → Reparative

What are X-ray findings in Rheumatoid Arthritis? LOSS
1-    Loss of joint space
2-    Osteophyte formation
3-    Subchondral sclerosis
4-    Subchondral cysts


What is rheumatoid arthritis?
Part of rheumatoid disease usually affect hand or foot
1- synovitis (inflamm. Synovial fluid of small joints mainly)
2- tenosynovitis (synov. fluid + tendon) → atresia & rupture of tendons
     (1+2 → deformity small joints & long tendons of hand)

Why affect long tendons rather than short? Because of much synovial sheath around → more tenosynovitis → more tendon rupture


Wrist & palm (ulnar side of thenar ms 2 cm from distal wrist crease)= carpal tunnel
Wrist, Palm & finger = tendon repair
2 scars on med. side forearm? Donor site for tendon repair (palmaris longus)

Why carpal tunnel scar upto 2 cm from wrist crease only?
1-    end of carpal tunnel (base of abducted thumb)
2-    to avoid deep palmar venous arch inj.

Why with rheumatoid may be wasting of all ms? Disuse atrophy

How to differentiate wasting due to rheum.Arth. from that due to n.inj?
n.inj. → wasting specific group ms
disuse atrophy → wasting all groups ms

Common hand deformity in Rheumatoid arthritis?
Ulnar deviation of fingers (MPJ) & compensatory radial deviation of Wrist (Zig-Zag mech.) (pathognomonic to rheumatoid hand)
Swan-neck: rupture tendon FDS → PIPJ extended & DIPJ flexed by FDP (compens)
Boutonniere deformity: rupture central slip of extensor expansion → PIPJ flexed & DIPJ extended by 2 distal slips
Z-thumb:  rupture Fl.Poll.longus tendon → MPJ flexed & IPJ extended
Mallet finger: rupture extensor tendons → DIPJ flexed & cannot be extended except passively (IPJ normal)
Trigger finger (Stenosing tenosynovitis): inflamm.nodule prevent active extension of finger PIPJ & DIPJ(cannot be extended except passively with lag & snap)
Piano key sign: subluxation of lower radio-ulnar joint → popup lower ulna
MPJ swellings (nodules or subluxation of head metacarpals)

What is trigger finger?
Nodule at MPJ → lag on finger extension with snapping
Nodule can be felt at MPJ at distal palm crease

What are knuckles? Head of metacarpals

What are types of flexion deformity?
1-    fixed deformity: cannot be corrected (by feel) d.t. bone or joint patho.
      ttt: correction osteotomy
2-    mobile deformity: can be corrected (by feel) d.t. imbalance between fl. & ext.

Swelling in MPJ rheumatoid hand?
Usually at MPJ due to
Synovial swelling (synovitis) → soft swelling
Displacement of knuckles (head of metacarpals) → hard swelling

Why there may be no rheumatoid nodules? Pt. under ttt 

What type of bursa is common with rheum.Ar.?   
Olecranon bursa (so, must expose elbow)
If found swelling → Transillumination If +ve = bursa

How to manage olecranon bursa?
Transillumination → +ve, confirm by U/S
ttt → Conservative or aspiration under complete aseptic condition


Test for tendons?
Test for FDS: extend other fingers & ask pt. to flex tested finger (stop mass action of FDP)
Test for FDP: fix middle phalanx of same finger & ask pt. to flex distal phalanx (stop action of FDS)

What if flexion lost in PIPJ & DIPJ? Rupture tendon both FDS & FDP

What are the Flexors of thumb? Fl.Poll.Brevis → MPJ,
Fl.Poll.Longus → IPJ

Diagnosis, D.D. & management

Diagnosis of rheumatoid hand case?
Lesions of small joints & long tendons of hand inform of (ulnar deviation of fingers & rad.dev. wrist, finger drop middle finger, swan neck ring finger, Z-deformity of thumb)
→ Rheumatoid hand  
Notice that rheumatoid hand is usually bilateral & symmetrical (but not in exam)

How to manage?
Lab: FBC (anemia), ESR, Rh.F.
X-ray: (plain X-ray hand)

What are local complications of Rheumatoid arthritis in hand?
1- carpal tunnel syndrome: d.t. thichened tendons
2- rupture long tendons

How to test flexor tendons?
1-    FDS: fix other fingers & flex only the one examined
2-    FDP: fix middle phalanx by 2 fingers (to stop action of FDS)

What are X-ray findings in Osteo-Arthritis?
4-    peri-articular osteoprosis (in O-A osteosclerosis)
5-    narrow joint space 
6-    destruction & subluxation joint
no new bone formation (no osteophytes) unlike O-A

What are X-ray findings in Rheumatoid Arthritis? LOSS
5-    Loss of joint space
6-    Osteophyte formation
7-    Subchondral sclerosis
8-    Subchondral cysts

How to examine foot of Rheumatoid arthritis? Expose till knee
Look: skin,
           SCT → swelling = adventitious bursa due to dislocation of talus & friction
                                               (Bunion is bursa at MPJ of big toe)
           Muscles of foot (beware pes cavus)
           Deformity  - Hallux valgus (medially deviated metatarsal head of big toe)  -
- Hammer toe (Flexed MTPJ & Extended IPJ)
- Claw toe (flexed MTPJ & IPJ)
MOVE (ankle j.)

Hallux Valgus

What is hallux valgus?
medially deviated metatarsal head of big toe + lateral rotation of big toe (usually bilat.

What is TTT of hallux valgus?
1- Conservative: wear wide medical shoes  
2- Surgery: (if pain or cosmetic) By correction osteotomy

What are complications of hallux valgus?
Hammer 2nd toe

What is Hallux rigidus?
Stiffness & pain of 1st metatarso-phalangeal joint (due to osteoarthritis) → no take-off phase

What is Bunion? Protective bursa at pressure areas (e.g, hallux valgus)


If asked to examine hand. How to suspect n. inj. by inspection?
Claw hand → ulnar n.inj. & D.D.
Wasted Thenar (ape hand) → median n. inj
Wrist & Finger drop (cannot be extended) → radial n.inj. (finger drop at MPJ is specific but wrist drop is according to level of inj.)

Why look (inspection) is imp.? For scars of inj. or surgery

Why ask for tender area in scar causing n.inj.? painful neuroma

How 3 nerves enter forearm? Between
Ulnar: between 2 heads of flexor carpi ulnaris
Median: between 2 heads of pronator teres
Radial: between 2 heads of supinator

What are autonomus area of 3 nerves?
Ulnar: middle & distal phalanx of little finger
Median: distal phalanx of index & middle finger
Radial: dorsal 1st web pace

Ulnar nerve

Course of ulnar nerve?
Branch of med. Cord Br.Plex.
Enter forearm between 2 heads of flexor carpi ulnaris
In forearm supply → FCU & med. ½ FDP
Pass in Guyan’s canal = ulnar tunnel (above flexor retinaculum & covered by a slip of it) & gives palmar cut.branch
In hand supply → all hand muscles (except LOAF)= med. 2 lumbricals + interossei + hypothenar + adductor poll.
    → sensory to med. palm & med. 1+1/2 fingers ant. & post.

What is group action of small ms of hand? Writing position (MPJ flex. & IPJ ext.)

Why ulnar nerve inj. causes partial claw hand?
Due to paralysis of med. 2 lumbricals & all interossei → unapposed action of long flexors → claw hand of med. 2 fingers
(partial = not all fingers & not degree of paralysis)

Can thenar atrophy occur with isolated ulnar injury? Yes, some wasting due to adductor pollices wasting

What are types claw hand?
1- Partial (med. 2 fingers) due to ulnar injury
2- complete (med. 4 fingers) due to ulnar & median n. inj.

D.D. (causes) of claw hand?

A- Partial Claw Hand (med. 2 fingers)
1- Ulnar n.inj.: clawing med. 2 fingers (ext. MPJ & flex. PIPJ+DIPJ)
2- Duputyren contracture: clawing ring +/- little fingers due to cord like thickening of palmar fascia (but motor & sensory intact)
- Flex. All joints (PIPJ+DIPJ+MPJ)
- Band of fibrosis felt below MPJ
- no sensory or motor affection

A- Complete Claw Hand (med. 4 fingers)
1- Combined ulnar & median n.inj.
2- Volkman’s contracture: clawing med. 4 fingers due to ischemia of muscles of flexor compartment due to tight cast or trauma → bone fracture or vessel inj. (volkman can affect any compartment)
- Flex. All joints (PIPJ+DIPJ+MPJ)
- extension → ↑ deformity & flexion → ↓ deformity
- no sensory or motor affection
3- Klumpke’s paralysis (Lower trunk Br.Plex.):
4- Others: advanced Rh.Arth. or spinal cord lesions

What is ulnar paradox?
The higher the lesion, the less the deformity (less clawing) (reverse to normal)
Because in higher lesion → paralysis med. ½ FDP → weak flex. → less clawing

Muscles of 1st web space? Wasting of 1st web space means:
Palm: adductor pollices (ulnar)
Dorsum: 1st dorsal interosseus (ulnar)

What is cause of lost sensation little finger but intact palm sensation?
Palmar cut. Branch inj. only

How to test for adductor poll. ?
Froment’s test: when catch paper between thumb & other fingers have to flex thumb (due to weak adduction)
N.B. if cannot catch paper at all = combined ulnar & median n.

How to test for palmar interossei?
Finger adduction (PAD). if weak → +ve → do card test

What are common sites of ulnar inj.?
1- Elbow (High): supracondylar Fr., degenerative arthritis or tunnel syndrome (repeated flex. Of elbow, O-A, Fr) or
2- wrist (Low): Trauma, ulnar tunnel syndrome (ganglion or Fr. hook hamate)

How to detect level of ulnar nerve injury?
1-    scar
2-    degree of deformity (Ulnar paradox: higher lesion → less deformity)
3-    wasting med. forearm = higher inj. (FCU & ½ FDP wasting)
4-    test for med. ½ FDP & FCU (see below)

How to test for flex.carp.ulnaris (FCU)?
Flexion & ulnar deviation of wrist & feel tendon

How to test for med. ½ FDP (supplied by ulnar)?
Med. ½ of FDP flexes little & ring fingers (mainly little to avoid overlap)
Fix middle phalanx of little finger & ask pt. to flex distal phalanx (To block effect of FDS on middle phalanx)

Median nerve & Carpal tunnel Syndrome

What is course of median nerve?
Branch from med. & lat. Cord
Enters forearm between 2 heads of pronator teres
In forearm → muscles ant. Compartment (except med. ½ FDP & FCU)
 [FDS, lat. ½ FDP, pron.teres, pron.quadr., Fl.poll.longus, Palm.longus(+/- absent)]
Enter hand in carpal tunnel (under flexor retinaculum)
In hand supply → LOAF (2 lat. lumbricals + thenar (opp.poll., abd.poll.br., flex.poll.br.))
                         → sensory to lat. palm & lat. 3+1/2 fingers ant & post.

What in carpal tunnel affected sensation fingers but intact palm sensation?
Because palmar cutaneous branch of median arise before carpal tunnel & pass above it

How to test for abduct.poll.br.?
Rest hand on table (to block action of abduct.poll.longus coming from dorsum)
Ask pt. to raise thumb away from table against resistance
feel Abduct.poll.br. (the most lat. Muscle of thenar group

What are nerves cause thumb abduction?
abductor poll. Brevis supplied by median n.
abductor poll. Longus supplied by radial n.

What are common sites of median inj.?
Elbow: dislocation, Fr, Pronator teres syndrome
Forearm: Fr. → inj. ant. interosseus n.
Wrist: Tr. Or carpal tunnel syndrome

How to test for FDS?
Fix all fingers except finger examined & ask pt. to flex it (same for all med.4fingers)
Because FDP has mass action (needs 2 fingers intact at least to act)

How to test for lat. ½ FDP (supplied by median n.)?
Lat. ½ of FDP flexes middle & index fingers
Fix middle phalanx of middle finger & ask pt. to flex distal phalanx (same for index)
To block effect of FDS on middle phalanx

How to test for pronator teres & pronator quadratus?
Fix elbow (to avoid med. Rotation of shoulder)
Ask pt. to rotate wrist towards inside

Carpal tunnel Syndrome (CTS)
What is CTS? Compression of median n. due to swelling Fl. retinaculum

Causes? Ganglion, lipoma of wrist, Colle’s Fr., Rh. Arth., gout, DM, Alcohol, Fluid imbalance (preg., hyperthyroidism)

Diagnostic tests? Phalen test & Tinnel test

Radial nerve
Course radial nerve?
Branch of post.cord Br.Plex.
It gives branches before entering compartments
Enters forearm between 2 heads of supinator
In arm → triceps & lat. ½ brachialis
In forearm →  posterior interosseus → muscles forearm &
                   → superficial radial → sensory to dorsal 1st web & lat. 3+1/2 fingers
How to examine wrist & finger extension? In prone position (against gravity) & fix proximal joint

Why wrist extension not completely lost in post. Inteross. Inj.?
Because main radial supplies ABC (anconeus, ext.carpirad.longus & brachioradialis)

Is finger extension lost completely?
NO, Finger extension is lost at MPJ, BUT, fingers can be extended at IPJ if MPJ fixed (by lumbricals which are weak extensors act only on IPJ)

What are common sites of Radial n.inj.?
Axilla (High): Saturday night palsy (neuropraxia by arm over back of chair)
Midhumerus: Fr. (spiral groove)
Elbow (Low): Fr. or dislocation → post. inteross. Inj.

How to detect level of nerve injury?
- injury at axilla → wrist drop & finger drop
- injury at head of radius (post.inteross.) → finger drop & weak wrist extension (but intact sensory)

Why wrist extension not completely lost in post. Inteross. Inj.?
Because main radial supplies ABC (anconeus, ext.carpirad.longus & brachioradialis)


What are causes of painful abduction?
1- Pain in initiating abduction (0-30) → rotator cuff tear
2- Pain (60-120) (painful arc) (impingment syndrome) → rotator cuff tendonitis or minor tear
3- Pain (120-180) (painful high arc) → ACJ osteoarthritis

What are ms of rotator cuff?
SITS (supraspinatus, infraspinatus, teres minor, subscapularis)

How to determine site of pathology? According to site of pain
Ant. & med = sternoclavicular j.
Ant. & lat. = acromioclavicular
Posterior = scapular osteophytes

If painfull all range of abduction? Acromioclavicular osteoarthritis

If painful all shoulder movements? Acute Frozen shoulder. Later painless

What is painful arc?
Painful range of abduction (e.g, 40 - 90 degrees) with no pain before or after
due to supraspinatus tendonitis
pathology: supraspinatus tendon pass below acromioclavicular arch. Friction → inflammation → bursitis → atresion → rupture

What is pathology of frozen shoulder?
Capsulitis → adhesions → early: painful limited all movements of shoulder
                                       → later:  painless limited all movements of shoulder

What is apprehension test?
Test for recurrent shoulder dislocation
Stand behind pt.
Trial of abduction & external rotation of shoulder → pt. pulls arm
كأن واقف فى الأوتوبيس ماسك فوق و الأوتوبيس وقف فجأة

If pt. cannot do abduction by tricky movement (leaning to other side) how to stop it to demonstrate glenohumeral vs scapulohumeral joint affection?
Fix scapula (stop tricky mvt) & try to abduct → cannot = glenohumeral j. affection

Method of Reduction of Dislocated Shoulder?
TEAR (Traction  - External rotation -  Adduction - Rotation (Internal) )

ELBOW (very very rare)

Is pronation & Supination part of elbow examination?
NO, they occur at sup. & inf. radio-ulnar joints (N= 80 degrees) use vertical paper


What are ankle movements?
Ankle (tibio-calcaneous): Dorsiflexion & Plantar flexion
Subtalar: Inversion & Eversion
Midtarsal: Pronation & Supination

What is Simmond’s test? Test for tendoachilis
Pt. Prone → squeeze calf ms → if plantar flax. = intact tendoachilis