ORTHOPEDICS
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
LOOK:
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)
GAIT
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?
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
MOVE
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)
SPECIAL TESTS
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
NEUROLOGICAL EXAMIN.
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
PRONE
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
|
L5
|
S1
|
|
Dermatome
(Sensory)
|
Med. leg (L4)
Lat. leg & 1st
web space (L5)
|
Lat. leg & 1st
web space (L5)
Sole (S1)
|
|
Myotome
(Motor power)
|
Ankle dorsiflexion (L4)
Big toe dorsiflexion (L5)
|
Big toe dorsiflexion (L5)
Ankle plantar flexion (S1)
|
|
Reflexes
|
-------------
|
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)
Neoplastic
What is common pathology
involving different spine levels?
1-
lumbar area: disc prolapse
2-
Dorsal area: trauma
3-
Dorso-lumbar: T.B. or metastasis
HIP
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
LOOK
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
SPECIAL TEST → GAIT
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
SPECIAL TEST → MOVE
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.
MEASURE
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?
KNEE
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
LOOK
Can you examine knee in
supine position? Yes, if pt. cannot
stand or examiner asked. but will skip: gait.
Scars?
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=
WALK
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
FEEL
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)
MOVE
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.)
SPECIAL TESTS (KNEE
STABILITY + McMURRAY)
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.
MEASURE
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
Cong.:
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?
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
RHEUMATOID HAND & FOOT
What
is rheumatoid arthritis?
Part
of rheumatoid disease usually affect hand or foot
Pathogenesis:
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
LOOK
Scar?
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
MOVE
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)
FEEL
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?
Bunion
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)
NERVE INJURY
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.)
LOOK
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)
SENSORY
What
is cause of lost sensation little finger but intact palm sensation?
Palmar
cut. Branch inj. only
MOTOR
& SPECIAL TEST
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
LEVEL
OF INJURY
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.
SENSORY
What
in carpal tunnel affected sensation fingers but intact palm sensation?
Because
palmar cutaneous branch of median arise before carpal tunnel & pass above
it
MOTOR
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.
LEVEL
OF INJ.
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
MOTOR
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)
LEVEL
OF INJ.
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)
SHOULDER (rare)
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
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
ANKLE
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
