Other Common Conditions Seen Around The Ankle Tenosynovitis

Inflammatory changes in the tendon sheaths behind the malleoli may give rise to pain at the sides of the ankle joint. Tenosynovitis may follow unusual excessive activity or be associated with degenerative changes, flat foot or rheumatoid arthritis. There is puffy swelling in the line of the tendons, with tenderness extending often for several centimetres along their length. Tibialis posterior and peroneus longus are most frequently involved, and stretching of these structures during inversion...

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Ankylosing spondylitis 136 investigation 153-154 pyogenic arthritis 162 tenderness over 148 'Sagging rope'sign 199 Salter-Thompson classification 169 Sarcoma, osteogenic, knee 242 Scaphoid examination 96 fracture 105 Seapholunate instability 93, 102 Scapula 50,58 high 56 movement 50 neurological assessment 18 pathology 56 shoulder abduction 51 snapping 56 winged 56 Scapulothoracic joint 50 Scheuermann's disease 135-136, 155, 161 Schmorl's nodes 131, 135, 142, 155, 156, 161 Schober's method 149...

The hand

Dupuytrens contracture 1 1 0 Vibration syndromes 1 i 0 Tendon and tendon sheath lesions 1 1 1 Rheumatoid arthritis 1 1 2 Osteoarthritis of the interphalangea Carpometacarpal joint of the thumb 113 Tumours in the hand 1 1 3 Infections in the hand 1 14 Inspection 115-123 Movements T 19-123 Vibration syndromes 123 Assessing hand circulation 1 23 Tendon injuries 123-124 Infections 124-125 Assessing hand function 1 25-1 26 Pathology 126-127 Note that the separation of conditions into those affecting...

Hallux Rigidus

Primary osteoarthritis of the metatarsophalangeal (MP) joint of the great toe often commences in adolescence and gives rise ultimately to pain and stiffness in this joint. It is commoner in males, and is not associated with hallux valgus. Sometimes the toe is held in a flexed position (hallux flexus), and the proximal phalanx and metatarsal head are thickened following joint narrowing and circumferential exostosis formation. Treatment is usually by fusion or Keller's arthroplasty.

Guide to commoner causes of leg pain

Curing Period Tibia Bone Fracture

Osteitis or other infections Bone tumour Bone tumours (especially osteoid osteoma, osteoclastoma, osteosarcoma) Brodie's abscess 11.1. Inspection (1) Soft tissue swelling Note the site and extent of any swelling. In the case of oedema, note particularly if bilateral (suggesting a general rather than a local cause). Unilateral leg oedema in women over 40 is a common sign of intrapelvic neoplasm. 11.2. Inspection (2) Localized oedema Localized oedema is common over inflammatory lesions and stress...

Inferior Calcaneal Bursitis

Toe Ligaments

Inspection Great toe 4 Note the presence of excess callus under the great toe. This finding is highly suggestive of hallux rigidus. 13.28. Inspection Great toenail Note whether the great toenail is A deformed onychogryphosis , B ingrowing, possibly with accompanying inflammation, C elevated suggesting subungual exostosis , D uneven in texture and growth suggesting fungal infection or psoriasis . 13.26. Inspection Great toe 3 Note whether A the great toe is thickened at the MP joint,...

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Achondroplasia Limb Lengthening

Ossification In the first year of life the ossification centres for the capitate C and hamate H appear at 2 months, the radius R at 6 months, and the triquetral T at 10 months. After the first year, the lunate L appears at about 2. the trapezium Tr at 21 . the trapezoid Tz and scaphoid S at 3. and the distal ulna U at 4 gt i years. 6.63. Wrist radiographs examples of pathology 1 the radiograph shows a deformity of the upper limb in which there is absence of the radius and thumb, along...

Short Leg Syndrome

Trendelenburg Position Nerves

Congenital Transient Tuberculosis Still's Infective Slipped Ankylosing Prolapsed Rheumatoid Primary dislocation synovitis of the hip Perthes' disease of the hip disease arthritis femoral spondylitis intervertebral arthritis juvenile epiphysis Reiter's disc Secondary rheumatoid syndrome 'Low back osteoarthritis neck fractures Secondary bone tumours Table 9.1 Age distribution of common hip pathology 9.1. Inspection 1 Examine the standing patient from the front. Note A any pelvic tilting e.g. from...

Iy1 vutikal orthopaedic examination

Pathology 7 The radiograph is of an 8-year-old hoy complaining of back pain, malaise, night sweats, loss of spinal movements, and pain on percussion over the spine. There is loss of a disc space, slight vertebral wedging, and a fusiform abscess shadow on both sides of the spine. Diagnosis the appearances are typical of tuberculosis of the spine. 8.96. Pathology 8 The lateral radiographs show that there is forward slip of L5 on SI of a little less than 25 . There is an associated defect in...

Segmental arid peripheral nerves of the limbs

Upper Trunk Brachial Plexopathy

Brachial plexus Cervical part 1 2 Branches from roots 1 3 Branches from trunks 1 A Axillary part 14 Branches from cords 1 4 Assessment of brachial plexus lesions 17-18 Axillary nerve 1 9 Radial nerve 19-21 Ulnar nerve 21-24 Median nerve 24-27 Lower limb myotomes 27 Lower limb dermatomes 7 Lumbosacral plexus 28 Femoral nerve 29 Common peroneal nerve 29 Tibial nerve 30-31 Sciatic nerve 3 1 Lateral cutaneous nerve of thigh 32 Neurological control of the bladder 32 The roots of the brachial plexus...

The Mature Foot Summary Of The Key Stages In Examination 1318

Rheumatoid Arthritis Stages

Movements Examine the mobility 13.17. Gait Examine the gait, with and withoul shoes. If indicated, screen the ankles, knees, hips and spine examine the circulation, and carry out a neurological examination. Note the footprint and examine the shoes. 13.18. Investigations Study the results of special investigations, e.g. radiographs, serum uric acid, sedimentation rate, rheumatoid factor etc. 13.19. Inspection General Note whether the foot is normally proportioned. If not, look at the...

Positional Talipes

Everted Foot Child

Pain on dorsal and medial side of foot Tight shoes and stockings, Ingrowing toe nail Cuneiform exostosis Peroneal flat foot Freiberg's disease Pes cavus Verruca pedis Anterior metatarsalgia Plantar neuroma Pes cavus Verruca pedis Tarsal tunnel syndrome 'Normal foot' Vertical talus Knock knees Valgus heels Neurological disturbance Torsional deformities of the tibia In all age groups, this is due to muscle imbalance often from a neurological disorder, e.g. spastic diplegia, poliomyelitis,...

The cervical spine

Normal Range Knee Flexion Angle

Postural neck pain 34 Acute neck pain in the young adult 34 Cervical spondylosis cervical osteoarthrosis Osteoarthritis of the cervical spine 34 Thoracic outlet syndrome 35 Whiplash and extension injuries of the neck 35 Barre-Lieou syndrome 36 Rheumatoid arthritis in the cervical spine 37 Klippel-Feil syndrome 37 Neoplasms in the cervical region 37 nspection and palpation of cervical spine 38 Examination of cervical spine movements 39 Diagnosis of thoracic outlet syndrome 40-41 Diagnosis of...

Clinical orthopaedic examination

Adson Test

Movements 7 If lateral flexion cannot he carried out without forward flexion, this is indicative of pathology involving the atlantoaxial and atlanto-occipital joints. 3.14. Movements 8 Rotation 1 Ask the patient to look over the shoulder. The movement may be encouraged with one hand and movement of the shoulder restrained with the other. Normally the chin falls just short of the plane of the shoulders. 3.15. Movements 9 Rotation 2 Again a spatula may be used as a pointer for measurement....

Anterior Metatarsalgia

In anterior metatarsalgia there is complaint of pain under the metatarsal heads. The condition is particularly common in middle-aged women and is also often associated with some splaying of the forefoot. Symptoms may be triggered by periods of excessive standing or an increase in weight, and there is often a concurrent flattening of the medial longitudinal arch. Weakness of the intrinsic muscles is usually present, so that there is a tendency to clawing of the toes hyperextension of the toes at...

Fibrous Flexor Sheaths Fingers

Distal Interphalangeal Joint

Most or all fingers affected. Frequent episodes, summer and winter Occupation changed to avoid further exposure to vibration because of severity of signs and symptoms See also under Rheumatoid arthritis. Mallet finger In a mallet finger the distal interphalangeal joint is held in a permanent position of flexion the deformity may be moderate or complete. The patient is unable to extend the distal joint of the finger, either not at all or only incompletely. The problem is...

Guide To Painful Conditions Around The Ankle

Skin Dimpling Achilles Tendon

Sprain of lateral ligament Complete tear of lateral ligament Ankle fracture, fracture of the fifth metatarsal base Tibiofibular diastasis Ruptured Achilles tendon tendo calcaneus Complete tear of lateral ligament Secondary osteoarthritis e.g. previous ankle fracture Osteochondritis tali Rheumatoid arthritis Primary osteoarthritis Footballer's ankle Secondary osteoarthritis e.g. from osteochondritis tali Tenosynovitis Achilles tendinopathy Snapping peroneal tendons 12.1. Inspection 1 Look for A...

Dermatome

Froment Test Ulnar Nerve

Myotomes 6 A single segment again, namely TI. is involved in producing abduction and adduction of the fingers these movements are carried out by the small muscles intrinsics of the hand. Note In testing for myotomes the ability to perform the above movements should be assessed by MRC grading, and note made of the segments affected. Often the defect can be localized to a single segment. 2.9. Dermatomes Note that the middle finger is supplied by C7, and that there is a regular, easily...

Hallux Valgus

In adolescence, and particularly in girls, where there is competition between the rapidly growing foot, tight stockings and often small, high-heeled, unsuitable shoes, valgus deformity of the great toe first appears. In some cases a hereditary short and varus first metatarsal may contribute to the problem. As the deformity progresses, the drifting proximal phalanx of the great toe uncovers the metatarsal head, which presses against the shoe and leads to the formation of a protective bursa...

Uncovertebral Osteophytes

Uncovertebral Osteophytes

Radiographs 8 Proximal cranial migration of the odontoid process is also commonly seen in rheumatoid arthritis. In the adult this may be assessed by noting lhe distance between the pedicle P of C2 shown hatched and a line connecting the spinous process S with the arch A of CI. If this is less than 11.5 mm. proximal migration is considered to be present. pharyngeal shadow, which normally lies fairly close to the bodies of the vertebrae as at A . Displacement suggests a retropharyngeal...

Additional Investigations

Fluid Wave Exam

Occasionally a firm diagnosis cannot be made on the basis of the history and clinical examination alone. The following additional investigations are often a Arthroscopy may give much useful information, and in conjunction with the clinical examination will permit a firm, accurate diagnosis to be made in the majority of cases. Incorrect diagnoses are most common in lesions involving the menisci in their posterior thirds. An increasing number of conditions are amenable to arthroscopic surgery,...

Radioulnar Synostosis

Rheumatoid Arthritis And Hyperextension

Inspection 6 The carrying angle may be measured with a goniometer. Average values of carrying angle Males 11 range 2 -26 Females 13 range 2 -22 . 5.7. Movements 1 Extension A Full extension, 0 , is present if the arm and forearm can be made to lie in a straight line. B Loss of full extension is especially common in osteoarthritis, rheumatoid arthritis, and old fractures particularly of the radial head involving the elbow joint. 5.8. Movements 2 Hyperextension If the elbow can he extended...

Lij clinical orthopaedic examination

Hemivertebra Pes

Pathology 15 The radiographs show a regular dorsal kyphosis associated with anterior vertebral lipping and a degree of osteoporosis. Diagnosis senile kyphosis. 8.104. Pathology 16 The spinous process of L5 and less obviously SI , along with associated posterior elements, is absent. Diagnosis spina bifida occulta. The only disturbance noted in the lower limbs was a bilateral pes cavus. 8.105. Pathology 17 The radiographs shows a dorsal scoliosis associated with an anomaly of a vertebral...

The shoulder

Posterior Drawer Test Shoulder

Anatomical features 50 Common pathology arouna the sioulder 52 'Frozen shoulder' idiopathic adhesive capsulitis of the shoulder 53 Calcifying supraspinous tendinitis 53 Osteoarthritis of the acromioclavicular joint 54 Osteoarthritis of the glenohumera joint 54 Rheumatoid arthritis of the shoulder 54 Instabilities of the shoulder joint 54 Recurrent allocation of the shoulder 54 rtfections around the shoulder 55 Miscellaneous conditions around the shoulder 55 Assessment of combined shoulder and...

Excessive Cubitus Valgus Angle Varies

Cubitus Valgus

Anatomical features 74 General points 74 Important relations 74 Elbow function 75 Tennis e bow 75 Cubitus varus and cubitus valgus elbow instability 75 Tardy ulnar nerve palsy 75 Ulnar neuritis and the ulnar tunnel syndrome 76 Osteoarthritis and osteochondritis d'ssecans 76 Rheumatoid arthritis 77 Tuberculosis of the elbow 77 Myositis ossificans 77 Inspection 78 Movements 79 Palpation 80-81 Tennis elbow tests 8 1 -82 Radiographs 82-84 Pathology 84-87 Aspiration of the elbow joint 87 The...

Ankylosis Of Ankle

Sudeck Bone Atrophy Foot

Radiographs 3 In the standard AP and lateral projections do not mistake A the common os trigonum accessory bone and B the epiphyseal line of the fibula for fractures. The amount of tibiofibular overlap C is dependent on positioning and any diastasis. The os fibulare D is thought to represent an avulsion of the anterior talofibular ligament, and may be associated with instability. 12.41. Radiographs 4 The articular margins of tibia and talus should appear as two congruent circular arcs....

Simian Posture In Pagets Disease

Simian Stance Spinal Stenosis

Although usually suspected following history taking, clinical examination and the study of appropriate radiographs, the diagnosis is made largely by a process of elimination it is back pain which is not due to a prolapsed intervertebral disc or any other clearly defined pathology. The patient is usually in the 20 15-year age group, and complains of dull backache aggravated by activity. There is often a history of morning stiffness which is gradually relieved as the patient moves about. Physical...

The wrist

Complex Regional Pain Syndrome Fingers

Study of the wrist cannot be separated from that of the hand, and in many cases careful examination of both may be required. complications occurring after colles' fracture_ Considering the incidence of Colles' fracture, the commonest of all fractures, it is surprising that complications from this injury are not seen more frequently nevertheless, they do occur and are of importance. Excluding initial weakness of the wrist, the commonest complaints are of residual deformity, restriction of...

Achilles Tendinopathy

This generally results from excessive repetitive overload of the tendon to a degree that exceeds its capacity to recover. The preferred term ' endinopathy' includes a number of conditions which may only be differentiated by direct inspection and histological examination of the tendon or surrounding structures. These include tendinitis, where there is a clear inflammatory process involving the tendon tendinosis, where there is collagen degeneration within the tendon and paratendinitis, when...

Images For Quadriceps Angle Measurement

Femoral Condyles And Patella Test

Posterior cruciate ligament 2 With the leg still in 20 flexion, ask the patient to lift the heel from the couch while you observe the knee from the lateral side. Any posterior subluxation should normally correct during this extension of the knee, confirming the diagnosis. 10.79. Posterior cruciate ligament 3 Place the thumb on one side of the joint line and the index on the other to help you assess any tibial movement. Try to pull the tibia forwards with the other hand. If the posterior...

Trendelenburg Test

Normal Arom Hip Internal Rotation

Where there is significant true shortening the heels will not be level the discrepancy is a guide to the amount of shortening and the pelvis will not be tilted. The site and amount of shortening must now be further investigated. Begin by hooking the thumbs under the anterior spines. Feel for the greater trochanters with the fingers. If the distance between the thumb and fingers is shorter on one side, this suggests that the pathology lies above the trochanters. 9.15. Shortening examination 5 II...

The Delayed Trendelenburg Test

Trendelenburg Test

b Edinburgh method An AP film is taken with the child's legs held parallel, with slight traction and no external rotation. Centre the beam at a standard distance of 100 cm. Measure the gap between the most medial part of the femur and the lateral edge of the ischium. This is normally 4 mm over 5 mm is suspicious 6 mm is regarded as diagnostic of DDH. Proximal migration can also be measured in the same film. 9.71. Developmental dislocation of the hip DDH The older child 1 Appearance A The...

Peripheral Nerves

Nerves For Dorsi Flexion

The brachial plexus has a most extensive distribution, and the order in which the nerves come off is of value in determining the site of any lesion. This is of particular importance in traumatic lesions, where the prognosis and treatment are closely related to the level of injury. The first branches of the plexus to be given off arise from the nerve roots themselves. Two important branches in this category are 1. The nerve to the rhomboids dorsal scapular nerve . It arises from the C5 root...

Patella Skyline View

Pseudogout Knee

Radiographs 5 Note any joint space narrowing indicating cartilage loss N , lipping L , marginal sclerosis S . cysts C , loose bodies H , varus or valgus these are all common in osteoarthritis . Do not mistake a bipartite patella B for fracture bipartite patella, if present, affects the outer quadrant . Note any abnormal calcification, as in Pellegrini-Steida disease J , calcified meniscus K , and pseudogout. 10.124. Radiographs 6 Look for alterations in bone texture e.g. in Paget's...

The spine anatomical features

The complex relationships of the components of a typical vertebra may be illustrated by an exploded diagram shown here after Kapandji . The bony elements comprise the vertebral body 1 , composed of cancellous bone covered with an outer shell of cortical bone the horseshoe-shaped neural arch 2 two articular masses or processes 3 which take part in the facet interarticular joints the transverse processes 4 and the spinous processes 5 . When these components are brought together they form a...