Clinical Examination Methods in Orthopaedics (Supplement to Textbook of Orthopaedics) John Ebnezar
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Examination of a Bony Swelling1

A lesion in the bone could be congenital, developmental, metabolic, infective, inflammatory, neoplastic or traumatic. To diagnose a bony lesion, a proper history and an accurate examination is a must.
 
HISTORY
Age of Onset Ewing's sarcoma is seen in children less than 10 years. Osteogenic sarcoma in the second decade, multiple myeloma in the fourth decade, etc.
Thus, the age of onset of a bony lesion has a special reference to the diagnosis.
Sex Osteoid osteoma, osteomyelitis, osteogenic sarcoma are more common in males.
Role of trauma Trauma could be a contributory factor (e.g. fracture and its problems like malunion, nonunion, etc.) or could be a precipitating factor or aggravating factor (e.g. osteogenic sarcoma, Perthes’ disease, tuberculosis, etc.).
Thus, trauma has a definite role to play in the development of a bony lesion.
Pain This is the most common complaint given by the patient with a bony lesion. The nature and intensity of the pain varies. It could be acute and severe as in acute osteomyelitis, osteogenic sarcoma, etc. or dull aching as in giant cell tumour, tuberculosis, etc. If the patient complains of night cries, it is suggestive of TB arthritis, if a young male patient complains of pain in the tibia disturbing the normal sleep and relieved by taking Aspirin, it could more likely be a case of osteoid osteoma.
Duration This will be short in acute osteomyelitis, osteogenic sarcoma, etc. but long in cases of chronic osteomyelitis, benign bone tumours, etc.2
Deformity Deformities may develop due to the effects of a bony lesion near the growth plate in children (e.g. genu varum or valgum) (*see Figs 32.17A and B, refer page no 382). Malunion or nonunion of fractures can also cause deformities.
In congenital problems like congenital talipes equinovarus (CTEV) or developmental disorders like osteogenesis imperfecta, the patient can present with deformity as the main complaint.
Other complaints There may be complaints of restriction of movements, discharging sinuses, limp, etc. Constitutional symptoms are present in tuberculosis, malignancy, etc.
 
PHYSICAL EXAMINATION OF A BONY LESION
Inspection It is important to make the patient as comfortable as possible and the examining part should be adequately exposed and examined in broad daylight. Look for the following points during inspection.
  1. Site of the lesion A fairly accurate diagnosis of the bony lesion can be made depending upon the site of involvement (Figs 1.1A to D). Hence, determine first whether the lesion is epiphyseal (e.g. giant cell tumour—GCT), metaphyseal (e.g. osteomyelitis) or diaphyseal (e.g. Ewing's sarcoma).
  2. Extent of involvement After having established the site of lesion, it is now important to determine the extent of bone involvement. In GCT, one aspect of the bone is involved while in osteogenic sarcoma, the entire circumference of the bone may be involved.
  3. Colour and texture of the overlying skin The skin will be stretched and shiny with dilated veins in osteogenic sarcoma and will appear more red. In GCT, the skin may be just stretched and shiny.
  4. Presence of any scars or sinuses These indicate the presence of chronic osteomyelitis or old infections.3
    zoom view
    Figs 1.1A to D: Showing the different sites of a bony swelling
  5. Deformities like cubitus varus, valgus, genu valgus or varus, flexion deformities, etc. should be looked for.
  6. Length of the bone Due to the effects of a bony lesion, there could be alteration in the length of the bone like shortening (common) or lengthening (rare).
  7. Shape of the lesion Find out whether the lesion is globular, oval, etc. by a 3-dimensional examination.
  8. Size of the lesion Huge swelling is commonly seen in osteogenic sarcoma, chondrosarcoma, etc. Medium-to-small sized swellings are common in bone cysts, GCT, etc.
  9. Surface In benign bone tumours, the surface is smooth and regular; while in chronic osteomyelitis, malignant bone tumour the surface may be irregular.
  10. Edge of the swelling Determine whether the edge of the swelling is indistinct or clearly defined.
  11. Pressure effects Oedema of the limb distal to the swelling indicates the pressure effect.
  12. Gait Find out whether the patient has limp, antalgic gait, short-limbed gait, etc.
  13. Look for muscle wasting proximal and distal to the swelling.
Palpation In this step, effort is made to confirm most of the findings observed during inspection.4
  1. Local rise of temperature This is elicited by examining the bony lesion with the dorsum of the hand since it helps detect even minor changes in the temperature as this is the most sensitive part. Increased warmth indicates increased inflammatory activity of the bony lesion. Compare this with the opposite side.
  2. Tenderness has to be elicited and graded carefully as described previously.
  3. Size and shape The size and shape of the swelling is measured and expressed in centimetres.
  4. Consistency The whole swelling is gently palpated and the consistency is graded as follows:
    Grade I—very soft (like jelly)
    Grade II—soft (as a relaxed muscle)
    Grade III—firm (as a contracted muscle)
    Grade IV—hard (as a contracted biceps)
    Grade V—stony or bone hard.
    Bony lesions are usually hard, but there can be variable consistency as in osteogenic sarcoma or egg shell crackle like consistency as in GCT.
  5. Situation of the bony lesion By careful palpation, determine:
    1. Whether the swelling is epiphyseal (e.g. GCT)
    2. Whether near the epiphyseal line (e.g. exostosis)
    3. Whether the swelling envelopes the whole circumference or is eccentric (e.g. GCT)
    4. Whether swelling is metaphyseal (e.g. osteomyelitis)
    5. Whether swelling is diaphyseal (e.g. Ewing's sarcoma).
5
  1. Palpate the surface and find out whether it is regular or irregular.
  2. Edge In soft tissue tumours like lipoma, the edge of the swelling slips under the examining finger.
  3. Fluctuation This can be elicited in a cystic swelling.
  4. Translucency This can be demonstrated in a cystic swelling.
  5. Fixity of the swelling A bony lesion is usually fixed to the underlying bone and cannot be moved independent of it.
  6. Plane of the swelling It is important to determine the anatomical plane of the swelling. By putting the muscle over the swelling into contraction, the plane of the swelling can be determined:
    • If it is situated on the bone beneath the muscle—the swelling reduces in size.
    • If in the muscle—gets fixed and slightly reduces in size.
    • Above the muscle—no change in the size of the swelling.
  7. Scars and sinuses The presence of scars and sinuses in the vicinity of a bony lesion indicates an old infection and chronic osteomyelitis (*see Fig. 38.9, page 494). Find out whether the sinuses are old and healed or contains sprouting granulation tissue. If present, it indicates a nonhealing sinus and could be due to:
    • Anaerobic infection
    • Sequestrum
    • Foreign bodies
    • Epithelialisation of the sinus tract
    • Diabetes
    • Steroid treatment
    • Secondary infection
    • Neoplasm
    • Anaemia and debility.
  8. Neurovascular status It is important to determine the effects of the swelling due to compression of the nerves and vessels.
Due to the compression over the vessels, there could be distal limb oedema, discolouration of skin and weak or absent peripheral pulses.6
Compression over the nerves causes impairment of the neurological status of the limb distal to the lesion. Examination of the sensory system, motor system and reflexes has to be carried out.
Movements The movements of the neighbouring joints near the bony lesion could be restricted due to:
  1. The mechanical block created by the swelling near the vicinity of a joint.
  2. Soft tissue and muscle contractures.
  3. Intra-articular extension of the swelling (e.g. osteogenic sarcoma).
  4. Neurovascular compression.
Measurements The limb is measured for shortening, lengthening and wasting of the muscles. This is compared with the normal side (*see page no. 324).
 
OTHER EXAMINATIONS
A complete systemic examination is carried out to find out if the bony lesion is a local manifestation of a generalised disorder.
Find out if similar swellings are present elsewhere. In multiple exostoses, bony hard swellings are found at various sites.
Examine the thyroid, breast, lungs for evidence of primary.
Examine the local draining lymph nodes.
After completing the above examination of a bony lesion, an attempt is made to arrive at a proper diagnosis as follows:
  1. Is the lump congenital? If so, it will be present since birth or appears within a few months or years after birth.
  2. Is the lump developmental? If so, it will be seen during the developmental phase of the skeletal system and will be most of the times generalised.
  3. Is it traumatic? If so, there will be definite history of trauma and the patient could have suffered a fracture or dislocation and now could be presenting as a late complication of fractures like malunion, nonunion, contractures, deformity, etc.7
  4. Is it inflammatory? If so, the patient will show features of inflammatory disorders like polyarthritis, systemic involvement, etc.
  5. Is it infective? If so, the patient will give history of fever, pain, swelling, etc. in acute infections and chronic discharging sinuses in old infections, etc.
  6. Is it neoplastic? If so in benign, long duration, slow growth, painless, no constitutional symptoms, etc. and if malignant, fast growing, cachexia, constitutional symptoms, etc.
  7. If it does not fall into any of the above categories, it could be due to:
    • Metabolic origin
    • Degenerative origin
    • Hormonal origin
    • Idiopathic.