Clinical Orthopaedic Diagnosis Sureshwar Pandey, Anil Kumar Pandey
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IntroductionCHAPTER 1

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mithya drista vikarahi durakhyatastathawach.
tatha dusparimrstascha mohayetuchikitsakam.
Not taking a correct history and not doing a thorough examination by inspection and palpation can mislead the physician, in achieving the goal,
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tasmat bhisak karya chikirsu praka karya samarambhat.
parikshya kevalam parikshyam parikshaya karma samarabheta kartrum.
Therefore a practitioner keen to carry out any procedure should first of all examine and thoroughly investigate the same before venturing on the actual treatment.
(SUSHRUTA c. 500 BC.)
The word “SCIENCE” is derived from the Latin root “SCIRE” which means “to know”. The original meaning of science is knowledge dealing with the material world.
“Knowledge is power”.
—Sir Francis Bacon 1597.
“Union of Science and religion alone will bring harmony and peace to the humanity”.
—Swami Vivekanand
“I hear and I forget
I see and I remember
I do and I understand”
The word ‘patient’ is derived from the Latin word ‘patiens’ (means sufference). The emergence of medical practice is to relieve the suffering.
Medicare represents the essence of life experiences, the pinnacle of education and the epitome of empathy and compassion. It is a mission to heal and to comfort, and to further dignify our fellow human beings.
Direct or indirect evidences suggest fairly acceptable developed statins of orthopaedics in ancient period, such as:
  • Evidences of fractured bones healed in acceptable alignment in primitive man has been noted
  • Splints made of bamboo, wood bark, reeds padded with linen have been seen on mummies
  • Earliest known record about the use of crutches has been found in 2830 BC on the entrance of a portal on Hirkouf's tomb.
The word ‘orthopaedy’ (derived from French word orthopédie and Greek word orthos+ paidion) came into existence, signifying an art of correcting deformities in children, by Nicolas Andry, a French Physician, in the year 1741 who designed orthopaedic oncography in his book entitled—‘L’ orthopaedic Ou L'art de prevenir et corriger dans les enfants, les difformite's du corps’ in 1741. English translation of the title of Andry's book published in 1743, reads ‘Orthopaedia: or the art of correcting and preventing deformities’ in children as may easily be put in practice by parents themselves, and all such as one employed in educating the children. The word ‘orthopaedy’ comprises of two Greek words—orthos (meaning straight) + paideia (meaning rearingof children). However, this speciality today, is none the less, “Orthogerontics”. Frankly speaking, unless specified, all considerations in medical practice centres around the adults and middle age (40 to 60 years—mediatrics) however with constant increase in the life expectancy, the orthopaedic and trauma problems of old age (more than 60 years of age—geriatrics) are none the less, rather more, demanding. Of course the orthopaedic problems of children (paediatrics) definitely deserve special considerations. Today orthopaedics has grown into a multifaceted discipline and is now one of the most comprehensive specialisation in the field of medical practice, leaving far behind the art and craft of traditional bone setters.
In order to support the curvatures of the spine, a supportive corset, made of punched iron sheet was first used by Ambroise Pare, and Gersdorff (1530) had described an iron splint for stretching 4contractures, still it was not until after the First World War that the principles of rehabilitation were clearly included in the arena of orthopaedics.
In the western world, Hugh Owen Thomas (1834–1891) of Liverpool propounded several fundamental principles of orthopaedics. These were later put on a sound footing by his nephew, Sir Robert Jones (1857–1933), who also concerned himself with different operative techniques in this speciality. Discoveries of anaesthesia (Crawford Long of Athens, Georgia, 1842); antisepsis (Joseph Lister 1867); fundamental research on bacteria by Louis Pasteur (1822–1895); introduction of Esmarch tourniquet in 1873 (which provided bloodless surgical field) and X-ray (Roentgen 1895) led to a phenomenally rapid evolution, of surgery as a whole, and orthopaedics in particular.
A probe into ancient Indian literature reveals that knowledge regarding the skeletal system has been mentioned in the three different systems of Atreya, Sushruta and Vagbhata. Even in the Vedic period, the craft of orthopaedic surgery was of an admirably high standard. In the oldest Aryan literature of the Rigveda, we find evidence of the use of suitable artificial limbs as substitutes for limbs accidently lost in war.
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In the above mentioned passage, the priest Agastya requests the clinician Ashwini to fit the artificial limb to the leg amputated in war of king Khel's wife queen Vishpla in that very night itself. Further he requests that the limb should be strong and made up of steel but should be light like a bird's feather.
Hua Tuo (141–203AD), in China performed many kinds of surgical operations, such as leparotomy, amputation of limb, etc. He introduced general anaesthesia to China using the Chinese herb ma-fei-san, along with wine as the anaesthetic.
Today, orthopaedics has emerged as a distinct speciality in its own right, with even different sub-branches (Cold orthopaedics, Traumato-logy—Accident services, Sports medicine, sub-branches for different parts of limbs, joints; Spine, Hip, Knee, Hand, Foot, etc; different technologies such as arthroscopy, arthroplasties, Ilizarov technology, etc. Rehabilitation medicine and so on). Therefore the responsibility of an orthopaedic surgeon, in examining, investigating, diagnosing and managing the dysfunctions of the locomotor system (bones, joints, muscles and nerves), caused by congenital malformation, nutritional deficiencies, diseases, trauma, tumours and other known lesions, has also increased profoundly.
The American Academy of Orthopaedic Surgeons has defined orthopaedic surgery as “that medical speciality which embraces the investigation, presentation, development and restoration of the form and function of the extremities, the spine, and associated structures of the skeleton by medical, surgical and physical means”.
Accurate clinical diagnosis forms the basis for successful management of any ailment. No doubt, the development of a sound judgement is largely a matter of experience, yet one must remember the words of Sir Astley Cooper (1768–1848), “nothing is known in our profession by guess; and I do not believe, that from the first dawn of medical science to the present moment, a single correct idea has ever emanated from conjecture. It is right therefore, that those who are studying their profession should be aware that there is no short road to knowledge; that observations on the diseased, living, examinations of the dead, and experiments upon living animals, are the only sources of true knowledge; and that inductions from these are the sole basis of legitimate theory.” The great Indian surgeon Sushruta (c. 600 B.C.) had also warned against diagnosing a disease merely on speculation. He gave explicit instructions regarding history taking, inspection, palpation, auscultation, etc. An indication of the details with which the symptoms and signs were analysed can be exemplified by the list of the types of pain which were enquired 5into—i.e. whether pain was of pricking, piercing, churning, bursting, pinching, uprooting, stiffening, benumbing, indurating, contracting, or of a spasmodic nature, etc. Pain, which came on or vanished without any apparent cause, or was varied and shifting in nature was supposed to be the effects of deranged ‘Vayu’.
“Science is a dynamic discipline and only changes can lead to its progress”—Sir Issac Newton 1750. At the same time science and technology are being overrated in the present civilisation and every walk of life and so in the medical field. However, the immense importance of systematic clinical methodology in the practice of medical science can never be ignored. There is no short cut to familiarity with clinical signs and their interpretations. A ‘snap’ diagnosis based on a cursory examination may be disastrous for even an experienced clinician. On the other hand, an inexperienced apprentice examining his patient, methodically step by step, will certainly give a better account of himself.
There are five steps to learning: Silence, Listening, Memory, Practice, Teaching others.
—Old Hebrew proverb
These are very true in medical education.
The aim of the medical education should be familiarity with the scientific principles in an approach that will allow the physician to handle logically, correctly and safely even those diseases with which he/she may not have previous experience. The physicians of tomorrow should be educated rather than schooled. Medical science is nowadays characterised by more and more narrow specialisation burdened by new in-depth research works. Therefore, a threat emerges that the clinicians and subsequently the medical students loose their ability to see the sick persons in their totality. This phenomenon is one of the potential sources of dehumanisation of medicine.
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Fig. 1.1: Craniopedus(By courtesy Dr Pushpa Pandey and Pallavi Pandey)
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Fig. 1.2: Thoracopedus
The development of technical approach to the medical care has gradually led to the clinician to give less and less time to the patient. Earlier the clinician used to start the care taking with detail interrogations of the patient and/or relatives, which used to give an insight into the medical aspects of patient's past and present. Thorough physical examination was performed with great care before some tests were ordered. Though a little time consuming, such procedure promoted a holistic approach to the sick. Unfortunately there is a gradual reversal in that trend. Clinicians are cutting down their time spent in initial conversation and primary physical examination. The cult of numbers (uncritical acceptance of quantitative laboratory determinations) has almost replaced the cute clinical observation, the friendly attitude and psychic comfort of the former days.6
A clinician should not order a laboratory test/any investigation, unless he/she knows why it is being ordered and what will be done if test comes back abnormal.
Actually the computer addiction is prevailing over many clinicians, medical teachers and also the medical students all over the globe. The abilities and competence of the computers are being overestimated. However, a computer, though most helpful and serviceable in medical education and practice, can not replace a thinking clinician with searching eyes and probing brain and the practical examination. His associative reasoning can not be restricted to a software programme.
In a quest of achieving the accuracy and exactness computer-assisted orthopaedic surgery (CAOS) is being introduced. The principle of CAOS is simple. A digital image is produced which serves as a map for each particular procedure. That image is made available to surgeons to guide them through the operation. The accuracy can be achieved to the fraction of a millimeter or degree. Thus surgery can be compared to an instrumental landing of an aircraft. The CAOS is being aimed to benefit the patient in having less morbidity with a better functional outcome and greater longevity for implants. However, the machines, manpower and methods involved in this procedure are very expensive, operational time becomes longer, and it is premature to assess the overall benefit to the patients.
Moderately open surgery (MOS) and video-assisted endoscopic minimum invasive surgery (MIS) are proving to lessen the operative blood loss, operative exposure, the hospital stay and postoperative pain, but at the same time are hiking the cost of surgery and learning curve. Only good surgical training, judgement, technique and skill will be cost-effective.
Today, in an era of rapid industrialisation and mechanisation, orthopaedics occupies an important place in the field of medical sciences. The examination and management of an osteo-articular problem, very much involves assessment of the patient as a whole. However, two factors, quite often missed, must get their place while examining an orthopaedic patient.
  1. Proper documentation of case records, which has got immense value in this branch of reconstructive surgery.
  2. History taking and clinical examination should be rehabilitation oriented.
Remember nothing is 100%.
Accurate representation of the clinical findings, supplemented with sketches, graphs, photographs, X-rays, cine-films, writing tests, foot prints, topographical representation and moulds go a long way in helping the clinician in diagnosing, planning of treatment, declaring the prognosis and assessing the results of follow up.
An orthopaedic problem in a patient may arise from any of the following:
  1. Congenital, infective and developmental malformations (Figs 1.1 to 1.23).
    Siamese twins are the extreme forms of congenital malformations. They fall basically in three broad groups: Cephalopedus (Craniopedus) (Fig. 1.1), Thoracopedus (Fig. 1.2) and Pedopedus, according to the region of fusion.
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    Fig. 1.3: Congenital malformation of all the four limbs—rudimentary limbs
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    Fig. 1.4: Congenital cleft lip and palate
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    Fig. 1.5: Congenital contracture of hip, knee, ankle and foot
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    Fig. 1.6: X-ray of same child (Fig. 1.5)
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    Fig. 1.7: Arthrogryposis multiplex congenita. Note bilateral club hand, left club foot, right congenital vertical talus, bilateral flexion contracture of knee joint, wide perineum indicating bilateral CDH and congenital constriction band at right lower leg
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    Fig. 1.8: Arthrogryposis multiplex congenita
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    Fig. 1.9: Congenital hyperplasia of left upper limb
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    Fig. 1.10: Congenital lymphoedema of left upper limb
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    Fig. 1.11: Pott's puffy tumour in a boy aged 16 years
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    Fig. 1.12: Pott's puffy tumour in a lady aged 46 years
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    Fig. 1.13: Typical X-ray of multiple epiphysitis
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    Fig. 1.14: Melorheostosis (candle bone disease). Note that affections are mainly of radius, lateral half of humerus and hand. The peculiar streaked sclerosis of bone resembling candle driplings. It is oftenly associated with congenital neurofibromatosis
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    Fig. 1.15: Marble bone disease (osteopetrosis)
  2. Affections of bones.
  3. Affections of joints (Figs 1.24 and 1.25)
  4. Affections of soft tissues around and controlling the joints, e.g.—skin (burn con-tracture), subcutaneous tissue (Dupuytren's contracture), muscles, tendons (Figs 1.26, 1.29 and 1.31).
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    Fig. 1.16: A girl aged 9 years with osteogenesis imperfecta with multiple deformities following multiple fractures
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    Fig. 1.17: Osteogenesis imperfecta with multiple deformities in the limbs following malunited fractures
  5. Affections of nervous system (Fig. 1.28).
  6. Vascular affection of limbs (Buerger's phenomenon; Volkmann's ischaemic contracture (Fig. 1.27), etc.).
  7. Postural abnormalities (Fig. 1.32), e.g. (1) Pisa syndrome—a dystonic syndrome characterised by lateral flexion of the trunk associated with slight rotation due to high dose of chlorpromazine, given for neuro-epileptics.10
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    Fig. 1.18: Osteogenesis imperfecta
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    Fig. 1.19: Osteogenesis imperfecta. Note the malunion of forearm, tibial and femoral fractures
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    Fig. 1.20: Dwarf (rachetic)
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    Fig. 1.21: In osteogenesis imperfecta the fractures can be avoided by using telescoping rods
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    Fig. 1.22: Prophylectic telescopic rodding of the long bone to prevent pathological fractures in osteogenesis imperfecta
    There may be associated tardive dyskinesia; (2) Tortipelvis (L. tortus= twisted+pelvis= basin) meaning thereby muscular spasms in children distorting the spine and hip.
Medical knowledge alone is not enough to meet the patient's expectations from us. Fellow feeling, friendly intentions, moral support, relief from fear, human attitude towards the patient, as well as physician's efficiency, all these are essential.
1. Routine Hand-Hygiene
Before and after the physical examination of patient ‘Routine hand-hygiene’ is essential for the safety of both, the patient and the doctor and even others. The ideal routine towards the hand-hygiene should consist of:
  • Watch, bangles and jewellery should be removed
  • Wash the hands and distal forearm with water and 2% chlorhexidine surgical scrub solution for 2 minutes
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    Figs 1.23A and B: Hand-Schüller-Christian disease (a typical histiocytoses) with classic geographic skull: (A) Lateral view of skull, (B) Anteroposterior view of face and skull
  • Hands should be dried with a sterile dry towel or disposable paper towel/tissue
  • If the blood, discharge from a wound, pus or any body fluid gets unintentionally touched or is being touched without gloves in the process of examination, the above process of washing or scrubbing must be repeated before touching any other part or instrument or anything
  • Subsequently any hand rub (e.g. absolute alcohol or chlorhexidine in alcohol) should be used12
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    Fig. 1.24: Congenital syphilis with multiple joint affections and pseudoparesis
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    Fig. 1.25: X-ray of the same child showing multiple meta-physitis with collection in the joints, bilaterally (in knees, hips and shoulders)
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    Fig. 1.26: Burn contracture producing multiple problematic deformities of foot and hand
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    Fig. 1.27: Grotesque deformity of wrist and hand—very severe Volkmann's ischaemic contracture
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    Fig. 1.28: A cerebral palsy child (spastic) with mental retardation
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    Fig. 1.29: Typical bilateral symmetrical electrical burn in upper limbs
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    Fig. 1.30: Bilateral almost symmetrical gangrene of both hands and feet due to toxicity of an indegenous medicine
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    Fig. 1.31: Post-burn contracture of elbow
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    Fig. 1.32: A typical spinal deformity due to Pisa syndrome
  • The ‘hand-hygiene’ should be maintained while examining each patient; while touching common objects, e.g. pen, telephone, stethoscope, etc.; putting hand in pocket, etc.
2. Armamentarium Necessary for Examining an Orthopaedic Patient
  1. A measuring tape.
  2. Goniometer (large and small).14
  3. A tendon rubber hammer.
  4. A pocket torch.
  5. A pin with protected point.
  6. Skin marker pencil.
  7. A stethoscope.
  8. A diagnostic set (tongue depressor, auroscope, ophthalmoscope).
  9. A plain white paper and impression ink for taking prints.
  10. Camera (more important than even a stethoscope for a reconstructive surgeon).
  11. For neurological cases—cotton wool, tuning fork, test tubes.
3. Certain Factors Essential for Examining an Orthopaedic Case
  1. Hear the patient with patience, even if he is confused, disoriented and annoying.
  2. Reassuring the patient and gentle handing of the affected parts.
  3. Good bedside manners.
  4. Sympathetic appreciation of the patient's problems.
  5. Doctor should be well-dressed, composed, and not in hurry.
  6. As far as possible communicate with the patient in his/her language to get the clear story and facts.
  7. All physical complaints should be taken up seriously.
  8. Remember that the patient is almost always right while narrating the problems.
  9. Remember that the snap-diagnosis can be mostly wrong.
  10. Diagnosis of Functional Neurotic Disease (FND) should always be at the last, after excluding all possible diagnosis.
  11. An insight into the patient's future rehabilitation programme.
  12. Need for examining the patient as a whole, and not a particular limb or system.
  13. The patient must be placed in comfortable position.
  14. Usually patients feel comfortable, confident and free, when one of their own man remains there while being examined.
  15. The patient is to be fully exposed, at least the corresponding part or limb.
  16. Do not hurt the patient during examination.
  17. Before coming to final conclusion remember that the patient is always right, and doctor is always wrong unless the doctor proves that patient is not right, which requires keen observation, thorough clinical examination, deep scrutiny of patient's complaints and findings and wide application of knowledge.
The first impression, that a keen clinician gets of his patient while he/she is entering the examination room, forms the basis for his/her onward assessment.
At the first sight note:
  1. Facial expression (for stress, agony, uncared, depressed, unconcerned, anxious, hyperbola, tetanic face [Fig. 1.37], Mongoloid face, etc.).
  2. Nutritional status (dehydrated, cachetic, emaciated, marasmic, hypoproteinemic, anaemic, bloated, obese, etc.)
In presence of vague, bizarre, unexplain-able (generalised pain and allied complaints):
  1. Assess for the fitness of body according to the age (accelerated aging; activity assessment; stamina assessment; flexibility assessment; overall strength assessment.
  2. Assess for habit/drug depending (smoking, alcohol, drugs, narcotics, paan, paan-masala, gutka, etc).
  3. Assess for thyroid functions, especially in ladies by: thorough clinical examination, estimating T3, T4, TSH levels and investigations if needed, e.g. Fine needle aspiration cytology (FNAC) especially to know the proper nature of thyroid tissue and thyroid swelling (benign or malignant); ultrasound of thyroid, which helps in defining the non-palpable nodules and the nature of swelling (cystic or solid).Clinical features of hypothyroidism are usually obesity; less or loss of appetite; constipation; lassitude; letharginess; increased sleep; depression, swelling of face; swelling of hands, feet, legs, thighs; generalised weakness and tiredness, dry skin, slowness of activities; 15increased menstrual flow; intolerance to cold; thyroid swelling, etc. These patients have low levels of T3 T4 hormones and excess of TSH (hormone).
    Clinical features of hyperthyroidism are usually loss of weight, increased appetite, tremors in fingers, sweating, dirrhoea, sleeplessness, anxiety, exophthalmus, emotions, tension, palpitation, amenorrhoea, abortions, etc. These patients have high levels of T3 T4 hormones and low level of TSH (hormone).
Most of the thyroid dysfunctions (except advanced malignant tumours) are amenable to proper medical and/or surgical treatment.
Common Orthopaedic Complaints
  1. Pain.
  2. Disability in using the limb.
  3. Inability in using the limb.
  4. Deformity.
  5. Stiffness of the joints.
  6. Swelling/abscess.
  7. Discharging wounds/sinus.
  8. Limb length disparity.
  9. Altered power and sensations.
  10. Cramps in the calf.
  11. Allied complaints, e.g. hyperhydrosis, tremors, muscular fasciculations.
History Taking
History of complaints forms the key step for making the diagnosis. History taking is an art of collection of datas over which you are planning your examination. The importance of relevant and detailed history taking can never be overemphasised.
Do not forget that your responsibility does not cease on getting a disease cured or a fracture united, rather management is incomplete without total rehabilitation of the patient. Therefore, history taking and examination must be rehabilitation oriented.
At first, note the full name, age, sex, race, religion, occupation and complete postal address, telephone number (including mobile), fax number, e-mail address of the patient. Carefully listen his/her story about the problem in his/her own language and words.
Enquire about the complaints in order of their appearance and note their duration. Each symptom should be thoroughly analysed. ‘Suck each symptom dry, like a dog sucks a bone’. Patients sometimes talk irrelevant, never be irritated on them.
Chief Orthopaedic Complaints Center Around the Following
PAIN: Pain is derived from the Latin word “POENA” (meaning punishment) and was associated in early civilisation with the concepts of demons, sin, and punishment. The terminology used for pain in Ayurved is ‘SHOOL’—originated from the weapon ‘TRISHUL’ of Lord ‘SHIVA’. Pain is a more terrible lord to mankind than the death itself.
Pain is one of the four elementary sensations. It is the master symptom in medicine. Pain has been defined by the International Association for Study of Pain (IASP) as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (except in psychological pain)”. IASP has also defined “analgesia” as “absence of pain in response to stimulation which would normally be painful”.
Nociceptors (derived from Latin ‘nocere’ meaning to damage and ‘capere’ meaning to understand i.e. to understand the damage) scattered in the fatty tissue around the ligaments and other tissues when pressed (e.g. by oedema) lead to perceiving of pain.
Pathophysiology of pain: Pain is a multifactorial phenomenon. Pain pathways are not hard-wired but are plastic and involve many processes that both signal and temporally increase the sensation of pain after tissue damage (e.g. after surgery). The nerve endings of A-delta mechanothermal and C-polymodal nerve fibres are the receptors for painful stimuli or nociceptors and normally they have a high threshhold for activation.
The ‘first pain’ (sharp immediate pain) is transmitted by A-delta fibres and the prolonged 16unpleasant burning, pain is mediated through the smaller unmyelinated C-fibres. A plethora of neurotransmitters including glutamate (most important excitatory neurotransmitters in the central nervous system) mediate transmission of the sensation of pain both in the brain and spinal cord.
Depending on the site of origin and nature, pain may classified as:
  1. Nociceptive pain—Pain produced by activation of normal nerve by noxious stimuli (mechanical, thermal, chemical). Site of origin of pain may be: (a) somatic, e.g. skin, muscles, bone, joints, (b) visceral—Pain in tubular structure (especially in abdominal viscera) is colic in nature, usually severe, deep pain; palpation may not reproduce pain.
    Pain in solid structure is continuous in nature, usually dull, superficially felt; and palpation always reproduces it.
  2. Neurogenic pain—Origin of pain is in nerve itself, e.g. herpetic neuralgia, diabetic neuralgia (neuritis), post-infarction pain, causalgia.
    Causalgia is a clinical syndrome associated with a lesion of a peripheral nerve containing sensory fibres, first described by SW Mitchell et al (1864). It is manifested by pain in the extremity coming spontaneously or with any stimuli, with or without change in the patient's mental state. Pain is usually of intense burning character, and may be intermittent or persistent diffused in the area of cutaneous supply of the involved nerve.
    Perhaps the only manifestation of (complains) pain in the neonate or young children is “weeping” (which may be due to hunger or fear even). Infants must not be taken as the young adults, and they should be examined with deep scrutiny.
    For correct diagnosis of pain it is better to follow ‘PQRST’ approach:
    Palliative factor (what makes it less; Provocative factor (what makes it more)
    Quality of pain (type of pain)
    Radiation of pain (path of reference of pain)
    Severity of pain
    Timing of pain (is it all the time or intermittent, etc).
    With timing its circadian variation should be noted. Rhythms that cycle about once a day are called circadian rhythms. Those of higher or lower frequency are respectively termed untradian and infradian rhythm.
    Climate pain: Few patients complain of pain only in some season; or aggrevation of pain in certain climate; or after easternly wind.
  3. Psychological pain—with no organic cause various factors are responsible for origin and perpetuation of pain, e.g. mental stress, sleepless night, etc.
  4. Total pain, in which all the above three factors are responsible, e.g. pain in cancer.
    Pain in cancer patient has a dreaded psyche overlay. One of the worst aspect of cancer pain is that it is a constant reminder of the disease and death.
  5. Phantom limb pain—It was originally described by Ambroise Pare in the seventeenth century. It may be defined as an unpleasant sensation often painful with or without burning sensation distal to the site of a nerve injury (phantom sensation), and may result in marked physical and psychological morbidity.
Chronic widespread pain (CWP): About 10% of adult population complain of CWP. The incidence is higher in women and generally increases with age. Usually there is no constant correlation between CWP and tenderness. CWP is likely to be associated with depression or other symptoms of psychological distress. Once established CWP is likely to persist or recur, especially if associated with other somatic symptoms in older age.
It is difficult to measure pain on a mathematical scale, however approximate assessment can be done in adult—“nonverbal pain scale” in the following points (Table 1.1).
Certain Sitewise Reference of Pain
  • From cervical region to shoulder, arm and even up to fingertips (brachalgia or cervicobrachial neuralgia)17
Table 1.1   Nonverbal pain scale
Category 0
Category 1
Category 2
No particular expression or smile
Occasional grimace, tearing, frowning, wrinkled forehead
Frequent grimace, tearing, frowning, wrinkled forehead
Activity (Movement)
Lying quietly, normal position
Seeking attention through movement or slow cautious movement
Restless, excessive activity and/or withdrawal reflexes
Physiology (Vital signs)
Stable vital signs
Change in any of the following:
• Systolic blood pressure
> 20 mmHg
• Heart rate > 20/minute
Change in any of the following:
• Systolic blood pressure > 30 mmHg
• Heart rate > 25/minute
Lying quietly, no positioning of hands over areas of body
Splinting areas of the body, tense
Rigid, stiff
Baseline respiratory rate/SpO2-pulse oximetry, compliant with ventilator
Respiratory rate > 10 above baseline or 5% decreased SpO2, mild asynchrony with ventilator
Respiratory rate > 20 above baseline or 10% decreased SpO2, severe asynchrony with ventilator
Each of the 5 parameters is scored 0–2, which results in a total score between 0 and 10. Document total score by adding numbers from each of the 5 parameters. Scores of 0 to 2 indicate no pain, 3 to 6 moderate pain, and 7 to 10 severe pain.
Note: The above pain scale is from Strong Memorial Hospital University of Rochester Medical Centre, 2004 (provided by Indus Citadal Aurobindo Biotech Ltd).
Assessment of Characteristics of Pain
Potential elements
Acute, recurrent or chronic; Onset and duration
Course and daily variation, including breakthrough pain*
Pain “on average”
Pain “at its worst”
Pain “at its least”
Pain “right now”
Focal or multifocal
Focal or referred
Superficial or deep
Any descriptor (e.g. aching, throbbing, stabbing or burning)
Familiar or unfamiliar
Exacerbating/relieving factors
Volitional (incident pain) or non-volitional
*Breakthrough, episodic, incidental and transient are few of the terms commonly used to refer to pain flare that can occur as a symptomatic overlay to baseline persistent pain.
Breakthrough pain has 3 subtypes:
  1. Incident pain: Pain with activity or movement (most common)
  2. Idiopathic pain: Pain with no known cause
  3. End-of-dose pain: Pain appearing before a scheduled dose of around-the-clock analgesic medication.
  • From supraclavicualr region to arm, forearm, fingers
  • From shoulder to arm, forearm, hand and fingers
  • From wrist to thumb, index finger (mainly from front of wrist)
  • From upper mid dorsal spine to side of chest (girdle pain)
  • From lower dorsal spine to abdominal wall
  • From lumbar region to loin, groin, upper medial aspect of thigh
  • From lower lumbar region to lumbosacral region to—along sciatic roots—sciatica
  • From sacroiliac joint to back of thigh and knee
  • From hip to anteromedial aspect of thigh and knee
  • From thigh to knee according to the aspect of thigh involved
  • From knee to shin of tibia.
Exact measurement of pain is rather impossible at the present stage, however pain threshold can be assessed by dolorimeter, e.g. by providing a ratio of finger tenderness on the affected/unaffected hand in Complex Regional Pain Syndrome (CRPS).
Complex regional pain syndrome (CRPS): Also seen in the chapter on “Syndromes” on page 653.
CRPS previously known as Reflex Sympathetic Dystrophy (RSD) comprises of abnormal pain, swelling, vasomotor disturbances, contracture and osteoporosis. Exact cause is not known. Hand and foot are mainly affected, although knee, elbow, shoulder and even hip (in pregnancy) may also be affected.
Usually CRPS starts by a month after precipitating trauma, by which time direct effects of injury mostly subside, and a new diffuse unpleasant neuropathic pain arises. Spontaneous or burning pain, hyperalgesia (increased sensitivity to a noxious stimulus), allodynia (pain provoked by innocuous stimuli, e.g. gentle touch) and hyperpathia (the temporal and spatial summation of allodynia) are common feature. Pain is unremitting, however sleep is usually not affected.
  1. Concerning pain: Note its site, depth of severity (ignorable—trivial; not ignorable as it interferes in activities—moderate; constant even in rest—severe; tossing and incapacitating—very severe), mode of onset, character, diurnal variation, path and site of radiation, relation with activities and rest, relieving/aggravating factors. Reference of pain can be due to same source of sensory supply or cortical confusion between embryologically related areas.
  2. Deformity: Mode of onset, progressive or static, any earlier attempt for correction, disabilities due to deformity.
  3. Disability or Inability: in using the limb, with clear description.
  4. Limitation of Movement: How it started, whether progressive or static; any massage done and, how it hampers the activities.
  5. Swelling: Site, how it started, associated with pain or painless, size, increasing gradually or rapidly, any decrease in the size if ever, any similar or other type of swelling elsewhere.
  6. Discharging wound: How it started, type, colour and nature of discharge, intermittent or continuous, painful or painless, any history of indigenous applications or cauterization and any history of bony spicules in the discharge.
  7. Constitutional features: Like fever, anorexia, constipation, headache, urinary trouble, eye trouble, night sweating.
  8. Cramps: Cramps and cramp-like complaint in both calves are not uncommon. There can be several causes, which may be specific or nonspecific. Claudication [(the word derived from Latin ‘Claudicatio’= to limp) the Roman emperor Claudius (10 BC to AD 54)—walked with limp probably due to polio] should be differentiated from the cramps. Claudication may be due to neurological (e.g. spinal stenotic syndrome) or vascular causes (e.g. Buerger's phenomenon), and they can be confused with each other. In rare cases both causes may co-exist presenting with superimposed features. The neurogenic and 19vascular claudications can be differentiated as in Table 1.2.
    In claudication (vascular e.g. Buerger's phenomenon; neurogenic, e.g. spinal stenotic syndrome), the patient feels gradually ensuing catch in both calf muscles after some walking. The walking distance, before the symptoms start appearing, gradually decreases. The claudication of spinal origin usually disappears after sitting or bending forward in chair, while that of vascular origin requires rest from walking for relief. Neurogenic claudication is defined as the onset of lower extremity pain, paraesthesia or weakness on walking.
    In cramps, the patient feels a sudden painful catch in the calf muscles with or without the contracted muscles forming a hard ball (systremma), which almost disappears within a few seconds, either following local massage or rest or itself, leaving behind a dull aching pain lasting for few hours to a day or two. Constipation, overexertion and walking without habit can precipitate cramps in the calf. Calcium deficiency, and advanced pregnancy can also induce these cramps. However, symptoms like cramps can also be seen in vague ankylosing spondylitis, thyrotoxicosis, poly-insersinitis, metabolic diseases, e.g. hyponatraemia (as in heat stroke) and hypomagnesaemia, myopathies, aesthenia and depressive syndromes in adults. Chronic leg compartment syndrome and stress fractures should be differentiated from intermittent claudication.
  9. Any other complaints, even unrelated to orthopaedics, should be noted chronologically. Usually there are more than one presenting complaints, which may appear one after another or simultaneously. Note the sequence of their appearance.
Raynaud's Phenomenon
It usually occurs in ladies and in upper limbs. It is a self-limited reversible vasospastic disorder characterized by transient stress-induced (e.g. cold temperature) ischaemia of digits, nose-tip, and/or ears. Due to vasospastic alterations in blood flow a triphasic colour response is usually noted. The initial colour is white/pale (ischaemic pallor), the blue (congestive cyanosis) and finally red (reactive hyperaemia).
Management: Stop smoking; keep hands and body warm—repeated soaking in warm water; vasodilators (calcium channel blockers, e.g. nifedipine); angiotensin II receptor antagonists; topical nitroglycerine ointment. In severe cases intravenous prostacycline and its analogue are helpful.
Buerger's Disease (Thromboangiitis Obliterans: TO)
It is an inflammatory obliterative nonathero-matous vascular disease which most commonly affects small and medium sized arteries, veins and nerves typically in young smoker males (18–50 years). Initial manifestation is ischaemia or claudication of both legs (and sometimes hands) which begins distally and progresses proximally. Pedal-leg claudication, dysesthesias, sensitivity to cold—ultimately ending in gangrene and ulceration. It should be differentiated from atherosclerosis, embolic autoimmune disease, diabetes, hypercoagulatable state. Confirmation is by arteriogram.
Management: Stop smoking, trial of calcium channel blockers, foot care, sympathectomy, treatment of the ulcer (if present) and ultimately amputation.
Hyperhydrosis (Excessive Sweating)
Normally sweating occurs when ambient temperature is greater than 32.5°C and during exercises. In hyperhydrosis there is excessive and uncontrollable sweating induced by sympathetic hyperactivity. It occurs typically in young people involving palmar, plantar or axillary areas, etc. where eccrine glands are most dense. The eccrine glands are innervated by cholinergic fibres from sympathetic nervous system and shows exaggerated response to mental stimuli. Secondary hyperhydrosis may occur in hyperthyroidism, obesity, menopause and condition involving autonomic deregulation, e.g. in cardiovascular accident patients and paraplegics.20
Table 1.2   Difference between neurogenic and vascular claudication
Neurogenic claudication
Vascular claudication
• Claudication is in the calf muscles due to pressure on or affection of cauda equina (spinal nerve roots). Patient after exerting/walking for sometime develops neurogenic pain and paresthesia along the lower limb (mainly the calves, but may be in buttocks as well).
• Claudication in the calf muscles due to narrowing of the vascular tree (earlier spasmodic, but gradually organic narrowing due to athromatous deposits and fibrosis). Pain may be also in thigh.
• Spinal canal stenosis is commonest cause.
• Buerger's disease is the commonest cause.
• Persons beyond 40 yrs. of age are usually affected.
• Young and middle age groups are usually affected.
• Males are more affected.
• Mostly in males.
• Patient complains of pain usually, in both calves/legs; catch and tightness in muscles; difficulty in walking; paresthesia.
• Patient complains of gradually increasing pain and fatigue and burning sensation, usually to start with in one leg, but later on in both after some walking.
• Burning is not associated with pain.
• Burning is usually an accompanying symptom.
• Pain is aggravated by extension of back.
• Pain is aggravated by continuation of walking.
• There is no particular time or walking-distance for initiation of the claudication. Rather distance of walking before precipitating of symptoms may remain same.
• Claudication always starts after walking some distance, which gradually decreases (the length of distance) with the advancement of pathology.
• Claudication pain is relieved only by bending forward or sitting, not only by resting in standing. Rather as soon as patient stands from sitting posture, the pain is initiated.
• Claudication pain gets relieved after rest for sometime. Pain is not relieved after stooping.
• Going uphill reduces the pain.
• On going uphill pain is not reduced, rather it may increase.
• Cycling reduces the pain.
• Cycling does not reduce the pain, rather it may increase.
• Peripheral vascular pulsation normal (according to the age).
• Peripheral vascular pulsation (dorsalis pedis pulsation upwards) is decreased, or even may not be felt.
• There may be neurological deficit features (muscular weakness, wasting, sensory or visceral affection).
• No neurological deficit.
• Usually there is no trophic changes.
• Trophic changes do develop.
• Gangrene does not develop.
• Gangrene develops in advanced cases.
• X-ray, CT scan. MRI helps in confirming the diagnosis.
• Doppler flowrnetry is helpful to assess the status of the peripheral circulation.
• Management mainly consists of surgical decompression of the spinal stenosis. Non-operative management like limitation of activities, spinal exercises, neurotropic vitamins, orthotics have limited role.
• In early stages management mainly consists of antiplatelet, antiathrogenic. vasodilator drugs (medical sympathectomy).
If no response—surgical sympathectomy. For gangrene—amputation.
Botulinum toxin type A has been found to address this problem at palmar, axillary, facial and other sites overactive eccrine glands.
Causes of Generalised Sweating
  1. During shock, vasovagal attack, anxiety, excruciating pain, motion sickness.
  2. In systemic diseases, e.g. rickets, infantile scurvy, hyperthyroidism, pink disease, tuberculosis (night sweating).
  3. Drugs, e.g. alcohol, salicylates, pilocarpine.
  4. Occasionally during menstruation.
Localised Hyperhydrosis
Localised hyperhydrosis occurs due to:
  1. Injury to spinal cord or nerve
  2. Brain tumours
  3. Post-encephalitic Parkinsonism.
Few Common Sites of Hyperhydrosis
• Palms and Soles
• May be normal Psychoneurosis
Rheumatoid arthritis
• Sweating at tip of nose
• Granulosis rubra nasi
• Generalised with small vesicles on the skin and trunk
• Miliaria or sudamiel
• Lesions in crops on any part of body with perspiration.
• Miliaria papulosa or rubra (prickly heat)
Tremor (Latin—Tremor, Tremere, Shake, Tremble; Greek—Tremein, Tremble)
Tremor may be defined as involuntary shaking of the body or limbs (regular or irregular; fine or coarse) with an oscillatory character.
Tremor may be grouped under following headings:
  1. Physiological, e.g. due to fear, weakness, anxiety, alcoholism, fever, nervousness.
    The tremor of anxiety is usually fine and rapid but it may be coarse and irregular.
  2. Benign essential tremor: It occurs as a familial disorder as the coarse distant tremor, usually exaggerated in awkward postures, e.g. when the patient holds his outstretched fingers pointing to each other in front of his nose. Though it is usually relieved to some extent during movement, but it is present both at rest and movements.
  3. Senile tremors are similar to benign essential tremor.
  4. Parkinsonian tremor: In Parkinsonism, tremor is usually the initial presentation for which patients seek advice. It first involves the fingers and spreads to proximal portion of arm, and gradually it may extend to the tongue, lips and legs. The tremor is rapid, rhythmic, and alternating tremor, mainly in flexion/extension, but often with rhythmic rotatory component between finger and thumb (pill-rolling tremor). It is often associated with features of extrapyramidal disease such as hypokinesia, cogwheel rigidity, postural abnormality, gait disorder (festinant gait—short and shuffling steps), and expressionless quiet voice.
  5. Cerebellar tremor: It usually occurs in elderly persons, in whom the tremor occurs only during movements (intention tremor). Such tremors increase when the limb approaches a target and gets relieved when the affected limb is supported and relaxed.
  6. In thyrotoxicosis, tremor is always rapid.
  7. Hysterical tremor usually involves a limb or whole body and is characteristically worsened by examiner's attempt to control it.
  8. Tremors of hand may be even congenital.
  9. Tremors may also occur in multiple sclerosis, uraemia, hepatic failure, mercurial poisoning, etc.
Muscular Fasciculations
These are spontaneous contractions of groups of muscle fibres. They originate from abnormal generator sites in the peripheral nervous system. They vary in distribution and frequency and most commonly occurs in motor neurone disease (anterior horn cell disease), however may also occur in fatigued normal subjects.
Many patients complain of generalised weakness and vague pain in body, joints or limbs. Usually the cause is systemic such as generalised 22weakness or fatigue, anaemia, hypothyroidism, hypoproteinaemia, cardiopulmonary disease, chronic infection, hyperthyroidism, depression, poor physical condition, malignancy, etc.
History of Present Illness
Let the patient narrate the story of his ailments in his own words from the beginning to the present condition. Pick up the salient points. Dilate on each point with relevant leading questions. Any history of injury or febrile attacks must be explored through leading questions. Treatment received for the present complaints should be noted in detail.
Broadly orthopaedic problems fall in two major groups—injury related or noninjury related.
(A) In Case of Injury—Enquire about its mode and nature, and if associated with any abnormal sounds, the amount of impact, the portion of body hurt, immediate effects of injury, delayed effects of injury, could he/she stand and walk or was carried (then mode of carriage), did the injury affect mobility/activities.
High velocity injuries are getting more and more common and usually produce multiple injuries with or without injury to vital organs. Hence enquire with leading questions about the general effects of polytrauma (e.g. shock, haemorrhage, etc) and about level of consciousness at the time of trauma and later on.
  1. Direct hit (Contact injury).
  2. Indirect injuries.
    • Rotational strains (e.g. fracture neck femur).
    • Violent muscle pulls (e.g. fracture of patella).
    • Compression injuries (e.g. compression fracture of vertebra).
In Case of Fall—height of fall, surface on which fallen, level of consciousness after falling, if he could stand up or walk or even take weight on the affected side or not following the injury, immediate posture after injury, any manipulation at the site of injury by himself or any one else.
  • Mode of transportation to home or hospital.
  • Attempts by bone setters or quacks and/or any other treatment given.
(B) Fever: Onset, any associated rigor, range of temperature, continuous or intermittent, if only at particular time, e.g. in the evening, sweating, response to treatment, accompanying symptoms.
Enquire about appetite, polyuria, loss of weight.
History of Past Illness
Any earlier injury; history of earlier infections, specially tuberculosis, syphilis, leprosy, pyo-genic; average duration of bleeding after any cut; any particular treatment received. History about TORCH profile (To= toxoplasmosis, R= rubella, C= cytomegalovirus, H= herpes virus), which can be detected with ELISA test.
The incidence of bone and joint tuberculosis is on increase over the past decade in several regions of the world, may be due to the spread of human immunodeficiency virus (HIV) infection. Diagnosis of osteoarticular tuberculosis is becoming frequently difficult due to polymorphism of the disease, bizzare manifestations, and the weak specificity of the clinical features. Hence, wherever in any doubt, histological examination (besides other investigations) is essential to confirm the diagnosis.
Personal History
Occupation, any tobacco/drug habit, personal hygiene, hobby, sensitivity or allergy to any drug or object.
Occupation should be verified and noted clearly. Several conditions, especially in upper limb have been attributed to manual activities, which require force, repetition, overuse or the use of an awkward posture alone or in combination, e.g. carpal tunnel syndrome, lateral or medial epicondylitis, de-Quervain's disease, Dupuytren's disease, ganglia and carpometacarpal 23arthritis in the thumb. The blame was so deep that the de-Quervain's disease was called ‘Washerwoman's strain’, because there was discomfort during wringing out clothes or turning a mangle. However, except for a very few conditions, mixed or even oposite conclusions have been drawn about the occupation as the causative factor for such conditions. Exacerbation of the symptoms should be distinguished from the causation of the underlying condition, especially keeping in view the legal aspects and compensation factor involved in several works and manual activities.
The term ‘repetitive strain injury’ used to generally describe the conditions noted above has now been replaced by ‘work-related upper-limb disorder’ (WRLUD). More recognised WRLUD are cramp of the hand and forearm, which can occur after ‘repetitive work’; traumatic inflammation of the tendons of the hand and forearm or of the associated tendon sheaths can occur in those involved in manual labour or whose occupation demand frequent or repeated movements of the hand or wrist; carpal tunnel syndrome occurs more in hand-held vibrating tool users and so on.
Without blaming a single factor, the incidence of above mentioned nontraumatic soft tissue musculoskeletal disorders may be a synergy between genetics, physiology and life style factors (intrinsic) in addition to biomechanics and workplace (extrinsic) risk factors.
In case of females—marital status, number of children, any gynaecological complaints.
Family History
Any familial incidence related to the recent complaints, tuberculous infection in family, any hereditary disorder (Figs 1.33 to 1.36).
Social History
  • Economic background, status of living.
  • Topographical surroundings.
  • Barriers in and around home.
  • Education in the family.
History of present illness: Analysis of relevant points. The onset of the symptoms can provide clue to the origin of the disease, e.g. Congenital (present since birth); Developmental (defect in developmental period of childhood and adolescence); Infective/Inflammatory (associated with constitutional features); Metabolic (nutritional and/or economic deficit); Endocrinal (evidences of hormonal imbalance); Traumatic (history of injury); Neoplastic (painless or painful, gradually or rapidly increasing, swelling or ulcer—benign or malignant); Degenerative (in older age groups, or chronic or old pathologies); Idiopathic (causes not known); by indirect questions assessment for HIV.
History of past illness: Trauma, tuberculosis, syphilis, gonorrhoea, bleeding diasthesis.
Personal history: Addiction, immunization, allergy or sensitivity to drugs, education, hobby.
In case of females: Any gynaecological disorder, number of children.
History and Record Chart
Registration No.
Marital status and family. Photographic records with dates
Complete postal address:
  • Pain
  • Deformity
  • Disability
  • Disparity of limb length
  • Swelling
  • Any other.
zoom view
Fig. 1.33: A family of five, all having deformities of the limbs due to osteogenesis imperfecta—hereditary familial disorder
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Fig. 1.34: Group photograph of available family members showing multiple exostosis, familial incidence had been followed upto four generations. Third brother in this group consulted for his foot lesion (exostosis in 1st web) (Fig. 1.35)
Family history and social status: Social status, hereditary disorder, economic status, infectious disease.
  • General examination
  • Regional examination
  • Local examination.
zoom view
Fig. 1.35: X-ray of the foot of the third brother in the family of Fig. 1.34. Note the disabling exostosis from the first meta-tarsal head region
zoom view
Fig. 1.36: A family of five—all suffering from myopathy
General Examination
  1. Look, intelligence, built, any special posture, cyanosis, oedema, pulse, temperature, blood pressure, jaundice, lymph glands, nail conditions (the appearance of nails can serve as a barometer of a patient's general health).
  2. Attitude—While entering the examination room, note the first impression and posture (general, regional, local) (Fig. 1.37).25
    zoom view
    Fig. 1.37: Typical facial expression in tetanus (risus sardonicus). Note the tetanic spasm in the right hand and fingers. On the dorsum of the same hand there is reddish source-prick wound
  3. Attitude of standing and height (in cms)
    • with full weight
    • with partial weight
    • with support.
      If patient can stand, also perform Trendelenburg's test.
  4. Weight: Body weight should be taken with bare minimum clothings and in erect standing position in kilograms.
    Since obesity has been the cause and predisposing factors for several diseases, its assessment is essential.
    The WHO (1997) and National Institute of Health (NIH 1998) have endorsed the BMI as a measure of obesity. BMI, expressed as weight in kilograms divided by the square of height in meters (kg/m2), has been adopted as the preferred method of expressing body weight, especially from obesity point of view, since BMI correlates greatly with most laboratory measures of the body fat. According to assessment of BMI, under-weight (BMI < 18.5 kg/m2); normal range weight (BMI 18.5–24.9 kg/m2); and overweight (BMI > 25 kg/m2) have been defined. Obesity has been classified into three classes: Class I 30.0–34.9 kg/m2, Class II: 35.0–39 kg/m2; and Class III: >40 kg/m2. The risk of morbidity and mortality is increased in BMI range 25.0 to 29.0 kg/m2, moderate in class I, severe in Class II, and very severe in class III groups.
    The crux of obesity management are diet therapy, augmented physical activities, behaviour modifications, changing of lifestyle and pharmacotherapy [anoretic drugs—e.g. appetite suppressants, noradrenergic agents (acting or opposite centre), serotonergic agents (acting on hypothalamus to decrease satiety), adrenergic/serotonergic agents, etc.].
  5. Gait
    1. Limp or lurch
    2. Specific gait (also see page 257):
      • waddling
      • high stepping
      • hemiplegic (spastic)
      • ataxic
      • scissor
      • festinant
      • lathyriatic
      • stamping
      • knock knee, etc.
Systemic Examination
  1. Skull and face—Contour, swelling, decubitus ulcer, and any stigmata (of syphilis, rickets, etc.).
  2. Neck—Lymph nodes, venous engorgement, any swelling.
  3. Cardiovascular system—Pulse, blood pressure, heart.
  4. Respiratory system—Thoracic cage, rib contour, chest expansion, abnormal shape of chest (flat, barrel, pigeon), rib hump, rachitic rosary (Harrison's sulcus, scorbutic rosary).
  5. Abdomen—liver, spleen, kidney, any lump, iliac fossae, any abnormal finding.
  6. Central nervous system:
    • Higher mental functions
    • Cranial nerves
    • Motor system: power, bulk, tone, reflexes, coordination, involuntary movements
    • Sensory system.
  7. Genitourinary system.
  8. Endocrinal functions.26
Regional Examination
The examination of the part complained of only, does not complete the examination, because sometimes the symptoms felt in one part have their origin in another. For example, pain in the leg is often caused by a lesion in the spine, pain in the knee may have its origin in the hip, a pain or tingling and numbness in hand may have its origin in the cervical spine. Hence, the necessity of regional examination.
  • For lower limb examine lumbar region to tip of toes.
  • For upper limb examine cervical region to tips of fingers.
  • For trunk examine as a whole (and the supply region if cord is involved).
  • Also examine the regional lymph nodes.
Local Examination
Inspection (look for)
  1. Posture of the patient and position of part/limb—attitude.
  2. Inspect from different sides.
  3. Normal anatomical points
    • bony
    • soft tissue.
  4. Skin:
    • colour
    • texture
    • elasticity/stretchability
    • erythematous changes
    • puckering
    • cafe-au-lait spots
    • tattoo marks
    • ‘pachh’/vaccination scar
    • superficial cuts or scars (linear scar with/without suture mark—usually operative scar; irregular scar—injury; broad, adherent puckered scar—old suppuration)
    • warts or callosities
  5. Muscle condition:
    • swelling
    • wasting
    • spasm
    • contracture
    • fasciculations
  6. Vascular:
    • venous prominence
    • pulsation
    • varicosities.
  7. Abnormal findings, e.g. swelling, sinus, ulcer.
In case of ulcer(s), note the followings: site, size, shape, surface, floor, base, margin (edge), relation to deeper tissues, surrounding tissues, discharge on the surface [especially ICHOR (a thin watery discharge from an ulcer or unhealthy wound) which usually denotes chronicity and deeper involvement], pigmentation, regional lymph nodes.
Broadly the ulcers are classified as (i) Nonspecific, (ii) specific, (iii) malignant (Table 1.3).
Examination of Any Sinus
A sinus (Latin= a hollow; a bay or gulf) is a blind ending, usually lined by granulation tissue track opening onto the skin or mucous membrane [cf. Fistula (Latin= a pipe or tube) is a tunnel connecting two epithelial or endothelial surfaces]. Sinus may be (1) congenital (arising from the remnants of embryonic ducts that persist instead of being obliterated or (2) acquired (usually secondary to the presence of foreign body or necrotic material. Note:
  • number, site, relation with deeper tissues, relation with skin, margin, discharge—intermittent/continuous, colour and type of discharge, relation with pain, possible source, discharge of any bony spicule, nature of scar (if healed).
  • sinus tract—feel, traceability to parent site, fixed to bone or mobile. Probing should be avoided.
Causes of Persistence of Sinus
Persistance of infection; presence of dead tissue within, e.g. bony sequestrum; presence of any foreign body, e.g. bullet, metallic foreign body, pieces of cloth, etc; persistence of cavity within the bone; epithelialisation/endothelialisation of sinus track; puckering of soft tissues around the tract; intractable infection, e.g. fungal infection; malignant changes in the tract; diabetes; general debility; prolonged use of corticoids; persistent discharge, e.g. of urine, cerebrospinal fluid, faeces, etc. after irradiation.27
Table 1.3   Ulcers (discontinuity of epithelial surface)
Non-specific ulcer
Specific ulcer
Malignant ulcer
• Varicose ulcer (ulcer developing on underlying varicose veins)
• Tuberculous (undermined edge)
• Carcinomatous (everted edge)
• Trophic ulcer [trophe (Greek)=nutrition] (ulcers developing due to impairment of nutrition which depends upon properly Intact vascular and nerve supply)
e.g.—Ischaemic ulcer,
—Diabetic ulcer
—Ulcers developing in spina bifida, tabes dorsalis, leprosy, peripheral nerve Injury—due to anaesthetic skin, and are called neuropathic/perforating ulcer.
  • Pyogenic (sloping edge)
  • Syphilitic (usually punctated)
  • Actinomycotic (multiple ulcer with sulphur granules)
  • Rodent ulcer (basal cell carcinoma usually occurring on upper face.
  • Marjolin ulcer (carcinoma developing on scar).
  • Tropical ulcer
Sinuses must be differentited from fistulae which are abnormal communications between two epithelium lined surfaces.
(A) Superficial (touch): Skin condition; temperature; sensation; superficial tenderness; anatomical points—bony, soft tissue; induration (oedema)—regional/local; arterial pulsation; crepitus (may be due to entrapped gas, e.g. in surgical emphysema, gas gangrene (Fig. 2.60); fracture; tenosynovitis).
(B) Deep Palpation (feel): Deep tenderness: It should be avoided in presence of any inflammation (clinically diagnosed by noting the cluster of symptoms and signs of colour (heat due to vasodilatation), dolor (pain), rubor (redness due to vasodilatation), tumour (swelling mainly due to oedema, exudate) and functio-laesa (less or loss of function). It can be tested by direct pressure, indirect twist, and deep thrust. Tenderness of a bone, joint or soft tissue can be classified into four grades according to the reaction (facial and verbal) of the patient during examination for tenderness.
Grade I
— The patient says that part is painful on pressure.
Grade II
— The patient winces.
Grade III
— The patient winces and withdraws the affected part.
Grade IV
— The patient will not allow the part to be touched.
While palpating (mainly for the soft tissues) the “tendor point” and “trigger point” can be differentiated as follows:
Tendor point
Trigger point
Referred pain
Usual cause
Myofascial pain/neuro-fibromatous lesion
Presence of abnormal tissue
Deep Palpation of the Bone
Bone should be palpated for surface, alignment, deep tenderness, abnormal prominence, disturbed relationship of the normal bony landmarks, any crepitus (fracture).
Palpate the girth of bone for THICKENING (there is increase in almost all surfaces which 28are usually irregular, anatomical configuration is distorted. Bone is thickened usually due to deposit from outside, e.g. in chronic osteomyelitis); BROADENING (breadth of the bone increases, surfaces of the bone almost regular, anatomical configurations are usually identifiable. Broadening occurs from within, e.g. in rickets); EXPANSION OF BONE (bony surfaces are expanded, surfaces are usually nodular or bluntly irregular, all dimension of bone in the affected zone are increased, e.g. in giant cell tumour).
Deep Palpation of a Joint
Palpate for:
  1. Synovial thickening—soft/boggy/doughy feel—any tenderness.
    To palpate a joint for synovium an optimum pressure to balance your thumb-nail (about 4 kg/cm2) should be adequate.
    Many times it becomes difficult to ascertain the origin of pain—whether from intraarti-cular or extraarticular structures. However, stressing a joint is easily accomplished by gentle passive range of motion of the joint by the examiner. In contrast, pain occurring while the patient performing active range of motion against a joint held rigid by the examiner is usually due to pathology in the surrounding tendons. Further, by selective direct palpation of periarticular structure (such as skin, subcutaneous tissue tendons, etc.) one can ascertain the origin of pain to a fair extent.
  2. Joint line—a slit all around in between the articular ends—feel for any tenderness, any abnormal mass.
  3. Fluid in the joint—yielding/cystic/fluctuant/tense feel.
  4. Articular ends—for any tenderness, roughness, crepitus.
  5. Adjoining bones—for any thickening, expansion, crepitus, irregularity, tenderness.
  6. Abarticular (at a distance from or not involving a joint) structures and tissues.
Crepitus is an audible and/or palpable ‘grating’ sensation felt during joint movements. Crepitus may be fine or coarse. The fine crepitus of inflamed synovium is of uniform intensity and perceptible only with a stathoscope. The coarse crepitus is of variable intensity, can be detected easily and transmitted from damaged cartilage and/or bone. It can be elicited by compressing a joint throughout its range of motion.
Palpation of Fossae (if any)
Palpation of muscles: Girth, feel, tone and pliability of muscles.
Examination of any swelling should be in detail: skin over the swelling, site, size, margin, extent, surface, any veinous prominence, hyperaesthesia on the surface, shape, vascularity, tenderness, consistency (cystic, very soft, soft, doughy, firm, hard, stony hard), fixity, deeper relations, mobility, fluctuation test, transillumination test (if cystic).
To elicit pain at the site of lesion by intermittently compressing the distant part of the parallel bones, e.g. in fracture of the neck of radius pain can be elicited by compressing the lower forearm.
Transmitted movement: In case of fractures, feel for transmitted movements across the fracture site.
Percussion (tap)
Specially over the bone in suspected crack fracture; over the spinous processes to elicit tenderness in spine.
Auscultation (hear)
  • If needed, e.g. for systolic bruit (haemangioma).
  • May be of value in localising crepitations, snaps, mild friction rubs in joints.
  1. Linear measurements
  2. Circumferential measurements
A. Linear Measurements
  • (a) Apparent measurement
  • (b) True measurement29
  1. Apparent measurement
    • Make the limbs parallel to each other and to the trunk.
    • Handle the unaffected limb to make the limbs parallel (without touching the affected limb).
    • Measure from any fixed central point to the most distal sharp bony point of the long limb bone.
    Therefore, in the lower limb, measure from:
    • in the upper limb—from vertebra prominence (C7) to radial styloid.
  2. True measurement
    • Reveal the concealed deformity by handling the affected limb.
    • Limbs to be kept in identical position after revealing the concealed deformity.
    • Measurement is ipsilateral and then comparison with the other side is done.
Lower limb
  1. Total length-from anterior superior iliac spine to medial malleolus. ii. Segmental length.
    • Anterior superior iliac spine to mid-medial knee joint line (thigh length).
    • Mid-medial knee joint line to tip of medial malleolus (leg length).
    • The components of thigh length are measured as follows:
    • Infratrochanteric-tip of greater trochanter to knee joint line.
    • Supratrochanteric-indirect measure-ment-e.g. through Bryant's triangle.
Upper limb
  1. Total length-from acromial angle to radial styloid process tip.
  2. Segmental length
    • From acromial angle to lateral epi-condylar tip (arm length).
    • From lateral epicondylar tip to radial styloid process tip (forearm length).
(B) Circumferential Measurements
  1. At affected point—for any swelling.
  2. At fixed distances, proximal and distal, from the affected part
    • for muscular wasting
    • for muscular hypertrophy
  3. For disorganised joint.
Across Measurements (for cross check-up of measurements)
In identical position of the limbs:
  • From left anterior superior iliac spine to right medial malleolus tip.
  • From right anterior superior iliac spine to left medial malleolus tip.
Ascertain first that the patient is not having ‘abulia’ (loss or impairment of the ability to perform voluntary actions or to make decisions).
Ask to perform—Active movement—performed by patients without any assistance; performed by others—or even by the help of patient's opposite limb—passive movement.
Always compare with the opposite joint. In general, the range of movements at any joint, is more in females than males. First look for anky-losis or stiffness of the joint. Also identify any hypermobility of joint. The easily measurable criteria are hyperextension of knee and elbow more than 10 degree with concomitant fifth finger metacarpophalangeal hyperextension and thumb-forearm apposition (Beighton and Horan 1969).
Ankylosis (no apparent movement in a joint)
Types of Ankylosis
  1. Bony (True)
    • No movement even on using force.
    • No pain.
    • Bony trabeculation across the joint in X-ray.
  2. Fibrous (False)
    • Slight yield or jog of movement on using force.
    • Pain on using force.
    • Joint line visible in X-ray.30
Table 1.4   Types of joint stiffness
• Obvious evidences of extra-articular tightness or adhesion like scars subcutaneous fixity, musculotendinous contracture, sinus tract in vicinity.
• No obvious scar, adhesion, sinus or contracted tissues.
• Joint line is usually nontender, except when any Inflammatory process lies over the joint line.
• Joint line tender.
• Painless range of free movements active and/or passive.
• Possible movements are usually painful, especially at the extremes.
• On X-ray—joint space sharply defined and clearly visible: articular ends nearly normal.
• Joint margins fluffy, joint space reduced. Articulating bony ends usually osteoporosed with or without evidences of underlying pathology.
• Dealing with the contracted extra-articular tissues, releases the stiffness.
• Dealing with the extra-articular tissues does not release the stiffness.
• Manipulation under general anaesthesia Is not helpful In mobilising the joint.
• Manipulation may mobilise the joint. Arthroscopic arthrolysis may improve stiffness. Arthroplasties of different types are usually required for mobilising the joint.
Stiffness in the joint: (i.e. joint in which complete movements cannot be obtained—either active or passive): Limitation of movements can be:
  1. In all directions—due to arthritis
  2. Not in all directions—due to synovitis and/or spasm of muscles.
  3. Fixed movement in one or more direction—due to fixed deformity.
Limitations of movements are painful in active arthritis (due to stretching of or pressure on the inflamed capsule and/or rubbing of exposed subchondral bone) and painless in healed ones (due to short fibres fibrous bondage).
Milder form of joint stiffness (arthrofibrosis) mainly due to intraarticular surgery or injury (mainly in the knee joint) disrupts the kinematics of the joint and may lead to degenerative changes.
  1. Extra-articular, e.g. due to burn contracture, myositis ossificans, post-infective contracture of periarticular tissues, congenital contracture, e.g. quadriceps contracture, arthrogryposis multiplex congenita, etc.
  2. Intra-articular, e.g. due to septic arthritis, tuberculous arthritis, intra-articular fractures, etc.
If there is no ankylosis, assess the movements in various planes:
  1. Sagittal plane—flexion/extension
  2. Coronal plane—abduction/adduction
  3. Rotational plane—external/internal; supination/pronation.
The range of movement of a joint should be measured by the goniometer (the term goniometry is derived from Greek words—Gonio = angle + Metron = measurement).
For each movement:
  • Fix the zero position.
  • Mark lag of movement (usually extensor lag).
  • Assess angle of fixity of any movement (e.g. fixed flexion deformity).
  • Range of active movement.
  • Range of passive movement.
  • Range of utility or activity = Free active movement.
  • Range of possibility = Free active movement + Free passive movement.
  • Any pain during the movement—If painful focus is in the vicinity of the joint (not in the joint), patient will still be reluctant to initiate active movement. Taking the patient in confidence, passive movement can be demonstrated to variable range, in such cases.31
  • Limitation of terminal range.
  • Achievement of ‘critical arc’.
  • Achievement of ADL (activities of daily living).
  • Any abnormal movement (e.g. hypermobility in neuropathic joint, e.g. Charcot's joint).
  • Any abnormal sound during the movement (heard/felt).
  • Assess the power of controlling muscles.
Active movement of a joint—Movement produced by patient himself, without any assistance.
Passive movement—Movement produced at a joint either by patient's other limb and/or examiner.
Fixed deformity: It is a fixed position of a joint from where the limb cannot be brought back to neutral position, but further movement in the same axis (direction) may be possible.
Normally active and passive ranges are equal.
Passive range is more than active in:
  • Paralysed joint.
  • Lax/Torn
    • Capsule
    • Ligament
    • Tendon
    • Muscle
  • Subchondral/condylar fracture.
Test for any laxity or tear of the aforesaid components.
Critical Arc
For any joint, the minimum range of active movement, which is necessary for the important functions of that joint.
ADL (Activities of Daily Living)
The bare minimum necessary for daily living, like—eating, clothing, cleaning the private parts and minimum necessary mobility.
Understanding about the Muscle Action
In producing the movement, a single muscle can not be all effective, rather the movement produced will be the ultimate outcome of the actions of several muscles acting in different capacities individually or in groups.
Muscles can be
  1. Agonists: Chief muscle (prime movers) to produce particular action.
  2. Synergists: (syn = with) Acting with the agonists they augment the effort.
  3. Antagonists: Their action is against that of the agonists. By neurological reflex they go for relaxation to make the action of agonists effective.
  4. Fixators: They stabilise the fulcrum, while the agonists produce controlled desired action, e.g. in abducting the arm the deltoid contraction becomes more effective when the muscles attached from shoulder girdle to trunk act as fixator.
Power of Controlling Muscles (Table 1.5)
The assessment should be accurate from prognostic point of view. According to Medical Research Council (MRC) scale, muscle power is grouped under five grades. We feel that each grade is further divisible into 4 quadrants; depending upon lag of completion of full range, the deficit can be assessed, as e.g.
‘2- - -’, ‘2- -’, ‘2-’, ‘2’.
Special tests: (Pertaining to individual joints) Diagnostic tests must have the following qualities: sensitivity, specificity, reproducibility, predictability, accuracy, minimum hurting to the patient.
Heel Walking/Toe Walking
If the patient can walk, quick inferences can be drawn by making him walk on heels and toes alternately.
If he can walk swiftly in both positions without any complaints—probably there is no serious affection in the lower limbs including its neuromuscular control.
Erect posture along with integrity of the hip, knee, ankle and foot are essential for painless, quick, heel/toe walking.
Any limb-length disparity will obviously affect these walking and any inequality will be apparent.
If patient cannot walk swiftly, there are two broad probabilities:32
(A) If There is Inability/Difficulty in Walking on Heels, it may be due to:
  1. Weakness of muscles and/or abnormal joint condition:
    • Weakness of dorsiflexors of ankle; stiffness of the ankle joint.
    • Probable weakness in quadriceps femoris and erector spina.
    • unstable hip.
  2. Pain—This may be felt due to any of the following pathologies:
    • Pain in back of thigh, knee and leg—due to sciatic stretch.
    • Pain in sacroiliac region, in hip region (affection of the joint line, e.g. trauma, tuberculosis).
    • Back of the knee, e.g. in cases of trauma—posterior cruciate lesion (?), condylar fracture/crush of tibia (upper end).
    • Pain at ankle—In any traumatic, inflammatory, degenerative or neoplastic condition.
    • Pain at heel—Any cause of painful heel syndrome (see chapter on Foot, Page 505, Fig. 15.100).
(B) If There is Inability/Difficulty in Walking on Toes, it may be due to:
  1. Weakness of muscles and/or abnormal joint condition:
    • Weakness of plantar flexors; stiffness of ankle (except where in equinus); genu recurvatum; unstable hip.
  2. Pain—Pain in the forefoot—trauma, meta-tarsalgia, inflammatory lesion.
    Usually pain in ankle is not complained of in early affections because the gravity line falls forwards.
    • If pain is in knee region—in case of trauma—probably anterior cruciate involvement, involvement of anterior horn of semilunar cartilage, affection of the quadriceps apparatus.
Peripheral circulation: Impaired peripheral arterial circulation may produce symptoms in a limb, especially in lower limb. So a thorough examination should be done to assess the state of circulation, which is done by examination of the colour and temperature of skin, the texture of skin and nails and by palpating for arterial pulsation, which must always be compared with opposite side.
Peripheral Nerves
(e.g. lateral popliteal nerve, ulnar nerve, etc.).
  • tenderness
  • thickening
  • beading
Table 1.5   Grading of muscle power
MRC scale
Suggested subgrouping
‘0’— Not even flicker of contraction.
‘1’— Flicker of contraction.
‘2’— Contraction of muscles with no assistance and gravity eliminated, but moving the joint to full range.
Depending upon lag of completion of full range
2- - -, 2- -, 2-, 2.
‘3’— Contraction of muscles against gravity but with no resistance, moving the joint to full range.
Depending upon lag of completion of full range
3- - -, 3- -, 3-, 3.
‘4’— Contraction of muscles against gravity and with moderate resistance, moving the joint to full range.
Depending upon lag of completion of full range
4- - -, 4- -, 4-, 4.
‘5’— Normal.
Depending upon lag of completion of full range
5- - -, 5- -, 5-, 5.
(While ‘5’ is normal, the rest are subnormal in that order).
  • irritability
  • detailed muscle power and sensory charting.
Investigations: For confirming the clinical suspicion, certain investigations are needed. One must not have a ‘shortgun approach’ in ordering the investigation (all around investigations), rather it must be an ‘arrow head’ targeted approach to order the really just needed investigations.
  1. General investigations.
  2. Special investigations.
  3. Electrical investigations.
  4. Radiological and allied investigations.
A. General Investigations
  • Routine haemogram.
  • Erythrocyte sedimentation rate (ESR).
  • C-reactive protein (CPR.
  • Routine urine examination.
  • Stool examination.
  • Grouping and cross-matching of blood.
  • HIV tes.
  • Test for hepatitis B.
  • Assessment for diabetes (Table 1.6.
Erythrocyte sedimentation rate (ESR) is a measurement of the distance in millimeters that RBCs fall within a specific tube (Westergreen or Wintrobe) over 1 hour and 2 hours—and the average of two hours fall is calculated. It is an indirect measurement of alteration in acute phase reactants (a heterogeneous group of proteins which are synthesized in liver in response to inflammation) and quantitative immuno-globulins.
Table 1.6   Assessment for diabetes and allied complications
Name of the test
Fasting blood glucose, post-prandial blood glucose reflect acute changes in blood glucose
To assess the current blood glucose level
Glycosylated haemoglobin
HB A1C (Glucose Memory Test), i.e. assessment of glucose or glucose phosphate moieties bound to the amino terminal value of one or both beta chains.
To monitor blood glucose/sugar control for the last 2 to 3 months
Assessment of Fructosamine
For assessment of diabetic control
Routine urinalysis. Morning and post-prandial sample
To assess the presence of sugar in urine and overall status of renal function
Urine micro alb/spot
To detect even a minute quantity of albumin in urine
Blood urea Serum creatinine
To assess the kidney function
Fasting lipids and lipid profile
To assess cholesterol
SGOT/Serum proteins
To assess liver functions
Diabetics are more liable to have heart problems, which can be detected by these (investigations) tests
X-ray chest
To detect any lung and (chronic) cardiac pathology
Ultrasonographic scan of abdomen
To assess the abdominal organs
To assess the blood flow and nerve sensation in the feet
NB: The level of HB1C, which comprises 3 to 6% of the total haemoglobin in healthy individual, is proportionate to the average glucose concentration and the lifespan of RBC in circulation. Hence in haemolytic anaemia the HB1C has lower value due to shorter lifespan of RBC and in polycythemia or postsplenectomy HB1C value increases due to longer lifespan of RBC.
C-reactive Protein (CRP) is a pentameric non-specific acute phase protein comprised of five identical non-covalently linked 23KD subunits arranged in cyclic symmetry in a single plane. CRP is produced as an acute-phase reactant by the liver in response to interleukin 16 and other cytokines. It is present in trace concentration in the plasma of all humans. Elevation in the level occurs within 4 hours of tissue injury/insult with peak within 24–72 hours. It falls rapidly in the absence of inflammatory stimuli. It is measured by immunoassay or nephelometry. CRP test, though costly, is more specific as compared to ESR (which is inexpensive, easy to perform and is affected by multiple variables).
CRP disappears when inflammatory process is suppressed by steroids or salicylates. This test is used to monitor recovery from infection. It is most useful as an indicator of activity in Rheumatoid disease like rheumatoid arthritis and rheumatic fever.
B. Special Investigations
  1. Serum biochemistry, e.g. sugar, urea, calcium, phosphorus, alkaline (particularly alkaline phosphatase isoenzyme determination by electrophoresis which differentiate alkaline phosphatase of osteoblastic origin from alkaline phosphatase from other sources) and acid phosphatase, fluorine, creatinine, serum and urine amylase and lipase for chronic pancreatitis.
  2. Serology—Washerman's reaction (WR)—presently not necessarily recommended, Kahn, VDRL, Rheumatoid factor (Rose Wallar test).
  3. Arthrocentesis—Aspiration of any collection and its examination—physical, chemical, cytological, serological, culture and sensitivity, inoculation test. Arthrocentesis should be avoided if cellulitis is overlying a swollen joint, in bleeding diatheses (haemophilia, anticoagulation therapy, thrombocytopenea).
  4. Foot print, Ichnogram (imprint of the soles of the feet taken in standing position), hand print.
  5. Arthroscopy (Diagnostic/therapeutic—knee, shoulder, ankle, elbow, and even IP joints). Arthroscopy: The word ‘arthroscopy’ comprises of two Greek words: ‘arthro (= joint) + skopeir (to look). The term literally means ‘to look within the joint’. Japanese physician Dr Takagi was the first to perform arthroscopy with a cystoscope in 1918. Nowadays, arthroscopy is being widely used to diagnose and variably deal the pathology (mainly traumatic) affecting the interior of the joints. It is particularly useful for the knee, followed by shoulder. However its use is being extended to other joints like ankle, wrist, elbow, hip, spine and even interphalangeal joint.
  6. Biopsy:
    • FNAC (Fine needle aspiration cytology)
    • Needle biopsy
    • Aspiration biopsy
    • Core biopsy
    • Endoscopic/arthroscopic biopsy
    • CT aided biopsy
    • USG aided biopsy
    • Open biopsy
    • Excisional biopsy.
C. Electrical Investigations
  • Electrocardiography (ECG)
  • Electroencephalography (EEG)
  • Electromyography (EMG)
  • Strength duration curve
  • Nerve conduction test
  • Electrophoresis.
D. Radiological and Allied Investigations
One should remember that imaging procedures may only give a “shadow of truth” and “truth” can only be nearly accomplished by thorough clinical examination.
  1. Plain radiography; xeroradiography: Xero = dry, thus xeroradiography does not involve the wet process of developing and fixing the film (using the photoconductive behaviour of a selenium plate and by photo-electric 35process, the conventional X-ray exposure is recorded as positive image)
    • Routine projections
      • Antero-posterior/postero-anterior view
      • Lateral view
      • Oblique view (internal oblique and external oblique, i.e. opposite rotational oblique)
    • Special projections
      • Axial view
      • Stress radiography.
        Plane film radiograph will not show an osseous erosion until approximately 40% decrease in bone density has occurred
  2. Contrast radiography
    • Air contrast radiography.
    • Radio-opaque dye contrast radiography [water soluble (metrazimide), oil soluble].
    • Myelography.
    • Radiculography.
    • Discography.
      Carried out for the patients with low back pain, discography is a safe, accurate, reproducible, objective diagnostic tool when tested for volume, pressure, fluoroscopic changes and pain provocation. The process involves the injection of water-soluble nonionic contrast dye into a disc in an effort to relate a radiographic image with the patient's pain.
    • Arthrography.
    • Sinography.
    • Venography: After applying a fine tourniquet just above the malleoli a nonionic contrast medium is injected to outline the veins.
    • Plathysmography assesses changes in volume of a limb or digit over the cardiac cycle.
    • Arteriography: In arteriography a radio-opaque solution is injected into the arterial tree, generally by a retrograde percutaneous method involving the femoral artery (occasionally brachial or axillary artery).
    • Cystography is done by injecting the contrast medium through a catheter introduced into the bladder. The mictu-rating cystogram is done to look for the presence of vesicoureteric reflex.
    • Lymphangiography is used to demonstrate the nature of lymphatic abnormalities and to diagnose lymphoedema. Pedal lymphangiogram is done by injecting blue dye subcutaneously between the toes to outline the lymphatic vessels.
    • Duplex imaging—A duplex scanner uses B mode ultrasound to provide an image of vessels.
    • Doppler flowmetry—to assess the status of the peripheral circulation, a continuous wave ultrasound signal is beamed at an artery and the reflected beam is picked up by a receiver.
    • Laser doppler flowmetry—for direct measurement of the circulatory disorders in chronic compartment syndrome (CCS).
    • Doppler ultrasonography—A doppler flow probe is used to exclude arterial disease, and to determine the patency of a vein. A bidirectional flow probe is used to detect venous reflex.
    • Bone densitometers—to assess the bone mineral density (BMD)—the single best method to diagnose osteoporosis and to assess the future risk of osteoporotic fractures. Of many types of densito-meters, two commonly used are:
      1. Ultrasound densitometer—nonioni-sing safe and cheap, but not that precise.
      2. Dual energy X-ray absorptiometry (DEXA): it is accurate, precise and reproducible ‘Gold standard results’, but is costly.
  3. Tomography (stratigraphy; planigraphy; Tomos=cut or section): X-ray taken after being focussed at a desired depth blurring all the structures above or below, and anterior or posterior of the area of interest.36
  4. Stereoscopic—bi-dimensional picture studies.
  5. Cine-radiography.
  6. 3D C-arm CT.
  7. MPR and SSD
    Multi planar reconstruction (MPR) and surface shade display (SSD) combined together provides 3D images and virtually brings the advantages of CT. It is especially useful in operation theatre, and is extremely suited to Minimally Invasive Surgery (MIS). It is very useful in spine and trauma surgeries, and helps in choosing the right implant.
  8. Scintigraphy (Radio-active isotope studies or radio-nuclide studies or nuclear imaging). A three phase study aiming to show the vascular, soft tissue and bone uptake is performed using TC-99 m MDP. It is sensitive for detecting osseous abnormalities, but should be correlated with plain radiograph or other techniques, since it is nonspecific.
  9. Granulocyte scintigraphy is a sophisticated investigation to diagnose osteomyelitis especially in acute stage, of course it is not that useful.
  10. Ultrasonic scanning, and high resolution ultrasonography.
  11. Computer assisted X-ray tomography.
  12. Computerised tomography and intrathecal low osmolarity contrast media studies.
  13. Plain tomography is being replaced by computerized axial tomography with coronal and axial reformations. These are of much value in assessing the complex fractures such as pelvic injuries, acetabular injuries, pilon fractures, fractures around knee, shoulder injuries, etc.
  14. Nuclear Magnetic Resonance Imaging (NMRI)
    or Magnetic Resonance Imaging (MRI)—In order to avoid using the word nuclear, which induces fear, the changed terminology is MRI.
  15. Spinal cord monitoring—Recording of somatosensory evoked potentials (SEP).
  16. Neurosensory testing (NST) with the Pressure Specific Sensory Device (PSSD) is a state-of-the-art non-invasive painless and accurate diagnostic instrument by which one can carefully evaluate the degree of neuropathy starting at its very early onset, especially in diabetic neuropathy, Hansen's neuropathy, etc.
  17. Meterecom (a 3-D skeletal analyser)—A precise, computer-based, non-invasive, 3-dimensional digitizer designed to access bony landmarks, at any point on the body for various patient's positions.
  18. Roentgen-Stereophotogrammetric Analysis (RSA) allows the accurate three-dimensional measurement of relative implant movement and in certain circumstances, measurement of wear. The accuracy of RSA can be upto the detection of 0.1 to 0.8 mm for translation movement and 1 to 2° for rotation at the 99% significance level.
  19. MSI (Roser Boldlex 1995): The combination of technique of MRI and Magneto Encephalographic Recording (MEG) is being known as Magnetic Source Imaging (MSI). This indicates a functional description rather than only anatomical detail.
  20. Study of genome
    Virtually, every human ailment, except perhaps modern trauma has some genetic basis. A Genome is all the DNA in an organism including its genes. Genes carry information for making all the proteins required by all organisms. DNA is made up of four similar chemicals (called bases and abbreviated as A, T, C and G) that are repeated millions or billions of times, throughout a genome. The human genome has 3 billion pairs of bases. The sequencing of these three billion base pairs is likely to be as fundamental to medical science in next few hundred years as the periodic table was to chemistry in the last. Understanding genetic make up will help greatly in the field of gene-therapy both for cure and prevention.37
    Next step in the Genomic is Proteomics (isolation and identification of proteins from normal versus perturbed cells). In the next decade genetic tests will routinely predict individual susceptibility to disease. By 2010 to 2020 gene therapy should become a common treatment at least for a small set of conditions. By 2050 many potential diseases will be cured at the molecular level before they arise.
Clinical Diagnosis
Basically clinical diagnosis is based on sound knowledge of anatomy, physiology, and pathology; a specific history and detail clinical examination. To come nearest to the (final clinical) provisional diagnosis, always keep in mind that patient has been always right and the clinician remains always wrong, unless the clinician proves that the patient was not right in his/her expression. In the process of making a diagnosis at the end of careful listening and analysing the history, guess the diagnosis; after thorough clinical examination make a provisional clinical diagnosis, which should be nearly confirmed by the relevant investigations. But the final confirmed diagnosis should be made only after histo-pathological examination (medicolegal aspect).
Thorough clinical examination leads to more or less accurate clinical diagnosis. However, in certain situations, this may not be possible. In such conditions, provisional diagnosis with immediate differential diagnosis should be mentioned. The most probable provisional diagnosis should be reached by the process of elimination, starting from the common to rare conditions.
In expressing the diagnosis of the disease, it is essential to make it a complete expression under the following headings:
  1. Duration
  2. Anatomical site affected
  3. Causative pathology with its stage of advancement
  4. Any obvious complication
  5. Any particular treatment given
  6. Affection of the patient's routine life, specially the activities of daily living (ADL),
    1. 5 months old, untreated, advanced tuberculous arthritis of right hip joint with discharging sinus, and patient not able to perform ADL.
    2. or B. 7 weeks old conservatively managed traumatic ununited fracture of neck of left femur with 2 cm of supratrochanteric shortening and patient not able to perform ADL.
Management: In clinical practice the word management comprises broad outline of main etiological factors, principal pathology, diagnosis, planned investigations and treatment.
(Based on CME lecture by Prof HKT Raza) Congenital anomalies of the limbs can be considered under two broad headings.
  1. Congenital limb malformations: such as clubfeet, polydactyly, syndactyly.
  2. Anomalies due to failure of formation of certain parts of body which have been named as congenital limb reduction anomalies or congenital skeletal limb deficiencies. “Thalidomide tragedy” in 1961–62 (when there was a high incidence of phocomelic children born to mothers who had taken thalidomide for morning sickness) aroused interests in this group of anomalies.
(Based on as proposed by Swanson AB 1976—and adopted by the International Federation of Societies for Surgery of the Hand)
  1. Failure of formation (Congenital skeletal limb deficiencies or congenital limb reduction anomalies)
    • Transverse arrest, e.g. absence of all fingers; amputation thru carpus, forearm or arm.38
    • Longitudinal arrest, which may be pre-axial or para-axial, e.g. absence of radius and thumb; absence of tibia and medial ray of foot.
  2. Failure of differentiation (Separation of parts)
    • Soft tissue involvement
    • Skeletal involvement
      e.g. simple or complex syndactyly
  3. Duplication (Polydactyly)
  4. Overgrowth (Macrodactyly)
  5. Undergrowth (Brachydactyly)
  6. Constriction ring syndrome
  7. Generalised abnormalities and syndromes (Limb anomalies as a part of syndromes)
According to Frantz and O'Rahilly classification which is simple, though it does not account complex anomalies like syndactylism, fused joints (etc.):
  1. Terminal defects: Involves the distal rays + proximal segments like forearm or leg, in which there may be transverse defects (absence of all fingers, amputation through carpus forearm or arm) OR longitudinal defects which may be pre-axial or para-axial (absence of radius with thumb or absence of tibia with medial rays of foot).
  2. Intercalary defects (intermediate segment is missing):
    1. There may be transverse defect alone phocomelia (e.g. distal part of radius and ulna are absent). Complete phocomelia, e.g. radius, ulna and humerus are absent; tibia, fibula with hypoplasia or aplasia of femur
    2. Longitudinal, e.g. absence of radius or ulna or fibula or tibia alone.
Descriptive terms usually used while describing congenital anomalies:
Acheiria (achiria)
= Absence of hand
= Absence of hands and feet
Adatylia (adactyly)
= Absence of fingers/toes
= Absence of development
= Complete absence of a limb
Amelia totalis
= Complete absence of all four limbs
= Absence of distal part of a limb
= Absence of a specific bone or bones
= Absence of the foot
= Partial or total missing of hand
= Partial or total absence of digits/fingers
= Partial or total absence of hand or fingers
= Absence of one or more phalanges
= Total or partial absence of the foot
= Absence of one of the paired bones of the limbs
= Less than normal number of phalanges
= While proximal and deficiency distal portions of limb are intact, the middle portion is missing
= Absence of the limb deficiency extending parallel to the long axis (may be preaxial, post-axial or central)
= Partial absence of a limb
= Absence of few fingers
Paraxial deficiency
= Only the pre-axial or post-axial portion of the limb is affected
= Hemimelia, especially the ending in stump
= In its complete form the arm and forearm are absent in the upper limb and the thigh and leg are absent in the lower limb (the hands and feet sprout directly from the trunk). The deficiencies may be proximal (arms and thighs missing) or distal (forearms and legs missing).
= Pertaining to the ulnar side of the upper limb, and the fibular side of the lower limb
= Pertaining to the radial side of the upper limb, and the tibial side of the lower limb
Terminal deficiency
= Absence of limb with all portions in line with and distal to defect involved
Transverse deficiency
= Entire width of the limb is affected.
Because of immence power adaptability for functions, the persons with the terminal transverse defects should be better managed with fitting with suitable prosthesis.
“If a child cries when you examine it, then it's probably your fault”
—John Apley
The above sweeping statement may not be all correct, but the basic philosophy is right. It is always paying to spend some time trying to gain their confidence. Younger children are always comfortable in mother's lap. Some toys and toffees will help you to make familiar with child. While in mother's lap, watch the expression, general built and behaviour and obvious abnormalities, movements of the limbs, etc. before touching the child.
While the basic methodology remains the same, one should not expect to get same degree of cooperation as in average adults. Try to derive as much informations as possible in the short period when the child cooperates with. The child gets irritated by repeated examinations and gets frightened by the white coats, examining tools and heavy environments.
“In the end it is not the years in your life that count. It's the life in your years”
—Abraham Lincoln
By 2000 AD, the average life expectancy in India has just crossed 60 year mark (which was just around 30 in 1947), while that in USA is 75 years (72 for men and 79 for women).
Heterogenous population above the age of 60 should be in the bracket of elderlies. Chronologically they can be subgrouped as: young old (60–69), old (70–79), very old (>80). This century has proved to be the ‘Century of longevity’ and a “century of cognitive decline”. Though the maximum height of age has not increased, the average life expectancy has remarkably increased globally and thus unprecedentally increasing the numbers of elderlies in the world with all their problems. As on today the number of centenarians is round about 1,35,000 and is likely to increase to 25,00,000 by the year 2050. With 1,15,000 in India alone, i.e. one centenarian will be in every 5,000 of population.
In Indian mythelogy the achievement of ‘desired death’ has been noted by several saints and kings. Saint Tulsidas lived for 126 years, Ramaniya for 120 years, Kanchi Parmacharya for 100 years and so on. Even politicians like Guljarilal Nanda and Morarji Desai touched their 100 years.
Besides the chronological count, the old age requires a broad assessment. Co-morbidity is the hallmark of the elderlies. Multiple system involvement at a time, symptoms varying from 6 to 12 and diagnosis around 2 or 3 at a time usually characterise the clinical profile of elderly patients (Venkobe Rao 1990). Usually there is overlay of depression and/or anxiety—a condition called ‘Cothymia’ (Tyrer 2001).
Exact causes of ageing are not well established—hovering around 30 theories. However, 40more convincing ones are: (1) deccumulation of unrepaired DNA (free radical theory), (2) concept involving telemeres. Economics, though helpful, do no essentially influence the longevity.
There are two aspects of old age. The positive aspect visualises the old age as the period of grandeur and exquisitness, crystallized wisdom and crystalline intelligence. On the opposite aspect it is looked down upon as a period of dreary waste land with diseases, disabilities, dependance, depression, decay and an ailing continent. In the gradual ebbing away evening period of life, many elderlies have to unwillingly face a host of losses—loss of status, income, self respect, body functions, sense organs (e.g. vision, hearing, etc.), memory, mental status, motor power, mobility (due to instability, muscle power loss, paralysis, fractures, etc.) near and dear ones, etc. The sense of wellbeing remains in a small percentage of elderly (on an average about 30%).
Preventive Geriatrics” involves the concept of ‘successful ageing’ by improving the health of the mass above sixty entering into the erena of ‘old age’, so that they pass their final years in a state of ‘engeria’—the term coined by Aristotle to qualify the state of freedom from disease, disabilities, dependance and depression without being burden to others.
Geriatric medicine is not a new concept. At least the great Indian surgeon Sushruta classifying Ayurveda into 8 diversions has categorically described one of them as “Old-age-medicine”.
A “healthy life style” is the hallmark of “preventive geriatrics”. It involves nutritious diet, avoiding smoking and alcohol, less sodium intake in diet, adequate fresh fruits and green vegetables, high complex carbohydrate, reduced saturated fat, adequate protein (non-animal source), cognitive exposure, cognitive stimulation in childhood, healthy natural environment, reduced exposure to pollution and infection, physical and intellectual activities, and none the less religious and spiritual believes and practices and meditation—are the ingredients to foster the happy journey through the evening of life. Spirituality has been observed to have definite scientific base. There is a set of neuronal circuits in the left temporal lobe (limbia system) which serves as a substrate for religeousity, spirituality and belief in God.
While examining an elderly person Alzheimer's disease must be kept in mind. It results due to deposits of amyloidal substances and several other inflammatory proteins in the brain.
Physical examination processes of the elderly person are more or less of the same as described in individual chapters. However, they deserve more sympathetic approach in each step of examination. Confusing pain syndromes are not uncommon in the elderly, e.g. Hip-spine syndrome—significant lumbar canal stenosis and arthritis of lower extremity joints may coexist. This combination of radiculopathy and osteoarthritis usually produce diagnostic confusion. However careful repeated examination taking the elderly patient in full confidence, diagnostic tests, and investigations are essential to discriminate them, since both require separate effective management.
Ernest Codman became known as the first true medical auditor following his work in 1912 on monitoring surgical outcomes.
Clinical audit compares current practice to the standard practice. The clinical audit is essential to assess ones performance. Audit guides us if we are doing the things in the right way and right direction. Of course the knowledge about the thing to do comes from research.
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