This patient following
road traffic accident
had pain in neck and
consulted her three
On each occasion she
was told the x-rays are
normal . When
strenuous effort was
made to show the
entire cervical spine a
Of C6 and C7 could be
seen at the very bottom
of the film.
spino laminar lines
are use ful for
of the neck.
c- spino laminar.
Normal range of movements. In full flexion the chin normally
touches the chest. In full extension the imaginary line joining
the chin to the posterior occipital protuberance( the occipito
mental line) forms an angle of at least 45 degree with
horizontal line , and usually 60 degree in young people.
Lateral flexion and rotation are equal in both directions.
power in the
Examination In this patient with signs of a prolapsed disc, flexion and tilting to the left are
The examination may be broken down into six distinct
3. Examination of movements
4. Conduction of special tests
5 Examination of radiographs
6. Arranging further investigations.
It is not always necessary to keep strictly to this order
or indeed to carry out all of these procedures.
Look carefully at the joint, paying particular attention to the following
1. Is there swelling? If so, is the swelling diffuse or localised? If it is
confined to the joint it may be due to excess synovial fluid (effusion),
blood within the joint cavity (haemarthrosis), or pus (pyarthrosis).
Swelling extending beyond the confines of the joint may occur in major
infections in a limb, tumours and problems of lymphatic and venous
2. Is there bruising? Is this due to trauma; or an abnormality of the
vessels or the clotting mechanisms?
3. Is there any other discoloration, or oedema?
4. Is there muscle wasting? If so, is this due to inactiviw- from pain or
incapacity, or from denervation?
5. Is there any alteration in shape or posture, or is there evidence of
shortening? This will require careful examination to establish the cause.
Sonic' of the points to note include the following:
1. Is the joint warm? If so, note whether the temperature
increase is diffuse or localised, always bearing in mind the
false impression which may be caused' by the effects of local
bandaging_ A diffuse increase in heat occurs when a
substantial tissue mass is involved, and is seen most
commonly in pvogenic and non-pyogenic inflammatory
processes, vascular abnormalities and tumours. A localised
increase in temperature generally pin-points an inflammatory
process to an isolated structure..
2. Is there tenderness? The causes of diffuse and localised
tenderness are similar to the causes of increased joint
Estimation of the range of movements in
the joint is an essential part of any
orthopaedic examination. To assess any
deviation from normal, the good side may
be compared with the bad. Where this is not
suitable (e.g. when both sides are
Muscle power is usually graded on the Medical
Research Council scale:
Grade 0 — no movement
Grade 1 — only a flicker of movement
Grade 2 — movement with gravity eliminated
Grade 3 — movement against gravity
Grade 4 — movement against resistance
Grade 5 — normal power
It is important to recognize that muscle weakness may
be due to muscle disease rather than nerve disease.
In muscle disorders the weakness is usually
symmetrical and sensation is normal.
4: CONDUCTION OF SPECIAL TESTS
In the case of sensory testing, the MRC gradings may be used:
SO— Absence of all modalities of sensation in the area exclusively
supplied by the affected nerve.
S1— Recovery of deep pain sensation.
S2— Recovery of protective sensation (skin touch, pain and thermal
S3— Recovery of ability to recognise objects and texture; any residual
cold sensitivity and hypersensitivity should now be minimal. In the case
of the hand, recovery of two point discrimination to less than 8 mm.
S4— Normal sensation.
X-RAYS / RADIOGRAPHS
Routine blood test
Specific blood tests .
Rheumatoid factor tests
Rheumatoid factor (RA Factor) is an autoantibody (or antiglobulin)
which is often present in patients with rheumatoid arthritis (RA).
HLA antigens can be detected in white blood cells HLA-B27 this is
frequently used as a confirmatory test in patients suspected of having
Biochemical tests are essential in monitoring patients after any serious
5: EXAMINATION OF RADIOGRAPHS
Check the following:
1. Are the bones of normal shape, size and contour, or are they
thicker or thinner than normal, shorter or longer than usual or
abnormally curved or angled?
2. At the joints themselves, are the bony components in correct
alignment, or are they displaced or angled?
3. Is the bone texture normal?
4. Are there are any areas of new bone formation, such as
exostoses or subperiosteal new bone formation, or is their
evidence of bone destruction?
5. Is there any evidence of congenital abnormality, infection or
inflammation, rheumatoid or osteoarthritis?
Specific tests .
Synovial fluid analysis
Bone marrow aspiration and Bone biopsy
Arthroscopy. Methods for the examination
of all the major joints have been developed,
and allow direct visualisation of the
articular surfaces, the joint capsule, many
associated ligaments, and in the case of the
knee, the menisci. At the same session,
biopsy samples may be taken if required,
and sometimes treatment procedures may
be carried out.
FUNCTIONAL IMAGING TECHNIQUES
Technetium bone scans. Bone scans may be performed after
the injection of technetium tagged methylene diphosphonate
(99Tcrn-methylene diphosphonate [MDP]). The facility is
widely available, inexpensive and gives rapid results. In the
trauma field, such scans may assist in the diagnosis of hairline
fractures (e.g. of the scaphoid, shin or neck of femur). They
may assist in gauging the age of a fracture, and in detecting
avascular necrosis of bone. They are of value in the
investigation of unexplained pain in the long bones and the
spine, infections in bone and in the region of prostheses, and
in assessing Sudeck's atrophy (complex regional pain
fluid is removed from
a joint space or
medication may be
administered into the
joint cavity for
•To evaluate synovial fluid and
determine whether the cause of effusion is
•Infectious (for culture sensitivity) ,
•or crystal-induced etiology
•To remove exudative fluid from a septic joint
•To relieve pain in a grossly swollen joint (e.g.,
•Cellulitis or broken skin over the intended
entry site for the injection or aspiration
•Anticogulant therapy that is not well controlled
•Septic effusion of a bursa or a periarticular
•Joint prostheses (If infection is suspected,
consider a referral to the orthopedist who placed
the prosthesis, if at all possible)
Bone marrow aspiration and biopsy are
now well-accepted procedures for
evaluation both the cellularity of the
marrow and the nature of the cells
Although sternum is the traditional site for
bone marrow aspiration
preferred site is the posterior Iliac crest
(the hip bone) because of ease and safety
and the fact that the posterior Iliac crest is
usually quite cellular.