Masculoskeletal system

1. Mohamed Ali Hussein
MBBS MMED ORTHOPEDIC AND TRAUMA
The MSK system

2. Lecture Outline
 The history
 The physical examination
 Detailed examination of the musculoskeletal
system
 Fractures, dislocations and trauma
 Investigations

3. The history
 Common presenting symptoms
 Pain
 In musculoskeletal pain, the acronym
SOCRATES. prompts questions that reveal useful
diagnostic clues
 Site
 Illustrates the anatomy of a typical joint. Determine
which component is painful: the joint (arthralgia),
muscle (myalgia) or other soft tissue.
 Pain may be localised and suggest the diagnosis,
such as a red, hot, tender first metatarsophalangeal
joint in gout, or swelling of several joints suggesting
an inflammatory arthritis.

4. Conti…
 Onset
 Pain from traumatic injury is usually immediate and
exacerbated by movement or haemarthrosis (bleeding
into the joint).
 Inflammatory arthritis can develop over 24 hours, or
more insidiously Crystal arthritis (gout and pseudogout)
causes acute. Joint sepsis causes pain that develops
over 1–2 days.
 Character
 Bone pain is penetrating, deep or boring, and is
characteristically worse at night, Localised pain suggests
tumour, osteomyelitis (infection), osteonecrosis or
osteoid osteoma (a benign bone tumour). Generalised
bony conditions, such as Osteomalacia, usually cause
diffuse pain,
 Associated
 symptoms For example, swelling and redness of a joint
indicate inflammatory arthritis.

5. Conti…
 Fracture pain is sharp and stabbing, aggravated by
attempted movement, and relieved by rest and
splintage, Muscle pain is often described as
‘stiffness’ or aching, and is aggravated by use.
 Shooting’ pain is often caused by impingement of a
peripheral nerve or nerve root for example, buttock
pain, which ‘shoots down the back of the leg,
Progressive joint pain at age of 40 is caused by
osteoarthritis.
 Radiation Pain from nerve compression radiates to
the distribution of that nerve or nerve root such as
lower leg.

6. Conti…
 Timing (frequency, duration and periodicity of
symptoms)
 A history of several years of pain with a normal
examination suggests fibromyalgia, A history of
several weeks of pain, early-morning stiffness and
loss of function is likely to be an inflammatory
arthritis. ‘Flitting’ pain starting in one joint and
moving to others over a period of days is a feature
of rheumatic ‘Flitting’ pain starting in one joint and
moving to others over a period of days is a feature
of rheumatic, intermittent with resolution must likely
rheumatism.
 Exacerbating/relieving factors
 Pain from joints damaged by intra-articular
derangement or osteoarthritic degeneration

8. Conti…
 Severity
 Apart from trauma, the most severe joint pain
occurs in septic and crystal arthritis.
Disproportionately severe pain is seen acutely in
compartment syndrome (increased pressure in a
fascial compartment, compromising perfusion and
viability of compartmental structures) and
chronically in complex regional pain syndrome.
 Neurological involvement in diabetes mellitus,
leprosy (Hansen’s disease), syringomyelia and
syphilis (tabes dorsalis) may impair joint
sensation, reducing pain despite obvious
pathology on examination.

11. Conti…
 Patterns of joint involvement
 Different patterns of joint involvement aid the differential
diagnosis . Are the small or large joints of the arms or
legs affected? How many joints are involved?
Involvement of one joint is called a monoarthritis; 2–4
joints, oligoarthritis; and more than 4, polyarthritis.
 Predominant involvement of the small joints of the hands
and feet suggests an inflammatory arthritis, such as
rheumatoid arthritis or systemic lupus erythematosus.
 Medium- or large-joint swelling is more likely to be
degenerative (osteoarthritis) or a seronegative arthritis
(such as psoriatic arthritis).
 Nodal osteoarthritis has a predilection for the distal
interphalangeal (DIP) joints of the hands and the
carpometacarpal (CMC) joint of the thumb

13. Conti…
 Stiffness
 Ask what the patient means by stiffness. Is it:
 restricted range of movement?
 difficulty moving, but with a normal range?
 painful movement?
 localised to a particular joint or more generalised?
 There are characteristic differences between
inflammatory and non-inflammatory presentations of
joint stiffness.
 Inflammatory arthritis causes early-morning stiffness
that takes at least 30 minutes to wear off with activity.
 Non-inflammatory, mechanical arthritis causes
stiffness after rest that eases rapidly on movement

14. Conti…
 Swelling
 Ask about the site, extent and time course of the
swelling. The speed of onset of swelling is a clue to
the diagnosis:
 Rapid (<30 minute) severe swelling suggests a
haemarthrosis
 Swelling over hours or days suggests traumatic effusion,
such as with a meniscal tear or articular cartilage
abrasion.
 Septic arthritis develops over a few hours with pain,
marked swelling, tenderness, redness and extreme
reluctance to move the joint actively or passively
 Crystal-induced arthritis (gout or pseudo gout) can mimic
septic arthritis. It commonly starts overnight or early in

15. Conti…
 Erythema and warmth
 Erythema (redness) occurs in infective, traumatic and
crystal-induced conditions, and mild erythema may be
present in inflammatory arthritis. All affected joints will be
warm
 Weakness
 Weakness suggests joint, neurological or muscle
disease. The problem may be focal or generalised
 Joint disorders cause weakness, either through inhibition
of function by pain, or by disruption of the joint or its
supporting structures.
 Nerve entrapment may be the cause: for example,
carpal tunnel syndrome at the wrist.
 Muscle disorders can produce widespread weakness
associated with pain and fatigue, such as in myositis.
 Proximal muscle weakness can occur in endocrine
disorders: for example, hypothyroidism or excess of
glucocorticoids

18. Conti…
 Locking and triggering
 ‘Locking’ is an incomplete range of movement at a
joint because of an anatomical block. It may be
associated with pain.
 Patients use ‘locking’ to describe various problems,
so clarify exactly what they mean,
 True locking is a block to the normal range of
movement caused by mechanical obstruction
 Pseudolocking is a loss of the range of movement
due to pain
 Triggering is a block to extension of a finger,
which then ‘gives’ suddenly when extending from
a flexed position. Triggering can be congenital, in
which case it usually affects the thumb.

19. Conti…
 Extra-articular symptoms
 Patients may present with extra-articular features of
disease that they may not connect with
musculoskeletal problems
 Ask about:
 Rashes: occur with psoriasis, vasculitis and erythema
nodosum.
 Weight loss, low-grade fever and malaise: associated with
rheumatoid arthritis and SLE.
 Headache, jaw pain on chewing (claudication) and scalp
tenderness: features of temporal arteritis.
 Raynaud’s phenomenon.
 Sicca symptoms (dryness of mouth and eyes)
 Rashes.

20. Conti…
 Respiratory problems, including dyspnoea from
interstitial lung disease, or pleural pain or effusions
associated with rheumatoid arthritis or connective
tissue disease
 Back pain and stiffness or arthritis associated with
abdominal pain, diarrhoea, bloody stool and mouth
ulcers: may suggest arthritis associated with
inflammatory bowel disease

21. Past medical history
 Note past episodes of musculoskeletal involvement,
extra-articular diseases as listed in the previous
section, fractures and possible complicating
comorbidities such as diabetes or obesity.
 Drug history
 Many drugs have side effects that may either
worsen or precipitate musculoskeletal conditions

22. Family history
 Inflammatory arthritis is more common if a first-
degree relative is affected.
 Osteoarthritis, osteoporosis and gout are
heritable in a variable polygenic fashion.
 Spondyloarthritis is more common in patients with
human leucocyte antigen B27.
 A single-gene defect (monogenic inheritance) is
found in hereditary sensorimotor neuropathy
(Charcot–Marie–Tooth disease),
 osteogenesis imperfecta, Ehlers–Danlos
syndrome, Marfan’s syndrome and the muscular
dystrophies

23. Social, environmental and occupational
histories
 Identify functional difficulties, including the ability to
use pens, tools and cutlery. How does the condition
affect the patient’s activities of daily living, such as
washing, dressing and toileting? Can they use the
stairs and do they need walking aids? Ask about
functional independence, especially cooking,
housework and shopping
 Ask about current and previous occupations. Is the
patient working full- or part-time, on sick leave or
receiving benefits? Has the patient had to take time
off work because of the condition and is their job at
risk
 Smoking is a risk factor for rheumatoid arthritis and
possibly other inflammatory arthritides High alcohol
intake contributes to gout and falls that may result in
fracture

24. Conti…
 Sickle cell disease may present with bone and joint
pain in African patients Osteomalacia is more
common in Asian patients. Bone and joint
tuberculosis is more common in African and Asian
patients.
 A sexual history may be relevant, since sexually
transmitted disease is associated with
musculoskeletal problems, such as reactive
arthritis, gonococcal arthritis, human
immunodeficiency virus infection and hepatitis B.
 High alcohol intake contributes to gout and falls that
may result in fracture. It can also cause myopathy,
neuropathy and rhabdomyolysis.

25. The physical examination
 Practice examining as many joints as possible to
become familiar with normal appearances and
ranges of movement.
 General principles
 Firstly, examine the patient’s overall appearance for
features such as pallor, rash, skin tightening and
hair changes
 Look – feel – move
 Follow a process of observation, palpation and
movement for each joint or group of joints in turn
 Look at the skin, subcutaneous tissues and bony
outline of each area. Before palpating, ask the
patient which area is painful or tender. Feel for

26. Conti…
 Assess if deformity is reducible or fixed. Assess active
before passive movement. Do not cause the patient
additional pain. Compare one limb with the opposite
side. e. Always expose the joint above and below the
affected one. Use standard terminology to describe
position and movement.
 Flexion: bending at a joint from the neutral position
 Extension: straightening a joint back to the neutral
position
 Hyperextension: moving beyond the normal neutral
position (indicating a torn ligament or underlying
ligamentous laxity, such as benign joint hypermobility
syndrome)
 Adduction: moving towards the midline of the body
(finger adduction is movement towards the axis of the
limb)

27. Conti…
 To describe altered limb position due to joint/bone
deformity, use:
 Valgus: the distal part deviates away from the
midline
 Varus: the distal part deviates towards the midline.
In the wrist and hand, use:
 Radial deviation: the distal part deviates towards
the radial side
 Ulnar deviation: the distal part deviates towards the
ulnar side

28. Conti…
 General examination
 Skin, nail and soft tissues
 The skin and related structures are common sites of
associated lesions. The skin changes of psoriasis may be
hidden. The rash of SLE is found across the cheeks and
bridge of nose. Nail pitting and onycholysis occur in
psoriasis. Small, dark-red spots due to capillary infarcts
occur in rheumatoid arthritis, SLE and systemic vasculitis,
Common sites are the nail folds.
 Reactive arthritis is associated with conjunctivitis, urethritis,
circinate balanitis (painless superficial ulcers on the prepuce
and glans) and superficial mouth ulcers

33. Conti…
 Nodules
 The firm, non-tender, subcutaneous nodules of
rheumatoid arthritis most commonly occur on the
extensor surface of the forearm. sites of pressure or
friction such as the sacrum or Achilles tendon, or in the
lungs.
 Rheumatoid nodules are strongly associated with a
positive anti-cyclic citrullinated peptide (anti-CCP)
antibody or rheumatoid factor.
 Bony nodules in osteoarthritis affect the lateral aspects
of the DIP joints (Heberden’s nodes) or the proximal
interphalangeal (PIP) joints (Bouchard’s nodes, Fig.
13.8). They are smaller and harder than rheumatoid
nodules
 Gouty tophi are firm, irregular subcutaneous crystal
collections (monosodium urate monohydrate) Common
sites are the olecranon bursa, helix of the ear and
extensor aspects of the fingers, hands, knees and toes

34. Conti…
 Eyes
 Redness of the eyes may be due to conjunctivitis in
reactive arthritis or ‘dry eyes’ in Sjögren’s
syndrome, rheumatoid arthritis and other connective
tissue disorders.
 Scleritis and episcleritis occur in rheumatoid arthritis
and psoriatic arthritis.
 The sclerae are blue in certain types of
osteogenesis imperfecta and in the scleromalacia of
longstanding rheumatoid arthritis.

35. Conti…
 General features
 Weight loss, muscle loss, fever and
lymphadenopathy are all features of systemic
involvement in inflammatory arthritis and connective
tissue disease.

36. Joints: the GALS screen
 GALS (gait, arms, legs, spine) is a rapid screen for
musculoskeletal and neurological deficits, and for
functional ability; it helps to identify joints that require
more detailed examination, as described later
 Initial questions
 Do you have any pain or stiffness in your muscles, joints
or back?
 Do you have difficulty dressing yourself?
 Do you have difficulty walking up and down the stairs?
 If all three replies are negative, the patient is unlikely
to have a significant musculoskeletal problem;
otherwise, perform the GALS screen

37. Conti….
 Hypermobility
 Some patients have a greater than normal range
of joint movement. If this is severe, patients may
present with recurrent dislocations or sensations
of instability. Milder cases may develop arthralgia
or be symptom-free. Mild hypermobility is normal
but Marfan’s, Ehlers–Danlos and benign joint
hypermobility syndromes

39. Detailed examination of the
musculoskeletal system
 The GALS screen provides a rapid but limited
assessment. This section describes the detailed
examination required for thorough evaluation
 Gait
 Gait is the cyclical pattern of musculoskeletal
motion that carries the body forwards. Normal gait
is smooth, symmetrical and ergonomically
economical, with each leg 50% out of phase with
the other. It has two phases: stance and swing
 The stance phase is from foot-strike to toe-off, when
the foot is on the ground and load-bearing.
 The swing phase is from toe-off to foot-strike, when
the foot clears the ground

40. Conti…
 Examination sequence
 Ask the patient to walk barefoot in a straight line.
Then repeat in shoes
 Observe the patient from behind, in front and from
the side
 Evaluate what happens at each level (foot, ankle,
knee, hip and pelvis, trunk and spine) during both
stance and swing phases
 Pain
 An antalgic gait is one altered to reduce pain. Pain
in a lower limb is usually aggravated by weight
bearing, so minimal time is spent in the stance
phase on that side Patients with hip pain may lean
towards the affected side, as this decreases the
compression force on the hip joint.

41. Conti…
 Structural change
 Patients with limb-length discrepancy may limp or
walk on tiptoe on the shorter side, with
compensatory hip and knee flexion on the longer
side.
 Weakness
 This may be due to nerve or muscle pathology or
altered muscle tone. In a normal gait the hip
abductors of the stance leg raise the contralateral
hemipelvis In Trendelenburg gait, abductor function
is poor when weight-bearing on the affected side,
so the contralateral hemipelvis falls.

42. Conti…
 Common causes of a Trendelenburg gait are:
 painful hip joint problems, as in osteoarthritis
 weak hip abductors, as in poliomyelitis or after hip
replacement
 structural hip joint problems, as in congenital
dislocation.
 A high-stepping gait occurs in foot drop due to
common peroneal nerve palsy.
 Increased tone
 This occurs with upper motor neurone lesions, such
as cerebrovascular accident (stroke) or cerebral
palsy

43. Conti…
 Spine
 The spine is divided into the cervical, thoracic, lumbar
and sacral segments Most spinal diseases affect
multiple segments, causing altered posture or function of
the whole spine.
 Definitions
 Scoliosis is lateral curvature of the spine.
 Kyphosis is curvature of the spine in the sagittal
(anterior– posterior) plane, with the apex posterior.
 The thoracic spine normally has a mild kyphosis.
 Lordosis is curvature of the spine in the sagittal plane,
with the apex anterior.
 Gibbus is a spinal deformity caused by an anterior
wedge deformity of a single vertebra, producing
localised angular flexion

46. Conti…
 Cervical spine
 Anatomy and physiology?????
 The history
 The most common symptoms are pain and difficulty
turning the head and neck.
 Neck pain is usually felt posteriorly but may be
referred to the head, shoulder, arm or interscapular
region
 Cervical disc lesions cause radicular pain in one
arm or the other, roughly following the dermatomes
of the affected nerve roots If the spinal cord is
compromised (cervical myelopathy)

47. Conti…
 The physical examination
 Be particularly careful when examining patients with
rheumatoid arthritis, as atlantoaxial instability can
lead to spinal cord damage when the neck is flexed.
 In patients with neck injury, never move the neck.
Splint it and check for abnormal posture.
 Check neurological function in the limbs and X-ray
to assess bony injury

48. Conti…
 Examination sequence
 Ask the patient to remove enough clothing for you
to see their neck and upper thorax, then to sit on a
chair
 Look
 Face the patient. Observe the posture of their head and
neck. Note any abnormality
 Feel
 Feel the midline spinous processes from the occiput to T1
(usually the most prominent).
 Feel the supraclavicular fossae for cervical ribs or enlarged
lymph nodes
 Note any tenderness in the spine, trapezius, interscapular
and paraspinal muscles

49. Conti…
 Move
 Assess active movements.
 Ask the patient to
 Look down to the floor so that you can assess forward
flexion The normal range is 0 (neutral) to 80 degrees
 Look upwards at the ceiling as far back as possible, to
assess extension The normal range is 0 (neutral) to 50
 Put their ear on to their shoulder, so that you can assess
lateral flexion. The normal range is 0 (neutral) to 45 degrees
 Look over their right/left shoulder. The normal range of
lateral rotation is 0 (neutral) to 80 degrees
 If active movements are reduced, gently perform
passive movements

52. Conti…
 Thoracic spine
 Anatomy and physiology???????
 The history
 Presenting symptoms in the thoracic spine are localised
spinal pain, pain radiating round the chest wall or, less
frequently, signs of cord compression: upper motor
neurone leg weakness (paraparesis), sensory loss, and
loss of bladder or bowel control. Disc lesions are rare
but may cause pain radiating around the chest that
mimics cardiac or pleural disease.
 Osteoporotic vertebral fractures may present with acute
pain, or painless loss of height with increased kyphosis.
 Vertebral collapse due to malignancy may cause cord
compression. Infection causes acute pain, often with
systemic upset or fever With poorly localised thoracic
pain, consider intrathoracic causes, such as (MI,
Infraction AA).

53. Conti…
 The physical examination
 Examination sequence
 Ask the patient to undress to expose their neck, chest and
back.
 Look?
 Feel?
 Move?

55. Conti…
 Lumbar spine
 Anatomy and physiology???????
 The history
 Low back pain is extremely common. Most is
‘mechanical’, and caused by degenerative changes
in discs and facet joints (spondylosis).
 Analyse the symptoms using ‘SOCRATES’. For
back pain, ask specifically about
 occupational or recreational activity that may strain the
back.
 red flag features suggesting significant spinal pathology
 prior treatment with glucocorticoids

56. Conti…
 Radicular pain caused by sciatic nerve root compression
radiates down the posterior aspect of the leg to the lower
leg or ankle (sciatica).
 Groin and thigh pain in the absence of hip abnormality
suggests referred pain from L1–2.
 Consider abdominal and retroperitoneal pathology, such
as abdominal aortic aneurysm.
 Mechanical low back pain is common after standing for
too long or sitting in a poor position. Symptoms worsen
as the day progresses and improve after resting or on
rising in the morning.
 Acute onset of low back pain in a young adult, often
associated with bending or lifting, is typical of acute disc
protrusion (slipped disc).

57. Conti…
 Coughing or straining to open the bowels
exacerbates the pain. There may be symptoms of
lumbar or sacral nerve root compression.
 The motor disturbance may be profound, as in
paraplegia. Cauda equina syndrome and spinal
cord compression are neurosurgical emergencies
 Acute back pain in the middle-aged, elderly or those
with risk factors, such as glucocorticoid therapy,
may be due to osteoporotic fracture
 Acute onset of severe progressive pain, especially
when associated with malaise, weight loss or night
sweats, may indicate pyogenic or tuberculous
infection of the lumbar spine or sacroiliac join

58. Conti…
 The physical examination
 Examination sequence
 Ask the patient to stand with their back fully exposed.
 Look?
 Feel?
 Move?
 Special tests
 Schober’s test for forward flexion?
 Root compression tests?
 Sciatic nerve stretch test (L4–S1)?
 Femoral nerve stretch test (L2–4)?
 Flip test for functional overlay?

61. Conti…
 Upper limb
 The prime function of the upper limb is to position the
hand appropriately in space. This requires shoulder,
elbow and wrist movements. The hand may function in
both precision and power modes
 Hand and wrist
 Motor and sensory innervation of the hand is shown in.
The wrist joint has metacarpocarpal, intercarpal,
ulnocarpal and radiocarpal components
 There is a wide range of possible movements, including
flexion, extension, adduction (deviation towards the
ulnar side), abduction (deviation towards the radial side)
and the composite movement of circumduction (the
hand moves in a conical fashion on the wrist). Always
name the affected finger (index, middle, ring and little) in
documentation to avoid confusion.

62. Conti…
 The history
 The patient will often localize symptoms of pain,
stiffness, loss of function, contractures,
disfigurement and trauma. If symptoms are vague
or diffuse, consider referred pain or a compressive
neuropathy, such as carpal tunnel syndrome
 Painful, swollen and stiff hand joints are common
and important presenting symptoms

63. Conti…
 The physical examination
 Examination sequence
 Seat the patient facing you, with their arms and shoulders
exposed. Start by examining the hand and fingers, and
move proximally
 Look?
 Feel?
 Move?

68. Conti…
 Elbow
 Anatomy and physiology?????
 The physical examination
 Examination sequence
 Look?
 Feel?
 Move?
 Special tests
 Tennis elbow (lateral epicondylitis)
 Golfer’s elbow (medial epicondylitis)

69. Conti…
 Shoulder
 Anatomy and physiology???
 The history
 Pain is common and frequently referred to the upper
arm. Glenohumeral pain may occur over the
anterolateral aspect of the upper arm. Pain felt at the
shoulder may be referred from the cervical spine or
diaphragmatic and subdiaphragmatic peritoneum via the
phrenic nerve
 Stiffness and limitation of movement around the
shoulder, caused by adhesive capsulitis of the
glenohumeral joint, is common after immobilisation or
disuse following injury or stroke. This is a ‘frozen
shoulder’. Some rotator cuff disorders, especially
impingement syndromes and tears, present with a
painful arc

70. Conti…
 The physical examination
 Examination sequence
Ask the patient to sit or stand and expose their shoulder
completely.
 Look?
 Feel?
 Move?
 Special tests for impingement
 Neer test?
 Hawkins–Kennedy test?

77. Conti…
 Lower limb
 Hip
 Anatomy?
 The history
 Pain is usually felt in the groin but can be referred to the
anterior thigh, the kn ee or the buttock. Hip pain is usually
aggravated by activity, but osteonecrosis and tumours may
be painful at rest and at night. Lateral hip or thigh pain,
aggravated when lying on that side, suggests trochanteric
pain syndrome.
 Fracture of the neck of the femur is common following
relatively minor trauma in postmenopausal women and
those aged over 70 years. The classical appearance is a
shortened, externally rotated leg

78. Conti…
 Distinguish pain arising from the hip from:
 lumbar nerve root irritation
 spinal or arterial claudication
 abdominal causes such as hernia
 Ask how the pain restricts activities. Record
walking ability in terms of the time and distance
the patient manages outside and on stairs, and
note whether walking aids are used

79. Conti…
 The physical examination
 Examination sequence
Patients should undress to their underwear and remove socks
and shoes. You should be able to see the iliac crests.
 Look?
 Feel?
 Move
 Thomas test?
 Special tests
 Shortening?
 Trendelenburg’s sign?

84. Conti…
 Knee
 Anatomy?????????
 The history
 Pain
 Generalised knee pain is likely to be due to pathology in the
tibiofemoral joint. Anterior knee pain, particularly after
prolonged sitting or going downstairs, suggests
patellofemoral joint pathology. Medial or lateral pain could
come from the collateral ligaments or meniscal tears Pain in
the knee may be referred from the hip. Take a detailed
history of the mechanism of any injury. The direction of
impact, load and deformation predict what structures are
injured

85. Conti…
 Swelling
 The normal volume of synovial fluid is 1–2 mL and is
clinically undetectable. An effusion indicates intra-
articular pathology. Haemarthrosis (bleeding into the
knee) is caused by injury to a vascular structure within
the joint, such as a torn cruciate ligament or an intra-
articular fracture
 Locking
 Two common causes in the knee are a loose body, such
as from osteochondritis dissecans, osteoarthritis or
synovial chondromatosis, and a meniscal tear. Bucket-
handle and anterior beak meniscal tears are especially
associated with locking. Posterior horn tears commonly
cause pain and limit movement in the last few degrees
of flexion

86. Conti…
 Instability (‘giving way’)
 Any of the four main ligaments may rupture from
trauma or become incompetent with degenerative
disease. The patella is prone to dislocate laterally
because the normal knee has a valgus angle.

87. Conti…
 The physical examination
 Examination sequence
 Observe the patient walking and standing, as for gait. Note
posture and deformities such as genu valgum (knock knee)
or genu varum (bow legs).
 Look?
 Feel?
 Move
 Special tests
 Anterior drawer test
 Lachmann test
 Posterior drawer test
 Patellar apprehension test

90. Conti…
 Ankle and foot
 Anatomy????????????????
 The history
 A ‘twisted’ ankle is very common, and is usually related to a
sporting injury. Establish the exact mechanism of injury and the
precise site of pain. Frequently there has been a forced
inversion injury stressing the lateral ligament. A sprain occurs
when some fibres are torn but the ligament remains structurally
intact. A complete ligament tear allows excessive talar
movement in the ankle mortise with instability
 Achilles tendon rupture is associated with sudden plantar
flexion at the ankle. It is common in middle-aged patients doing
unaccustomed activity such as squash, and is associated with
some medications such as oral glucocorticoids and
fluoroquinolone antibiotics.
 Forefoot pain, often localised to the second metatarsal, after
excessive activity such as trekking, marching or dancing,
suggests a stress fracture

91. Conti…
 Non-traumatic conditions
 Anterior metatarsalgia with forefoot pain is common,
especially in middle-aged women. Acute joint pain
with swelling suggests an inflammatory arthropathy
such as rheumatoid arthritis or gout. In severe
cases the metatarsal heads become prominent and
walking feels like walking on pebbles or broken
glass.
 Plantar surface heel pain that is worse in the foot-
strike phase of walking may be caused by plantar
fasciitis and tends to affect middle-aged patients
and those with seronegative arthritides
 Spontaneous lancinating pain in the forefoot
radiating to contiguous sides of adjacent toes
occurs with Morton’s neuroma. A common site is the

92. Conti…
 The physical examination
 Examination sequence
Ask patients to remove their socks and shoes
 Look?
 Feel?
 Move
 Special tests
 Achilles tendon??
 Thomson’s (Simmond’s) test?????
 Mulder’s sign for Morton’s neuroma????

94. Fractures, dislocations and
trauma
 A fracture is a breach in the structural integrity of
a bone. This may arise in:
 normal bone from excessive force
 normal bone from repetitive load-bearing activity
(stress fracture)
 bone of abnormal structure (pathological fracture,)
with minimal or no trauma
 The epidemiology of fractures varies
geographically. There is an epidemic of
osteoporotic fractures because of increasing
elderly populations. Although any osteoporotic
bone can fracture, common sites are the distal
radius, neck of femur, proximal humerus and
spinal vertebrae

96. Conti…
 Fractures resulting from road traffic accidents and
falls are decreasing because of legislative and
preventive measures such as seat belts, air bags
and improved roads
 The history
 Establish the mechanism of injury. For example, a
patient who has fallen from a height on to their
heels may have obvious fractures of the calcaneal
bones in their ankles but is also at risk of fractures
of the proximal femur, pelvis and vertebral column

97. Conti…
 The physical examination
 Use the ‘Look – feel – move’ approach. Observe
patients closely to see if they move the affected part
and are able to weight-bear
 Examination sequence
 Look
 See if the skin is intact. If there is a breach in the skin and
the wound communicates with the fracture, the fracture is
open or compound; otherwise it is closed.
 Look for associated bruising, deformity, swelling or wound
infection

98. Conti…
 Feel
 Gently feel for local tenderness.
 Feel distal to the suspected fracture to establish if
sensation and pulses are present.
 Move
 Establish whether the patient can move joints distal and
proximal to the fracture.
 Do not move a fracture site to see if crepitus is present;
this causes additional pain and bleeding
 Describe the fracture according to. For each
suspected fracture, X-ray two views (at least) at
perpendicular planes of the affected bone, and
include the joints above and below

100. Investigations
 Common investigations in patients with
musculoskeletal disease are summarised in box