Orthopedics & Physical Medicine

A complete history and physical examination are important in a patient with problems which may be part of localized or systemic disease. Laboratory and x-ray are usually of only supplementary help.

Physical Examination

Each involved joint should be inspected and palpated, and the range of motion measured. This usually determines the presence of joint disease and establishes whether the joint, adjacent structures, or both are involved. Involved joints should be compared with uninvolved joints or with those of the examiner. 

Joint motion is generally painful in joint disease but, may not be painful in periarticular, bone, or soft tissue disease. Swelling is an important finding. Palpation of swelling helps to (1) elicit the presence of fluid; (2) differentiate between synovial thickening, bony enlargement, or simple effusion; (3) determine whether the swelling is confined to the joint or is periarticular. 

Increased heat over the joint should be carefully localized. Many normal joints are actually cooler than adjacent skin. Crepitus may arise from joint structures or tendons. The crepitus producing motions should be determined.

Small joints near major joints may actually be the source of pain in some cases. For example, the acromioclavicular joint rather than the shoulder, the tibiofibular at the lateral aspect of the knee, or the radioulnar at the elbow may actually be the cause of pain and overlooked.

Hand

In rheumatoid arthritis (RA), the character of swelling is synovial, capsular, or soft tissue. Bony swelling occurs only in the late stages. There usually is tenderness. Of the fingers, only the distal thumb may exhibit some involvement. Involvement of the proximal fingers is usually found. Wrist involvement is commonly found. 

With osteoarthritis (OA), swelling is bony with irregular spurs. Occasionally small cysts are found. Mild or no tenderness is found except during occasional acute onset. Proximal phalangeal involvement is usually seen and distal involvement is frequent. Metacarpal involvement is rare as is wrist involvement, except in the base of the thumb.

Changes in the hand due to one disease may resemble those of other diseases. 

Elbow

Synovial swelling and thickening caused by joint disease occur in the lateral area between the radial head and olecranon, producing a bulge. Full 180° extension of the joint should be attempted. Although full extension is possible with nonarthritic or extra-articular lesions, its loss is an early change in arthritis. In tennis elbow, sharply localized pain is elicited by placing firm pressure over the lateral epicondyle.

Shoulder

Limited motion, weakness, pain, and disturbed mobility can be tested by having the patient attempt to raise both arms above the head. Careful palpation of the relaxed shoulder may identify tenderness caused by inflammation of bursae or tendons. Localization may permit aspiration and injection of a corticosteroid-lidocaine solution to relieve acute tendonitis and to confirm the diagnosis.

Foot and Ankle

The patient should stand for part of the examination. In the normal ankle joint, 15° dorsiflexion and 40° plantar flexion are possible. Swelling just below and in front of the maleoli is characteristic of synovial or intra-articular disease. Palpation of such tender swelling with pain on extension and flexion of the foot, demonstrates synovitis or the ankle joint. Pain on inversion or eversion suggests subtalor or ligament disease. Metatarsophalangeal joints are commonly swollen in RA, gout, and other diseases.

Knee

Standing and walking will make gross deformities such as swelling, quadricep muscle atrophy, and joint instability more obvious. Careful palpation in a supine patient to detect the presence of joint fluid, synovial thickening, and local tenderness is important to detect various diseases, especially arthritis. 

Full 180° extension of the knee should be attempted to detect knee flexion contractures. Lateral or medial knee bending upon leg extension will produce pain associated with cartilage or ligament tears. The patella should be tested for free, painless motion. To gauge excess knee mobility, especially lateral instability, the thigh is firmly fixed and an attempt is made to rock the relaxed, almost extended knee from side to side.

Hip

Limp may be caused by pain, shortening of the leg, flexion contracture, hip arthritis, other leg joint disease, or muscle weakness. Loss of internal rotation (usually the earliest change), flexion, extension, or abduction can usually be demonstrated. Placement of one hand on the patient's iliac crest detects pelvic movement that might be mistaken for hip movement.

Vertebral Column

Cervical and lumbar motion should be measured. The effect of movement on pain should be noted. Palpation and firm percussion over each vertebra and sacroiliac joint may elicit superficial or deep bone tenderness that should be distinguished from muscle spasm lateral to the spine. Psychogenic ("touch-me-not") reactions should be noted, as should muscular tender points typical of fibromyalgia. Chest expansion should be measured because it is typically impaired in ankylosing spondylitis.

Diagnosis

Conditions easily misinterpreted as arthritis by the patient include phlebitis, arteriosclerosis obliterans, cellulitis, edema, neuropathy, vascular compression syndromes, stiffness of Parkinson's disease, periarticular stress fractures, spinal stenosis, myositis, polymyalgia rheumatica, and fibromyositis. A tentative diagnosis is made for treatment, with other possibilities kept in mind. Systemic diseases should be considered in all atypical and undiagnosed conditions. Lyme disease and other infections should always be considered early because they may respond to specific treatment.

Certain problems require immediate attention and prompt treatment. Hemorrhagic joint fluid suggests fracture, bleeding diasthesis, or malignancy. Intensely inflammatory effusions suggest pyogenic infection, requiring immediate antibiotic therapy and aspiration or other drainage to establish the diagnosis and to prevent joint destruction.

Blood tests are useful in diagnosing some specific types of arthritis. X-rays are important in the initial evaluation of relatively localized, unexplained joint complaints to detect possible primary or metastatic tumors, osteomyelitis, bone infarctions, periarticular calcifications, or other changes in deep structures that may escape physical examination. Other useful studies include needle or surgical synovial biopsy, ultrasound, arthroscopy, arthrography, bone scanning, electromyography, nerve conduction times, thermography, and muscle or bone biopsy.

Inflammatory v. Non-Inflammatory Disease

It is important to determine if the disease is inflammatory or non-inflammatory in nature. Some ways to help determine this is:

• look for soft tissue swelling (this favors inflammatory processes).
• measurement of synovial fluid.
• compare synovial fluid and serum complement levels.

Diffuse Connective Tissue Disease

Rheumatoid Arthritis. An inflammatory disease of the synovium (joint lining) joints, potentially resulting in progressive destruction of articular and periarticular structures. Symptoms include pain, stiffness, swelling, deformity, and loss of function in the joints. It tends to be symmetrical which is a diagnostic feature. Treatment includes rest, nutrition, NSAIDS, gold compounds, corticosteroids, various slow-acting drugs, cytotoxic or immunosuppressive, exercise, physiotherapy, and surgery.

Systemic Lupus Erythematosis. A chronic inflammatory connective tissue disorder of unknown cause that can involve joints, kidneys, serous surfaces, brain, and vessel walls and that occurs predominantly in young women (90%) but also in children. Also known as lupus or SLE. Treatment for mild cases may require no treatment or aspirin, NSAIDS, antimalarials, and DHEA. More severe cases may involve corticosteroid therapy such as prednisone-immunosuppressive therapy. General medical management of complicating conditions must be provided.

Discoid Lupus Erythematosus. A chronic and recurrent disorder primarily affecting the skin and characterized by sharply circumscribed macules and plaques displaying erythema, follicular plugging scales, telangiectasia, and, atrophy. It is most common in females primarily in their 30's. Treatment includes minimizing exposure to sunlight (ultraviolet light) and the use of sunscreen. Topical corticosteroid creams and antimalarials are helpful.

Systemic Sclerosis. A chronic disease of unknown cause, characterized by diffuse fibrosis; degenerative changes; and vascular abnormalities in the skin (scleroderma), articular structures, and internal organs (especially the esophagus, GI tract, lung, heart, and kidney). It is four times more common in women than men and is relatively rare in children. No drug has significantly altered the course of this disease. 

Arthritis Associated with Spondylitis

Ankylosing spondylitis affects primarily the spine, but may cause arthritis of the hips, shoulders, and knees. The tendons and ligaments around the bones and joints become inflamed, resulting in pain and stiffness, especially in the lower back. It tends to affect late adolescents and early adults.

Osteoarthritis

Also known as degenerative joint disease, osteoarthritis is the most common type of arthritis affecting more than 20 million people. It primarily affects cartilage and occurs when cartilage begins to fray wear, and decay. In severe cases, the cartilage may wear away entirely, leaving a bone on bone joint. Symptoms of osteoarthritis include joint pain, reduced range of motion, loss of function, and disability.

Avascular Necrosis

This disease, also known as osteonecrosis, aseptic necrosis, and ischemic bone necrosis, results from a temporary or permanent loss of blood supply to the bones. Without blood, the bone tissue begins to die. This leads to collapse of the bone. If left untreated, the disease will progress leading to bone and joint collapse, pain, and arthritis. It may be caused by injury, use of steroids, or excessive alcohol use. Diagnosis is best done through MRI. Treatment involves reducing weight on the affected bone, surgery to decompress (reduce pressure) the bone core, osteotomy (surgical reshaping of bone), bone graft, or arthroplasty (joint replacement). Experimental drugs are being used as well as use of electromagnetic and/or electrical stimulation to increase the growth of new bone and vessels.

Infections of Bones and Joints
 

Infectious Arthritis. Most types of infectious arthritis is caused by bacteria, but it may also be caused by viruses or fungi. The most common bacterial agents include

• gonococcus - symptoms include fever; chills; abdominal pain in women; vaginal or penile discharge; rash which appears as a few, red rimmed, dime-sized, pus filled spots raised in the center; tendonitis; arthritis in joints, especially knees or wrists. 
• gram-positive bacteria (staphylococcus, streptococcus, pneumococcus) - symptoms include fever; redness, swelling, tenderness in a single joint; pus (yellowish-white) draining from a wound or abcess.
• gram-negative bacteria (hemophilus) - symptoms include sore throat and meningitis; more common in infants; rare in adults.
• spirochete - Borrelia causes "Lyme Disease"; comes from tick bite; symptoms usually occur about 3 weeks after a bite; early symptoms include skin rash 5-20"
  in diameter that's white in center and bright red on the outside, the center is hard and hot to touch; flu-like symptoms; joint pain and swelling; sore throat; dry cough; stiff neck; swollen glands; dizziness; light sensitivity. Untreated later symptoms include temporary facial paralysis; numbness and tingling in hands or feet; severe headaches; depression; memory lapses; poor muscle coordination; heart problems.
• tuberculosis - "TB" bacteria usually spreads slowly from the lung to a single joint.
• viral (hepatitis, mumps, mononucleosis, German measles) - usually joint inflammation lasts only 1-2 weeks, but German measles may produce an infectious arthritis lasting up to a year after the measles rash is gone.
• fungi - produced by fungi found most commonly in bird droppings, soil, and plants (roses).

Differential diagnosis of bacterial v. viral v. fungal infectious arthritis:

Osteomyelitis. Inflammation and destruction of bone caused by aerobic and anaerobic bacteria, mycobacteria, and fungi. It occurs in vertebrae and in bones of feet in patients with diabetes or at sites of bone penetration through trauma or surgery. In children, it also affects the metaphysis of the tibia or femur as well as growing bone with a rich supply of blood. Diagnosis is with laboratory, x-ray, CT scan, bone biopsy, and/or culture. Treatment is usually with broad spectrum antibiotic for gram positive and negative bacteria until culture results are available.

Crystal-Induced Conditions

Gout. This is a condition that causes severe attacks of pain, redness, and swelling of joints. Most often, the big toe is affected. It is caused by the accumulation of uric acid in the joint fluid. Uric acid is a waste product of foods that we eat. 

Tumors of Bones and Joints

Benign Tumors. These tumors enlarge slowly and do not cause danger. Some may cause fracture of bone, pain, swelling, nerve impairment, circulatory impairment, and others may carry some risk of becoming malignant. Examples include:

Malignant Tumors. These tumors are cancerous and may spread through the bloodstream. These may produce the same symptoms as benign tumors. Biopsy is important to determine if malignant or benign. Treatment of tumors is usually by excision, chemotherapy, and surgery in the form of curettage or bone grafting. Examples include:

• Ewing's sarcoma - found anywhere; very aggressive
• osteosarcoma - usually found around the knee
• leukemia (usually presents as bone pain but blood tests will confirm the diagnosis)

Osteoporosis

Osteoporosis is a decreased density of the bone. Mineralization is normal in this condition unlike osteomalacia or Rickets. There is a decrease in bone mass, often referred to as thinning of the bone. This leads to weaker bones that have a greater risk of fracture. Type I occurs in postmenopausal women and is due to estrogen deficiency. Type II occurs in both men and women and is due to aging and calcium deficiency over many years.

Unfortunately, diagnosis is often made following a fracture but can be made earlier with a test called bone densiometry is very useful in making an early diagnosis which involves x-ray. Laboratory tests are not very useful in detecting osteoporosis. 

Treatment may be through calcium replacement therapy and/or hormone replacement therapy (HRT). Calcitonin and estrogen are commonly prescribed HRT medications. 

Paget's Disease of Bone
 

Paget's disease is known as bone remodeling disease. Bone is replaced where it is not needed and old bone is removed where it is not needed. The remodeling process becomes dysregulated. The cause is not known, however, it is believed to involve a virus known as paramyxovirus nucleocapsid which has been found in the bone cells of people with Paget's disease. Symptoms include pain, swelling, and redness involving joints, and weakness of bone. 

Diagnosis is made through examination, x-rays, and laboratory studies. Abnormally high levels of alkaline phosphatase is found in lab studies. X-rays show abnormal bone deposition.

Treatment involves use of bisphosphonate drugs and the hormone calcitonin as used in osteoporosis. Sometimes surgery is necessary to correct deformities. 

Non-Articular Rheumatism
 

Spasmodic Torticollis. Involuntary tonic contractions or intermittent spasms of the neck muscles causing rotational (torticollis), lateral (laterocollis), forward (anterocollis), or backward (retrocollis) tilting of the head. The cause is unknown. Any pathologic abnormalities of the neck must be ruled out. Treatment usually involves physical therapy, EMG biofeedback, chiropractic treatment, and passive stretching. More drastic treatments may include surgery of neck muscles (sternocleidomastoid), or "botox" injections (botulinum toxin type A) into the dystonic muscles, or denervation of selected muscles. Muscle relaxants are of limited effectiveness in most cases. Psychotherapy and/or the use of psychotropic medications may be indicated in cases involving stress or possible signs of psychopathology.

Low Back Pain. Pain in the lumbar, lumbosacral, or sacroiliac region sometimes accompanied by pain radiating down one or both buttocks or legs in the distribution of the sciatic nerve (sciatica). It is multifactorial and may be related to acute sprain, strain, arthritic conditions, or numerous other possible factors. It is treated conservatively with weight reduction, exercise to strengthen back muscles, stretching, chiropractic, adjusting body mechanics ("back school"), and analgesics. Soft tissue injection of a combination of steroids and local anesthetics may alleviate inflammation and tender areas (trigger points). Injections may be in the form of nerve blocks, trigger point injections, or other techniques. Surgery may be required if pain involves herniated discs, stenosis, or other more severe factors.

Bursitis. Acute or chronic inflammation of the bursa (synovial fluid sacs).  Symptoms include pain, swelling, tenderness, and limited motion of the joint, usually the shoulder. Treatment may include rest, splinting, immobilization, NSAIDs, narcotic analgesics, pendulum exercises, steroid injections, and manipulation under anesthesia if adhesions are present.  

Tendinitis. Inflammation of a tendon and the lining of a tendon, usually occurring simultaneously. The cause is usually unknown, but may result from trauma, strain, overuse, or various diseases. Treatment may consist of rest, immobilization (splint or cast), NSAIDs, local analgesic drugs, controlled exercise, colchicine (if urate deposits are found), steroid injections, local anesthetic injections, and, rarely, surgery.

Fibromyalgia. A group of common nonarticular disorders characterized by achy pain, tenderness, and stiffness of muscles, areas of tendon insertions, and adjacent soft tissue structures. It occurs most often in women who tend to be stressed, tense, depressed, anxious, and striving, but may be found in children or adolescents. Symptoms may be exacerbated by stress. Treatment may include stress management, sleep hygiene, exercises, heat application, low dose tricyclic antidepressants, NSAIDs, trigger point injections with steroid-anesthetic agents, biofeedback, and nutritional therapy, particularly calcium-magnesium supplementation.

Other Common Orthopedic Disorders

Sprains. Sprains involve ligament injury. 

Salter-Harris Classification:

Grade I/ Minor Incomplete Tear: Ligament pain but joint is stable with no excessive movement.

Grade II/Significant Incomplete Tear: Ligament pain with noted joint instability upon examination, however an end point of movement is felt.

Grade III/Complete Tear: Ligament and muscle pain with no stability or endpoint for movement of the ruptured ligament.

Treatment may involve application of ice to reduce swelling and/or bleeding, and/or heat to promote circulation and healing. Often alternating heat and cold application is prescribed. Only in the more severe cases will casts, splints, or surgery be necessary depending on location of injury and type of activity the person must undergo.

Carpal Tunnel Syndrome. Disorder characterized by a specific pattern of numbness or weakness caused by nerve compression in the wrist. It usually involves the median nerve which passes through a rather small carpal tunnel to the thumb, index finger, middle finger, and part of the ring finger. It occurs more often in women probably because they have a smaller carpal tunnel than men. Some common causes include arthritis, fracture near the wrist, diabetes, overuse, and hypothyroidism. Treatment includes the use of a wrist splint, NSAIDs, cortisone injections, and surgery. Vitamin B6 tid in large doses has shown to be quite effective. Work modifications, especially in the case of overuse, is essential to treating and preventing CTS. 

Ganglia. Ganglion cysts occur on the hands, especially on the dorsal aspect of the wrists. They usually develop spontaneously in adult males, but may occur in females. This condition accounts for about 60% of the tumor like soft tissue swellings affecting the hand and wrists. Treatment is usually not needed as the ganglion usually goes away on its own, however, if it is tender or painful, aspiration of fluid is the most common treatment. If this fails, surgical excision may be performed. Recurrence after surgical removal is up to 50%. 

Reflex Sympathetic Dystrophy. Properly termed complex regional pain disorder, type II, RSD is pain and limited motion of the shoulder and ipsilateral involvement of the hand. Causes include trauma (crushing injury), cardiovascular insult, stroke, or certain drugs (barbiturates). Patients usually report severe pain, loss of function, burning though temperature of skin is below normal, and discoloration of skin around area injured or affected. Treatment may include nerve blocks followed by physical therapy, high dose corticosteroids, tri-cyclic antidepressants, and sometimes medications such as Tegretol or Neurontin. Temperature and EMG biofeedback are quite helpful in normalizing muscle activity and circulation in the affected area which may reduce pain and improve function. 

Fractures. Fractures (broken bones) occur because the bone is not able to support the energy placed on it. Two factors determine fractures: the energy of the event, and the strength of the bone. 

Closed fracture: Skin intact with no wound related to fracture. 

Open fracture: Open wound resulting from underlying fracture. 

Articular fracture: Involves joint surfaces; look for ligament injuries. 

Colles' fracture: Fracture of the radius 2-3 cm proximal to wrist joint with dorsal displacement. A.K.A. Silverfork fracture. 

Smith's fracture: Fracture of the radius 2-3 cm proximal to wrist joint with volar displacement. A.K.A. reverse Colles'. 

Boxer's fracture: Fracture of the fifth metatarsal.

Strain:  Sprains involve muscle and tendon injury. Like sprains, they may range from partial to complete tearing of muscle tissue. Treatment may involve application of ice to reduce swelling and/or bleeding, and/or heat to promote circulation and healing. Often alternating heat and cold application is prescribed. Only in the more severe cases will casts, splints, or surgery be necessary depending on location of injury and type of activity the person must undergo.

Review Questions:
 

1. What is the difference between strain and sprain?

2. What is the difference between rheumatoid arthritis and osteoarthritis?

3. What is the difference between a comminuted and a compound fracture?

4. List at least five possible causes of low back pain that would not require surgery.

5. What is the difference between osteoporosis and osteomyelitis?

6. How would you determine if a disease is inflammatory or non-inflammatory?

7. What is the difference between crepitus and swelling?

8. What are at least five things you would look for in an examination that might indicate something is wrong?

9. List at least five diagnostic tools you might use with a patient that has an orthopedic problem.

10. How would you properly diagnose someone with infectious arthritis?

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