dr john trantalis. how to examine a joint look scars, alignment, wasting, redness, swelling feel...

Dr John Trantalis

How To Examine a Joint

LookScars, alignment, wasting, redness, swelling

FeelTenderness (Location!!!!!)

MoveActive movementPassive movement

Passive vs Active Motion

ACTIVE MOTIONPatient moves the

joint on their own

For active motion to be intact:The joint must be

mobile.The “motor” must

be working

PASSIVE MOTIONThe examiner moves

the joint for the patient

For passive motion to be intactThe joint must be

mobile The “motor” does not

need to be working.

“Motor”= tendon, muscle, nerve, plexus, roots, spinal cord, brain

PASSIVE vs ACTIVE motion

Loss of active MotionPreserved Passive Motion

Joint OKMotor is broken

Loss of both Active and Passive Motion

Joint Stiffness

8 yo girl Fall from monkey bars Off-ended # distal humerus

Pale handPulseless

Pre-post operative assessment after an elbow injury Arteries

Compartment syndrome

Nerve Damage

Skin etc.

Pulseless Fractured Limb

Management: Why?

The elbow joint: arteries crossing the joint Brachial artery

If damaged:6 hours till amputationWhite handNo pulsesCap Ref >2 secsPain

Super Urgent

Prevent This !!

25yo, cast applied yesterday after fracture radius : now severe pain

Xray OK position

Unable to move fingers

Sensation and pulses intact

Compartment syndrome

Only clue is PAIN

Pulses normal Cap Refill normal

Unable to move fingers

When you move them for the patient Severe PAIN !!!!

Compartment syndrome

Broken arm: should still be able to move fingers

6 hours to save the arm

Otherwise: amputation

Missed Forearm compartment syndrome: useless arm

Compartment Syndrome

Why are the Pulses normal and the Fingers Pink? Ischaemia to muscles

Capillaries 5mmHg- shut down with small rise in compartment pressue

Radial ArteryPressure of 120/80mmHg. Therefore it stays open and hand stays pink

Therefore….

Only need one thing to diagnose compartment syndrome…..

PAIN

How can we differentiate normal fracture pain from Compartment Syndrome?

Active Finger (or Toe) MovementNo compartment syndrome

What to do if you suspect Compartment Syndrome….

CALL FOR HELP!!!!!!!!!!!!Speak to the orthopaedic team urgentlyDo not leave messagesYou must speak to somebody urgently

Then…○ Remove all encircling bandages…

A tight bandage or plaster can cause compartment syndrome

But it can also occur without anything wrapped around the limb… skin & fascia

How Do We Surgically Treat Compartment SyndromeUrgent Fasciotomy (less than 6 hours)

Allows muscles to bulge out of wound and blood supply to return.

If you miss the diagnosis AMPUTATION

Clinical case 56 yo male, 24 hour h/o right

knee painNo traumaCan’t walkOtherwise well

Exam: temp 37.0C Swollen Knee (patella tap) No redness Markedly reduced ROM active

and passive

Provisional Diagnosis?Septic Arthritis

Differential Diagnosis?GoutPseudogoutHaemarthosis

Key Clinical Sign for Septic Arthritis in any Joint Decreased active and passive motion

The joint is very inflamed and painful.

Patient’s muscles spasm when movement is attempted.

The Work-Up Bloods:

FBC, EUC, CRP, ESR, UA, Cultures

ECG, MSU, fast NBM

XRAYUsually normal

Joint Aspirate

Inflammatory Markers

CRPC Reactive ProteinVery Sensitive for inflammation or infectionIndicative of what was happening in the body

1 day ago

ESRErythrocyte Sedimentation RateIndicative of what was happening in the body

3 days ago.

Joint Aspirate

Before any antibiotics are given.

Never through red skin (can introduce skin infection into the joint)

Send off for MCS, crystals, cell count.

Septic Arthritis: Treatment Joint Washout (arthroscopic)

Removes the enzymes from white cells which otherwise destroy the articular cartilage

IV antibioticsEmpirical: cover Staph Aureus

Risk Factors: Elderly, Female, Osteoporosis

One Year Mortality Rate for a Fractured NOF

30%

Within 1 year, 30% or patients who sustain a fractured NOF will pass away.

Due to comorbidities usually

Presentation Fall Can’t walk Pain in Groin

Exam: LegShortenedExternally rotated

The Work-up Xrays

Pelvis and hip

Pre-opFBC. EUC, G&HECGCXR

Fast Patient

Analgesia, Fluids, Pressure care, IDC

XRAYS

Subcapital Fracture Trochanteric Fracture

Hip Anatomy Acetabulum

Femoral head

Neck of femur

Trochanters

2 common types of Hip Fractures

Subcapital fracture

Intertrochanteric or Pertrochanteric fractures

We Treat these differently

Why treat these fractures differently?

Blood Supply to the head of femur

Disrupted with a Displaced Subcapital Fracture

Intact with a displaced trochanteric fracture

Hip Joint Capsule

The blood vessels run up through the capsule

Hence the terms:

Intracapsular # (subcapital)

Extracapsular #(trochanteric)

What are the aims of Surgical Treatment Relieve Pain

Every time patient moves in bed- pain

Regain MobilityPatient should be

able to Fully weight bear after surgery

Improve Quality of Life

Before the 1970’s3 months Traction for

everybody50% mortalityPneumonia, pressure

sores etc

The Surgery Relieves Pain Patient with # NOF in bed…The fracture ends grind

and cause pain with every movement

Even with very ill patients, we still try to complete their surgery asap to relieve their pain and improve their quality of life (nursing etc)

The faster the patient gets to surgery the less chance of pneumonia / pressure sores developing.

Subcapital Fractures: 2 typesNon-Displaced

Screws

DisplacedHip replacement

○ Half (hemiarthroplasty) ○ Total Hip Replacement

Non Displaced Subcapital Fractures

Blood supply not likely to be affected

Fix with screws and hope that it heals

Displaced Subcapital Fracture Blood supply is disrupted to

femoral head# won’t healAvascular Necrosis likely

Therefore: replace the headHalf replacement

(hemiarthroplasty)

Total Hip Replacement for the more mobile patients

Hemiarthroplasty

Total Hip Replacement

Intertrochanteric Fractures

Dynamic Hip Screw (DHS)

Short femoral NailIntertroch #

• Internally Fixed to allow early weight bearing• Plate• Nail

Post-Op Care

NV Obs Analgesia DVT prophylaxis Bloods Mobilise FWB Pressure area care

Dr John TrantalisOrthopaedic Surgeon

Dr John TrantalisOrthopaedic Surgeon

Dislocated Joints Should all be reduced ASAP

Pressure off NV structures

Pain XRAY 2 views alwaysCT if you are unsure

Beware LOC○ Trauma, Head injury Secondary survey

You will detect decreased ROM

○ Seizures, electrocution

43 yo F soccer player Painful swollen leg after tackle.

?Management

Why?

Managing The Injured Limb in ED

Managing The Injured Limb in ED

Managing the Injured Limb in ED Analgesia /

Sedation

Reduce the deformity, splint the limb

Backslabs only- NEVER apply a full POP in ED.

Managing the Injured Limb in ED

Dress the wounds

THEN… get Xrays.

Tet tox, IV antib, Fast patient

Pre-op work-up.

How do we reduce the deformity? It’s very complicated……..

JUST PULL!!

How to describe a fracture

Principles of fractures and joint injuries

Questions to ask…- Open or closed?- Which bone?- Location in bone? - Pattern of Fracture- Joint involvement?- Displaced or non-displaced?- Type of displacement?

Principles of fractures and joint injuries

How fractures are displaced

Principles of fractures and joint injuries

Direct healing - If fracture absolutely immobile, eg. Fixed with metal fracture healing occurs directly between fragments.

Principles of fractures and joint injuries

How Long Does It Take To for a Fracture to Heal?

• Depends on……• Patient Factors: Age, Comorbidities etc

• Fracture Factors: which bone, type of fracture etc

• Can take up to 6 months for a tibia versus 2 weeks for a phalanx.

• Healing seen on XRAY always takes longer than clinical union

Clinical signs of fracture Union

No tenderness, movement or crepitus at a fracture site.

The injured limb – Clinical features

Clinical Features

If you remember nothing else about examining a limb…

LOOK FEEL MOVE

Clinical Features

LookAny Swelling?Any Bruising?Any obvious Deformity?Is the skin intact?Where is the wound?And, what size is the wound?What colour is the skin?

Clinical Features

FeelTenderness

Swelling

Crepitus

Vascular and neurological examination before and after treatment

Clinical Features

MoveActive and passive movement

distal to the injuryAbsolutely criticalKnow your anatomy

The injured limb - Imaging

Clinical Features

XraysRemember the rule of 2’s!!!

○ 2 views – a fracture or dislocation may not be evident on a single film, at least 2 views mandatory – usually AP and lateral

○ 2 joints – joints above and below the fracture, eg. Monteggia/Galeazzi #’s

○ 2 limbs – in children, appearance of immature physis may confuse diagnosis of fracture

○ 2 injuries – severe force often causes trauma at more than one level, eg. Calcaneal or femur #, important to xray pelvis and spine.

○ 2 occasions – some lesions notoriously difficult to detect immediately after injury, eg. Scaphoid #

Beware Ipsilateral injuries

For any # or dislocation- always image to joint above and below

Clinical Features

Special ImagingCan’t see a # on XRAY but suspiscious eg

scaphoid○ MRI, CT, or bone scan.

CT scans useful in complex or intra-articular fractures (eg. Calcaneal, Tibial plateau)

The injured limb – Management principles

Treatment of Closed Fractures

Reduction

Putting the bone into an acceptable position

Two methods – open or closed

Treatment of closed fractures

Closed reduction

Sedation / Anaesthesia

Pull the limb into alignment

Splint the limb

Treatment of closed fractures

Closed reductionIn general, closed reduction is used

for…

○ For most fractures in children○ For fractures that are stable after

reduction and can be held in a splint or cast

Treatment of closed fractures

Open reduction○ Articular fractures – want anatomical

reduction○ Need bone to heal in perfect position;

eg. Adult forearm shaft fractures

Fracture Immobilisation

Following reduction, the available methods of holding are…

1) cast splintage2) Internal Fixation (plates, screws, nails)3) external fixation4) Traction

Fracture Immobilisation

Continuous tractionCan be applied by

○ Gravity, eg. Hanging cast○ Skin ○ Skeletal, ie. Via pin inserted into

bone

Cast splintage

Plaster of Paris commonly usedSpeed of union similar to traction, but

allows patient to go home soonerGenerally need to immobilise joint

above and below to provide stabilityHowever, joints can become stiff –

leading to “fracture disease”Functional bracing is an alternative in

some situations, allows joint movement

Internal Fixation

Types…○ Pins○ Wires○ Plate/screws○ Intramedullary nails

• Holds fracture securely, so that movement can be introduced early and “fracture disease” abolished

• ** Even though fixation provides mechanical stability, biological union can in fact be slower

External Fixation

External fixation particularly useful for:○ Fractures associated with severe soft tissue damage○ Fractures with associated nerve/vessel injury○ Severely comminuted/unstable fractures○ Non-unions – can be excised and compressed, sometimes

combined with elongation○ Pelvis fractures○ Infected fractures○ Severe multiple injuries: Provides rapid stabilisation with minimal surgery = “damage control orthopaedics”

Complications of fractures

Early Complications, including:○ Vascular injury○ Nerve injury○ Compartment syndrome○ Infection○ Fracture blisters (elevation of superficial layers of skin by

oedema)

Late Complications, including:○ Delayed/Non-union○ Malunion○ Avascular necrosis○ Growth disturbance○ Stiffness, CRPS, post traumatic osteoarthritis, etc

Complications of fractures

Common nerve injuries

○ Shoulder dislocation = axillary nerve○ Humerus shaft fracture = radial nerve○ Humerus supracondylar fracture = radial or median nerves○ Hip dislocation = sciatic nerve○ Knee dislocation = peroneal nerve

Injuries of the growth plate

Childrens bones grow longer at either end via Growth Plates.

If a Growth plate is damaged, it can result in abnormal (crooked) growth.

Complications of fractures

Delayed Union and Non Union

• Delayed union = prolonged time to fracture union

• Non Union = failure of bone to unite

Factors – multiple: Smoking increases risk 30%

Complications of fractures

Types of Non UnionHypertrophic Atrophic

Complications of fracture healing

Malunion = when fragments heal in unsatisfactory position, ie. unacceptable angulation, rotation or shortening.

Due to either…poor reduction of fracture failure to hold reductiongradual collapse of comminuted or osteoporotic

bone

Complications of fracture healing

Avascular Necrosis (AVN)

Certain fractures/injuries are notorious for their propensity to develop ischemia and subsequent bone necrosis…

1) Femoral head - #femoral neck (#NOF) or hip dislocation

2) Scaphoid – particularly with more proximal fractures, as blood supply is from distal to proximal

3) Talus – similar to scaphoid, blood supplies bone from distal to proximal, therefore body talus at risk AVN

Common Upper Limb Injuries

Common Fractures and Joint injuries

Clavicle Fractures

Common Fractures and Joint injuries

Shoulder Dislocation• most common direction = anteroinferior•Don’t forget xray rule of 2’sEg. Posterior dislocation•If unsure on AP and lateral views, then demand an axillary view!!!•Don’t forget to check axillary n.

Common Fractures and Joint injuries

Distal radius fractures• not all are Colles fractures!!•“Colles” = low energy osteoporotic fracture•“Smith’s” = reversed Colles•Radial styloid•Comminuted intra-articular fracture in young adults

Numerous different management options!!

Common Lower Limb Injuries

Common Fractures and Joint injuries

Hip fractures – “# NOFs” • generally used term to describe proximal femur fractures •Strictly = Neck of Femur (versus Intertrochanteric #)•Risk of AVN with #NOF, not intertrochanteric #•Clinically leg is shortened and externally rotated in both•Managed with either fixation or arthroplastyNeck of femur Intertrochanteric

Common Fractures and Joint injuries

Common fractures around the knee

Patella fracture

Tibial plateau fracture

Supracondylar femur fracture

Common Fractures and Joint injuries

Common foot/ankle fractures

Simple ankle fracture Calcaneus fracture

“Lisfranc” fracture/dislocationComplex “Pilon” fracture

Neck of talus fracture

“Jones” fracture

Common Paediatric Injuries

Common Fractures and Joint injuries

Common Paediatric Upper Limb Fractures

Fat pad sign

Supracondylar humerus

Lateral condyle fracture

Monteggia #/dislocation

Galeazzi #/dislocation

Common Fractures and Joint injuries

Common Paediatric Lower Limb Fractures

Avulsion fractures - tibial tuberosity and ACL

Physeal fractures around the knee and ankle

Femur # in children under 2 years – think

child abuse!!!