TheThe Locomotor SystemLocomotor System

Daniel Eshetu

Includes the Includes the bones, muscles, tendons bones, muscles, tendons andand ligaments ligaments – the skeletal system and – the skeletal system and all that makes it moveall that makes it move

The art and science of the The art and science of the DiagnosisDiagnosis and and TreatmentTreatment of all the disorders of the of all the disorders of the human locomotor system – human locomotor system –

OrthopaedicsOrthopaedics

The LocomotorThe Locomotor SystemSystem

The word Orthopaedics was The word Orthopaedics was coined by coined by Nicolas AndryNicolas Andry, a , a physician in Paris, in the year physician in Paris, in the year 1741 derived from two Greek 1741 derived from two Greek words words

‘‘OrthosOrthos’ meaning ’ meaning straightstraight ‘‘PaediosPaedios’ meaning ’ meaning childchild

Some of the conditions that affect these Some of the conditions that affect these structures are :-structures are :-

1.1. Congenital and developmental Congenital and developmental abnormalitiesabnormalities

2.2. Infection and inflammationInfection and inflammation

3.3. Arthritis and Rheumatic disordersArthritis and Rheumatic disorders

4.4. Metabolic and endocrine disordersMetabolic and endocrine disorders

5.5. Tumours and lesions that mimic themTumours and lesions that mimic them

6.6. Sensory disturbances and muscle Sensory disturbances and muscle weaknessweakness

7.7. Injury and mechanical derangementInjury and mechanical derangement

Diagnosis in OrthopaedicsDiagnosis in Orthopaedics

As in all of medicineAs in all of medicine, , is the is the identification of identification of

disease/disorderdisease/disorder having a picture ofhaving a picture of

• the the pathological processpathological process • the the functional lossfunctional loss • the the disabilitydisability that goes with it. that goes with it.

Clinical examinationClinical examination Follows the same principle as Follows the same principle as

applicable in general surgical applicable in general surgical casescases

Careful history taking and then Careful history taking and then physical examination is performedphysical examination is performed

Physical examination basically Physical examination basically can be broken into can be broken into observation of observation of gaitgait and and trunk deformitiestrunk deformities and and examination of the individual examination of the individual jointsjoints and and musclesmuscles

HistoryHistory It should be systematicIt should be systematic If carefully and patiently compiled, it can be very If carefully and patiently compiled, it can be very

informative as examination and laboratory tests.informative as examination and laboratory tests. history of history of trauma, fevertrauma, fever, and , and previous illnessesprevious illnesses

and and treatments (Past medical & surgical history)treatments (Past medical & surgical history) Family HistoryFamily History Social backgroundSocial background –occupation, travel, –occupation, travel,

recreation, home circumstances the level of recreation, home circumstances the level of support from a family and friendssupport from a family and friends

Obstetrics historyObstetrics history Growth & developmental historyGrowth & developmental history Immunization statusImmunization status etcetc

Common presenting complaints in Common presenting complaints in OrthopaedicsOrthopaedics

Injury,Injury, Pain, Pain, Stiffness, Stiffness, Swelling, Swelling, Deformity, Deformity,

Instability, Instability, Weakness, Weakness, Altered Altered

sensibility, and sensibility, and Loss of functionLoss of function

Pain most common symptommost common symptom What What character?character?

Throbbing –(abscess)Throbbing –(abscess) Aching – (chronic arthritis)Aching – (chronic arthritis) Burning – (neuralgia)Burning – (neuralgia) Stabbing – (ruptured tendon)Stabbing – (ruptured tendon)

SiteSite – ask the patient to – ask the patient to point to where it hurts; point to where it hurts; not merely to tell us ( the not merely to tell us ( the site of pain is not always site of pain is not always the site of the pathology)the site of the pathology)

RadiationRadiation

severityseverity GradeGrade I I (mild) (mild) – that can be – that can be

easily ignoredeasily ignored GradeGrade IIII (Moderate) (Moderate) - that - that

cannot be easily ignored, cannot be easily ignored, interferes with function and interferes with function and needs treatment from time needs treatment from time to timeto time

GradeGrade IIIIII (severe) (severe) – pain – pain that is present most of the that is present most of the time, demanding constant time, demanding constant attention.attention.

GradeGrade IVIV (excruciating) (excruciating) - - totally incapacitatingtotally incapacitating

Stiffness Localized/GeneralizedLocalized/Generalized When it occursWhen it occurs Verify painful movements Verify painful movements

and lockingand locking

Swelling Site – soft tissues Joint or Site – soft tissues Joint or

bonebone Dose it appear following Dose it appear following

an injury?an injury? Appeared rapidly or Appeared rapidly or

slowlyslowly Associated pain?Associated pain? Whether it is constant or Whether it is constant or

comes and goes comes and goes Continuing to enlargeContinuing to enlarge

Deformity Round shoulders Round shoulders Spinal curvatureSpinal curvature Knock kneesKnock knees Bow legsBow legs Some are variations of Some are variations of the normalthe normal

Weakness Generalized/confineGeneralized/confine

d to one limb or to a d to one limb or to a single muscle groupsingle muscle group

Instability Patient complain of a Patient complain of a

joint joint giving waygiving way Ligamentous deficiency Ligamentous deficiency

or to ligamentous or to ligamentous deficiency from laxity or deficiency from laxity or rupturerupture

Change in sensibilityIts exact distributionIts exact distributionWhat triggers itWhat triggers it

Loss of functionIs more than the sum of Is more than the sum of individual symptoms and its individual symptoms and its expression depends upon the expression depends upon the needs of the patientneeds of the patient

ExaminationExamination

Begins from the moment we set eyes on the Begins from the moment we set eyes on the patient – patient – general appearance, posturegeneral appearance, posture and and gaitgait

Walk freely?, use stick?, are they in pain?, do Walk freely?, use stick?, are they in pain?, do their movements look natural?, characteristic their movements look natural?, characteristic facies ?, spinal curvature?, A short limb?facies ?, spinal curvature?, A short limb?

The routine is – The routine is – examine the good limb, then the bad.examine the good limb, then the bad.

LOOKLOOK FEELFEEL MOVEMOVE

Gait cycleGait cycle Stance Phase (60%)Stance Phase (60%)

Heel strikeHeel strike Foot flatFoot flat MidstanceMidstance Push-ofPush-of

Swing Phase (40%)Swing Phase (40%) AccelerationAcceleration MidswingMidswing DecelerationDeceleration

LOOKLOOK

Antalgic / painful Hip Antalgic / painful Hip gaitgait

Stiff hip GaitStiff hip Gait Unstable hip gaitUnstable hip gait

Trendelenberg gaitTrendelenberg gait Gluteus medeius gaitGluteus medeius gait

Gluteus Maximus gaitGluteus Maximus gait Quadriceps gaitQuadriceps gait High stepping gaitHigh stepping gait Short leg gaitShort leg gait Scissoring gaitScissoring gait

LOOKLOOK

Types of gaitTypes of gait

Skin – scars & colour changes, Skin – scars & colour changes, abnormal creasesabnormal creases

Shape – swelling, wasting or is Shape – swelling, wasting or is there a definite lumpthere a definite lump

Position – see for a deformity in Position – see for a deformity in three planesthree planes

LOOKLOOK

Terminology of deformityTerminology of deformity Varus / ValgusVarus / Valgus Kyphosis / LordosisKyphosis / Lordosis ScoliosisScoliosis EquinosEquinos CalcaneousCalcaneous CavusCavus Etc.Etc.

FEELFEEL

Skin – Warm / cold, moist / dry, Skin – Warm / cold, moist / dry, sensationsensation

Soft tissues – lump, its Soft tissues – lump, its characteristics, pulsescharacteristics, pulses

Bones & Joints – outline normal?, Bones & Joints – outline normal?, Synovium thickened? Excessive Synovium thickened? Excessive joint fluidjoint fluid

Tenderness – feeling for Tenderness – feeling for tenderness keep your eyes on the tenderness keep your eyes on the patients face patients face

MOVEMOVE

Movement comprisesMovement comprises ActiveActive – degree of – degree of

mobility and mobility and whether it is painful whether it is painful or not, to assess or not, to assess muscle powermuscle power

PassivePassive Abnormal or Abnormal or

UnstableUnstable

Geniometers

Inclinometer

Terminology of movementTerminology of movement

Flexion / ExtensionFlexion / Extension Adduction / AbductionAdduction / Abduction External Rotation / Internal RotationExternal Rotation / Internal Rotation Pronation / SupinationPronation / Supination CircumductionCircumduction OppositionOpposition Inversion / EversionInversion / Eversion Lateral flexion and rotation – (spine)Lateral flexion and rotation – (spine)

ShoulderShoulder

ElbowElbow

The elbow flexes from 300 to 900 (300 900)

The elbow has a flexion contracture of 300

with further flexion to 900 (300 FC 900)

Wrist & FingersWrist & Fingers

ThumbThumb

HipHip

The hip flexes from 300 to 900 (300 900)

The hip has a flexion contracture of 300

with further flexion to 900 (300 FC W/FF 900)

HipHip

Knee & AnkleKnee & Ankle

The knee flexes from 300 to 900 (300 900)

The knee has a flexion contracture of 300 with further flexion to 900 (300 FC W/FF 900)

FootFoot

SpineSpine

Skin distraction measurement

Cervical spine

movements

Thoracic & lumbar

spine flexion

Visual estimation

SpineSpine lumbar flexion

Modified Schober test

Double inclinometer method

lumbar flexion

lumbar extension

Tape measurement of lateral bend

SpineSpine

Spine rotation

Double inclinometer method

Visual estimation of spinal rotation

MeasurementsMeasurements AlignmentAlignment

Special testsSpecial tests

FABER or Patrick's testTrendelenberg test

Anterior drawer test - Lachman test

Straight leg raise manoeuvre

Ober’s Test

Valgus stress test Varus stress test

Special testsSpecial tests

Neurological examinationNeurological examination

Look for motor Look for motor weakness and weakness and sensory deficienciessensory deficiencies

Superficial & Deep Superficial & Deep reflexesreflexes

Compare to the Compare to the contralateral sidecontralateral side

Observe color and Observe color and hair distributionhair distribution

Feel the temperature Feel the temperature of the skinof the skin

Palpate the peripheral Palpate the peripheral pulsespulses

Vascular examinationVascular examination

Muscle strength testingMuscle strength testing

Tone & PowerTone & Power

Muscle power gradingMuscle power grading Grade 0Grade 0 – no movement – no movement Grade 1Grade 1 – only a flicker – only a flicker

of movementof movement Grade 2Grade 2 – movement – movement

with gravity eliminatedwith gravity eliminated Grade 3Grade 3 – movement – movement

against gravityagainst gravity Grade 4Grade 4 – movement – movement

against resistanceagainst resistance Grade 5Grade 5 – normal power – normal power

InvestigationsInvestigations Lab. Invest.Lab. Invest.

HaematologyHaematology BiochemicalBiochemical EnzymologistEnzymologist Synovial fluid analysisSynovial fluid analysis Culture & sensitivityCulture & sensitivity

RadiographyRadiography Plain radiography - at Plain radiography - at

least two veiwsleast two veiws Contrast radiographyContrast radiography

• SinographySinography• MeyelographyMeyelography• ArthrographyArthrography

Radio Nuclede Radio Nuclede Bone scanningBone scanning

CT scan CT scan MRIMRI UltrasoundUltrasound ArthroscopyArthroscopy ElectrodiagnosisElectrodiagnosis

EMGEMG Nerve conduction testNerve conduction test

Biopsy Biopsy – – Closed / OpenClosed / Open

DiagnosisDiagnosis

History + Ph./ exam.History + Ph./ exam.

Anatomical DiagnosisAnatomical Diagnosis (Is the condition congenital, Traumatic, (Is the condition congenital, Traumatic,

Inflammatory, Degenerative or Inflammatory, Degenerative or neoplastic?)neoplastic?)

Essential investigationsEssential investigations

Pathological DiagnosisPathological Diagnosis

Clinical Clinical DiagnosisDiagnosis

Clinical DiagnosisClinical Diagnosis should not be should not be the mere identification of the the mere identification of the physical disease or disorder of a physical disease or disorder of a limb or part of the patient’s bodylimb or part of the patient’s body

A holistic approach should A holistic approach should include the recognition of the include the recognition of the patients whole condition patients whole condition including the including the psychologicalpsychological, , familyfamily and and environmental environmental relationshiprelationship which contribute to which contribute to the total health of the personthe total health of the person

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