Alan Graham

Apley
1914 1996
Inspired teacher
Wise mentor
Joyful friend

Orthopaedic
Diagnosis
Apleys System of Orthopaedics and
Fractures
Section 1, Page 3 25

Orthopaedic Diagnosis

History
Symptoms
Examination
Diagnostic imaging
Blood test
Synovial fluid analysis
Bone biopsy
Arthroscopy
Electrodiagnosis

History taking
Patient may complain:
That something looks wrong (deformity, swelling, or
lump)
That something feels wrong (pain, tingling or numbness)
That movement is wrong (limp, weakness, instability or
stiffness)
Present history
Past history
Family history
Social background

Orthopaedic Diagnosis

History
Symptoms
Examination
Diagnostic imaging
Blood test
Synovial fluid analysis
Bone biopsy
Arthroscopy
Electrodiagnosis

Symptoms

Pain
Stiffness
Swelling
Deformity
Weakness
Instability
Change in sensibility
Loss of function

Pain
Grade
I : Mild
II : Moderate
III : Severe
IV : Excruciating
Type
Referred pain
Autonomic Pain

Stiffness
Where?
Generalized
Localized
When ?
Morning stiffness
Transient stiffness
Locking

Swelling

Where ?
Appear slowly ?
Appear rapidly ?
Painful ?
Constant /comes and goes ?
Continuing to enlarge?

Deformity

Common deformities
Variations of the normal
Disappear spontaneously with
growth

Weakness
Where ?
Is it confine to one limb
Is it affect a single muscle group
Discover precisely which movement
is affected

Instability
Due to:
Muscle weakness
Ligamentous deficiency
History of injury

Change in sensibility

Tingling
Numbness
Interference with nerve function
Exact the distribution
What makes it better / worse

Loss of function
Sum of individual symptoms and its
expression depends upon the needs
of the patient
What can't you do..
that you used to do..

Orthopaedic Diagnosis

History
Symptoms
Examination
Diagnostic imaging
Blood test
Synovial fluid analysis
Bone biopsy
Arthroscopy
Electrodiagnosis

Examination

Look
Feel
Move
Deformity
Neurological examination

Look

Skin
a)
b)
c)
d)

Shape
a)
b)
c)
d)

Scar
Colour changes
Oedema
Abnormal creases
Swelling
Muscle wasting
Lump
Bone bent

Position
a)
b)

Deformity
Posture

Feel
The skin
The soft
tissues
The bone
The joints
Tenderness

Move

Types
1.
2.
3.
4.

Active movement
Passive movement
Provocative movement
Unstable movement

Move

Joint stiffness
1.
2.
3.

All movement absent

All movement limited
1 or 2 movements limited

Move

Joint Laxity

Hyperektension of knee and elbow

MCP joint extending to 90 degrees
Thumb able to touch forearm

Deformity

Varus and valgus

Kyphosis and Lordosis
Scoliosis
Postural deformity
Structural deformity
Fixed deformity
Bone deformity
Joint deformity

Neurological
Examination

Appearance
Tone and power
Tendon reflexes
Superficial
reflexes
Sensibility

Appearance

Waiters tip deformity

Appearance

Wrist drop

Appearance

Muscle wasting

Tone and power

Grade 1 -5

Tendon reflexes
Upper limb

Tendon reflexes
Lower limb

Sensibility
Sensory dermatomes

Sensibility
Axillary nerve sensory distribution

Sensibility
Radial nerve sensory distribution

Sensibility
Median nerve sensory distribution

Sensibility
Ulnar nerve sensory distribution

Sensibility
Sciatic Femoral Common peroneal
Tibial
Nerve Nerve
Nerve
Nerve

Orthopaedic Diagnosis

History
Symptoms
Examination
Diagnostic imaging
Blood test
Synovial fluid analysis
Bone biopsy
Arthroscopy
Electrodiagnosis

Diagnostic Imaging

Plain film radiography

X-rays using contrast media
CT
MRI
Diagnostic ultrasound
Radionuclide imaging

X-rays

CT

MRI

Orthopaedic Diagnosis

History
Symptoms
Examination
Diagnostic imaging
Blood test
Synovial fluid analysis
Bone biopsy
Arthroscopy
Electrodiagnosis

Blood test

CRP
ESR
Leucocytes
Hypochromic anaemia
Rheumatoid Factor

Orthopaedic Diagnosis

History
Symptoms
Examination
Diagnostic imaging
Blood test
Synovial fluid analysis
Bone biopsy
Arthroscopy
Electrodiagnosis

Synovial fluid analysis

Indication :
Acute joint swelling after injury
Suspected infection
Acute synovitis in adults
Chronic synovitis

Suspected
condition

Appearanc
White
Vicosity
e
cells

Crystals

Biochemistry

Bacteri
ology

Normal

Clear
yellow

High

Few

As for
plasma

Septic
arthritis

Purulent

Low

Glocose low

TB arthritis

Turbid

Low

Glocose low

Rheumatoid
Cloudy
arthritis

Low

++

Gout

Normal ++

Urate

Normal

Pyrophosp
ate

Few

Often +

Cloudy

Pseudogout Cloudy
OA

Clear
yellow

High

Bone biopsy

Open Bone biopsy

Closed Bone biopsy

Arthroscopy

The knee
The shoulder
The wrist
The hip

Electrodiagnosis

Motor nerve conduction

Sensory nerve conduction
Electromyography

Orthopaedic Diagnosis

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