Contents and specifities clinicodiagnostic examination of patients with injuries and diseases of the locomotor system

Contents and specifities clinicodiagnostic examination of patients with injuries and diseases of the locomotor system

Although orthopedics and trauma are separate subjects, they both involve the study of bones and joints. Because of this, in most study courses, they are dealt with together. The student, who wishes to acquire a working knowledge of orthopedics and trauma, must first learn the definitions and usage of a sizeable number of words or terms and phrases, virtually all of which are unique to the subjects. The second step in approaching this problem is to acquire a thorough knowledge of orthopedic examination of the patient with injuries and diseases of the locomotor apparatus.

The method of clinical examination of the patients is the same both in cases of injuries and diseases of the locomotor system. The methods of the clinical examination of patients with orthopedic injuries and diseases have some peculiarities.

At the beginning of the practical lesson much attention is paid to the general principles of the treatment. Then the students acquaint with the methods of conservative and operative treatment of the patients with injuries and diseases of the locomotor system;

With this information the following points should be noted:

·        Conservative and operative methods are widely used in the treatment of many diseases and injuries of the locomotor system. As a rule these methods are applied together.

·        The majority of these diseases and injuries may be treated successfully by conservatively.

·        The three pillars of fracture treatment are: 1) reduction of the fracture (if required); 2) support of the fracture, and the prevention of displacement (until the fracture unites); 3) mobilisation of the related joints and of the patient as early as possible.

·        In the majority of fractures and dislocations the deformity may be corrected by closed methods (e.g. manipulative reduction or continuous traction).

·        As a rule open reduction and internal fixation is indicated where a fracture cannot be reduced by closed methods.

·        Unstable fractures in the adult are usually best treated by operative methods.

·        Both conservative and operative methods of treatment may cause potential complications. Great care must be taken to avoid risk of any complication whether early or late.

·        Careful currying-out of the methods and technique of the conservative and operative treatment is necessary in order to achieve a higher quality of reduction and fixation of the fractures.

 

 and to the actual problems of these injuries, general principles of diagnosis and treatment. Then the students acquaint with the patients and the methods of conservative and operative treatment.

These methods are carried out in strict order.

1.     Questioning the patient: a) the patient’s complaints; b) the orthopedic history) the life history (the family history).

2.     General examination.

3.     Determination and measuring of the joint movements and measuring of the length of the extremities.

4.     Palpation.

5.     Percussion.

6.     Auscultation.

7.     Determination of the muscular strength.

8.     Determination of functional disorders.

9.     Additional methods of investigations.

 

Complaints

The patient’s complaints usually determine the proper direction of further examination.

Often the orthopaedic patients have troubles such as pain, deformity of the extremity or spine column, disorders of function.

In all cases during questioning the patients much attention is given to condition of different systems and the principle inner organs (the heart, the lungs, the stomach etc).

The trauma patients with combined or multiple orthopaedic injuries usually complain about more painful damage, but some painless and more severe injury is often located in another region of the body (ruptures of inner organs, concealed internal bleeding). Therefore violation of the scheme of the examination causes the mistakes in diagnosis and serious complications.

It is necessary to separate main and secondary complaints in orthopedic patients.

Case history

In case of the othopedic injury you must determine exact date and time when the accident has been happened. The determination of the circumstance and the mechanisms of the injury are very important in making a correct diagnose.

In taking the history of a trauma patient who may have a fracture, the following points may prove to be helpful, especially when there has been a traumatic incident.

1. What activity was being pursued at the time of the incident? (e.g. taking part in a sport, driving a car, working at a height, etc.);

2. What was the nature of the incident? (e.g. a kick, a fall, a twisting injury, etc.);

3. What was the magnitude of the applied forces? (e.g. if a patient was injured in a fall, it is helpful to know how far he fell, if his fall was broken, the nature of the surface on which he landed; trivial violence may lead one to suspect a pathological fracture: severe violence makes the exclusion of multiple injuries particularly important.);

4. What was the point of impact and the direction of the applied forces? In reducing a fracture, one of the principle methods employed is to reduplicate the causal forces in a reverse direction. If a fracture occurs close to the point of impact, additional remotely situated fractures must be excluded;

5. Is there any significance to be attached to the incident itself? (For example, if there was a fall, was it precipitated by some underlying medical condition, such as a hypertensive attack, which requires separate investigation?);

6. Where is the site of any pain, and what is its severity?

7. Is there loss of functional activity? For example, walking is seldom possible after any fracture of the femur or tibia; inability to weight bear after an accident is of great significance.

Then it is necessary to find out what kind of the first aid (immobilization, etc) and transportation has been used because some complications may be follows this injury or these wrong actions (dislocation of fragmented fractures, lesions of the nerve trunks, the blood vessels, the spinal cod injuries, etc). The patient’s condition during transportation should be recorded in the case history.

During the examination of the orthopedic patient with the inflammatory or degenerative dystrophic lesions of the locomotor system the following questions are determined:

1.        the beginning of the disease (sudden or slow);

2.        how long the disease has been continued;

3.        character of the process (acute or chronic, mild or severe);

4.        what kind of treatment has been used;

5.        the result of the treatment (satisfactory, excellent, good).

In case of orthopedic congenital deformities during the questioning of the patient’s relatives (the patient’s mother) is determining the course of the pregnancy, the character of the child’s birth (normal or pathologic), when the deformity was founded and what kind of treatment has been used.

In case of orthopedic static deformities (for example, platyspodia, scoliosis) the following questions are determined:

1.        when the deformity appeared;

2.        the degree of the deformity;

3.        when the first signs of the deformity appeared;

4.        what kind of treatment has been used;

5.        using the orthopaedic devices by the patient.

Life history (family history)

History - taking is not just a way of killing time before writing up an x-ray form. It makes the diagnosis more often than does examination or x-ray alone. A complete history would be very boring, but it is important to include developmental and family histories.

The thorough questioning enables to determine the influence of the environment on the cause and the course of the disease (the trauma). In order to examine the patient you are to find out the living conditions of the patient, the conditions of his work, his direct or indirect contacts with the similar patients, the patient’s habits, etc.

General examination

The orthopedic patient should be examined in the light room. He must be bared enough. Certainly the students have to make the comparative examination of the patient’s extremities and the parts of his trunk.

First it is certain to look for position of the patient (active, passive or enforced), look for the shape of the body of the patient (if the patient holds his body upright or there is a stooping position of the body).

In cases of orthopedic injuries or some diseases the normal structure and function of the patient’s extremities or his trunk are harmed or weakened.

Then it is certain to look for posture of the patient. Posture can be defined as the position of the body at any given time when not recumbent (lying down).

Good posture while standing demands that much of the vertebral column and long axes of the bones of the lower extremity be fairly straight with reference to a line passing from the mastoid process to the floor. In a person of average weight, this represents the line of gravity of the body. Such a line passes through most of the cervical and lumbar vertebrae, just posterior to the centre of the hip joints, and slightly anterior to the centre of the knee and ankle joints. In this position, each of the weight-bearing bones and joints can more effectively contribute to the efficient support of the body. In good standing posture, there is equal pressure on the weight-bearing joint cartilages, including the intervertebral discs.

There are following main types of the postural abnormalities:

1. Flatback (the spinal kyphosis and lordosis are decreased, the neck is elongated, the spine is flexible, anterior pelvic tilt is increased).

2. Swayback (the spinal kyphosis and lordosis are increased, the head is bended toward).

3 Roundback Deformity (increased thoracic kyphosis) includes not only rounded thoracic spine but also rounded shoulders, increased lordosis (gooseneck), anterior pelvic tilt.

4. Habit Scoliosis (a lateral deformity of the spine column, spinal kyphosis and lordosis are normal).

Classically, children with a history of poor posture present in juvenile or adolescence period (i.e. between the ages of 10 and 15 years). These forms of posture are initially flexible and may be corrected easily. In the late juvenile period, certain children who are initially flexible begin to lose spine flexibility and develop hamstring tightness. That is why the clinical exam should include a test for flexibility (can they passively correct the deformation?) and a test of hamstring tightness (inches lacking in attempting to reach the floor with forward bend). Standing X–rays should be required in some cases.

Begins by inspecting the limb most carefully, comparing one side with the other. Look for any asymmetry of contour. Sometimes varus or valgus, antecurvation or recurvatium deformity may be determined. While examining the patient the students are to determine the shape and axis of the extremity and to find out the type and degree of deformity.

The normal axis of the upper extremity passes through three points. These points are the centers of the heads of the humoral, radial and ulnar bones.

The normal axis of the lower extremity connects three points too. These points are the spina iliaca anterior superior, the center of the kneecap and first toe of the foot. In cases of fractures or some diseases these axis may be curved.

The angular deformity that appears at some angle to the external side is called valgus deformity. The angular deformation that appears at some angle to the internal side is called varus deformity.

  

 

             

 

              norma                       valgus deformity          varus deformity

If the angle of the deformity is opened toward this type of deformity is called recurvation. Іf the angel is opened backward this type of deformity is called antecurvation deformity.

Bilateral angular (O-like or X-like) deformity of the lower extremities may occur in some cases, for example, rachitis.

Measurement

Clinical measurement of the length of the limbs is following.

Leg or arm length discrepancy may be found among the most characteristic symptoms. Many injuries of the bones and impairments of the joints begin with this symptom. Sometimes it occurs in cases of congenital underdevelopment of the limbs. In these cases it is necessary to find out the length of the limb and clinical measurement should be done to determine the exact data.

Types of limb length discrepancy (LLD):

1. Real (anatomic) LLD may occur due to fracture or congenital anomalies (for example, bone dysplasia, hemihypertrophy, etc). In these cases one leg or arm grows faster than the other.

2. Apparent LLD is due to telescoping of the hip or humerus resulting from dislocation.

3. Positional LLD is due to an adduction contracture or fixed flexion at the knee or hip. In these cases the limb is shortened. The abduction contracture can make the limb surprising longer.

4. Mixed LLD is the total sum of all before mentioned types of LLD.

Techniques of measurement

Clinical measurement should be done in several different ways to avoid error. There are following methods of clinical measurement may be used. (each of these methods gives a slightly different value):

1.     Comparement the length of the limbs.

2.     The block method.

3.     Measurement with a metric ribbon.

4.     Radiographic methods.

Following anatomic points are usually used to carry out of measurement with the metric ribbon (Table 1).

Table 1

 

№	Name of the limb or its segment and length of the limb	Anatomic points		Comment
		Proximal	Distal
1	2	3	4	5
1	Upper limb (total length)	The edge of the acromial process	The apex of the styloid process of the ulna	The arm is completely extended in the elbow
1	2	3	4	5
2.	Brachium (total length)	The edge of the acromial process	The apex of the styloid process of the ulna	The forearm is flexed at right angel in the elbow
3.	Brachium (anatomic length)	Greater tubercle of the humerus	Lateral epicondyle of the humerus	–
4.	Superbrachium (total length)	Insisure of the breast bone	The edge of the acromial process	–
5.	Forearm (anatomic length)	The apex of the tip of the elbow	The apex of the styloid process of the ulna	The forearm is flexed at right angel in the elbow
6.	Lower limb (total length)	Spina iliaca anterior superior	The apex of the medial malleolus	The lower limb is completely extended
7.	Femur and hip joint (total length)	Spina iliaca anterior superior	Joint line on the medial side of the knee	–
8.	Femur (anatomic length)	The apex of the greater trochanther	Joint line on the lateral side of the knee	–
9.	Crus (anatomic length)	Joint line on the medial side of the knee	The apex of the medial malleolus	–

 

     

     

 

Clinical examination of the range of movements in joints

The movement produced by the action of skeletal muscles of the body of the patient is called an “active movement”.

Joint movements may be restricted as a result of trauma or diseases (for example, osteo-arthritis). In some cases the pathological process leads to weakness of skeletal muscles. In a number of these cases there is neurological disturbance occurring immediately after fractures or dislocations. When there is a nerve palsy the limb may be immobile.

In this case the movements should be examined passively and assisted “passive movements” will be required. The examiner’s goal is to gently adduct, abduct, flex, and extend the patient’s limb in its joints is an attempt to demonstrate mobility.

The special instruments (the goniometer and rotatometer) are used to determine a range of the movements in the joints. The value of the angel is determined when the limb is completely flexed and extended in the joints. For example, the maximal flexion in the joint is 135° and the maximal extension is 20°. In this case the range of the movements in the joint is 135° – 20° = 115°.

 

 

   

 

There are three degrees of joint stiffness:

1.     Ankylosis (all types of the movements are absent);

2.     Contracture (there is visible limitation of the movements);

3.     Regidity (the range of the movements in the joint is less than 5°).

 It is necessary to record regularly the findings of the clinical measurement. It should be done during the all course of the treatment.

Palpation, percussion, auscultation

By means of these methods the wide range of the symptoms may be determined.

The impairment of the lungs, hurt and other inner organs especially in cases of their combined injuries are determined. The sharp edge of a fracture may be palpable. Note also the presence of localised oedema. This is a particularly useful sign over hairline and stress fractures. A tender area, vascular pulsation, crepitating are may be determined too.

Determination of the muscular strength

Impairment of the muscular strength is caused by paralysis, the injury of the muscles, nerves, and some diseases, for example, Little’s disease.

The muscular strength can be determined in various ways.

Subjective method: the patient is proposed to make some type of the movement in his joint, the doctor himselves makes forced resistance with his arm which acts in opposition to this movement.

There are following levels of muscular strength may be determined:

Þ              5 points (excellent);

Þ              4 points (good);

Þ              3 points (satisfactory);

Þ              2 points (unsatisfactory);

Þ              1 point (the separate muscular contractions are hardly determined);

Þ              0 (any muscular contractions are absent).

Objective examination of the muscular strength can be determined with the muscular dynamometer.

Determination of the function

A thorough clinical examination of the function of the locomotor apparatus is always of great importance in making a correct diagnosis. To examine the patient the students are to pay attention to the gait of the patient and his movements and adaptions.

There are following typical disorders of the human gait may be determined (Table 2).

                                                                                                             Table 2

The types of the gait	The typical impairments
Halting gait	Shortening of the lower extremity, the pain in the lower extremity
Saltatory gait	Stretching of the lower extremity, ankylosis, pes equinoexcavatus
Waddling gait	Developmental dislocation of both hips
Swaying gait	O-like or X-like deformations of the lower extremities
Spastic gait	Spastic paraparesis
Paralytic gait	Paralytic paraparesis

 

     

Real (anatomic) LLD

Apparent LLD is due to telescoping of the hip or humerus resulting from dislocation.

Positional LLD is due to an adduction contracture or fixed flexion at the knee or hip. In these cases the limb is shortened. The abduction contracture can make the limb surprising longer

Mixed LLD is the total sum of all before mentioned types of LLD.

 

 

Additional methods of examination

The additional methods of the clinical examination and all necessary analyses will show the truth diagnosis.

These methods and analyses are:

–                   X-ray examination (roentgenography, roentgenoscopy);

–                   Computer tomography;

–                   Magnetic resonance;

–                   Surgical examination (arthroscopy, biopsy, puncture of the cavity of the joints, lumbar punction, etc);

–                   Laboratory examination (total blood count, blood sedimentation test, urinalysis, microscopic analysis, etc);

–                   Electrodiagnosis (electrocardiography, electromyography, etc).

Roentgenography is more available method of diagnosis. During this examination the students are to pay attention to:

–       shape of the bones a joints;

–       contour of the cortical bone;

–       site of the articular ends of the bones;

–       structure of the spongy bone;

–       shape of the joints line;

–       state of the bone’s cartilage and its ossification;

–       structure of the soft tissues.

The main methods in the treatment of the patients with injuries and diseases of the locomotor system

SPLINTING IN ORTHOPAEDIC PRACTICE

Splinting of a limb is one of the very common procedures adopted in the
treatment of orthopaedic conditions. Splints are used for various purposes as
given below.                                                      

1.  To provide absolute rest to a limb:

 a). As first aid to a fractured limb. This relieves the pain and the immo­bilisation prevents complications due to movement of the fragments.

b). As a regular treatment after reducing a fracture by the application of plaster splint as a slab or cast.

c). To give rest to an inflammed joint to relieve pain as in the treatment of arthritis e.g. Thomas splint for arthritis of the hip or knee.

d). Post operative splints. Splints are applied after operations on limbs and joints to maintain correct position and relieve pain.

2.      To stabilise a joint, that has become unstable due to paralysis of the muscles controlling the joint e.g. Full leg (Hip, Knee, Ankle, Foot) and Below knee (Ankle, Foot) orthotic appliances (Caliper) are used to stabilise the leg and enable the patient to walk.

3.      To correct deformity: Splints are used to correct certain deformities and also to maintain the correction of some deformities e.g. Genu valgum in chil­dren. This could be corrected in moderate cases, by splinting with an appliance with long outside bar and knee straps.

4. To prevent over stretching of paralysed muscles e.g. a) Cock up rigid splint b) Dynamic or Lively splint in wrist drop. In fhe case of temporary wrist drop, a cock up splint is applied to keep the wrist in extended position so that the extensors are not overstretched. The disadvantage of this is that it totally immobilises the normal muscles and the joints. Dynamic or lively splint allows flexion movements of the joint by the unparalysed wrist flexors.

Materials used in Splints

Splints can be made out of metals like iron and aluminium or materials like leather, plastic and wooden planks. The most common material in use is the plaster of paris. More recently inflatable bags are being used to splint injured limbs as first aid splints in road traffic accidents. These are radio translucent and light. They also prevent shock by preventing edema and haemorrhage.

TRACTION PROCEDURES

Traction has been used since Hippocratic times for the reduction of frac­tures and dislocations. Traction and counter traction still form the basis of reduction of fractures and dislocations under anaesthesia. This is a traction of short duration.                 

There are two types of long duration tractions.                           

1.  Continuous traction

2.Intermittent traction

Continuous (sustained) traction. This is the traction applied over a period of few days or weeks. This is necessary in the management of many conditions as given below.

1. To maintain reduction of a fracture till the fragments are stable e.g.
Fracture shaft of femur.

2.    Correction of a deformity due to muscle spasm e.g. skin traction used in
the treatment of early stages of arthritis of the hip.

3.    To immobilise an inflammed joint e.g. septic or tuberculous knee.

4.    Spine: Cervical traction for reduction of cervical fracture dislocations
e.g. skull traction.

Intermittent Traction. This is the repeated application of traction of short duration of a few minutes to a few hours.

a)    Cervical traction — for Cervical disc lesion and spondylosis with root
compression using Cervical traction kit.

b)   Pelvic traction — for Lumbar I.V.D. Lesion using Pelvic traction kit.

Types of Traction techniques

1. Skin Traction e.g. Lower limb traction with the leg pulled by holding the skin of the whole leg with adhesive plaster as in the                    following methods. 

a)Thomas' splint traction.

b)Gallows traction.                                                                          

c)Russel traction.                                                                 
2.      Skeletal traction (Pin traction)                                              
Here the leg is pulled by a pin through the bone. Common types are:

a)  Upper tibial traction with Steinmann pin Upper tibial pin traction is applied by passing a  Steinmann's pin  across the         tibia   1/2"   below   the   tibial   tubercle

b) Lower femoral traction with Steinmann pin passed across the femur above       the. Gallows traction level of the condyles.

c)  Lower tibial/calcaneal traction

d)Olecranon traction with K wire

e)  Skull traction

Principles of Traction                                                          

The methods of traction are based   on   two   principles   described below.    

1. Fixed Traction                 

In this method, traction is applied to the leg against a fixed                point of counter pressure. This is done   by   the   use   of Thomas splint. The ring of the splint is made to hitch against the ischial tuberosity which acts as the point of counter pressure in the perineum.

2.  Balanced Traction

In this method, while traction is applied to the leg to pull the distal frag­ment downward, the counter traction is effected by the body weight itself. This is achieved by resting the leg on a Thomas or Bonier Braun splint and raising the foot end of the bed. The lee is pulled either by skin traction or skeletal traction.                        

2a. Russel Traction                                                  

This is a type of balanced traction where there is no splint. The leg is held off the bed with a sling at the knee level and resting on a pillow   under  the   calf.   With   a compound system of pulleys and an overhead beam,  below knee skin    traction    is    applied    and weights are hung at the end of the                                                         

MATERIALS IN ORTHOPAEDIC SURGERY

GENERAL

Expansion of knowledge and developments in various physical, material and other sciences has contributed a great deal to the development of medical sciences in general and orthopaedics in particular. The massive explosion of knowledge in recent decades in material sciences has helped the orthopaedic surgeons to use the newer alloys and other materials like polyester as surgical implants. Such materials are being increasingly used for internal fixation of fractures, replacement of joints and filling up of gaps and defects in the bones.

Such materials should be biologically compatible with the human tissues and should be physically, electrically and chemically inert so as not to cause reactions in the tissues.

They must also be strong enough to withstand the biomechanical stresses and strains as well as the cyclical loading of weight bearing, torsion and mo­tion. The materials could be grouped into 1) Metals and 2) Non metals.

1. Metals

Metals have traditionally been the material of choice for restoring continu- , ity of bones and replacement of skeletal parts. The metals used must satisfy certain standards of composition, yield strength, tensile strength and fatigue strength which have been laid down by institutions like the International Stan­dards Institute, Bureau of Indian Standards (BIS), British Standards Institute and the American Society for Testing and Materials (ASTM).

Generally metals of the following 3 types are being used for making Or­thopaedic implants.

a)  Iron based alloys e.g. Stainless steel.

b)  Cobalt based alloys e.g. Vitallium.

c)   Titanium based alloys.

1. Stainless Steel alloys

The composition of the commonly used 18-8-S M O surgical stainless steel. is approximately as follows.

2. Cobalt alloys

These are Chromium Nickel alloys with Cobalt as the main ingredient in­stead of Iron. The composition of Cobalt Chromium alloy is approximately as follows.

Chromium and Cobalt give strength and corrosion resistance to the alloys.

          3. Titanium alloys

The titanium alloy contains 90% metal is also used in its pure form.

II. Non Metallic materials

The most common Non Metallic materials used are Plastics which are usu­ally polymers. The common polymers used are:

a) Ultra High Density Polyethylene (UHDP) used in making acetabulum cups for total hip replacement.

b) Bone Cement: This consists of Polymethyl Methacrylate (PMMA) with barium sulphate and a catalyst to anchor the prosthesis in joint re­placements. This is self curing. On the addition of the liquid methyl methacrylate monomer to the methyl methacrylate, the powder changes into a dough like consistency. This sets to become the bone cement with evolution of heat in about 8 to 10 minutes.

More recently biological bonding methods are being introduced to elimi­nate the use of cement.

Other materials in use are:                                                                     

a. Silicon is used for artificial interphalangeal joints, radial head etc. in
the form of silicon elastomer (Silastic).   -

b. Ceramic compounds are recently being introduced in total hip re­
placement as well as for filling cavities.

c. Carbon materials: Carbon fibre ligament prosthesis are being used in
replacing lateral ligament in the ankle.

PREVENTIVE ORTHOPAEDICS

General

Locomotor or Orthopaedic disabilities form a major group among the dis abled and handicapped population in India. Accidents, anterior poliomyelitis, infection of the bones and joints and leprosy are the most common causes of deformities leading to locomotor disabilities. The incidence of orthopaedic dis­abilities in India has been estimated at 2.0 to 2.5 percent of the population which, works out to about 20 million orthopaedically disabled persons in India. The vast majority of these disabled live in rural areas.

Prevention of Orthopaedic disabilities

The problem of the disabled population is a vast social and economic prob­lem and hence preventive measures must be planned at the community and na­tional levels. Most of the conditions causing disabilities are avoidable by mas­sive preventive measures against poliomyelitis, accidents, skeletal infections and leprosy.

While considering the management of any orthopaedic condition, the pre­ventive aspect must be given due importance and the patient and the parent of the child must be given proper health educational guidance.

Primary prevention by measures like immunisation against poliomyelitis, accident prevention in all areas like traffic, industrial and domestic must be given great importance. This will greatly reduce the load and necessity for the secondary prevention of disabilities after the occurrence of the disabling condi­tions.

Congenital conditions

Many congenital deformities and limb deficiencies are caused by intra uter­ine environmental factors during foetal life and could be prevented by avoiding   the use of teratogenic drugs and exposure to radiation by the pregnant mother. Conditions due to birth trauma and cerebral anoxia are due to inefficient peri­natal care and should be prevented by better obstetrical management.

Some of the congenital conditions are familial due to genetic factors and are common in communities where consanguinous marriages are common. The primary prevention is by genetic counselling and avoidance of consanguineous marriages. With advances in intra uterine diagnosis by aminocentesis and ul-trasonography, many gross deformities and chromosomal disorders could be diagnosed in utero. The birth of grossly deformed babies could be prevented by medical termination of the pregnancy.

Accidents

Accidents are becoming an epidemic killer disease of modem times caus­ing an enormous toll of mortality, morbidity and disability particularly amongst the younger age group.

This can be prevented by effective measures of accident prevention in the homes, and in the factories. Road traffic accidents are minimised by better road engineering, public education and enforcement of traffic rules. It also needs public education in first aid and resuscitation. Safety measures like compulsory use of crash helmets by two wheeler users and seat belts in cars are very useful in preventing serious injuries. Better organisation of the early and efficient management of the accident victim by an efficient Ambulance service, prompt first aid and immediate care reduces and prevents disabilities.

Home accidents in children are a common cause of morbidity and disabil­ity. These include falls during play, cracker accidents, bums in kitchen fines. Steps must be taken to prevent mem.

One of the common causes of fracture neck of femur in the elderly is slip­ping on the wet floor and falling in the bathroom. Senior citizens must be ad­vised to spread a dry towel in the bath room floor and step on to it to prevent slipping while drying themselves. They should not bolt the bath room door from inside. They must be encouraged to use a walking stick while walking outdoors as an additional support to prevent falling.

Anterior Poliomyelitis

With the availability of oral polio vaccine, the primary prevention of this crippling disease is becoming possible by a massive country wide immunisa­tion programme. This consists of efficient organisation of the distribution of Oral Polio Vaccine through an unbroken cold chain in storage and delivery to the children. Once the disease occurs secondary prevention of deformities is by efficient physiotherapy to minimise and even eliminate the disability.

Skeletal Tuberculosis

Control and eradication of pulmonary tuberculosis in the community will be the major programme for primary prevention of bone and joint tuberculosis and the resulting deformities. Efficient and prolonged treatment of the active disease in bones and joints will minimise the deformities and disabilities.

Deformities of Leprosy

Leprosy a common disease in India is now a curable disease. Control and eradication of leprosy on a national scale can prevent the millions of orthopae­dic complications and deformities in the hands and feet that are caused in the victims of this disease.

Nutritional Disorders

Malnutrition is still very common in the children of the weaker sections of our society. Diseases like rickets are seen frequently causing deformities in the knees like Genu valgum. Preventive measures for rickets by maternal nutrition should be started before the child is bom and continued after the birth.

GERIATRIC ORTHOPAEDICS

With the increasing life expectancy of the Indian population the proportion of elderly citizens is increasing year by year.

The management of the problems of the elderly persons is assuming greater importance. With any age beyond 70, there is a general muscular weakness and weakening of bones due to senile osteoporosis.

The orthopaedic problems of the elderly, include mainly arthritis of joints and fractures around the hip joint and generalised osteoporosis. Many of them may have history of multiple medical problems like hypertension, diabetes, coronary artery disease, chronic renal failure, cerebral vascular accidents and compromised pulmonary functions. The patients may also have visual and hearing handicaps.

The geriatric orthopaedic patient needs the full collaborative support of the geriatric physician and his team, as prolonged immobility in bed itself exacer­bates many of their problems, worsens the osteoporosis and also precipitates bed sores. It is necessary to plan early surgery when indicated as well as early ambulation and rehabilitation.

Apart from all the above physical problems, there are often psychological and emotional problems in many elderly persons. They may also have family and social problems with inadequate support and care at home from the chil­dren, particularly after the recent break up of the joint family system. Visits by social workers should be encouraged to help the patient recover their morale.

The overall aim should be to restore them to the pre injury status and help them enjoy a good quality of life.

Pre Operative Assessment of Geriatric Patient

Whether it is elective surgery for joint replacement or urgent surgery for fractures around the hip, the geriatric patient needs a thorough pre operative assessment. A thorough physical examination should be followed by assess­ment of the patient's cardio vascular status particularly if the patient gives a history of previous myocardial infarction or cardiac failure. In the case of dia­betes a reasonably good control is essential. In hypertension and diabetes a few days of treatment to stabilise the condition makes the surgery safe for the pa­tient.

If renal function is impaired as shown by the blood urea and creatine level, it should be improved with appropriate fluid and electrolytes replacement prior to surgery.

Intra operative monitoring of pulse, BP and ECG is very useful to alert the anaesthetist and the surgeon.

Post Operative Management

In addition to the general maintenance of B.P., pulse etc and preventing hypovolumic shock, electrolyte balance is very important in the elderly pa-v    tients.

One of the important complications in the elderly patient is upper Gastroin­testinal bleeding due to anaesthetic gas irritation. Nasogastric tube is put in place and prophylactic ranitidine is given. The patient must be made to sit up and even ambulate in a few days.

Nursing care                             

In the care of the geriatric patient, nurses must not only be highly professionalised but also take extra care and concern. Every attempt must be made to prevent bed sores by change of position and local massage over pressure areas.

Physiotherapy

In addition to good nursing, geriatric patients need efficient physiotherapy. Active exercises to the uninjured limbs, quadriceps exercises in bed and breathing exercises are very essential.

In the male, prostatic hypertrophy may precipitate retention of urine. A catheter is kept in place for the first one or two days after operation. Inconti­nence of urine is very common among the elderly female and it can cause wet­ting of the sacral skin and bed sores. This must be prevented by an indwelling catheter.

Infection of the wound, the lungs or the urinary tract often cause serious morbidity and mortality in the geriatric patient. This must be prevented by providing an antibiotic cover for all elderly patients by broad spectrum antibi­otics. Blood replacement must be arranged to prevent hypovolumic shock. A fluid intake output chart must be maintained and-the 24 hours urinary output—_ should be kept around 1500 cc.

In the case of fractures, the patient must be assured that even in old age the fracture unite normally although the bone breaks easily.

Common trauma problems in the elderly

1. Fractures around the Hip

a. Trancervical fractures

b. Trochanteric fractures

2. Fractures around the shoulder

a. Fracture neck of humerus

3.      Colles' fractures

4.      Pathological fractures

 

Common Orthopaedic Problems

1. Senile Osteoporosis, Kyphosis

2.      Low Back Pain

3.      Lumbar Spondylosis

4.      Cervical Spondylosis

5.      Osteoarthrosis knee                            

6.      Periarthritis shoulder

 

         Injures about the shoulder girdle .

Fracture of the Clavicle

This is common in all age groups, resuits from a fall on the shoulder or some times on an out-stretched hand.

Patho-anatomy:  The junction of the middle and outer third of the clavicle is the commonest site. The other common side being the outer — third of the clavicle. The fracture is usually displaced, the outer segment displaced medially and downward be cause ot the pull by the sterno chedomas toid muscle attached to it.

Clinical Feature & Diagnosis

There is a history of a trauma followed by pain swelling, crepitus etc. at the site of fracture. The patient usually supports the flexed elbow with the normal hand. The diagnosis can be confirmed on a x-ray

 

Treatment:

1)  Triangular sting is sufficient. Active shoulder exercises should be started after 10 to 14 days

2)    A figure of 8 - bandages.

 

3)          Open reduction.

MOS the fracture of the clavicula

Complicationsr

a)                   Early Complication: The fractured fragment may injure the subclavian
vessels or brachial plexus.

b)        Late Complication: Shoulder stiffness, mal-union or non-union.

Pseudoarthrosis of the clavicula after noncorectly MOS

DISLOCATION OF THE ACROMIO - CLAVICULAR JOINT

This is an uncommon injury, caused by_ fall on the prominence of the shoulder.

Path-anatomy: The injury may result in partial or complete rupture of the acromio-clavicular or coraco clavicular ligaments. Acromio clavicular joints injuries are divided into three grades depending on their severity.

Diagnosis: Pain, swelling localised to the acromio - clavicular indicates an injury to this joint. In a grade III injury the lateral end of the clavicle may be unusually prominent.

Treatment: Grade I and II injuries are treated by rest in the triangular sting and analgesics. Grade III injury in young athletic individuals is treated by sur­gical repair.

FRACTURE SCAPULA

This is very uncommon. It is mostly due to direct injury from the back. The fracture may be:

a)  Fracture neck of scapula

b)     Fracture of Body of Scapula

c)       Fracture of Acromion

d)  Fracture of coracoid

Most often the fracture is undisplaced because the fragments are held in position by the surrounding muscles.

Treatment: The mainstay of treatment is to restore shoulder mobility by active exercises as soon as the pain subsides. A triangular sting for the period of pain and swelling for 1 - 10 days.

 

With this information the following points should be noted:

Union in fractures of the clavicle is nearly always rapid and non-union is rare.

The fractured rib may puncture a lung leading to a pneumothorax. There may be rapid bleeding into the chest cavities and the formation of a haemothorax.

Only the most unstable of acromioclavicular dislocations should be considered for internal fixation.

The majority of scapular fractures may be treated successfully by a short period of rest in a sling followed by early mobilisation.

The rules of diagnosis

Having examined the orthopedic patient and having got all the subjective and objective findings it is necessary to make an initial diagnosis. This is a very important thing. As you know, the word “diagnosis” comes from Greek dia gnosis – through knowledge. Examiners should understand that early correct diagnosis of diseases and injuries of the locomotor system provides the best chance for the treating orthopedic surgeon to achieve the treatment goal and also decreases the risk for the complications. The diagnosis includes following data (Table 3):

Table 3.

Damages	It is necessary to point out
An orthopaedic inflammatory process	Character of inflammation (acute or chronic), cause of inflammation (dystrophy, arthritis, etc)
An orthopaedic injury	Pattern of the injury (closed or opened). What type of the injury is present (a fracture dislocation, contusion, wound)?
A fracture	Type of a line of the fracture (oblique, transverse, comminuted), displacement of fragments (displaced or undisplaced fracture)
A dislocation	The time when the dislocation was occurred, stages (complete dislocation or subluxation), direction of the dislocation.
Complications	A pattern of complications
Concomitant injuries and diseases	A pattern of damages