Rapid Orthopedic Diagnosis
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Seyed Behrooz Mostofi, FRCS (TR&Orth)
Senior Registrar in Orthopaedics
University of London
UK
ISBN 978-1-84800-208-1 e-ISBN 978-1-84800-209-8
DOI 10.1007/978-1-84800-209-8
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Control Number: 2008925046
© Springer-Verlag London Limited 2009
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To Kian and Tania Mostofi
Foreword
It is indeed a pleasure to write the foreword to this useful book
which describes the most commonly used orthopedic clinical
diagnostic tests to assist a wide audience within the medical
world.
The organization of this book is easy to follow and logical.
Each chapter begins with the patient’s initial presentation, which
is followed by an outline of the need to take account of specific
variables in arriving at a differential diagnosis. The author under-
lines the importance of using the patient’s own account as a valu-
able tool in reaching a diagnosis. Essential anatomy is included
throughout the book. For ease of reference, all the chapters are
similarly structured. Its style is simple and uncluttered, offering a
step-by-step approach and avoiding overlong explanations.
All in all, this book fulfills the criteria of a reference book, a
practical guide, and a succinct aide memoire for those preparing for
exams. It is truly a text for everyone who must conduct orthopedic
examinations, including medical students, general practitioners,
and orthopedic residents. It is an outstanding contribution to the
orthopedic literature.
Francis J. Hornicek, MD, PhD
Chief, Orthopaedic Oncology Service
Co-director, Center for Sarcoma and
Connective Tissue Oncology
Massachusetts General Hospital
Harvard Medical School
Boston, MA, USA
Foreword
Judgment – the ability to make the correct decision for the indi-
vidual patient is the hallmark of the good clinician. For the
surgeon, this is “the knowing what to do” and when to do it or
equally important “the knowing what not to do.” For the general
practitioner, it is the art of distinguishing the ill from the worried
well and knowing which patient needs specialist advice.
Good judgment derives from the ability to synthesize clinical
experience, basic knowledge, and clinical diagnosis (i.e. the his-
tory and signs) with the interpretation of investigations to reach
the best treatment option. This basic process of how to practice
medicine dates back to the ancient Egyptians, probably to the era
of the Pyramids. If you have never read the case histories from
Mr. Edwin Smith Papyrus, your medical education is incomplete!
The Egyptians only had history and signs plus clinical experience
by which to reach a conclusion. Today, we have the power of
modern science and a vast array of treatments. However while
the advances in results are remarkable, errors remain.
All too often, failure is the result of history and signs, the areas
in which the ancient Egyptians excelled. Only rarely is error due
to the lack of high-powered knowledge. If you do not believe
me, read the annual report of any medical defence society. Doc-
tors who take a proper history, know how to examine, and keep
good records do not often feature in these publications. If by
mischance they are sued, they have a good defence, for it is clear
they have provided conscientious care.
This book aims to remind, refresh, and improve the essential
basic skills of history taking and clinical signs. With practice,
they can indeed be “rapid.” Without these, “judgment” will be
prone to error. I am reminded of a story about the late Professor
Kessel of the Royal National Orthopaedic Hospital, who in being
asked by his trainee “sir what shall I do with this x-ray?” replied
“file it my boy, file it!” Imaging, however clever, does not tell you
whether the pathology is relevant or, if relevant, how much it
hurts. The knowledge and skills so clearly summarized and dis-
played in this book remains essential to good practice.
Frederick W. Heatley
Emeritus Professor of Orthopaedics
King’s College
London
Preface
The first decade of the twenty-first century has witnessed the con-
tinuation of an explosion in our knowledge and understanding of
all aspects of disease. Accompanying this has been the increas-
ing reliance of clinicians on more and more complex imaging
modalities and laboratory tests. It is the assertion of this author,
however, that the fundamental skills of history taking and clinical
examination remain the most important tools in reaching diagnosis.
This book aims to nurture these age-old skills of listening,
observation, and examination by demonstrating their invaluable
application in modern medical practice. In writing this book,
I have drawn on not only my own experience, but on a wealth
of advice from both those I have taught and those who have
taught me. The omission of an exhaustive inventory of differential
diagnoses for every clinical finding has been an intentional one;
I strictly adhere to listing the most common conditions that a
clinician will encounter to maintain practical value and clarity.
For the same reason, I have also endeavored to describe the most
useful and frequently performed clinical tests only, rather than
the multitude of possible tests that exist for all conditions.
It is my hope that the resulting book will be useful for all those
involved in the care of orthopaedic patients; for medical students
in emphasising the most salient features of common presenta-
tions, for general practitioners in providing clear and concise
information on which to base daily practice and for residents
as a ready reference for day-to-day use and also for professional
examinations.
Seyed Behrooz Mostofi
London
January 2008
Acknowledgments
I acknowledge the help and advice I received from the following
surgeons who have helped me enormously with constructive
criticism and helpful suggestions:
Richard J. de Asla M.D.
Co-director, Foot and Ankle Service, Department of Orthopaedic
Surgery, Massachusetts General Hospital and Instructor of
Orthopaedics, Harvard Medical School, Boston, MA, USA
S. Ali Mostoufi MD, FAAPMR, FAAPM
Assistant Professor of Physical Medicine and Rehabilitation,
Tufts University School of Medicine and Medical Director,
Boston Spine Center, Boston, MA, USA
Roderick G Wetherell MD FRCS
Consultant Hand & Orthopaedic Surgeon, East Kent Hospitals
NHS Trust. UK
Philip L. Housden FRCS (Orth)
Consultant Orthopaedic Surgeon, William Harvey Hospital,
Ashford, Kent, UK
Adrian J Carlos MBChB, MRCS, MSc
Specialist Registrar in Orthopaedics, South East Thames,
London Deanery,UK
Barry Hinves FRCS
Consultant Orthopaedic Surgeon, Conquest Hospital, St. Leonards-
On-Sea, East Sussex, UK
Francis Lam FRCS (Tr & Orth)
Consultant Orthopaedic Surgeon, Hillingdon Hospital, UK
Benedict A Rogers MA, MSc, MRCGP, MRCS
Specialist Registrar in Orthopaedics, South West Thames,
London Deanery, UK
Seyed Behzad Mostofi DDS, MDS, FRACDS
Consultant Oral & Maxillofacial Surgeon, Toronto, Canada
xiv Acknowledgments
In addition:
I am grateful to Dr. Andrée Bates, whose unfailing support is a
source of inspiration.
I am appreciative of the assistance from Dr. Joanna Maggs, who
has critically read many versions of this manuscript.
I would like to express my appreciation to the many patients who
agreed to have their photographs appear in this book.
I am grateful to Mrs. Emma Singh for being affable and extremely
tolerant while modeling, and to Mr. Ravi Singh, consultant
orthopaedic surgeon, for his photography skills.
I thank Mr. James Farley for his time and cooperation while
modeling for some of the photographs.
I recognize the efforts of Mr. Abbas Rashid for his help in the
preparation of the elbow chapter.
I offer special thanks for the help, support, and encouragement
which I received from Mr. Grant Weston at Springer, who made
the production of this book possible.
Seyed Behrooz Mostofi
Contents
Foreword by Francis J. Hornicek............................................ vii
Foreword by Frederick W. Heatley .......................................... ix
Preface ..................................................................................... xi
Acknowledgments ................................................................... xiii
1 Shoulder ............................................................................. 1
2 Elbow ................................................................................. 39
3 Wrist and Hand ................................................................. 61
4 Spine .................................................................................. 133
5 Hip ...................................................................................... 189
6 Knee ................................................................................... 217
7 Foot and Ankle................................................................... 259
Index ........................................................................................ 313
Chapter 1
Shoulder
LISTEN
Mechanism of Injury (If Applicable)
Certain mechanisms of injury result in characteristic patterns of
structural damage.
Common Examples
Fall on outstretched hand → anterior dislocation of shoulder
→ fracture of proximal humerus
Electrocution, seizures → posterior dislocation of shoulder
Holding on to an object while falling from a height (severe
traction to the arm) → brachial plexus injury
Fall on to the elbow/blow to the tip of the shoulder → acromio-
clavicular joint (ACJ) dislocation/subluxation
Age
Young → instability
→ ACJ dislocation
Middle age → calcifying tendonitis
→ rotator cuff tear
→ adhesive capsulitis
→ ACJ arthritis
Old → rotator cuff tear
→ glenohumeral joint arthritis
→ cuff arthropathy (combination of cuff tear and arthritis)
2 RAPID ORTHOPEDIC DIAGNOSIS
Pain
Site of Pain
Localized pain (to which the patient can point with a finger
(Figure 1.1) → ACJ pathology
Generalized pain (especially over deltoid) (Figure 1.2) → rotator
cuff lesion
→ subacromial pathology
FIGURE 1.1.
FIGURE 1.2.
1. SHOULDER 3
What Activity Brings on the Pain?
Pain during midrange of arm elevation → subacromial impingement
→ rotator cuff lesion
Pain during terminal degrees of arm elevation → ACJ pathology
Pain during throwing → SLAP (Superior Labrum Anterior to
Posterior) lesion
Type of Pain
Aching pain → degenerative changes
Sharp pain/catching pain → ACJ pathology
→ subacromial impingement
Pain after activity → inflammatory arthropathy
→ tendinosis
Night pain → rotator cuff lesion
→ glenohumeral arthritis
→ adhesive capsulitis
→ infection
→ tumor
Stiffness
Rest stiffness/ early morning stiffness → rheumatoid arthritis
→ inflammatory arthropathy
→ osteoarthritis
LOOK
From the Front
Alignment:
Ask the patient to stand facing you. In this position the patient
should be able to keep both arms by the side.
Arm held in internal rotation → posterior dislocation of shoulder
Arm held in internal rotation with flexion of the wrist → Erb’s palsy
Arm held in abduction → inferior dislocation of shoulder (luxatio
erecta)
4 RAPID ORTHOPEDIC DIAGNOSIS
Shoulder Height
Normally shoulders should be at the same level.
If one shoulder is higher than the other → painful shoulder
→ Sprengel’s deformity
If one shoulder is lower than the other (drooping shoulder)
→ trapezius paralysis
Scars
Comment on:
Position: posterior triangle incision may have caused spinal
accessory nerve palsy Surgical or traumatic
Healed with primary or secondary intention
Deformity and muscle wasting
1. Trapezius muscles: These should be symmetrical. Wasting
can be easily identified (Figure 1.3). Injury to spinal accessory
nerve which supplies the muscle can occur in:
Dissection of the neck
Lymph node biopsy
Brachial plexus injuries
FIGURE 1.3. Injury to the spinal accessory nerve following a lymph node
biopsy. Note drooping shoulder and wasting of trapezius. Prominent left
SCJ is due to osteoarthritis.
1. SHOULDER 5
2. Deltoid: Makes the contour of the shoulder. Anterior and
middle fibers are best visualized from the front.
Flattening of the shoulder → anterior dislocation of the
shoulder (causes prominent lateral edge of the
acromion)
Swelling of deltoid → fractured neck of humerus
Atrophy of deltoid → axillary nerve injury
3. Acromioclavicular joint: Prominence of the ACJ is usually easy
to spot (Figure 1.4). It varies between individuals and may be
normal. Pathological causes of prominent ACJ:
Subluxation/dislocation
Degenerative arthritis
Chronic/acute inflammation
4. Clavicle: A subcutaneous bone, but may be difficult to see its
length in obese individuals.
Asymmetry of clavicle → fracture/non-union
FIGURE 1.4. Subluxation of left ACJ (black arrow).
6 RAPID ORTHOPEDIC DIAGNOSIS
5. Sternoclavicular joint: this is easily seen in most patients
though more difficult in the obese.
If SCJ is more prominent →
Anterior dislocation/subluxation of SCJ as a result of
trauma or subsequent to incorrect internal fixation
of the clavicle (Figures 1.5)
b
FIGURE 1.5. Subluxation of right SCJ. (a) Note the surgical scar, subcu-
taneous plate and prominence of SCJ. (b) On shoulder abduction, the
subluxation is more visible.
