Clinical Orthopaedic Examination-1 PDF

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Clinical
Orthopaedic
Examination
Senior Commissioning Editor: Laurence Hunter
Development Editor: Sheila Black
Project Manager: Joannah Duncan
Designer: Kirsteen Wright
Clinical
Orthopaedic
Examination
R0 naId McRae FRCS(Eng, Glas) FChS(Hon) AIMBI,
Fellow of the British Orthopaedic Association
With original drawings by the author
SIXTH EDITION
ELSEVIER
Edinburgh London New York Oxford Philadelphia StLouis Sydney Toronto 2010
CHURCHILL
LMNGSTONE
FLSEVIER
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CONTENTS
Preface vii
1. General principles in the examination of a patient with an orthopaedic

problem 1
2. Segmental and peripheral nerves of the limbs 11
3. The cervical spine 33
4. The shoulder 49
s. The elbow 75
6. The wrist 91
7. The hand 111
8. The thoracic and lumbar spine 131
9. The hip 169
10. The knee 205
11. The tibia 249
12. The ankle 259
13. The foot 275
Index 313
PREFACE
The ability to make a good clinical examinatioo can lines of inspection, palpation, and the examination of
only be mastered by practice, and I have no doubt that movements and pertinent anatomical structures. In
the basic techniques are best learned by performance practice, this logical order is often altered by the
uoder supervision. Unfortuoately, the size of student experienced examiner to avoid undue movement of the
classes in relation to teaching staff, and the not patient. It must be stressed that not all the tests
infrequent dearth of an adequate raoge of suitable described need be carried out routinely. Many are
clinical cases, makes this ideal difficult to achieve in performed only when a specific condition is suspected,
practice. Many students may acquire only a sketchy and it is assumed that this will be obvious to the reader.
knowledge of the techniques of examination, which In particular, in any joint assessment, it is necessary to
are fundamental to diagnosis and treatment. It is hoped discover if there is any restriction of movement. In
that this book may help to fill some of these inevitable many cases simple screening tests will suffice, and these
gaps uotil souod practice based on experience is are highlighted in most sections. The more detailed
achieved. examination and recording of movement are generally
reserved for cases uoder lengthy cootinuous observation
THE TEXT and for medic<>-legal work.
Radiographic examination plays an essential part
It is assumed that the value of good history-taking is
in the investigation of most orthopaedic cases, and to
appreciated and practised.
aid the inexperienced I have made some observations
Patients parade their complaints on an anatomical
regarding the views normally taken and how they
basis, and the text has been arranged accordingly. The
may be interpreted. Only a fraction of the possible
emphasis in each section is on the common rather than
pathology can be illustrated in a small work, but
the rare cooditions to be fouod in the regioo. Although
I have concentrated on the common or informative.
this approach is open to criticism, it is nevertheless true
The spatial requirements of the captions have set
to say that although the obscure will tax the most
some restriction on their content; this discipline has
experienced, the most frequent mistake is a failure to
resulted in brevity at the expense, in places, of
diagnose the common. An encyclopaedic text,
completeness. Nevertheless, wherever possible I have
commendable on the grouod of completeness, may
tried to show not only how each test should be carried
nevertheless often confuse, especially where no
out, but also its significance.
indication is given of the incidence of the conditions
I have taken the opportunity in this new sixth edition
observed. I have purposely avoided detail, and where
to update the text in a number of areas, and to include a
this is required a fuller orthopaedic textbook must be
number of new tests and methods of assessing overall
coosulted. In some areas too I have made deliberate
limb function.
sirnplificatioos where a blight of terminology suggests
the independence of a number of conditioos that caonot
be distinguished by symptomatology or investigation. CONVENTIONS AND REFERENCES
For clarity in illustrating the techniques of examinatioo,
THE ILLUSTRATIONS the patient and the examiner are shown in shades of
The illustrations dealing with the practical aspects of light and dark grey respectively.
clinical examination have been arranged in an Where two limbs are illustrated, the pathology is
essentially linear sequence following tbe traditional shown on the patient's right side.
viii PREFACE
Where several conditions are described, and one 2. Kapandji A 1974 The physiology of the joints.
representative illustration only is given, it refers to the Churchill Uvingstone, Edinburgh
first condition mentioned. 3. Lusted L B, Keats T E 1972 Atlas of roentgenographic
When joint movements are being considered, the measurement. Year Book Medical Publishers, London
4. Boone CD, Azen P S 1979 Normal range of motion of
patient's normal side shonld, if possible, be used for
joints in male subjects. J Bone Joint Surg 61A/5: 756-759
comparison. Angnlar measurement is an approximation,
and the figures quoted are in most cases values rounded
to the nearest s• from figures published by the American ABBREVIATIONS
Academy of Orthopedic Surgeons, 1 Kapandji, 2 Lusted L & R = left and right
and Keats' or Boone and Azen.' L & M = lateral and medial
A & P = anterior and posterior
REFERENCES
Ronald McRae
I. American Academy of Orthopedic Surgeons 1965 Joint Gourock, 2010
motion: method of measuring and recording. Churchill
Uvingstone, Edinburgh
1
General principles in the
examination of- a patient with
an orthopaedic problem
Step 1: Inspection 2
Step 2: Palpation 3
Step 3: Movements 4
Step 4: Conduction of special tests 6
Step 5: Examination of radiographs 6
Step 6: Arranging further
Investigations 7
Additional Imaging techniques 8
Functional Imaging techniques 8
Arthroscopy 9
Equipment requirements 9
2 CLINICAL ORTHOPAEDIC EXAMINATION
In practice, the primary area of interest of the orthopaedic surgeon is in the

joints of the limbs and spine, and how well they function. The major part of
most orthopaedic examinations is tb.erefme centred on the joint that troubles
the patient, but the examination must often be extended to include the
nerves and muscles that are responsible for movementB in the joint; some of
the patient's other joints may also have to be checked to see if they are
affected as well.
Joints possess a remarkable degree of individuality, and it follows that the
techniques for examining one joint may have to be varied when it comes to
look at another. However, a common sequc:nce is followed, and it may be
helpful to keep it in mind. (It is assumed that a full, relevant histmy has been
obtained, and any general physical examination has been canied out.) The
examination of the joint itself may be bro1ren down into six distinct steps:
1. Inspection
2. Palpation
3.Examinationofmove~
4. Conduction of special teats
5. E:ramination of radiographs
6. Arranging furthec investigations.
It is not always necessary to keep strictly to this order, or indeed to carry
out all of these procedures.
The contentB of each chapter of this book are generally ordered in this
sequence unless special circumstances dictate otherwise.
STEP 1: INSPECTION
Look carefully at the joint, paying particular attention to the following
points:
1. Is there swellbac? H so, is the swelling diffuse or localised? If the
swelling is di1fusc, does it seem confined to the joint or does it extend
beyond it? Swelling confined to the joint suggests distension of the joint
with (a) excess synovial fluid (effusion), e.g. from trauma or a non-pyogenic
inflammatory process (such as :rheumatoid or osteoarthritis); (b) blood
(hacmartbrosis), e.g. from recent acute injury or a blood coagulation defect;
or (c) pas (pyarthrosis), e.g. from an acute pyogenic infection. Swelling
extending beyond the confines of the joint may occur with major infections
in a limb, tumours, and problems of lymphatic and venous drainage.
H there is a localised swelling, note its position in relation to the
underlying anatomical structures, as this may give a clue to its possible
nature or identity.
2. Is there bruising? This might suggest trauma, with a point of impact
or gravitational or other spread.
3.18 there any other dlscoloratioD or oedema? This might occur as a
localised response to trauma or infection.
4. Is there mUlde wasting? This usually occurs as a result of disuse,
from pain or other incapacity, or from denervation of the muscles affected.
5, Is there any alteratioD in shape or pomtre, or Is there nidence of
shortening? There are many possible c8llses for each of these abnormalities
(including congenital abnormalities, past trauma, distmbances of bone
mineralisation and destructive joint disease); their presence should be noted.
and explored in further detail during the course of the examination.
GENERAL PRINCIPLES IN THE EXAMINATION 3
1.1. Nom my IIWdliDg OOII1IDcd to the joim. 1.2. Note any sftllitlg ex1aldi.Dg beyCllld the 1.3. Nom my localiJed swelliDg(a).
joim.
1.4. Nom any bruising or oedema. 1.5. Noc.e any muscle wuling. 1.6. Noc.e any lltcnltion ohhape or~
STEP 2: PALPATION
Some of the points you should note include the fallowing:
1. Is the joint W8l'lll? H so, note whether the temperature iDcrease is
diffuse or localised. always bearing in mind the false impression that may
be caused by the effects of local bandaging. A difftue increase in heat
oocurs when a substantial tissue mass is involved, and is seen most
commonly in joints involved in pyogenic a1ld non-pyogenic infJammatory
processes, and in cases where there is anastomotic dilalation proximal to an
arterial block:. Away from the joints themselves, infection and tumour
should be borne in mind. A localised increue in temperature generally
pinpoints an inflammatory process in the uruierlying anatomical structure.
Asymmetrical coldness of a limb commonly occurs where the limb
circulation is impaired, e.g. from athero!IClerosis.
l. Ia there ten.d.em.els? If so, note whether it is diffuse or localised.
Where tenderness is diffuse, the cause is likely to be the same u for an
increase in local heat When there is localised tenderness the site of
maximal tenderness should be assiduously sought, u this may clearly
identify the underlying anatomical structure that is involved.
1.7. Note any iDaeued.local beat. 1.1. Note any 1ielldcrneaJ,IIIIl 'Whdht.r
localiled or dii!Use.
STEP 1: MOVEMENTS
Most (l:nJt not all) orthopaedic conditions arc as!IOCiated with some
restriction of movements in the related joint(s). Complete loss of movements
follows surgical ablation of a joint (arthrodesis), or may occur in the coarse
of some pathological process (such as infection) where fibrous or bony
tissue binds the articular surfaces together (fibrous or bony ankylosis): the
joint then cannot be moved either actively or passively. In many conditions
there is loss of that part of the range of movements which allows the joint to
be brought into its neutral position. The commonest loss of this type
prevents the joint from being fully extended; this is Jmown as a fixed flexion
deformity. Fixed deformities may be caused for example by the contraction
of joint capsules, muscles and tendons, or by the interposition of soft tissues
or bone between the articular surfaces (e.g. torn menisci. loose bodies).
Estimation of the range of JnOllement.t in t~ joint is an essential part of any
orthopaedic examination. To assess any deviation from normal the good side
may be compared with the bad; where this is not suitable (e.g. when both
sides are involved) resort must be made to published figures of calculated
average ranges. Restriction. of 1M range of movemenu in a joint is nearly
always due to mechanical causes and is consequently a sure indicator of
pathology. If the ID.WICles controlling a joint are paralysed. then the passive
range of movements must be assessed; occasionally pain m other factors
may restrict the active range of movements to a range that is less than the
passive. Sometimes a partly m totally paralysed joint can be persuaded to
move by invoking gravity m movement elsewhere (trick moverMilt.t), and
the confirmation of paralysis generally begs the determination of its cause.
1.t. M.cuure tile rmae of moftlllCIIU and 1.10. Thlt for li10VCIDtJit in abllormal planea. 1.11. Noce any joiat crepitu1.
recon:lany fixed defoanitie1.•
In many joints it is also mandatory to look for evidcnc:e of movemenu in

an abnormal plane. To do this the joint is generally stressed in a particular
plane and excessive movements are assessed by inspection or by the
examination of radiographs. Other aocompaniments of movement may
require assessment. Rough articular surfaoes will produce grating sensations
(crepitus) when the joint is moved, and tbis may be detected by palpation or
auscultation. Clicks coming from the joint on 'IJIUVement may be produced
through soft tissues moving over bony prominences (generally of little
importance), from soft tissues witbin the joint (e.g. displaced menisci), or
from disturbances in bony contours (e.g. from irregularities in a joint surface
following a fracture involving the joint).
The strength of muscle contraction (and hence the strength of each joint
movement) must be carefully assessed, and especially if found reduced,
recorded on the Medical Research Cou.nc:il (MRC) scale:
MO No active contraction can be detected.
Ml A flicker of contraction can be seen or found by palpation over the
muscle, but the activity ia insufficient to cause any joint movement.
M2 Contraction is very weak. but can just produce movement so long as the
weight of the part can be countered by careful positioning of the limb.
M3 Contraction is still very weak. but can produce movement against
gravitational resistance (e.g. the quadriceps being able to extend the
knee with the patient in a sitting position).
M4 Strength is not full, but can produce movement against gravity and
added resistance).
MS Normal power is present.
Muscle strength may be impaired by pain, wasting from disuse, disease or
denervation. Fmally, attention should be paid to any impairment of overall
function in the affected limb as a result of disturbance of movement or
muscle power. in the case of the legs, this implie& an asseasment of the gait.
Many tests are available to detect di.stUJbance of separate aspects of upper
limb function.
STEP 4: CONDUCTION OF SPECIAL TESTS

For most joints there are a number of specific tests for particular aspects of
that joint's function. These include tests for the integrity of certain joint
ligaments, and for the examination of structures associated with the joint
(e.g. the menisci in the knee). Of particular importalwe is an appropriate
neurological examination (e.g. the testing of specific muscle groups and the
determination of any sensory loss). When applicable, the MR.C grading of
motor and sensory levels should be recorded. The latter is as follows:
SO Absence of all modalities of sensation in the uea exclusively supplied
by the affected nerve.
Sl Recovery of deep pain sensation.
SZ Recovery of protective sensation (skin touch. pain and thermal
sensation).
S3 Recovery of protective sensation with accurate localisation. Sensitivity
(and hypersensitivity) to cold is usual.
S3+ Recovery of ability to recognise objects and texture; any residual cold
1.12. 'n:8t for KUOry iolt llld Ill}' oilier sensitivity and hypersensitivity should now be minimal In the case of
~defect.
the band, recovery of two-point di.scrlminati.o to less than 8 mm.
S4 Nonnal sensation.
STEP 5: EXAMINATION OF RADIOGRAPHS

When a radiograph is requested, in most cBSCS the standard views
comprising an anteroposterior (AP) and a lateral projection will be provided.
Someone experienced in looking at radiographs will recognise the main
pathology at a glance without following any analytical procedure, just as a
familiar face is identified without apparently paying conscious attention to
the relevant position and size of its main features. Until such skills are
developed, it may be helpful for the student to have some simple scheme to
follow. One such is to look at each radiograph as though in the cinematic
sequence of long shot, medium shot and close-up. In the long (wide-angle)
shot a scene is established and the overall relationship of the important
features is made clear. Start by looking at the radiograph in a general,
unfocused way, as though you were standing well back from it; ask yourself
the following questions:
1. Are the bones of normal shape. size and contour, or are they thicker or
thinner than normal, shorter or longer than usual, or abnormally carved or
angled?
2. At the joints themselves, are the bony componenss in COI"ICCt alignment,
or are they displaced or angled?
Looking a little more closely, note whether the bone textwe appears
normal or disturbed, such as in osteoporosis, Paget's disease, avascular
necrosis, osteoporosis etc. Note if there are any areas of new bone, such as
exostoses, subperiosteal new bone formation etc. Note whether there are
any areas of bone destruction, such as may be found in the presence of
many tumoms.
Rumination of the bone in close-up may be done in two ways: either
trace methodically round the contours of the bone, noting any abnormality
en route, or go through a checklist of yO\D' own making; checklists can have
different bases, and can be used in combination. A list may be based on
pathology: you might then look for evidence of congenital abnormality,
infection (or an inftiiiDJDJltory process), trauma, neoplasm, metabolic
disturbance. degeneration; a list may have an anatomical base: you might
then assess ligamentous attachments, joint liLIIIgi.ns, the joint space, and
the cortical and cancellous bone elements.
In some situations radiographs additional to the standard AP and lateral
projections may be required. These may include:
• Comparison films Here films of the other limb may be taken so that the
two sides may be compared; this may be indicated where there is some
difficulty in interpreting the radiographs (for example in the elbow region
in children, where the epiphyseal structures are continually changing, or
where there is some unexplained shadow or a congenital abnormality).
• Oblique projeeti.ons In the case of the hand and foot an oblique
projection may be helpful. especially when the normal lateral view gives
rise to cxmfusion owing to the superimposition of many bone structures.
Such oblique projections may have to be specifically IeqUesU:d when they
are not part of an X-ray department's routine.
• [«a&secJ views Where there is marb:d local tenderness, but routine
films are normal, coned-down localised views may give sufficient gain in
detail to reveal, for example. a hairline fracture.
• Stress films S1less films can be of value in certain situations, especially
when a substantial tear of a major ligameut is suspected. For example,
where the lateral ligament of the ankle is thought to be torn, radiographs
of the joint taken with the foot in forced inversion may demonstrate
instability of the talus in the ankle mortice.
STEP 6: ARRANGING FURTHER INVESTIGATIONS

This last stage is not always required, but the indications are usually quite
clear. The clinical and radiological examinations may have resulted in a
differential diagnosis that requires additional tests to allow a firm diagnosis
to be made; in many cases the additional tests serve to confirm a strong
impression. Occasionally clinical examination faih to clarify the problem
and one remains baffled by the cause of the complaint: further investigation
may throw some light on the situation. perhaps indicating an area that
should be concentrated upon. or suggesting that temporisation and
observation may be embarked upon with safety; or occasionally it may
suggest that some of the complaint at least may have a functional basis.
The commonest screenln1 tests Include the following:
1. Erythrocyte sedimentation rate (ESR) (and, in certain cases, C-reactive
protein)
2. Pull blood count with differential

3. Estimation of rheumatoid factor
4. Serum calcium, phosphate and alkaline phosphatase
5. Serum mic acid
6. Chest X-ray.
Other regloDal inftStigatiou iDdacle the followiDg:
ADDITIONAL IMAGING TECHNIQUES

1. CT scaas These can show tissue slices in any plane, but characteristically
in the median sagittal, p11C88agittal, coronal and, most importantly, the
lmlsvene planes. The last projection cannot be readily obtained with plain
X-rays, and can often provide useful additional infonn.ation which is not
otherwise available. In addition, in the cr scan there is a greater range of
grey-scale separation, allowing a greater differe:nti.ati of tissue types.
.2. AP and lateral tomography In this X-ray technique the tube and film
are rotated (or slid) in opposite directions during the exposure. Their
positions relative to one another and the part being examined determine the
tissue slice being clearly visualised. The results are inferior to those
obtained by cr scanning, but may be helpful if the latter is not available.
3. MRI scaDS These avoid any exposure to X-irradiation and produce
image cuts as in cr scans, with a greater ability to distinguish between
different soft tissues. They are of particular value in assessing neurological
structures within the sk:ull and spinal canal, and meniscal and ligamentous
structures about the lmee and shoulder.
4. lntrasound lntrasound imaging, which is generally regarded as being
hazard free, readily available and inexpensive, has great sensitivity and is of
value in assessing the presence of fluid (e.g. blood) within and around joints,
as wen as discontinuities in soft tissue struct\lres. It is frequently used in
evaluating cases of developmental dysplasia of the hip.
FUNCTIONAL IMAGING TECHNIQUES

1. Technetium bone scans Bone scllDJ may be perfonoed after the injection
of technetium-tagged methylene diphosphonate ~methylene
diphosphonate (MDP)). The facility is widely available, inexpensive and
gives rapid results. In the trauma :field such scans may assist in the diagnosis
of hairline fractures (e.g. of the scaphoid, shin or neck of femm). They may
assist in gauging the age of a fracture, and in detecting avascular necrosis of
bone. They are of value in the investigation of unexplained pain in the long
bones and spine, infections in bone and in the region of prostheses, and in
assessing Sudeck's atrophy (complex regional pain syndrome).
2. SPECT (single-photon emission controlled tomography) This
technique may be used to give beUx:r local.isation and assessment of an
active area discovered by a technetium bone scan. It is of particular value in
the investigation of back pain.
3. PET (8uorodeoxygluooae (FDG)·poaitron emission tomography)
may be of value in localising infection within a bone. Other methods in the
investigation of 8U8pCCted infectiow include the we of gallium. or direct
labelling of the patient' s own leukocytes with indium or technetium.
Leukocyte labelling is of particular value in the evaluation of infection
round implants, but requires specisl facilities.
ARTHROSCOPY
Methods for the examination of all the major joints have been developed
and allow direct visualisation of the articular surfaces, the joint capsule,
many associated ligaments and, in the case of the knee, the menisci. At the
same session biopsy samples may be taken if required. and sometimes
treatment p:rocedures may be carried out.
EQUIPMENT REQUIREMENTS
The special tools required for the clinical examination of a patient with an
orthopaedic complaint are modest in character. Four are desirable:
1. A tape measure (prefe:ably of the type used by tailors) for measuring
such things as limb lengths and girths (for evidence of inequality in
length, or evidence of muscle wasting), and sometimes for assessing
movement (e.g. in the spine, knee and no cage).
2. A goniometer, preferably with an easily read scale with reciprocals, for
measuring the range of movements in a joint.
3. A tendon hammer for eliciting limb reflexes.
4. A disposable sharp point (by default a hypodermic needle), fresh for
each case, for assessing any disturbance of sensation to pinprick.
2
Segmental and peripheral
nerves of the limbs
The brachial plexus: cervical part 12

Branches from the nerve roots 13
Branches from the trunks 14
The brachial plexus: axillary part 14
Branches from the cords 14
Upper limb myotomes 15
Upper limb dermatomes 16
Types af brachial plexus Injury 16
Assessment of brachial plexus
lesions 17-18
Axillary nerve 19
Radial nerve 19--21
Ulnarnerve 21-24
Median nerve 24-27
Lower limb myotomes 27
Lower limb dermatomes 28
L.umbosaaal plexus 28
Femoral nerve 29
Common peroneal nerve 29--30
Tibial nerve 30--31
Sciatic nerve 31
Lateral cutaneous nerve of thigh 32
Neurological control of the
bladder 32
1Z CLINICAL ORTHOPAEDIC EXAMINATION
I
I
RHOMBOIDS SUPRASCAPULAR
variable
contribution
SUBCLAVIUS
sympathetic ~ <> o <>

to the eye 0 1<>
-......;:~-----.., <' <> I
LONG THORACIC
SPINAL
CORD NERVES ANTERIOR RAMI/ROOTS TRUNKS I DIVISIONS
Fig. 2.1.
THE BRACHIAL PLEXUS: CERVICAL PART

The TOOts of the brachial plexus are fOI'IDed by the anterior primary rami of
CS-Tl inclusive. with occasional contributions from C4 and 1'2. The roots
lie between the scalene muscles in the neck. (Do not confuse the roots of the
plexus with the roots of the tegmenlaltpinalnerves, which are intrathecal.)
CS and C6 form the upper trunk, C1 forms the middle trunk, and C8 and Tl
form the lower trunk. (Preganglionic sympathetic nerve fibres to the upper
limb arise from T2-T6, ascend in the sympathetic trunk, synapse in
cervioothoracic ganglia, and pass to the upper Hmb mainly through the
lower tnmk of the plexus. An important localising point to note is that
preganglionic fibres en route to the eye via the stellate ganglion arise from
Tl .) The trunks are found in the posterior triansJ.e of the neck. The
mbclavian artery lies in front of the lower trunk.
Each tnmk forms an anterior and a posterior division. The division& lie
behind the clavicle. The three posterior divisions form the po.rterior cord,
the anterior divisions of the upper and middle trunks form the ltJteral cord,
and the anterior division of the lower trunk contimes as the medilll cord.
The divisions and commencement of the cmds lie in the posterior triangle of
the neck.
SEGMENTAL AND PERIPHERAL NERVES OF THE LIMBS 13
LATERAL PECTORAL
.:;::::::;~~~;;:;:;;::::;::::;;;;;;LJ MUSCULOCUTANEOUS
MEDIAN
UPPER SUBSCAPULAR
THORACODORSAL
POSTERIOR RADIAL
~:::;~;;;:=;;;;;;) AXILLARY
LOWER SUBSCAPULAR
ULNAR
MEDIAL CUTANEOUS OF FOREARM
~:=:::;;;;;:;:;;:;:;;:============~====::::J MEDIAL CUTANEOUS OF ARM

' - - - - - - - - - - - - - - - ' - - - - . . , MEDIAL PECTORAL
CORDS PERIPHERAL NERVES
The brachial plexus has a most extensive distribution, and the order in
which the nerves come off is of value in dete:rmining the site of any lesion.
This is of particular importance in traumatic lesioDll, where the prognosis
and treatment are closely related to the level of injury.
BRANCHES FROM THE NERVE ROOTS

The first branches of the plexus to be given off arise from the nerve roots
themselves. Two important branches in this category are:
1. The nerve to the rhomboids (donal scapular nerve). It arises from the C5
root alone.
2. The nerve to serratus anterior Oong thoracic nerve). It has contributions
from C5, 6 and 7. Its most proximal part arises in conjUilction with tile
nerve to r:bomboids.
C5 also contributes to the phrenic nerve, and C5, 6, 7 and 8 supply the
scalenes and longus colli. Although not strictly branches of the brachial
plexus, these segmental brancbea are of some im.portance; paralysis of the
hemidiapbragm. when found after a brachial plexus injury, indicates a
proximal lesion.
BRANCHES FROM THE TRUNKS

There are two 'bralK:hes only at this level:
1. The suprascapular nerve is importmt, supplying the suprupinatus and
infraspinatus.
2. The nerve to subclavius: this is of little clinical significance.
Both these nerves arise from the upper trunk. All the branches from the
nerve roots and trunks arise above the clavicle (the supraclavicular
branches).
Not.
1. In F..rb's (upper obstetrical) palsy (E in Ftg. 2.1) the C5-(i roots are
affected bllt the nerve to rhomboids and the lana tboraci.c nerve are spared.
2. In Klumpke's (lower obstetrical) palsy (K. in Fig. 2.1) the C8-Tl roots
are involved. The sympathetic nerve mpply to the eye (arising from Tl) is
often also affected, leading to a Horner's syndrmne. It wu said that 80%
of birth injuries to the plexus make a full mcove.ry by 13 mon1hs, and
persisting severe sensory or motor deficits in the hand are rare; recent work
suggests that this view is somewhat: optimistic. Note that a number of
obstetrical injuries to the plexus are accompanied by facial nerve palsy and
posterior dislocation of the shoulder.
3. In tranmatic plexus lesions in adults the commonest patterns of injury
are (a) CS-6 (Erb type); (b) CS, 6, 7; (c) ~Tl incluaive.
THE BRACHIAL PLEXUS: AXILLARY PART

The cords for the most part lie in the axilla, and are closely related to
the axillary artery. (The axillary artery commenr.es at the outer border of the
first rib and ends at the lowc:c border of terea major. The second part of the
axillary artery lies behind the pectoralis minor, with the first and third parts
of the artery lyiDs above and below it. The three cords eotec the axilla above
the first part, embrace the second part in the position indicated by their
names, and give off their branches around the third part.)
BRANCHES FROM THE CORDS
The lateral cord (CS, 6, 7) This gives off the following branches:
1. The lateral pectoral (which supplies pectoralis major)
2. The musculocutaneoua (which supplies coracobrachialis and biceps)
3. The lateral root of the median nerve.
The medial cord (CI, T1) This gives off:
1. The :medial pectoral nerve (wbich supplies pectoralis major)
2. The :medial cutaneous nerve of the arm (which mpplies the skin over the
front and the :medial side of the arm)
3. The :medial cutaneous nerve of the forearm (which supplies the skin over
the lower part of the arm and the medial. side of the forearm)
4. The :medial root of the median nerve
S. The ulnar nerve (in 90% of cues the ulnar nerve :receives a branch
(C6, 7) from the lateral cord).
The postwlor cord (CS, 6, 7, 8, T1) This gives off:
1. The uppec subscapular nerve (CS, 6), which partly sapplies subscapularis
2. The lowct subscapular nerve (CS, 6), which supplies subscapularis aod
teres major
3. The thoracodorsal nerve (C6, 7, 8), which supplies latissimus dorsi

4. The radial nerve (CS, 6, 7, 8, Tl)
5. The axillary nerve (CS, 6).
Details of the most important branches (median, ulnar, radial, axillary) are
given later.
~C78
:1.2. s.gm.ne.l dlltrlbutlan: Wbt:re you 2.3. MJotan!a {1): Normally two roota 2.4. ~u W: Ia a diatal or pro:dmal
auapcct inrol~t of eplDal Dl':l'Vea radlet ~ IIIOVCIIIalt of a joint in one dlrccdoll, joint !be four lpBial eegmenta inrolved differ
than peripllerU Dl':l'Vea <e.r. inJurlc• to 111e IDd two in 11101hr:r. Tbia il true at !be elbow, by plua or minD• <me, eo tbat tbcoretically tbe
apine or 'brld1ial plcxu1, ccnicalllpOIIdylolia wbcre weabeu of elbow ~oallld an lbouldc:r lbouJd be CXlllttOilcd by C4,5,6,7.
~.) yau llllllt cumine IDJOIO!Dtlllld alMalt bicep• tclldol1 jca:k iJJdicalc C5,6 However. C4 baa beal ~ wi1h tbc
dcrmllocla. Tbcee ~ the mueclc - iawlvemrat; aad wbcre MakDcu of rault that llbcb:tioo il mcdillcd 1hroulb CS
IUid m:u of *ill IUpplicd by lin&Jic !lpiDII atallioo ancl an ablcDt tricept jcU: IIUIF't a akJao (deltoid, IUprupiutua etc). ~
J~Cnet (Jio maam how 1bc acne flbreJ wi1llin c:l,8 Je&a 'D1iJ ccacnl twle is foiJowcd (inwlvin& ~ peciDnlillllljor) iJ
tbeJe lpiDal Dl':l'Vea are 8Dally diltrilacd via lllroo&boat !be lower limb, bat is IDOdilcc1 ia CODirolkd by C6,7.
the limb pJcmlet IDd peripkral acne~). !be Jqbly apccialUcd upper limb.
2.5. IIJDIDI'MI (I); At tile wtiJt, wbac 2.6. ...,.,..... (4]: Bod!. flc:lioa mel 2.7. MJ-••u 15): Ia 1bc cue of~
C6,7 woald have beeD cxpoclled to COidml ~of the bgen .-e COCIIrolkd by llld IUpiDaCiocl I liDP iplnallq!DCIIt iJ
Jlllm- bioo ooly, it ia 1bc cue 1hlt tbelc c:l,8. iavolved. IWIIely C6.
two secme:nta coarol ~ u well.
T1 --
2.8. MJvtomu (6): A 1i11aJo 11egmaat agaiD, 2.9. ~ Note 1bat the middle 2.10. TypR of bntchlal plaus Injury
namely Tl, ia involvtd in procluc:iD& fiDge:r i1 ~~appliecl by c:T, aad that lllere ia a (1 )1 Lcliont in continuity: more Ibm bali of
abduction 8lld adduclioD of !be 1n£cn: dlcee regular, eaaily remt.lllhered ICq1ICIICC of pJcxaa injarielm: of lhil pattem. 'l'nlctioa ia
lJIOYCIDCDIB m: carried out by die tmall ICIIIOr)' diatributioD rouad die preuialliDc of die I)OII!mcpwf CIUIC, 111111 die acrve rootll m:
IIRI8Ciu (in1riDI.ic1) af the lwld. Note: In !be limb. ~ bctwet:a die inbcrVertelnl fonlmina
telling for ID)'Iltomcl the ability to perform aDd die olavipJdoral fucia. (po~).
tJie llboYe moveJJIICIIU lbould be lllle.lled by Tbe laiool may be tranlient (Deaopruia).
MRC gndiJI&, IDd note llllde of !be ~tl If thc IXODI clegc:DI:fttle (UOIIOtmclil),
lffeded. Ofla1 tJie defect ()U be localid to ~ OCCIIll 1t the me of 1 IDIIIIUy,
a lingle ICIJDCill proYided the Gonl CID pcactnlte the
illariDeall ICIII'.
--
2.11. Lui- with ,.und n•rw roCIIII 2.12. Compl41te nulllon luiGnS (S): Tbe 2.1 S. Pllrtlalnulllon IMIGnS (4): Rarely,
(2): In more ~evc:re izijudet die lll".l\U m: acrve il mUsed from !be cord ll.lld amgical thc polll::riar rootJ Ire lpm:d, 10 1llat 1llae
diaupted at thc IIIDC level. ODly llqical. repair ie impo11iblc. M.ofct aou ~ may be !be paradox af DWJCle pcal)'lit
intervcDI:ion can of[u lillY bope af rtCOVe!Yo and thc paml}'led IIIIJICict allow ~ acc:ompmkd by~ af llellaltion.
but tepair, ew11 wUh ~~CtW &rdinl, may be llbrillltion potadials on the cJcctromyogmph Tbe pmpotll toe the motor l.oN il in ~
impoMibk bCCIIliiC af ClfeDiiVC ~ (EMG). Tbe ccn. of tJie lleD.IOlY lll".l\U in ~alto bopelcll. AWiough the
damage. It ia impodant to dim:rcntiaz the donal root gmglion remain intact cua nmm:: of die Jeaa may aecm fairly
between laiool af lllil type, laiClll& in (prqmgliollic klion); alllloa&h ICIIKiion il clear lfla c:lillical erunmlfim md farlbc:r
conliDIIity (wbcll: the tn:a~ment ia c:xpectal), lolt, CCICidDctiaa withia tile dial ~ inftq,aoa, ia many c:aact tile pil:tae ie
Uld caRl awlaioo laiool (wbae tile remains IDd may be deteclled through ~ owill& to the filet that aae <.: ~
progDOiil il ~). eDcmally ~ cJeetrodet. of tbclc U!jw:ia may be COII1biBcd
2.14. Long-.tllndlng pl..u1 IBI0111 (1): In 2..15.Long-~t~~ndlng plaullellons (2): ln 2..16. Long..andlng plaulleuons
Erb's palay (upper oblltelrUlal ptlly), which K/umpl:l'6 paralyln tbc IIIDiil (iDtriasic) (S}I 'lbc Tl root alone may be involved, lhe
afbta lhe upprz trunk of lhe brachial plexue ~ illcludUig the hypotllaw and theDar IOJc fi&n• being wAiting of tile ltiDalliDIJIClel
(and hence C5,6), lbcze ll cldormity of lhe groupe, are waned and there ll a claw hand of die bmd, including tile lbcDar group, along
Hmb, wbich il bcld in • clwlcterlalic deformity. 1bae ia 8al80rY 1o.. oa the willllaiiOr}' Wit OD tile medial aide of tbc
position: tile Milt il ~ and pronated, and medial aide of die forearm and Wlilt. ln many hand only. Leaiou of thll type are IICCI1 in
the lingers kl.cd. 'lbc elbow ll me:aded lllld cuea ~ ll an U80CiaJled Homer sylldromt. iacompld:e lDwer obltemcal pllay, cervical
the ~boulder iDtemally rotallCd (waiter'• tip (Note alao that 38~ of petien1B who receive lpO!ICiylotil, cervical rib syDdrome,
defoanity). 'lbc ~to ~ aDd lhe ndiothl::apy for maat carciooma develop a o.eurolibromatosll, aDd apiW and llldaltatk:
long lhorlcic ~ are u.ually •pared. brdial DeUrOpll1hy.) carcinoma.
2.17. Acllle tn1um11tk lulons Gf the 2.18. Auellrnent (1 ): Begin by 2..1t. Aualrnent (2): Aficr determiDillg
br•chl.. pl.aal: Tile ~t delaminiDg lhe utftt at the luion, i.e. wbich aegmenta are affected, you lbould try
mcchuiam• of injury invol~ cleprealion of wbich aegiii«<U are involwd, aDd wbe1bct ID flxm an opiDion u to die ryp. of iDjmy.
the lhouldcr combiiiCd wiab latttallltxion lhe illvolvemem ll pertial. or compkte. Start 'Ibi• may be diMcuJt m clarify, bat 1bt ~~~CR
of the neck to tile oppotite lide, or traction by teltillg for lll:tive ~ in the evidaace ~ ia of proximal cllmage, 1bt
oa the 1n11. ~~are tile lbouldcl', elbow, wrist and fill&cn, rdatin& greater die c:lwl= of cord avulJion and a
lingle DIM COIIIIIKil CIIIIC. On Wpedioa, your ti.Dding1 to tile m:yofiol:DICI reaponlible for poor propollll. Hmll:r'l syBdromc..
look for tile JRICIMlC at tcllllk btu:iliDa over lheiC IDOVCIIIa:IU. 'I1Ial clleclt for -.atioD to ~by (A) paeudoptolia, (B)
lhe &houldcr or at die root cl die DeCk. ln the pillpick and li&ht to!ICII, api.n DOlin& tbc llllailDcM of die pupil OD 1bt llffecticd aide,
more ecvcre - tbc lllllbapllaily It tbc dermalr«nea invdved (wbich nonaally and (C) dryDeA of lhe blll4 fmm ~ cl
lide.. curelpO!Id 1rifh 1bt pr.-emualy dcamiacd ~ OCXQI1I wlla1 tbc Tl root ia ia¥olved
myotome~). clole to 1bt call.
2.20. Assasm...t (:t): Look for !leiiiO!)' 2.21. AIIMamMt (4): Now test the fi.nt 2.22. AIIMI!Mid (5): Nerw to 1erTGIIU
loss above the clavicle. 'l.bla - Ia IIOI1IIll1ly DmVel that come off the plexua. Nerw to 11111Brior (CS,6, 7): Damage to lhia nerve
aupplied by C3,4, BDd if this Ia aO'Jicted it rilomboids (CS): Aak the paaieat1D place the prochK:el wiD8iDg of the scapula, wbidl is
gemnlly i.udi.cates that the injury baa been 10 band OD the hip IIIJd to teaiJt the eJ.bow beiog DOJ1D8l1y dem.onltntm by ulinc the pal:ient
IMMD'I! that i1 baa not ouly involved the plexus pushed forwards; feel for ClOIIIJ:Ktion in the ID Inn with bolb banda against a wall, but
bill the roots above; it Ia liiWilly iDdialive of rilomboid muscles. Ableoce of lldivity Ia lhia test may have to be abadimed in the
a proximal injury with a poor propwm1. indh:alive of a lelion proximal to the J l l " - of 1111 ext~msive plexu1 1eaioa. (Note
Deep btuiainJ in the poahlrlor trianaJe Ia abo fmmalion of the upper II1.Uik. of the plex111 lbat the nerve to IMirTUIII 1111tsior may be
atrnagly •lliPIIive of a~ J.ion. (aod IUiPI1i'ftl of c:or:d awl.si.on). PmlalCII of clamqed in Uoltltitlfl 1hmu&h li.ftin& vecy
activity IIIIIIIIII a lesion distal ID the heavy wei&IJtl.)
iDtmvertebnl fOI"'IIIIeel.
2.24. AIMIInMIIIt (7): Other testa, ob1tnalion BDd invelliprionJ. (1) 1&Nl~ 1ip: 'Illp
vi&orouai.Y at the side of the ~ warkiD& from above dowBwuds in the liDe of the lliKVII
roots u they-. frmllhe ~The tell Ia posilift if thin is JDXbd, painful~
in the COIIellll rwfin& dcnrw!mn.· b eumple, if tappina ov. the C6 mot produces ~
paia ad tingling in the thumb. A politift r.t pllliD)Iy iDdlAtm a rupblred DSW root BDd a
poatpnglimi<: INion. (It is uid, ~. that the tat may abo be posiliftl in the ~ of
1111 awlled pollmior root gaugli011.)
(2) X-ray twl JIR1 8CfiiU: (a) Plain fllmt of the I:CMW !lpillc &hould be obtalDcd. Altboa&h
lheae 1rt of priDclplll value in eliminating 01la palholoJy, they may occaaiO!Ially revellla
ll'IIDIYCDC pnx:a1 :Cr:actuR;; IIUCh a :Cr:actuR; ia iDdiclll:ive of the acvc:rity of aa iajury aad the
probabllity of aa i.aecovetable lcaioa. (b) A plain poatcriar-cla:lor (PA) radiograph of the
chest may reveal paralyai• of a bemidiapbragm, iDdicative of a poximally lited lclion. (c) A1J
MRIICBD may clarify the aitc of DCrVe diaruptioa, particullrly iD. the cue of prepag1ialdc
laion1. (d) Myelogmphy may gl.ve valuable inCotmalioD regarding the prea= or abecaMle of
ligDa of avulllioD of roota from the cord. Sipl iwili:alive of a poor progi1CMia iDclucle traumadc
~ lou or dlminndon or cuggcralion of root poucllcl. IIJid cystic III:CIIDIIIlali of
CSP witbill the 8piDal clllll].
(3) Electromyography: It baa been :rerommended tbalat lcut two lllUiclea IIUpplied by each
root llhould be examiDed by the iuertion of oeedJc clccllodee: the ))II'IICIII:C of any lll:tiaD
potadiala will iDdicated 80Die contimlity in that root.
(4) &IIIOIY corJduction: Sensory CQDdnctioa may be INCised in two waye: (a) by ekcCI:i<:ally
ftjmqlating (aay) the median nerve at the wrist, lllld by mcana of ltp. .~ cleclrodea attemptiDg
2.2J, AssalmMt (&): Supra~Ct~plllar IIIITW to pick up tetultant pottll.tiala over the ple:mt or in the neck (tmlbd pottll.tiala); or (b)
(CS,6): This!IIIIVe IIi- from the ~~p~Hr ftjmqlating (aay) the median nerve at the wrist, lllld ldlaDpti.D& to pia up potr:atialJ di.rtDJly by
mmk of the plexul ad mppllet the IDCIIIS of rillg cleclrodea toUIId the iDdex finger (-.ory action (antidromic) potentiala). 'lbc
auprupi.uama lllld infrupilllltaa. 1b tell for J.aaa md!IOd IIPPCirll prefmble. ODt aide i1 compared wi1h the other. If the lidea are 1lle aame,
activity in the IUpiUpiaatul, uk the paait!lll 1hia auggcltl a ~CVere or compldc prqllll(liollic lelioD (avullion of ncne roota from 1lle ecld).
ID try 1D abduct the lllD apinat rmi~WK:e; If 110 llaii(X)' action JIO(CDtWa are obtaiDcd on the ~urecllide, lhia auggea a JIOI(&anglionic
feel for IIIUicle COD!ndion above the spine of lelion; IIDil if dimjnisixd action pofcDtiall are preiCI1t, a mWd lesion illikdy.
the K!lplla. (The ilf/rrupinalwl may be tMted (S) H~ ten: A drop of I 'lo hiltanliDe ia placecl over lbe cc:mre of each a1licc(ed dmnltm!e
by feeling for IIIIIICle c:oatrKtion klow the BDd the akiD pdcCd 1ll:ough il; the IIODIIalllide Ia 1lled u • caaaol On the DOnllallide llae
apme ~the IICipllla while the pD!Dt abould be the uJIIal triple re.-e, wiCh tbe llare filly cleYdopecl within 10 mi.nuicl. AbleD:e of
atlaJJpta lo rolale the llboald« atanally.) a flare OD tbe iajurecllide IUgat poCpngljonic damage. If I normal triple retpOUe il foaDd
peniltiDg lftc:r 3 wceb in anacJtbe1ic lkia, a preganglionic 1eaion ia 'rirtually certain.
2.25. sr,n.
lndiAtf. . . , _ pf'OIIIOII•
In tn1umdc piau Iaione
1. A complete lesioD illvolvl.D& all !i-.e roou.
2. Severe plin in an IIIICIIbdic: lrtll.
3. SCDJOrY loa above !be da~ 1114
bruWJa& iD. tile perior trilqle.
4. Flxlure of a lrani'Yene procesa.
s. Homer'•~
6. l'anllysiJ of rllomboidl 1114 leftiGis
anlielior.
7. R.dentioo of llCDIOI)' ~ in tbc
preiCIDCC of IICIIIOf)' loin.
oa••,..ltm or bnddal p~au -.art. m
diDdrm: Tbc Nll'llw claffiflcad!W! ia aimplc
1114 1lldul for grading tbc IICVCI:Ity of any
luion. It may bclp iD. dcc.ldia& wbcliw:t to
embark Oil IRII'gical repair.
Group 1: C5,6: peralyaiJ of the lboulder 1114
bicept.
Group D: C5,6,7: paralylia of !be llboulder,
bicept IIDd fararm. cxtadcn.
Group m: CS-Tl: COIIIpl= paralylis of die 2.16. EDmlnlltlon oftha pll1'1pharal 2.Z1. Axillary narva (2): Alit the patient to
limb. .-ws of tha upper limb; n. tailllUy attempt to IIIOVC the arm from 1lle aide, pain
Group IV: CS-TI: comple1le paralysia of !be (circllntflu) nerve (polterior com) C5,6: pcrmittina, wbilc you .resiat ID'J ~
limb with a Harner'• tylldromo. (1): Tbia merve it 111011t commoaly damaged Look.ll.lld fed far deltoid conlllclioo.
durillg llboalder dUJ.ocatiou ll.lld displa=f SomdimeiiJJiJ ia difl!cult ID UIICII.t, aDd 1he
In aurgically 1llll:l'tldCd - it lw beta fral:attea of the pnni.mallmmcml (humeral two lidellhould be carefully compared if
fOUDd tbJl thtrc ia fulllpoDtancout l'CXlOWl')' DeCk. fral:attea). SpoD.taieoal recovery usully 1Jia'e it IIIJ doubt.
In 90'Ai of cuet In Group I. In Group II. OCWll. FlatteiWig over the lateral upect of
DOmJal fia:lioa wu n~piaed in cmly 2S'Ai of !be ~boulder develope wbal JmJJCie wuting
~ No child in Group m uwle a full it It itl beigbt.
niiXMI[)', llltlwqb in the majority of caMt
hand fum:tioD wu good. In Group IV, SO'Ai
- fouDd to have oo or poor hand f'lmclion.
2.21. Axillary narw(S): Look for lms of 2.2t. bdlal nai'WI: (podallor CDrd} 2.30. RMial nai'WI (motor distribution)
Mmution.lmii lbe ·~ b q e ' - of C5,6,.7,I (T1 ): Motor distribldiorl: (A) In lbe contd.: (C) In tbe IIOpinanr IUmlelthe
the sboulder. this ia lhe - exclulli.wly Upplll' am! lhe IlldiaiDIII:WI IUpplim llialpa. pterior in~ braDcl! of lhe radial
IUpplied by 1lJe uW.ry J8W, WiHe the (B) In Crout of lbe elbow, it lllppliea 1upplie1 tbe rat of sopiDatar; lsiou here
lhouldllr .iJ too pmd'ulto 'IDOVI! (e.g. if brad!ioradialia, es.kmor carpi ndi.al.iJ i<JIIIIII may C8111elocal tmldmDeu. (D) On INviDg
dilhx:alld) lo11 of IMIIIIItion i1 l1lfficialt and bracbial.iJ. Its pollla:ior ~~ 1upiaator below tbe elbow it supplies
~ of uillary llllln'e invol:¥t~~~~~~Dt brach, bafcn it tllfeo the mpiaaor IDDDel. es.llmer diJj&orum COIIIII!IIIIil, extenaorl
wilbout llllti.n& muiiCie ~· supplies extenaor c:ar:pi radial.iJ lnvis aud diJili miDimi - iDdic.iJ, ell.. . . . ~
part of l1lpiJIDr. u!Darll, alxb:tur pollic:is ioQgul-t
es.llmal poUicis J.oacu• - bnMJ.
2.51. RMial .....,. Sm10ry dUtrilnlliort: 2.52. RMial nerw: COIMIOII mu q/fect.d: 2.33. II!Dmlndon of the l'lldlal ...,.
(A) 1bc terminal part (the aupedlcial radial (A) In tb.e llldlla (e.g. from crutchel, or tb.e (1): Note iD particular the followiDg: (A) Ia
nerve) aupplica the radial aide of tb.e biiCk of btck of a clWr In the ao-calk:d 'Saturday lhtrc 1111 obvioua Milt drop? (B) lllllere
the haDd. (B) 'lbc poalaior CUWICOU& brmch Digbt' paby); (B) mld-bumeru• (from wutillf of the forearm llllliCiu7 (C) lllb:R
of tb.e radial. given off In lbc appcr part of fw:turca IUid toul'Diqoct palalea); (C) lll.lllld wutillf of the ll:kcpe, IIJ&&CICiag a higl1
the arm. wppJJc1 a variable lll'ca on the btck below tb.e elbow (e.g. after dialocadooa of tb.e (proDmal) luion7
of tb.e arm 8lld forearm. elbow, Montl:ggia ~ pnglioo•, IUid
aomdjmCI lllrgical traiJma following
CXpotUlC& iD 1hia regiOD).
1.J4. EDmlndon of the nella! ...,. :z..JS_ EDmlndon of the ncllal...,. :Z..Ja. I:DIIIInallon of the ncll•l ...,.
~ Teat lbc eUeDioi& of !be wrist IUid (J): Now I2St !be mpillator muscle. The (4): Telt the tnchioradialil. Aak !be patieat
linpl. The elbow dmuld be ftexeclllld the elbow IDIIIt be exlellded to e1iJninm: the 1D ~ the elbow in lbe mid-~ pOOiion
!wJd placed iD p:ooa!ion. Sappm the wrist, aupiulinf adion of biceps. Alk the patieDt to apilllt relistmc:e. Feel IUid look for
IUid uk !be patieat tint to lr7 IUid lll'aisl*n tum hi.a !wJd wb& ycu apply coauleifm:ce. r.:oomaim in the IIIIISC1e.. Loa• of power
!be finaeJ:a IUid then ID pull t.ck the wrist: if Lou of mpiution mgrstl a lesion proximal augeltl a lelion above (proximal to) tb.e
tiJa'e i l my activity, judp lbe ltl'allth by ID lbe exit of the supillator l:llllllel. Look for aupiulor llmllel.
app1yina coun~ oo the fiDp1 or lr.lldr:mr:n owz the twJad.
hmd..
:Z.J7. Examination of tlw Mdlal Mrw 1JL Examination of the r.cllal- 1.19. Ulnar- (medial card) ca,
(5): Now tell lbe lricep&. Bmmd the aboulda- (6): Teat for ~eusory loss in the IOU T1: Mtltor dUtribldion: (A) In the forearm it
and aak lbe patient to extead the elbow, fint IIUpplied by !be uerve. Loss confiDed to lbe supplie1 flexor cupi ulnaris 111111 half of flexor
apiut gravity and Ibm apin.at R&illtalu:e. baod iDIIicaJM that the le&ion is ualikdy to be ciJ3itorum profundu. (B) In the hand, it
Weakness of triups augpm a lelion at lll1ldl proximal to die elbow. Careful aul.yais supplie1 die hypolhenar lll1llcles, the
mid-humr.nllevel, or m iiM:o.m.plde high of both the IDOtD£ and lell&my deficit& should ialmo11ei, the two mafial]mnhrical•, and
le&ion; lou of all b:kep1 activity sugplll a allow IK:CUI8le kx:ali.salion of tbe lesion. adductor pollicis.
high (plsaa) IMicm.
2AO. Ulnar...,. Sm.rory di.rtriblltiort: 2A1. Ulnar nai'WI: GHnmon altai atr.ctec1 2.42. Ulnar-- annman sn.. affected
Note that !hare m~ vwria1:10111 in the IOU (1 ): (A) In the ulDar: tu.mJel syudrome. where (2): (C) Distal to tbe elbow, by c:DIIlJIR'IUOD
supplied by tbe IIJIIIIian and ulnar DmYM in tbe nmve passes between the pisiform md the u It puae1 between tbe two heada of flexor
the hand: the wmm._t pattmn is IDUIII'ated. hook of tbe lllrr!we (e.g. from the pmuw. of cupi uhwis (ubr IIIDDB1 ayndrome). (D) A1
'I'bll bnDdi llllpp!yq the donum (A) .rue. a pqlion, or a hook ofb.amml! fncture). the level of tbe medial epiccmdyle (e.g. in
in !be fomum; loR hln iDdK::atM a lelion The molt diltalleaiau affect the deep palmar ulDar: -.itil llaClOIIdmy to looal fi::iction,
proximGI to the wri.Jt. ~~~nt~ and .., eulimy mmor. (B) A1 the pre11111n1 or~. u amy occur in
wrist, elpecially from laccnlioDa, cubitaa va1p ..t olflloarthriliJ). (E) In tbe
I!CX:I!!IM'i...., ll'8lmla aud poglicm. bndlial plema. u a 111suk af tnuma, or from
otiB' 1eailma in tbiJ IJU.
2.43. Ulnar.,.,.. ...miMtlon (1): NC>Z 2.44. Ulnu...,. ...miMtlon (2): Note 2.45. Ul•r narve . .mlnadon (3): 1he
the preaew:e of (A) iDvolunllry abduction of wbether 1hi:R is m ulDar claw band. with ulDar ~ ll1lpp1iu all die iDII:IotiCi, 80 look
the liUJc fiD&et; (B) bypotlltmr wutiDg; (q flexion of die riDg and lit& finge:r8 at the fc. the preiCIICC of any iDteroaeeoaa Dll*le
ulccnlion of the lkin, britdeacl1 of die aaila. proximal iDtcrpllalaDgea (lP) joiDII. If die wutiD&. 1he ftnt donlll iDteroaeeoaa Dll*le
and any other mdew:e of trophic ciJaDF. diltal IP joiDII are~ as well, this iJ almott alwaya the lint to bec:omc
IUggelta tbat the 1lexar digilomm prof1mdal DOticeably affected, llld the hollowillg of tbe
il il1tact llld the kaiOD il distalJ1 pW:ed: i.e. *in on the donll upect of tbe lint web
~y. the deformity of die bad iJ 1f*C 11 often molt allikillg.
lelt nwbd iD leaionl proximal to tbe wrilt,
wbe:e tileEe iJ mme motor iDvolvemalt
2.46. Ulnar nerwe ~lnedon (4): NC>Z 2.47. Ulnu...,.... eumiMtlon[S): Flex :Z.AI. Ul•r nerve ...mln..lon (6): Roll
(A) if there ia any cubia valgu• or 1VIIJ llld extend die elbow, looking fur llloorma1 tbe oerw undtr the fingers above die medial
deformity IIJ&&Citi.D& an oJd injury, nd1 u a mobility in die aerve wbtle it puse1 behiDd epk:oudyle llld foiJow it diltally 1Jiltil it
supracondyilr fracture (of &i&l'ifi...,ce in the medial epkoodylc. If the - il - to diSippCII'I under cover of lle.zor carpi ulnariJ
tardy ulnar ~~~~ne palsy). (B) Muacle wlltiq map over die medial epicoadyle, a tramnatic - lboal4 em dilbl to the IDI!dial epiamdyle..
OD tbe mt:dial aide of b forearm, coo.finnin& ulnar IHIIII'iti1 (secotldary to a ddideoqt ia N~ the pre~a~ce of any tendemeu,
a Lesiou proximal to tbe wriJt. Cam.pam cme the c..- tlw Dlllmllly IDCbor it. ia polilim) tbjcbnina, or die pmdm:tion of an 1IIIIISIIlll
beano with the~- may be diapnu:d with~ depeof~
confidence.
ZM. Ulnar nerw ...mlnlltlon (7): Z.SO. Ulnar nerve ...mlnadon (8): 2..51. Ulner nerw ...mlnetl• (t):
Palpe the Dcrve .. it liea jult lateral to the Temng the iDteroeaei.. Alt tile piUialt to bold 'Ibllill& the flnt dc:nal inlmleseoUI lllUlle.
teDdon of flexor caqU ulaaril It the wrilt. a 8bcet of paper betweeD the riDg aDd liUk> Plaoe the pMicnt'1 band in a palm-dowawardl
Follow it down to the reaiOD of the u1Dar :IIDgen. The 1iDgen IIIIUt be tully emnded. potiaioa aDd alt bim. 10 retilt wbile you
tunDd, again lookiag for Wldue lt2ldtzDeM Willldn.w the paper aDd note the reliabmcc attempt to adduct tile index. Look and feel tor
and paneldlcaia. affcred. I'D a complete peJty lhe liUk> ~ i1 contraction in the ant donal intero1eeoaa.
aoanally beld iD. aligbt abductioD and the
plltieat will be llll8bJe 10 grip the paper It all
2.52. Ulnar ne,.. ...mlndon (10): :1.5J. Ulner nerve ....,lnetlon (1 1): ::1.54. Ulnu nerve ...mlnetl• {12):
'ltsting ab:lu4:tor digiti minimi. Ask tile 'ltlling adl:laaor pollicis (I). Ask tile patient 'lCitill& llddactcr pollidJ (2)• .Alte~Dmvdy,
ptdialt 10 retilt u you llddllct tbe ~ 10 grasp a s11eet of paper betw=n the tbambl tea the pltient's lbility 10 grup a meet of
little fiD&cr 'rib your i.Ddex. Note tile and Jidel of the i.Jide%. fiDFI wbile you paper bcld betweeD the tbumb llld tile
retiatiDce offered. and compile OIIC halld with a11empt 10 withdraw it. If tile ld&K:IOr af the Q1111er/or upect of tbe index~
the otbr.r. tbumb il paralysed tbe thumb willlb at tbe
~joint, in contrast to the aood
Aide (Promtm's tat).
\ \
\\
2.55. Ulnar.,.,.. ...miMtlon (15): 2.56. Ulner...,. ...mln.tl• (14}: 2.57. Ulnar nerw -.nlnadon (15):
TcatiDg llcKar carpi ulnaria (1). Aak the ThltiDg ll.exor carpi uiDaria (2). Place Che TcatiDg lloxar cJiai1omm profimdus. ODJ.y tile
patient to reaist whilt; yw attempt to mend llaDd 011 a 11.at awface 8lld uk tbc patient to ulDar hl1f af thiJ mutele .iJ .upplied by the
the flexed wriJt. Feel fc. the 1lelldaa Jeaitt while yoa attempt to addru:t 1hc little ulDar acrve. Support the middle phaJaDx af
ligh1r.Ding at the wrilt wlillc yw ~ the llDgc:r. Again feel for 4l0Dtraction ia 1lle lllc little ~ llld ask the patient to Uy to
reaillalll:e offered. tmdoD. ~..ott of activity i.ladical:ct a lelion flex the dialll jomt Apply coontcqlre811Ure
proximal to the wriat. to lllc flaptip IUid DOte the reai~tm:e. I...ota
af power iDdicala a lelion ~~eu or above
lllc elbow.
:z.sa. Uln•.,.,.. ...miMtl• (16): 2.59. Mllclla1'1 narva {letanl e1'lll madf•l 160. Med..n ~..aery
~ far ~e~U~llli.on. Test for 111)' cards) C(S)6.7,8. T1 : Motor dillribati.oa.. (A) dlltr1butl•: Note lhlllbrre is conlliderable
dilltllrbao.:e af pinprick lell&ll:ion in !be ~re& Hmd: the tbt.Dar mu.sclt:a and !be lafenl two vada!lou in !be relllli"Ye _ . aupplied by the
supplied by the nerve. Note d!.ll~e~U~ory lois llllllbricak. (B) Forearm (through its anla:ior median and ul.ur llt:IVel. Note also that the
on tbe dortUM is indicllli"Ye of a lesion inlrmllleOU branch): ftexot pollicis lOIIJIIS, ~ aide of the posrmim upect of the hlUid
proximal to the wrilt. half of flaor digitorum profundus, proaator is mpplied by the ~ part of tbe radial
qudnms. (C) Near the elbow: :flum: aerve (superficial radial Dr.rVe) (R). 'I'he
digilmum superficialis (aublimi.), :flum: carpi ClOIIIDIDIIell pMIIm of ~~m~~ory diltribatioa is
radialis, palmaris leap and pmaatDI" ~ern. sbown.
c - --+•
-+-- 0
2.61. tMdl• nllfftl common ..... 2.62. MMian nem1 eamlnadon (1 ): 2..6J. Mtldlan nem1 eamlnllllon (Z): In
~ (A) In tile carpallumlel (e.g. Note (A) Cbenar waeti.Dg. In IODg..ftanding lcelonl of die amcrlor interoNeOUI bnml:ll, or
carpal tunDel I}'DIIroJDe, llld - fnlctwel c:uet die thumb may come to lie in tbe pllmc of die medlm Dt"ZVe illclf at or above tbe
and diaJoc:atioal about !be wriat). (B) At tbe of !be palm (Simian thumb). (B) Atrophy of elbow, thrze may be wueiDg of die latenll
wdat (e.g. from lal:c:rlti.au). (C) At !be elbow !be pulp of tbe iade:l, cnckiJI& of die DaiJI upcct of tbe forearm, and tbe iDda il beld in
(e.g. after elhow dillocalioaa in cbllilra1). (D) 8lld othl:r lrOpbic dlange8. (C) Cigateae a polition of men.iaa ('benedil:timl attimde';
In the forearm (anlaior i.ll.tuoaeoul ncne) buml md oda aigal of akin trauma but note that il1 IOIDIC: quarter~ am uiDir ~
from farelrm. boDe fnlc:Curel, or by a tigbt ICCODdlry to local~CUXY deprivation. pllly willian alnar claw b.ad bu
tiJaue band at tile origil1 of tbe IUpc:dlcialia. confllaiD&1y aaractcd die eamc tl:rm).
(E) Just diatal Ill tile elbow, in tbe proDitar
tela aerve enllapmc:at •}'lldrome.
2.64. Meclllln nerv. .-.nfMtlon ()): us. Meclf•n ne~W -..mlnatlon (4): 1.01. Median nerve -..mlnatlon (5):
'ltstmg proD111or ~~era. Bxlald tile ptticllt'a Ar~terlor blterrme011.1 bl'di!Ch (1}: 'le.t die Ar~terlor bete708HOIII bl'di!Ch (::Z): Screenbtg
elbow llld feel for coalrw;tioa in the muecle ~ of flexor pollids J..oagua in the tbamb. rut: Ask die pltieat Ill form a cin:le with bis
11 he ldlem.ptl to pouate the arm lglinst 1114 flexor digitmlm profalldas in !be illdcx i.Ddcx llld thamb 1114 presa their tipl tigbtly
taiJtaoce. Loll i.Ddk:ala a lui011 at or above by uking the pUient to try til flex !be topCber. In Ill. lllferior imr:rolleOOS paiJy the
the elbow. Aa:ompanyias pain and ~ distal joint while yoaiiJIIIIM the llmDiDal pb.al.anp of tile thumb and iDda
tendemea over proaaror Br:a ia foald in tbe pbalmx proximal to it. Lou of power here will h~ (owiJii Ill paralyais of II.J:mr
pr:ooa1Dr tau Gilltlapueut lyadrome. may a1ao occur in median 812'\'e !aioos pollids to.ps -'. tile lalrnl half d flexor
pmximalto the m:r:ri.or ~ bnoch. diptDnlm prafaadaa), but tile thr::aar IIIIIScle&
will remain illillll::t.
2.67. Median...,... .mlnatlon (6}: 2.61. Median n•rw-mlnatlon (7): 2.69. Median_,.. ...mlnatlon (8):
~rior inr.rwuoru ,.,..,. paby (3): Dillltll Hgment: Pint localr; the poati.cm of Apply arm ~11\Jl'e avr:r !be area of tbe
Scnming lttllt in c:hildT.n: Wbal a child wilh !be DI'%VC at !be wri&t. Aak !be patimt lxlllcx llltZVC at !be wri&t aod diJCally in the liDe of
an anterior D«Ve palJy il ubd lXI bt.ad the hit wri&t, dieD attl:mpt to cxteDd it while be the carpal tunDd. looking for tellderae8a.
elld joint of the iDdelt flDger be Mll111e hil remtl. Loot tc:. tbe llC:mdou wbidl ue (If the carpal Immel J}'DIIramc is IOapecll:d,
odlt:r lwld lXI do 10. 'lbillhowl tbat be promineDt at tbe ftoot, near the midlmc, apply Jll'CIIIIIe with both lhamba, timing tbe
IUiderataDdl the requelt, that movemeat of !be palpatiDg tile area if BCe~~aary. Tbe nerve liee 0111et of~ IID4 cmy out tile other
finger iaiiOt paiD!ul (U it mi&ht be ill I between (A) flexor cazpi radialia loogul ad !etta ddailed liter ill Chapter 6.)
compctment tyDdromc), lad dlat it il (») palmariiJ.oaaua (cr: adial to flclor carpi
unlikdy dlat be iJ able Ill Ulldc:dakl: the radialia IOJI&UI if !be IaUer ia lbtent).
~ llltiYely. PalJy may be idioplt!W:,
due lXI c:atrapmeDt, or follow 1 lapriii:ODdylar
tw:ture.
.2.70. Medf•n n•rw . .mlnatlon (t): 2.71. MMI•n n•rw . .mlnldlon (1 0): 2.n. Medl•n n•rw . .mlnallon (11):
Te.tmg llixllldor pollici• brevi• (I): 'lbil ~ lbdm:tm' pollicis brevis ('2): Now uk Telling llbciDI:tDr pollicD lnvia (3): A* the
Dl.Uicle is invuiably md IIXclaaiw.ly aupplied tbD patimt tD raiJe his thumb aDd try tD tcuch palilmt to nsiJt ~ yau attmnpt to force
by tbe ~ omve. To tlllt it, bep by your finger. If he 1lmds tD IIKMI his hm:l tbe tbm:nb t.:k down to the ·~ pomticm.
placing liJD pUm'l bmd, palm upwards, OD while c1rJiq 10, lleady it with your otha' Notll tbe reaiiW!a! offered; palpdll tbD
a lbt llllfKe. Hold )'OW' iallsx. fiD8er llbo9e iwld. Allen his ability tD cany out the IDIIacle to coofum illl loDII aDd balk, aDd
tbDpalm.. IDIIW!IDIIDt (he may DOt be abl.e tD do it), ad compare tbe J:IOW'S' OD the atfeded We with
loolt f<r 1'1'«'4rw1icm in the IIIIJicle.. lhlt of tbe ad..
L2345
L45 L23
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L34 5 S1 I
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L45 S12 ,, ' - . ___ ,' I
Z.7S. tMdl• nllfft a~~~~~lnadon (12): 2..74. Segri'MIIItlll nerws In thei-r 2..75. MJotom• (Z): FleDoD of the hip
'Th8tillg for eeuation: Look for implirmellt of limb: ~~yo:ome, (1): As prcvioullly deaaibed (maialy llioplou) ia c:onttoUed by 1.2,3.
eeaaation 1D piaprk:k ill the me of ia relation 1D die 1Jill)a limb, the geDCr8l. Extauion of tbe bip (nWDly gluteua
dillributioa of die D«VC. 8l%8llgCml:8t ia dlat four ~ulive apiDal maimulf 111111 die bamJtriDg&) it CODtrolled by
8Cglllel111 COIIIJol ead1 lower limb joint. Ia die L4,S (Ll,3 llJo control iDtemal rollltioD, md
cue of the lowet limb adberelll:e to dliJ plaa L4,S Wcmal ro1lltiaa of the hip).
ia more r:igoroua. 'lbe progrea&ioa of CODtrol
from hip to llllkle ia abown ia die dilgnan.
L45
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2.76. M,otomet (1): Bxtenllon of die bee 2..77. MJotomes(4): Dorsiflexion oflhc 2..71. Myammes IS): It ia abo 1IJCful to
IIIII die lmec jed;: (~) ia COIIWlled llllde ia controlled by IA,S (mainly libialia !mow that invenion (mainly tibialis llllferior)
by 1..3,4. Flexion af tbe lmec (mainly llll=iot and tbe ioD& ~ of tbe hallux ia COIIWlled by IA. Bverlioa iJ ~by
blmJtriD&a) is CODIJolled by 1.5, Sl. IDd toes). Pltmar ~leWD. iJ controlled by 1.5, Sl (tbe peroaei).
Sl). (mainly the mulcle1 of die calf). The
lllllll: legmt:llb CODl:rol. tbt: ankle jerk.
2.7t. O.riMIG-: R.emmnber by !be

followiu&: !be aide of the foot. s1, il
IXIIDIIDily involvtd in J..S...S I clisc IRiom.
l2 15 I'MIIIpl from the medial aide of !be foot
~t 1D SliD the lalllnlllide of the leg. IA
ocwpia the !lllldiallide, 1..2,3 ocwpy the
tlqb. It may be bclpful to remember 'we
~~ ClCl Sl, kDccl oa L3, IDd lit ClCl 53'.
Sl
2.80. Pertpher•l...,... of the ...., limb:

1bc most importiDt IIICl'ml of the ~ Other bralldles sboWD include the padeodal Tbe lum~ tronk ia formed from L4
limb are: (52,3,4), the iliohypogastric llld ilio.inguiDal 1114 15. In ita propas it cro..ea the triagle
1. 1bc femoral (1..2,3,4) (Ll), 1114 the geaitofemoral (Ll,l). Not of Mald1le (bou.Ddecl medially by 15,
2. 1bc oblundor (1..2,3,4) illustrlb:d are the lateral c:utallcouJ nerve of infieriorly by the proximal ptll't of the I8I.:NIJI.
3. 1bc superior gluU:al. (IA,S Sl) lbe tlligb ([.2,3), the IIICI'VCS ID quadratus 1114lall:nlly by the medial bordc:t of p60U),
4. 1bc infierior glu11eal (LS, S 1,2) femoris and the iDferior gemd.lus (IA.S Sl), wbtze it may be Talnerlble to local presAR
5. 1bc sci* (IA,S 81,2,3) 1114 ita two lbe ~~C~m~~ to obturator in11emus 1114 the 01' ~ (Some con.idcr lhlt allUID.ber of
divilioal, the tibill (IA,S S 1,2) llld auperior gemei]Q (LS 51,2), the nerve to aues of drop foot 1114 olDer IIClQI'Ological
eommoo pcroueai (IA,S 51,2,3). piriformiJ (S( 1),2), the nerftl to 1ev1tor ani pobleml ocauriD& ialate ~may be
aDd the emma~ spbiDCtr:r ($4). dae to invalvemem af the hmiboucral tronk
n!brr lhm diJc polaple.)
2.11. hmoral.__ U, S, 4c (1): Motor 2..12. Femoral namt (2): Snuory 2..1S. r.mon~lnarw (S): SiJe1 of
diltribulion: (A) Above o.e.
proximal to) the di.rtrilnltion: On c:mc.rgiag below the iaguiDal ilrvolwlflertt: Qoeed lelliou of the fi::mora1
lDgumall.igamad.lhe fanonllocrve aupplle• l.igamad. it IU]Ipliea the front d the thigb. aervc arc nrc. JJamagc may occur wbiz a
UiopiOU. (B) lhluw the in&ulJW l.igamad. it Tbc tamiDal part af the faDonll ar:rve haemaloma ia formed In the iliacut DlUICle,
aupplb the quaddctp1, lart0riu1 aDd (reJWDild the eapbenou1 aervc) aupplb the caulin& local preamre. Tbia ia - ill.
pcctineua. medial aide of the leg aDd the foot. haemopbilia aDd In c:xlallion ~urlca of
the bip.
2.14. Femoral nerw (4): 1't1U: (A) Thlt 2.15. Common ...,_..1 nerve (lateral 2.11. Common ...,_..1 nerve {2):
tbe qiWirU:cpl by uk:.iDJ tbe patient to emn4 popiMMQ; L4,5, $1,2 (1): Motor Souory dUtrlbldloll: (A) The firat web spue
tbe knee lgainlt taistance. (B) Thlt the ~ (A) Musc:les d tbc anterior (deep ptZOilC&l CODtribGtioa). (B) Tbe dorlam
ilioplou (hip flexion lpbllt taistance). The compartment (tibialis anterior, ex1alsor d tbc foot and lhc front IDII side of the leg
tel(lOII80 to tbeee ~lllboalci clellcmlinc tbe blllUA:U longus, exteoaor digitorum.loqu, (Aipel'fi.eW peroneal r;ontr:ibution).
level af any lesim. In dod:ltM caes 1ry to pero~~eQ tertiu). (B) Muscle~ d pc:lOIICil
elicit tbe knee jedt. Oblen'e Ill)' quhicepa compartment (peroaeus brevis ud loqu).
wutiDg, and tat for lets d IICIISalion to (C) On tbe foot, extcn5or digitorum blms.
pinprick in the area supplied by tbe nerve.
211. Cammon,.,.,..... ntna (J}: Sit.z 2.11. Comm• peronul nerve (4): 2M. Cammon r-er-1 n•,. (5}: '111m:
uJ mvomm.rat: (A) A1 the fibular uc:k. e.g. Deformily: The paDeot will blmJ a drop foot (A) Aak.lhe paDeo1 to dorsiflex the foot (deep
from IJIIuma (e.g. lallnllipmelll ~uriea of IUid Ibm! will be diltur:bii!We of the gait: per:OIIII81 br-=11) and (B) to evmt the foot
the~ cti.nK:t blow.), lllldjnml pnrzun, either the leg will be lifted high to allow the (aupediclal plll1lDII8l branch). Tt!at fa£
e.g. from plulm c:uta (m the llide inm af a plaotarflexed foot to clear !be grouod. or the _..lion iD the arM af distribulion of the
Thomas ~plilll), gauglion, lldwmia (e.g. foot will be slid along the p1)lllld (1111!llting omve. Note my wasting of the front or lide
toorniquet). It l.e allo involved iD • DDmber of iD rapld IUid obriowl1ll1ilalenl wear of tile of tile leg.
aeurologklll dilordcn. (B) Dlltal to the shoe).
fibular DeCk. e.g. iD !be aotmior ~
IJD'kome, wbn !be deep ~ br-=11
may be llfl'a:tlld.
A A
c
D
8
:LtO. TUMI _,. (I"MCCIIII popiiiRI) (1): 2.11 • n111111 Ml"ft (2): s,_,r, tlimiiRIIion.: 2.tz. 11bl•l ..., . (S): c- rit.z of
LA,5, 51,2,.S: Motor di.rtrihtioll: (A) Solcwi (A) Tbc IOie of foot dlrougb 1be mediallllld ini'Olwnwl&t: (A) Whm pUiiDg Wider die
lllld tile deep mu.cb of 1be polteriar lab:ral plantar ae:rvea, wll.<* 1r:nicty loleal. llrdl, e.g. from pnWmal tibial
compatmcnt (tibialil polteti«, flaor !Wluda iDcladea (B) 1be ll.lilbeds lllld diatll Jilalu&a ~. (B) From ja:lw:rnic biou of the
lcmg1la, flcl.ar digifomm lon&U•>· (B) All 1be 011 the donal alllflcea of tile toea. Note lhlt ell! (c.,. from tiaht plum aDd thc poltel'icl'
maacla of the IIOic of thc foot throu&h iii thc lide of the foot l.e lllppli.ed by 1be mnl compatlllalt IIYIJdromu), aDd from cliabetic
tenDinaJ. bnDocllet d tile mcdiall.lld lmnl ocm:, wllicb iJ ck:rived from tile tibial ocm: DCIIEOpiiCby. (C) WbeD pulia& bdliDd thc
plaDUir lllln'CI. It 1110 IUppliea &llltroc:Dcmial aDd the CCCDDOI1 pe:rcoea1 ocm:. medill mllkciDI (e.g. from laceaitiCII1s aDd
bdarc pulin& 1IDdcr 1be IOleallrCh. ~). (D) Wben ia tile foot (e.,. iD the
buill tumid IIJIIdromc).
-./-....-- 0
~---E
2.93. nblal n.,. (4): DiopMil: Note any 2.94. Dbl•l n•rn (5): PTO%imDlluiolu of 2.95. Sd8tlc...,. (1 ): 1.4,5, S1,2,S: Tbe
mueclc wudDg in abc IOlo af abc foot, tho DttVe (Le. u it llee in the popliteal fotea) ID1110t lDclude lhoae 110011 in bolh tibial aod
clawiD& of tbc IAlel aod trophl.c ulccration. arc II!MlOIDman owing to the protecdon common peroneal D«VV palaie1. Motor lo.r1:
(B) That tho power of llJO fiaion. (C) Look a1Jardt:d by the alllTOWldiDg 80ft tialuee, (A) 1bc bamalriD&e in the lbigh. (B) Tbe
for eaaaory IDat in abc arc. IUPPlied by IUid the IJIICO IV1ilabl.e to accommodate IUperllcialiiDd deep lll1liCiu of the calf (tibial
the aenc. expaDdiDg bicm. Tbe filldiap are ~). (C) Tbe IIIIIIClet of the IOit of the
e1ecaially tbc same u in diatalleaiou, foot (IDICdial aDd lafcral plaDtar oena). (D)
but wilh wa8liDg aDd Iota of pcnw:z of 'lbc peiiOIId (auperllcial peroacal). (B) The
p!mtufle;don owillg 1C paralyait of antai« compartm~:at muecla (deep
gutrOCDemiue u well u tho aoleua. peroaelll).
2.16. Sclldlc n•rn t2.): Snuory los1: (A) 2.17. Sd8tlc...,. (3): Silet involwd: (A) 2.11. Sclallc ._,. (4): Diaposil: Note
The eutim tole of tbD foot. (B) TbB clanwn BebiDd tbD hip, e.g. llfiE pollmior dialoc:lllion uteuai'ftl wulinJ in (A) tbD thi&b, (B) tbe
of the fooL (C) The ~Ural upect of the lee of tbD hip, l'liRily afta: IODle pelvic fm:tilnll, calf, aod of tbD pllnlllfli, aod (C), tbD BOle of
mMIImnl half of tbe calf. Note that the aod afta: hip lllli«Y· (B) Followiug d.p tbD foot. Nllfll (D), a drop fooL Observe my
medillllide of tbe calf mMI foot a. tplnd. H WtliiDds in tbe baa. of tbe thigh, which - trophic uh:marlcm. Nllfll ID11 of power in tbe
tbc pottedor ~ acne of the lbi&b i& allo \JDCl'lllmon Do DOt confuee a IICilliA: blmlttinp md Ia Ill tbtte compartmcDb
involYCd, tblft !1 lou of -.daD • abc back pliJy with root iavolYOIIICDt Ia iDt.crvcndnl below tho bee, - abiCIIllllklc jelk. md
oftbc lbqb. diec proilplc. extcDit~ 11C11101Y lou.
2.99. ......,., mtlin•u• ne!W of thigh (1) 2.100• .....,.. cutMeous ne!W of thigh 2.101. Newologlml mntrol of 1M
(1..2,3): The IIIIMI piiiRJIIII or p - UDdm the (2): 1Ut: Pressure over the IIIIMI may give blaclder1 Not•: (a) Autonomic fibru
l.aknl portion of the inpinallipmlmt and rile to parH&Ibesia in the thigh. Teat for CXlldrollhar the detnuor muscle of the bladder
supplies the lallnl upect of the thi&IL It may Mllllory .imptlinnent ill the IUUIUpplied by IIIJd the inlllmBl sphinc1m travel from cmd
be~ by the iD&uiDal n.-t. the IIII[Ve, Jellllllllb 82, 3 and 4 to the bladder 'ria the
c:uda equina (1). (b) Under lllli1DIII
giving rile 1D pain and~ in the
leg (meralgia p~). Note, hoMM:r, cin:umatucel bladdtt ICIWIIion and
that symptomJ with the same dillrllrudon wbmtary 12Jlptyin& ll'C mcdian:d through
may 00011[ IMICOIIdaiy to llpiDallfml.olis. palhwiiYIItrtlfclliac ~ the 1mlii1111Jd
the lla'l1 ceatn. (2).
2-
t t
2.102. Neurologlml c:antrol af 1M 2.101. Neurologlml c:antrol aftM
b!Mder CDntd.: (c) If the cmd is~Il~Dl~ec:~ed. bladder CDntd.: (d) Injmiea tiW damage !he
llbove L2 (e.g. by a lboncic: spiDe f'rlll:ture) uaal ceolrs (1) or the ClRida (2) ~
voluntary c:omro1 is loll, but the poflllltial for c:oordi.ull!d rellex conb:ol of bladder aaivily.
c:oordiDarecl conlnK:Iion of the bllddm wall, Bladda" emptyiDs u alwaya inoomplete and
nllaWim of the •phiDI:tm" aod complete in:egu1-. and occun only u a raull of
emptying mnainJ. (Normally 200-400 mL of diltrmi.OD. Ju efli.c:imlcy varia wilb the
ariDe are paaed. rrvery 2-4 houn, the rellex ptdilm'• lUte of hm1th. the ~ of
IICCivity blii.q trignd by rWnc iUddm' .m.:y iD.Iilctioa, aud !DIIcle JpUIIIJ.
JIIWSUie or llkillll1imD1aticn.) (Autcma!X: (Autouomou1 or iJolaaed atoaic biaddllr.) Ia
bllld.d« or c:ord bladd&) IIUIIIIIIIIDJ, lhe eft'ectl 011 the bladder are
dc!pmKimt an the level of illjwy.
3
The cervical spine
Postural neck pain 34

Ac.U«! neck pain In the )'Oung
adult 34
Cervical spondylosis (cervical
osteoarthrosls: osteoarthritis of
the cervical spine) 34
Thoracic outlet syndrome 35
Whiplash and extension Injuries of
the neck 35
Barr~Lieou syndrome 36
Rheumatoid arthritis In the cervical

spine 37
Kllppei-Ferl syndrome 37
Neoplasms in the cervical region 37
Osteitis of the cervical spine 37
Inspection and palpation of cervical
spine 38
Examination of cervical spine
movements 39-40
Diagnosis of thoradc outlet
syndrome 40-41
Diagnosis of cord compression and
cervical myelopatny 41-42
Examination of radiographs 42-45
Radiographs of cervical
pa1hology 45-47
POSTURAL NECK PAIN

In this common condition, pain in the m:ck. and shoulders oCCUia in
association with some abnotmality of neck: posture. It is commonest in
females under the age of 40, many of whom have sedentary jobs (such as
computer operators) which entail the head being maintained for long periods
in a position that may be short of ideal. In some cases there may be a
history of minor trauma which exacerbates or precipitates tbe complaint
Clinically tbe head and neck: may be beld in a somewhat protracted position,
with some loss of the nonnal. cervical curvature, but there is usually a full
range of neck movements with normal radiographs. Analgesics and
physiotherapy are usually helpful in the acute case. but in the long term
change of woti practices and in the patient's working enviromncnt are
likely to be of the greatest benefit
ACUTE NECK PAIN IN THE YOUNG ADULT

In the 20-35-year age group, and often befcn the.re is any radiological
evidence of arthritic change in the spine, a sudden movement of the neck.
may produce severe neck: and arm pain accompanied by striking protective
muscle spasm and limitation of cervical movements. In some cases these
symptoms are produced by an acute disc prolapse similar to those OCCID'ring
more familiarly in the lumbar region. In others, with identical symptoms,
investigations including MRI scans may be quite negative; some disturbance
of the facet joints or related structures is often thought responsible. Most
cases respond to a period of rest in a cervical collar, or physiotherapy in the
form of traction. In a few resistant cases gentle manipulation of the cervical
spine may be helpful
CERVICAL SPONDYLOSIS (CERVICAL OST!OARTHROSIS:

OSTEOARTHRmS OF THE CERVICAL SPINI!)
Cervical spondylosis is easily the most common condition affecting the
neck. Degenerative changes appear early in life in the cervical spine. often
dwing the third decade. The disc space between the fifth and sixth cervical
vertebrae is most frequently involved. 1he earliest changes are confined to
the disc, but the facet joints and the uncovcrtcbral joints Goints of Luschk:a)
may soon become involved. There is inevitable n:striction of movements at
the affected level, but this is often impouible to detect clinically as it is
masked by persisting mobility in the joints above and below. The condition
may in fact never attract attention, but unfortunately in many cases
symptoms do occur, sometimes being triggered by minor 1rauma. Pain may
be felt centrally in the neck. and may radiate to the occiput. giving rise to
severe occipital headache which may be confused with migraine; pain may
also radiate Wstally, often and inexplicably further than might be expected
on anatomical grounds, to the region of the lower scapulae. Often there is
pain at the side of 1he neck. quite shatply localised, or in the supraclavicular
region. With necve root involvement from arthritic changes in the facet or
uncovertebral joints, there may be radiation of pain into the shoulders, atmS
and hands, with paraesthesia and. on rare occasions, demonstrable
neurological involvement; this may include absent arm reflexes, muscle
weakness, and sensory impairment
THE CERVICAL SPINE 35
In cervical spondylosis the cervical canal may be narrowed by

osteophytic lipping of the facet or 1liJCOVertebra1 joints, by central disc
herniations, by thickening of the li.gamentum flava, or even from local
cervical vertebral subluxations associJWd with ligamentous laxity.
Developmental narrowing of the canal may be an additional factor. The
reduction in the size of the canal may lead to cord compresaioo (cervical
.spondylotic m~lopathy). The di.stwbance of cord function that resulbl may
cause neck pain, difficulty in walking and unsteadiness on the feet,
numbness, paraesthesia, weakneu, and lou of upper limb dexterity. There
is often coexisting compression of cervical nerve room, leading to radicular
symptoms which may complicate the clinical picture. Bladder dysfunction
may occur, but is not common, and extensor plantar responses may appear
late. Severe progressive myelopathy from spinal stenosis often requires
operative trea1ment by decompreuion and stabilisation.
Vertebral artery involvement by osteophytic outgrowths or local spinal
instability may cause drop attacks precipitated by extension of the neck.
Osteophytes arising from the anterior vertebral margins may sometimes,
because of their size, give rue to dysphagia.
The ma.iostay of treatment in spondylollis iB the judicious use of a
cervical collar and the prescription of analgesica. If root symptoms are
prominent, intermittent or continuous, cervical traction is often employed.
Manipulation of the cervical spine, especially in the younger age groups
with no nemological involvement, is sometimes advocated. Severe,
protracted symptoms may be investigated further by MRI scans, or
myelography followed by cr scanning. If a positive lesion is demonstrated.
exploration may be carried out; if not, a local cervical fusion may
sometimes be advised.
THORAOC OUTLET SYNDROME

The lower trunk of the brachial plexus and the subclavian artery pass
between the anterior and middle scalene muscles and over the first rib.
Compression of these structures may result from a cervical rib, a definite
but rare occurrence. Slightly more commonly, the same structures may be
kinked by fibrous bands or abnormalities in the scalene attachments at the
root of the neck. or by a Pancoast tumour. Paraesthesia in the hand is
usually seve.te, and there may be hypothenar and, less commonly, thenar
wasting. There is sometimes sympathetic disturbance, with increa&cd
sweating of the hand. The radial pulse may be absent, and other signs of
vascular impairment may be present Complete vascular occlusion,
sometimes accompanied by thrombosis and emboli, may lead to gangrene
of the fingertips. In some cases symptoms may be precipitated by loss of
tone in the shoulder girdle, with drooping of the sboulden; in such cases,
physiotherapy is often successful in :restoring tone to the affected muscles
and relieving symptoms. When vascular involvement predominates,
arteriography and exploration may be required.
WHIPLASH AND EXTENSION INJURIES OF THE NECK
Whiplash i:Djurics a:re now a common cause of persistent cervical symptoms.

A true whiplash injury occurs classically when. as a result of a rear impact.
a stationary or slowly moving vehicle strikes another vehicle or object in

front. Became of the inertial mass of the bead of the car occupant. there is
rapid extension of the cervical spine followed by flexion. In the partial
whiplash injury the main element is extension of the neck; this also
commonly occurs as a result of a rear impact, but in this case the vehicle in
which the occupant is travelling comea to rest more gradually, without
striking anything ahead. Unfortunately, the attractive nature of the tmm has
led to its misuse, and some recommend that becanse of ita present
imprecision it should be avoided altogether. If, however, it is going to be
mcd, then it should be reserved for soft tissue injuries of the neck where
extension is the main element. In the majority of cases the radiographs show
normal alignment of the cervical vertebrae, but occasionally small avulsion
fractures of the anterior margins of the vertebral bodies give evidence of the
forcible extension of the spine. In some cases there arc minor fractW'es
involving the uncovertebral joints. Where there are spondylotic changes that
interfere with the dissipation of the forces involved (because of localised
areas of rigidity in the spine), there may be avulsion of anterior osteophyte&.
The flexion element may sometimes produce wedge compression fractures
of the vertebral bodies or avulsion fractures of the spinous proce!IBes.
Nevertheless, the discovei}' of unequivocal pathology in the spine is
uncommon, and it is now apparent that there is a significant non-organic
element in many cases. Although m.alingering does occasionally occur, this
is considered to be rare. It is thought that in many cases a significant
component of late disability is psychological, even if this is not at a
consciow level, and that psychological elements and sometimes
illDess-related behaviour are often establiahed within 3 months of injury.
Symptoms of all degrees of severity may be encountered. There is always
pain and stifl'ue8s in tbe neck, sometimes with neurological disturbance
involving the upper, and oocuianally the lower, limbs. Even IIlin<r
symptoms may be most proiiacted, often lasting 18 mmths or longer. In
some cases disability is permanent Analgesics for short periods and an early
return to worlt are generally advocated. and it is thought best to avoid the
me of cervical col.lars.
Severe extension injmies may occur in falls (often downstairs), when the
neck is forcibly exteDded as the head strikes the ground There is often
telltale bruising of the forehead. In a car accident an unbelted occupant may
also suffer severe extension of the neck in the early phases of deceleralion,
when the forehead strikes the roof aDd ricochets backwards. In both sets of
cireumstances the head injury may attract prior attention, but the possibility
of these injuries must not be overlooked. Cervical spondylosis again has a
deleterious localising effect an the forces involved, and the neurological
disturbiUlCC may be profound. In some cases thrombosis emends from the
area of local cord involvement, so that there may be a deteriorating and
somdimes fatal neu:rologi.cal outcome.
BARR~-LIEOU SYNDROME
This may follow a whiplash incident There is complaint of headache,
vertigo. timritus. ocular problems and facial pain. It is thought that it may be
due to a sympathetic oc:rve disturbance at tbc C3-4 leveL and in 75% of the
cases tbcrc is impairment of sensation in the C4 dermatome, with weakness
of shoulder and scapular movements. Myelography may show nerve root
sleeve disturbances. Good results have been claimed for anterior diacectomy
combined with local cervical fusion.
RHEUMATOID ARTHRITIS IN THE CERVICAL SPINE

Rheumatoid arthritis frequently involves the neck, often in a patchy faahion
ao that additional stresaea are thrown oo the rema1ning mobile elements.
Wlth the ligamentous stretching that often ~ Jheumatoid arthritis
there may be progressive subluxation of the cervical spine, particularly at
the atlantoaxial and midcervicallevels. As this progresses, pain and stiffness
in the neck become accompanied by root and cord symptoms. In the case of
atlantoaxial subluxations there may be severe occipital headache. The gait
tends to become ataxic and there is progressive paralysis, often with bladder
involvement. These lesions are usually trea!ed by local cervical fusion if the
patient's general condition permits.
KLIPPEL-FElL SYNDROME
In this condition there is restriction of movements in the cervical spine
owing to a congenital abnOl'lDAiity characterised by a failure of the c:ervical
vertebrae to differentiate. One or more groups of vertebrae are fused
together, and the condition may be associated with congenital elevation of
the shoulder (Sprengel's shoulder). The condition gives rise to an increased
susceptibility to injury and often neurological compromise.
NEOPLASMS IN THE CERVICAL REGION

'1\mwun! of the cervical spine are rare, sec<liKiary deposits being the most
CQIDDl()D.They may cause vertebral body erosion or collapse, affect iasWng
nerve rootB, or give rise to cord involvemcot. Of the primary tumoon in this
region, sarcoma and nwltiple myeloma are the most common. Primary
involvement of the cord may arise with meningiomas and intradural
neurofibromata, which may also affect isolated nerve roots.
OSTEITIS OF THE CERVICAL SPINE

Osteitis affecting the cervical vertebrae is a rare occurrence in the UK.
Thberculosis, when it occurs, is seen most frequently in children, and may
produce widespread bone destruction, vertebral collapse and cord
involvement
s.1. lnlpectlon (1): Note my 4I)'IIIIMiry m S.l. lnipfttlon W contd.: 7brticoUil s.s. .......... (1): Begin by lookiag b
the ~~~pnu;/4vU;rdar/oll4e: 1hil will require contd.: 'l'be ~!tad ia tilted aad. rotated, die tenderDCII in 1be lllidline, woddDg from the
8qlll8te investigation (e.g. Pancout tumour). atl::lno!DI8toid cord-like, IUid tbete iB often oodput ciUIIlly. 'It:adc:rneaa loiJaliJed to one
(l) Note the prea= of torticoUil, wbc:re the r.:ial uymmetry. ID w;q•i'fWI torticollil ~pace 11 common in c:c:rvical !lpOIIdyloaia, aad.
bead is pulled to the lffedcd lide IUid the ~ mu.cle S]ltill1 may remit from JIRlllb mme rudy IIOCOillplllies iDfec:tiou of
dlin oflm tiltecl to lllc oppotite. In COflprailal tonlillar or vertebral body infl=c:Ci.oiL 11 i1 lllc ccrvicallpJae.
tol'tlcollil tbcre may be in the iDfant a amall IIO"'dimea seen accompanyillg lllc Klippei-
tamour in the at=DomaltoJd m\IJdt, llld in Pcil 5)'lldromc. 11 may aiJo be doe to a
lllc 'Uilfrelted caae aome r.:ial uymmetry. vertd:nl ma!!!lignmen~ (especjally It the Cl/
NB: in about a lllird of c - 1be llmmmal cz level), from trauma or apper retpirltory
bead poaure is doe to OC!IIar ~mUCk iDfedioD. In advaD=l .i.ufec:tiolliiUid tumourl
weaknul, llld I epecialilt ocolar UlaaneDt the held may be npported by die blllda.
is IDIIIdltory in rHry cue.
SA. Pllp.tlon (2): Now palpllfll the bdmal U. hi,.Cion (3): Conliuoe palpation S.6. Np.tlan (4): Comp!BII palpllioa of
upecla of the wmbrae, Jookin& for IIWMII into tbe aupraclavicular fouae, J.oomng tbe JJeCk by um~ining the antsim 1tr11a1m1a,
- tmJdaDmL Note that tbe 11101t pmmilleat pG1K:ul.ly Cor the promiJ:woce of • anical includiq the thyroid sJ.-1.
llpinoul procliiM il lbat of Tl, - 1101 the rib with local tlmdemeu; look aiJo for
~ promi.Deaa, c:7. tlliiKa :mana aDd Sll.ar:pd ~allyqlb
IIOdea.
3.7. Mon!Mnts 111: Flmon: A*. the 3.8. Mowlftllftts (2): &tmrioft: A*. the S.t. Mow-ts (S): Rccordlag motion ia
patient to bead the held forward. Normally pa&nt to tilt the heed beckward. The patient the cervical apiDe with my llllCili'IC)' it
the cbln can be brougbl dowa to touch the mould be aeatec1 (prefuably Ia a high-backed ditlkalt. but may be attempted 1laiDg a
region of the a~ jointa. 1bc chair) 8Dd erect. 'Ibt plane of the note aad lplhlla in the clmchcd b:elh u a poimer.
~ dJitaiiCC may be mcuured for fordlead ahould DOmlally be DC8tly StiDd bact, IDd ut the pltialllrl flex the
record purpoec:e. horizontal, bot goa1'd agai.Dat COIII:ribulory bad fOrward. Lillc up the leg• of a
lllaracic md lmDbar spine IDIM'2IItllll. gonWmt1rz with the ipiUula aad thc
horizontal, rttpeetivc.ly. Read off the
iar:Juded~
NGIIIIII r-. = ...
3.10. -.....entl (4): Now ut tile pltiall 3.11. Movements (5): Lakrul/fakm: Alk S.12. Mftementsl6): Lat~rul jlakm: For
110 extald tile held 110 meu~ tbcranac of tbc pltialt tc tilt bia head on 110 hia rigbt greGet .ccur~C)', I llpalula clcarlJcd iD the
cx11eD&ioo from tbe oeutral posilioo- ~- lD tbc IIIOI:Dial. cue lJterll kltion. llceCii ~ ~&lin be 1IICd U I poill=
NGIDW raup = W. 1be rottll ran&e in tile with only sligbt Jbruggi.ag of tbe ~boulder, NGIIIIII r - . = .UO. Aboot a fifth of this
flexion 1114 cxteation pltaet llloul4 be will allow tbc elf tc &ouch tile llloaldc:.r. movanent OCCUl'l at tile llflantnnjaJ 1114
--.d. eithcr by •linP ~ l r Rqleat on tbc odlcr aide 8lld aoec any at~anto-«eipitai jomu. Lou it COIDliiOil m.
by the wnwnatioo of llcxioa md extrmi011. ~ cenic:al !lp08dylo8il.
Nenul raiiF = 138". Of thia tolal, llboala
fifth CXCUl'l in the "". . .xlal and atlan&
occipital jcials.
3.13. MOMIMIIb (7): lf lateral ~!Won 3.14. Mowm•nts (8): Rotolion (1): Alk 3.15. Mannl.nts (9}: Rotation (2): AplD
CIDIIOt be carried out wiChout bwlrd lltxioo. !be patient to look over tbe aboulder. Tbe a IJl8IU]a may be uted u a polDter fur
1hia is indicative of plllhology iavnlvilla die movement may be cacouragcd with one hand ~
atlanlxluial 111111 at1aDto-cccipital jaintl. aDd ~of the ~boulder rcatralacd with NGI'IUI rtiJIP = 10" to either llldc. About a
!be oth«. Normally 1ht cbin tan• jast abort of third of thil occun iD the lint two cervical
!be pJallc of tbe lboulden. joiata. R.oUtion i1 lllllllly rcatrictl:d lllld
paiDfal in ccmcai 8p08dylolia.
3.16. CNpltus: Spmad tbe lmnda em each 3.17. lllonclc outlet syndroiM (1): Thil S.18. Thol'llck ou&l qndroiM (2):
side of the IlliCit aDd uk th8 pas:ieot to flex may !Malt from imolWJ:Ilellt of tbe lpiiCII PaJptde the ndia1 pahe aod apply IIKtion to
aDd extald tbe apiDD. Fu:et joilll CMpims is betwiiCIIIIICilams anttl:ior. ac:alemD IMCiilll tbe llllJL Oblitmmiml of the pulle il not
nonr.W1y ~ ia thil fahioa. aod is a aDd the lim rib, 10 tha th8 mbclavian lll1llry ~tic. bat wiJm the llllt :nMIIib DO
CODIIIIOII 1iDdin& in ~ llp(llldylolia; if in IUid/or tbe lllllmior primuy IliDli of th8 lowtlr clJm&e wb.ea repeated 011 the O(ber side it is
doubt, aulalllllfll 011 eithm- aide of the lpiDe anica1 aDd lint thcmlc.K: DeJ:WS may be IIJIPICiye. Note that the syudrome occun
wbile tbe pGieDt flmel aDd extlmdl. affected. Becin by looking for eWimce of mOll COIIIIIIDIIly whm the ~pace illlllliOwed
iacbamnia in cme lmld (e.g. coldoMa, with :fibroaa t-da or ott. J~Gholocy, mrh
diiCOlcnticm, 1:rOjlbk chaps). BilDt•ml u a anK:a1 rib or a l'aiKlout tliiJKJm'.
cllmt.ru m1 Illlll1l in flmlur of Rayu.xi'1
di-.
3.1t. '111-tc outlet tyndrome S.20. lhor~~ck outlet .,ndn~~~~e: A!bon:r S.21. lbOJMic outlet ayndrurne (4): 'lhe
(3): Ad.ron ~ tut: Abduct die lhouldcr to tnt contd.: The paliC'.IIl ahould then CJdlale, Rcxn r.n: 1bc lhouldcrllhoald be abducn:d
about 30" aod l.ocafe tile l'ldial palJe (wlili::h look forward, aod lower the arm to the aide. aod cxtttDally rotated, aod the elbow• flexed
is uiAimtd 1D be prtiCllt). Now uk die The pulae obcaiDccl in the tint po&ltion lb.ould ll'l a ri&ht aoaJ.c. (Inlhia poeilioa the III1DI ae
peticDt 1D tam hil bead tally to die lffccted be COII1p8%lld wi1h die 8CCOIId. Obliteration or in the aptly named 'IW:IeDder' potitioa.) Tbe
side. He lhoald lbca be ubd to lAke aDd redllctioll, eapecially if there il dup&atioo of haodl DruJd be repealloclly aod llowly
bold I deep brealh. die patkat'a symptom.~, ia uually aipiflcaDt, clt:adltd for up 1D 3 mimltce. Neurological
but llOmpiiEC die &idea. Tbe 1l:at may alJo l!ldlu vucul8 aymptoml, aad early
be tried wi1h the head rotaled to the dieappeatRDCC of the radUl pulae OD the
oppolli~ llide. afrec:lcd aide, 111C hi&biY aignlii4J1111
J.D. Cord COMpi'MSion Mel CIII'VIal

~ (1): In tim cooditioa
dyllfuoaim in the cem:at cord JemJb from
local ~It may be let:D wbem
~here il developmeatalllllTOWiDg of the
~!pinal emil, ar follow old 111111Dilrd fDcmre1
of the dens, ar spiDalsubhaatinn1 Jt may
occur in cervical spoodylosis (from
olltmJi!ytes protruding poslr.riorly from the
vertebral bodies or from the 1lllCOVel1dnl
joints) ar from cervical dUe pmlaplea. The
main fiDdina is of m118Cle weatne. which i1
paler in the upper dian in the lower IUnb..
In 1M tum~ lower motor aigu Ill: the level of
1IJe COIDpreWOD pmdnminate (altboush lhere
may be a llliDd lesion). In tM I.gs them
il a lower IDDtor lesion. which may iDdude
~ lower limb reflexes, clOil.'DI,
an extzmar pllllllar respcm.se, lou of
propricx:eption, 8lld often a broad-based or
ataxic gaiL E11ensor plantar respouea are
lale in Ollllet, aod the IMmOI)' deficit il not
3.22. '111-tc outlet ..,ncl10me 15): Look dmmatomal The differantial cliagDoUs S.24. CervfceiiiiJIIGp!dhy (2): (a)
for neurological diltmbaDce, PIYill& pllltii::Qlar illcludes lllllltipkl sclerosis (where there are Hoff- 'I tell: Rlpidl.y at=ld the diatal
att=tioD to myotxlma!IDd demlatomea. Note usually almoaDal. c:rmial nem1 1i.odiJI8•). phallllx af the middle fiD&er by fl.aiDg its
any hypothenar or, much lela commouly, amyotropbic latmalllcla:om (wbln there il 111tcri.or lladlce (i.e. the pulp): the felt is
thc:Dir wuting. Note 111y dillmbaDce of die DO al.tlntiOD in HlllaliOD), I)'Iingomye1ia, pomiYC (indicati!lg ~
paUem of ~Welting .ill tile bml (6): lllbaculll CCIIIIbiJied degeoenaioa (where tbe d~ if it retailS infk:xiOD of 1fle
AuiC!Iltae over tile IObclaviaD mcry. A cliflilreace betwea1 the 1i.odin8• in the upper illferpbllaD&el joinll of tile 111omb aod iDdc:L
mmmur is ~aCF~tiYC of 1lli"C""icll IIIII lanr liiiD il leu llli1in«), apiul cord (b) Dyttlllftic Hoff- r.n: Repeat while the
obl1nlaioa, but repeat .. tile ofhc:r llide. (1): ar anbni111IDCQr. mel hydmc:epbalua. patient 1lc:la md cDe!Jdjl1fle IIICdt, wbid1
Bumiae ~for tile~ of I often faciliUIIa the l'CipOIIIe.
cervical lib.
3.25. c.rvtcal ~hr (1): 3.26. C.I'YICIII ,.,..o~Ntthr 14): My.lopalliy

(c) L'lw,Utu'r t.lt: Flt:Jtion c. extallion lumd: (ii) Po.rtural: There ia dcflcieat
of die Dedi: prodllc:ea elcc:a:kl ahock-lik addootion, IUid a1b:a meoaiOD, of the ulDar
ICDIIIItioDJ, particularly in die legl. flDgcn 1-3. In tbe mildeat caaea, wba1 die
(d) lnv.rtrd radiiU rwjfu: Thi1 biably flDgcn are c:DeDded 1he littJc fiD&er lies in a
8pCCiflc felt iJ pcGtive if die ll.D&a'a !lex llighlly IIIN:Iuctd pOOtim (a); if it can U7. bcllograpbl (1): The staadard
wba1 the radial rdla iJ elicited. (e) Clmuu. adduct, lllis poaiWm C8I1I.10t be beld foe long. projectl0111 are the lmmal and anteropollmior
(f) MJelopotlr] 1Wl1ld (illdicltive of pyriiJiidll 'lbe fKilNT of aiHiuction ia D.Orlllll, views of the IDwm" IUid upper cerW:al
!net damage). 'lbiJ hu two ell:mc:nll: dilliDguiahlag it from u1Dar: lll':rVC pelay. In ~ lllnatra!M IIOI'IIIallabmll
(i) KiMtic: lllae is illability to rapidly !lex more severe cuea the little, dng (b), IIIII projectloo, with a mW1 DOD~t
aDI1 exlald die flqen. 'lbllc the patient em:: IOD'eflme~lhe middle fill&u (c) may llbdoct, opa:ity lying anlr.rior to the body of C5. Ne
10 ICCOI!dl. TM IIOnrNil u iff tat:•ll of .20 IJidlu the aame :llDgera may flu (d) IUid 1oM: the well ddiDed piwyDsea1 ~
C]del. tbcir power of extallion.
l.28. -.llog,.phs (21: Beeln yoar ltady of 3.29. Redlotr•phJ (3): Now loo1c at tbe 3.30. Redlotr•phl (4): N«* die
the lateral projection by nodD& die cervical gemcrlllhape of tbe bodiea of tbe veztebrle, rdati.oall1ip of e.ch vedebra to the onea
cune, whidl. ia IIOml8lJy sJ.i&bti.Y convex oompl!ing ODe with aootber. Note, for above llld below. It is often belpful. in
aau:riorly: (A) IIOI1DAl, replat curve; (B) lcs• example, (A) CODplital veriebnl fulion, doaWul cue1 to trace the post-erior llllii.'Jiul
of curvature: Ibis can be a poaiticmal emr, such u occurs in the Klippel~ syndrome; of lbe bodiea. Dispbcr.ment ocean in
but in thme with c:broo.ic DeCk pain (B) vertDal collapse, from tu~ dilllocadooa, IUid z.y be amall wbea lbe fal:et
(eapeci.ally pottural in aritin) it z.y be due tlilnl:a or fral:ture.. joiala 011 ODe side oaly ll'e iJrvomd.
to prokdive mucle i!paiUL 11lis is, however,
a rlllber 1liiJ'di.able sip; (C) kiDkinl (from a
locallaica such u a 111blautioo, or from
iotenle loca11D111Cle llpMm).
3.31. Radlogntphl (5)1 Look at 1lle diiC 3.32. Radlogntpht (6): N~ tbe pre8CIWC 3.33. bdlogntpht (7): (A) Note that 1lle
I[*CI IUid 1lle related JDil'lilla of the (A) or an 01feollllyte or margiDal :fracture. anterior arch of the atlas liee in froDt af tbe
vertebrae. Note (A) diec IPfiA:e aamnriag, auggelti~ of a~ injury of tbe aeck; lowc:r cervicll vcrldne. (B) The diallml:e
(B) anaior lippiag. (C) pottaior lippiag (B) fracture of a spi.aoue procea~, 111ggelti.~ between the arch &Dd t11e w. iJ Dotlll8lly
(an typil:al. of cavical apolldyiDiiJ). N~ ,.y of a llexiOD mjuey of 1lle cervicallpinc. 1-4 mm. A greater diataDce (C) 10gge1t1
evidt.aoc of ver1dnl. faaionl, (D), typical of Syriagomyelia (wbi.cb. ea produce pain in roptmc or laxity of 1lle mmavene ligameDt
ankyiDsing tpolldyliliJ. the bead, DeCk IIDifJi.mbl) may CIIIUe (e,a. from llaUml, dleamatoid arlllritia or
vertebral body erOiiou aad dililtalioD of the ill:l'oclioll).
canal. The dilmetl::r af the CUll atcs (C)
lbould DOt exceed tbe vertdnl body cliamel:er
(D) by JIIDre dwl 6 mm.
3.34. Wlogntpht (1): Proximal (crtnill) 3.35. Radlogntpht (9): N~ tbe plwyDgeal 3.3t. Wlogntpht (10): Where iDitability
migtation of the odontoid procell u llso ~Mdow, whidl aormally li.el fairly c.lc8e is supccllCd tile JmqJ projection abould be
commonly - il1 dJeumatoid arthritis. In the ID the bodia of 1lle Wl1iebne :u at (A). aupeniled with 1lle ne&:k (A) in extmsion,
adult thia m&y be -lied by IIOtiD& the Diaplacemrm mgeall a retropharyngea1 &lid (B) in ~ Ally lalmiL instability
dilb!Jce betwem the pecllcle (P) of C2 lllliSI, e.g. (B) aubcccipital tubm:ulolis with abould be cliscemible by COIIIplll"iDs lbele
(sbown hatclMd) 8lld aline~ the ahM:esa. C>dw:r callle& iiidlde harmatnma view~. (f doubt remains, ~ ICl'eellin&
apiaoua procat (S) wilh the an:h (A) of Cl. &lid tumoar. of IIIO'V'eDW:Dt au.y belp.
If tbil is lea dwl 11.5 mm. prM.imal
miJnlioo i1 CllDSidered ID be pnsent.
3.31. Radlogn1phs (12): In the

antr.ropoataior view interpretatioD ia difllcult
owiDg to the complemy of die RJpCrimpo8ed
atrocturea. Note the abape of die vcrttbnl
bodice, obecrviag (A) tii1'J latcnl wedging.
3.37. Radfogn~Ph• (11): NOIIDlll 3.39. Radlog..phs (1J): NOIIDlll
e.g. from fractlue, tumour or infection. Note
antrmpostr.rior view of the lower cen1ca1 (B) ~ preleDCC of any ccn1cal rib. anllmpllllmior' (thmugh-the-lllDUih)
vertebrae. view ofCl- 3.
3.40. Radlognlpht (14): In the 3.4l. . .dlognlph• (16): Right and left
an1aopoltaior view of Cl-3, no11e (A) tile obl.iqQe projec:tiODJ lllC invalalble in
atlanto-oa:ipital joiDta, (B) the lti.IDtoaxial dciDoDitnltin& (A) localised lipping in tbe
joi.rlts, (C) tile lamrll mus of tile lldu. Note ~ joiDta (jointa of Lusdlta) wbidl
any 1act of symmetry in tile alipnent of the may be eoaot~Ching on the neural foramina
odolltcid procas with the ada&, and look for (B). 'lbey may also sbow ov=ilpping
any cvideDI:e of~ (B). ()a:ui,.,ally .1.41. bdfogniPhS (15): NOIIDlll oblique ~> racet jomu (C) in CCI'Viw
c:ongenitallbftonnalitia of tile ocloDfoi4 projection of the cer:vK:al. lipiDe (oae of two). aubh•ntioaa
proce81 (audl U bypopluia. IX failure of
fusioa between jta Olloi1k:ltioa cat!e and tbe
IDIIin :m.ua of the uia) IDil1 cau~e difficuJiia
in illk:qlrr:tatic
A/8=1.0
.3.44. bdlog,..hs (18): Sup.cted cuviall

~lopotky (2): If tbm:e m:e axial MRIIKliiDII
( ot polltmyelograpbic cr 1C8111) wbi.ab llhow
A/8=0.8 1he cord Ill 1he ll1lllpC!Ct levels, 1he JI!I'I'-
8Dd degree of cmi COIIIp[elllioD may be
3.43. Redlagr•phs (17): S.upccr.d c.rvicGI ueued by woddng out 1he cord
mJ4lopathy (1): (a) the Pavlov rtJtio. comprullimt ralio. 1bi8 Ia cah:ulaled by
Noanal.ly, the depth (A) of tbc cervical caaal, divid!Dg tbc (aagittal) diameter (thlckneaa)
aa acen Ia tbc lateral projection, II aa peat (A) of tbc cmi by ita wldah (B). (Aa thla 11 a
.. that of ill rclalcd vertebral body (B). l'llio, tbc reductioll ctrecta of 1he ICIDa are
giving a Pavlov ratio (AlB) of 1.0, lllld lmmlllcrial.) N~ aJM) lhlll the cord may be
3..45. c.rvtalipiM Ndlagr•phs:
more IJw1 adeqoaz room for tbc apinal em!. conaidetab!y disttnd, so use ill minimGI
......,..... p8thology (1): The cervical
A Pavlm ratio at 0.8 or leal illdicalta a lagittal ~ for the cak:ulalioa A valac
CUl'VItllm is reversed: lhr.re il wedgiDs of the
developmeDially IWfOW ccrW:al caaal, with of 0.4 it illdk:ali'le of • eeriout decree of
c:omprcalion, aDd if decompreetion aw:gc:ry Ia
body ofC6.
riek at em! compteMiaa. If the ratio Ia DiapGIII: fradure of C6.
redw:ed cbcck tbc lumbar tpiDc. ., lhcre may pllumcd it Ia beat done before I figure AI low
well be an aaiOCia!M lumbar iplnal Rc:DOm. .. lhilla reacbcd.
3.46. ,.thoiOIJ (2): 1ba'c is a vcdial 3.47. r.thology (l): ThiJ oblique 3.A8. htho!OIJ (4): Tbe inferior trtiQUar
fiuure in tile body af CS, aDd Leu obviously, projcctioD show• odcopbyta arising from tbc prcxeN af CA is ~ antl:riotly OYer
inC6. ~bral jCliBt. the upper llticoltr ~ of CS. (The
~: ~ ofCS 1114 C6. Diapalll; ccrvil:al spoadylolil, IIIOCiatcd ia conapoodill& oblique projcctiol1 af the
1biJ cue with 1IDi1Cral compl'CIIi.all of tbc otber licle is IIOIIDII.)
C6 DCne root. ~~ UDi1Mcral facet joiat disloc:atioo,
illi!Jis cue with ealnlpDent of CS.
3.50. PldhoiOD (6): 'lberc: iJ widespread

fulion of the illte:mztebtal facet joints, aad J.51. PMMIOD (7): 1'ht:re is slipl forwanl
.JA9. hthology (5): C3, 4/llld S are
~ anterior Jongitudi•al l.iga.n:lalt is Clllci1ied. shift of the body of C6 ~Ye to !bat of C7.
n:prnentm by a IOlid lxmy IDliK.
Dlqaolls: lllkyloliDg spcmdylitia. ot.pam: 1llliJJdma1 fKet diskx:a!ioo of C6
Dlapolla: ~ fuaicm of cemcai
spine. ODC7.
5.52... "-'hology (1): Tbcre il :matbd loti 3.53. PllthoiOD (9): 'lba:e Ia uaowlng of J.54. "-'hology (tO): 'lbere ia pw1
of~btal alignment, l.lld tbe iDR:dor the CS-6 diac IPa&le aad, to a ba ~U:Dt. 8III:Crior Upplna of CS, 6 aDd 7, with acar
artb1u proceuee of C6 arc lyin& In front of !bat of C6-7. 'lba:e II aoterior lipping of C4, 8III:Crior lntl:l'body fuliDD. Tbc pharyDgeal
the lqiCrior 111ku1Jrprooc•- of C7. Tbc 5, 6 aDd 7. 'lba:e II polterior lipping of cs. lbadow II diatmtcd..
ipiJIOII& prooc•- of CS IDII C6 are ~. nt.palll: II1Cderlre degree of ccrvlA:a1 Dlilpcl.t.: ~~evae cervical lpoDdylolil,
Dllpolla: ditlocldao. of cc::rv:icallpinc: (C6 lpolldylolil. ueocllted In tbia cue with cly!lpbqi.a.
011 C7) wilb locbd facet~. Similar~ arc foaad In Parcltler'1
dilcuc, a ccadilila in whldl tb::R: il
actlll~ wldclpi'Cid Olll:qlbyte fomWlcG
aDd abaomW ll&...,.,.,mu• calclJlcldoa
(eepedally of the IIIIICdor laqi!Ddlnal
llpmcut).
155. P..hologJ 111): TbtJe iJ lo11 of the 5.56. P.thology (12): Tbe radiograph lw S.S7. hthologJ (13): 'lbele it defonnity of
DOD2Ial cervicll carvatarc. IW1'0Wia& of the beea tak= in flexion (oae part of A flexioa lbo cervicll • • willl the preiiCIICC af cmly
CS--6 w.c lpii:C 111111 llllterior lipping. 1bere il 111111 emuioa pair) 8Dd abowa an CXl:ellive half of a wrldnl body at the C6 level.
an avulaion fracture of tbe antaior iD1icziot glp betweea die lll1tCI:i.or arch of the at1u 1114 Dlqaolll: congenital dcfmDity of \tie
margin of C4. ~ odoafcid proc;eaa. 1bae is gcaaa1iJccl cc:rvU:al ipine (hc:mivertebra CCIVi<:lliJ).
Diapolll: extallioa iajwy of~ spine willl vutebnl demiJieraliaatioa.
A Dlllginll fractm'e 1114 ~ Jm11C1e . . . . . . .: Jheqmatoid arlllritia willl an
1pum ia A pitic:Dt IUOCplib~ to injuly ltlmtooill IU'blmlti.OIL
'beclule af ~ ~ lp(JIIdyto.il.
S.SI. hlhaloo (14): 'lbc trauvcnc procc:ucl of~ ICVC!IIIl 3.51. hthology (1 2): 'l'bele ie an extra :rib oa ODC llidc.
cc:rvU:al vutebra ac C1llarpd oa both akke. J)lapaMI: 1lllilJferll ccrW:al db.
Dta&u* COQFDilll dcfarmity of~ cervical apillc rclal:cd to
cc:rvU:al db.
4
The shoulder
Anatomical features 50
Common pathology around
the shoulder 52
Impingement syndrome 52
Rotator cuff tears 52
Rotator cuff arthropathy 53
'Frozen shoulder'/idiopathic adhesive
capsulitis of the shoulder 53
Calcifying supraspinatus tendinitis 53
Osteoarthritis of the acromioclavicular
joint 54
Osteoarthritis of the glenohumeral
joint 54
Rheumatoid arthritis of the
shoulder 54
Instabilities of the shoulder joint 54
Recurrent dislocation of the
shoulder 54
Infections around the shoulder 55
Miscellaneous conditions around
the shoulder 56
Assessment of combined shoulder and
elbow function 57
Assessment of total upper limb
function: DASWQuick DASH 58
Work module 59
Sports/Performing arts module 59
Inspection and palpation 60-61
Examination of movements 61-04
Rotator cuff examination 65-66
Glenohumeral instability 66-67
Biceps tendon 67
Suprascapular and long th01adc
neM!S 67-68
Radiographs 68-70
Pathology 70-73
Spedal investigations 73
SO CLINICAL ORTHOPAEDIC EXAMINATION
ANATOMICAL FEATURES
1 )
J
)
OI -l ___ _
J
)
Fig. 4.A. 1bc llhouldc:t ia complex, llld it ia importlllt tc note that it baa two main componeDia, Fig. 4JI. Ill tile scapalotbenlde Joblt the
namely the glcDolmmcral joint~ tbe bead of the IJIJmcrwlllld the glenoid) IIDd tbe ICa]IUla (S), move~ over !be rib cage IIDil
8C8plllothorlci joint (bdw=1 tbc ICapula llld the chclt wall). 1bc latter ia a pb.yaiological IICmllol u1r.rior. It ia IUppCJrllcd by !be
radler IJlaa 118 llllltomh:al. joint, U it bu DO II}'DOVial cavity. clavict. (C) (wbich artiallallCI wBh the
'lbe ~ jolllt MlCOallla for llbout balf of eboalder lbcb:liOD (1), llld thia COIDCI 10 ICa]IUla at tbe ICrolllioclavicular joint (AC).
an end wbta !be ~ tuberotity (2) lmpiDael oa !be glenoid rim (3); tile range of IIDd witll tbe IU:rllUDl It tbe I~
glmohmnenl mDVCIIII:I1t (about 90") ca be iDcla.Jcd if lbe 11m ia eztemally rotaDcd (4), joint (SC)),Illd by trJ~EHtilu, ~ifh,
1Dcleby delayiDg the i.mpiD&elllcnt of !be ~ lllberotity. Note dlat aboulder 10Udilm OCCIUI t.vGwr ~ llld Hm#lu lllllerior. Tile
mainly ill tbe gleonlmmeral joillt iDfelior lll&le af tbe .apula a.armally liel It
tile level af D7.
J
J
.j
J
)
J
J )
.) J
J I
I ,
_.J.._ _ _ _ _ 'r _ _, _
I
_:L,....J_ ...,L
J \ I ..) ·~ '
..J d--'J" J
u
.)
Fig. 4.C. The IC&pu1a. ~ il oormally be dialiJI3uisbl!d from ~ qf tJv t.lmL glmoid llllg).illg in a cortMJlCllldin8 fuhioo.
a very mobile lllrul:tw"e, vuyiDg in i%1 The lllllr:r tean enjoys 10111e popul.aity u a Whim tbe glaloid is directed upwards, the
pccitim ad peaniJ1i.ns a wide range of rep~Kaoent fot abduction or flexion, but angle betwem tile Ylmbnl bardlit of !be
~ lllllftiiiDII. The IC&pllla became it ia IO!IleWbat confuling it is IC&(IUla llld the w:rtica1 may reach 60°.
may be •lewliM (e) or dqrwmd (d). with a probably be.t avoidl:d.) 'I'be .:apul.a may be Scapula' DJDYellltd ia oaly pouib1e if there
muimal kltal excuni<lll ia the ordm of miiJtH mtdially, or latentlly md fonnnb il 6-tcm lllbe latllllioclavialt. ad
12 em. (No2 dlat •llwJtiofl of tiN tltoiWI6r ia (m, 1) I'OIIDd tbc cbelt wall. It may a.1Jo be ~ jaiob. aod between the
a pure ICapalolhoncic 111011emeat. aod muat tiJJad upwm11 (u) or tbtuwaufa, witll tbe ICIIpll1a aod tbe cbelt wall.
THE SHOULDER 51
-;
- ..)
Fig. 4.D. Abduction Gf the shoulder (1): During the firat 90" of Fig. 4.E. Abduction (2): ~ clcltoid JDUtCle (d) ariaes from lbe
abduction Cbe glmoJmmcral joillt i1 involved more Cbllllbe sc:apula lateral eod of lbe clavicle, the acramim IDII die spine of die IICipula;
(a), whereu beyoad 90" abduotiaD ia c:ontinued mainly by aeapular it is at1adled to Cbe deltoid hlbcrcJc af the bUIDI'2Ua. WbeD the arm il
DIOVCDICilt (b). Dw:ing the 1aJt 30" of abdw:tiOD, wllcn the at tbe aide, tbe deltoid IC1in& ahmc ia iDclpllble of initialing
glenohnmcral joiat il J.ocbd IDd die aeapular alt8chii!C'.IIt8 are abduction: ita COidnlctioa laldl to raiJC lbe bead of die llanwu
tightening, movcmr:ata of 1M llpiM may make a c:onttibutiOD: e.g. tdalive to die glenoid. OD tbe othtz band, when lbe aan it lit tbe
abdw:tion of the ~boulder may lead to IOJIIC lal.ml jluion of the side tbe IUpnlpiJudua <•> il m tu poation at pe~~eat mechaniw
tborlcic lpille (T). ~ cuvical • • may 1110 llferally flex to die advaatage; with deltoid it fmDI a couple IUid illiliDk1 abdudion
other side, to pre~C~VC lbe po~ of the bead. Wilen both 1rm1 are (whidl ia lbea taken ~by deltoid). A tear af tbe IUprupinltua (or
abdw:ted, DdthiCr the lbmclc nor die cervical ipille latl:nlly 6exea, televallt part of die lhoulclet c:u1l) will pn:vent tbe a.armal illitiaticm
but thtze may be 1D illlcRac: iJl lamba" lardolia. of lbductiOD, which will then oDl.y be pollible by tra IIIOVelllalta.
(b = IUbddlllid buna)
Rg. 4.F. Abducllon (1): In apim of tbe extmnal rotation, wbicll does oot involve ~inaerticms ofsuprupinama
leDdmcy fa£ glenohumeral aad IICllp01ar acapa1ar IIJOYelllalt. (a), aubec!lplllW (IIC), infrupimdus (i) aDd
movemr.Dll to domiulle apecific podiooa of 'l1le lhaalder calf: The gleooid. (g) il widat 11ere1 minor (t), which fuR wilb tbe caplllle
the abdudion m:., illbould be aotrd that i.Dfmiady. Amerimty lie• tbe c:orKIOid (co), lallnlly. fnrmin8 a complde tisaue ammlua
there is oo abrupt tnmition from oae to tbe and above ia the aupr:aglmoid tllbacle (II). (tbe alwuldrz cuff). The saprupinatus is its
ather. and ~ all tbe lbouldm girdle joints from wbid! lhe J.oaa had ofbU:ep. (b) .n-. IIJDit important part. Thia in eftilct IlllUI throup
mM-e a comributial to -ty f!ller'J The fi.brocartilJI8inc labrum (I) deepen• a~ t'onned. by tbe spine of tbe Kapula
1110\'l!llll!lll tbat tlba place ia this repm. ~ lhe glmoid a.c:avity &il.a.:bed to a (u), tbe EroiiJicn (a.), and tbe c:<DCOICtOOiia1
cw:epliooa are ~ DIOW!IIIImts, wbir:h pmipbcnl margin. alms wilb tbe jcUt apsu1e lipment (ca). I1 ia partly ll!pamed from tbe
do act in'¥Cive tbe glmc ~ joiBI. and (c). The apsu1e is :teiafuraxl wilb tbe IICI1IIDion by lbe ldxlel1oid bana (b).
SZ CLINICAL ORTHOPAEDIC EXAMINATION
COMMON PATHOLOGY AROUND THE SHOULDER

The commonest caw~e of shouldec pain is cervi.ca1 spondylosis. Pain from
irritation of nerve roots in the neck is referred to the shoulder in the saolC
way u pain originating in the lumbar spine may be referred to the hip.
There may on occasion be simultaneous pathology in both shouldec and
neck, but diffemlti.ation is usually straightforward; in parti<:ul.ar, restriction
of movements of the shoulder with pain at the extremes points to the
shoulder as the site of the principal pathology.
IMPINGEMENT SYNDROME
The rotator cuff (and the subdeltoid bursa) may be compressed during
glcnohumc:ral movement. giving rise to pain and disturbance of
scapulothoracic rhythm. The commonest site is subacromial, causing a
painful arc of movement between 70° and 120° abduction. Compression
may al&o occur beneath the acromioclaviclllar joint itself, when there may
be a painful arc of movement during the last 30° of abduction. or deep to
the coracoacromialligament. Symptoms may occur acutely (e.g. in young
sportsmen, especially those engaging in activities involving throwing) or be
cbronic, particularly in the older patient In this latter group there are usually
degenerative changes in the acromioclavicular joint which lead to a
reduction in size of the supraspinatus tunnel; this may cause attrition and
rupture of the shoulder cuff.
There is a small group of cases where thece is no naJroWing of the tunneL
but where there is often thickening of the subdeltoid bursa or of the rotator
cuff tendons. Note also that severe shoulder pain may occur in patients
being dialysed, and is often due to subacromial impingement on amyloid
depo&its.
In the acute case. symptoms generally respond to rest or modifica1ioD of
activities. In the chronic case, physiolhetapy, analgesics, and the targeted
injection of local anaestbetic and steroids may be helpful. If symptoms
become persistent and remain disabling, surgery may be required. The
commonest procedure (by open surgery or by artbroscopy) is a
decompression of the subacromial space; this may involve excision of
osteophyte&, an AC joint arthroplasty, and excision of the coracoacromial
ligament.
ROTATOR CUFF TEARS
In the young athletic patient the shoulder cuff may be tom as the result
of a violent traumatic incident. In the older patient tears may occur
spontaneoualy (e.g. in a cuff weakened as a result of chronic impingement
and attrition) or follow more minor trauma, such u sudden arm traction.
It may occur in pati.entJi suffering from instability of the shoulder joint.
Most commonly the supraspinatus region is involved, and the patient has
difficulty in initiating abduction of the arm. In other cues the tom shoulder
cuff impinges on the acromion during abduction, giving rise to a painful arc
of movement. Although the range of passive movements is not initially
disturbed, limitation of rotation may supervene. so that many of these cues,
particularly in older patients, become ultimately indistinguishable from those
suffering from SCH:8lled frozen shoulder. In the yOililg patient, smgical
repair of acute tears is generally advised. In the oldcc patient the indications
THE SHOULDER 53
for surgery are less clear, but operative Iql&ir, often combined with a
decompression procedure, is becoming inCJeasingly recommended.
Arthroscopic: repair may be performed, although it is technically demanding.
In every case, prolonged postoperative physiodwmlpy is usually required.
ROTATOR CUFF ARTHROPATHY
If complete rotator cuff tears are ~ the loss of soft tissue above the
head of the humerus may lead to iiB proximal migration. Friction between
the humeral head and the acromion may result in bony collapse and gross
degenerative changes in the glenobumeral joint, which in severe cases may
lead to joint replacement having to be considered.
1
FROZEN SHOULDER'/IDIOPATHIC ADHESIVE
CAPSULITIS OF THE SHOULDER
'Frozen shouldc::r' is a cliDical syndrome characterised by gross restriction

of shoulder movements and which is associated with contraction and
thickening of the joint capsule. It is a condition that affects the middlc>aged.
in whose shoulder cuffs degenerative changes are occurring. Reslricti.on of
movements is often severe, with virtually no gl.enolnJmeral moveJDalts
possible, but in the milder cases rotation, especially internal rotation, is
primarily affected. Pain is often severe and may disturb sleep. There is
frequently (but not always) a history of a minor trauma, which is usually
presullXd to produce some tearing of the degenerating shoulder cuff,
thereby initiating the low-grade prolonged inflammatory changes and
contraction of tbe shoulder cuff responsible for the symptoms. In a number
of cases thele are fibrotic changes in the coraoohumeralligament which
resemble those found in Dupuytren's disease. In some cases the condition is
initiated by a period of immobilisation of the ann. not UllOOillDlODl.y as the
result of the inadviscd prolonged use of a sling aftc:c a Collcs' fracture. It is
commoner on the left side, and in an appreciable number of cases there is a
preceding episode of a silent or overt cardiac infarct. It is commoner in
diabetics. Radiographs of the shoulder are almost always normal. If
untreated, pain subsides after many months. but there may be permanent
restriction of movemeniB. Generally those with the most severe initial
symptoms have the poorest outcome in tmns of final mobility and overall
function.
The main aim of treatment is to improve the final range of movements
in the shoulder, and graduated shoulder exercises are the mainstay of
treatment. In some cases where pain is a particular problem, hydrocortisone
injections into the shoulder cuff may be helpful. In a few cases. if there is
no improvement with appropriate treatment for 4 months, manipulation of
the shoulder under general anaesthesia or athroscopic capsular release may
be helpful in restoring movements in a stiff joint
CALCIFYING SUPRASPINATUS TENDINITIS
Degenerative cbanges in tbe shouldec cuff may be accompanied by the local

deposition of calcium salts. This process may continue without symptoms,
although radiographic changes are obvious. Sometimes, howevec. the
calci1ied material may give rise to inftammatory changes in the subdeltoid
bursa. Sudden, severe incapacitating pain results; the shoulder becomes

acutely tender, and is often swollen and warm to the touch. It is important to
differentiate the condition from an acute infection, or an acute attack of
gout. Symptoms are relieved by the removal of the material by aspiration,
curettage, or shock-wave therapy, but often local injections of
hydrocortisone suffice. Note that the joim is frequently so acutely tender that
general anaesthesia is necessary for any attempted aspiration and injection
of hydrocortisone. Ultraaound-guided needling in combination with bigh-
enmgy shock-wave therapy is more effective than shock-wave therapy
alone, giving better elimination of the deposits, better clinical results and
lesser need for surgery.
OSTEOARTHRITIS OF THE ACROMIOCLAVICULAR JOINT

Arthritic changes in the acromioclavicular joint may give rise to prolonged
pain associated with shoulder movements (with or wi1hout shoulder cuff
involvement and the production of an impingement syndrome). There is
usually an obvious prominence of the joint from arthritic lipping, with well
localised teodemess. Conservative treatment with local heat and exercises
may be helpful. but occasionally, in severe persistent cases, acromionectomy
may be considered.
OSTEOARTHRITIS OF THE GLENOHUMERAL JOINT

Osteoarthritis of the glenohumeral joint is rare, and when it occurs is most
frequently secondary to avascular necrosis of the humeral head. This may be
idiopathic in origin, or follow a fracture of the proximal humerus which
interferes with the blood supply of its bead. It may reault from faulty
decompreasion regimens in deep-sea divers, cai.uon workers and pilots, and
it may follow radiotherapy (radionecrosis), particularly following treatment
for carcinoma of the breast If empirical treatment fails, joint replacement
may have to be considered.
RHEUMATOID ARTHRITIS OF THE SHOULDER

Rheumatoid arthritis is more common than osteoarthritis in the shoulder,
and the features are similar to those of the condition in other jointlll. It is
necessary to localise the site of the main pathology 110 that treatment may be
directed effectively, and diagnostic sequential injections (into the
acromioclavicular joint, the shoulder cuff, and then the glenohumeral joint)
may be helpful in this respect Medical treatment and intra-articular injection
therapy are 1ried first. In more advanced cases, where the symptoms are the
result of impingement, decompression procedures may be highly effective.
Where the glenohUJJJelal. joint is severely diseased, joint replacement will
generally produce pain relief and improved function.
INSTABILITIES OF THE SHOULDER JOINT

RECURRENT DISLOCATION OF THE SHOULDER
The shol1lder may be affected by anterior, posterior or inferior instability.
When the sbonlder is unstable in several planes, then multidirectional
instability ('loose shoulder') is said to be preaent.
THE SHOULDER 55
Anterior instability is the commonest, and in many cases this follows

a frank dislocation of the shoulder. It OCCUl'll most frequently in the
20-40-year age group. 'There may be a history of repeated dislocations in
which the causal trauma bas become progressively less severe (recurrent
anterior dislocation of the shoulder). The shoulder is often symptom free
between incidents, but there may be some pain and weakness. Surgical
repair is generally advised if there have been four or more dislocations, but
each case nmst be carefully assessed to exclude shoulder 1axity in other
planes: many case of failed reconstruction are due to an associated posterior
instability.
Trauma to the shoulder may also result in posterior dislocation, which
can proceed to recurrent posterior dislocation. Posterior dislocation of the
shoulder is much less common than anterior dislocation and the diagnosis is
sometimes overlooked, especially when only one radiographic projection is
taken. Surgical reconstruction is sometimes required. but this may fail if
concurrent anterior instability is not taken into account
Anterior and multidirectional instabilities may occur without previous
trauma, and never proceed to fnmk. dislocations or obvious subluxations.
The condition may be congenital in origin. The prinwy complaints are of
pain and weakness in the shoulder, and the rapid onset of joint fatigue
during activity. The ann may feel 'dead'. In the case of multidirectional
instabilities muscle retraining is generally advocated, although surgical
reconstruction is sometimes atlcmptx:d.
Recurrent dislocation of the shoulder should be differentiated from
habitual dislocation. In the latter the patient is often psychotic or suffering
from a joint laxity syndrome. The shoulder repeatedly dislocates without
much in the way of pain; the patient is often able to dislocate and reduce the
shouldec voluntarily and with ease; aod tbe radiological changes that are
found in recum::ut dislocation are DOt pl-esenl in habitual dislocation. When
habitual dislocation is found in childn:n the prognosis is good, and surgery
is DeVer indicated. In the adult, surgery is usually best avoided (as the
results are often poor), but good results are being claimed for biofeedback
re-education of the shoulder muscles.
INFECTIONS AROUND THE SHOULDER

Staphylococcal osteitis of the proximal humerus is the commonest infection
occurring near the shoulder in this country at present; nevertheless, it is
comparatively uncommon.
'IUberculosis of the shoulder is now mrc. In the moist form, commonest
in the fu:st two decades of life, the shoulder is swollen, theie is abundant
pus productioo. and sinuses may form; the progress is comparatively
rapid and destructive. In the dry form, carle:~ sicca, an older age group is
affected and the progress is slow, with little destruction or pus formation.
(Howevec, it should be noted that it is now thought that many of the cases
of caries sicca described in the past were in fact suticring from frozen
shouldec.)
GoMCOCcal arthriti.r of the shoul.dcc is uncommon. but when it occurs
there is moderate swelling of tbe joint and great pain. which often scc:ms out
of keeping with the pby&ical signs.
MISCELLANEOUS CONDITIONS AROUND THE SHOULDER

Acromioclavicular dislocation The acromioclavicular joint may be
disturbed u a result of a fall on the outstmched hand or on the point of the
shoulder. If care is taken during examination, a lesion of this j oint will not
be confused with one of the glenohumeral joinL In major injuries the conoid
and trapezoid ligaments are tom and the clavicle is very unstable: surgical
fixation of the clavicle to the coronoid (by a screw or a sting procedure) is
sometimes advised. In less severe cases the acromioclavicular capsular
ligaments only are tom. Although the outer eDd of the clavicle becomes
prominent, it follows the movement of the acromion and conservative
treatment with a sling for seve:al. weeks is all that is required. These injuries
are frequently missed, as they often do not show in the routine recumbent
radiographs of the shoul.de.r.
Cnlde Primary pathology in the clavicle is uncommon, but a cause of
confusion is pathological fracture due to radionecrosis years after treatment
for breast carcinoma. The fracture may be preceded by pain for many
months, and be mistaken for metastatic spread.
Scapula
Snapping scapula A patient may complain of a grinding sensation arising
from beneath the scapula This is often due to a rib prominence, but in so.me
cases it may be caused by an exostosis arising from the deep surface of the
scapula itself. When symptoms are persistent, excision of such an exostosis
may give relief.
High scapula Tb.el:e are several relalcd congenital malformations affecting
the neck and shoulder girdle. In the most minor cases one scapala may be a
little smaller than the other and be more highly placed; in more severe cases
one or both sbouldas .-e highly situated. the scapulae are small, and tbele
may be webs of skin running from the shoulder to the neck (Sprengel
shoulder). In the Klippel-Feil syndrome the neck is short and there are
multiple anomaHes of the cc:rvical vertebrae, which may include vertebral
body fusions aDd spina bifida. Apart from highly placed scapulae, other
congenital lesions may be found in association with the Klippel-Feil
syndrome; these include diastomatomyelia J.WUlting in tethering of the
spinal cord and neurological involvement; lumbosacral lipomata; and renal
abnormalities.
Winged scapula The patient complains of prominence of the scapula,
its vertebral border being raised from. normal contact with the chest wall.
This is due to weakness of the serratus anterior. The cause may be
primarily muscular (as in progressive muscular dystrophy) or follow
traumatic paralysis of the long thoracic nerve. Active treatment is seldom
necessary.
Rupturad bleeps tendon Rupture of the long head of biceps may occur
spontaneously or as a result of a sudden muscular effort, usually in an
elderly or middJ.e..aged person in whom degenerative tendon changes are
present. No treatment is usually :required. In some cases the tendon may
cause a detachment of its origin from the superior part of the glenoid
(SLAP lesion); in the young athlcti.c patient surgical Jeattadmlcnt may be
advocated.
THE SHOULDER 57
Bleeps tendon Instability and tendlnlnltfJ Anchorage of the biceps

tendon in its groove may become faulty, so that certain movements of the
shoulder may cause it to snap in and out of its normal location. This often
occurs in association with a shoulder cuff tear, and isolated tendon lesions
may be difficult to differentiate from pme cuff tears. The tendon may
become inflamed (biceps tendinitis). No specific tieatment is lWlally
required.
Stemodavicular joint Dislocation of the stemoclavicular joint is
comparatively uncommon; there is always a history of trauma, and the joint
asymmetry is obvious if looked for. In some cases, especially where the
medial end of the clavicle comes to lie behind 1he sternum, there may be an
associated thoracic outlet syndrome.
Good radiographs are oftm hard to obtain and their interpretation is
difficult. The diagnosis should be made primarily on clinical grounds.
Symptoms of pain on movement normally settle spontaneously, and only
rarely is surgical repair required.
,..bla 4.1 Age distribution of common shoulder pathology
-.-- - n
II
1-- - -
n
u -
ASSESSMENT OF COMBINED SHOULDER AND ELBOW FUNCTION

It should be noted that overall function in the arm is disproportionately
affected when the elbow is also involved. The American Shoulder and
Elbow Surgeons have devised a scoring system which may be used to gauge
overall f'uDd:ion in both joints. Each activity is evaluated on a scale of 0-4
and the results may be summed (0 = uuable; 1 = only with assistance; 2 =
with difiiculty; 3 =mild compromise; 4 =normal).
The tests include:
1. Putting the hand in a back pocket
2. Washing tb:: opposite axilla
3. Combing tilt hair
4. Cmying a 10 1b weight (4.5 kg) at 1hc side
5. Sleeping on tbe affected side
6. Using the hand overhead

7. Lifting
8. Perineal care
9. Eating with a utensil
10. Using the arm at shoulder level
H. Dressing
12. Pulling
13. Throwing.
ASSESSMENT OF TOTAL UPPER LIMB FUNCTION:

DASH/QUICK DASH
Ra1hec than restricting the assessment of upper limb function to the shoulder
and elbow alone it is often preferable to coosider function in the arm as a
whole. The so-called DASH (Disabilities of the Arm, Shoulder, Elbow and
Hand) questi.o:nna.ire was developed to address tbis issue. It was shown to be
reliable, but the 30 items involved al.oDg with their subsequent grading made
it somewhat tiJne..consuming. A simplified 11-it.em version (QuickDASH)
has been shown to be equally reliable. The function revealed by each
question given below is graded in a range 1- 5, and their sum fo.rms the
basis of a guide to overall function.
1. Open a tight or ~jar
2. Do heavy household chores (e.g. wash walls or floors)
3. Cmy a shopping bag or briefcase
4. Wash your back
5. Use a lalife to cut food
6. Recreational activities in which you take some fo.roe or impact through
your ann, sboulder or hand (e.g. golf, hammc:ring, tcDDis etc.).
1 =DO c:lifficul.ty; 2 =mild difficulty; 3 =moderate difficulty; 4 =severe
difficulty; 5 =unable
7. During the past week. to what extent bas your arm, shoulder or hand
problem interfered with your normal social activities with family,
friend&, neighbours or groups?
1 =DOt at all; 2 =slightly; 3 =moderately; 4 =quite a bit;
5 =extremely
8. During the past week were you limired in your wort or other regular
daily activities as a result of your arm. shoul.der or hand problem?
1 =not limired at all; 2 =slightly limired; 3 =moderately limited; 4 =
very limited; 5 =unable
9. During the past week have you had arm, shoulder or hand pain?
10. During the past week have you had tingling in the arm. shoulder or
hand?
1 =none; 2 =mild; 3 =moderate; 4 =severe; S =extreme
11. During the past week how much difficulty have you had in sleeping
because of pain in your arm. shoulder or hand?
1 =no difficulty; 2 =mild difficulty; 3 =moderate difficulty; 4 =severe
difficulty; S = so much difficulty that I am unable to sleep
The QuickDASH system has optional additional modules dealing with the
effects of 1imb disability on work. sport and the performing arts. These are
included hctc for completeness.
THE SHOULDER 59
WORK MODULE
Do you have any c:lifficulty:
1. using your usual technique for your work?
2. doing your work because of pain in tbe III1D, shou1der or hand?
3. doing your work as well as you would lib?
4. spending your usual amount of time at your work?
1 = no difficulty; 2 = mild difficulty; 3 • moderate difficulty; 4 = severe
=
difficulty; S unable
SPORTS/PERFORMING ARTS MODULE
Do you have any c:lifficulty:
1. using your usual technique for playing your instrument or sport?
2. playing your instrument or sport because of pain in your arm. shoulder or
hand?
3. playing your instrument or sport as well as you would like?
4. spending your usual amount of time practi&ing or playing your instrwnent
or sport?
1 =no difficulty; 2 =slight difficulty; 3 =moderate difficulty; 4 =severe
difficulty; S =unable
Scoring for each of the three modules deliClibcd is done by adding up the
values for all the items in that module, dividing the sum by the number of
items, subtracting 1, and then multiplying by 25: i.e. Score= [(sum of
itemalnumber of items)- 1] x 25.
For example, if all 11 items in the disability module added up to 44, the
Disability/Symptoms score would be 75.
4.1. lnspectl• (1): Tlulftrml: N~ ~ IMPectl• (.2): Tlullie/6: Note if th~ 4.J. Inspection (J): From bahiNJ: Are the
wbt.tber ay of the foUowiug are plQtlll: is ay sweDiDg of the joiot, •1188miDs IC8}l'lllae IIOIIII.IIly ahaped arui aitumd, or
(A) Prominent lllmnoclavh:ular joint iDf=lioD or inflammatory reaction from. fur IIDliD and hish. u in Sptmgel's shoulder aad
(sublUWion). (B) Defmmity of clavi.IZ example, calcifying mpnupi.o.ams teodioilil, the Kllppei-Peil syndrome? Ia ~ webbing
(old :fractum). (C) PromineDl pyogmili: infec:tion. of dle glenobl1lllllDI joint, of the akin at the mot of the oeck, also
aaomioclaW:ular joint (aubblution. or or trauma. typical of lbe l.altrC111 there wingins of the
omoartbrit.is). (D) DeJicid wuting K:apu1a owing to paralysis of llmllltus
(dia!Uie or ui1huy oave palsy). lllltmim1
4.4. lnspHtl• (4): From abow: Again 4.5. PIII,.Cfon (1 ): Palpate the anlmior IIIJd 4.6. Plllp.tlon [2}: Continue tbe
look fur swelling of the aboulda', deformity J.atmal aspects of the glmobnmenl joint. IIUIJlimlion by palpaling tbe upper lmmmal
of thll clavicle, u~ of tbe Diffu.e teDdmneu is suggeaem, of infeclioD. abaft and bnd via thll uilla. Bxoltmel of the
supnclaW:ular fouul. or c:alcifying auprupiiJatus 11mdmilis. Vay prmimal b.umeralllhaft are oftal readily
madad fmld.,..... is parW:ul.v:ly u•oc:iatld plllpllble by this mafll.
with calcifying aupnpiuatas lm!dinilil and
puocoa:al infec:tiOIIll.
THE SHOULDER 61
4.7. Palpation (5): Tc:lldc:aacN over die 4.1. Pelptdlon (4): Paxinos sign: TbiJ tellt 4.9. Pelptdlon (5): Preas below die
acromioclavicular joint it found after :mlCIIt may be used to coll1lrm die pre8CIIIlC at IICl'OIIIi.oD 111111 abduct the arm. SuddcD
dilloc:atioDa, 8lld in ollteoel1llritia at the joim. ollteoatduilit iD the acromioc.lavic:alar joim. ~.. oocarring duriDg a portion or die
In the lac= lipping iJ 1IR1I1ly pllpabk, 111111 StadiDg behind die ptticm. 8lld 1lliD& your arc af m.ovcmaJt ie foaDd in tea IUid
ctepilu1 may be detectlblc wba1 the arm it left hiiDd to eumiDe die rigbl ahoulder, hook iD!IIIIII!IIatory leaiODJ iDvolvillg the ahoulder
abducmd. die thumb W1der die potlaolatetal m.ugin at cuff 111/J/or the mbdcltoid barla.
tile llaOIIIicm lllld pre81 iD 111 llllterosapcrior
directioll; It the same tin:le puah the clavicle
iaferiorly wid1 the inde:lt aad middle :I!Jigcn.
Tile felt ia positive if die patient
ape:ieDce!l pliD.
4.10. Plllpatl• (1): Palptie die 1cng1h 4.11. Movemerdl: llbclucdon (1): Alii: die 4.12. Mftementl: llbclucdon (ZJ: Note
of the clavicle. 'l't:DclerllcM iJ foaDd iD patient to lbdi:Ja bo1h arm.a; oblerve die wbeCher d1e ~ hu any problem wid1
·~ dillocatioaa and iDfec:Cicm IIIIOOtillleaa at the mow:ment aad die range illitiafiD& lbdoceiaD. Di1!il::mty iD doing 110 ia
(particularly tubc:rl:1ololil), tumoun (tare), ldlieved. A fall, free aDd ~· raae it IUgeltive of a ajor ~cuff tear. A
and ndiaDearolil (ulllllly after tralmellt far !'Ire in the ~ or any lignificam hi.lfiOry of violcm iDjuzy ay be obUilled in
brealt cancer}. RdologiW cumiDition or palllology in the dloaldct region. the )'01ID& ldulL In the llli.ddle-lpl or elderly
the clavicle ja eiiCIICial if local ~ patiellt a ar IDlY follow ccmparatively
il~ miDor traWDI, or ClCCa IJI""'-rmily in a
tlbouldCir cuff weaD:aed by lllllitiUl ftom
cbrc:llic i"11i"&C""""
4.13. Moftmonts: Ucludfon (S): N~ 4.1 4. Mowtmonts: abclucdon (4): If tile 4.15. M-monta: abduction (5): Aat the
pain dutiDg abduoticll (which may have 1D be patient caDDOt lllldact the arm IU:tively, patient to bold ~~~c 11:111. in 111c nmw politicm
Uliatrxl): (A) DariD& tile an::70-120", attempt to do thil puai.vely, remembering himlclf. If be Cia do 10, deltoid ad tile
auggemve of aboulder cuff impinaemmt in to rotaz die arm em::many wbilc doing uillary llm'C arc likdy to be inllct.
the region of IDe acromiaD. (B) During the ao. A fall range inO:ates a. intact
latter pba8e of abduc1ioD, tuapalive of glc:Mhnmml joiat.
ahoulder emf impingc:mellt in die rcgioa of
the acromi.oclavia::allr joint or conooacramial
ligamalt, or from Olteoldbri!U of IDe
aaomioclavicular joint (See ~ 4.34 for
od:ltt rotltar cuff ecmeDiD& teltl.)
4..16. M--ta: Uclucdon C•l: If the 4.. 17. Moamonts: abclucdon (7): 4. 18. M~ abduction (8): If both
palient has puaed tbe bat tat, uk him ID Meuure the rmp of abthlcti.oo.. In the dYe IIIIi pus.ive IIIOVelllmltl 8l'e restrided,
lower the ann 1D the aide. Apin DOte lbe oormal ahoulda' tbe amJ. can touch tbe ear fix tbe ag1e of tbe .:apala with Olle hand
preteii'Z of any paiDful an:: of IDOW!Dall. wilb only slight tilting of tbe bead. The IIIIi try to abdw:t the ann with the otbrr.
Sudden droppil:ls of the ann in lbe proc:eu is ahouldrn have already been comp!Rd AblczK:e of lllOWIDall indK:alle1 a fiied
a CODIIIIOD filldi.us in major ~boulder cutJ <- f'nlml! 4.11). glenobnl"'ll"nl joint, the pn:vioualy noted
tl:ml (drop 8llll teat). N-.1 rup: ~1'70". ~ havins t-Il entirely I!CipUiar.
THE SHOULDER 63
4.19. Monmonts: addudfon In 4.20. Mowmonts: forward tloxlon: Aak. 4.21. M-!Mnb: beckwards.-nllon:
..._lon: PJaoc CIIC lwld em 1llc llhoulder the patieDt to awing tbe aan forwards llDd Aak. tbe patient to swing the arm directly
llld ewillg tbe lllll1, ll.cxcd It the elbow, lift it above hit bead. Vl.CW tbe patient from blctwlrdl, qain viewiDg and meuutillg
the chelt.
IC1'088 the aide. from lhc lldc.
Narmal raqe: e-a•. Narmal nqe: ~te•. (Note that illall:ld of Normal nmae: 0-60".
mcumillg abduaioa 81111 fle%ioD, 80IIIC prefer
Ill -~ 1lle maximum bdght to which 1llc
arm can be railed, imlpeclive of the plane.
of movement - 8lld recm1 thia u 'lxltai.ICtive
el.efttioa'; but aee aote in Frame 4.C).
4.22. MAwniMitl: hortzontal tlalon •nd 4.D. M-IMIIts: rotMion - l n g 4.24. MowiMIIts: rabllon 1CI'MIIIIng
ldcluctlon: Oa:uiOILII.Iy meuurmneol of tats (1): Aak. the pa!ient to pbu:e the bmd 00: With llipt eatric:lioa be will DOt be able
this mgle may be beJpful. but it need not be bebiDd the opposite sboulda: blD. This is a Ill get the hand far up the bid. 111111. with
romine. Vl.CW tbe pa!ient from llbove.. The u.mui ~ of i.ldema1. rotation in eUeD.Iion. III!Va"e Jellridiml be will DOt be able Ill get it
arm is lllOWCi forwards from a position of 90" behiDd 1llc back at all. Tbia IDDVellleDt is
abcb:tioD.. CIIIIIIOOIII.y a&ctecl in frozm lilouldcr. To
NDI'M nap: 8-140". Nocz 1bar pain during tut 1llhlmpMIMU (wbicl! may be tom by
this UWJOeUvre is COJIIIJKlll in 01~tis or violeut external mtarl011, h~ or
trauma to tbe acromioc:1rfica joint. antaior di.aJR:Ition af the abouldrr), Ilk 1he
patlcut if be can draw the hand away from
m
oon!Kt with the bad: whim the positica
abown.
4.25. Moftments: .,...,on tcnenlng 4.26. Mowmentl: ........,n scnenlng 4.27. r.o-ents: lnwm•II'GIIItlon In
(3): Ask die paticllt to pW:c bo1h haDdl (4): Sometime& iD. die lut felt the pelient abduction: Abduct lhe IJboulder to 90", 111111
bebiDd die head to IIC.\1'etA Cl1temal rotation at lDIIII8pl to get die 11m:J OD die affected tide llt:at the elbow to a rigbt angle. Aak die
90" abduction. Compere die two lidce. Lack bebiDd die head, but in a pc8itiOD of piDcat to lower die forearm from die
of success oc reltrictiaD ia common in froza1 horizoDtal kxioo. If 80, geatl.y pull both lmzoatal. plane.
ahoulder. elbowa backwa:lda, DOting any di1fcreDce. NOI'IIW rup: 70".
(PaiD 111111 reatrictiou are commoa in frozen
llioiJld«.)
4.21. Moftments: .Wm•l rcadon ._ 4.29. Monments: atem•l romtlon In 4.30. M.-ts: l"'-1 rvtlltlon In
•bductlon: From tbc lllllle tlldiDg position ..-ulon: PW:e tbc elbow• iato lht lidel .-nllon: Move the bind to die dleat from
with lht foreaan perallcl to the grouad, ut IDd llt:at diem to 90" with lht baada flciDg die :fadaa tarwml potiliOD.
lhe plltic:Dt to raiae tbc iwld, k=pillf die forward~. Move the llandt J.aterall.y, Nonaal rm&e: 7r.
ahoulder in 90" abduction. eompariDg ODe aide wid!. tbc od!.t:r. For 11101t clillicxd wo1t, MHI.mwnl of
Narmal rup: 100". Narmal nqe: 7G". N~ d!.at an incJwue in abdw:tlml aM &e,...,U,., rotGtioll in 1M
exlmlll rotation in extr:aai.on ia a feature of U.ONld.r 1/tollld 1'11/fiu (bat record mgular
liCin of lht IIJb~ a:acle (ICC alao raap of IIIIO'ICIIItDII in all plana~ for
Jltamc 4.24). IIIOIIitxma proa;rea• llld for llll:dico-lqll
J:q!Cirll).
THE SHOULDER 65
4.31. ShouldR elwtdlon end 4.n. CervlaiiPIIMN AlWIIJI~ct=a die US. CNpltus: PW:e ODC haDd over the
clep......,n: 'lbia may be ulleMed by direct ctnicalllpine iD enmining a caec of llhoulder llhoaldrz, with the middle ~ lyiDg aloag
measareDII':Ilt (ICC llr1lmc 4.C), but~ pain; lbia is doubly importaDt if lboulder thc acromioclavicu1ar joint Abduct die arm
llld 01lnal advoc:ate the uc of a gaaiomder, lll09e:IIICDII are fouDd to be DOallaL wW1 the otM lwld. Detect IID'J crepitu
centred on the jugular DOtd1. with cme mn camia&' from 1lle moulder lllllllocaZ it8
verticallllld the othc:t OD 1fle IICIOJDion. IOUJ'CIC (Jlenohumr:ul or ac:romioclavkol).
NGniW rup: clcvalioDIIld depretlion in R.epelt wbile the llrDl is allCMly abducted,
the Older of 37° llld s·. Elevltioa (lbruggiJI&) lllld if iD doubt, IRIJCU!%a~ Clicking DillY arise
gives a -~ of trapczi111 tlmctioa, llld from I DUmber of~ illlcludillg ICipU]ar
may allo be ued to AlleN lwld ftiCOVClY ClUlttotea IUid c:aruoid impiDgemeat. ('I1Ie
ata:r alrokl:. 'l'bcle IDOVCliiCIID ~ allo latter DillY c:aoae abouldec Jilin llld c:otiCOid
imp8imd in IIDY c:oaditioll involving felldemeaa.)
~ IIIIOVaiiCilt
U4. ......., cull' . .mlnlltlon (1): 4..35.. Rotlltar cu« lllllUI'IIMtlon (2): the Ul. ....._cull' . .mlndon (J): the
PaaboJosy in lbe rotatllr caff may be HMIIclns-Kaftnady lmpln,--t 111n: the CNU-bodJ lldductlon wt: with tbe elbow
suspemd by the performaM:e of lbdiK:tion ~boulder llld elbow ~ both ftexed!D 90". ~ tbe llhoulder is ftexed to 90". The
llld tbe drop mn ~It (aee Frame• 4.14 llld md the sboalder geotly Demally rob2d ~ tbra adduct~ the mn ICI'OII the
4.16). Neu ~elfiDII 1lp.: pain occ:an until r.itbrz the patient complains of pain or clust. The ~It is deiCribcd u being po&itive
wt-. !be dJoWder ia ftexed to 90" md tbe scapula ia felt to begin to move. The tat if tbe JMdiat a!lllplainl of pain. 'Ibree other
fcm:ibl.y Dema11y ~ N••r ilftpilviiiUIII is po&itive if there is allllplaillt of paiL tea (bDnsias tbe !Dial to 8) may be tab:n
tut: tbe tell ia repeaBI atb!r iAjectioo of into acc:oaet . , . ~ tbe rol3lol: cuff:
10-15 mL of 1.. xylocaiDe imo the tbele ~ tbe Speed tell (Frame 445). the
IUJ.aomial~pK~e, wtJr.m lea pan dxJuld be IIIJilUPnalua (Frame 4.48) - the
eiJa)lllltrzed if !be pain ia dae 1D iupngement infraapillldua llelb ..men aa:ompaaied by pain
of the rolalm cuff apilul tbe .:mmion. (Frame 4-.49).
4.37. Robtor cutf euml....lon (4):

eaMalng the tut .,..ultl: the pltholop:al
buiJ of tbelc eight tall iiiOIIICWblt
uncedliD. llld C>ODboVeraitl. but tbe followiD&
iDterprdltions bave been made:
1. Wbellthe Neer llld c:roN body llddactioD
tall are poative, Ibis i• indiative of
periarticular aoft liaue ( dlollder cuff)
iaiahility at !be utiWJfU at movemtld.
2. Wbelltlae i1 a paiafu1 m: llld positive
drop mn, Ibis illikdy ID be uaoci*"'
with ~boulder cu1f lz:lldemeaa, md
weabeu in a IDOI'e CDII7'alan: a.f
-=t.
3. Polilive infrupiuama. r.uprupiuam& md
Speed 2111 suggest Urlmbillty 111111 pouible
weabeu of the lhou1dm- calf JriUClea
wbm they are made ID CODtract apinr.t
ruilllallce.
From IIIIOther poiat of view, wbal. thele lata
iJidicam the libly preiCDI)C of IOIDC ~boulder
cuff a\mQnnality, it il claimed 1blt a poative 4.31. A!Mrlor glenohumen~llnstebllltJ Ut. A!Mrlor tl•ohum. .llnstebllltJ
Necr ~is the belt iDdicltor of a bunitiJ or (1 ): TM oppneiNnsion tut: SII.Dd bdliDd the ()): R111ocGtion Ullt: Repeat the apprebal.&ion
partial ~~boulder cuff tell', wb& a painful.rc, pa1ient (preferably teated) aDd abduct the tat with lhc patialt in the rec:ombCDt
drop arm and poative iDfruplJialuJ tat aboulder to 90". Slowly memany rotam the por.Uion; abduot and ex1mlally rotate the
suggest a full rotator cuff tear. aboulder with ODe lwld wbile pulbing the aboulder (1). When pain or~ 8nt
bead a.f the lmlllcrua for.'warda with the thumb appear, prca1 down oa the app:;r arm (2).
of your odl« baDd. A~ fear or 1bil will •llbil.ise the belli of the llommlf in
ftiflllal. to coatimJe is evi.deace of cllro!IW the gkiDol4 at the time wbal. IUbluxation ia
an11c:rior instability of the 8hoaldeL Rqlelt at immintmt, and ahould relieve my pain or
45• &1111135° abduction. Pain O.Diy may be appreheaalon. 'Ibis, and the retum of paia IIIII
felt in minot lllblaxatiou. appreheaalon on reJeue of the dowDwa
JII'CI&are, il tlC'!Dftnnatrxy of 1D11c:rior
inltability.
4.A4. Antllltor g.._h~nerellnmblllly 4..41. Postarlor glenohumaNIInfDIIDIIJ 4.42. PostelfOJ gl•n•u!MNIIftltllblllty

(J): Drawer Ullt of ChriHr aNJ (]Qnz: (1 ): D~r ten: Wba:e rec:w:rent po.rt¥rlor (2): TIM Jm Ullt: Wllh !be patimt'• aboulder
Support tbe (supine) pa!ient'a Jdaxed arm dillocaOOn il ~ bold the relaud. over !be edF of the exam.i.D.mon coucb (I),
against your aide, with his lboal.der in !10" lUpine paDem'l forearm with tiJe elbow fle.x both !be lhou1dm- 111111 elbow ID 90" (2).
abdw:tioa, sliJht flexioa 111111 e.mmai rotmOD.. ftmai IIIII tbe aboulder in 20" flexioa 111111 90" With ODII b.md OD the elbow, push
Studyina the aci(!Ul& with the tiJIImb oa the ahdl!ction PW:e !be thumb jut blleral to !be dmtnwards (3) .ad attempt In sublllX the
coracoid and the liDpl br.biDd, try ID move coracoid. Now inEmlly mt1te the ~boulder bumtnl bead pollle!:iorty. If tbia occun,
the bumenlllad llllledody with yoar otbrz and fle.x it ID about 80". JftUiD8 !be bwoenll illdK:atiDs i.ubbil.ity. a jm or joomp will be
Mad. Obwne any lllllftlllmlt, c:&kJ llld lad backwards with the thumb: any felt. If ueptive. repeat wifh the lliloulder
pUmt ~ _. oompare the &idea: backward dicpll!.,.,.... of !be bwoenll bcld ~and intanally mlldlld..
axial radiosnPIH may be tmm in should be de1rded with the tbwob, but X-ray
mnfirmalicm darins the procedure, which ia r::onfinJmlioll may mo be made.
101Ddime1 pe:tlixmed -sm- anaelllhraia.
THE SHOULDER 67
4.43. lnr.rtor glenohurr~~~n~llnstabllltr: 4.44. limps wnclon lnstA!blllty test: 'lbc 4.45. limps wndlnltls: n.. Spud tm:
77u1 lflkru ngn: Wah ~ petialt ltiDdiDg, IJbouldet it allducted to 90" IIDd the elbow With tbc elbow fully extcDdcd 8lld aupilwecl,
grup die arm aDd puD it downwuda. If there fh:lted to a right angle. Tbc llcadoD it 1hr:a tbc lboak1er ia flexed to 9()0. 'lbc plliall il
il inferior laxity dieD I dcprealioD will localcd .. it 1iea in tile bicipital groove 8lld, ubcl to rc:Mat u tbc cxamlllcr trlee to cxtelld
becomt obviooa bctwecD ~ bummal bead kcepillg the examjnjag finger& in positioa, die l!lc llboaldcr. 'I'berc il complaiDt of pain
8lld tbe 8l.':rolllioa. 'lbiJ it of ~t patiellt'l lbouldet il in1allally rotated. If die durin& tbilmanocuvre if there is
sipifiC'UIAle if abient or bl on~ good lide, taldoa ii~U~Jtable it may be fdt to move oat i121111111m8tioa in the lcDdoD. A poailive Speed
or if IIOOOIDpiDied by pllin 8lld apprebc:DiioD of polilicm; 1hia may be accompanied by an ~t may .., be fOUDAl wbcre there il
em the dlicctecllidc. A ~ tt.t it UJually audible click. pathology in tbc lhoalAicr cuff.
indicative of multidircctioiW inltability.
4.46. lnt.grltJ of the long h..cl of 4.47. DeltDid power: AU: the~ to 1Iy 4AL 111esupJUQpu..r nerw (1):
blmps: Support the ~·· elbow with 011e to bep the arm elevlbd in llbduclim while SuprrupiNmu: Palpate the ICapula IIIIi
haDd. &up hi• wriJt IUid uk him to pull )'llll pnlll down DB bis elbow; look IIDd feel idadify ita lipiDe. Place the fiDgms of ODe
tcward his dwuldm whiJe )'llll rmiJt Ibis for deltoid c:oonctioo. 'n:xWm injurie1 of hiUid alxM! the liPiDe. IMir the lllp[Upiutul
IIIIOVtiiDmll. If the km& tSidllll of bk.epl it tbe axilbry DmVe reaul.ti.ng in delfDid llllllcle. S!Mdy the fcnmn with the other
ruptured. tbe belly of bicep~ willllppCG' iDvoivemalt arc aec:n matt frequently lf'ta hiUid IUid aak tbe p8tieDt to attempt to llbclw:t
globular iD lbape. Compare tbe two aidea. dialoc:ationa of tbc ~boulder. If ui1l.ay IICI"'e tbe arm aaam.t tbla reai~WK:e. If tbc
pmy ia au.peeted, teat for ICIIIMJI)' lo• in tbe eupriiQPIIlJr ~~tnC Ia intact, tbe COIItl'ldiol1
'tqlmcatal badge' area DB tbe 1JIC:rll upect of tbc ~ llboald be eaaily felt.
oftbemn. Repeat with tbe am in 90" abductica: giving
way oa ali&)ll preaae iJ a liF of ~boulder
cuff pidlology.
4.49. The supr•smpulu _ , . (2): 4.50. Long thoracic n•rw: Wbcrc

lrtfnupiNibu: Jn a al.mllar maoner palpate the paralyllia of 8tli'8IDI IIDiedor Ia IU&pccted, Ilk
iDfrup.lnalUa, caudal to the &pine of tbc tbc )llliall to lean with both lwlda apiut a
ICipllla. wbilc aUing 1he patieot to CXIemllly wall. Ally 1aldawy to wingina of the ICapula
rota~e tbc lhouldc:r aplnst relliataDCC. Pain im!l1!'ldiately bccomca apparaat.
may occur in lhouldcr cuB' palhology;
paralyllia of 1he IIIUICk, with aboalder pein
IDil ~•• may reault from a gmglic8l in
1llc p:celer lltlplllar IIOCclL (Confirm with 1D
MRI IICID.)
4.51. bcllograph• (1 ): Jn tcreelli.ng tile ~boulder an lllllcropolltcrior 4.52. RNiographl ()): Tbc '1811dmllhouldc:r projcctioD is taken in
~ is uNilly eaaiccl out, lltboqb .sdilioDal views are highly recumbeacy. BxamiDe the radiogmpll mclbodil:ally by idc:ntifyillg (A)
detirablc. 1bit lbows a typieal aormal film. tile &lelloid, (B) tile l.llcnl border of the ~ (C) tile medial
border of the ICapula, {D) the apiDe of the IQpula, (B) tile acrtmioa,
(F) the concoi4. Note 1he ~ of (G) the t.mcrsl bcld and (H)
tile cltiYk:le to the gleaoid and the la'Omioa.
THE SHOULDER 69
4.53. Radlogntpht (S): 1D the child or 4.54. Rlldlog111pht (4): ClllcilklaCicm in 1be
adolucent, do not IDi.ltall:e (A) the anlaior NprUpillldua faldoll in lbe upper part of lbc
and/or postedor margin~ of die epiphyiCIII lhouldet cuff IWI m amorpbou1 appeanlll:e
plate for fracture or (B) !be acromial (A) and iJ ~Y Jimalm It may
ouifulatiaD came for a too.e body. Note be IYJilll(.om flee. Note (B) arthritic dlangcl
(C) lbc typicll ~of alimple ia llle ~joint Jaferiarl.y 4.55. bdlogntphl (5): llddltl-.1
exottotil (ouifying chondroma) of projecting a.teophyta are c:ommoaly
pnalectl- (1): NomttJl axUJJ (pez-axillary
epiphy!eal pilte origin. uiOCiated with abould« cuff palJiology. or axillJry) ~~feral.
4.56. RMiogn~pht (f): Tbe axial ~.~feral 4.57. Rlldlog111pht (7]: llddltfon•l 4.51. bdfogntpht (II: Normal trrmllakral
givea die molt 111Cfulldd:itional. informltion, proJedlont (2): N01"11141 t1'dNUUetrll (I): If (:Z): Note (A,) ICip1lllr spiDe;
bot iJ dcpemdcnt on lbe pltieDt bein& able to tbe plllieat is DOt able to ~ tbe arm (B) &Jenoid; (C) COI'ICOid;
abduct die ~ It iJ 'ftq' belpfal in ~ a tnms1atera1 is aootber view that (D) u:romicx:l&vk:alar joints and
c1.arifying the n:l-tiOMhip& of lbe aJamid and may be IUed to give addiaioaa1 iDfmD.aiDa. IUpezi!llpoiOCI clavialllr llladows. Note
llllma:al bead; tbe lalmU border of tbt: Unfortllnm:ly ddail iJ often poor. especially !be pll'lbolk: curve formed by tbe hUDIO'Il
sapula (A); tbe acromioa .S spine (B); the iD tbe stout J111timL (Same p:e(a 111 l!pkal .wl and lbe ~~feral border of the lalpUia.
conooid (C); tbe rJcooid (D); and tbe oblique projection, takm with tbe plm at 45" 'Ibis is dislurbccl ia 11101t sOOulder
c1mc1e (B). aDd tbe beam anpd appmpria8ely; Ibis diJioc:ltioal IDd IUblaJ:IItionS.
duplicatr& and fcrabor1all tbe talurea 1t:e11
iB Frame 4S2, bat belpa clarify tbe
glmCJimmerll TelatiooiNp.)
4.59. bdlogl"'lphl (9): llddltl-1 4AO.. Rlldlogrephl (10): ecldltlonal 4.61. RediDgl'llphJ (11): llddltlonel
project!- (SJ: Ia IUIJICC)Ccd J.'CCIIm2lt prujKdonJ (4): In caaee at cliddng or projKtlonJ (5): Wbere IAJb)UllftliOD Of die
disloclllion of die lllloaldc:r - addWoDal anappiDg lbouldet, tangential viewl at the acromioclavkular joint is .u8pCCfed, it is
an~ view llhould al.wayt be llka1 blade of die acapula will teVC8l any causal e111CDtial dllt the ID!mopolll:ei'D view of
with die arm iDfemall.y rotated. ThiJ may cxotto&ia, padi.cululy 011 the cottal 8Ul:l'll:e. die lhoaldcr is tUm with the patient erect
8bow a CODflrmatory defect in die (A) A.cromiOI1; (B) gk:aoid; (C) blade of IDil holdlJl& a wciabt on the afl"ec:fed Bide.
~ part at the hWDI:IIl head IC8pllla. (A) Narmaljomt; (B)~
(Hill--Sachl, or 'ba11cbet bcld' lcaion). An clialocidioo.
axiallMerll view will bclp to CODflrm lhil.
4.62. Should.r ndlogl"'lphl- aampiH

of p.thalogy (1): Tilm'e is a calci1ied IIWI
ovm tbe IDa:mnllbaft: iJa pedicle is llll8cbed
to tbe mmpb:yml.
Di.apalil: lhB appAillllall are of a llimple
exostom (IIUi.fyiua clJDodroma, 4.63. P.chalou (2): 'I'henJ is Ill aomphous 4.64. Pelhalogy (J): Thin i1 llllmlWing of
em:boudroma). IIWIIof cak::i1ied lllllb!rial situated ovm lhB tbe u:romioc:laviaalar joint qEe. IOIII8
hlliiiiinl head. .imlplarity of the joint aurfaa!s aod a little
Diapellil: cak:if'yiJII Rlp[lUpimtas llmdimtia. liwinl· 'l'!.e is a mini.mal cleglee of
cak:ifyiaa mpupiaatua telldinim allo
)JI1IIIIIt.
Di8pelia: Otteoanhri1is oftbe
~joiDL
THE SHOULDER 71
4.85. hthology (41: 'l1lae la~J~arbcl 4.66. Plldlology (5): 'Ike is 1100-llllion in 4.67. Pllthologr (61: 'lbeJe il irregulal:ity of
aarrowiDg of tlle g)ennhnmeral joiDt JplllC, a fradme of 1ile proximal humaua. 1bc bODe !be bwlltlll bead, with pat.cbea of~
with a )£F c:IOifoliJ ariJia& from !be cadi are roUDded off ad rlfher ollteopolotic. deuity.
lmmcnl bead. Dillpolfl: biatory JeVeals that thi4 bu been a DlqDolll: avacular necroti1 of die lad of
Dlapalll: otllcollthti~ of the &)alohWDICftl. pdbological fradme reaal.ting from !be bwllaul. Ia llli1 cue tlle CO!Idition wu
joim. n4iODCI:IOtia, followi.Dg tbellpy far breut due to ClialoD diaeue.
tcciaoma.
4.61. PlltholagJ (7): Tbe muw poiDb to a 4.81. Pllthology (1): dl. .nodl: lllis uial 4..70. Pllthalogy (9): This uial. ndiograph
fm:bn liJrcJqb. tbe proximal h11111mm of a projection mows non-uaioD in a ~ of ~bows 1111 Ulfllrior IIIJbluutiou of the lboulds'
dJild. 1bc tx.c il cxptlldcd l!ld ~ ia the CCC'allOd UIOdall:d wUh • clcf.ect in the humeral bead.
lhl.mdlla of the c:cJitCX. IJiapc*: tbc fiDdill&l C(aflnn a cliDical
~: 1hil ia a pllholop:al f'ncbae, diapotil of lCCIII'l'Cill dlllocalloa of !be
ill thia CIIC liJrcJqb. a limplc (unk:lmerll) lbouldc:r.
'boue cyllt.
4.71. hthologJ (10): 'lbe b.anlerll bead

1w been replal:ecl by • hqe mill at poorly
di1l'ereDtialed boac. 4.7S. hthology (12): 'lbe lmmcnJJ aad
4.7:1. PldhoiOSJ (11): 'lbe bead af the ICipa1a allow 'Widelplcld pab:by ICle:otic
Dlapolll: 111e ~· are typical of
~ (gilDt c:cll tumour at boDe), a
klcally llllligDant CODditioD wbich ~·
oo-, on occuioD ~ illvui~ 111111
lmmcnJJ lw been deatroyed.
ot.po~~~: .in 1hia cue d:le appearliiiiCCI are
the n:IO!t af a (maligaaat) chondrolllri:OIIlL
=.: the ippelft!ICCIIfC typical of
llldutatic lprad from • cm:iDoma af the
mdutuile. prDitlllc.
4.74. P.thologJ (1J): dl-.nosls: the radioJrapb shows a .

diJlocation of tbe ~ joilll. In ldd.itioa, tiHe II
evidall:e of ca!dfication in tbe harm•lnm• wbidt hu relllllll!d from
tbe teariJ:1s af the COllOid ad trapezoid ligamenta.
THE SHOULDER 73
4.77. Splldellnvadglltlons (1 ): 4.71. Splldellnvestlglltlons (2):

Arpiration. Couidcr if pae i8 111epected. Wbcro there ia ahoukla pain re1abld to
Method: with tile patient 111piDc, follow die DKm:~~Dmt 111111 tile IOU!\le ia 'llllCertain, aecial
cJavicle lall:rally aDd fiDd the coracoid, wbidl iojcctiou with loc:al-.thetic may be tmd.
lie8 about 5 aa obli41Jcly below the Start with the acromioclavicular joint (I): if
4.76. Pllthology (15): 1b:re il grotl
aaomioclavi.:alar joi.Dt. Now rotate the arm, pam OD ~ i8 not relieved afla 5-10
wla1 you aboald be able to feel die bead af llli!lu11:1, proceed to tile app« put af the
distortion of !be lwmclll bead llld tile
die bumerua. A!b::t l.oc:al ~ pua a ~boulder cuff (l); if this aliO fllill, iD1iltrate
glcaoid, rill ll1%eration of bone ~ md
llrge-~ Deedle di.tec11y backwards into tile die llenohWIIIC:Dl. joint (3). 'Ibis may be
dealluc1iw ~. joint below aDd ju8t lateral to !be CCllUOid. approaclled u deCailed ill. tile previooJ frame.
Dlapalll: the ~ ~ typictl of
Olarcot'a diaeue.
4.71. Spedllllnvsdslldons (3): Other illveltipli.cm can incladc tile foDowilli:

Slupectftlil{ecfiON
1. Whi%c cell COWit aDd di1feralti.al blood count
2. Blood cuJmre
3. ESR.
4. CbcltX-1'11)'
5. AJpirltion of tbe joiot. with die appropriate euminationa to exclude pyogenic, &OIIOOOOCil
1114 tu~ infecti0118.
UttdtatMud ~t~«haltlc4l probleN or ptl/Jijid atr tJIUI-.r
1. Bumin•tion af tile joint by cr or MRI &elliS
2. ArlbJ:ocrlphy, with !be UIIC of nd.io·opeqae dye in (a) the gleoobumeral Jol.Dt. or (b) tbe
aubdelloid buna
3. Bnmin•tion af the joint UDder geueraL -abesia
4. Artbroloopy.
5
The elbow
General points 76
Important relations 76
Elbow function n
Tennis elbow 77
Cubitus varus and cubius valgus/elbow
instability 77
Tardy ulnar nerve palsy 78
Ulnar neuritis and the ulnar tunnel
syndrome 78
Oleaanon bursitis 78
Pulled elbow 78
Osteoarthritis and osteochondritis
dlssecans 78
Rheumatoid arthritis 79
Tuberculosis of the elbow 79
M~ltls osslficans 79
Inspection 80
Movements 81-82
Palpation 82--a3
Tennis elbow tests 83--84
Radiographs 84--86
Pathology 87--a9
Aspiration of the elbow joint 89
1e CLINICAL ORTHOPAEDIC EXAMINATION
Fig. 5.A.
ANATOMICAL FEATURES
GENERAL POINTS
The calliper-like cl011e fit between tbe ulna and tbe trochlea (1) contributes
to the impressive stability of the normal elbow; tbia is aided by the strong
collateral ligaments (2). Instability may be seen following certain fractures
of tbe coracoid or olecranon, owing to impairment of tbe stabilising bony
features of the joint. It may follow ligamentous laxity from repeated
stretching and tears in athletes; or it may occur when tbe ligame:nts become
lax in the coune of r:beumat.oid arthritis or an elbow joint infection.
At the end of flexion the coronoid process tucks into the coronoid fossa
(3), and at full extension, the olecranon process fits into the olecranon fossa
(4). The clearances lll'C IIDllll, and only a little local disturbance, such as a
1malllo011e body in one of tbe fossae, may produce a significant restriction
of movement.
The elbow joint is normally extended by gravity (G); forced exlension is
powered by triceps (T); and triceps acting with the elbow flexors (bicep1
(Bi) and brachialis (Br)) holds tbe elbow straight and rigid.
The axis (5) of pronation and supination passes through the radial head
and the attachment of the triangular fibrocart.i.lage.
Mechanically, pronation and supination may be restricted by problems
involving the elbow, wrist or forearm bones. Pronation is oontrolled by
pronator teres and pronator quadratus; supination is carried out by biceps
and supinator.
IMPORTANT RELATIONS
• The median nerve (MN) and brachial artery (BA) lie medial to tbe biceps
tendon and superficial to the brachialis muscle.
• The radial nerve (RN) and its important posttrlor interosseous nerve
branch (PI) lie lali:rlll to lbe biceps teodon.
• The ulnar nerve (UN) at the elbow lies bdUnd the medial epicondyle.
THEELBOW 77
• The main extensor muscle origin (E) is from the lateral epicondyle.
• The main flexor origin (F) is from the medial epicondyle.
ELBOW FUNCTION
Note that disturbance of arm function secondary to elbow pathology ill
disproportionately greater when the shoulder is also impaired (see
alsop. 57).
TENNIS ELBOW
This is by far the commonest cause of elbow pain in patients attending
or1hopaedi.c clinics. 11 is generally believed to be due to a strain of the
common exteDllor origin, but fibrosis in extensor carpi radialis brevis or a
nerve entrapment syndrome have been suggested as alternative causes. The
patient, usually in tbe 35-50-year age group, complains of pain on the
lateral side of the elbow and difficulty in holding any heavy object at arm's
length. There may be a history of recent excessive activity involving the
elbow, e.g. dusting, sweeping, painting, or even playing tennis.
In sportsmen, a period of rest or modification of a flawed game-playing
technique may allow the condition to settle. In manual workers relief may
follow avoidance of the SllSpCCted causal activity, although this may not
always be possible. When these basic measures fail, an elbow clamp
(employed to redirect the pull of the forearm extensors) can be effective.
Symptoms are also usually relieved by one to three injections of local
anaesthetic and hydrocortisone into the painful area. and local ultrasound
may be tried. Excellent results have been claimed from extracorporeal
shock-wave therapy. In resistant cases, when all conservative measures have
failed, exploration of extensor carpi radialis brevis may be considered (with
excision of any fibrous mass or lengthening of the tendon).
In golfer's elbow there is a similar history, but here pain and tenderness
involve the common flexor origin on the medial side of the elbow. This
condition is much less common than tennis elbow.
CUBITUS VARUS AND CUBITUS VALGUS/ELBOW INSTABILITY

A decrease or increase in the carrying angle of the elbow generally follows
a supracondylar or other elbow fracture in childhood. Although the normal
child has great powers of spontaneous recovery following injury, there may
nevertheless be some epiphyseal damage that fails to correct; where there is
evidence of interference with the carrying angle the child should be
observed for a number of years. If there is failure of spontaneous correction,
or even deterioration, and the deformity is very unsightly, correction by
osteotomy may be undertaken. In later life either of these deformities may
be followed by a tardy ulnar nerve palsy.
Medial instability may occur in athletes who subject their elbows to
severe valgus stresses by throwing, e.g. javelin throwers and baseball
pitchers. There may be attenuation of the medial collateral ligaments, or
even rupture. Mild cases may subside with rest, but in some a reconstruction
may become necessary if there is the desire to continue with the activity.
Instability ill also seen in rheumatoid arthritis, the Ehlers-Danlos syndrome,
and in Charcot's disease.
TARDY ULNAR NERVE PALSY

This ulnar nerve palsy is slow in onset and progression. It appears usually
between the ages of 30 and SO, and the pteceding injury to the elbow,
considered responsible for the ischaemic and fibrotic changes in the nerve,
has usoally been in childhood. 11 is seen most frequently whe:le there is a
cubitus valgus deformity. The progress of the palsy may be 811'Cstcd by
transposition of the necve from its normal position bebiDd the medial
epicondyle to the front of the joint.
ULNAR NEURITIS AND THE ULNAR TUNNEL SYNDROME

Ulnar neuritis, with its frequent accompaniment of small muscle wasting
and sensory impairment in the hlmd, may occur as a complication of local
trauma at the elbow or at the wrist. At the elbow, it is also seen where the
nerve is abnmmally mobile. In these circumstances it is exposed to frictional
damage as it slips repeatedly in front of and behind the medial epicondyle.
In such cases reanchorage or 1lansposition may prevent further deterioration.
Some advocate epicondylectomy.
The nerve is also subject to pressure as it passes between the two heads
of flexor carpi u1naris below the elbow (the cubital tunnel), or as it lies in
the ulnar tunnel in the hand. Where the local findings are not clear enough
to localise the site of involvement, nerve conduction rate studies are often
most helpful
In a number of cases no obvious cause for an ulnar neuritis may
be found.
OLECRANON BURSITIS
Swelling of the olecranon bursa is common in carpet-layen and others who
repeatedly traumatise the posterior aspect of the elbow joint Swelling of the
bursa is also common in rheumatoid arthritis, and there may be associated
nodular masses in the proximal part of the forearm. The condition is usually
painless unless there is an associated bacteri.al infection within the bursa.
Excision is sometimes advised for cosmetic reasons.
PULLED ELBOW
This condition occurs in young children under the age of 5, and is produced
by traction on the arm. as for example when a mother snatches the hand of a
child wandering towuds the edge of a pavement. The radial head slides out
from under cover of the orbicular ligament, and the child complains of pain
and limitation of supination. The orbicular ligament and radial head may
be reduced by fon:ed supination while pushing the radius in a proximal
direction (by forced radial deviation of the hand). On the other hand,
spontaneous reduction, without manipulation, usually occurs within 48 hours
of the incident if the arm is rested in a sling.
OSTEOARTHRITIS AND OSTEOCHONDRITIS DISSECANS

Primary osteoartbritis of the elbow joint is not 1I.DCODliDOU in heavy manual
worms. Ostcoartbritis is also seen secondary to old fractures involving the
THEELBOW 79
articular surfaces of the elbow. It may also follow osteochondritis dissecans.

Both osteoarthritis and osteochondritis dissecans may give rise to the
formation of loose bodies, which restrict movements or canse locking of the
joint. The joint may lock in any position, and the patient often develops the
trick of unlocking the joint himself. If loose bodies are found, they should
be removed to prevent further incidents of locking and to reduce the risk of
their causing more damage to the arti.cular surfaces. Joint replacement
surgery in those suffering from osteoarthritis of the elbow is seldom
indicated, as the physical demands are likely to exceed the capabilities of
any current replacement.
RHEUMATOID ARTHRITIS
Rheumatoid arthritis may affect either one or both elbows. If both elbows
are involved the functional disability may be particularly greaL
Clinically there may be marked synovitis, painful restriction of
movements, and a fixed flexion deformity. Pronation and supination may be
restricted and painful, although in some cases the distal radioulnar joint may
be responsible. When there is gross destruction of the elbow, the ulnar nerve
may be affected and the joint may become llail.
Medical treatment and steroid injections may help in the early stages.
Later, synovectomy with excision of the radial head may delay progress;
and in advanced cases, with gross instability, joint replacement may be
considered.
TUBERCULOSIS OF THE ELBOW

Thberculosis of the elbow is now very uncommon; marked swelling of the
elbow with profound local muscle w1111ting is usually so striking that there is
unlikely to be a delay in further investigation by aspiration and synovial
biopsy.
MYOSITIS OSSIFICANS
This condition occurs most commonly after supracondylar fractures and
dislocations of the elbow. Calcification occors in the haem.atoma that forms
in the brachialis muscle covering the anterior aspect of the elbow joint It is
particularly common in association with head injuries, and may also follow
over-vigorous physiotherapy. It leads to a mechanical block to :Dexion. If
discovered at an early stage, complete rest of the joint is necessary to
minimise the mass of material formed. In later cases it may be excised after
the lesion has appeared quiescent for many months, and postoperatively a
single dose of radiation therapy may help prevent recurrence.
A B
5.1. lftllpectlon (1): Look for (a) 5.2. lftllpectlon (2): Note 1liat the earlim 5.3. ln.,.ctlon IJ): Note wl!cth« tb::re arc
genera1Ued lwdling of the joiDt aDd (b), c1inil:al. ligD. of effusion is 1bc filling out of my locllliled IWdliDgl roond 1bc joiDt, e.g.
IDilscle wamq. both 11118PIIive of lnfeclive the hollows &elm in the fiexlld elbow above (A) olea:aDOD banitis, (B) rheumatoid
ar1hritiA (e.g. tubrn:ulo&is) or rbelllllll!oid the olecranan (A). The next sign is swelling nodulea.
artllriliJ. The awollcD elbow u alwaya held in of 1llc :nldiohUJilClal. joiDt (B). Fklicl may be
tbe semjftewJ politiOD, u in dill politilll1 squeezed between tbele two areas.
intta-ll'licular pn;~ lllld hence pain. ia
least marbd.
5Ao. lnspecdollll4l: AJk the pltlent to 5.5. INpectlon lSI: (A) In albitua valgus 5.1. 1ns,.ct1on 161: The curyiDg angle may
exlc:ad boCh elbowlllld. DOte 1bc cmyiag tbc:te is an increue in die cmyiDg angle. be meuUICd willl a gOIIiom.etJe:r.
aagle OD bach ridel. Any maa1l difl'lnDce (B) In cubitus varus there is a decreale in the Aftl'alt na- .r UIT7iD& agle:
betvnim the lida willlhen be obvious. carrying mg1e ('guutoc:k deformity'). The Maim: u• (range 2-260)
COIDIIIOIIe.$l (:IIQJC of llllilalaU 1111e:rltioa in F.W.: 13° (range 2-220).
the canying aogle ilan old IIUpr'IICODdyJar
fral:mre. Valgua IDd/CJI' VUIII laxity lllld
imtability (coofum by ~ may al.!o
fnDow amiD elbow fnctura.
THEELBOW 81
5.7. Movements (1): Exmuioo: (A) Pull 5.1. Mnements (2): 1/yperutmsion: If the S.J. Mnements (3): Flexion (1 ):
extrmion, 0", is present if the arm and elbow can be exteDded beyond the neutral (ScreeniDg telt) Ask the palienltD aaempt to
forearm can be !lllldD 1D lie in a l1lllight line. positicm, record tbia 1111 'X" hypmexlmsion•. 1Ducll both shouldm&. A lliight d.ifl'emK:e in
(B) Loss of full exlension is especially Up eo 15° is~ as ncama1, especially in :ftexion between the side8 is then usually
common in osteovthritia, dleumatoid women. Beyond. this, look for hypermobility obvioua.
lll1hritia. and old fracturea (particularly of tbe in other joint& (for example u may cx:cur in
mdi.al Mad) involving the elbow joint. the Eblen-Danl.os syndrome).
5.10. Mowm•nts (41: Fluion (2): 'Ibc 5.11, M~•nts (5): Pronaticm/~~~pinaticm 5.1 Z. M-•nts (61: Prrmution/611pinatirm
l'ILll&e of flexion may be measured. screening (1): Ask lhe plllient 1D hold the screening (2): Now tum. the palms
Nonll&l rup = 145°. elbows cbely to the aides. Tam the palms downwmis in pmnaticm, again comparing
Restriction of :ftexion is common after all upwards into supination and ~ the the sides.
fracture~ J:OUIId the elbow, and ia all formiJ of llide8.
1111hrids.
5.13. Mvftmentl (7): Sl4piNIJion: 5.14. Movement (8}: Pf"'OIlUion: 'lbUI may 5.15. P•I~N~tlon (1): Begin by locating the
Supination may be reoordcd. Give tbe plllicnt he measured in 1he lall1C way. epicoadylt:lllld 1he ol.ec:nDoa. If ia doubt,
a pmci!ID hold, md noll! the q1e from the N01111.11. r11J1111 =75°. llex the elbow 8lld note tbe equilatmal
vcrtic:al lhat can be IChieved. Prowdionllllpination IIIOVCIDelds may be lrianp ommally t'onmd by these stnK:tliml.
NOIIIUII nup • so•. reduced after fractures at the elbow, in tile 'J1Iil re]ltionattip iJ diltarbed in elbow
forearm aDd at tbe wriBt (e.g. ID08t COIIDIIOilly IUblllutionl.
after Colles' fmcture). Lou may also oa:w:
after dialoc:ation of the elbow, and rbmmllfnid
and oDoarthritis. Pare supination losa may
occur in c:bihtreD with pulkd elbow.
5.16. P•lpMion (2): Palpete the lallnl 5.17. hlpMion (3): Palpate the medial 5.18. PlllpMion (4): Teodsne11 over the
epiamdyle with the thumb. Sharply 1ocaliJed epicoodyle.. Thldrnleu oc:cun here in olecnlaoc iJ 1JIIroliiii!OD, apart from aflm
tc:adcrnelf ~ c." jut diltal iJ almost golfer' I elbow, tars of tbe 1llDir collatcrll fi:ll:tllle aDd inficctiCd olemnoa bumtil. both
dilpoltic ol teDDia elbow. Cfltly our 1ipmml, aad injariea ol the medial ol wlli.dlare IIIUll.ly obvioaa.
ronfinnatmy 11111:1 (22 « Mq.). NofB tbat .t'tllr apicoodyle..
the injeaion ol hydroconiJoDe locally (e.g.
for teDDil elbow) ademea bcc:amea more
di1fule..
THEELBOW 83
5.1 9. Palpation (51: ~ dlc thumb lirml.y 5.20. Palpation (6): Palpate 111c front of the 5.21. Palpation (7): Roll the ulnar lllm'C
into the space on 1he lateral side of the elbow elbow IB1 bo1b. llides of 1be bicepllmdon UDder 1he fiD.gerB behind the medial
betwemJ. the radial head and lmmmls. Now while ftexins and extmJdins the elbow epioondyle. Note whl!thllr lhml is any
J110IU111! aud lllpiDale the ann. 1endemess t1JrouP 20". Note the prae:oce of any difl'me:ol:e between the lli.des. If indicated,
here iJ common a&r injuries of dlc radial abnormal muses (e.g. myositis osaificans, carry oat a fuller eumjnatlon of the nerve.
head, ollteoardni.tis lll!d osteoc:hlmdriti1 loOie bodiel).
dlssecans.
5.22. Additional tub: 'lenni.! 11/bow (1): 5.23. ,._nil ..bow (2): All an allmnalive, 5.24. ,-_nil ..bow (3): TM cluJir III&L Alii:
Flex the elbow and fully pnmate the hand. pain may be Mlllghl by pronating the arm the patimtiD at1mDpt Ill lift a chair (of about
Now exlald the elbow. Pain over lbc lai=8J. with dlc elbow fully exfaldcd. 3.5 lrg in wcigbt) with the elbows extc:odcd
epicolldyle iJ almOBt diagnoltic of tewliJ aDd the lhoal.den flexed to 60". Difliculty in
elbow. perl'orming llilillll81IOCIJYl'e, with complaint of
pain on the llllmDl. aspect of the llffected
elbow, i s sugpstivc of Rmris elbow.
5.25. Tennl• elbcaow (4): Tltomlm:, t.1t: 5.26. Adclhlon•l tats: golfen elbclw: 5.27. Adclltlon•l tests: ulnar nerw (1 ):
Ask the palicnt to clcach tho flat, dorsiflex tho Flex the elbow, IUpinare the baDd, IIJ1d lbaD ID.Ipect the mediallide of the elbow carefully
wrist IUid extlmd the elbow. Try to fon:e the exltllld the elbow. Pain over the medial while the plllient ftexes md extends the joint.
hand into palmar flexion wlrlle lbe patient epirondyle iR very sugpti.ve of golfer's The nerve is vi.r.ible in the thin paDeot, and
n:lista. Sevae paiD over the c:De:mal elbow. cllipliiCC!Dellt on movement may be obvious.
epicondyle il apia II10it •uae-dvc of tenDU
elbow.
(S): Repeat, lhia time aUmnpting llo Sex the
cxlaldcd middle &lger l'llber tlwllbe wrist.
5.21. Uln11r .-v. (2): Palpaae qain aDd 5.2t. Addltklnlll t.m: alb-lnmbllltJ:
no11e the extent of any 1elldemcls, and Both va1p :md Vllnlll instability IIIII)' be
wbdbc: the Da"Ve il tbic:kalcd. Look ~gain U:lted by stR:uing the joim in extcasioa lllld
for cabima vllgua. Loot for cvidcDce of u111ar 30" flexion (u peJfarmed for the collaa::nl
DmW,.hy. ligiD*Itl in the liMe). Allemalively. for 5.30. RadlatNphs (1): Nmmal
valgus instability (whicll i.r. the COIIIIIIOIIelt), . . .opolllerior radi.opaph C1f the elbow.
IIICbor the patial's ann in 30" elbow flc.xim
.,.wt your side (1), apply • Vl1gul stn:ss
(2), Md fed fer ay pp opcDiDg up Oil 1llc
medial lide (3).
THEELBOW 85
5.31. Radlogl'llphs (2); In gamjning tbe 5.33. bdlogniiphl (4); In cxamiDiDg 1lle
ltandard AP view trace CJUt 1lle outline of lltaDdard lataal projection, DOte (R) the radial
(M), the medial epicondyle; (OF) tbe head; (Co) the caronoid process of the ulna;
oll!c:ranon aud comnoi.d fossae; (L) the lalmal (01) the olecnmon.
epieoudyle; (Ca) 1lle capitulum; (R) tbe radial
5.!12. bdlogr•phl (3): Normal lateral
bead; (Th) 1lle tuberollity of tbe radius; (Co) radiograph af tbe elbow.
the 001'CliiOid procea& of ullla; (Tr) tbe
tmchlea..
5.34. R..slograph1 (S): Look for (J) my 5.35. Radlognphs (6): Note the ~ 5.36. RH!ographs (7): Where the radiaJ.
drlecta in tbe capitulum sugpting af (N) a. oongenitalll)'lllllltosis (with head is suspect, radiographs should he
os1icochoodritis dis~ 00 loose bodief incvU:a.blc lou of pronation and 110pina.lioll); ta.ka1 in 1lle anD:ropollk:rior piaiiC (A) in
(umally aeccmdaJy to osteoarthritis or (0) myositis olllificans (with cliDically midposition. (B) in supination, (C) ill
osleochondritis); (L) incompletely nmmdelled nllllrictian of flexion). Note any osteoarthritic pronation. Tbese may bring an IIRIII of
supnu:ondylar fracture (umally IISIIOCialm change.& with, for example, (P) joint apace os~tis of tbe radiaJ. bead or an
with loss af llcxiOil}; (M) olc1 Momeggia nmowing, (Q) bony sclmlliJ of 1lle joint olc1 fracture inl!J pro1i1c.
fracture (fnwture af 1llDa and dislocation head margiaa. (R) osteophyrea, (S) loosc body
of l'llllius), 1111ually IIJIIIOCiated with educlian forma1ioll, or (.T) evidcm&:e of pmvious
of pronation aud supination. fnctnre.
5.38 bdlogNphS It): All six cpipllylel S.3t. ...dlogNplu (10): In molt sitoations
~ llhownllimn!tanemaly in lllil diagram. lhe old mnemoaic 'cite' (capimlam, inlmlal
5.37. bdlog....,...(l): Normal
Mcmori8ing lhe time of their appearaiiCC may epicondyJ.c:. ttocblea. extemal epicondyle) for
antaopostcrior ndiograph of the elbow of a
be aided with the popular mDI!ITJmric lhe IIJIPIIIIlBIICI of tbe epiphyaeal cenlnll at 3,
child of 8. 'l'lue 11111 llix epiphya IOUDd the
elbow, llllll thelle appear: lllld milie at vmioua CRITOL, where C = capitulum (capitdlum) 6. 9 and 12 years, il normally mfficiently
timu. 'I"'ae ~ comiderlble iDdividiJa1, =
at I year, R ndW head Ill 3 years. I = ~.
intemal (medial) epicondyle at S yean, T =
gelid« and %liCial variation• in 1bclc: fimiD&a.
Nevcrthelcu, in certain lituatiou (e.a. in lrochlea at 7 )"llll"", 0 = ola:nmon at 9 JHD
auspec~Bl filll:turea llllll ciWocaliODJ). a
and L = laD'ai epicoadyle at 11 yean. 1'bele
epipllylet geDetally 1Diite 2 yeara aftc: they
la!owledF of tbeae il aaential. ftnt appear.
y y
SM. ""dlogn~plu (1 1): If theft luay 5.41. Rlldlogn~phs (12): In exmnining 5.42. bcllotlr.phl (1S): Apart from
doubt, ndiogriJila of both lidel lbould be lhe latc:ral X-ray projec:don of a ciJlld'a patholoty at lhe elbow (aDd wrllt) pronation
bkm. Nob! that if a dlilcl over the ap of 6 elbow, eapecially aftm: IRISpected IIllllma, lllld supination may be affected by
hu injured lhe elbow there il evuy alwaya dHdt the alignment of lhe 1Iumrral diltllrbaau:e of ndial bowing (e.g. Uls a
likdihood that the medial epicoodyle '* cpipbylea1 complex with the humeral alulft. forann frlclure). Bowiag may be asaeued
'become dilpl.aad iliAD 1llc joint ifit CGI!IIot be Becau11e of ltl aaterior tilt of «;•, a liDt 1llill& the me1bod of Schc:miUch and RicbllrdJ
- i n 1iiD a~~ltilupollfllldor view, or if it Cdll (1) dn.wn down tbe ammior llll"fiK:e of tbe which u.. an AP radiopph tabn in the
be -.u in the btmaL (A) Noanal, (B) IJummus dJould ~~rib the allllpleL Similarly, mid~ Tbe localion of maximum
di~. I line (2) lbwn along lhe abaft of the radiUI bowini (x/y X 100) iJ normally sitaaticd 60'J.
ahould lllik the <lCIIIpllex if the mdial IJbaft 11 ll1co& lhe lblft. wbile lhe depe of bowing
in alip!!Bil (Le. if be is DO elbow (rly X 100) il.,.._ 7CJ.IIIII I01l..
dilllllCidioo).
THEELBOW 87
5.43. Pathology (1): 'lbe proximal radioulnar joint iJ DOt

present, lll!d no pnmatioD/mpillatioD lllOVCllll2ltl are
possible. The epiphysis of the olemmon has not yet UDited.
Diapcllll: congenital radioulnar s)'lll!SID8iJ.
5.44. Pathology (2): Afb:r an elbow injury a large mu1 of bone

has formed iD the front of the joint, and baa virtually obliterated all
moveJDllllh.
Diapcllll: myositis ossifu:ans.
5.45. Pathology (J): All the joint surfaces ~e irrqular, and the .5M. PalholofJ (4): There is srnn d.illlmbam:e of the ~
bone texture bas a IDDIIIcaten appeal'lllliCC. of the elbow joint, aDd boDy ankyiom has occumd.
Dfapods: septic (iDfective) ar1hritis of the elbow. Diapolll: iD thiJ case the came wu a guD&hot WOUDd to the elbow,
with extensive bone clamap.
5.41. Pllthologr (1): The radioanph il of m acu cue whele,

5.47. Pftho!DgJ [5): 1bcte il an obviou1 defect in tile olecnmaa,
wilh eplllldion of the CJ:asmlmtl. Tbe llClUiplainU Willi of 'Mlllkne1s of lllOYllllleDbl.
w•
following a dialocati.oo of 1lle elbow, there marked reatriaioD of
elbow movemenlll. DiapoiJt: tbe JMdiaJ. epicondyle lw c!Uplaced.md become trapped
Diapolil: GI11Uiited ~ of the olecranon. Injuciea of this type
in the joint.
may have aU1priliDgly few ll)'mptoml, but there i1 oflcD weabela (u
was the case !.e) md reltri.clioo of utmaian.
5.49. PlllhoiDIJ [7): Beth projectilllll show Daii'OWing af tbe joint 5.50. Pllthology (8): The ndial. head baa loll its DOriDa! site af
space betwe=111e uJaa IDI1111e htlmel"uJ, with a degree of III1qiDal artil:ol.atiol1 with tile capitalum, and there il a cubilua valgus
bone IC.k:roail. In 111e lateral view there i1 lipping of the o1ccrmon, ddonnity. Tbc appearance• life of aJ.oDa-atandiDg lesion.
BDd multiple loose bodiel are pn!lllllt. map.il: 1hU iiiiD old Monteggia fracture disl.ocalion of the elbow.
Diapom: os~tia of 1he elbow with loole body fm:m.Ui.an. The ulnar fndure hu healed.md il DO longer vbibJe, ballhe
Synovial eboadromatosia may have a aimi1lr lppeii"IDCC. diJiocaJion of 1he radial head pen.illll. In d.U1 case !here wu an
uiiOCiafcd Wdy 1llDir oene p&I.Jy.
5.52. Pathology (10): Tbcrc is a gap 5.53. PathoiOIJ (11): 'l'llc arrow points to
5.51. PathalofJ(I): The articalar lllll'falles
between dle distal artic:alar complex of dle an aboormalily in tbe J:eiiou of lhe conmoid
between dlelmmt:ru aadu!Dahave been
bUIIIa'IIS aDd tbe distal Jmmaoal abaft. 'lhl!re fossa. This was associa!l!:d wilh sevem
virtually oblill!:ra1lldfollowiagalcq period of
was little IDIJVGilent left in the elbow joint
pain, sftllins aadlosa offuadimin the elbow. relltridian of elbow flexion.
itadf, but dJaoe was a 1imimd DIIJe of rather Diaposll: this .is a large 1ooae body. In the
Diapolls: in dlis case this was due 111
unstable IIIOvellleDts proximal to it. siagle view the soun:e .is uot obvious, bat
tabem1lou .infection of b joiDI, and
DlapaliJ: Ilia is an example of lonptallding tbe most libl.y CIIIISel are osteochondritis
ankybis has maulbl.
non-uaion followiJis a suprllllOIIdylar fracture dissecma or ollbloarlhritis. The loss of fle.xiou
of dle lnmlems. is due to a purely nw:banical block Ill
movement.
5.56. Alpl...lon ofthe.utow joint: The

most dimc:t aDd safest approach is from the
lalenll aide. Flex the elbow to 9()0; Ill locllkl
the ndial head, piOIIlllB aad Npina!B the lll1ll,
and feel with the thumb for ill mtaliou. After
5.54. Pathology (12): Thia hmn1 5.55. Elbow racllogr.phs: umnpiH of infillralion of the II!N with load aoaeethetic,
radiograph shows a Imp l001e bony mass patllologJ (1 3): 'Ibis Jlldiognph sbowll m imnxluce the aapimiDg .-die in the - o f
lying in the fnmt of the elbow joint. ilmgubrity of the capitulum inwlvillg its the palpable dGpmuioD between the proximal
DiapaliJ: 100111 body, probably secoodary 111 articulllr surfaal. 'Ibis Wllll uaoc:iated with put of the radial head aad the arpitulum.
olteCKlholldrids dl811CC8111 or oateoll'lhritie. Ja achillg paiD in 1he joint of aeverallD.Oilths'
IIODIC euee IOOIIC bodies of thie type may be duratiOD.
extruded and eome 111 lie in the blacbialis DlagDosls: os1eochclldrids of the capilulum.
-1e. wiHn their mec;lwliw efl'ects on
elbow BuiaD are less obttulive.
6
The wrist
Complications occurnng after Colles'

fracture 92
Ganglions 92
de Quervain's disease 93
Extensor tenosynovitis 93
Kienbock's disease 93
Osteoarthritis of the wnst 93
Carpal tunnel syndrome 94
Ulnar tunnel syndrome 95
Ehlers--Danlos syndrome 95
Tuberculosis of the wrist 95
Carpal Instabilities 96
Inspection 97--98
Palpation 98--99
Movements 99--100
Joint hypermoblllty I 00--101
Crepitus 102
de Quervaln's tenosynovitis 102
Carpal tunnel syndrome 102-104
Radioulnar laxity 104
Carpal Instability 1OS
Radiographs 1OS-1 07
Pathology 107-110
Aspiration ofthe wrist 110
t:l CLINICAL ORTHOPAEDIC EXAMINATION
Study of the wrist cannot be separated from that of the hand. and in many
C8lles careful examination of both may be ~uired.
COMPLICATIONS OCCURRINCi AFTER COLLES' FRACTURE

Considering the incidence of Colles' fracture, the commonest of all
fractures, it is smpri8ing that complications from this injury arc not seen
more :frequemly; nevertheless, they do occur and are of importance.
Excluding initial weakness of the wrist, the commonest complaints are of
residual deformity, restriction of movements and pain.
The common deformities arc radial deviation of the hand and promineru:c
of the ulna. Owing to resotption of bone at the fracture site during healing,
there is shortening of the radius with radial deviation of the hand. This may
be aggravated by a poor reduction. At the back of the wrist, the head of the
ulna becomes prominent. (Gross subluxatiODS of the ulna of this pattern are
sometimes referred to as Madelung's deformity; this term was used initially
to describe a condition occurring in adolescents where, following some
disturbance of growth in the distal radial epiphysis, often idiopathic in
origin. the ulna becomes relatively prominent.)
In all CoDes' fractures there is disturbance of the inferior radioulnar joint.
In some cases this is responsible for persisting pain and tenderness just
lateral to the ulnar styloid.
Again. disruption of the inferior radioulnar joint is partly responsible for
loss of movements in the wrist. This certainly accounts for the loss of
supination that causes patients the greatest concern. Although restriction of
dorsiflexion occurs after moat CoDes' fractures, this seldom gives rise to any
functional problems.
Two othec important complications are seen after Colles' fracture: (a)
delayed mptore of extensor polliciB longus teDdon may occur some months
after injury and is due to ischaemia or attrition of the tendon, and (b)
Sudeck's atrophy (complex regional pain syndrome), which is usually
diagnosed some weeks after cast fixation has been discontinued, and which
is characterised by DlJilbd swelling of the wrist, hand and fingers, gross
stiffness of the fingers, and decalcification of the carpal bones which is
obvious on radiographs of the region.
Regarding treatment of these complications, the patient is generally
advised to accept minor degrees of residual deformity and stiffness. When
there is gross prominence of the ulna causing symptoms, excision of the
distal end of the bone may be advised. Ruptures of extensor pollicis longus
are treated by tendon ttansfer (extensor indicis proprius is generally
employed). Sudeck's atrophy generally ~uires inten11ive phy11iotherapy, and
often other measures if much permanent stitfness is to be avoided.
GANGLION$
Ganglions are extremely common about the wrist and hand. In many cases
they may have a tenuous COIIliiiUilicaton with a carpal joint or tendon
sheath. Some are spherical in shape, firm, aod have oo obvious connection
to other structures. Tiny ganglions of this type are comJDOQ in the fingers.
Pluctuations in tbc size of ganglions and their rupture from trauma is well
known, and diagnosis is not usually diflicult UD1es11 the swelling is small.
THEWRIST 93
This applies in particular to small ganglions on the back of the wrist, arising
from the radiocarpal joint; local swelling and tenderness may only be
obviDWI when the wrist is palmarflexed. This type of ganglion is often the
cause of persisting wrist pain in young women: their symptoms are often
labelled as functional when Ibis difficulty in examination hall not been
appreciated. Excision of most ganglions is advised, and this is essential if
the ganglion is producing nerve complications (e.g. if a ganglion in the ulnar
tunnel in the hand is producing ulnar motor and sensory loss).
DE QUERVAIN'S DISEASE
Thnosynovitis involving abductor pollicis longus and extensor pollicis brevis

is known as de Quervain's disease. It occurs in the middle-aged. The walls
of the :fibrous tendon sheaths on the lateral aspect of the radius are greatly
thickened, and there is often IllBI'ked underlying swelling. The patient
complains of pain on certain movements of the wrist, and weakness of
grip. Treatment is by splitting the lateral wall of the sheath.
EXTENSOR TENOSYNOVITIS
Acute frictional tenosynovitis occurs most frequently in the 20-40-year age
group, generally following a period of excess activity. Any or all of the
extensor tendons may be involved. The condition has a benign course and
usually settles if the wrist is immobilised in a cast for 3 weeks.
KIENBOCK'S DISEASE
In this condition the lunate undergoes a form of avllSCUlar necrosis. The
cause is unknown, but there is commonly a history of trauma. Abnormalities
in the shape of the lunate and local osseous alignments have been described.
The condition is seen most often in males in the 20-40-year age group,
and gives rise to pain on the dorsum of the wrist and diminutions of grip
strength. It may be complicated by an accompanying carpal tunnel
syndrome. Although the diagnosis is usually established by plain
radiographs, in the early stages an MRI scan may be helpful, and a cr
scan may be used to detect early fracture or fragmentation, Thmporary
immobilisation of the wrist in a cast or other support may help relieve
symptoms although not affecting the progress of the condition. A number
of surgical procedures have been prescribed, none of which has any clear
superiority over any of the others, or over conservative management.
OSTEOARTHRITIS OF THE WRIST

Osteoarthritis of the wrist is smprisingly uncommon considering the
frequency with which the joint is involved in fractures. It is seen most often
after avascular necrosis of the scaphoid following fracture of that bone,
non-union of a scaphoid fracture, comminuted fractures involving the
articular surface of the radius, and Kienbock's disease (spontaneous
avascular necrosis of the lunate, see above).
Where sy:mptoms are severe, fusion of the wrist (radiocarpal joint) may
be undertaken.
M CLINICAL ORTHOPAEDIC EXAMINATION
Rheumatoid arthritis of the wrist is common, and extensive synovial
thickening of the joint and related bmdon sheaths leads to gross swelling,
increased local heat, pain and stiffness. Fluctuation can sometimes be
transmitted from just above the wrist to the palm, the synovial fluid being
displaced from one level to the other underneath the flexor retinaculum
(compound palmar ganglion). With progressive joint involvement the carpus
tilts into ulnar deviation and subluxes in a palmar direction. The bead of the
ulna displaces donally, disrupting the inferior radioulnar joint and causing
painful and reduced pronation and supination. Rarely tuberculosis of the
wrist may produce a similar clinical pi.ctul'e, but the multifocal nature of
rheumatoid arthritis usually makes differentiation easy.
As far as treatment is concerned, local measures can include the use of
night splints; later, synovectomy of the wrist and of the inferior radioulnar
joints may be effective in slowing the progress of the condition. Where
pronation and supination are particularly affected, excision of the distal end
of the ulna may give worthwhile functional improvetnent. Where there is
gross destruction of the joint and marked local symptoms, fusion may have
to be considered.
CARPALTUNNELSYNDROME
This condition OCC1D1i most commonly in women in the 30--60-year age
group. Basically there is compression of the median nerve. which leads to
symptoms and signs related to its distribution. In some cases premenstrual
fluid retention, early rheumatoid arthritis with synovial tendon sheath
thickening, and old Colles' or carpal fractures may be responsible by
restricting the space left for the nerve in the carpal twmel. The CODdition is
sometimes seen in association with myxoedcma, acromegaly and pregnancy;
often. however, no obvious cause can be found, and it is vecy frequently
bilateral. The patient complains of paraesthesia in the hand: often all the
fingers are claimed to be involved, although theoretically at least the little
finger should always be spared. Paraesthesia may also radiate proximally to
the elbow. There may be pain in the same areas, and weakness in the hand.
The symptoms may become most marked in the early hours of the morning,
often waking the patient from sleep and causing her to shake the hand or
hang it over the side of tbe bed. In many cases the history and results of
the clinical eXIIDlination are unequivocal. In others it may be difficult to
differentiate the patient's symptoms from those produced by cervical
spondylosis, and indeed both conditions may be present at the same time;
a trial period of immobilisation of tbe wrist in a cast or the use of a
cervical collar may be helpful. Nerve conduction-ti.me tests, showing a
delay at the wrist, may be used to confirm the diagnosis. These studies are
being employed with increasing frequency in tbe practice of defensive
medicine.
Most cases are treated quite simply by division of tbe flexor retinaculum,
which forms the roof of the carpal tunnel, tllcRby relieving pressure on
the nerve; the procedure may be performed arthroscopically through a
minimal incision. Conservative measures may be tried, espccia11y in cases
occw:ring in pregnancy, when diuretics may be prescribed witb success.
THEWRIST 95
Other measures include 1he use of night splints and injections of

hydrocorlillone.
Note that on rare occasions the median nerve may be compressed
prcuimalto the carpal trmnel. Above the elbow this may be due to a
supracondylar bony spur (obvioua on radiographs); just distal to the elbow,
by 1he origin of pronator teres; and in the proximal part of the forearm by
the sublimis. Proximal lesions of the median nerve give rise to the anterior
interosseous nerve y-yndrome.
ULNAR TUNNEL SYNDROME
The ulnar nerve may be compressed as it passes through the ulnar carpal
canal between 1he pisiform and the hook of the hamate. Both the sensory
and the motor divisions of the nerve may be affected, but often one only is
involved. The symptoms therefon: may include small muscle wasting and
weakness in the hand, with sensory distorbance on the volar aspect of the
little finger. The sensory supply to the domun of the hand is given off in the
distal forearm, so that sensory disturbance on the dorsum of the hand and
little finger excludes a lesion at this level. In all cases every effort should
be made to exclude a more proximal cause for the patient's symptoms (e.g.
ulnar neuritis at the elbow, and cervical spondylosis). Nerve conduction
studies are often of particular value in this situation. The commonest
causes of nerve involvement at the wrist are ganglionic compression.
occupational l.t'8WnB, ulnar artery disease, and old carpal or metacarpal
fractures.
On the establishment of a firm diagnosis of a localised lesion in the ulnar
tunnel, exploration and decompression of the nerve are carried out.
EHLERS-DANLOS SYNDROME
This is the name given to a number of closely related connective tissue
disorders which are due to a collagen abnormality. The condition is
comparatively rare (50 000 cases are said to be affected in the UK), with a
strong (autosomal dominant) hereditary tendency. It is found in llll8ociation
with Marfan's syndrome and osteogenesis imperfecta. The skin has a velvety
feel and is fragile and hyperelastic; when grasped it can be raised and
stretched by a remarkable amount. Wound healing is poor, leading to
abnormal and somewhat keloid scarring, evidence of which may be
widespread. Cases vary in severity, but in some healing may be so poor
that surgery is contraindicaled. The walls of blood vessels are affected, and
bruising is a common problem. Ligame111s lose their resistance to stretching,
so that there is usually a striking increase in tbe range of movements in the
affected joints; this is often well in excess of the normal range (sometimes
to a grotesque degree), and there may be instalrility, leading to sprains and
dislocations. There is no effective treatment.
TUBERCULOSIS OF THE WRIST

TubeiCulosis of tbe 'Wrist is now rare in Britain. Maiked swelling of the
joint is followed by muscle wasting in the forearm, erosion, destruction and
anterior subluxation of the carpus. The diagnosis is confirmed by synovial
M CLINICAL ORTHOPAEDIC EXAMINATION
biopsy. Monoarticular IheumaDsm is the only other condition in this area

that is likely to cause difficulty in diagnosis.
CARPAL INSTABILITIES
A carpal instability is a condition in which tbe:re is a lou of normal
carpel alignment wbich develops at an early or a late stage after an injury.
Untreated cases may lead to the development of osteoarthritis in the wrist.
In static carpal instabilities there iJ an abnormal carpal alignment, which
can be seen by careful study of standard AP and lateral radiographs of the
wrist.
In dynamic carpal instabilities routine radiographs are normal. The
patient is usually able to toggle his carpal alignment from normal to
abnormal and back. To establish the diagnosis in this situation, lead markers
may be placed on the skin over points of local tenderness, and radiographs
taken in both stable and unstable positions.
In the case of scapholunate instability (acapholunate dissociation), the
commonest of these problems, AP views of lhe supinated wrist in both
radial and ulnar deviation a:e usually diagnostic. Other investigations
include examination of the wrist in motion using an image intensifier and
radioisotope bone scans.
Acute cases may be stabilised by manipulative reduction and the insertion
of K-wires, or by ligamentous repair. In chronic cases reattachment of the
avulsed ligaments may be carried out, but where there are arthritic changes
and subluxation a salvage procedure may have to be considered.
THEWRIST 97
&.1. lnsFJKI:Ion: front (1 ): Note any 6.2. Front (2): Note (A) 1henar WliBtiDg in 6.3. Frant (3): Note any l.ocaliaed swellings
defomlity of tbe wriBt, e.g. radial deviation of hand, (B) hypotheDar wasting, (C) IQt'l suggelltive of gauglion, rbeumatoid DOdale or
the band, common after Collel' fracture, and mggeltive af pteVious surgery ar injucy. tumoar.
striking in ccmgenital abllzce of the radius.
Note any ulnar deviation, common in
rheumatoid arthritis.
iI
I
~
I
f
I
6.4. Front (4); If tllele is swelling at 1he 6.5. Front (5): Note the preaeace of lll1liCie 6.6. lnspecdon: side {1); Note any undue
wrist and abo in the palm. try to dmnoosllll1e wasting in the flmliiiDl, also suueative of promimmce of the ulna (amunm after
crnss-ftUI:Iualion.. This ~ in campouod dieumatoid arthritis aDd tubm:ulosis. Colles' f'ractue or Madelung deformity), any
palmar ganglion. scen most often in Widespread bi1at='a1 wasting is common in anterior tilting of tbe plane of the wrist (e.g.
rheumatoid arthritis and tuberl:ulctia. many neurological CODditiont (e.g. after after Smi111's fractule), backward 1illiDg (post
oervical spine injuriel, multiple sclerosis etc.) Calles' f'ractue) or anterior IUbluxalicBI.
ami in the muscular dyllropbies. (Ibeumatoid lll1hrilis, old cmpal injwy or
infective arthritis).
t8 CLINICAL ORTHOPAEDIC EXAMINATION
&.7. Side (2): SwelliDg OVIII' the lateral u.. Inspection: dorsum (1): Ganglion• In e.,. Dorsum (2): Palmarftex the wriat and
upect of lie diatal radius OCCIIllln de relation to the wrist, caqK~J and c::DeDsor compare one side with 1be olber. Small
Quervaln'l teDolynovitia. l'f tbia it JRIICill, 1aldoWI may be qui~ ornoua 011lnrpeetion. aqlioWI between lie radiu aDd carpus are a
cany out additioul!Mts (~ee Pnme 15.34). c:ammon 10un:e of obicme wrilt paiD.
Palm.artl.exion mae• IIIICh pnglions obvioo&,
llld tbe ~ of local telldemeSI lhouJd
COIIfiml the cliqDDiil.
&.1D. ~"' (J): Swelling of the wriat, &.11. hlpdon (1): Pain iD the wriat &.11 Palpation (2): 1'eadrness iD lie
lwi41Dd fiD&en, with a &lued appearliiiCe of peraiJtiDg lifter a Collea' fi:lctare, IDd due to lllltOIIIictllllllffbox ocean clallicllly after
the lkiD, diffuJe lii:Ddemell, pain and ltiffncll dWuptioll of the iJifl::rD l'ldioulDar joild, il ICIJiloid fnlctulea, but in fact iJ prele!lt afll::r
iJ typical of Sudeck's atrophy (complex always usocllled with welllocallled mmy wriJt 1pBiaa and other miDor iajurle1.
n=giooal pain syndrome), wbicb may occur as tmd,.._. • thalllile.
a aequd to Colla' rr.:t.e or c:arpal iajury.
THEWRIST H
6.13. Palpation {J): Th help dislmguiBh a 6.14. Plllp.tlon (4): Difl'u!e 1mdmneu ill 6.1 5. Pill-Ion (5): Temieineu localislld to
aprain from fracture, abo palpam the dofflll common in all inflammatory lesi.cms (e.g. the sheaths of ahdudor polliciB loqus and
surface of die scaphoid. 'Iendeme8s be:re iJ dleumalnid arthritis aod tuberculosia of die extensor polliciJ b%eviB iJ fouDd in de
ullllllly pleiCD.t aflrr fracture• bot not sprainrl. wriat) and in Sudeck:'l alrophy (complex Quervam.'s tenosynovitil. Thrze iJ often
Scaphoid mdio8Jl1Phs 111111. pla&blr finlicm are regional pain syndrome). striking lcx:al thicbniug of the tendmJ. shealha
necessary in all CUC:I of IU~ fractlm:. over the don!olmeral aspect of lbe ndius.
6.16. Palpation {6): 'l'lmllllmesa DVm" tbe 6.17. PaiF*Ion (7): In the •~ way, 6.18. MonmMts: dorslftulon
median nerve, with the production of teJJdmnel5 wi1h JM~IM~Ihesi.a on pre~~ure over (1 ): ~elling t~tt: Ask the pa1ieDt to pm!l
paraesthesia in the fiDgerll 111111 lall=ral side of the ulnar nerve iJ tNggeStive of lbe ulnar the hands togdbe£ in the vertical P"-
and to
die hand, iJ suggestive of the carpal tunnel tunnel syndrome. mile die elbows to die horizonlal. Loll of
syadrome. (See abo Frame 6.36 et seq.) any dorsiflexion lhould be obviOU&. Tbe
ctlllllliOIIelit c111111: illatiftileas llflls a Colles'
fracture.
100 CLINICAL OR'IHOPAEDIC EXAMINATION
6.19. Donlflulon (2}: ~on may be 6.20. Palmarllalon (1): Scrnriin8 rut.· 6.21. Palmarftexlon (2): Palmarllexion may
lDIIIUU1'1ld with a goDiometer. Alk lhe paliemt co put the barb of the haDdl be lllfi8IIUeCl with a goniometer.
NamW I"BDp = 75'. in COIIlal:t. aDd then 1D bring the flesnna into Nonaalr~UJ~e = 'ISO. If the range exceeds
Hypennobility iJ not IID('O!DIIlOD in women. tbe horizontal plane. Loss of pa1marflexion thi8, look for other aignJ of wrist (aDd other
If hype;rmobility iJ gtoll, however, o1har aboul4 be obvious. jolnt) hypc:rmobility, u dciiCribed in the
joints should be eumiDed co exclude a jo!Dl followil1a frame~.
laxity~.
6.22. Joint ..,....oblllty (11: (1) Try to 6.U. Joint hyperMOblllty (2): (2) Teat U4. Joint llyper!Mblnty UJ: Other
brillg the tlumb into contact wl.tb die fotarm wlleCbl:r 1he littk:: fiDger can be puaively evidcDcc of hypc:rmobility ~
and measure any gap. The ~~NrrJI• lqiiU'8Iiaa dorsiflcKd co goo or more. (3) Ckck the (6) hypercxii:IISIOD of tbe ll1kle beyOJid 45";
is 4.S c:m al ap 17~ and it mer- with elbow md (4) the knee 1D - i f they em (7) an abnoanal :nmge of abduction of the
age (u the lipmadl be 10111e al their hypemztald by 10" or llll!Xe. (S) Cba:k if the liltle fiDp; (8) 111 inaeue in hip mtation in
elutidly). Allllloall1 tbe tiiUmb contletillg tbe apinc am be :llacd ao tllat die palms of tbe cllilclr=1 (from 90-93" to about 110"), wl.tb
:fcnatm IUgseiiJ llypetmobility, tllil iJ hallda can be pW:cd on tile !loot. Joillt laxity tbe centre of the f11111C d.iJpltl:ed iafcDl to tbe
~•• Aid to Olli:W in .56~ of nmma1 is macoo-t if any 1hme of lhHe !ella (1-') midlioe. JoiDt hypermobility is a feature of
subjccta. - poAil:ive. lbe ~syndrome, Marfm's
diseue, oAeopleli• impc:fteeta and
Morq~Braillfonl'1 cliJeuc.
THEWRIST 101
6.25. Radl•l devllltlon: RAdial deviation iJ 6.26. Uln•r clwllltion: Ubw' deviation may 6.27. Pronation/supination: Scrftening
measured as the angle f'om!8d between lhe be lllfl8l1ll'cd in the same way. teat: Ask the palien1 tn hold the elbows firmly
forearm and 1he middle :IIIIellK:arpal Thia lest NormaiJ11DRe = JS<'. Ill the Bides. Orup the haDds and tmn !hem.
is best carried out in the mid position of the SO tha1 tbc palmB IR trppemiOilt. Compare the
p!ODitioll/mpiJiafioa rao,e. ammmt of supinllti.oa in both llides.
NOI'DUII. l'1UI&fl = 20".
1.211. Pronatlon/suplnldlon: St:remiltg te.rt 6.l!t. Pranlltlon: For aa:un11e measurement, 6.30. Suplnlltlan: SupinaliDn may be
(2): Repeat, lurlliDg the palms downward. 1IJ give the palieDt a pen 1IJ hDld. Ask the patiel1t measured in lhc same way.
UIICU prcmation. If DO Obvioua Cllll8e for lou tD keep lhe elbows firmly at the llide8 and to Normal raaae = w.
Df prooaliun or 11Upina1icm is found at the pronate the wrist. Me~ the angle between ~ pnmalion lllld supillaliun have been
wrist then the :fmurm and elbow muat be the vertical and the held pen. found tD be aftUted, be aure tD examine the
~yexamined Normall'llllp"' 75". elbow, and if neceasary UIICIIJ the curvature
of the radias (see Frame 5.42).
6.31. CJepltul (1): .Uiouln•r joint: 6.32. CNpltul (2): .Uioa~rp11l Joint: us. c...,lulJ): While grasping the
Place lhe index md thumb over lhe joiDt IIDd Encircle the wrist with the band md ask the wrlat, flex md exlmld the :IIDgers. AU: the
pronate md supinare the wrist. Crepi1u1 ia pa1ient to doraiflex, palmarfiex, radial devWe pa1ient to repeatlbese movements on his
c:ommon when the joint is dilol:pnlaed, and ulnar devia the wrist. O.lieolrthritiJ of own. Crepibu, fiDe in char.:ter, OCC:\11'1 in
elpeCillly aftl::r a Colle1' frlcture. the Wlilt is 'UIII:OIIIIllll but OIXl1lll after ~til crf the cDcnlar lell.dowl.
acapboid md diltlll ndi.WI fractures, AUJCUltalioa aver the tendonJ may reveal
Kilmbcx:k's d i - lite. cbaracteria!H: piing 101J11da.
6.M. • QueMIIn't tenoeynovltlt (of 6.35. de QueMIIn't tenoqnovltiG Now 1.36. C..rplll tunnel qndrome {1):
•bductor pollldll~mgu• Wid at.n•r move tbe biiDd into 1llDar deviation. lA de Wilel'c lhil ia IUqJeC!td, apply very firm,
pollldlbrnll). Whme thia ia •Wipeded Qasvain's ~ynovilia ~pUll lteldy prelllliRI with both thlllllb. for 30
fmm the hiaiDry, local swe1lini md aa:ompuiea this lllliiiOeUVTe.. ~ ova the IIUidian nerve u it I1lllll
laldemeN, CXIIIfirm tile ciiqDosil with lhe wi1tlill the Clqlll twllld. Note the iDm'll.
followia& tat. AK the pmcat to liCl the ~ lhe applli:atioa crf prealllC md lhc
dmmb md dOle the fiDsen eMil' it. ontet of manbneu, pain oc ~in the
llllldim dillribution (~ 16 -=ooda in
ctrpll tuDDeltYDdfome). Tltil u tM lfiMt
rwlia#M tut far cupal t1IIIDel tyudromc.
THEWRIST 103
6.37. C.rpal tunMI qnc~ra.,. (21: 6.38. Cuplll tunnel syndrome (31: 6.39. CarJNII tunMI syndrome (4): Noce
Phakn t111t: AH 1he patimlltn hold both 11MI :t lip: die test il positive if genl1e my pain and plll'8f!Sihesia on stretclrlllg die
wrists in a fully fteBd position for 1-2 finger pm:w~lioo. ove£ lhe mMian nerve nave by 1he IJIIIIIIlellvte of exleDding !he
minutes. The appc8l'lll(e 01' exacerbation of prodii()CS paraesthelia in its diBtribution. 'Ibis elbow and doniftcxing the wrist.
para.es11leaia in 1he mediaD distribution ia test is said to be positive in 56'1& of cues of
suggestive of 1he carpal tunnel syndrome, and carpal tiiiiDel. !ylldrome.
is positive in 70% of those sufierint; from
this condition.
6.40. C.rpal tunnel qndrame (5): Test 6.41. Cuplll tunnel syndrome (6): Look 6.42. CarJNII tunMI syndrome (7): Slide
die mot1r div.iai.on of the medim nerve. Note for 1C111DIY impairDlrm in the medim the tip of the i.ndm; finger B£mll& the palm.
die resiatmce ofi'eml. by die pa1iem as you distribution. noting frictional resilltml:e and~·
try to pullh the vatically held thumb inln the Incmu.cd 1llcnar rellilllanc.e (from lack.
plme of the palm. Feel !he tone in lhe thenar of sweating) and lr:mpelatare rise
JD.IIICles. (vaondilataJi..,) may oa:ur with Illl!ldim
nave involvement.
6.41 C.rpal tunniiSJRdruml (I)J Apply 6.44. C.rp~ltunn•ISJRdrom• (9); If ~ 8.45. Ulnlrtunn•IIJRdram• (1): Look
a tourniquet llllli iDf!llle it to jU11: above the is lllill doubt, a:pply a scaphoid plaaln' fm for tmdemeas OVS" the liiDDel, IIDil for signs
sylllolic blood preuure; maintain thia for 1-2 7-10 days. Im.pmvemeo1 of symptoms while of ulnar nerve involvement (hypothenar
minutes. 1be appea1'IIIICC ar euccrbltion of ia plaster, IDii detcrioration on removal, is wutma:. abductioa. of tbe little finger, early
l}'lllptomJ apia aaggen. 111e carptl t1lliDcl. auggcative of the carpal twmcliiYJidromc. cl&wiq of tbe ria&' lllld middle IIDgett).
syudrome. This teat, however, lbould be Nmve c:mdw:tion ltwliea that mow
inlmpett:d with caution. impairment oi cmub:lion allhe level of tbe
tllml.el.-e virtaa1ly ~tic, and are ulled
by IIWIY to CXl1ll1fcl' tbe ~ of fu~
litigation.
6.46. Ul._ t11nnel.,..._me (2): Ten fm U7. UIMr twiMhyndramo ()): Test for 1.41. Olltll r1dlou1Nr jolftt lulty: Test
iawlvcmalt of the motor cliltribution of the IICDIIOrY impairment ia the COIIIIDDD Ire& of fe&' luity in tbe joiat; ill pmence may be
nene. The power of adduction of the little lelliKlrY dilttibulitlll of tbc DCl'YC. uiOciaecd with weakDcaa of the wrist,
fiDpr is a uaefu1 ~ 1e1t. Note that clicll:ina ~on• llllli u1nlr uerve
wealmeu of Gd.tlllctr-, but with nmma1 involvemmt. Stady tbe carpus with 011e
polm' of abdfrctkm, ia ODe eaiy al,p of lwld ad ase tbe l!tB to bokl tbe distal .ma
cc:rvicaliPillll mydoplthy. llld ateempt to move it ia a clolulllld then a
vola' diledicm. notiaa any clic:kinc --nc.s
or cnmpl•i• of pain. Compare tbe llidea.
THEWRIST 105
6.49. C.rp~llnmbllltlu 11): 6.50. Cllrptlllnstabllldes ~ 6.51. Carpiillnmbllhlu (3): MidcwptJl

Scapho'-te instability: Watscm.'1 telll: prell l.unotrlfi'"tral butability: Ballouemellt IMt: butability: witb one hmd steadying lhe dlJtal
the thumb apioat the tuben:le of the the IIiqumal and lunate ~vely are fmurm and the other gruping the patieDt's
IICIIphoid, aod witb the other hand palmarfiex grupcd betw=n the thumb aod index of each hand. push the carpus against lbc radius and
and. radially devim: the pa1ient's wrist. A of thi: examiner's hands, and an attempt made gallly swing the wrist from 11 position of full
clli:k. lboald be felt if thi: !IC&phoid BUblaxel to di11pl8cc them relative to one 8DOther. lint ulnar deviation to full radial deviatiOD.. Tbe
over the diatal radius, and reducdon ahould in II dorsalll.lld 1htm in II vcililr directi.OD. Note tellt is pclllitive if this lliJJ1IIlll. IIIDOOib
occur if the pMII8IIn' of the lhumb ill any asaccian.d aud amfu:malmy pain 01' movement is Umgular, witb for example an
Jlackened. k<:ompanying pain is crepitus. aa:ompanying chmkiDg IICDI8timL
1l0111imlatary.
6.5J. bdlogl'llphs ~ Landnulrb: In lhe 6.54. Radlogl'llplu (J): Note the lllllOOih
ante:topo..1:erlor, idmtify tbe caipal lxmes curves f'oimed by the pmlrimal and distal
and me their shape, denllity and position: I'OW!I of the carpus, and that lbe dlJtal end of
(A) scaphoid. (.B) lunate, (C) tliquetral., the ulna stop1 short of the radius to mate
6.52. Radlogl'llphs (1): Nmmal (D) piliform, (E) hamate with hook, (F) room for the triangular fibrocartilage. If lllcre
anteroposterior radiograph of the wrist. capitare, (G) ttapemid, (H) tmpezimn. Note is any widmliDg of the gaps between the
the gaps between the various caipallxmes, scaphoid ll.lld lunate, or the lunate and
particularly between the scaphoid and. lanate U:iquetral, or any suggeslion of carpal
(SL). and wbelher theBe are diminished or iDstabllity, obtain additioDal view& in fun
t!XCelllli.ve. radial IUid ulnar devialion. Q) Ulnar styloid,
(K) l'lldial styloid.
6.55. Rlldlogr•phl (4); Note the radial 6.56. Rlldlognplui (5): A liDe drawn
iru:liMtion: tbit ia the IID&Ie bctwcal tho tbrough tile middle metacarpal (M) llld
diBtal u1icular sudiM:e of 1he :radiu1 and the carpull (C), IIDd its diJilmce from 1he l'llllial
radial shaft. It iJ often ~ altm a styloid (RS) and Wnm: axis (U), may be very
CoDes' fi:acture. For ctWcll aNel lmlllt it OCC:uimlally 1lJCd to UIICSS (:arpal height aDd
ma.y be meaiiiRd oa tho radioaraph•. drift, expreuiDg tbele u ratioll. Cai]W 0.57. bcllofp•phl (6): Nonul lsleral
NoraaalraGp = 19-.15". heiglat miG = CIM (llOI'IIIlll = O.Sl-157); radiopph of the wa.t
CiwDaJ llleU1IftiiiCIIt" RSIM (DODDal =
IUS-0.31); McMurtry'• iDdei = U/M
(Dormal • U7-0.33).
0.51. . .dlognph1 (7): It i1 IUUally 6.59. Rlldlognphs Ill: When the c!llplls iJ uo. Rlldlognplal 19): In SlllpCdl:d carpal
poltible to make oat ill the latxnl the aul!pCCt, at Jeut oae (but preferably two) twlllel l)'lldrome a taagcntill projection of tbc
following, ill i!pitc of1llc superimposition oblique views lbould be takm in ldditioll to IWIDCllhoald be obtabled. 'lbil view
of the bony lllrUcCUiel: (H) lDpeliUJil; lbe routiDe lllllmopDitcrio aad lalmal. 1bele oa:uionally abows ~W: lipping or
{A) tuben:le aad body of tbe ~cl; are of particular value ill c1c:tectiJ11 bairlinc oCher cauJal. palbolocy.
(D) pUifoaD; (B) a:aceat of)Ulllle; crack fractlaet of tbo carpll bonct. (Tbe (A) Sclpboid, (B) iDIIIec, (C) tl:iqudral,
(C) triquelral. Note tbat lbc plaDc of tbe lahelllllr u 1llc same u in prerioua (D) pbtform. (B) IKd ofMmatc.
wriat joiJillw IICIIDIIlly • so~ tilt. diaplm.) (H) trapa!UIIl.
THEWRIST 107
6.61. bdlographs (10); Look for evidem:c d!ange& are uncommon after Coll.es' fraclurl::, olltcoaJUJritis. Note any carpal maJatignmeut,
of previODS iDjury. In the malm!ited Colle&' but an: seen afttz (F) radial nylmd frlu:tun:B. IIJCI! as dislocation of lhc llmare (K), which ia
fracture 1hilRl may be (A) Dllii-UDion of the Osteoarthritis may not always follow (G) the mollt OODIIIlOIL Gross porotic clmnges are
ulnar styloid; (B) pmllliJHw:e of the distal non-UDion of a scaphoid fr:aclun:, but is -=n mollt fr:equmtly in riJrnmgtojd ar1hritia
ulna sceoudary to (C) diJUrion aDd DCVCl11Jdcs1 common. Note inaeued booc aDd in Sudect's atrophy (compkx n:gional
n:&arption at the radial fracture, with drmity aDd deformity iD (H) Kimboc:k's pain a}'lldrome). wben:as grou destructive
distw:banoe of the radial illc1lnation. In the dlsease of the IImale or in (J) avucuiar chaDges are a featun: of (L) tuberculosis and
1aleral the joint liDe (D) may also be tilted necrosis of the scaphoid. both of which ar:e other infeclioua.
away from {E) the nonnal. Os=arthritie almost invariably accompanied by
1&. Oalllutlan: In the finlt year of 6.64. Pathology (l): The radiognlphs
life the OSrdficatiOII. CCDtn:l for the capitate llhow aa upper and lower limb wllere the
(C) aDd hamate (H) appear at 2 lllOI1du, the width of the bcmea is aorma1. but they an:
ndl.ue (R) at 6 monlh&, and the ttiquettal propodioDalely dJmt, WDiribuling to the
(T) at 10 IIlOidhs. After the finlt year, the dwarfism asiiOciaied with lhill benditary
lunate (L) appears at about 2, the trapezium abllormally. 1bc metaphyses are wide, and
(Tr) at 2M, the flapezoid (Tz) and acaphoid 6.63. wrist l'lldlognphs: IDJI'IIIpiH of
there i& defective modelting of the dlafts.
(S) at 3, aDd the distal ulna (U) at 4 ,K years. .-.halagy (1): the radiograph llhows a
defmmity of the upper limb in which there is
DlagDolll: achondroplasia.
~ of the radiuJ and thumb, along with
fililure of carpal diffemlti.lltioll.
Dlapoll&: caagenital deformity.
6M. PMhologJ (4): 'lberc are dcformitica 1.67. hthOIOIIJ (5): Tberc i8 gro11
6.65. hthaloiiJ (S): In Ibis ndiopph of a
of the diltal IlllliWI ami ulna, wbi.c:h ans diJtortion - ' cou.ap. of diB lllllale.
splayed. Tbme i1 Rlati.ve ~ of the DiqD.oldJ: Kialbock'• diseue..
child'a fmann t11ee ill a little metaphyseal
wideDing and inqularity, with alDir ulna, which ill 1Uiduly prominent at tbe aide
ml bad!: of tile Wlillt.
mdlpl1ylell cuppia& (lai4 tD be due tD
preuure ttansmiued in crawtm,). DiapGU: MadclUDg deformity of the w:riat
Diqlu~U: ridm.
1.70. hthoiOIIJ (1): Tbe ndiognlph llllowi

a loug-e~tabliabed defect aituated in tiJD wailt
of tbe ICI.phoid. 1'hrre ill IIOIIle llliDOWing af
..... , ....... . , (1): 1be history i8 of the joint IJ*'IC between the IICeplloid lllld tbe
wcakDeu ml iDIUbility of Cbe Wlilt, willl radiul.
clickia& IIC:Diatiolll . . pain ooazn:iDa with 6M• ........, (7): 1be radiograph lbowl ~ .......]jobed non-unima of tiJD
c:mWn~. a defect in diB c:oabnui1y of the xapwid, ~c:~.pboid followiq fnlcmre., with early
Diapular. cmpal i.utabllity ~ ID with mam.ed density diD p:mimal pole. aecoadlry fflllioctrpd ~
ICipboliiDIIIc diNocilltioa. Dlap..U: tlae: tw bee:D a fi:1lcttR d the
~ followed by 11011-'llllioa llld
avucular necram.
THEWRIST 109
6.72. ,..holou (10): Tbe radiogrllph was

taken llhortl.y after a fall on the oumlletl:hed
haDd, wben tbere wu complaint of pain ia
6.71. Pathology (9): 'lbcre is grou the wriat aDd paracalheaia aver the ball of the 6.73. P..holou (11); The radiograph
deltructicm. of the carpal 8lld wriat jointl, with thumb. llhowJ an abDormality of the distal radius.
fibrous ankylosis. l>iapam: the lllleral. projection shows two 'l'hml i.a IOilDIIing of the proximal pat of the
Diapclm: the fiudings are typical of the late bODeB lying proud of the mt of the carpus at small bone 1'rBgmiD in the Mgion of !be
appearances of an infcctivc arthdds (in this the front of the wrist: ODe is the normally styloid process.
cue due to tuben:alollis). situated pisiform; !he ocher, semilUDal' ia Dlapolll: :fractulC of !he styloid proce11 of
shape .md lying l!lDie proximal, is a the radius, wbich has :failed to UDite. The
dWocab:d lunate. The symptoms suggest appealiiiiCIIS are of a long-sbmding lesion.
involvemell.t of the median nerve. Such a condition may be 1ymptom free, or
give pain if 8eCOII.dary arlbritic clwlges
clcvelop betwc:ea the radius and acaphojd.
<IIIII 6.74. ,..hologJ (121: Tbia radiograph of

a clrlld's wriat ami foremm shows gross
distortion of the distal radius. Tbue are
apparently cystic spaces in the radial shaft,
with ext=sive DeW boDe formation.
Diapolil: the a:ppearamllliii!N typical of
grt11111 osteitis, with boDe ab~K:e~~s fmmation. In
this cue the causal organism wu, wwsually,
the tubc:rcle bacillus. (NB: Moet tuberculoua
infectiaaa have their principal effects on the
joinU, ratla than the shafts of the long
bones.)
6.75. ,..holou (13): 'l'bele is widespleld ...

decalcification of the carpua ami adjacem
long ~ with loss of Illlliological carpal
detail 'lbcre was complaint of pain ami
lltiffDela following a minor injury.
Diagaoldl: Sudeck's attophy (complex
regional pain syndrome). The radiologK:al
appearances are similar to thoae found in
dleumatoid arthritis.
6.76. Pldholofv (1 4): This antr.mposterior 6.77. hthalotJ (15): The lalaal
rldiograpb lbows diltortion of lbe iDfaior radiograph of 1he SIIIIIC cue mows mazbd
l'ldloulDar joiDt. relative k::ogtlu::DiDg aDd alteration ia tile plme of tile radiocarpal joint,
~of !be ulna, llllll widmrlng of the ~t~lliD dUll to malUDion; this, •put from the
radius. The palient ()OIIIplainr.d of pain in the ddonned. appelllliiiU, hu the eft'ect of
wrlat (ln the nllliouloar joim) llllll ratriction leriouly ratricting palmlr 4exim.
of pro!IJtioaf.upinltioa li10VC:IIIaltl.
Dtlpalll: malllllion of a Oollea' frlcture.
6.71. Aaplmlon of the Wl'fst Joint: Uliq

your dmmb, feel for 1ile dcpl:allio.n It the
blck of tile wrilt wbidlliel betMeA !be
distal ead of the Jlldius aDd acapbaid. aDd
wbicb is bordrnlcl. by emmor ciisitorum
COIIIIIIW1il aDd Clfemar c:.pi radillil btev.il.
:ln1lltra 1llis -=with local eeet"¥1ic
befom ~ 1he upimljDg lll!lldle. The
tip of the -ne sbould he dim:1zld. aania11y
It magle of 30" from tile vuticd.
7
The hand
Dupuytren's contracture 112

VIbration syndromes 112
Tendon and tendon sheath
lesions 113
Osteoarthritis of the Interphalangeal
joints 115
Carpometacarpal joint of the
thumb 115
Tumours In the hand 115
Infections In the hand 116
Inspection 117-120
Movements 121-125
VIbration syndromes 125
Assessing hand drculatlon 125
Tendon Injuries 125-126
Infections 126-1 27
Assessing hand function 127-128
Pathology 128-129
112 CUNICAL ORTHOPAEDIC EXAMINA110N
Note that the separation of conditions into those affecting the wrist and
those affecting the hand has been done for convenience, and that in many
cases examination of both regions is necessary.
DUPUYTREN'S CONTRACTURE
In this condition there is nodular thickening BDd a contracture of the palmar
fascia. The palm of the hand is affected first, followed at a lab:r stage by
the fingers. The ring finger is most frequently involved, followed by the
little and middle fingers. The index and even the thumb may be affected.
In some cases there is corresponding thickening of the plantar fascia. The
progressive flexion of the affected fingers interferes with the function of the
hand and may be so severe that the fingemails dig into the palm. The
condition mainly affects men over the age of 40. There is a definite genetic
predisposition in 60-70% of cases, and in some cases there may be an
association with epilepsy, diabetes or alcoholic c:ixrhosis. There is a distinct
geographical distribution: it is rare in Africa, India and China. Below 1he
age of 40, and in either sex, its onset may be precipitated by trauma. Under
these circumstances it may pursue a particularly rapid course.
As far as tteatm.ent is concerned, a waiting policy may be pursued if the
condition is confined to the palms. When tbe fingers are affected surgical
treal:'ma1t is usually advised, but this is complicated by a numbec of factors.
H the fingers have been held in a flexed position for a lang time, secondary
changes in the interphalangeal joints may prevent fingec extension even aftec
the involved tissue ha.s been removed. In the case of the little fingec,
amputation in these circumstances may be the best line of trea1meat. The
digital nerve sheaths may blend with the fascia so that dissection is tedious
and difficult; involvement of the skin may necessitate Z-pl.asties or other
plastic proceduies; and the p&tient's age and general health may be adverse
factors. In most cases wide excision of the affected fascia is advised. When
this is not possible, improvement in function, often lasting for some years,
may follow simple division of the contracted fascia in the palm.
VIBRATION SYNDROMES
Prolonged exposure to bigh-iiequency vibration (such as may be
experienced from the use of jack hammers or hand-held buffing, riveting
and caulking IlliiCbines) may affect bone, nerves and blood vessels. Bone is
rarely affected to a significant degree. but oew bone formation and hairline
fractmes (which are slow to heal) are sometimes seen. Involvement of the
peripheral nerves may lead to pain and paraesthesia, numbness, tremor, loss
of fine touch sensation. proprioception and discrimination. There may be
muscle denervation and weakness involving especially the small muscles
of the hand. In the case of the peripheral blood vessels there is disturbance
of their autonomic control, and the arterioles of the hand become
hypersensitive to cold and vibration. In the typical case there are attacks in
which one or more fingers tum white on exposure to cold ('episodic
blanching'), with reactive hyperaemia on warming; and there is usually
associated discomfort and clumsiness of the hand during attacks. As the
condition progresses JnOie fingers become involved, incidents occur both in
SlJDllDCC and in wi.ott:r. and hand function becomes permancnlly disturbed.
The hand becomes weak and clumsy, and with impaired sensation and
THEHAND 113
proprioception the patient has difficulty in dressing (e.g. doing up buttoDS

and shoeJaces), handling small objects (e.g. coins, nuts and screws), and
carrying out many other tub (e.g. tying fishing bookB). The differential
diagnosis includes Rayrumd's disease, cervical rib and the costoclavicular
syndrome, cervical spondylosis, and sensitivity to ~blockers.
There are a number of cl..assi.fu:atioDS of the stages of the cooditioo, and the
long-established Taylor-Pelmear scale is still widely used (Table 7.1). Well
established cues are recognised as one of the prescribed diseases under the
Social Security Act. and tbe qualifying critma ue clearly stated. (The
condition must occur throughout the year, involve at least three fingers of one
hand (with the middle and/or proximal phalanges being affected), and be due
to exposure to vibrating tools.) No treatment is effective, but deterioration
may be slowed or prevented by avoiding further exposure to vibration.
Table 7.1 The Taylor-Pelmear scale

Ste.- Condition of digits
0 No blanching of digits No complaints

OT intermittent tingling No InterferenCE with actMtles
ON intermittent numbness No Interference with activities
Blanching of one or more fingertips, with No interference with activities
or without tingling or numbness
2 Blanching of one or more fingers, with Slight lllterference with home and social
numbness; usually confined 1D willter activities; no Interference at work
3 Extensive blanching. Frequent episodes, Definite interference at work, at home, and
summer and winter with social actMtles. Restrktlon of hobbles
Extensive blanching. Most or al fingers OccupatiOn changed to CMlid further
affected. Frequent episodes, summer and exposure to vibration because of severity
winter of signs and symptoms
TENDON AND TENDON SHEATH LESIONS

See also under Rhew:rultoid arthritis.
Mallet finger In a mallet finger the distal interphalangeal joint is held in a
permanent position of :Bexion; the deformity may be moderate or complete.
The patient is unable to extend the distal joint of the finger, either not at all
or only incompletely. The problem is 1bal the extensor tendon, usually as a
result of trauma. either ruptures close to its insertion in the distal phalanx.
or it avulse& its bony attachment Healing may occur spontaneously ovet a
6-12-month period. but it is usual practice to treat these injuries for 6 weeks
with a light splint that holds the distal interphalangeal joint in extension.
M•llet thumb Delayed rupture of the exteDSor pollicis longus tendon may
follow Calks' fracture (see Cb. 6) or rheumatoid arthritis, and repair by
taldon transfer (using exteDSor indicis proprius) is usually advised. If the
taldon is damaged by an incised wound, repair by direct suture is
undertaken.
Boutonnlin deformity Flexion of the interphalangeal joint of a finger
with extension of the distal intapbalangeal joint cbaractaisea thia
deformity, which is due to detacbmcm of the central slip of the extensor
tendon which is attached to the base of the middle phalanx. This may follow
incised wounds on the dorsum of the finger and avulsion injuries, but is
more commonly seen in Iheumatoid arthritis. Surgical repair of the extensor
band is often undertaken for isolated lesions of this type.
Extensor tendon division in the blck of the h•nd Extensor tendons
divided by wounds on the back of the hand carry an excellent prognol!lis and
are treated by primary suture and splintage for approximately 4 weeks.
Profundus tendon InJuries
1. Isolated avulsion injuries, which are uooommon, may be treated by
surgical reattachment of the tendon..
2. Profundus tendon division in open wounds: in the palm, repair by
direct suture is usually feasible. In the 8.e;xor tendon sheaths there is
considerable risk of adhesions spoiling function. In uooontaminated
wounds where good facilities are available, primary 8.e;xor tendon repair
may be undertaken; otherwise, free ftexor tendon grafting is usually
advised. Accompanying digital nerve divisions may also be dealt with
by primary repair.
Trtgger ftnger and thumb This condition result. from thiclrening of a
fibrous tendon sheath or nodular thickening in a O.exor tendon.
In young children the thumb is held flexed at the metacarpophalangeal
(MP) joint, and a nodular thickening in front of the MP joint is palpable; not
infrequently the deformity is wrongly cousidered to be congenital in origin
and untreatable.
In adults, the middle or ring finger is most frequently involved. When the
fingers are extended the affected finger lags behind and then quite suddenly
straighteus. Nodul8r thick.ening, always at tbc level of tbc MP joint, may
also be palpable. Division of the sheath at the level of the MP joint gives an
immediate and gratifying cure, although it should be noted that in childreu
spontaneous resolution occurs in more than 60% of cues.
Rheumatoid arthritis, as is well known, very frequently affects the haDd, and
as it progresses may involve joints, tendons, muscles, nerves and arteries,
prodocing most severe deformities and crippling effects on hand function.
In the earliest phases the hands are stri.t:ingly warm and moist; later the
joints become obviously swollen and tender. Synovial tendon sheath and
joint thiclren:ing, with eJfusion. muscle wasting and deformity, then becomes
apparent. Tendon raptures and joint subluxations are the main factors
leading to the more severe deformities.
Surgery of the rheumatoid hand is highly specialised, requiring particular
s.kills and experience in judgement, timing and technique. and is difficult to
summarise with any accuracy.
In the earliest stages of the diseaae, medications which have analgesic,
anti-in:Hammatory and antiautoimmune effects may be prescribed, with the
judicious use of physiotherapy and splintage to al.J.eviate pain, preserve
movement and minimise deformity. Wben there is much synovial thickening
at a stage before joint destruction has advanced, synovectomy is often
helpful in alleviating pain and delaying local progress of the coodition.
In a few well selected cases, where there is severe joint destruction and
THEHAND 115
progressive deformity, joint replacement may be helpful; some cases of

major tendon involvement may benefit from repair and other procedures.
OSTEOARTHRITIS OF THE INTERPHALANGEAL JOINTS

Nodular swellings situaU:d dorsally over the bucs of the distal phalanges
(Heberden's nodes), or less commonly over the bases of the middle
phalanges (Bouchard's nodes), are a sign of osteoarthritis of the finger
j oints. They occur most frequently in women after the menopause, and are
often familial. They are not relaled to osteoarthritis elsewhere. In many
cases they are symptom free. but they may be associated with progressive
j oint damage which does cause pain.
CARPOMETACARPAL JOINT OF THE THUMB

Osteoarthritic changes are common between the thumb metacarpal and the
trapezium. and they may give rise to disabling pain and i.tnpaired function
in the band. 'I'here may on occasion be a biatory of a previous Bennett's
fracture, or of occupational overuse. Several surgical procedures (e.g.
excision of the ttapezium) are available which give relief of pain,
sometimes at the expense of some functional loss.
TUMOURS IN THE HAND

Tumours in the hand are not uncommon. Most involve the soft tissues and
are simple, but it need hardly be stressed that where the diagnOBis is
uncertain a full investigation is essential. Among the commonest tumoura
are the following:
1. Ganglion.r occur in the fingen, most commonly along the volar aspects.
They are small, spherical. and tender to 1be touch. They are generally
treated by excision.
2. Implantation d~rmoid cysts occur along the volu surfaces of the fingers
and palms. They are treated by excision.
3. Glomus trunour& are leu common. These Slll.llll, vucular, exquisitely
tender tumours are seen most often in the region of the nailbeds. They are
also treated by excision.
4. Mucous cy&tl. These always occur on the donal swface of a distal
interphalangeal joint Excision is best avoided unless their rupture bas led
to a synovial fistula.
5. Osteoid osteoma. This tumom may involve a distal phalanx (or a carpal
bone) and has a typical X-ray appearance. If there is doubt about the
diagnosis, an isotope bone scan will show it up as a 'bot spot'.
Spontaneou8 resolution may occm, but if symptoms are marked the
tumour should be excised
6. Chondroma. This is a very common benign tumom which occurs in the
m.etacupals and phalanges. It is generally confined to bone (enchondroma)
and may give rise to a pathological fracture. or to gross swelling and
deformity. It is often solitary, but multiple tumoms of a similar nature are
found in Ollier's disease, which bas a hereditary diathesis. Thmours of this
type may be treated by excisioo. and boac grafting of the defect
7. Meuutatic tumours. These are UllOOIDDlOD, but have a tendency to involve
the distal phalanges. Lung and breast are the commonest primary sites.
The treatment is dependent on the 1111t1e of the primary and the spread
elsewhere.
INFECTIONS IN THE HAND

1. Paronychia. This is the commonest of all infections in the hand, and
occun between the base of the nail and the caticle.
2. Apical infections occur between the tip of the nail and the underlying
nail.bed.
3. Pulp infection~ occur in the fi.brofatty tissue of the fingertips and are
extremely painful. If llJlChecked, infection frequently leads to involvement
of the terminal phalanx.
These three common infections are treated along well eatablished lines,
wing antibiotics and surgical drainage if pus has formed.
4. Tendon sheath infections. Infection within a tendon sheath (Fig. 7 .A)
leads to rapid swelling of the finger and build-up of pressure within the
tendon sheath; there is always a serious risk of tendon sloughing or
disabling adhesion formation. In the case of the little finger there may be
retrograde spread of infection to involve the ulnar bursa in the hand. In
the case of the thumb, infection may also spread proximally to involve
the radial bursa. In either case, swelling appcan in the palm and in the
wrist proximal to the flexor retinaculwn. It should also be noted that in
70% of cases there is a connection between these two bunae, allowing
spread from one to the other.
5. Web space infections. Web space infections ~R umally accompanied by
great pain and systemic upset. There is redness and swelling in the
aft'ected space. Infection may spread along the volar aspects of the related
fingers or to adjacent web spaces across the anterior aspect of the palm.
If seen early, most web space infections respond tD antibiobcs, splintage
and elevation, but drainJige is sometimes occesaary.
6. Midpalmar and tMnar space infections. These two compar1ment3 of the
hand lie between the flexor tendons and the metacarpals. Infection may
Fig. 7.A. Some polmltial diE& af ~ in spread to them from web spliCe or tendon abeath infections: dissemination
tbe iwld aad finFs. S = ayuoviallaldca
sbeatha; U = ulnar buna; R • radial ban&; through the hand is then rapid and potentially crippling. In either cue
M = midpa1mar apa~Z; T • theDar IJlll= there is UBUally gross swelling of the hand and a severe systemic upset
Nole: C = commaaicatioa between tbe radial Uoless there is a rapid response to antibiotics, elevation and splintage,
8lld ulnar barue.
early drainage is essential for the preservation of function in the hand.
It should be noted that where splintage of the hand is advocated, and if
functional recovery is tD be hoped for, the fingers should be held in a
position of right-angled flexion at the MP joints and extension in the
interphalangeal joints.
7. 1Uberculo.ris and ~hilis. On rare occasions either of these two
infections may produce spindle-shaped defonni.ty of a finger. Spindling of
a finger is much mm:e common, however, in rheumatoid arthritis. gout, or
collateral ligament trauma.
8. Occupational infection~. Superficial infections are common in certain
trades and the following may be noted:
• Pilonidal sinus in barbers
• Erysipeloid in fishmongers and butchers
• 'Butcher's wart' (tubcrculous skin lesions) in botcbcn aDd pathologists
• Malignant pustule (anthrax) in hide sorters and tanners.
THEHAND 117
\
' ~,
7.1. lnspactlon (1}: Look firlt 111: the general 7.1. lnspactlon (2): In Marfm'ssyudrome 7..1 IMPHtlon(J): Notethe~of
shape of the baud aad its llize In proportion to the proximal pbalaaaes in particular are 10111 any hypertrophy of a finp. Tbia may occur
the rat of the palialt: e.g. In IICb.oDdropluia aDd thin. In Tamer's syndrome the ring in Pqet'a diJeue, oeurofibromaloai& 111111
the lingers are short aod lll1mpf; In ~ is often very abort. In 1Dca1 artmiovenoaa fiJtula.
acroJDeply the band ia Jarre aad ooane; aad hyperparalhymidism the fingertips may be
In myxoedmna the baud ia oflm podgy and abort and bulbous, and in Down's and
theilindry. Hurler's ayodroma the lit& 1ingen are
i.Dcurvecl
7.4. lnspactlon (4): Note the praencc of 7.S. Inspection (5): Mallet ftng•r: 'Ibe 7A. Inspection (6): Mall.r thumb: Leas of
any fuaiform twclliag. 'Ibe COIDIJIOIIeat diltal in11."lpbalqW. joiat is llcMcl 'Ibe ldi.w c:llaWoll in the iDierpllllaDgea joint
cauM:I lll'C coiJaferlllipmalt tara aDd patialt CIIIIIOt exfi:Dd tile tenninll pbalau, of the lhumb ia due to ruptore of ext=Jor
rheumatoid llltlu:itia. l..eM c:ommonly lllil ia although the joint can unalJ1 be all:llded pollicl1 J.oa&as. Tbia .il ICCil u a We
ICeD in aypbilil. TB, aarcoido.u IUid goat In pulively. It is cmaed by 1VJ1G11e or awJaon compW:alion of Colla' ~. from
ptOriatic artllritil tile dim! joint ia uoally of the ClteUlr teDdon, Qually from trauma ~ anllritia, ar 'lt'OUIJdjj of tile wriat
involved. or rllcumatoid ardlriti1. or the lhumb witll tclldoll di'YUUIL
7.7. lnspKtlon (7): Swcin-Mf:k Mformity 7... •......... (8): Swatwwd; Uformily 7.t. lnspKtl• (9}: Swdn-ud; dlformity
(1 ): Tbc dilltal iDierpha1aDaca1 joilllll lk:xed (2): BxteDd !be mr.tacarpopbalaDgeal joint of (3): Hold all the fiDgen in an cxlalded
and the pro:dmal inlaph•IJIIIIC*l joilll !be affCCUld finger. lmprovemcDt in !be potb:lon but leave !he affCCUld finger free.
hype:rextt:mdcc It IIICCD molt of'lrln in dcformlly IDdil:au:alhat ab.ortaling of AM: the pelieDt to ftc:x lL If be C8DDOt, this
rbeumaloid arthrllia, aDd may be produced by cxtrmor digitorum communla II a factor. If IDdicau:a • ruplU1'C of llcxar digltorum
• llllmber of difl'.tn::ml facton. !he dc:fOJ'IDity II made wane, tight inlerolaci aublimilaalhc c111110 of !be dcformlly.
are likdy to be respo~~~~"'bbt.
7.10. lns,.cllon (10): BOIIIONIJA~V 7.11. Inspection (11): Z tkfomtlly 7.1:Z. lnspKtlon (1:Z): Flexion of a fiD&er at
tkfomtlly: The proximal inla'ph.alaapl joint aftlte thwftb: The tbumb is flcxt:d at the !be ~joim, with inability
is flcxt:d IJld the dillal joint ~ It mmcarpopbalange joint and hypa:extalded to ex1lmd, fullow• 1:11p111m or divilliml of tbc:
occan wt-. the central exllmar tr.adm dip at tbe ~ joillt.. The ddmmity is extrmot tmdon in the back of tbe baod or at
to the middle piM1anx is ~ by a WOUIIIl ICCD in d!rmnatnid arthriti.& leCOIIdary Ill tbe wrist.
on the donum of the fia&rr, by trmDiatic di.J~pb<z!!H'!Ill of tbe e.J:I:en8or tr:odoos or
avulsioD., or by IIJICllllaDeOUI r:uptme u in rupture of hxot pollicis kmgu1.
d!mmatnid artb.ritia.
THEHAND 119
7.15. l....,.ctlon (1S): F1clion of 1bc liU!c 7.14. lnspecdon(14): Flexioaofdle 7 .15. ln..,.ctl• (15): Fk::lion of lbe
~ m.aiDJ.y at 1bc proxlDW iDterphalangeal 1IDgm at die~ aDd ~~~ide& or dDg fiDgcn at the proximal
joint. ia leCD in CODgCDilll ClOIIIr1ll:tW:c of the in~ageai jomu, usociated wW1 DOdular iDtetphalaD&eal joint. wW1 sudden eltleUion
liU!c finger. thicft:Ding in 1bc palm aDd 1lDgen, ia on ctrort ar wi1h ulimDI:e. ie 8eeD in tdgger
~of Dupuyllen't CODtractu1'e. 'lbc IIDFt· '111=: ia IJiaa!ly a palpal)W DOdular
thumb ia OW'ai opaJ!~ involved. ll*ktnill& over the con:e~polldiDg
~joint
7.16. lnspKtlon (16): Flexim of the 7.17.1n..,.ctl•l171: rn~·· 7.11. ln..,.ctl• (11): llclwmJic
intmphaJJalpal (0>) joim ot the thumb in ildwmW:: COill:riJI:tUrl (which uually DCC1Il1 amll'al:lun! of the mW1 muaclea of the lumd
inflalU md young cb.iJdJen II \IIIWJy due u a aequel to bnd!ial. ar:tmy damage (unal.Ly u a rMult of •welling within a tight
kl llmKMiDg lellovaiiDitb invoiWI& &alDtllpllll'yi a suprw:cmdylM fnK:mnl) !bin fonllllm plasts') IMdl kl finpn whicll are
fiMor poUi&:ia longus. A IIOdular is clawing of tb.e JJmmb aud fiD&In, md flllud at 1he IIIIIW:mpopbalaDpal joint» IIIJd
Jbickmin& ia liiWiily .-Jpable OWl" the foremm Wl!Sting. 'lbe finpn can be eUmJded extlmded Ill the illfmpbalan&ea1 joiDts. 'lbe
matBca~popbal.anpal joiJit. T!Je llDIJditiOD iJ if the wrist illleud. Slilbt &W.oa of 111.1 1he tbumb il addw:ted inkl1he palm.
said to be ~ (i.e. it is not CXJIIIalital) 1iDpn at the MP md IP joiab is ~
aDd tiigeriaa il DDt a fellluM. - ill ISICX:j!!!ljtw with diabetes (w.beOO
cbmropathy); wb-. the !wJda ~ put in •
prayjnc poUtioo. 1hml il - tux:lcwwble pp
betwem tlan.
7.19. ln.actlon (19): Uhw dmation of 7..l.O.. ln~lon (20): Unil.aleral 7.21. l...,_.lon(21): ~lllng,r(l):Nott:
the fi.ogers at the~ joints hypolbr.ur wasliag 11188esll a root, plexus or (A) IW!eldm'a nodes on the donlll. alllfKe
oc:cura in rheumatoid mhddt. In the latr.r nerve le&iOD.. Wideapmad involvement of tbe dill:al iDterpbalangeal joint. (Tiley are
slap the llleUciii:JIOllbal.ul jointl may oeces&itate1 a full examination in order to oftr:n uiiDCialm with deviation of the diatlll.
di.alocam. r:xclllde diaordl!ra auch u genera1isecl phabDx IIlli are a lip of olllrlcartbrilia of the
~ earopaJhy, syriDgomyelia. finps.) (8) The proximal i.Dir:rphalanpl
llllllliple sclerosis alld the mmcu1ar joints may be aimiJady ~ (Boudlard's
dystrophies. ucxlel).
7.22. lnsPK~~on (22): Stwl/btg1 (2): Note 7.23. ln~lon (D): Sw•Uii&B' (3): Noll! 7 .24. ln~pectlon (24): Note tbe lllllrilim of
(A) liim, pea-lib pDIIi0111 are COIIIIIKBl (A) iaolaled d!eu!muoid IMXIu.1e& or synovial tbe aldn IIIJd. naila. In the cue of tbe nails,
lll.ong lhe !iDe of tbe tmJdon abealbs. (B) swellings. (B) Eodioodroma is ooe of tbe 110111 liD)' d:i.ltDrbaDal of growth. dmormity,
Nodul.lr awell.inp of tbe plllm alld finpn CODIIIIOIIIIIt booe ttlmDUill "' oa:ur in tbe evidmJi:e of fuaslll. inf«<ion or piOriuis. In
IICCOIIIpllll.y ~·· ccmlndun!. halld. 'l'amDun of this type are stmJelimel tbe akin, note tbe JID'-=tl of fiDpr boms
lllllltiple, alld there may be a hendlEy or tmpbk: ubraaioD, ~ve of a
dildbmis. If IIDII1l, 111 ~may DOt -.vlop:ai ~ Note my lll.IKation
be DDticed 1llllil it declar:aa iuelf with a of llkiD colour, IU&PiliJII circulalmy
patbo1ogic:.J ~ involv.~e~~t from local artmial or
IIYJDpalbetic llllpp}y dillturbmce.
THEHAND 121
7.25. Palpation (1 ): Nom my gaw;ralUed 7 .26. Plllp!ltlon 12): Palpate the indhidual 7 .27. Plllp8tlon (J): Try 10 tid eadl:linger
or local cli8tw:btmce of ccmpcratare or fiDget joint& betweela tbe fl.ager llDd lhumb, lato tbe palm. and Ilk thc paliellt
eweating in the palm or volar aud'a£e1 of the lookiDg for lhiclrentag, ICIIdemtaa, oedema 10 rqiCillhil unaided. Loll of acdve
finger&. Tbc 01b.tr bmd may be oacd for llDd iDI:reaaed local beat. Noto that in gouty move.mcnta Ollly il uiWilly due to DerVc or
comparlaon. ll1hrltia a liDgle joint Ollly may be affecltA 1mlkm dUco.Diinuity, whcreaa palive loll&
capecially .in 1hc early etagca. may be due to joint or tcDdon adhcli0111 or
ll'thriU.
7.18. M_,_..ta (1): Whanl indica1ld for 7.29. Movtiments (2): Altamatively, ak 7 .30. Movtiments (1): Pnladmal
CODI.inllllll UIIUIIIall or medicolepl tbe patimt 10 put his lumd, palm upwards, on lnterphalanpal Joint: NorD181
pmposs. bolh tbe IICiiw mMI the puaive a table, 8lld 110111 tbe li.oear diJcrepam:y rup - &-100".
rmge in liD afflll:llld fiDp ahould be betwem1 it 8lld the 1ip of lhB affected finF u
recorded. he attmllptiiO extald it. When pusiw
M~jobd: extmsim is poaaible, loss of ~dive exlmlsiou
N..aJ. nace = ' - ""· sugpltl di'liaion, rupt11n1 or di.spbaommt of
Nllfle that lhB llllltal:~ joillb tbe extm110r tiiDda!Js, or a poalllli.or
&:a usually be pusiwly hypllrex...W by immoll«<lll palsy if allan~ affected.
up 10 45".
7.31. MOMIMIIb(4):DIJtal 7 ..12. Movam•nts (5}: An allemative 7..JJ. M . . - t s (6): The wire iJ 1hm
ll'ltlrph•l•ng... Jalnts: Normal method of JDeiiSIII'iag die range of mo-ts trau.sfm'red to the cue lKOI"d, aDd an OlllliDe
J'lUI&e .. 0-10". in die finger joint& involvea moulding a drawn round it. Tbc finp which bas bet.n
Jmsth of malleable wire over die fiDp eumi.utd aDd dam dmald be notM. An
(14 G, electrician's or other solder wile, addiliooal record of extea.lion may be
approximately 2 mm in diiiiD.etr.r is suitable). ~- Snb&equent useslllllCIIt of
prosiDI is euily made by ~ die
proc:eu.
7.34. MGvenll!ldl (7): 'lbtal fing•r 7.35. M.wments (8): Oaly a a1igbt IDult 7.H. MGNIMIIts (9): Greater redocliol1
~: A4 Ill tile joi!D of Ill tbc liDgert pY levd iJ AJf'licialt t.o ~ 'tack in'. All in movemeata will prevent llle finp's from
ue invom:d in grupiDg llld holdiJI(, lltllle llle fiDpa may be involved, II sbown. If I IadJin& tbc palm. Suc:b I Jlllld-df iDdk:all=s
pttialt t.o mab Ifill Noanally tbc clillll lingle finger iJ affec:fled its p1'0II1illellce will men JCrioua ~of tile patient'a
pbalangel dlould 'lllct in' . lo1ICbiDa tbc palm be obviou. 'I'IIiJ saetaing test may be ability t.o ~ lllld bokl.
lit rigbt anglu. <:lrried oat earlier in tile enmjnMion if
~
THEHAND 123
7.:J7. Manmants (10): This important 7..JL Auesarnllftt of the a .... of 7.19. Mawmants (11):11tadtumbel'M
rellril:ticm. af fuuctiooal ability may be lou of miMimants 1ft thaiP Joints: TM lnterphalangul Jalnt: NorDIIII fteDon
measured by notiag the dlJWu:e that the
finps mnd p:oud af lbe palm on maximum
ltui!Mli-Lttrkr t~tt: lfDld the MP joint af the = W ; NorDIIII ~ W (i.e. =
~ finp in extensi.cm. aad pasai.~y Delt lbe IP joint can be extaiiW 20" beyoDd the
flexion. it, Dillin& the total movement obtaiMd. Now neutral polition).
repeal with lbe MP joint Delted, notiag my "lUW ..... 100".
differeDce.
~ if /lOW gl'Wer, CODtrllcture of the
i.mriosic lliiiScles; if the 1111114, joint caplllle
contm:tllnill; If len, an exlmsot leDdou.
conlal:tllre.
7.40. *-•nts (12.}:1'Mthumb:1'11e 7 .41. MIMimantl (1 S): At lhiutage, felt 7.41. MIMimants (14): CGTpOIMtDearpal
metacupophal•ng•l Joint: Normal 1llc Aability of tbe ~joint joiN: tclt eDcDiiOD (abduction paralld tc tbe
~ ..
llalcm "' 1baat 5~; Nermal
~.
in • lide-to-aide plane. Exad llle joint llld
ltrelt tbe mcdial coJlm::rllli.&amtnt.
CompaEc tbe aides. Bll:eM mobility followl
plae af the palm) by placing tbe baDd palm
doWI111Dd llleUJiiD& tbe I:IIIIF from •
J,lCiiticll in CODtact with the illdex tc itl fully
tan ('pmelr.cql«'• d:lamb') IIDd dlaimltoid at=dcd potition.
adhritil, lllld am be very di•abliJI&. Nonul race ot carpameCacarp~~
......... w.
/
/
/
/
7.43. •--a (15): Carpotll6fDCilrpal

joiN: tell flexion: Measure dlllalllrting fmm
7..44.. M-m•na (145): .A.bd.uclllm afw
thumb In a piiiM t.1t rlghi11J18kl to w palm:
7AS. •--ts (17): Wb& exunining
tbe c~ joint of the dmmb, note
tbe oeulral position wi.lh tbe thumb In coobct The Jllllit.lll asmmpta 111 point tbe tlmmb at the any ~1111 In tbe joinL Thia finding is
with the index. ceillnf, with tbe baclt of tbe baad resti.q on a common wbr.n ollrmrthritis aod d!t:wnatoid
NGIIIW rliJIIC of~ table. arthritia Invol-ve lhi• joint, and there is oftm
ll.eldoD = 15". Nonaal r-ae of tllu.mb abduction = fiO•. prDIIl.iJirnce af tbe bue of tbe metacarpal
This augJ.e i1 difficult to llleliiiR, and an
aa:urate uleii!DID isleldmn af value.
7M. MowrnMda (11): 0ppolitf0fl (1): 7A7. Mowm•nts (19): Opposition. (2): 7AL Mowm•ntJ (a): Oppomitm (3):
This tells aevera1 COIIIpOIIalb of owrd Lou of oppoailion may be ueessed by Allamdively, tbe dislllnce bet-.m tbe tip of
tlmmb and 1ilt1e finF IIIOWliMDt, md llleiiSilrins the distulce between tbe tip !be tlmmb and tbe ~jolnl
Involves abduction af the thumb Ill right of tbe tlmmb aod tbe little fi.nsu. of tbe little finger may be ~
aaglel111 the palm. md tlmmb flexion and
rotation. NomYI!y tbe dmmb lbould be llble
111 toucll tbe tip of tbe little fiDF.
THEHAND 125
7A9. Manmonts (l1): Fin&a' abdoction 7.so. VIIINdon SJIIIdromes: In 7.51. 'lila Allen tut for hand circulation:
may be aaaeued by me-'ng the spre.t vibra!im whi.m fiop, although littk clinU:al Place your thumbs over the patient's radial
between the iDdex aod liule liDgal. ar the ~ may be fuaDd, (1) IIOZ if the IDd ulnar artrriea and get bim to cle!u:h his
1prud between individllal dnpn.. Bxceuive band becomes pale on elevali.on, aad the band three times in quick succession (1).
abduction of the tilde finpr k fowul in speed with which it piDb up on depreJJiDn; Campreas the vessel• aad ask bim Ill ~
l!bl.era-Daal.oa syndrome. (2) see if an al:IKk is p:ecipitaled by holdiag the finprs. Tbe band abould be blanched (2).
the haad 1IDder cold water fur 2 minutM; (3) Now re1eaae the radial artr.ry aod DOle
aod check the fiow in the disital vealda with wbdber the return of skin colow is delayed
a Doppler llowmeta. Note that the peripbaal fur more than 3 lleCOIIdJ (3). Repeat the lest,
circulation may be disturbed by onl tbia time re1eaaing the ulnar artr.ry. This gives
anlihyperteoaiYM. a meaame of the COIIIribulioa uwle by each
artmy to the ciR:almm of the baad.
7.51 Joint thkkanl. . MCI-IIIng: The 7.M. TIIMien lnJurlas (2): If the profuDdus
lldi.vity of the jnfi•IIDD•tnry ~~ in a IIDion is suipeCt. support the fiDgm- aod uk
swollen joint k ~ Ulelsed by the pllliallll bend the tip. Lou of the ability
meuurlng the joint c:ircum1'eraM:e from time to 1m the tmminal pba1anx occurs wben the
to time. Jux:vnq wilbout special equipment fieaor c!isitorum pmftmdoa tmdan is divided
k d.iffiallt to ~ IDd the raultJ are d
limi.12d value.
7.55. Tendon lnju.._ (S): lf tbc 7.56. T•ndon ln,Jurlu (4); FluorDNl 7 .57. Tlmdon l~urla (5): E:w1110r
eupedlclalls laldoa ia alllpCCt. bold alllbe extDuor poUit:U loftgu: Support the digitoTIIm COffllfUIIIil: Aak lbe paliellt to
fiDgen QAlellllbe 1uapcct ODC Ia a fully proximal phaliDx IIDd aak tbc palicnt to lk:x c:xte3ld the fiD&t;n. Ally cxtcDaor teDdon
eD':Ildeci po&ilion 10 DCUII'IlUc the clfr.ct of IIDd c:xte3ld the lip. diYkkd OD the donum of the biiDd or finger
fl.cxot proflmdoa. If tbc ptdiallll able to flex will be obviou1 by the lack of exlr:aliOD Ia
the finger llllbe prcmimallata'pbal.IJI&eal tbc fl.a&a', ulliiDlD& tbc IIDger jomra have
joint IJxD sapcr1lcialiJ ia i.atlrt bcal cbecbd for mobility. To UICN lbe
diltll . . arup tbc middle pllalau IIDd
Ilk tbc ptda:4 10 try 10 exlald !be diltal IP
(DIP) joiDt.
7.51. Tendon lnju.._ (6): Bt-'1 midd!. 7.st. lnhctlons (1 ): (A) Paronychia ia thc 7.eo. lnlwctl- (2}: (D) Pulp iDfectiOilll are
1lip tut: Flex the proximal IP (PIP) joint of eoml1lODeSt iD!eaiOD. Pain ia aggravated by exquiaitcly taldcr and may lctd to deatructiOD
the finger cm:r the edge of a tlblc and atady pmmre on the eDd of tbc ll8iL (B) Apical of tbc diatal phalmx. (E) Tendon lbelit1
the prcWmal phalau (1). A.t tbc petialt 10 i.D:fec1iona give paiD whidl ia aggravated by illfectiOillllad to a fuaiform klcd :II.Dgc:.
try to ex11cad tbc PIP joiDt, and fctJ for any dowDward IJRUUl'e Oil tbc ll8iL A aubungual Ally IC::mpt to &Craighlal tbc liiiF ~
activity (2): PIP exii:UiOil OCCUII if tbc CXOitolia (C) (wbidl can be comlrmcd by pain. ~ ia marlald and locllilled
middle &lip ia inDia, but tbc DIP joint will l'lldioplpbe) may ~~ caue coa1'uaimL (uaoally to lbe bale of tile abeatll,).
be flail (3). If tile middle: lllip il ~
c:zfclllioa. at tile PIP jaiDt cloet DOt occ:ar
and thc DIP jaiDt lti1fea and ex11cada.
THEHAND 127
7.61. lnfKtlon ()): (F) Ia web IJ*lC 7 .Q. lnf'Ktlon {4): (G) Ia thcDar and 7.d. AIMII!Mid of th• principal
IDfecliODI there ia uauaDy maW:d awelling of midpalmar i!piCC IDfecliODI there ia g1'088 functiON of tM hand {1): PiN:JJ frlp: Aak
the back of tbc baDd 111111 web, wilh JprCidlng IWclliDg of tbc baDd illvolviag both the donal the p!l1imt to pid: up a amall object ~
of the finger~. Note the altc of any cauaal aDd palmar llll'facea. Ia the cue of the theDar the tip• of the thumb aDd index. Intact
WOUDd. i!plllC, the aweUillg may be more pJ'ODOIIllaxl .million ia IIIICelllll}' for a salillfactory
on the ndial slde of tbc palm. pmfllllJIIIDU. The pammt slmald be uklld to
repea the 1Mt with bia eyea cloeed. Note
wbdber the tip of the adjaam middle finger
em utiat (chuck grip).
7.64. Hand fundl•n W: Tlucmb to 1ille of 7.65. Hand fu_.n (3): Gnup: Al1l. tbc 7.a Hand "-ctton (4): Pa/mQr gnup:
intJa rrip: 'lbc pltic:at lbould be ubd to patialt to pap a pen firmly ill the bad, Teat tbc capping IC1iOD of the biDd by ukillg
grip 1 kty betwcea tbc thumb ad lide of the uaiDg the thumb md ti.Dgela. Attempt Ill the pltic:at to &fliP I IIDill ball ill the palm
iDda iD tbc D<lrDl8l fullion. Telt tbe linmleu wilhlkaw 1ile pen aDd DOte the ~ of 1lle bad Note tbc patialt't lbility to reliJt
of the grip by aa=npti.n& to withdraw tbc ~ ofli=d.. Wbal: fulgct flexion ia lCitridcd, the bill beill& witbdrawn.
1lliD& your own piDdl grip. rqlCit 1IJiD& 111 object of grealer diamellcr.
7.69. Hand function (7): Bifalualjwlctioll:

Allhmlsb tbe fimctian in 011e lwld may be
u aeued u delcrlbed, it la important to DOte
th.t impairment of fmH:tion in cme bad may
c!Nrly affect m.lY aaMtis th.t llmiimlly
involve both~ toptbs'. 'l'bB degree
of cmnll fuadimW impainnmt may be
invellisllled. by eoquirina about, Ol' tstins.
IIIII pDmt's ability kl perfonn certlin tub.
'Whea ~ is beins JMIJIDd, 5Ch of
lhDte may be IIIXII1Id on a ICale (0-S or 0-10)
IUid aiiDIIDI!Ii. The follllWini llat (adapted
fl'am 1eltl dBvUed by Lamb et al.) may be
fOUDd to be helpful. llilhm' IMI1ec:ted Ill'
uawbole:
1. UlllmiW IIIII top from a bottiA
2. Fill a cup IUid drink.
3. Open I tin with I tin-oplllllll'.
4. Remove a matcll from itl box lllld li&bt
il.
S. U1e a lmife 111111 fork for eating.
6. Apply pute kl a toothbrush &Dd clean the
7.67. Hand function (5): 'Wbt::D i'uDcliollla 7 .61. Hand function (6): Grip mmgth: tcceb.
markedly impaired. ll<*l wbc4btr hook grup Thi1 may be te4ted uiDg a dynamome1Cr; 7. Put 011 ajldlr;t.
!a retained. altcmali'Vdy, ~ a roBed 8. Do up buUODJ.
8pbygDl01D11110DlCt adf 10 20 mmHg 8Dd 9. Futcn a belt rooJld the waiat.
uk the plliall to lquet.r.e it .. bard .. he 10. 'l1c ahoc lacea.
caD. A IIOI'IDillwld lhould be able to acllieve 11. Sb.arpt.a ptaCiL
a~ of 200 mmHg or over. 12. Write Jllelll!p.
13. Sblp]c JlllPCriiOgella.
14. Wrap atrln& rouad a parcel.
15. UIC playilla canlt.
(See abo Aslelllllmlt of Combimd Shoulder
&Dd Blbow fmldioa -'. QaickDASB,
PP• S7- 59).
7.70. Hand radlogrllplu: ...mpl• of

p.tholou n ): in 1hiJ llldiop'aph of a 7.71. Nhology (2): 'I1Im8 is a par1ially
child., bmd IIIOit of tile fCimiul plla1au oslified swelling arising from tbe region of
of tbe ring linger la 110 loapt viliblt, llld
tbe loft tla111C dwlow IU&&e* ~Welling of
tbe di&it
tbe IJIIICk md distal portion of tbe iadex
~.
Diqaalil: IOlitlry (beoipl.) eaclJoDdroma.
7.72. ,.....OIJ (3): 'lbe thumb md iDdelt
appear quJfc oormal, but tile ~ IUid
Diapolll: CIAcitla llld clalructiocl of tbe pllaial&el of the oda liqal ~ clistmed
lamiaal pbalaax eecoadary to I p)'O&CIIic rih IIIIDJ cyltil: CliiiiWn.
iafec1ioD of tbc pulp of tbe rill( fill&c:r. Dl8pelk: muWplc ~typical of
OWer'• clu-e (muUiprlc ~).
THEHAND 129
7 .n. PMboiOIJ (4): 'l."bere is broadlmins 7.75. hthology (6): ~ is a bony

aud distmtion of lbD pmximallll!d of lhD fmgJDmt lyills in rel.ltion to the Illlildia1 aide
tbumb mebK:arpal. llllll1lWiDg of lbD of the bue of lhD proximal phalaox of the
carpomeiiK:alpa joint ..,_, aud lipping. tbamb.
Dtllpam: the appeanm:ea are typU:al of Diapam: an awllion &aaure of the bue of
advauad a.lliollrtbritic cllap in the the proximal pbalaDx of the thumb where the
~joint af tbe tlwmb. medial collalr:nllipmmt is altlclJed. This
wu u.t0Cia11L!d clinically with instability in
the ~joint (pmekeeper'•
tlaanb).
8
The thoracic and lumiJar spine
The spine: anatomical features 132

Back pain 133
Scoliosis 135
Kyphosis 137
Scheuermann's disease (spinal
osteochondrosis) 137
Cal~'s disease 138
Ankyloslng spondylitis 138
Diffuse Idiopathic skeletal ~rostosls
(DISH) 139
Senile kyphosis 139
Paget's disease 140
Tuberculosis of the spine 140
Pyogenic osteitis of the spine 141
Metastatic lesions of the spine 141
Spondylolysis, spondylolisthesis 142
Osteoarthritis (osteoarthrosls) 142
Spina blfida 143
Spinal stenosis 144
The prolapsed lnteNertebral disc
(PID) 144
Mechanical back pain 146
Coccydynia 147
Commoner causes of back complaints
In the various age groups 148
Inspection 149--151
Percussion 151
Movements 152-153
Suspected PID 153-154
Suspected functional
ove~ay 154-155
Suspected thoracic cord

pathology 156
Suspected ankyloslng spondylitis 156
Radiographs 157-164
Pathology 164-168
FJ
Ag.U
THE SPINE: ANATOMICAL FEATURES

The complex relationships of the components of a typical vertebra may be
illustrated by an exploded diagram (shown here after Kapandji). The bony
elements comprise the vertebral body (1), composed of cancellous bone
covered with an outer shell of cortical bone; the horseshoe-shaped neural
arch (2); two articular masses or processes (3) which take part in the facet
(interarticular) joints; the transverse processes (4); and the spinous processes
(S). When these components w:e brought together they form a protective
covering for the cord (6) and issuing nerve roots (7). The neural arch (2) is
divided by the articular processes (3) into pediclca (8) and laminae (9).
Each vertebra articulates with the one above and below by means of the
facet joints and the intervertebral discs. Bach disc, lying between the hyaline
cartilage endplates of adjacent vertebral bodies, is composed of a nucleus
pulposus (NP) smrounded by concentric sheets of fibrous tissue (annulus
fibrosis) (AF).
Movements between the vertebrae are possible in several pl.aocs, and the
axes of these movements pass through the approximate centres of the
niE THORACIC AND LUMBAR SPINE 133
intervertebral discs. At all levels of the spine, fiexion (F) and extension (B),
and lateral :flexion (LF) to both sides are possible. In the thoracic spine, the
plane of the facet joints lies in the arc of a circle which has its centre in the
DllCleus pulposus (CNP); as a result, (axial) rotation (.AR) is possible in this
part of the spine. In con1rast, the orientation of the facet joints (FJ) in the
lumbar region is such that rotation is blocked. i.e. virtually no vertebral
rotation occurs in the lumbar spine.
A3 a result of the elasticity of the annulus the nucleus pulposus is under
constant pressure, and may (uncommonly) herniate into a verrebral body
anteriorly (A), or centrally (Schmorl's node) (SN). A much more common
occurrence is for the annular fibres to tear (as a result of trauma or
degenerative changes) so that the nucleus can bulge posteriorly (P) or
laterally (L): ('slipped discs'- central or lateral protrusions). A posterior
(central) disc protrusion may affect the cord directly (or the cauda equilla in
the lower lumbar spine); this may lead to bilateral lower limb signs with or
without bladder involvement. With lateral protrusions the neurological
disturbance usually results from pressure on one or two nerve roots only, so
that the effects are more localised and usually predominate on one side. In
the neural canals (NC, circled. top right) the space for the segmental nerves
is restricted, and in this region symptoms may be caused not only by disc
prolapse but by any other pathology compromising the space available (e.g.
arthritic facet joint lipping).
BACK PAIN
Back pain is one of the commonest and most troublesome of complaints;
its causes are legion and an exact diagnosis is often difficult. The disability
with which it is usually associated is often severe and prolonged; therapy is
often ineffective, and the anxious, impatient and dissatisfied sufferer often
resorts to lines of treatment which are unproven, illogical and irrational. In
this difficult area it is not possible to provide a guide to pathology and
diagnosis which is simple and at the same time comprehensive and
foolproof. Nevertheless, it may be helpful to consider this subject under
three headings:
l. Back pain due to clearly defined spinal pathology, such as vertebral
infections, tumours, ankylosing spondylitis, polyarthritis, Paget's disease,
and primary neurological disease, osteoporotic spinal fractures, senile
kyphosis, spondylolisthesis, Scheuermann's disease (spinal
osteochondrosis), and osteoarthritis.
2. Back pain associated with nerve root pain, where the commonest causes
are intervertebral disc prolapse and compression of nerve roots within the
neural canals.
3. Back pain caused by a disturbance of the mechanics of the spine
(mechanical back pain), where in the majority of cases it is not possible
to discover the exact canse with any degree of llCC1ll"llCY· This is the
largest group of conditions causing back pain, and formerly attracted
many emotive but valueless names (such as lumbago, low-back
strain etc.).
In taking a history, examining and investigating a patient suffering from
back pain, possible extraspinal causes should be excluded and an attempt
should be made to place the patient in one of the three groups described
above. Thereafter, and if possible, a more precise diagnosis may be
attempted.
Important points in history-taking:
1. Note the patient's age and occupation: both may be relevant
2. Ask about the onset of the pain:
(a) When did the symptoms commence?
(b) Was the onset slow and insidious, rapid, or sudden? The la1n:r is
strongly suggestive of mechanical factors.
(c) Was there a history of an injury, such as, for example. a sudden twist
or strain, or a sneeze OCCUJring when the patient was in a flexed
position? (This is a common history in cues of intervertebral disc
prolapse.)
3. Ask about any directly relevant previous history:
(a) Is there a history of a previous similar atW:k?
(b) Is there a history of any previous trouble with the spine?
4. Ask about the site and nature of the pain:
(a) Where is the pain sit:ualed? Is it well localised, or is it diffuse?
(b) Is the pain always present, or does it disappear at times? The latter is
suggestive of a mechanical cause.
(c) Are there any factors that aggravate or alleviab: the pain? Note that
with mechanical back pain bending or suddtm movement may make
the pain worse, whereas lying flat, particularly on a bard surface, or
applying local heat, or even sitting, may relieve the pain. In the cue
of baOOlche associated with spinal pathology - particularly in the
case of tumour, infections or inflammatory disease - the patient may
be unable to find a position of rest; constant nigbt pain (as distinct
from short-lived pain when turning in bed} is a feamre.
5. Ask about radiation of the pain:
(a) Does the pain radiate into the legs?
(b) If so, exactly how far down does the pain go, and what area is
involved? (Note that the commonly affec:tcd roots of the sciatic nerve
(1.4, LS, Sl) supply areas of sensation below the knee.)
(c) What is the pain like?
(d) Is there paraesthesia?
Note that pain radiating into the legs is not necessarily due to nerve root
involvement: it seems that irritation of facet joints, ligaments and
muscles may produce dull, aching pain in the buttocks and backs of
the thighs. In contrast, pain arising from nerve roots is usually sharp
and knife-like, and in addition, in the case of the commonly affected
LS and S I roots, it often extends below the knee to the ankle or foot.
In the common situation where there is involvement of one, or at the
most two, nerve roots, the whole limb cannot be affected; instead, the
area of sensory disturbance should correspond with the relevant
dc:mlatomc(s); and it should be noted whether paraesthesia occum
within the same restricted tenitory.
6. Ask about motor involvement:
(a) Has the patient noted any weakness in the lower limbs. or any muscle
wasting or fibrillation?
(b) Has there been any disturbance of gait or balance, any tendency to
giving way of the legs, any sign of drop foot?
7. Make enquiries in the followiDg areas:

(a) Has there been any IDlllaise, fever, or involvement of other joints?
(b) Has there been any weight loss?
(c) Has the patient had any large bowel or other gastrointestinal
problem?
(d) Have there been any genitominary symptoms, especially retention or
incontinence?
(e) Has the patient had any respiratory difficulty?
(f) Has the patient any symptoms suggestive of a major neurological
disturbance?
A positive answer to any of 1hese questions will generally necessitate
appropriate further investigation. The possibility of an invasive primaiy
tumour or metastatic lesion must always be kept in mind, and examination
of the abdomen, rectum, and common sites of primary tumour is wise if
there is any likelihood of malignancy.
The spine should then be examined clinica1.ly; if the symptoms have
remained unchanged over a 2-week period, radiological examination
and estimation of the sedimentation rate should be carried out. At this
stage any well defined spinal pathology should be detected (such as
spondylolisthesis, ankylosing spondylitis, osteitis of the spine etc.).
H conditions such as these have been eliminated, the question as to
whether the symptoms are due to a prolapsed intervertebral disc should be
considered. The history, clinical findings, and plain radiographs of the spine
should be in harmony before it is reasonable to make this diagnosis. By the
process of eHmination, if a diagnosis has not yet been made the patient is
likely to be suffering from mechanical back pain: but note that both the
history and findings should be in accord with this. If not, caution must be
exercised, close surveillance should be maintained, and further investigation
may be indicated.
SCOLIOSIS
Scoliosis is primarily a lateral curvature of the spine, but there is often a
degree of associated kyphosis. Mathematical analysis of the curves has
revealed several distinct patterns, which are dependent on the relative
contributions of these two deformities.
In the management of any case, the first and most important decision to
make is whether there is any deformity of the vertebrae (s1ructural
scoliosis). If the vertebrae are normal (non-structural scoliosis) the deformity
is usually due to one of the following conditions: it may be compensatory,
resulting from tilting of the pelvis from real or apparent shortening of one
leg. It may be sciatic and due to unilateral protective muscle spasm,
especially that accompanying a prolapsed intervertebral disc. Postural
scoliosis occurs most commonly in adolescent girls and generally resolves
spontaneously.
In structural scoliosis there is alteration in vertebral shape and mobility,
and the deformity cannot be COll'eCted by alteration of posture. A careful
history and examination is required in an attempt to find a cause and give a
prognosis, the two factors on which treatment depends. Structural scoliosis
may be congenital, the defonnity being due, for example, to a hemivertebra
(only half of a single vertebra is fully formed), fused vertebrae, or absent

or fused ribs.
In paralytic scoliosis the deformity is secondary to lou of the supportive
action of the tnmk. and spinal muscles, nearly always as a sequel to anterior
poliomyelitis.
Nt!uropathic scoliosis u seen as a complication of neurofibromatosis.
cerebral palsy, spina bifida. syringomyelia. Fried:reicll's ataxia and
neuropathic couditions. Primary disonlers of tbe supportive musculature
of the spine are respons1ble for myopathic scoliosis (e.g. in muscular
dystrophy, arthrogryphosis). Metabolic scoliosis is uncommon, but
occurs in cystine storage disease, Marfan's syndrome and rickets.
Idiopathic scoliosis is the commonest and by far the most important of
the strucnua1 scolioses, and its cause remains obscure. Several vertebrae at
one or, less commonly, two distinct levels are affected (primary curve). In
the area of the primary curve there is loss of mobility (the fixed curve) and
rotational deformity of the vertebrae (the spinous processes rotate into the
concavity, and the bodies that carry the ribs in the thoracic region rotate into
the convexity). Above and below the fixed primary curves, secondary curves
which are mobile develop in an effort to maintain the normal position of the
head and pelvis. The spinal deformity is accompanied by shortening of the
trunk (which may be assessed by using anthropometric tables of normal
values) and there is often impairment of respiratory and cardiac function.
In severe cases this may lead to invalidism. Cor pulmonale may feature in
cases where the primary curve exceeds 80°.
Once scoliosis has appeared in the growins child the natural tendency is
towards deterioration. The prognosis of a given case is dependent on the age
of ooset, tbe level of the spine affected, the size and nwnber of the primary
curves, and the type of strudural scoliosis (e.g. idiopathic or congenital).
The maximal rate of deterioration tends to occur between the ages of 11 and
13 in girls, and 13 and 15 in boys, during tbe growth spurt that takes place
around puberty. In assessing or obsenting any case it is uaual to record the
height, and the cunent stage of sexual and skeletal maturity. In many cases
deterioration stops when skeletal maturity is reached, but sometimes
continues as a result of disc degeneration and vertebral subluxation: 17°
deterioration in 70° thoracic curves, and 20" deterioration in 30° lumbar
curves have been recorded. Generally speaking, the higher the level of the
spine involved in the primary curve, and the younger the patient, the worse
the prognosis. There is the notable exception that in some cases occurring in
infancy there is spontaneous recovery, which is as remarkable as its
mysterious onset. Favourable factors are left-sided curves occurring in the
first year of life in males where there is a rilrvertebral angle of less than
20°. Life expectancy may be reduced in congenital and paralytic scolioses,
but not in idiopathic scoliosis.
In all cases of structural scoli08is appropriate investigation, radiographic
measurement of the curves and careful ob&ervation is essential. Note in
particular:
1. Syringomyelia u present in 25'11 of cases of juvenile idiopathic scoli08is.
As decompression may lead to improvement, and failure to deco1npress
before attempted surgical com:ction or stabilisation may lead to
neurological complications., an MRI scan is mandatory in all cases of
juvenile idiopathic scoliosis.
2. Scoliosis is not normally a painful condition at onset. When there is pain

(especially night pain relieved by aspirin) the commonest CIWSC in the
adolescent is an osteoid osteoma of a pedicle.
1i'ea1ment may be advised in the face of a poor prognosis, evidence of rapid
deterioration. or for cosmetic purposes. (Curves are not usually considered
for correction unless they are in excess of 25-30°.) The methods available
are highly specialised, as is the decision regarding their use and timing.
Deterioration in a curve may be controlled by use of the Milwaukee brace
(a device incorporating moulded supports for the chin, occiput and pelvis,
interconnected by vertical metal struts). This support is employed in older
children approaclrlng skeletal maturity who have just acceptable curves, or it
may be used in the young cbil.d until an age suitable for spinal fusion (1 0 or
ovec) is reached. Other patterns of support are available. although none has
been shown to have statistical superiority (and some doubts have been
recently cast on their overall effectiveness). Fusion of the entire primary curve
is aimed at preventing further det.eriorati.on and at allowing braces to be
discarded. Prior to fusion it is necessary to correct the primary deformity as
much as is possible. Often a hinged plaster spica (Risser jacket) or the surgical
insertion of internal apparatus (e.g. Hanington instrumentation) is employed.
KYPHOSIS
Kyphosis is the term used to describe an increased convexity of the thoracic

spine. This is usually obvious when the patient is viewed from the side.
(Diminution of the lumbar concave curve is referred to a.s loss of lumbar
lordosis or :flattening of the lumbar curvature; in extreme cases there is
reversed lordosis, or posterior convexity of the lumbar curve.)
Kyphosis generally affects a major part of the thoracic spine (i.e. several
vertebrae are affected), and the increased curvature is then said to be
regular. In angular kyphosis, which must be carefully distinguished. there is
an abrupt alteration in the thoracic curvature which is usually accompanied
by undue prominence of a spinous process (gibbus).
Where mobility is normal in the kyphotic spine, the deformity is most
frequently postural in origin; this is often seen (as is postural scoliosis) in
adolescent girls. In some cases the deformity is secondary to an increased
lumbar lonlosis (which in tmn may be due to abnormal forward tilting of
the pelvis, and sometimes to :flexion contracture of the hips or congenital
dislocation of the hips). Less commonly, kyphosis may remit from muscle
weakness secondary to anterior poliomyelitis or muscular dystrophy.
When the thoracic curvature is not mobile but fixed, the most frequent
causes are senile kyphosis, Scheuenrumn's disease (spinal osteochondrosis),
ank:ylosing spondylitis and Paget's disease. When there is an angular
kyphosis the most common causes are tuberculous or other infections of the
spine, fracture (traumatic or pathological, e.g. secondary to osteoporosis), or
twnours. In adWts the commonest tumour is the metastatic deposit, and in
children the eosinophilic granuloma.
SCHEUERMANN'S DISEASE (SPINAL OSTEOCHONDROSIS)
This condition (whose exact aetiology is unknown, although there is a

strong familial tendency), results in a growth disturbance of the thoracic
vertebral bodies which in 1atcral radiographs of the spine are seen to be

DaiTOWer anteriorly than posteriorly (anterior wedging). There may be
associated b;u:k pain. The diagn011tic protocol for the condition specifies that
no fewer than three adjacent vertelmle sbould have at least 5° of anterior
wedging. The epiphyses of the vertebral bodies are often irregular and may
be disturbed by herniations of the nucleus pulposua. Nuclear herniation may
occur between the epiphyses and bodies anteriorly, or into the cen1re of the
bodies (Schmorl's nodes), thought to be due to iacbaemic necrosis of the
cart.i1aginous end-plates. Mobility iB impaired, thoracic kyphosis iB regular
and often quite marked, and there iB a compensatoJy increase in lumbar
lordosis. Secondary osteoarthritic chaDges may supervene in the thoracic
and lumbar spine.
The normal upper limit of the convexity of the thoracic spine (as
measured by the Cobb method) is reckoned to be 45°, and cases of
Scheuermann's disease in adolescence with curves of 50° or less should be
observed. Where the curve is in excess of this, a Milwaukee brace, worn
continuously for not less than 12-18 months (and afterwards till skeletal
ma111rity) may be advised in an attempt to prevent deterioration. (Some
question the effic;u:y of this method of spinal bracing.) If the curve cannot
be conttolled and reaches 75°, correction by surgical ins1l'UDlentation should
be considered. In the adult with uncontrollable pain and a curve in excess
of 60°, surgical fusion may be performed.
CALY~'S DISEASE
BIU:k pain in cbildren may be aa:ompanied by gross flattening of a single
verlebral body. Symptoms usually resolve spontaneously. In many cases the
pathology iB due to an eosinophilic granuloma.
ANKYLOSING SPONDYLITIS
In this chrooic jnflammatory disease there is progressive ossification of the
joints of the spine; itB aetiology iB unknown but there is a hereditary
tendency, with the overall risks of children of an affected parent developing
the condition being 1 in 6. Unlike rheumatoid arthritis, to which it is often
related, it is comparatively rare in women. The male/female ratio varies
from 6 : 1 to 2 : 1, depending on the age of onset. The commonest
presentation is that of a male during the third and fourth decades.
The joints between T12 and L1 are often first affected, but the rest of the
thoracic and lumbar spine is rapidly involved. The costovertebral joints are
usually affected, leading to a reduction in chest expansion and vital capacity.
Pulmonary tuberculosis, or pulmonary infections with A.rperrillw are
sometimes found in association, and there may be cardiovascular, renal,
gastrointestinal and ocular complications.
Stiffness of the b;u:k and pain are the presenting symptoms in the
majority of cases, but on cx:casion involvement of the hip joints, or the
knees with effusions, may fint atttact attention. 1Mre may be pain at
the insertions of the Achilles tendons or the plantar fascia (enthesopathy).
Stiffness is usually wane in the mornings, and may wake the patient from
s]cep; it tends to improve with activity as the day wears on.
The disease is progressive, and although it sometimes arrests

spontaneously at an early stage it usually leads to complete ankylosis of the
spine, with characteristic changes in the radiographs (bambooing of the
spine). Progressive flexion of the spine may be severe, so that forward
vision becoiDell impossible 118 the head is flexed on to the chest. The
sacroiliac joints are almost invariably involved at an early stage, and there
may be fusion of the manubriosternal joint There may be a history of iritis
or its sequelae. The sedimentation rate is high (40-120 mmlh), rheumatoid
factor is not present, and estimations of human leucocyte antigen-B27
(HLA-B27) are usually positive. There is often associated anaemia. muscle
wasting aDd weight loss.
As far as treatment is concerned, exercise and physiotherapy are
generally regarded 118 being beneficial. Non-steroidal anti-inflammatory
drugs (NSAIDs) are usually helpful, although the risks of cardiovascular
toxicity with long term use must be considered. Disease-modifying
anti-rheumatic drugs (DMARDs) have not been found to be particularly
useful Deep X-ray therapy is often effective. but carries the risk of aplastic
anaemia. Remarkable improvements in disease activity, mobility, function
and pain have followed the use of anti-tumour necrosis factor (TNFa) in the
form of ilrlliximab or etanercept.
Where deformity of the spine is gross, spinal osteotomy is occasionally
undertaken to give the patient a tolerably erect posture. Replacement
arthroplasty of the hips or knees is often carried out, even if these joints
have progressed to fusion.
DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS {DISH)

This comparatively benign condition, also lrnown as Forestier's disease. is
sometimes mistaken for ankylosing spondylitis. It is characterised and
diagnosed by the presence of :flowing calcification and ossification along the
anterolateral borders of at lellllt four contiguous vertebral bodies. The disc
spaces are, however, preserved (unlike in ankylosing spondylitis), without
loss of height or other degenerative changes, and the sacroiliac and the facet
joints do not ankylose. Most cases are asymptomatic, or have mild or
moderate restriction of movements in the parts of the spine affected. No
treatment is effective.
SENILE KYPHOSIS
In true senile kyphosis the ageing patient becomes progressively stooped
and shorter in stature through degenerative thinning of the intervertebral
discs. Pain may occur if there is 118sociated osteoarthritis.
In elderly women the kyphosis may be aggravated by senile osteoporosis
or osteomalacia. which lead to anterior vertebral wedging and often
pathological fractures. There is usually radiographic evidence of
decalcification, the serum chemistry may be disturbed, and pain is a feature
if there are recent vertebral body fractures.
'Iieatment is directed towards controlling the underlying osteoporosis or
osteomalacia. Thoracic spinal supports are not particularly effective and
cannot be tolerated by the elderly, but often a simple lumbar corset is helpful
in relieving pain arising from the secondary increase in lumbar lordosis.
PAGET'S DISEASE
Paget's disease of the spine is comparatively UDCommon, and although the
diagnosis is made on the radiographic findings, it may be suggested
clinically by other stigmata of the disease. Paget's disease may lead to
disturbance of cord function, which may often be successfully treated with
bisphospbonates (e.g. etidronate and pamidrooate).
TUBERCULOSIS OF THE SPINE

Bone and joint tuberculosis iB uncommon in Britain, but the incidence is
increasing. The factors responsible include the increase in numbers of
immunosuppressed individuals, the development of drug-resistant strains
of Mycobacterium fubel'{;tdosis, and an ageing population. HIV is the
leading risk factor for the reactivation of latent tuberculous infections. The
World Health Otganization reckons that a third of the global population is
infected with the organism. and that it is the commonest cause of death and
disability on a worldwide basis. About a fifth of newly diagnosed cases are
extrapulmODJII}', and the spine is involved in SO% of cases of bone and joint
tuberculosis.
The onset of spinal tuberculosis is often slow, with aching pain in the
back and stiffness of the spine. There may be fever and weight loss.
Radiographs taken in the earliest stages of the disease show narrowing of
a single disc space; later, as the anterior portions of the vertebral bodies
become progressively involved, they collapse., leading to anterior and
sometimes lateral wedging of the spine. This may produce angular kyphotic
or scoliotic deformities. The local absceas may expand and track distally.
The spinal cord may be compromised extrinsically or intrinsically, and
weakness of the limbs or paraplegia may eDBUe. Extriluk causes include
caseous abscesses. granu.lation tissue and fluid. sequestered bone or disc
material, and spinal angulation leading to kinking of the cord over an
internal gibbus. Intrinsic causes include the spread of tuberculous
inflammation through the cord and meninges.
Initial investigation should include radiographs of the chest, culture of
urine and any sputum, Mantoux testing, brucellosis complement fixation
testing and, in the case of the lumbar spine at least, an intravenous
pyelogram (IVP) (renal spread being not unoommon}. CT and MRI scans
of the spine are also invaluable in demonstrating the extent of bone and
soft tissue involvement.
The clinical and radiological features of tuberculosis of the spine are
mimicked in the early stages by other infections (especially those due to
Staphylococcus aureus), and the only certain method of establishing the
diagnosis in the majority of cases seen at this stage is by obtaining
specimens for histological and bacteriological examination. cr-guided
needle aspiration biopsy may be employed if this facility iB available. Again.
as the abscess is small at first and the early removal of necrotic bone and
pus is generally of value from the point of view of accelerating healing,
many swgeom combine these procedures. In the later stages, where there is
groa bone destruction, minimal new boDe formation and the formation of
large abscesses, the diagnosis is seldom in doubt.
The aim of treatment is to overcome the infection, eliminate abscesses
and sequestra, and promote sound fusion in the affected spinal segment to
prevent any recrudescence. The mainstay of treatment is the use of the

antitubereulOUll drugs, although the emergence of resistant slrains ill causing
problems. Sensitivity testing is advisable, and drugs should not be used in
isolation. Drug therapy for periods up to 2 years was former'ly advised, but
it has been shown that regimens employing a combination of rifampicin and
isoniazid for 6 months only seem equally effective. This ill of particular
importance where compliance is low. It bas been noted that the addition of
streptomycin to the drug regimen, bed rest, or a plaster cast do not seem to
affect the outcome.
Conservative treatment alone leads to a comparatively low fusion rate,
and in about 70% of adult cases there is a deterioration in the kyphosis.
In those parts of the world where resources are good. there is at present
a trend to early surgi.cal intervention to achieve or accelerate the healing
process and assist fusion by early drainage of abscesses and bone grafting.
Where paraplegia is due to intrinsic causes, it may resolve following
antitubereulOUll therapy, but in many cases the causes are extrinsic, and
surgery is indkated to decompress the COid. An MRI scan may give
valuable assistance in selecting cases and delineating the scope of the
surgery required. H adequately dealt with in the early stages (i.e. within 6-9
months of the onset of paraplegia) complete cure is often achieved. In
paraplegia of late onset, where the cord is often acutely angled over an
internal gibbus, surgical intervention should always be carried out. but the
prognosis here is less good.
PYOGENIC OSTEITIS OF THE SPINE

Pyogenic osteitis of the spine is relatively uncommon. In the early stages of
the disease differentiation from tuberculosis of the spine is often extremely
difficult, so that the diagnosis may not be clearly establisbed unless material
is provided for bacteriological examination. Specimens may be obtained by
needle biopsy with the use of an image intensifier, or by exploration. At a
later stage (and many cases may delay in their presentation) exuberant new
bone formation in the region of the lesion may favour this diagnosis. The
presenting features are of pain and stiffness in the back, often insidious in
onset. but sometimes occurring quite rapidly. Nearly all cases resolve with
prolonged treatment with the appropriate antibiotic (the majority are due to
a staphylococcal infection, but Salmonella typhi (syn. Bacillus typhosw) and
other organisms are sometimes causal).
METASTATIC LESIONS OF THE SPINE

Metastatic disease of the spine ill seen particularly in the elderly and may be
complicated by paraplegia. Back pain at night. pain unaffected by rest or
activity, fatigue and weight loss are common features. The diagnosis is
made on the radiographic findings. Treatment of the uncomplicated lesion ill
dependent on the nature of the primary tumour; in some cases deep X-ray
therapy and supportive measures may help the local lesion and give relief of
pain. Where paraplegia is present, decompression should be undertaken
unless the case is terminal. In the patient with some pre-existing
cardiovascular disease the possibility of an abdominal aneurysm should be
considered; or if the pain is severe at night and there is weight loss, a further
search for evidenoe of malignancy should be made. Primary tumours of the

spine are rare; the common types are mentioned in Chapter 3.
SPONDYLOLYSIS, SPONDYLOLISTHESIS
In the erect position there is a tendency for the body of the fifth lumbar
vertebra (caaying the weight of the trunk) to slide forwanls on the
corresponding surface of the sacrum, as tbe plane of the LS-S1 disc is not
horizonbil but slopes downwards anteriorly. This movement is usually
prevented by the downward-projecting inferior articular processes of the
fifth lumbar vertebra impinging on the corresponding upward-projecting
articular processes of the siiCIUill. This mechanism may fail if there is a
fracture or defect in the part of the fifth lumbar vertebra lying immediately
anterior to its inferior articular process. A defect in this region, if
lllliiCCOIIIpaDed by any significant forwani movement of the vertebral body,
is known as spondylolysis. The defect may be unilateral or bilateral. When
fotward slip occurs, the condition is known as spondylolisthesis. Less
commonly, the fourth lumbar vertebra may be involved, the slip occurring
between lA and LS.
Both congenital and developmenbil factors have been recognised in the
causation of the condition. There is a higher incidence in the fBIDilies of
those affected (30-70%, with dominant tranJmission), in certain Inuit tribes
(where it reaches 54%), and among the Japanese. The lowest incidence is
in black females (1.1%), and in white males it is 6.1%. Defects are rare at
birth and before the age of 5, but the incidence in the population goes on
increasing up to the end of the fourth decade. Fradures due to trauma or
fatigue are thought to be the most likely cause, and this explains the high
incidence amongst gymnasts, weightlifters, labourers, loggers and
'backpacers. It may be associated with sacral spina bifida and
Scheuermann's disease.
Both spondylolysis and spondylolisthesis give rise to low back pain
which radiates into the buttocb. In adolescents, the majority of whom are
active in sports, resolution of symptoms may be achieved in 80% of cases
by the avoidance of sports and the use of a corset support. This may lead to
the healing of hairline fractures, or to the spine stabilising as a result of
degenerative changes occurring at the level of the slip. In m.ote severe cases,
where there is significant forward slip, local spinal fusion is the treatment of
choice. This may be performed with or without reduction of the deformity.
A number of patients may sufi"er from newological disturbances in the
lower limbs, either initially or as an uncommon complication of a local
fusion. In the cmu:la equina syndroTM there is usually low back pain
with radiation into the buttocks, spinal stiffness, hamstring spasm. gait
abnormalities, and disturbance of bladder and bowel control. This may be
due to an associated disc protrusion, or be caused by the cauda equina and
roots of the lumbosacral plexus being stretched over the prominent upper
edge of the fifth lumbar vertebra or the sacrum. These complications should
be dealt with by an immediate decompression procedure.
OSTEOARTHRITIS (OSTEOARTHROSIS)
Primary osteoarthritis of the spine is extremely common, especially in the
elderly. and is often asymptomatic. In the majority of cases there are no
obvious causes, apart from those associated with the degenerative processes
of age. Sometimes obesity and excessive use of the spine by manual
workers may be factors. In secondary osteoarthritis, previous pathology in
the spine accelerates normal wear and tear processes.
Occasionally osteoarthritis may be localised to one spinal level, at for
example the site of a previous fracture or a prolapsed intervertebral disc.
Often, however, many vertebral levels are affected, particularly where theJ:e
ill some alteration in the normal curves of the spine; for example, secondary
osteoarthritic changes may occur in the lumbar spine when lumbar lordosis
is increased as a sequel to Scheuermann's disease of the thoracic spine.
Osteoarthritis of the spine may be accompaoied by disc degeneration,
anterior and posterior lipping of the vertebral bodies, narrowing and lipping
of the facet joints, and sometimes abutment of the vertebral spines (kissing
spines) as a result of disc degeneration bringing the vertebme nearer
together.
When osteoarthritis gives rise to symptoms, these are usually of pain and
sti:ffness in the back.; once other conditions have been eliminated, the
radiological appearances are diagnostic. Treatment is by weight reduction
where applicable, spinal exercises to improve the back musculature, and
analgesics. Short-wave diathermy is sometimes helpful. In the commonest
area, the lumbar spine, a corset support is a widely used and generally very
helpful line of treatment Only rarely is spinal fusion indicated, but this is
sometimes considered in the younger patient suffering from secondary
osteoarthritis localised to a single level of the spine.
Rheumatoid arthritis may affect the spine; other peripheral sites are
normally involved, so that the diagnosis is not normally difficult
Radiographs of the spine in rheumatoid arthritis generally show widespread
osteoporosis, disc space narrowing, natTOwing of the facet joints, and often
reduction in the height of vertebral bodies. The treatment is that of
generalised rbcumatoi.d arthritis; locally, corset supports may give
considerable relief of symptoms.
SPINA BIFIDA
Spina bifida is a condition in which there is a congenital failure of fusion of
the posterior elements of the spine. through which the contents of the spinal
canal may herniate. The grosser fotmS in the newly born child present no
difficulty in diagnosis. A number require and are amenable to immediate
surgery, wbi.ch may prevent early death from ascendiDg meningitis and
ameliorate the frequently concomitant neurological and hydrocephalic
problems. The residual neurological defect may unfortunately be profound,
and the selection of cases for surgery is specialised and to some extent
controversial.
The older child or adult may present with spina bifida occulta, which is
diagnosed by radiological examination, although it may be suspected by the
presence of a hairy patch, naevus or fat pad, or dimpling of the skin at the
site of the abnormality. Many cases are symptom free. In some the only
manifestation may be the presenoe of pes cavus. In others there may be
progressive bladdec dysi'undi.on, weakness and incoordination of the legs, or

trophic changes in the feet.
SPINAL STENOSIS
In spinal stenosis there is a decrease in the sagittal diameter of the

spinal canal which may C8Wie compre&Sioo of tbe cauda equina and
associated nerve roots. There may be some narrowing of the nerve root
bmnels.
Spinal stenosis may be congenital or acquired Congenital spinal
stenosis is common in achondroplasia or otber short stature syndromes.
Acquired spinal stenosis is seen most often as a result of degenerative
changes in the spine. In women. the mean aae of onset is 73; in men it
usually appears earlier. Contributory factors include osteoarthritis of the
lumbar spine, spondylolisthesis, Paget's dillCil!IC, previous fracture or
spinal surgery.
The condition may give rise to vague backache and morning stiffness,
relieved by rest and aggravated by BCtivity. Occasionally there may be
temporary motor paralysis or neurogenic claudication, where there are lower
limb pains, cramps and paraesthesiae related to wal.ldng or exercise. There
may be weakness or giving way of the legs. The claudication distance is
variable, and pain may be rapidly relieved by forward flexion of the spine or
by sitting. The patient may have no difficulty in cycling, or wallring while
leaning on a shopping trolley, where in both activities the spine is in a
flexed postion; but he may be unable to toleraie walking upright. The
sensory loss is segmental, and impulse symptoms are usually preaent.
Clinically the straight leg-raising test is hardly ever affected, but motor
distnrbana:s and absence of the 1mce jerlt are common. The ankle jerk and
the plantar response are unaffected, aod there is no cloaus; if an abnormality
is found in this respect, anotbec neurological disorder or an abnormality in
the thoracic or cervical spine should be sought. Note also that in
claudication due to vascular insufficiency the claudication distance is
constant, the peripheral pulses are usually absent, and the sensory loss
generally of the stocking type.
The condition may be suspected on clinical grounds. Analysis of the
dimensions of the pedicles and the spinal canal in the plain radiographs may
be helpful in establishing the diagnosis, but cr and MRI scans reliably
demonstrate the space available within the spinal ciiDJil for the neurological
structures.
Mild cases may be treated with analgesics, NSAIDS, physiotherapy and
exercise (e.g. use of a stationary bicycle with the spine in flexion),
temporary use of a lumbar corset support, and epidural injections of steroids.
H symptoms are marked and the patient is otherwise fit, gratifying relief is
often achieved by a decompression procedure.
THE PROLAPSED INTERVERTEBRAL DISC (PID)

In the COID1ll.ODCSt pa11cm of intcrveJtebral disc prolapse, a tear in the
annulus allows protrusion of the ~~emiliquid nucleus pulposus. This may be
limited by intact fibres at the periphery of the annulus (conttJiMJ prolapse).
In other ca&CS extrusion of the nucleus is usually more extensive and the
prolapsed material may be cut off from its source (sequestered disc
prolapse).
Lumbar disc prolapses are by far the most common, and the diagnosis is
usually made on the clinical evidence alone. Confirmalion may be obtained
by means of non-invasive procedures such as CT and MRI scans.
Discography often yields valuable information, as does radiculography.
Nevertheless, it is most important to note that the investigative findings
must be interpreted in conjunction with the history and clinical findings.
(In a recent study of a control group completely free from symptoms,
abnormalities were found in the MRI scans in S7%: 36% had evidence of
disc prolapse. and 21% had spinal stenosis. In addition, among proven cases
of disc prolapse the MRI scan is negative in 20% of cases, or shows
incompatible abnormalities in 30%.)
The disc between L5 and S 1 is most commonly involved, followed in
order by IA-LS, and that between L3 and lA. In a typical case there is a
h.istoiy of a flexion injury which tears the annulus fibrosus, allowing the
nucleus pulposus to herniate through. Back pain is produced by the annular
tear and protective lumbar muscle spasm may contribute to it. Pain is felt in
the lumbar region. There is usually tenderness between the spines at the
affected level, and sometimes at the side over muscles in spasm, although
this is a somewhat unreliable and controversial sign. MWicle spasm often
leads to loss of the normal lumbar lordotic curve, to restriction of
movements in the lumbar spine, and a protective scoliosis. The extruding
nucleus frequently presses on a lumbar nerve root, giving rise to sciatic
pain, paraesthesiae in the leg, and sometimes muscle weakness, sensory
impairment, and diminution or abolition of the ankle jerk. At higher levels
the knee jerk may be lost The neurological disturbance is segmental in
pattern, and i.r dependent on the side and level of the prolapse. Impulse
symptoms are common. When the prolapse is large and central the cauda
equina may be affected, producing bladder disturbance, diminished perineal
sensation, and even paraplegia. Such an occmrence is a surgical emergency
and immediate exploration imperative.
When a disc prolapse occurs in the adolescent there is striking restriction
of movemenlli in the lumbar spine. In the older patient. where degenerative
changes have occurred in the annulus, symptoms may be produced by an
extensive backward bulging of the disc without there being a f:raDk: localised
annular tear.
Disc prolapses in the thoracic spine are rare and have a variety of
presentations, often with a confusing clinical picture. There may be
bandlike chest pain, scoliosis, bizarre neurological disturbances with
peripheral temperature changes, altered reflexes, and weakness of the limbs.
A number are misdiagnosed as multiple sclerosis or amyotrophic lateral
sclerosis. They may be diagnosed by :MRI scan, and treated by transthoracic
excision.
In the long term, the extrusion of disc material from between the
vertebral bodies leads to narrowing of the disc space. The facet joints are
disturbed, and tend to develop secondary arthritic changes which decrease
the mobility of the spine at that level, and themselves be a source of pain
and sometimes nerve root irritation.
Occasionally, in the young in particular, the nucleus may herniate into the
substance of the vertebral bodies, giving rise to mild backache without root
symptoms. This pattern of herniation (Schmorl's nodes) is diagnosed

radiographically.
Apart from the large central prolapse all cases of acute disc prolapse are
first treated by conservative .IIIdhods. The present view is tbat prolonged
periods of bed n:st should be avoided, but an initial 2-week period of bed
rest with the use of strong analgesics may be required. If the response is
good the patient is then allowed up, although he is wamt:d to avoid lifting
and bending in case of recurrence. In some centres spinal cxtensioo
exercises may be advocated at this stage. If the response has only been
moderate, a number of surgeons nevertheless allow the patient to become
ambulant wearing a corset back support. If there is DO response to 2 weeks'
bed rest, the case must be carefully reassessed before this treatment is
continued.
Where ultimately there is an unsatisfactory response, or where residual
symptmns are severe, further investigation by CT or MRI scan, discography
or myelography is usually undertaken, with a view to specific treatment of
the lesion. The methods available include surgical excision by means of a
laminectomy, microsurgery, percutmeous endoscopic surgery, or by
chemonuclecJsis. The results of treatment, particularly as far as return to
work is concerned. are surprisingly little affected by either the physical
findings, the extent of the local pathology or the effects of surgery. (Social
or work-related factors have the greatest influence on the results.)
The following table (based on the findings of JollSOil and Stomquist) may
be helpful in differentiating between cases of disc prolapse and spinal
stenosis.
Finding PID Llltlrel IWiosls c.nnllhnolll
Average age 43 41 6S
Duration of symptoms (prior to Shortest
surgery)
Pain at rest, at night, and on + Equal +
coughing
Positive straight leg raising +++ Sometimes Hardly ever
Motor disturbance Commonest. especially
of knee jerk
Sensory changes Commonest
MECHANICAL BACK PAIN

Although usually suspected following history taking, clinical examination
and the study of appropriate radiographs, the diagnosis is made largely by a
process of elimination: it is back pain which is Dot due to a prolapsed
intervertebral disc or any other clearly defined pathology. The patient is
usually in the 20-45-year age group, and complains of dull backache
aggravated by activity. There is often a histoty of DJDlDiDg stiffness which is
gradually relieved as the patient moves about. Physical signs are often
slight, and extensive radiation of pain and positive neurological signs are
DOt a feature.
Acute cases may be precipitated by a traumatic incident, such as the

ftawed lifting of a heavy weight, a faD, or a head-on impact pattern road
traffic accident There may be intense protective muscle spasm As far as
treatment is concerned, analgesics should be prescribed for a short period
BDd prolonged bed rest should be avoided. An early return to work should
be encouraged, even in the presence of some degree of residual pain.
Physiotherapy should be started after a week if symptoms are still marked.
In the majority of cases symptoms resolve completely over a 4--6-week
period. In a number of cases, however, symptoms become prolonged, with
the impatient Sllfferer often trying any of the large number of alternative
medicine t:rea1:n1ents now so widely available.
In chronic cases there is often a long history of intermittent low back
pain over a number of years. The cause is often obscure, although
degenerative changes in the spine are not uncommonly present. Resistance
to treatment is a frequent problem, and many are ultimately referred to pain
clinics. Sometimes a change of employment to work of a lighter character
may have to be coutemplated.
COCCYDYNIA
In patients with this complaint of pain in the coccygeal area there is often a
history of a fall in the seated position on to a hard surface; consequently, in
a number of cases radiographs may reveal a fracture of the end piece of the
sacrum, or show the coccyx to be subluxed into the anteverted position.
Symptoms of pain on sitting and defecation are often protracted for 6-12
months, but tend to resolve spontaneously. It was formerly thought that if
symptoms proved persistent either a disc lesion in the lumbar spine (with
distal referral) or a functional problem was likely to be the problem, but this
is now discounted.
In stubborn cases conservative treatment should invariably be first
employed: 60% of cases respond to local injections of steroids, BDd 8S% to
the injection of a long-acting local anaesthetic followed by manipulation. If
there is complete failure to respond to a substantial period of conservative
treatment (this occurs in about 20% of cases), excision of the coccyx is
reported as being successful in 80% of cases.
COMMONER CAUSES OF BACK COMPLAINTS IN

THE VARIOUS AGE GROUPS
<lrlldren Scoliosis
Spondylolisthesis
Pyogenic or tuberculous infections
Calv6's disease
Scbenermann's disease
Scoliosis [Idiopathic aDd postural)
Mecban;cal back pain
Adolescent intervertebral disc syndrome
Young adults Mechanical back pain
Prolapsed intervertebral disc
Spondylolisthesis
Spinal fracture
Ankylosing spondylitis
Coccydynia
Spinal stenosis
Middle-aged Mechanical back pain, including primary osteoarthritis
Prolapsed intervertebral disc
Scheuermann's disease aDd old fracture
Spondylolisthesis
Rheumatoid arthritis
Spirull stenosis
Paget's disease
Coccydynia
Spirull metastases
Pyogenic osteitis of the spine
Elderly Osteoarthritis, primary and secondary
True senile kyphosis
Osteoporosis, with or without fracture
Osteomalacia, with or without fracture
Spirull metastases
8.1. lmpacllun from thulct. (1 ): Ask the 8.2. lnspKtlon (JJ: It is valuable to know 8.3. IMpeetlon 131: Now aU: the patkm to
palieDt to stand. Look l l the &pinfl fmm 1he whether the lhoracic &pine is mobile, staDd upright 8Dd brace back the !houlden to
Bide. Allhough nm:mal poatme is difficult to especially if there is a kyphaaia. Ask the produce extmsion. An increaJed ClllVlllllre
define, try tu make liD UBC~sment of the patient tu bcmd forward, carefully examining (kyphosis) which is rcgaiar and mobile is
thoracic eurvalure, noting wlle1her the curve 1he flow of movemcDt in the &pine, 8Dd found. in postural kyphollis.
i1 quill!> regular and if it appears to be whether the CUl'VliiUre inc:reues. ~ 1he range
inl:reued. of :llcxicm. in the thoracic spine is small it may
abo help to check rotation, which is the main
DllJVeiJlCIIt occmting in the thoracic spiDe
(see l.att:r).
SA. Inspection (4): If a regular but fixed 8.5. Inspection (5): If there .is liD angular 1.6. Inspection (6): Nob:: 1he lumbar
k:yphotis is fooDd, the COIIIDIDDeSt causes are ll:yplio8ia, wilh a gibbas or promiDeDt cmval:u!e. FlalteDiDg or J:eVer88l of the DOrllllll
serdle kyphosis (aomelime8 wilh 011eop0t0sil, vertebral spine, the commoJIIllt causea are lumbar lordosi1 is a common liDdlDg in
osteomaI a cia O£ palholosical1'l:acbln:), fuK:ture (1ralmlalic or palhological). prolapacd intllrvertebral disc, Dtlleolll1hriti of
Sclleoermann's disease and ankylosing tuberculosis of the spine, or a congenital the spine, infcctiona of the vertebral bodies
spoadylitia. vertebral abnormality. and ankyi.Oiing spolldylitiJ. FlaiOD of the
spiDe, hipl and kneel (simian stance) is
saggedi.ve of spinal slmotlis.
8.7. Inspection (7): (A) An iDI:Rue in tile 1.1. ln..,.ctlon (81 From behind.· Note (A) a.t. lntpedlon (tJ: Note the preiC8Ile of
11111lber curvature may be DOl'IDI1 (e~pecially caf6..au-lalt spot~. wblcb. may sugeat any lateral CUIVIlU1'e (scolioail). The
in WOIDID) or be fouDd in uiOciadon with neuroli.bromatotlis and associaled scoliollill; comiDIBII'!It scoliolill ia a protective scoliosis,
the~ of the •pine or u llld the (B) a fat pad or hairy patch suggestive or or lilt, in the lumbar region acroudary to a
sacrum (B) in 8p011dylolitlllelil. It may be apina bifida; (C) seming auggea1ive or prolaplled ~brll dilc. Nofe whetller
ucondary to ID increued cboracic curvaiUre, previous tborarotomy (and ponible !he lb.ouJ.derl and hips are level
ar to :flexion defurmity or the bip(s). Always thorlwopnK: scoliosis) or apiDal!IWpi)'.
screen !Ht the hips.
a.10. Inspection (10): In OOIIIick:rillg other 8.11. lnspKtlon (11): If, on aiaing,llle 8.12. lnspKtlon (12): If !be curvaaurc
caJill5 of scolioaia, eumine the spiD8 with ICOliom penista, ask the palient to 1Hmd 1111D11iD.s, this ~~~SPits 1llat the scotm.is is
the palient llitli.q. Obllieration of aa forward. If the (:Q1'VC cliJappean, this IUJPtl ftud (1tructuraliCOliolil). If a rib INIIIIp ia
abnomlal curve ~R~g&CIU 1llat the scoliolia is 1bat i1 il qoite UlDbile and llllllt libly to be praent, this c:oufirma the clilglloliJ. Note
mobile llld may be ~to lllonenln& IX*Um1 in origin. lhoald be mde of itslleYCiity. (Go!Uomc:un
of a Ills- Cstainly tbD uext 1U1p to take ia to for meaaurlni the anaJe of the hump ..,
check..!~ the Jes lqth.l. available.) a-mber tba •yrinsomyelia ia
praent 111 tbout a quner or euc~ otjuva~&
idiopldlic IICOiiolia, ad aa MRI - ia
mmdatary.
1.13. lmPKtlon (13): In 1lle ease of 8.14. Inspection (14): Note 1hat in 8.15. PaiJNIIIon (1): Aak the patient to lean
lnfanlile sooll.osis, assess the rigidity of a idiopathic ICOliosis with double fixed forwant if possible. Look for tendemen: (A),
CUIV1IIure by noting any allmllti.ODJI aa the (primary) curves the defmmity may nat be betw=n the spines of the lumbar~
child is 1i&d by tbc armpits. ob\'ioua. There will, ~. be Bhortcning llll.d at the lumboiiiiCI'al junction (common in
of stalure, wi111 a tnlllk whieb iJ short in prol.apsed inll::rveltebtal disc, but 1hought
proporliaD to the Hmbs. (If delired, lhil may difficult to explain llll.d Ull1'61iable) and (B),
be ll&llllSIIIId usilli the anthmpornmric tables over 1lle lumbar muscles; Ibis iJ especially
of~ and Agostini, which give values lihly ID be £rnmd where these is prolective
for the ratio of sitting bc:ight to standiog muscle spasm in cues of PID and mechanical
bcight in each sex at diffi:ralt ~.) back pain.
I.16. Palpation (2): 1'1mderm!sss over 1lle 1.17. Plllpdan (J): With 1lle palitmt 1.1I. Pwcuulan: Ask the patimlt Ill bend
JaCl'Oiliac joints (C) may aiJo oocur in ease~~ standing, slide the finger~~ down the lumbar forward. Ligbtly percuss the spine in an
of mechllllicd back pain and in sacroiliac lpine on to tbc IIIICl1IIII. A palpable slll:p at 1lle orderly prog~essiml from the root of 1lle neck
joint infecdons. Re-eumlne with lhe palient lumbotactal. junction iJ a fealure of to lhe aacrum. Significant pain ia a fealure of
prone. Renal tenderness (D) ID.Wil be IIJKllldyloliathellill. Note any other curve tuberculDWI and other infeclioos, tnwma.
invesligmd fully. Look also for ~s mgularity (e.g. gibbus). Note also any (especially~) llll.d neoplaamB.
bi.ghe:r in the spine (E), e.g. from vatebral. clumge in fri.cGou (cme to altull:ions in Otherwise a Dllll'ked response may be a
body infccti0111. nveatiDg pattems), whic.h may help in the featme of a non-organWally baaed complaint
hxlalislllion of any pldbolo,gy.
a.11. rMnments: tlalon (1~ Alk the 1.20. MIMIIMIIts: llalon (2): Flexion may 1.21. Mowments: ftnlon (J): F1Woo may
patient to auempt to toueh hiJ tnCI 'll'hilc you be re<:orded in aev=-al way~, the (:OIIliiiOliCJt abo be rccordcd u: 'the patient flexes 10 that
waldl the spine dotcly for 1Ul0011mea1 al beillg lo note the didallioe betwee.D tbe ti.Dgcn tbe ~ reach mid-tibia', or IOIDC o1her
movement aad any lll'CU of rcstrlclioD. NC* and the groUDd, e.g. 'the patient flexes to appropriate leveL The majority of normal
the importam:e of hlp tle.xicm (A), wbicb Cllll. wilhin 10 em of the floor'. This is 1111 plllienb can IUCb the floor or within 7 em
acc.oant for appareut nw;Jti011. in a rigid liPiDe. indiclti on of the IWDIDlltion of thoracic, from it (Actual maximum raqe flexicm is
hmlblr and hip IIIOVaDCDtl; it docl DOt epproximatdy 4So 1llorlcic, (1)0 lmnbar.)
diltinguilh betweallhtm, aDd is undc:z Apin, CIU doe& not illdic:atc the relative
vohmlllry conlrol. ClOIIIrlbuliou of the hips llllli spine.
1.22. Mwn~•ntl: tlalon (4): Wla the I.2S. MIMIIMIIts: tlalon (5): In Schober'l 1.24. Mwn~•ntl: flalon (6): Anchor the
•pine a.-. the dilmm:e 'bet1mm eacll pair rrvl1tod a 10 em Jensth of 1mnbar apine is top of the tape wilh • Iinam llllli uk the
of vmtelmd spina hlaeuel. By meuurlng IIIIICl ... hue.. Glealrr acc:anq is c:1ailllllll ea ..
Jlllient to far forward u he CIIIL Nee
the spine when the patiall i1 CRd, llld then for the modfMd Schobn''l metllod (molt wbcl'e the 15 em madt slribl ~ tape llld
whca b=t foJwvcl, 111y pin is clat evicltA:e often IIIIICl in the UX), wbc:re a 15 em lalgth wuk out the iDcraDt:Dr. wllil:h is entilcly doc
of spinal flexioa. In pracUa! 1hi.a is IIIIICl molt of spiDe is mnpklyed. Begin by pa.itillllins a to lamb.- spine flmion. This is DOI1IIlllly
~yin aueuiDs 1110~ io the t11pe llllle8&llm with the 10 cmiii.IIU.I~ with about 6-7 em. Lea than 5 em is iDdicali"Ve
lumbar ipi.ae (where flexioa is palelt aad the dimpla of Venus (wbicb mark the of orpak qlinal padlololf.
pelbolo&y - COIDIDOII). pcllltezior IUpCricr iliac ipiDcs). MKk 1bc lkia
It 0 llld 15 em.
.J_---
I
I
I
~ ~ .../_ --
8.25. Morvements: tlexlon m Flexion in 8.H. Movements: alenslon: Ask the 8.27. MCMIIIIents: llter•l tlulon (1):
the thoracic spine may be meutm:d with the pll1:ieDt to m:b. ilia back, umtiDg bim by A* the patieDt to slide the hand8 down the
upper poiD130 em from the previou1 zero lteadying the pelvil and pulling back OD lite side of each leg in tum, and record lite poJnt
lllliik. Thmacic Jlexian ia not great. and ia llhouldm:. Pain is common in pml.apsed ~ either in centim.etxes from the liDO£,
normally in 1be Ol'der of 3 em. NB: to exclw.ie ~bral disc and in spoudylolysia. or the position that the :finps r=ch on
the pc811i.bility of overlay, repeat theBe ~lie lll!lellllleD.t with a gcmiometel is the iegJ.
mea8\lleDlelltJ widJ. the patieDt diltraeted, diflicult The maximum lhearetical nmge is
sitting up, ami l.eauiD8 furwlu:d 1111 the 1h.oJ:acic; 2S0 ; lumbar 35°; IIOIIIIaliDtal range
examina!ion couch. (N~ that abdominal about :w. The~ in distance between
girth may iDa:aJe aftu ost=porotic fractures Ll aud Sl on aleD&ion may abo be
of the lumbar spine.) measmed with a tape.
1.21. Monm1111ts: llltllnd tlafon (2): 8.29. M-•nts: rutlltlon: The patialt 8.30. Sas,.a.d prola,..cllnt.rwrwbn1l
Al1r:rnat:ivcly, meuure lite llllg1e formed llhoulcl be seated, and asked to twist rouad to cl1c Always start by ~ the bips.
between a line dnnm tl!mugh Tl, Sl and the each side. RDtalion is measured bttwean the Osteoarthritis of the hip and prolapsed
vertical. The averase range ia 30" to either plane of lhe sl:toulders ami lhe pelvia. The in~ disc are fequeully mnfused.. A
side, and 1hc contribations of the 1i1oracic and narmal. muimnm nmge is 40" and ia almost full nmge of rotation in the hips, PQ[ormcd at
lumbar spiDc are usually equal Clltirely thoracic. (Lumbar contributicm is 90" flexion (I) without pain at the extremes,
s• or less.) Some claim a mme aa:urate ia s-aJiy !llll'fu:ient to exclude o!IIDollr1britis
a~~~enment may be made if the test ia carried as a significant Callie fill: lhe patient's
out with the patient's amas folded ac:rou romplams, Nom llll1 if thlz ia complaint of
the cheat pain on flexing the hip with the knee flexed
(2) this negates a positive !ltnlight leg-raising
test, and suggests ostmarthrltis or overlay.
8.31. Suspedlcl pNIIIPMd 1....,_.....,.1 8.32. Strlllght leg raising (2): NO(e the UJ. Sftltht leg raising (J): Now lower
dltc: Sfraitht U&·railin& tut (1 ): If die hip1 reRI1t (e.g. SLR (R) +ve at 6QO or lltraigbt leg lhc le& UD1:Il pam diiiiPJICill (I); dieD
arc DOl'lllal, nile lhc leg from the coud1 raUblg (R) full (no pain)). Note the site of dorliflclt the foot (2). Thi• iDa'eaJes teDSion
while watcldng the paliem'l face.. Stop when pain: bad: pain mggellll a cmtral dUe 011 the nerve molll. generally 1188Il1Vllting my
the patieut ~laina. lllll con1inn that he is prolapte, leg pain a la=al protrusion. pain or paraelthelia ('+ve llciatic strdl:h
complaiDiDg ofblck Cll' lee pain lllld not DiJtin&uilh IUid igDare hamatriJig tighmeu. liCit' ). n:y this, 1114 recxmt tile rapcme.
hamatriag ~ (lhc lett i• Dq"llive if Repeat on lhc good aide. If well-leg raiJiD& Altematimy, once lhc lcvcl of pain has been
lhmll u no pam). The prodacti011 of produces pain BIJd plmlll!llbuia 011 the reached, ftiiX the lmee llliJhtly (3) IUid apply
paraathe.U. or ndiatiq root paiu Ia highly llfl'ec1m side, this is higbly suggestive of a finn JRIBUle with the tlmmb in the popliteal
ligui1icant, illdk:atiDg nave root i.rrillti011. llrge prolapse close to the ~. N011c Cblt foua ovu the ~ tibitl nave (4):
Pain from 51 geocnlly ocean befote that paill.lfllllt be below tlw bte~ if die root1 of l'*li&tilla plin md paraeaCbtaia mggellt nerve
fromU. 1he llciEc aerve 11n1 invoMd. root iirllalioa (bownrilll kd).
I.M. Stral1ht ... Nlslng (4): If there is

IOIDC doubt reprdiac lhc IOVUity Cll'
gcnninCDCM of the patlaat'l complaintl, uk
I.J5. 5tNIIht leg ,.Ising (5): Alnt'l tur:
Allematively, ult the patieDt lo lit with the
legl ovu lbe edge of the eumiaation c:oud1.
ue.
disc: functl-.1 _rt.,
Suspedlcl pNIIIPMd 1.......,.,...,.1
CDntlnued: (2)
Apply pretRR to lhc bead. (M:rlay il
him lo sit up UDdm: the pmm of a•mining Now tty 1D lift thllles until thlllmee il fully •uspted if this agravaJM 1he back pain. (3)
tbe b.:k from behiDd. (F1exioo of the spiDe eDeDded, and oote the r:apmue. Ifcxllmaiou PiDI:h the sldn. the aids. Snch ~
may allo be~ with the tape in lbiJ is lcllieved, this i5 eqaivaleut to a slraigbt let ttimvhdion lhould not produce~
poaition.) Tbe llllllDgcret will !lave 110 raiaiD& at 90", • IAiggeltl that thea: i1 DOt a blct p.uL (4) Any motor Cll' ICDICll')'
difJK:ulty, but lbe s-iDe pltUmt willlrilher 1CJDDd CJrP1E basil for my positiw IICmiPl diiCUdJuce llbould be Mlpnmtai ad
flex tbe kneea Cll' fall back 00 the coacb with leg tming obtaiJm wbr.n the pillilmt is localiJed. Widespread wakneu and/0!"
pain (jlJp IUt). supine. 1JtockiDi 1111atbeaia aJ.o Ageat OYerlay {bat
do ccy out a Cbarougb IICIJIOiogiclliDd
cin:ulalmy eumination).
8.37. Suspected prol•psecllntervertebral 8..31. SusiJKled prolapMd lnt.rwrt.bral 8..39. Rewrse Luegue IZI: 'Ihe pain
diK: fundi-!~ contd.: (5) Note elise: NVerse Luegue test (1): 'Ihe palieDt produced in such a test, if positive, i.J
the amow11 of rotation required to prodoce sllould be prone. Flc:ll: each knee in tum. TbiJ llllrlll&lly aggravared by exrenaion of the hip,
pain in the back. Now ask the palic:nt to k£ep gives rise to pain in the appropriate 111111. tbia should be notl!ld. Attmnpt this with
his hands fumly at his sides and repeat: the distribulicms (by s1Ieldrlng of femoral nmve the knee ll.exed to 90" (illummd.) 111111. also
major put af the movement will now tae mots) it& high lMmbar disc lesimu. fully flexed. High disc lcaions are rare
place in the lega. Pain. oc:eurring with the compared with dlose affecting the LS-Sl and
I8IDl!l IIIJlllllDt of lrJIPIIRDll rotali.on spin lA-LS ~ Note also lha1 pain in the
suggests ovc:rlay. rn many c:entreB. if three or iplil.ateral bultod or thigh on full bee
mme of 1lle preceding telllll are pollilive fiexion may a«:aa' in more distally llitaated
&utgQy is conaidered to be IXllltraindieat ltisc prolapses.
8.40. Suspected prol•pMCIInl:8rveiUbral 8A1. Suspected pralapud lntti1W1rt8bnl 8.4-l- Sulpilct8d prol•psad lnt8rwrtHNI
diK (2): Look for fur1llcr evidmcc of ciiJc (3): Similarly, S1 alone may be assigocd cll•c (4): Root presiUlC from a disc may
neurological involvement A reduced or to the antle jerk. Abse:nce of one or both affect myotome& aDd de:rmatl:Jmcs in a rather
absent laldon reJiex is a highly signiftc&Dl ankle jerks ill umally a sigDificant cliDical selective falhion (see Cb. 2 on segmental
finding accmnpanying positive I1Illight-leg finding, and does not occur in nonnaJ. innmval:ion). Note the pmsem:e of my Illl1lcle
raising ar pollitive ~ l..alegue telllll, but individu.ala below the a,e of 30. Unilat=al wasting. Ask the patient to dorJi.fl.ex both
in practice coafirmatory fiDdingJ of thiB absence may be found in the absence of feet Now attempt to force them into
nature may not be present. Allbough two pathology in 3-S'll> of individu.ala in the plaDtar:Dexion againat hi& reaidallOe (1.4,5).
spinal segments are involved in both the knee 40-60 age group, and in 7-10'1& of those
and ankle reJiexes, it is r;ommon pm:tk:e to over 80. Absence of both reflexes im:rease8
aase&B the integrity of L4 by Che presence of to 80'1& in those aged 90-100.
the bee jerk.
1.43. SIIIPHIN prol•pad lnt8rwrt8bl'lll 1.44. SuipKIH prol•pMd lnt.nrlebnl 1.45. 5ulpect8d prolaopud lntllrwrtllbMI
disc {5): Shift 1be grip to tbe pat toes and dllsc (0): Encircle the feet with the handJ and diK (7): Teat aenJation to pinprick in the
tellt 1be power of OOni1lexiaD. Repeat with tat lb.e power of the peronei agaillat the ckrmaiiJmel af the lower limb. Thlt pc:riDeal
the lcaiiCI' toes (IA,S). Not. dtat mt111J n1tml patieat's resiJI:ance (LS, Sl). Test the power ICliJIIiaD in sUipCCI:Cd ceD1:l'a1 diac prolapte.
wm.bw.u of dor.rij!Ddoft oftlv grut to. 4f tJ of the quadricept~ (1.3,4) when a Jrl8h dia: Dimlnulion of IICIIIIIIion Ill the Bide of the
1II08t leJUitive rut of1M L5 root aiolre, a root lesion ill .uspect=i. Nou r1uu prokmgt4 foot (Sl) is one of the (XJII!IIIQI!ett findina:s
wlae ~ il DO appropriate laldoD rdlex IIUUClt Weaknul will H ac~ by (lee lllo Ch. 2, SegmeDtl]. ad Pcriphc:ral
available for UIICUIIItllt Now at the power 11U16Clt wo.rting. Look. for tml cliaically, aad Nervet of the Umba). Note lllo 1llat ltockiDg
of plantarllexiuu of the pill aod lesaer toes if you IUIJM!Ct it compare !he girths of both aaeltholia may be Cmmd in diabetic
(51,2). lhealves. DflUI'D(IIIlby aod ~ vucalar diseue,
ad il DOl~ evideDc:e of I
IIOIIOrJIIlic probk:m.
U6. SIIIPHIN thortldc arc! 1.47. Su.,.aed 1homlc motGr root 1.41. Su.,.ctec~•nllylcNing spon..,.ltll:
co111pnul•n: ThiJ lDIIY be crudcJ.y u-IICd ct,sfunctktn: B«vor:J ri111: 'lbe patient il Cllect the patieat'1 cheat expaaaioa 11 lb.e
by tesdag tbe aMorrdnal rdle:xes. U1e a blunt alhd to plJcc IU haDds bchiDd his held, flex level af tbe fourth i.llr.c:rlpue. Tbc DllriDil
object md! u the lumdle of a teudon bmuner bia lmeea, and ail up. Movement of the niiiP ID m .mit of awose build il at least
to lltroke tbe s1:in in each paaumbilical akin umbiliCUA ID <me side (aod up or down) 6 em. Las than 2.5 em i1 regarded u hi.gbly
quadrant. Fa!JB of the Ulllbllials to twitd! in NJpatllbllt the abdomiDal m.aac:kl on dlat ~UJptive af ank.ylolillg spoadylitil. ID
tbe dim:tiol1 of the atimallfed quadnllt lidc ue 11DOppOICid. i.e. tbcre il weMDe&1 oa addition, look fer ~ of iritia, wllich is
IIJI8Pill amllOIIIplWiion oa t1ut lido at the tbe opposite aide. (See F'mme 8.46 for the oftm UID"i•ted with this comliliou.
appropiale 1om. (The !DIIIIdea d the upper te1eva !lllllde ~)This may mull
qaaclmnts are npp1ied by T7-10, llld die from IICn'e root OOIDP""'IIioo by Ill
]OWQ' by TlO-Ll.) olltcophytc, from a local lllmour,
poliomyelitis ar spinal dyanpbi1111.
lAt. SuspKtaod sacrall..c Joint 8.50. Suipedeci~R~m~~IIIM: Joint 8.51. AbclomiMI.amiMtfon: This is m
lnvalvament (11: Flex the hip aud knee aud lnwvlftlllent (2): N* wbether pain iJ essential part of the investigation of all cases
forcibly adduct the hip. Pain may accompany prod!Wild by pelvic COIIlpl1ISSi011 ar by ~ of back paiD. Rectal or vaginal examination
thil manoeuvre in early ank:yloaing to 'open 0111' the pelvis wilh the thumbs may be reqllin:d on 1lle iDdicaticm of the
spoudylitia, blben:ulollis and other .int'eclions, hooked I'OIIIId the anterior spines. history and my other elmnelnls in the Cllllfl.
and Reita's syndrome, but many &lse Altemativel.y, with 1lle patieDt in 1lle ptoDe The sscrococcypl. joint may be examined
polli1ives do oo;:w: with dli.s test. polli.1ion, phwe the side of ODD baud ovm: the by first graspiDg the coo:qx between the
SIICIUIIl aud IIppe£ llldDl. cleft; pre!IS down index (in 1lle rectum) and 1lle 1hmnb Oll18ide,
hard, Wling the other hand to assist. True and tllrA gendy moving the joint. In
1acroiliac paiD may oo;:w: in womea llhortl.y coc:cydyDia. ma.rlted pain normally
before and after cltildbjrtb, aa:ompanies this J:lllUIOeiMe.
I l
8.52. On:uldon: The peripbmal pulaea and 8.53. S.cllmentdon ate: Ea1imalion of
cin:u1ation should also be checbd in all the sedimr:nlalion ne is a valwlble screening
cues. Bd and leg pain caoaed by arterial test in the investigation of all spinal
instJftlciel1cy iJ uually aggravated by complaims. It iJ normal in prolapsed
aceivity, IUid ab~~~ma~ of fmmmll pubation ill intuvmtebrul disc, mechanical back pain,
of particular sipifu:ance. ll)linalaW!osis and Scbmermann's disease.
but e1ewted in ankylosing !lpOildylilis, many 8.54. Rlldlograplu 11): An anteropoeterior
illfec:lions aDd neoplasms. It is belt if 25 mm IUid l.aleml are the standard projeclicms for
ia taken 118 1lle upper Umit of JlOl1ll8l.. False both the lumbar aud thoracic Rpine. Localised
polli.tiws are not IIJICOIIlii10II but false view& of the lombolaaal junction are a ulleful
negati~s are rare. addition. 'lbiJ is a typical example of a
IIDI1IIllllatmal radiograph of the lumbar spine.
In filling oot the ~t card, if a RpeCifu:
area is UDder 8IUpicion state this if po1111'ble,
so that 1lle cen1ral ray of the projection can be
appmpriately positioned.
1.51. Radiographs (3): In the 1lllmal, nom 1.57. Racllofraphl (4): In tbe thonlcic
fiDt lbe lumbar c:urvc: (A) typieal normal; (B) spine DOte (A) a typh:aliiOllllll. curve; (B) an
loll of l.ordolli1 (most often seen iD. prolaplcd illcreued bat regular c:urve typical of seDile
iD1mwr1l!lnl diac as a reauh of protective qpbo1ia. ScbeUI!IliWID'a di•- ia aoothm
Jlllllcle IIJlUIII, but not amfirmatmy). fleqiMml c~~~~e of a regular dmsal. kyphoaill.
Xypbolis may be m.euarcd 011 the
t'ldioppba with the ~ for ulltUiag
11.55. Rlldlographl (2): Normal blaa1
ICOliOIIs (ICC 111m). 45° illllhn as tM IIPI'U
1llorade spine. limit fl/ NJmtGi.
1.51. Rlldlographs (5): In both the lumbar 1.59. Rlldlographs (6): Now look at the lAO. Radlogr.phl (7): Note (A) dlac
aDd the tboncic: apiDe DOte any llarp abape of !be bodie. aDd the size of the diaca. cak:ificalioa.; (B) the typical ~ of
alteration ill the curvUure (aqular kypboliJ), Compare with the bodiea aDd diac ·~ Scheuemlalm'• c!Ueue, with (C) qphOiis,
foulld typally Tdlete CIMR Ia pelbology above ad belaw. 'Ole followiDg ~ IIOllllll. (D) anterior wedglag of not lea lball so
n:alrlclcd to OIIC or two vcrtdinl boclb, e.g. lA the cblld'a ~ (A) alllCrloc cldll, (B) il1¥01v!Dc lllaat ~ JCqiJCIIdal w.:ndmle,
li:um frKiw-, TB or otbclr .iDfectioaa, antmior ooa:hes, (C) iDcomplete fuliCD of (E) raged appearaKe of!be epipby1ea. Note
Wmollr, Olteoporolis aDd oateomaiJcia with elemeall, (D) epipbyJea, (E) VUI:Uim" tiKb (F) a cadral diac baniJiliou (Sclanorl'a
l.ocll. "YCI1dnl body coillpae. (wbidl may pcmist). aodc); Ibis iJ DOt llwaya usociatcd with
~'adilcue.
1.61. bdlograplu (8): Note (A): diJc 8.62. Radlo. .phs (t): Note (A) inl:reased 8.63. bdlog111phs (10): Note the
narrowing at any 1evd in the spine ill the deusity and the ·~frame' appearanc:e of relatioD&bip of each vertebra to it8 neigbbolll.
earli.elt evidence of mlle:rallo!lis aDd otbcr 1fle vertebral bodies in Paget's diseaae; (B) In particular, note (A) spoadylolisdlelis (see
infections; (B) Nllll'OWillg 111 LS-Sl aDd, len r:narbd narrowing 8lld increa8ed deasity seen abo later); (B) retrospODdylolistbesis (usually
commool.y, in the two spaces above oa:un in in Calvi's dUease (vertebra plana); (C) any IIBIOI:iam:i with di~~e degeommon).
loug-.tanding dille lesioo.s aod is aflal llp'liJ;e-OO:Upying lesion in a vertebral body
usociated with anterior lipping. (usually due to 1umour or infection (but DOte
Schm.ol:l's nodes)); (D) comer vertdJraJ.
muaiom (RomanuslesiOD.ll), llellll in
llllkylosing spondylitis.
8.64. bdlograplui(11): Upping is seen in

chrtmK; diJc leainoa, mainly at LS-S1' but
also at the otbel- rarer disc prolapt!e si.t5.
Note (A) anterior 1ippiDg; (B) pos11:rior
UppiDg. Lipping ia alao 1fle main featme
(at 1111 levela) of ollteoarlhri1is. Note (C)
8.65. bdiogl'llphJ (12): Normal 8.16. bdlogl'llphs (13): Normal
~of spinous proc:esaes ('kissing
spines').
anmroposterior view of the lumbar spine. antmoposterior view of the thoracic spine.
8.67. Rlldlov,..phs 114): In 111e 1.68. Redlov,..phJ 11 SJ: Note a11o any 1.69. bcllogr•ph1(16): Note (A) lbo
anteropOsterior view note the pre1M111Ce of any anomaliel of the lumbosacrallll'lklulation, preMACe of any localiled lateral angulaliaD of
congeuiiBl ahnormalilie8, lid u (A) auch u (C) plll1lal sacralisation of the fifth the lpine due to lateral. vertebral collapse, e.g.
congeuiiBl vertebnl fusion, often uaociallcd lumbar v=ubra, a possible cause of low bad;: from fracture. infection, tumour, oa11:oporosis
with a coageuitaliiCOliolil; (B) aatc:lior apiDa pain. Note also (D) 1lle preaeuce of (portetior) or <Xhel' cauaea; (B) hcmiw:rtebrl, a common
biflda, in which there i1 failure of fullion of spina biflda. cause of COIIpllital~eoliolls (note tha1, u
the va'lllbnll body e1emmt1 (lbiJ iJ uaually ili\IJtl'llbld, this iJ umal.ly uiiCICimed with an
symptom me). extra rib).
1.70. Rlldlog...phl (17): Look at tile soft 1.71. Rlldlognpht (11): ll.xaD:IiDc tbe psoaa 1.72. bcllogr•phl (1t): Loot for lateral
tiuue lbadowJ at the lidel of lbo vertebrae, liwlowl for lymmelry. Lateral dilplacemcnt lippjn£, (A); at D12,..Ll it may be m cmly
~fur IIUIDple, the fulilorm of the edp of !he llhadow, aDd im:mual aitn of lllkyloling spcmdylitis, ba1 thrn lllld
inaeued dmlity typil:al. of a tuba'c:uloul dalsity within the main area oa:upied by elleWbere it uaually iDdicata oltlloaltbritis..
ablceu. Nolie dilc oblitcntioa aDd eaty piiOU, suggeata a peou ablccu, typically 'Bamboo IJ)iae' (B) iJ diqnc8tic of
lateral wedgia&. fualld in tuberc:ulolil of the llllllbu or lllkylotill( ipOIIdylitia. Note my body ud
w-mo.t l:luDcic spiDB. facet joiDt faaUma md lipnmlt c:ah:iiicDm.
8.73. Radlog111phs [20): Look at 1he 8.75. lbldiographs ~ Loot for evideoce
&aerolliac joints. (A) UDilalinl involvement of apcmdylolilthes!J. In tile DDI'IIllll lpine the
(aclemais. cystk changes or oblitlnlion) may pan interarlii:ularis (P) lying between (S) the
~in tabcrcalosiB aad other ~5. superior and (I} the~ ll'ticalar fac:d8 is
Any LIS}'IIllllctry llhoaJ.d be in~ by intact, and a vertical rai!led from 1he anterior
oblique prQjeclions and, if necemry, 1.74. lbldlographs (21): Noanal localbcd margin of the sacrum lillll in front of 1.5.
tomography or cr !IC8II8. Bilideml lm:ral view of the lumbosacral junction.
involvement (B) is COIDJlKIIl in ank.ylosing
spondylitis. and. sbould alway~ be II01Igbt
wbr.a tbis amdi.tion i.l aUBpeCIId
8.76. Radiographs (23): If 1.77. lbldiographs (24): Note that (S) DCW
apondyloli.lthellil is suspectl:d. tbc lm:ral bone formation (buttreuing), if prescm, may
ahould always be tabu with the patient make use of the anteriar edge of the IIIICI1IID.
standing. Note any dda:t (P) and any as a refmmce umeliable. Instead, note the
forward slip (U). The dc:fomlity may oo;ur rcl.atioJWiip betweeD the posterior edge of the
between L5 and Sl, and nmdlleu frequeDtly slippiDg vem:bra to the one below. The
between I.4ll15 or L31L4. example shows a forward slip of 259&. 1.18. lbldlographs (25): Normal oblique
view of 1he lumbosacral jlmclion.
8.79. "-dlov,..plu (26): Oblique vicwl are 1.10. Redlov,..plu 127): In 1.11. lldlog...phl(21): Wbcre spinal
invaluable, provided &bey are lllbn in the spollllylollstbe&ls (A) lhe 'dog' become& stenoliJ ia auspecll!d. cak:olate the
pllme of any dmct. In intezpreliDg tbele, decapitated owins: 1D forwml. slip. and the cmaliD body Illlio, AxB:CxD, whee
identify the 'Sootty dog' Wdows (lhown inferior lll1icular process of the vertebra A • inCerpedicular dilltaDQe, B • spinal canal
dark: grey aDd balcbed). 1be IIOtC (N) u above eacroacbea oa the neck. In froot-ID-bact (mcutued to the root of the
formed by 1 trllllvene proc:ea1; 1be Nr (S) by apollllylolysl&. where 110 slip hu OllCID'l'ed, the spinou1 proceu), C = width of venebra1
a aupmior llrtic:ulu proceu; the front less (I) neck (B) it el.OII(IIIIed or (C) develops a body, D = body, front-to-bad. The DDIIIIlll
by an iDferior uticubr proc:e11; lhe neck (P) collar.cr IICaii8 em also be of value r1IIIF II from ~y I :2-1:4.5.
by tbe pan: in~f. provided the so-Q)led gmlry lllglc of the Vlluel ~ ltwl4.5 IUggeat spinll
projccliOD U at rigJit aogk:1 to tbe ~ of lteuoliJ, but cr ICIIIA are of particular value
1be table. in clari.fyi.Da the lite md exii!Dt of my
naoow~nr.
1.12. Redlov....-129): Note the JRICIII:C a.u. "-dlog...plu (30): To - the 1.14. bdlogr•phs (S1): Now lftlll
of any l1nll:turlll. scoliom. 1bi1 i.a uaociall!d 1eVerity of a scoliotk: c:urw, aDd to allow ita pspeadiculan from the vmtllbrae llmt form
with rotation of the vatebral apinel towanls proglell to be monitored it ia ue<:easary to the limita of the curve (marbd 'X'). Note the
tbe com:avity (A), aDd IWIOWin& al pedlclca. meuure the defoanil:y. 1be Cobb mecbod u q1e betwee:D tbtm. Tbi.a is 1 mcu~ af the
On lhe convcdty of lhe C1liW there Ia lniMt popalat, althougb h ia diflicult to obb.in primary curve, llld can be uecd for
wideaiJI8 of diM: lplall (B). In the tbcnl: amsi.atlllllllllllltl with it. Finl. fiDd. the upper co.mpaiJon with put llld fulm1l ndHJsnplm.
tbtre ia riJx:aae distortioa (C).Ideutily the aDd Jov;oer 1imitJ of the primary curve by Xypbatk: ~may be meulnd in a
primKy euna clinically, or by INCI&ia& dmrillg ta&enta eo tbe bodiea llld DOCillc lllmilar way. Any dccUioo JeCwdiDg
~~ of IDOYCIDCilt in llla'll fiQioo 1i'hcle the dilc ~ 1qin to widen 011 thc ll'CibllCilt _ , 1llkc inlo Kallllll the clinical
ndioppla. OOIICIIYity of the curw. piclm1l. aad DOt rely 011 the radiographs alone.
S=4a
8.86. ~lng ........ maturity (1): 8.87. Als-lng sua.tal maturity (:Z):
1.85. Radlogr11phs (32): Capasao's metbod R4 = up to the wbolc of the apophyJis is
Sc:oliolic curvea detericmde with growth. and
of measmiDg scoliolic curves is said to be Ollified. R5 = tbe apophylis has fused and all
11m prognosis is oflml dcpeDdmt on bow
~~~CJm senailive aDd liCCUillte. The IDJ1811illlde
much more the cbWI has CO grow. This may growth has ccued. ln girla, Risser I aDd 5
of the scoliotic ClllVC (S) in degrees is
be judged by examining appropriate cmnmonly occur Ill ages 13~ and 15~. and
obtaiDed by multiplying by 4 1lle angle (a) in boys at 15X aDd 17~. It hu been fouruJ
radiopllphl aDd asseslliq sexual Dllllurity.
subleDded by a line joining the ends of the that those having 5-19" or 20-29" c:mves at
Ri$&er grw1ing Df $Ulet1Jlllllltrnity useR
curves, with one I1llllling from the cen1Ie of Ris!ICl' 0 or I haYe respectively 22% and 68'l&
radiographs of the iliac aest aDd its
11m c:urve to one end of the cun>e: i.e. S = 4a. apophylis (which Mllifte& from in front cham:es of dMmionding 6° or more; 'While
Again, note 111at in any case of SUJpcctcd those at Risser 2-4 in 11m N~De range had
backwmdl). RO = the ollifu:a1ion amlre baa
idiopathic IICOliolli1 an MRI sc:an is lDIIDdatmy
not appeared; Rl =up to 2S'Jo i1 present; oaly a Ui'l& md 2391. chance of de1l:riorating
to exclude ayringom)'l'lia, which is said to tbe same 8Dl01JII1
occur in 2S'A> of cues.
R2 = up to SO% is pment; R3 = up to 7S'Jo
il pteSeDt.
Assessing skeletal maturity (4}: Tanner staging.

BOVS GIRLS
Stliga Pubic hair Penis/lastal Pubk: hlllr BNUts
Prepuberty 1 None Small None None

Puberty 2 Scanty/slight Slightly Sparse, Iightly Small mound
pigment enlarged pigmented
Puberty 3 Darker, starting Longer, larger Darker, starting to Breast and
to curl curl areela enlarged
Adolescence 4 Resembles adult. Larger g Iansl Coarse and Areola forms
but less quantity dark scrotum abundant secondary
mound
Adolescence 5 Adult. spread to Adult size Feminine t~angle; Mature
thigh spread to thighs
8.88. Asaulngsbllltlll m..ulltJ (3t. AB
The Tanner staging of sexual development is used along with radiographic evidence to help
lbc fiDal. growth spurt is well advanced before
assess a patient's remaining growth potential. (The radiographic evidence normally includes
Rl, a .IDCIIIlll of earlier staging is desirable, the Risser grading. and assessment of the olecranon epiphysis. In some centres the stage of
This may be IIChilwed by examining
ossification of the epiphyses of the metacarpals and phalanges Is analysed. Note also that
murlfu:lllion of lbc olemmon epiphysis. Prom
the trl-radlate epiphysis of the pelvis normally fuses at the same time as the olecranon
its first appearance to fusion occurs over 6 epiphysis becomes rectangular in shape. usually at age 12 in girls and at 14 in boys.)
111011thly stages between 1lle ages of 11 and
13 in girla, aDd 13 and 15 in boy&. 1 =
~of two ceulnl&; 2 = the epiphysis
bec:omea half moon Rhaped; 3 = the epiphysi1
beoouu::s llqiUile llhaped; 4 = partial Wlion;
5 = complete Wlion.
l.to. Other lnwstlglltlansln suspect.d 4. M~oppby emic8 a bigh riJk of

PID: c:omplieatiou, but may be required when
1. Plain !'lldiognphs of lhe lUIIIbv spine md !be cr IICm iJ imxmclusive and MRI
lumbow:ml jaaction ICldom bavc mach IKlllllliag ia oot JIOim'ble; it ia invaluable in
to offm- in amfimring !be pn~.-ce or clemoDitratiDa 1il1iq ddeett in 1he
othawise of a pm1apsed ~bral ~ of 1he coal or cauda eqaiDa, or
c1iJc. but are uRful in eliminatina otber: of 1he root tlccvea.
palholo&Y. S. Sinp pbofo emisai<m compulllr
2. A cr acan u .em a good~ for IDIDDJliPby (SPHCT) IJCIDIIiDg it ueN1
clmuoosttKing the lim ad kx:aliaa of a for dellecliD& <*Oblutic acaYity. It iJ
diJc hemia. ~ ~ tblt tile L2IL3 hJ&I!ly ~ with low apcciflclty. Il iJ
diJc doet 110t lbow on 1he allmdmi IICaD. lllll!ful foc ~ out degmsalive
wllich ia geared to lhow IAILS IDd LSI m- or bony me1»1a1e1. Wbel'e
Sl, ll.lld that • negative cr IICIID ia of Iss multiple pathology Ui prc:acat, it may be
va]Qe in eliminating 1he preseDQe of belpful in idcl!.tifying 1he OliC rc:aponaiblc
rdevllll palhology thm a Deplivc MRI for pain.
acan; 1hc:rd"ore, if 1herc Ui llroDg cliaicll 6. DiJcoaraphy involves the injedion, under
evidmlce of a diiiC pmlapae md the cr lliiOlOIICOPY CODirol, of ccmlrUt m=di.um
IICIII1 ia negative, an MRI IIC.IIIl llhould be iDfo 1he diiiC 1IJider pre:lllll!'e, in ID attempt
carried oat. ID mimic the tdJecta of prollmpd llmlllias
3. An MRI ICliD lw 1he po1II:Gtial for or lilting. Su~t iiiiOIOIICOp)' m CT
supplying the most infmmalion about !be IICII!IIi.Di may ~ fissuring of lhe disc
8.8SI. Rib •ngle •IMIIIMIIII In ilifrmtile inlmvertebral di.Jcs aod the lllliiiVII roolll. or leakqe of 1he medium. lloweva', the
.rcoli<nir note lhe di8'ereDile in db analelat Note, ~. thai: the potential for Dlae paticm'l pain rc.pollle iJ lhe most
1he apex of lhe wrve by 1he abown negali'la in MRIIICIIIIJ in cue• of important finding, While lhe msul.ts of
COilltruetion. A cliff= of '1JJ" or more auapecred PID i1 of the order of l()llf,, lllld diJcoaraPhY alone may not be particularly
IDU8t be regilded u .illdicltllll a potaltillly that in about a third 1he lindinp IIRI not helpt\11. the proc:cdure may be UJdul in
progreuive scolloait. AD inrptovei:Dmlt aver a compaDhle with the clinical picture. clculy ida1lifying tile IOU1'Ile of a
3-mmdb period curies a good popoais Wbe:e lllrJCI"Y or dlemolmcleolil is beiDa patient's pain.
(Mehla). The bell proauom in infmt& plmned for a diac pmlapae, an MRIIICIID
scoliolia iJ in lllllu wbcre 1he oa.et occun in sbould be CllTied out to CODIIrm the size
1he lint year of life ll.lld lhe rib-vertebral ll.lld locatirm of lhe pmbU!m.
aap diffinoc:e (RVAD) is lelslblll 'l/Y'.
1.91. Spln•l Ndlognlphs: 11*1•1 r.turea: 'lbele tiDee radioppbJ demoutrate aoteriar 1.92. Spln•l Ndlogn1phs: -mpla of
cldll, antaioc D.Otda, epiphya tad vucular tracb - notmal fealurc:a of 1llc growiJig 1piac. p.thalogr(1): Tbe radiograph !bows
uaaowiJ11 of a ainp dia: spue..
.,.....: in thit cue the diagnolia wu of
tllberc:alolia of the lpiDe. In molt cuea of
spiDal infecti0111 lots of dilc belsbt is the
ealielt lip.
8.13. Patholol)' (2): The wrtebral bodies 8.514. hthoiOI)' (J): ln lbiJ radiograph of a 8.t5. P..hOIOIJ (4): Tbc.t'e is an angular
throughout the thoracic IUI.d lumbar spiDe are girl of 10 there is compleec fiatt=iDg of a kyphosis, with an1lerior wedgiDg of D9.
fuiCd, with early bambooiDg of the spine. The lhlgle vertebral body, with preservalion of the Diapolll: patbologWal. fractu1e IIIIOC.ialed
fK« jointa md the aacmiliac joints are alllo dille spaces above md below. witb oll1eomalacia. Similar appeiiilllll:el are
fused. Tbc.t'e is ~on of the inla'Bpinous Diqnom: vcrtm-a plana (Cal~'s disease) found in tbe ~ of spinal IIIdaBiue8.
ligaments. due to eos.iDophilic granuloma. Noll: also the
Diaposll: llllk:yl.olillg spondylitis. vertdmll D.Otdlel.
8.97, PathalagJ (61: There i1 a regular k:yphoBia, with slight

IIDimior wed8ing of the vertebnl. bodies, inegularity of the di~e
margins and ~ disc bcmildion (Sc:bmorl's nodes).
DiagJlolll: the appearancea are typical of Scheuer.maJm's di&eue.
Clinical.J.y the typhosia wu obvious, and spinallllOVeiileiits were
patly redu=l...
LN. PathoiOIJ (5): The ndi.ograph &bows a thoracic scoliosia,
convex to lbe patient's right. Tbc.t'e is ~bral rotation and
uymmetry of the rib cage.
Diapolll: idiopadlic BCOliosia, with fixed primary 1llmacic curve.
1M CLINICAL OR'IHOPAEDIC EXAMINATION
..,.. Pathology (7): The ndlogmph is of B.ft. Pdlology (B): The lateral radiographs show that thm:e is forward slip of LS on Sl of a
an 8-year-old boy complaiDiD,c of blllk ptia, little less than 25~. There is an UIOCialied dmct in the plll'l interarticalari1 of LS. In the
malaise, night twelh, 1011 of aplaal oblique projection the 'Scotty dog' hu be= decapilated 'lbe patialt compl.ainiCd of low bact
~. ad pain on percusaion over the and buttack paiD.
spiuc. 'I'bere is loss o( a dis<: sp:e, ll1i.sbt Diapalil: long-standing apaodylolidhelis ofLS 011. Sl.
vertebral wedgiag, I.Dd a fllaiform llb~Cal
abadow on both aid.ea of t1x: lpine.
Diapom: the appaumcea are typical of
tu~ o(the spine.
L 100. P.ebalogy (9): 'l1lllre is ~ dlmsity of the bony 1.101. Pdtology (101: Thia is the tnyelopam of a pitieat
ahadowa in the rep of the right aiiCIOi!W: joint, whose outline has complliniag of blllk and rlallt leg pain. 'lbel'e wu wealmeu of
beQ)me obiiCQI'ed. There wu usociallccllcx:al paiD, malaise I.Dd doraifiQion aDd cvcnion of tbc dgbt foot, and tbcre wall IOII.IC
pyMiia. Attempt~ to ~priDe 1lle 1aaoiliac joilltl prodaccd great pain. lmiiOl)' impllinnlmt over lbe Iatini upec:t of the calf. The
Diapom: 'lbe ~·are typical of • infective (pyopoic) myelogrun ~ a well detiDecl iodentltlon of the coatrut medium
artluilis of the uaoiliac joint It the I..AIS ~
Diapella: prolapecd iDtcr.~Uidllal diec. Al opcratioo tbc LS root
wa fo.i lltretdllld over the probpe.
8.102. Pllthology (11): 1bere u 8.10S. PathologJ {12): 'Ihrze iuwrowing 1.1 04. Pathology (1S): 'Ihrze i.J alritiDg
calcificalion in an inlmvllrtebnl diac with no of the LS-SI diac IIJIIWI'> with aDtmior liwini al.lmlllion of 1xme texlunl ~ a 11iniJe
lignificant narmwing of !be cmm~ponding of the conespouding vertebre. ~bra.
disc space. Dlapao&ls: lllc appeara~~CCS ~ typk:al of Dlapao&ls: lllis 'picture frame' appearance iJ
Dlaposil: Tbia i.J an inc.ideataJ. fllldiDs, and degenerative disc disease and lumbosacral typk:al of Paget's disease. At 1llis Bite 1hcre
i1 of liD particular sigaificiiiiCe Ill II CIIWI8 of -~-~-
0--LWIWI. would DDt llllCellllllrily be any II8IOCiated
low bad: pain. symptom&.
8.105. PathologJ (14): There is a traallilioaal vertdn, with 1lle traasvene process 011 one
aide 8Iticulalillg wilh botb 1he sacrum and ilium.
Diquusia: ~tal abnmmality of lumboiiiiClllliiiiK:uiJdiDD. 801118 COII&idl!r dllll: 1llis pattem
of spinal mmnaly, because it pnxloce.& an asymmetrical distribution of local sll'e8~e~~, may be a
CII1JJe of back pain.
L 101. PMhalotJ (1 5}: The radiographs 8.107. PMhoiOIJ (16}: Tb8 apinou pmc:eu
show a regular donal typwm assoeiall=d of LS (and lea• obvioullly Sl), aloug with
widl anterior vcztclnllipping lllld a degree of IIIIOciated po8lerior cleme.nta. II abient
olteopOroliJ. Diapolll: apiDa bi1lda occalllL Tb8 only
D~ap.Dm: -we kyphom. di.sturbmce noted in the lows: limbs was a
bilaleral peJ cavu1.
1.101. ,.thololf (1 7): Tb.e radiograpbl

&bowl a donaliiCOliollia aaociated widlm 8.10f. P..hOIOIJJ (11): 1be an"OW iDierted in tbiJ CT
IIDCIIIIaly of a vertebral body IIDd an ama rib lleanilbowS ID abuomJ.a1 ~t OD the spinal
em tbe coovexity of the carve. canal
Diapelll: bemivertebn. and ltrwdural Diapllil: true u aleft-lided iDiilnwtebnl cliJC
IICOliOiis. pro)aple (IIOfe tbe orlmla!ioD to the Dgbt of the
illU&trltioo), wi1h distmtim of tbe tbecalllhldow. It wu
..ac:illed widlleft.tided ll:ildc lympUII!II.
9
Developmental dislocation of the hip
(DDI-0 170
DDH in 1he older child 171
DDH in1headult 171
The dysplastic hip 172
The irritable hip 172
Transient synOIIitis 172
Perthes' disease 173
Tuberwlosis 174
Acute pyogenic arthritis of
the hip 174
Slipped femoral epiphysis 174
Primary osteoarthritis of the hip 175
Secondary osteoarthritis of
the hip 175
Other conditions affecting
the hip 175
Conditions associated with total hip
joint replacement 176
Assessment of hip, knee and lower
limb function 178
Inspection 182
Leg shortening 182-186
Palpation 186
M<Wements 187-191
Patrick's test 188
Trendelenburg's test 191
Testing the gluteal musdes 192
Aspiration ofthe hip 192
Ortolani's test 192
Barlow's test 193
Radiographs of the neonate 193
DDH in 1he older child 193-194
Radiographs 194--200
DOH 194
Perthes' disease 196-198
Slipped femoral epiphysis 198
Nter total hlp replacement 200
Pathology 201-204
DEVELOPMENTAL DISLOCATION OF THE HIP (DDH)
This condition occurs in the perinatal period and involves displ~t of

the femoral head relative to the acetabulum; if unueatcd it disrupts the
normal development of the hip joint which in the long term may lead to
joint dysplasia, subluxation with gait disturbance, avascu.Jar necrosis, and
ostcoartbritis. 'I'he term 'congemtal dislocation of the hip' (CDH), uow less
frequently used. is for the main part virtually synonymous. Note. howevl:l',
that the contraction "DOH' may be somewhat confusingly used for
'developmental dysplasia of the hip'.
The term 'neonabll instability of the hip' (NIH) is of particular value as it
is clearly defined: it describes a condition in which the hip is dislncat.ed,
able to be dislocated, or is unstable al examination during the first 5 days
after delivery. Similarly, 'late-diagnosed DDH' is used to describe a
dislocated or dislocatable hip diagnosed aftm- the age of 1 week.
The condition is much more common in girls than in boys (80%) and in
the first born; there is a familial tendency, and an increased frequency in
those suffering from Down's syndrome; and there is a weD established
geographical distribution of the disorder. It is commoner after breech
presentations, and it may occur in c~unction with other congenital defects.
A simple test devised by Ortolani in the 1960s was found to show
instability in the hips of some newborn children. and it was thought that this
instability was directly related in every case to congenital dislocation of the
hip. As a result, it Wall considered that if all newborns could be screened
with this test, and treated promptly if instability were found, that the
condition would no longer pose a problem. Unfortunately, later experience
showed that a number of clrlldren who had pasaed the screening test went on
to develop hip dislocations. It also became clear that some Ull8table hips
could resolve without tteatmellt; and that treatment itself (in an abduction
splint) Wall not free from oomplicationa (about 10% developing avucular
necrosis). When ultrasound scmming is added to tbe clinical examination,
there is a dramatic increase in the number of positive results, most of which
resolve without treatment.
To accommodate these confusing facts, a number of regimen& have been
developed. One typical example recommends the following:
1. All children should be examined during tbe fint 3 months of life on al
leut two occasions, by those expert in the performance of the screening
tests.
2. If the child is in a high-risk group (breech presentation, family history
of DOH, clicking hip, the presence of other deformities etc.), then
ultrasound screening should be added. If some doubt remains, the hips
should be X-rayed at ~ mo:nths. (Note that X-ray e,nminalion of
the hips is not of much diagnostic value at birth (owing to skeletal
immaturity), but can be helpful by about 3-4 months.) If still negative,
the hips should be re-examined clinically at 6 months and when weight-
bearing commences.
3. If the hip is clearly dislocated, then splintage should be commenced
immediately.
4. If the hip is not dislocated, but can be dislocated (Barlow's test), it
should be re-exami.nfd at weekly intervals foe 3 weeks. If instability
remains, then some recommend that splintage (in abduction) should then
THEHIP 171
be commenced, although others prefer to have both X-ray and ultrasound

confirmation. There are a number of splints available for the trealment of
DOH (Malmi;, van Rosen, Barlow, Pavlik harness, frog pattern plaster
cast etc.), and whatever is used it is continued until the hip becomes
stable (often by about 12 weeks).
Note that in an increasing number of centtes ultrasound screening is
performed routinely. With this there is a predictable rise in false positives
which are weeded out during routine after-care surveillance. It has been
shown that this can sigDificantly reduce the need for subsequent surgical
procedures, hospitalisation and late presenting cases.
DDH IN THE OLDER CHILD

This must be suspected in any child where there is disturbance of gait or
posture, shortening of a limb, or indeed any complaint in which the hip
might be implicated. If dislocation of the hip is diagnosed late, treatment is
aimed at restoring the hip to as near normal as possible. Each case must be
assessed on its own merits, but the general principles of treatment are
common to all:
1. The head of the femur must be reduced into the acetabulum. This may be
possible by manipulation alone, with or without a preliminary period of
traction (to bring the femoral head down to the level of the acetabulum).
An MRI scan can provide important information regarding any tissue that
bas the potential to prevent the femoral head from entering the socket
(such as adhesion of the joint capsule to the ilium, an inverted limbus
(the thickened acetabular labrum) or a displaced transverse ligament),
and be a guide regarding the necessity for open reduction.
2. Once the hip has been reduced, the position must be maintained until
stability is achieved; and from an early stage as much movement as
possible should be allowed, to encourage concentric development of the
head of the femur and the acetabulum. A popular method is to hold the
hip in internal rotation by the application of a Batchelor plaster; this
permits movements of the hip in other planes. Such a plaster is usually
retained for about 12 weeks.
3. In a very high percentage of cases there is an associated anteversion
deformity of the femoral neck To help retain the femoral head in the
acetabulum and encourage concentric development, this is often corrected
surgically by a rotational osteotomy of the proximal femur, performed at
the end of the period of plaster fixation.
4. If the acetabular roof fails to develop properly and remains shallow
(acetabular dysplasia), so that the femoral head is poorly contained
(predisposing the joint to secondary osteoarthritic change), a Salter
osteotomy of the pelvis may be advised.
DDH IN THE ADULT

Where trealment in childhood bas been unsuccessful, or even where the
condition has not been diagnosed, a patient may seek help during the third
and fowth decades of life. Symptoms may arise from the hips or the spine.
In the hips, secondary arthritic changes occur in the false joint that may
form between the dislocated femoral head and the ilium with which it comes
in contact In the spine, osteoarthritic changes Bie a result of long-standing
scoliosis (in the unilateral case), increased lumbar lordosis (in both unilateral
and bilateral cases). or excessive spinal movements that occur in waJking.
In a few cases hip replacement surgery may be considered, otherwise the
treatment follows the lines for the conservative m.anagement of osteoarthritis
of the hips and spine.
THE DYSPLASTIC HIP

Hip dysplasia is a condition in which the principal feature is that the femoral
head is imperfectly oontained by the acetabulum. The slope of the
acetabulum is frequently greater than nonnal, and it may be relatively small
in comparison with the femmal head. In early life this may be a major factor
in developmental dislocation of the hip, but if the hip does not dislocate it
may nevertheless give trouble later in life. In the dysplastic hip the central
area only of the femoral head lrllnsmits the forces of weightbearing to the
acetabulum, increasing the joint loadings and predisposing the hip to
osteoarthritis and in some cases instability. The symptoms are those of
osteoartbritis of the hip, and they may present during the ac:cond and third
decades of life. Rapid deterioration is the rule. In the younger patient a
Chiari osteotomy of the pelvis, an acetabular sbelf operation or a high
femoral osteotomy may improve the cont:ainmcnt of the femma1. head,
relieve symptoiDli and slow the onset of osteoarthritis. In the older patient,
replacement arthroplasty may be considered.
THE IRRITABLE HIP

In childhood there are a nmnber of conditions affecting the hip which may
be i.ndistinguisbable in their initial stages. They all give rise to a limp.
restriction of movements, and sometimes pain in the joint (ilritable hip).
Children with this history are admitted routinely and treated by light traction
until a firm diagnosis has been made. The commonest conditions responsible
for ilritable hip are transient synovitis, Perthes' disease and tuberculosis
of the hip.
TRANSIENT SYNOVITIS
This is the commonest cause of 1he irritable hip syndrome. The child
presents with a limp, and there is sometimes a history of preceding minor
trauma which in some cases at least is coincidental. Raised interferon levels
have been found. which suggests that a viral synovitis may often be the
cause. There is restriction of extension and internal rotation in the affected
joint, but there is no systemic upset and the sedimentation rate is generally
normal. Radiographs of the hip sometimes give confirmatory evidence of
synovitis, u does ult:ruound examination, but no other pathology is usually
demonstrable. Aspiration and cultuM of synovialftuid (which is not
1'0\ltinely performed) geoerally fail to provide any evidence of bacterial
infection. A full recovery after 3-6 weeks' bed rest is the rule. In a number
of cases that have been slow to respond there have been positive faecal
cultures of Campylobacter, and it is advised that this examination be
perfmmed routinely.
THEHIP 173
PERTHES' DISEASE
In this condition there is a disturbance of the blood supply to the epiphysis
of the femoral head, so that a variably sized portion undergoes a form of
avascular necrosis. The cause is unknown. It is five limes commoner in boys
than in girls, and in 12% of cases it is bilateral: and whc:n both hips are
affected they may be involved simultaneously or with an interval between
them. It commonly presents between the ages of 4 and 6, and there is an
association with anteversion of the femoral neck.
It usually presents with a limp, frequently accompanied by complaint of
vague pains in the region of the hips, thighs or knees. Oinically, Perthes'
disease may be suspected by the history, the child's age and sex, and by the
restriction of rotation in the affected hip. As a rule, radiological changes are
well established by the lime the child presents with symptoms, and these
will confirm the diagnosis. (IDtrasound exam;nation shows capsular
distension due to synovial thickening, with both hips being generally
affected at the earliest stages (as opposed to the findings in transient
synovitis).) A pattern where the age of onset is very late (i.e. over 12) has
been described and is noted for its poorer prognosis.
The severity of the condition is dependent on the age of onset and the
position and extent of the area of the femoral head involved. When a large
part of the epiphysis is affected, the:re is a tendency to :llattening and lateral
subluxation of the fumora1 head; these changes are mirrored by the
acetabulum, and the resultant deformity predisposes the hip to osteoarthritis
later in life. If there is some doubt regarding the extem of these changes,
an MRI scan will allow an accurate assessment Thereafter, as a guide to
management and prognosis, the investigative findings are used in an
attempt to grade the severity of the case and form a prognosis. This can
be difficult in practice, and the results not always consistent Systems for
the classification of cases of Perthes' disease have been devised by
Catterall (Frames 9.86--9.87), Stulberg et al.! Salter-Thompson and
Hening (Frame 9.91), and all have their advocates. Most recently a
radiological index has been proposed by Nelson et al. (Frame 9.92) to
grade these cases.
Half of all cases of Perthes' disease do well irrespective of any treatment,
and this is especially the case in the younger age groups (i.e. under 6).
Cases which have their onset in the older child, particularly over the age of
9, generally do badly. The long-term results are dependent on the growth of
the femoral head, and it is unfortunately the case that treatment has not been
shown to materially affect this, or to in:lluence the ultimate outcome.
Nevertheless the aims of treatment can be clearly summarised as the relief
of symptoms, the containment of the femoral head, and the restoration of
movements. It is accepted that in all cases the acute symptoms of pain and
severe restriction of movements should be treated by bed rest and traction,
followed by physiotherapy. In mild cases, where the prognosis by grading is
judged to be good. no further treatment (apart from prolonged observation)
is generally advocated, although some prescribe weight-relieving measures
for 11. further period of some months kl reduce the chances of weight-bearing
stresses leading to further deformation of the femoral head. The results of
intervention in those cases judged to carry a poor prognosis are perllaps less
clear. The lines of 1reatment frequently advocated aim at improving the
congruity of the femoral head and acetabulum, and improving the effective
range of movements in tbe hip (e.g. by a varus osteotomy of 1he femoral

neck, or a Salter innominate osteotomy).
TUBERCULOSIS
Tuberculosis of the hip remains rare in the UK. 1bc affected child walks
with a limp and often compJains of pain in the groin or knee. Night pain is a
feature. Hip rotation becomes limited. a fixed flexion deformity develops
and muscle wasting occurs. Radiographs of tbe hip in the early stages show
rarefaction of bone in the region of the hip and widening of the joint space.
As the disease advances there is progressive joint destruction, with abscess
formation and sometimes dislocation. The diagnosis is usually coDfirmed by
histological and bacteriological examination of synovial biopsy specimens,
or by bacteriological examination of the aspirate.
In early cases complete resolution may be hoped for by antituberculous
therapy, bed rest and traction. In the advanced case, joint debridement is
canied out with efforts to obtain a bony fusion of the joint.
ACUTE PYOGENIC ARTHRITIS OF THE HIP

Staphylococcus is the organism most frequently responsible for acute
infections in the hip joint. The infection is blood-borne and the diagnosis
seldom difficult. The onset is rapid, with high fever and toxaemia. All
movements of the hip are severely impaired and accompanied by great pain
and protective muscle spasm. The most important diagnostic features
distinguishing it from synovitis are fever and elevation of tbe ESR and
C-reactive protein.
The mganism responsible may be isolated by blood culture or joint
aspiration. Treatment is by use of the appropriate antt'biotica in doses large
enough to obtain high local coocentrations. Bed rest and immobilisati.on are
also essential.
SLIPPED FEMORAL EPIPHYSIS

This is a disease of adolescence and is commoner in boys than in girls. The
attachment of the femoral epiphysis to the femoral neck loosens, so that the
head appears to slide downwards on tbe femoral neck, giving rise eventually
to a coxa vara deformity of tbe hip. The cause is unknown. In a number of
cases there is a history of prea:ding trauma. A striking feature, however,
is that in a high proportion of cases there is the suggestion of a hormonal
disturbance. Many are fat, having tbe appearance of those suffering from
the Frolich syndrome. Some cases have been noted to occur in association
with hypothyroidism. The condition is frequently bilateral (25% at first
presentation, rising later to 60%), and it is essential that 1he contralateral hip
be kept under careful surveillllllCe, particularly during the first 3 months.
Pain may occur in the groin or knee, and if the onset is very acute
weight-bearing may become impossible. There is usually restriction of
intemal. rotation and abduction in tbe affected hip. The diagnosis is
confirmed radiographically, the earliest changes being seen in the lateral
projections. Late complications of slipped femoral epiphysis include
avascular :necrosis of the femoral head and cbondrolysis.
THEHIP 175
Sligbl degrees of slip are treated by internal fixation of the epiphysis

without reduction. H there is a large amount of acute displacement a gentle
reduction may be attempted before fixation, although some are unwilling to
undertake this as they are of the opinion that it may increase the risks of
avascular necrosis. If the slip is long standing, osteotomy of the femoral
neck (to correct the deformity) is often advised. If only one hip is affected,
prophylactic pinning of the other is sometimes undertaken, but this is not
advocated unless the risks are judged to be especially high.
PRIMARY OSTEOARTHRITIS OF THE HIP

Primary osteoarthritis of the hip occurs in the middle-aged and elderly, and
is often associated with overweight and overwork, although in many cases
no obvious cause may be found.
Pain is often poorly localised in the hip, groin. buttock or greater
trochanter, and may be referred to the knee. There is increasing difficulty in
walking and stmdiog. Sleep is often distmbed. and the general health of the
patient becomes undermined as a resulL Stiffness may first declare itself
when the patient notices difficulty in putti.llg on stockings and cutting the
toenails.
Fixed flexion and adduction contractures are common, with apparent
shortening of the affected limb. In the early stages weight reduction,
physiotherapy and analgesics may be helpful; total hip replacement is the
treatment of choice if the condition is advanced.
SECONDARY OSTEOARTHRITIS OF THE HIP

The symptoms of secondary osteoarthritis of the hip are identical to those of
primmy osteoarthritis. The condition occurs most frequently as a sequel to
developmental dislocation of the hip, congenital coxa vara, hip dysplasia.
Perthes' disease, tuberculous or pyogenic infections, slipped femoral
epiphysis, and avascular necrosis secondary to femoral neck fracture or
traumatic dislocation of the hip.
In secondary osteoarthritis a younger age group is generally involved
than in the case of primary osteoarthritis. In the young patient, where it is
thought desirable to avoid the uncertain long-term morbidity of total hip
replacement, a hip joint fusion may be considered in unilateral cases. Where
pain is more a problem than stiffness, McMmray's osteotomy of the hip
may sometimes be of value.
The hip joints are frequently involved in rheumatoid arthritis. When both
hips and knees are affected, the disability may be profound In the well
selected case, replacement of one or both hips may give a striking
improvement in the patient's symptoms and mobility.
OTHER CONDITIONS AFFECTING THE HIP

Of the rarer conditions a.t'fecti.ng tbe hip joint, the following are not
infrequently overlooked:
1. Ankylosing spondylitis may ptesent as pain and stiffness in the hip in a

young man. There may be no complaint of back pain, but there is almost
invariably radiographic evidence of saaoil:W: joint involvement.
2. Reiter's syndrome may also first present in the hip.
3. Primary bone tmooun are uncommon; of these, osteoid osteoma
involving the femoral neck may be a cause of persistent hip pain. As tbis
tumour is always small, repeated radiographic exami nation with well
exposed films may be required to show it The tumom may also be
revealed as a 'hot spot' in isotope bone scans.
4. The snapping hip. 'Clunking' sounds emanating from the region of the
hip on certain movements may be a source of annoy&DCe to a patient. In
most cases no more than reassurance should be offered, but where pain is
a feature an effort should be made to trace the source and, if found, to
consider surgery for the relief of the mechanical problem responsible.
The two commonest sources are the iliotibial tract (which flicks over
the prominence of the greater trochanter) and the iliopsoas at its
musculotendinous junction. The latter may be tested specifically by
flexing, abducting and externally rotating the hip; a click on extension
from that position is diagnostic. Both are amenable to a Z-plasty.
The following important points should always be remembered in dealing
with the hip joint:
1. The commonen cause ofhip pam in the adult iJ pain rrferred from the
spine, e.g. from a prolapsed intervertebral disc. Hip movements are not
impaired, and there are almost invariably signs of the primary pathology,
e.g. diminution of straight leg raising.
2. In the elderly, pain in the hip with inabiUty to bear weight is freqllelltly
dlle to a fracture of the femoral neck or of the pubic rami. In an
appreciable lliUilbec of cases there is no history of injury, aDd
radiographic eumio.ation is essential to clarify the problem.
3. Flaion contracture of the hip may result from psoas spa&m ucottdo.ry to
inflammation or pus in the region of its sheath in the pelvis. 'Ibis is seen.
for example, in appendicitis, appendix abscess or other pelvic
inflammatmy disease. Examination of the abdomen is essential.
CONDITIONS ASSOCIATED WITH TOTAL HIP JOINT REPLACEMENT

Because of the success of hip joint replacement procedures many of these
operations have been perfon1led. and complications, which occur in about
5% of cases, are being seen with increasing frequency.
The most widely used replacement is the Charnley low-friction
arthroplasty (LFA) or one of its many variants. In this, the socket is formed
from high-density polyethylene and the replacement head from stainless
steel. Both components are anchored with quick-setting acrylic cement.
During the smgical approach to the hip the greater trochanter may be
detached to gain better acceas; if so, it has to be reattached at the end of the
operation; tbis often done with stainleas steel wires.
There are a number of other replacements, which vary in the design of
the parts, the materials used, and the techniques of their insertion. In some,
the components are inserted without the use of acrylic cement, and the
surgical exposure may be made without detachment of the trochanter. Where
the functional requirements are not expected to be high (e.g. after
THEHIP 177
intracapsular hip fractures in the very elderly) a hemiartbroplasty may be

performed, where the femoral head is replaced with a slemmed prosthesis
and the acetabulum is not interfered with.
Excluding complications that may arise in the immediate postoperative
period, the probleiDll which may subsequently occur may include the
following:
1. Dislocation. The stability of the replacement is dependent on the
precision with which the components have been aligned dwing their
insertion, the design of the acetabular component (e.g. whether it has a
posterior lip), the time that has elapsed since surgery and the degree of
violence to which the components have been subjected. After any hip
replacement, the fibrous capsule that forms round the artificial joint thickens
and strengthens with time, leading to a progressive resistance to di&ocation.
In the first few months following surgery a badly aligned joint may dislocate
under comparatively minor stress; in other cases, and at a later stage,
considerable violence may be necessary. If dislocation occurs, weightbearing
suddenly becomes impossible and there is usually :ow:ked pain. The limb
shortens and may be externally rotated. The diagnosis is confirmed by X-ray
examination. Treatment is by reduction (which occasionally needs to be an
open one), usually followed by a period of traction until the hip becomes
stable. In those cases where there is a major problem of component
malalignment, a revision procedure may have to be considered should the
dislocation recur.
2. Component failure. Socket failure is 111l1:, but the stem of the femoral
prosthesis may occasionally fracture. This is most likely when the patient is
overweight or the component has a varus alignment, or loosens. Generally
there is immediate loss of the ability to weightbear, and replacement of the
fractured component becomes essential.
If the greater trochanter has been reattached with wires, these may
fracture and fragment, giving rise to local discomfort and sometimes
episodes of sharp, jagging pain. This may be treated by removal of the
broken wires. The trochanter itself may fail to unite and may displace. This
may cause local discomfort and a Trendelenburg gait Normally there is
slow, spontaneous improvement, but in the early case where the fragment is
large and displaced, reattaclunent may be considered.
3. Fracture of the femur. The femur may fracture (as it may do without
the presence of a stemmed prosthesis) as a result of direct or indirect
violence, e.g. from a fall. In other cases the forces responsible for the
fracture may be less than normal. The presence of the prosthesis
considerably reduces the total elasticity of the femoral shaft, giving rise to
high stress concentrations in the region of the tip of the prosthesis (one of
the commonest sites of fracture); the bone may also be weakened by fretting
at the cement-bone interface (where there may be abrasive particle
formation), by cystic changes, and by infection (which may be chronic and
low grade).
Treatment is dependent on many factors, including the site and pattern of
the fracture, its cause, and the general health of the patient, but in the
majority of cases further surgery will usually be advised.
4. Component loosening and infection. When this occurs, it is usually
at the interface between the cement and bone. It is commonest in the area of
the femoral stem, although both components may be affected. The complaint
is of pain and ilnpairment of function, and the diagnosis is usually made on

the basis of the radiological appearances. Loosening may be the result of
infection; in some cases this may be frank, and in others, orga.nimls of low
pathogenicity may be found in the a1lccted uea. In many cases, altbougb an
element of infection may be strongly suspected, no organism can be found
and an alternative canse may be sought. In many, loosening may be
associated with particulate wear debris, and in others tissoe sensitivity to the
metallic elements of the components of the prostheaia has been blamed.
Infection may be introduced at the time of the initial operation and
grumble on thereafter, leading to loosening, bone absorption, and distal
migration of the femoral component. There may be ~ups accompanied
by more acute pain, malaise, and sometimes abscess formation. In other
cases, it would seem that late infections may ariJe as a result of infection
being bloodborne from a septic focus elsewhere.
The treatment of these complications is highly specialised. In the
(uncommon) case of secondary infection, investigations by blood culture
and aspiration, immobilisation, and the prompt administraD.on of the
appropriate antibiotics may occasionally lead to resolution. In the case of
loosening without the discovery of any organism, a revision procedure may
be advised. Where there is evidence of a low-grade infection, a very
thorough debridement under antibiotic cover, followed by the insertion of a
fresh prosthesis of a pattern designed to acoommodate any migration or loss
of bone stock. may be attempted (either as a one- or two-stage procedure).
Additional measures to control rectllTCnce of local infection may include
the use of antibiotic-loaded cement. Where infection is well established,
removal of the components and cement may be the only solution which
will allow the infection to be overcome. even though limb function will
obviously be seriously compromised. In some of these cases, however, once
the infection has been eradicated a further repJacement procedure may be
contemplated.
ASSESSMENT OF HIP, KNEE AND LOWER LIMB FUNCTION

For over 50 years attempts have been made to devise a system whereby
overall lower limb function might be assessed, so that the extent and
progress of any disability might be assessed and the IeSults of surgery
evaluated Over 80 rating systems have been suggested, but unfortunately
the lack of standardisation has in many cases prevented the direct
comparison of reported series.
There is general agreement on the basic functional parameters which
should be assessed. These include pain, stiffness and the ability to perform
certain activities of daily living. In some systems there is also inclusion of
social and emotional factors (such as the return to work and any noted
restrictions), joint movements and X -ray appearances. There have been
problems over the weight placed on each of the items assessed, on how to
evaluate subjective findings such as pain, and how to reduce systems to
manageable levels: many have been abandoned because of their complexity
and time involved in their analysis. The presently popular WOMAC
(Western Ontario and McMaster Universities Osteoarthritis~ Index is in fact
a self-assessment questionnaire which has been simplified and modified1 to
help improve the patient's assessment of the standard 24 questions asked. It
THEHIP 179
is mainly used to evaluate osteoarthritis and rheumatoid arthritis of the

hip and knee, before and after joint replacement therapy. The WOMAC
Index is availilble in 65 alternative language forms and has been weD
validated.
The initial lower limb usessments were developed specifically for the hip
at the time when rapid developments were occurring in hip joint surgery,
particularly in the field of joint replacements. The Harris System.3 although
frequently modified, has stood the test of time. In it, a normal hip is rated u
scoring 100 points, while the hip being examined is described as being so
many peroent of this theoretical normal. Pain (which is subjective and hard
to assess with accuracy) is allocated 44 points. Function, which is highly
detailed, is broken down into gait, the use of supports and activities, and
merits 47 points. &nge of movemmts attracts only S points, and absence of
deformity 4 points.
If a hip scoring system is being used to assess the results of a hip
replacement (and this is one of the commonest indications), then it is
desirable to include details of the radiographic appearaDCes which are so
important. The terminology has been described as standard and unalterable
in its definition, so that without weighting results can be readily compared
between series. Although use of the full list (described in the reference) may
have to be considered where publication ia intended, the questions in the
clinical assessment are of such value in assessing any cue that they are
appended here.
P•in
Degree:
- None- no pain
- Mild - slight and occasional pain; patient has not altered patterns of
activity or work
- Moderate -the patient is active. but has had to modify or give up some
activities or both, because of pain
- Severe - major pain and serious limitations
Occuuence:
-None
- With first steps, then dissipates (start up pain)
- Only after long (30 minutes) walks
- With all walking
- At all times
Work/Level of •ctlvlty
Occupation, including housewife...............................................
Retired:
-No
-Yes
Nursing home:
-No
- Yes (date entered....................)
Laval of activity
- Bedridden or confined to a wheelchair
- Sedentary- minimum capacity for walking or other activity
- Semisedentary - white-collar job, bench wotk, light housework

- Light work- includes heavy housework. light employment, light
athletic activity (e.g. walkingS km or less)
- Moderate manual labour (e.g. work involving lifting weights of 23 kg
or less), moderate athletic activity (e.g. walking or cycling more than
Skm)
-Heavy manuall.abom (e.g. work fRquemly lifting 23--45 kg). vigorous
sports (e.g. tennis. squash)
Work cap~~clty in lut 3 months

-100%
-7S%
-50%
-25%
-0%
Putting on shoes and socks
-No difficulty
- Slight difficulty
- Extreme difficulty
-Unable
Ascending and descending stairs
- Normal (foot over foot)
- Foot over foot, using banister
- 2 feet on each step
- Any other method
-Unable
Sitting 1D standing
- Can rise from chair without using lllJD8
- Can rise from chair using arms
- Cannot rise indepeDdently
Wlllldng e~~padty
Usual support needed:
-None
- 1 stick for long walks
- 1 stick
- 1 crutch
- 2 sticks
- 2 crutches
- Zimmer frame or equivalent
- Unable to wa1k
nmewalked
Without support:
- Unlimited (more than an hour)
- 31-60 minutes
- 11-30 minutes
- 2-10 minutes
- Less than 2 minutes, or indoors only
- Unable to wa1k
THE HIP 181
With support:
- Unlimited (more than an hour)
- 31--60 minutes
- 11-30 minutes
- 2--10 minutes
- Less than 2 minutes, or indoors only
- Unable to walk
REFERENCES
1. StulbCig S D, Coopenrum DR, Wal.lcruite:in R 1981 The natural history of
Legg-Cal~Pcrthes di!Jease. J Bone Joint Surg Am 63:109S-1108
2. Whitehouse S L, Lingard EA. Katz J N, Leannonth I D 2003 Development aDd
testing of a reduced WOMAC function scale. J Bone Joint Surg 85:706-709
3. HarriJ W H 1969 Tnwmati.c arthritis of the hip. J Bone Joint Surg 81:737-755
Table 9.1 Age distribution of common hip pathology

70
60
~
50
,...- ~
40
r-
30
-- ~
20
r-
....--
n
- ...._
15
.. n u
10
,., u
5
0
....... ....... --
Congenital Transient Tuberculosis smrs Infective Slipped Ankylosing Prolapsed Rheumatoid Primary
dislocation synovitis of the hip disease arthritis femoral spondylitis intervenebral anhritis osteoa1'1hritis
of the hip Perthes' (Juvenile epiphysis Aeite~s disc Secondary Femoral
disease rheumatoid syndrome 'Low back osteoarthritis neck
arthrilis) strain' fractures
Secondary
bone tumours
9.1. ln.,edion (1}: BnmiDe tbe ltmding 1.2. Inspection CZI: Examine tbe patient u. lntpMtlon (J): Look at tbe patient
patialt from 111e front. Note (A) any pelvic from 1lle aide. Note aay inc:reued lumbar from behind. Note (A) any IICOiiosiJ (pouibly
lilliDg (e.g. from addw:ti.on or abdw:ti.on J.ordom suggestive of fixed flexion deformity IIIOOIIdaly to pelvic tilling from, far
ddmmity of the hip, llhort leg, acolio.U), of the hip(a). example. 1D adduccioD defmmi.ty of the hip),
(B) IDllscle wutiDg (e.g. IOCODdary to (B) glutl!al muaclc wutiDg (e.g. from dimse,
i.Dfcctioa, <lilule, polio), (C) rotatioul i.Dfcction), (C) linua scars (e.g. leOODdary to
ddormity (common in oiUlaa111ritiJ). tube:rwlolia).
9A. a.Jt: Ob~erve the pit from tbe front. 9.5. Short.nl111 (1 J: It it important in 1be 9.6. ..-ru. 1hort.nlng 12): True llhortelliag
~ides and behind. Analysjl JI"OWI from eumln!dion or the hip and the lower limb to from CIUMI clittal to the trodwtll!ln most
e&pcrieDoce. 'Icy to u - tbe abide lllld dwell dctmmiDc the praem:e or ab~e~~Ce of frcqueml.y raulta from (A) old t'ractues of
time on cadi aide, and the posliblc factors of lhortlening. In t1W .slwrtenillf, the ldicctled tbe tibia or (B) of the femur; (C) growth
JlliD, llti1fileu, lborlelliDa" ad &luteal limb iJ pbyli<:llly thorter tbaD 1lle odl.e:r. tbil diiiCulbence (e.g. from polio, bone or joiDl
ln111fDcieacy. N01e 1hat 1 shufD.iD& &~t may be cauaed by patboklgy (A) above or lafectiou, epiphyaeallr'llmll. or one of mmy
(wbcm cecll foot i.a dngpd OD the 8JDIIIId. in prmima1. to the grater 1mclmolcr or (B) hereditary bome diJeuea. (N) = DDmlllllidc
the nrinB phue) or a llmnpias pit (where distal. 1D the tmcbaalr:rs. b compari.aon. (Note tbat in drl1drm, likdy
tbe foot bill tbe grooDd ia I violent m.IDIIICI") J.cc di~ at llkeldll Jllllwity may be
may be IICCD in llUCI O[ polfUior coni predicted uling a number of method&,
ayudrome, .d a broad-baaed pit ia c:uea or iacludiq that fi mukiplic£ factln devilled
spinal. ard Clllllpi"CSiimL by Dror Paley et al.)
THEHIP 183
c
t.7. Tru•short•nlng {J): Above the t.t. Sbarunlng (4): Very nely t.t. Short8nlng (5): In 1J111HUm1 shortming
trochanter causes include (A) coxa vara (e.g. lengthenlllg of the other ltnlb gives relative the limb is not alb::rcd in length, but appears
from femoral DeCk fracture&, slipped. upper ttue llhortenillg. 'Ibis may be due to (A) abort as a zeiAllt of 111 addiJctioll o::onl:ractule
femoral epiphysis. Pcrthe&' disease, lllimulalion of bone grow1h from iDcreased of the blp, which bas to be compenAAted for
congenital coxa VIIIll; (B) loss of articular vucu1arity (e.g. after l q bone fml:ture in by tilling of the pelvis.
cartilage (from infection, arthritis), dilldren, or a bone tumour); (B) coxa va1p
(C) diJlocation of the hip (e.g. secoDdary (e.g. followiDg polio).
to ~ dWocati.on of tbe hip).
!MO. ShoNnlng (6): Limb lhollaling may 9.11. Sbarunlng: ...mlnlldon (1): 1be 9.12. Short8nlng: OBmlnlltlon (2): In tile
be rompen11ded by (A) pl.imlarflexiou of the patient shoold be lldjusled to lie squarely on normal patieat the heels should be level, and
foot on the al'fecled llide, or by (B) flexion the couch, with the 1runk. aDd legs parallel to the plane of the IIDtmior mperior iliac spines
of the knee on the othr:r side. Most frequendy illl edge. 1be pD11ition of the pelvis should be al right angles to the edge of the cooch.
tbe discrepallcy i.8 coanll:led. by pelvic tilting. oblem:d (by tile pollilion of tile 111terior
The latter may in tum be compenaated for superior iliac spinel) and adjuab::d where
by the clevelopmlm of a lumbar IICOiioaill. possible.
1'.1:1. Shortening: examln..lon (1): 1'.14.. Shortening: eumiMtlon (4): 9.15. Shorcenlng: eumiMtlon (5): Jf
Where there is lipificllllt 1111e lbartlziDg tile Begin by hookiDg tbc tlrumba 1Uide:r the ia the J..ut tellt lhc:le wu 110 mdeDcc of
heela will DOt be level (the cl.ilcreplncy ia a anterior ipines. Feel for the grea1er •ho!UlDlna above tbe tmchanlm', look for
guide to the IIIIKHIII1 of lllmrtenhlg) ad the lnlCbantms with the finFB. Jf the distance CIWiell below the 1mchmter. Slightly flex
pelvis will not be ti1lecl. The u and llnOUilt between the thumb and finger~ ia shorter on bo1h knoes and bip1, and pUla: a hand behind
of lbortaliDa mUJt now be fw:tbcr one lide, !hit IRIWIIU that the pathology 1.iet tile hcelJ to cbcck Chat you DOW have them
iDVCitigmd. above the trochlalcn. lqlllrdy togetbtz.
9.16. se-t.nlng: - ln..lon (6): The 9.17. Shart.nlng: ...miMtlon (7): 9.11. Shore.nlng: ...mlllllllon (1}: Now
poai1iou of the two lmees ahould be Further c:onfinmdion of tibial ahDIIIIDing may IIII!UIInl Cram the JDKrk to the tip of tbe
~ (A) ThilllppCai'IIICC IIIJICIU be made by cUred meuuremtnt. Flex ooe medial malkotas. Compare the two si.des.
femorlllborteaia&. (.B) 1bia appecace il knee, and wiCh tile lhamb J.oeatc tbc luly diffetall:e iadlc:atel true tibial
auggeadve of tiblallb.orlciiJD& (ia the pmmlnen...,. of 1Dc femur aad tibia, with tbc lhclncaiaa. Note alao IDY obviooa tibial
Wasnm. tbe rigbt aide is u uual tbe site of joint line lying betweaL Thill ia bst imlplmty •lliPI'ive of old fral:tlml.
the paabology). perfomled OD the medial side of the joint.
Now a:wt the joint 1i11c, IDd ~ 011 the
otller llide.
THEHIP 185
9.19. S'-tenlng: umnln..lon (tJ: 9.20. Shortllnlng: . .mln.tlon (10): 9.21. Shortening: eumllllltlon (11):
Mea.mrement of frmora1 shaft shortening can Measurement of tDtal (lnle) leg &bm1ming is Now measure to the middle or inferior border
ouly be altelllpted iD the thin palieut wbere tile most VBlQible lliiigle ulleiiiiiellt, al.lliough of the medial malleolus. Compare tile aide~,
the tip of the greater tJooltanltz ia eaaily iD itaelf it gives no iDdication of rite. Begin aDd always repeat the measurements until
palpable. Meuum from the 1mclumter to 1he by placing 1he IIII!tlll md of 1he tape owr 1he amaillllmq is obtained. Defmmity of the
laleral joint line and compare the ~~ides. anterior spiue; DDW preu it backwards until it pelvis (which ill rare) may IIOIIIdimes lead to
boob lmlkr its iDfcrior edge. In this way die Cll"OlJ in assessmeol
aid of the tape comes into firm contact wiJh
1he iliac apiae, and dlcre is leaa cham:e of
having diffic:ulty in getting a ~ find
measuring point at this level.
9.22. Shortenlng:ex~~mlnadon (12): 9.2!1. Shortening: aamln.tlon (1!1): 9.24. Shortening: ex~~mllllltlon (14):
When the patient is carefully poritioued em the Apparent ahottening may also be aaseued by Whe.a there is aa adductiOD. deformity of the
enmiuati!WI couch, and 1he pelvis i1 obviOUBI.y comparing the dislam:ell between the hip, and the tes Jens1bs am being measund to
tilted, try to coree~: tbia. If it CIIIIIIOI: be xiphistlmum and eam medial malleolus. assess any aaxm1panying true shortming, the
levelled, then expea to find some ~ good leg sbou1d be adducted by the same
shortening of the limb; the discrepiiDC}' amount before OOJJUIMlllcing measaremeDt
benv- the heels will give a IDiliiSUl8 of tbia. ~ !he IIDifllior spines aDd malleoli.
(Nole, however, that liS well Ill appaiml
shorteDing dlcre may be some additional true
shortening, wllidl abould be Lll8e8ICd by direct
limb IIIIl8SIImiiiii 81 just dfllllribed.)
9.25. Sborlanlng: aamln..lon (15): t.za. Shartanlng: aamlndlon (1&): U7. hlpallon (1): PW:e the fingers over
True leg sl1ort=liDg may lllo be meuared by In t11e diffu:ult case. llC(JIJCalial radiograpbJ or tile head of the femur below the iD3uinal
b~ up 1lle lhort leg Wltll botb llderior tbc bip1, beelllllllllllkles. tamn on a aiDgle J.ipmcnt, lateral to tile femoral aray. Note
aupm:ior ilia&: i!piDNIIDd the ilia&: calltl lie plale without moving the pa1icmt, afford any teudetnels. Now mta1e the leg medially
horimnt:ally, IIDd 1lle na!Dl. cleft i1 vatical; a ~ compariMm of the Rides. Foc IIDIIIatlnlly. Crepima 11IiDnJ in the hip joint
1'urtb=' ~ 1llat tile pdv!J .iJ level 11 to - ClWDple. (A) indicates ovellllllliortcuiDg, (B) may be cletecOed in IIIia way.
tblt Cbe polaior ililc •pillet raDiin illdicltet femarallhodcoing. (Note that in tile
horimntal when the pelieDt 11=1 forward&. older paliaal a dUaepancy of 3-4 em lead~
em walking to m inaeue in heart rate,
YCDti1ation aDd muacle activity wbicll may
ac:rioutly limit lll:l:ivil:y, e&peCially if Cbc:re il
llrcady some~. pulmolwy or
DellitiiiiiiiCU impairment }
9.2L P•l,.elon (2): Palptlie the oriain of 9.29. hlpdon {)); Bnemally rotate the t.JO. Pal,....n (4); Plllpare 1be resion of
addlldm Joogu.. 1'todanas oc:cun ~ in lq IIDd paJpa1e the lea~r.r lrtlcbmm.. 1lle ilcl!ia1 tubaolity klokins for ~
5podl illjuria (ltnlin of .wactor Joaaas) - Tcodemeu oa:ura ~ in ttraina of1be Stnin of 1be lwnltring origin oa:ura u a
in J)ltiaiU developiDc llldactl¥ CODinlctullca iliop1011 • a Rlllll1 of alllldic injmiea. -u ofCllleCic lll:l:ivua, ClpCdally 1n
in OlleOa1brllit of 1be bip. cbi1cksl. Lets c:ommoaly atblelic injmea
may a«ect 1lle anll:rim' IIUperior ... infaior
8pines.
THEHIP 187
\ "•
I
, . . ~ •• t ••• '·~ · -
I \J.
Ht
-------.. ·-
9.31. MGnments: atenslon (1): Place a t.3:Z. M_,.•ntl: llll:tllnsfon (2); Now flex t.33. Monments: uten~lon (3): If tbe hip
hand behind the lumbar spine so lhat you can the good hip fully, observing with lh8 band being examined rues fmm lh8 couch, 1his
dm:rmiDe whether in lbe spiDe at rest there is lhat lh8 lumbar curvature is fully obliterated. iodicalesloss of exWlllion in lhat hip (also
any iDcreue in lumbar lordosis, IUid later on d.eacribecl as a moo ll.exiOD defomlily of tbe
in the coune of the examiaalion, whe1hcr 1hi1 bip). Ally lo&a 8bould he measured aDd
has hem oblilmaled. l1lCOided. Thill lellt ia uswilly mfmm:l to all
Thomtu:r tut.
9.34. MGnments: atenslon (4): To check 1.35. M_,.•ntl: llll:tllnslon (5): Lift each 9.36. Monments: flalon {1): The good
lllllllller los- of IWmllion, 151pecia1ly whmi leg in tum IUid COIIIJIIIll' the IBDgll of bip is fiillt flexed to oblilmate the lumbar
tbe other hip is normal, tum the patient over movements. curve arul to study lbe pelvis. The patieDt is
OD to his face and steady 1he pelviJ with ODe NOIDIIII n111P of ateusioD • 5-2t•. aated to bold 1he leg in this position.
hand. A lo&a affcetiDg extension only is o&:n tbe
finlt dcitectable sign of an effusion in lh8 hip
joint.
t.J7. Mowmenta: flexion 12): The hip h t.ll. Moonments: tlalon (J): The rmp t.Jt. Mowmantl: abduction (1): A false
then fiexcd, using a hand to t:hed: that no of flexion may be IUOI'dcd in this example u impression of hip movement may be gained if
furtbel pelvic movement ocaut. Note 1be 'Flexion (R) hip: 30--90"', or 'Fixed. lleltioD the pelvit tiltl dwiDg the eumjnatjoo, to first
l'll!l&e of ltlOVeiDelll. deformity of 30", and hip flexes to 90'". grup the oppoaite antaior superior iliac
Narmal rup oflaiaD •120". Flexion may abo be ~tlld with the p!dimt spiDe with the finprs and thmnb, .md anchor
lying on hiJ side. the other spi.De with the forearm.
tAO. Movements: abduction 1.2): All 9.41. Movements: allductlon (J): Now, t.G. Patrfck'l tell: Buil:ally, thiJ is a
altemative way or tiDa& t1x pelvia it to t1a having ll.xed the pelvi1, move the J.cc 1atetally variation or abclacting tbe hip from a potitioa
tbe other 1e8 ovw tbe edp or the coudi lllld and note the~ lll:h.iend. of 9()0 tla.ion. Pain dwina the _ _, is
check that the pelvia doel DOt move by or
NOI'IIIIIIJ'1UIP llbdudion = 48". reprded u being the very :lint sign of
holding tbc anlaior IUpCricr 1lilc apiac 011 Abduction may l1so be tated from a lltlrtiq o~ in a hip. To perform (Oil tbc
tbe side beiD& cumilled. poetion of 90" hip II.Won (~« abo below). rigbt), fla bod! bip6 and lmcea, ~ the
This i• of pu1ic:ular valDe in suspected riP' foot 011 the left knee lllld pntly pnu
omn.tbriti1 of the bi.p or conpnita! clown on tbc ri&ht kue. Thi• ill abo !mown
diJlocafioll. • tbe faber lip (llcxilxl, llllductioa, cDcmal.
~-
THEHIP 189
9.43. Monn!Htl: •dclucllon (1): Ideally t.44. Movements: •dductlon (2); If 811. 1.45. Mowments: lnt.rn•l rot.tlon .t W
an usistant should lift the good leg out of the ullistant is not availahle, c:rosa the leg being tl8lllon (1): Steady the flexed hip by bolding
way to allow 1hc affected leg tn be adducted IWIJJiined over the olhm-. This brlap the the knee with cmc band, and move 1hc foot
wlrlle in full 6XUIDiicm. leg being examined into slight flexion, laterally to pmduc:e iDie:mal ml8lion of the
NOIIIUII ranp of addudiaa = 2S". but is suffu:iendy ~ 1lll.der mOBt hip. N~ that this is a never-endillg smm:e of
circumatanl:ea. If tile hip is normal, tbc legs confusion; be ~~ thal tbiJ is clear in yoar
abould crou about mid-thisb- Addocti.on may own miDd. Although the foot moves laterally
also be les~ from a starting position of 90" (or extemally), tile hip rotafell intemally (or
hipfiexion. IIUidially).
t.46. Movements: lnterMI rotation It W !t.47. MIWements: lntemaiNtadon .. ..,. 1.48. Mowments: extem•l rotltlon It
ftulon (2); Measure the range of inll:mal llulon (3): A sensitive compari11011 of tile to" flal•n (1 ): The position of tile hip is the
rotation by comparing the position of the leg sides may be made by asking the palieat to lllllD6 II for tesdng iDtemal mtaliOD, but in
and the midline. hold the kDiles togetl= while you move both this cue the foot is moved IIIII!dially.
NOIIIUII ranp of intemal rotatioa at 9CI" feet laterally.
1lnloa = 45".
Compare the Bide&. Los1 of intema1 mtalion is
common in most hip palhologies.
\I
\'
\'
I
\_
\I •·
\
9.49. Movement.: extern.l rollltlon .. 9.50. Moftments: eJdemld I"CMtiCCn at 1.51. McMirnenbl: I"CMtiCCn In atenllon
90" flalon (2~ Mcuure extcma1 rotation in tcr flulon (S): Compariaoa betwccA the (1 )I For a rough comptrilon of tile lide1, roll
tbB III!De gaunt way. aides may be made by crouing cme leg over earo leg medially and lmnlly, obiRVing and
Nonnal n.np of enuul rvtdon lit W the Dlber. allowing, however, for my play at the knee.
flaiaD.•W.
BxU:mal rotatiaD bccomea limited in molt
artb:rilic coodiliom o!lbe bip.
9.52. Movmn.nta: lnwm•l roe.don In 9..5.!. AniRMIIon of the fwn0111l -k: 1.54. M-•nts: awrn•l rotation In
ut.n~lon: For a lliiDn! aa:urate u iiMIIIll!llt AntevaDon may be useased whml the uten~lon: Complllrison and m.easurmmmt
the patient dmuld be proue, with tile keel patieDt ia in tile same position. Hold tile 1es m&y be made in the 11a111e way.
lleMd. 1be two lidee can euily be compmd wi111 oae band ud rock it from side to aide NOI1al nap of atmW rutatlcm Ill
and mcuurcmclltl takaL (A) whik: linmltlliCOualy fecHng the atelllloa .. 45".
Nonnal rup of bataul ....ad-. iD promimml:e of tbB gRII1IIr lnlclmll« with die
edcllllaa: l!o. odJer (B). When the trodlantl:l' b facin& 1ruly
literally, anteverlim b eqgal to tbe qle
~ lhc leg ud 1b:: vc:dicll. ADII:-ferioa
may mo be u-.d by • JlllldJar of
radiolop:al tl:clmiques..
THE HIP 191
9.55. Monmentl: tutlng fvr hlp fulton 1.56. M~•ntl: tatlng for hlp fullon 1.57. lNnd•l•nburg's tat (1): When
(1 ): When thee is doubt regardins the (2): Rl!peat th8 test. this time feeling for standing on one leg (here the left). the centre
10~ of a hip fusion, it is IIOIIIetimes :Bexar (iliopsoas) COIIIraclion while 11111kiDg a of gnavity (at S2) is brought over the stance
helpful to lot for protective JDUSCle IAid4e:n gentle attempt to exlelld the bip. foot by the bip abductors (gluteus medius md
contnctioD. Flex tile good bip and knee. Feel mininma). This till:a tbc pelvis md normally
for involunlllry adductor conlrm:1.1Jre while elevales th8 buttock of tbc non-llta!x:e aide.
auddmly allelnp1ing to alxllu:t the leg. The palient should be able to produce a
pater pelvic tilt (by being asked to lift tbc
llide higher) aDd hold tile poaitioa for 30
seconds.
9.58. Trendelenburg\1 ted (Z): Ask the 1.5!J. Trendelenburg's tat {S); The ten is 9.60. Duc:henne lllgn: Note wbether the
palicDt to lltaDd on the affected llide: any positive as a result of (A) gluteal pmalym or patient, whea walkillg, llll'Cbea to one aide. If
support (slick or hlmd) Imlllt be on the IIIIIIJe weaknss (e.g. from polio, mu~waaling pmlllllll, this is 'becauae the pa1:i1m1 is 1Iying to
side. Now ask him to raise the non-atanee leg disease); (B) gluteal inhibition (e.g. from pain reduce pain by shifting his body weight over
furtber. Prevent excesllive trunk movements arisi!lg in tbc hip joint); (C) from gluteal the bip. 'lbiJ is often allo IOUieWbat
(a vetUcaJ. dropped from c:7 ahould not fall illefilciebcy from coxa vara; or (D) coafulliDgl.y referred to as an abductor or
beyoud the foot). If the pelvis dmpa bWw developmlmlal dislcx:alioo of the hip (DDH). Thmdelenburg lun:h. It is oflm uiiOciated
th8 horimnlal or cannot be held llleady for 30 Nevertheleu, false positives have been with a positive Trendelenburg &i.gn (ill), but
secoads, tbc test is politive. It is DOt valid. rec:otded in aboot 10% of patiems. DOt invariably.
below • 4: paiJl. poor cooperalioD or bad
balance may give a !'abe positive.
l
,,/; I
'f, I
1.61. GlutHI muKiu: Teat the power of 1.62. GIIIIHI miiiCIH: Te&t the power in t.O. Aspiration: The hip IIlliY be aspinWd
the hip abcluctora with the patlcat lying on bU gluteus muimus by asking the patieDt lo by iD.Ie:rtiDI a needle above the trochanter,
side, attempting Ill lbdact 1lle I.e& apiDJt extewllhe hip against retiJCaDce. at 1lle lllllt allowiDI for fem.anl neclr. aDtevenimL
relirtance. lime :fcding the tone in the contrallliDg Altcmalively, a DCCdle may be paS8ed inlll
IDliiCle. the joint 6mn in front, a little below the
iquiDalligament and lalerallll the fem.anl
adery.
1.64. Ortol•nl'l tett (11: To be of my 1.65. Ortioluli'l tett W: Now flex 1he hips 1.61. OrtioiMI'I tett (J); If a hip is
value the '"nrnjnatjoa moat be caaied oat OD Ill a right angle and, lltartiDg from a pollitioD ditloca~ u full abdnction il approached
a mlaxed cldld, prefenbly after r-lin8· Flex w1Hn the dmmbs 11111 tiJIIclJiq. abduc:t the the fmu:nl head will be felt slippiDc imo the
the " - aDd eacircle them with the b.m 10 hip& llllOOtbly and gemly. Kldlbulum. Anllldible click may aa:ompmy
tblt the tbumbllie aloq 1he ~ lidel of 1llc displaccmad, but in no way moat tllia be
the 1lqbl and 1llc fiD&ert over die COIIJ.idacd • eaKDtia1 elcmad of the tat
troc:lwltcn. Note that l'Citrll:tion of llhduction may be
pllbol.osical. and repraem Ill ineducible
dilloc:atica. A poeitivc Orto1aai 1at is
mdk:lli~ of ~~CtW~alll inltlbility of tbe hip
(NIH), IDd il -.lly Ill iDdlcldoD f«
ipliDiage.
THEHIP 193
9.117. Bllrlaw's pnwoaltlft . . . (1 ): 9.68. ••rtGW'J ... (2): If the bead of t.r.t. Radlogl'llphlc uamlnatlon crf1he
H the Ortobmi test ia negative th8 hip may the flmmr: ia felt to mblux backwmls, its n~~an.- (a) wm Rmtm m~~tlrod: An AP
nevertbeless be 1IIIBI2b1e. Fix 1he pelvis reduction dmuld be achieved by forward view dmuld be takm with 1he hips in at leut
betweea. symphysis anc1 sacrum with ODC fulgcr pteSSUrC or wider abduction. Tbc 45" abduction and full iDiemal rotati.oll.. A
halld. With the thumb of the other attempt In movemeDt of reduction lhould also be line projected along the line of the femur in
dilll.cx:aie the hip by pile but firm backward appmc:iaud with th8 ~· If Barlow's test the nonnaJ. hip should strike the acetabulmn
Je118Dre. Check both sides. ia positive (!llld Ortobmi's neplive). JKbeck 111111, in a case of dialocalion. the n:gion of the
at weekly intervals. Instability persillting for a=rior IIUpel'ior spine. Note: To avoid
more than 3 weeb is aa indication for radiati.oll, this aomewllat IJIIleliable
spHntDge, or for further ilm:stigarlon with illvesliglllicm. should be done only where there
uliiuolmd BDd X-ray. ia still IIIICeltainty after clinical and
ultrasound testing.
9.70. Radlogl'llphlc eaMIMtlon: (b) 9.71. o-iopnlllntlll dlsloatlon of the 9.72. Dwelopm•ntal dislocation fill th•
Edinburgh tMtlwd: All AP film ia tltcD with hlp (DDHI: 1he older child (1): Appeamm:e: hlp (DOH): The older child {2): If both hips
the c:llild's legs bcld parallel, with slight (A) Tbc affected leg in a case of IIDilatmll are involved there ia ullll.ally widening of the
1Iaclion llllllno extllmlll. rol:ldian. Centre lhe dislocation of th8 hip may I:JIIIIIIIl' llliBbllY pmineum owing to the hip displacement. If
beam at a standard distance of I00 em. shorter, BDd lie in external rotation. (B) There the child has been walking. thee will be a
MeasuM the gap between the !DOlt medial may be as)'I!IIIIetry of the skin folds in the compeDJa4ory iDcrease in lumbar lol'do8is.
part or the femur and the lalrzal. edge of the 1lligb. although this sign ia of limitecl
ischium. This ia IIOIIIIall.y 4 mm; over S mm reliability.
is 1115picious; 6 mm ia ~ u diagnostic
of DDH. Proximal ~~ligation em also be
measured in the same 111m.
9.73. D4Mtioplftllltlll dlllocatlon of the 9.74. DnlllapiMnlal cllslomdon of th• 9.75. Dnlllopm•ntal cllslomtlan of tM
hlp (DOH): Th• old•r child (J): hlp IDDHl: The o~cWr mild (41: Tlllt the hlp (DDH): The alciM child (5): Attmnpt to
Traldeleoburi's 11e1t will be potl.tlve and tbe raase of abdw;tion from a position of 9()0 elicit tdelcoping in the af&:ctl:d limb. Steady
gai1 will be abDomlll, wUII ~ Hexion of die hip. lD DDH abducti.oD il die pelvil with one hllld, and push and pall
lhoulder sway. lD Ull.llateral C8*" 1hD chlld reatticted Ia thia poeidon, llld of counc 11 lloa& tbe uia of tbe femur with the otber.
will dip em the affected aide; in bilatsal cuea II!OIIt obvious in 1he 1lllilaknJ. cue. A 20" Abnonnal excuBicm of the limb is auggeslive
the clJi1d will have a wadd1iDs gait. difl'e=u:e between lhe llidm, or las thm 60" of DDIL Always axnpare the aides.
of llbdaaion, is regarded u highly significant,
llld fard!er iavelti&atioa il Clleldilll. 1be tat
abDu1d be parformed routiDely at 3 IIIOIIlhs,
specially in a higb-rilk ca~~e.
9.77. Radlogrephs: NOI'IIId labnl hip in

the a4alt.
THEHIP 195
9.78. Rlldlog,.phs: An allleropoetedor films any dUturbance of bOM lf!Xtun (e.g. in and arthritis. Note the relative tknsity of
view showing both hips (A) is the most Paget's disease, mtmporosis, tumour). Now the femoral head, which may be tkcNtJ.Jed,
uefulllingle ~ film, u it allows both ~ the jomr &paee (which i.Ddicales the e.g. in rbeamatoid artbritiJ, ~em aod
sides IX> be compared. If the joint is stroDgly depCh of articular cartilage and intaposing osteoporo8iJ, and inci'GHd in avascular
auiiJ)CCt, aa additimaal latenl projection (B) fiuid), which may be (D) iDcreaaed in I100lOfda (F), segmental avucular necroail
and aa antemposterior (C), amtmd em the Perlhes' disease, synovitis and infec1ion, aDd (0) and Pmthes' disease (H).
suspect hip. :aze euential. Naill filllt in the (E) clecreaBed in the laler slap of infection
9.79. Rlldlagr.phs cantd.: Now note the hip. Note Shmton'$lilu!, whil:h nonnally t1111Jk. Thi1 ill tkcrr!IJ3~ in congenital coxa
slulpe of !be femoral hea4, wbirJ1 may, for forma a IJID001Ii ClllVe fiowing from the vara (G), aDd ooxa vara leCOIIda1'y IX> rickets,
example, be (A) buifer.sha.ped afta Perthes' superior pubic rannu to the femoral neck (E). Paget'& disease, osmomalacia, fract1lnl etc. It
d i - , (B) flallmted a.llm avascular Dl!mlllia Compare the sides if posaible. Distmtion is incnaud in ooxa valga IMICOI1dary to polio
(total or segmllld:lll), (C) iiregular or occurs in many amdi.lions involving the (H) and otbet neurological dillluibam:es.
destroyed after iDfectioll, (D) atrophic ill femoral ncek.IIDII head, particularly~
peraillteDt developmental dislocation of the (F) and sabluutioDIJ. Naill the ~Nift
9.10. 1be neck-IMft angl• may be 9.11. Nvlc dl1tortlon: Thilllllllf be 9.12. OllhlouthrHia: Note the~
measured fn:Dn line• drawn through the fhaft localised and of the pattem found in protruido of any of tbe cblnpl QOIJlDlOilly Been in
and a1o11g tbe centre or the uect inro the acetabuli (A), wbich iJ often hereditary llld oltcolrdrriliJ. IUCh u (A) joint apace
ceDIR: of the bead. frequently aaaoclated with 01100m'thritia; or it DII'1'0WiDg, (B) marginal Olteqlb.ytea,
Narmai ~ aaaJe m. maae. us•. = may be ~ (B), leading 1D clafmmity (C) llllll'giD.Il tc:1mom. (D) C)'llic chmgea
Narmal ~......, m r-.~a .. mo. of tbe pelvic: inlet (~ pelvia): dll1 il in the bead of tbe femur and in tbe
1bc centre of the bead may be euily foand fOUDd in oncom•lacia lllld ocbea' w.ea- ICCIIbuhml.
with the aid of an ortboplledic rule ar limillr aa:ompllllicd by baDe IOfteDiDg, auch •
trmlapmmt drawiDg tamplme imaibed wilh rK:bta md Pap'a diJeue.
couamric circJa of diffmmt radii
9.U. Conlpl... obl"-r.clon of the hlp t.M. PertiMt' dl...,. (1): The earliest ,..,. ,......en..... Ill: H tbe 'tear
joint (boDy lllkyloril) il 1ee11 ill aatyloliDg ~ lligD ilm illaeue ill joint drop' (farmed by IDe mtaior ll:etabular
apoadylida ( wbcft; there il invadably ll*)e. (Note. bowevcr, !hat dlla il abo 1ee11 floor) Ia 110t clear. note (A) lhc overlap
involwmmt of tbe uaoili.al: joiml). It il alao in ayuovilia of the bip IIDd. ill infective lbldowl of tbe bead md ~on the
ICCil u a tale IUult of tubercWous aod other dlritiJ). Minor depea ofjoint IJII"C Kdlbulum, ~ one hip widt the
~ ad Iller Slqic:al r.k& ~may be dell:ded by - m , tbe odler. Alkrlliol1 (B) occurs in Pedbca'
diltaDce betwecD. (A) '1hc at drop' 11111 tbe dileue, aynovilia md ~.
capital tlpiphysia on both llide11.
THEHIP 197
9.86. "-thu' diiHH {4): Catterall 9.17. Perthet' dlleiiSe (5): Catterall 9.88. PllrtMs" dl..... (6): The so-called
gTQtli"f (a): This ill the cmmnonest method grading (b): Grad#: 3: Most of the head is 'frog' latmal (Lcewenstein projection, (L)) ill
ued ID 111111e111 the severity of the bone involved. Gnuk 4: The whole head is routine in lllleRsing theae CllleS. Apart from
changes wileD they appear. Grade 1: Cyst aff'ected. Bony collapse is inevitable in grades the cystic clwlges that appear in the capital
formaliOD. OCCU1'I in the anterolateral aapect of 3 and 4, and 1he prognosis is consequently epiphym, 1he acetabulum may be aimilarly
tb8 capital epiphysis. Rl5vascularisal may pO<Rr. aft"ec1:lld (A); cystic c:hmges ma.y abo rxx:ur
be cmnplded without bone collaptie, and the in the mel:llphysis, which may widm (M).
prognosis without treatment is goocl. Grtuk The femoral bead may ll.aUcn and eztnJde
2: A little mme of the head i.a .involved, and laferally (H). MRI IICIIIIDiDg allows more
bony aillap&e is imlvitable. 8llCII1'lltll ,grading.
9.89. Perthu' dlleue {7); Lateral eDrusi.oa 9.JO. Perthet' disease (1): Olber advene 9.91. Perthet' dlseue (91: Htrrlng laural
may be expn:Ned u a pm:ea.tage of the faciDn placiDg the cue in the 'head-at.flak' pilku ckusijication: Divide 1he head il1lo
diameter of the metaphyaill on 1he llOI1ll.lll Bide cacegory include (a) Pf"'*""'alian above 1he three c:olunma cluriJlg the fragmeDtation stage;
(N): if abkd X 100 >20..,, tbmJ. the prognoBia age of 4, (b) calcilicalion IIJellllllllmlll 1o the then, if the 1lllmlll part is of nmma1 heisht
ia poor. An ~ uJCIBIIIent of 1he amount epiphyJis or ok evirience of ~or (Herring A), the prognosis is exc:ellent. If the
of avucular boDe may be made by cxtmsioa, (c) lateral subluxation (S), (d) a late:ral part is depreNed up to SO% (even with
ndl.onuclidc bone &caDDiDg. Prognollill ia pollitivc Gage Bign (a aequeatrum slllYOIIlldcd the CC2dl'al. column involved) (Herring B), 1he
mainly depeollcm on the masa and d8gnle of by a 'V' of viabl8 epiphysis (0). msults am generally good UDder age 9. In
epiphyaeal involvement (a.aessed, for Herring c the lateral pillar is las than sot.
example, by Catll::rall gradiag). and all develop permanellt ddormity.
01= h+w
d
9.92. Pwthu' d ...... (10~ The Defmmity t.U. Sllppad t.monl •plphpls (1): The t.M. SII!IPH t.monl •plphpls (2):
Indu. (DI) is uae:ful in 1ll1i1amra1 ~. To earliest changes are 11een in the lateral Solllhwlt:k.'l mnllod of q111111tifyillg the
111e dlis, liB a radiograph of the normal bip projection. A liDe drawn up 1hrougb tb.e uwrlty uf any rUp: In tb.e frog lateral draw a
(a), revene it (b), IUid rupetimpole it on 1 c:enlre of the DCCk failll to meet the midpoint perpend.icolJr (p) from a line (ab) drawn
film of the arr.:ted lidD (c), liDing up each of the bale of the epiphysis. The distaDile 1a011 the bue of the epiphylia. Note the
calcar femorale. The DI expre&RI the between the centre of the baae of the 111J81e (A) between dli1 md a line (e) drawn
flat=ing (b) llld 1ttera1 extruaioo of the epiphysis (X) ~ with the width of the dJrouih the c:enlre of the femoral shaft, IDil
epiphyliJ (w) u a frlctiaD of tb.e diameter bue of 1he epiphylil may be UJed to CO!IIJIUI the llidcs. (If the QO!Iditioa is
of the femotal DeCk. VUuet ill euesa of ~.0 calculate the degree of slip. Less than lf3 unilal:eral, Nbtract 12° to allow for the
cury a poor pmgoom. may be cliiSIIified u pde 2; grade 3 = lf3 to IIOIIlla!· lhaft angle in dlis pmjedioo.) 3()0 is
1l2; grade 4 "' more dian 1/l.. (Gnde I is rqarded u mild; 3()....600 il moclerUe, llld
uad for pr:Wlip cuca.) - IliaD 60" lleVCR.
9.95. Sllpf*l ,.mcnl.,lph,sls (3): 9.96. Sllppad t.monl •plphpls (4): In 9.97. Sllpf*l t.moral.,lphJIIs (5):
Allhoush the earliest l'lllliograpbic c:baDsa the lllim ~ some 'Mieb lifts: ebB inil.i.al Plryual uparutioft.· the frog lalmal
are 11een in the 1atrzal, p-ear ~ of llip llip (now the .,.called 'chrooic llip' stap) ndiopph i l again used. The dillaDI:e
become detl:etabk: in the AP projectiolla. 1bcn:: iJ di!fodion of tb.e iDfeDor part of the belweeD the tDtelior lip of cpqmyw aDd the
'lbe lint aiga is that 1 taqclldalliDe drawn femoral DCCk, wiCh DCW boac fomWion clo-t poiDt or tb.e mdlpbylia is IIII:&I1Rd.
Oil the uppar femmil BliCk [liJ.s to lt1ikB ('bultiM&iJI8'). In the majority of ca.. of slipped flllnonl
tbe epiphysis (A), wbiRu in a oorma1 well epipbyail there is in fact DO phyleai
CCII~ Yiew 1ucb I tlqellt (B) iocludea plrt sepatloo. (f aepntiOil is preiCIIt, it ia
of 1he epipllylil. lddom dc*ctcc1 uDku it c:m:cdl 4 mm.
Detected llpCili01111 IIOI'IJially Jle ill ebB 4-12
mm rqe. Sepam1ion i1 a llipifu:al fiDdiDg.
11 it lalds to be auocilfed with a high
iDcideDce of avucalar necrom.
THEHIP 199
9.91. Radiographs In the child (1): should touch 1he downward-pointing apex of Dyspluia of 1he acetabulum al1l:n ill slope
Interpretation of hip radiographs in the older 1he acetabular e1emeDt of the ilium. Vertical (B), which der:teases with growth (it usually
child is depeodell1 on the presence of lines (Perkim' lines) should 1ben be drawn cines not exceed 30" at 6 months). There are a
OIS!dfialtion in 1be epiphysis of 1be femoral from tbe Iaterallimita of 1be acetabula. These number of other measurements of a
head. 'lbiJ narmally appears between 2 and 8 lines divide 1he legion of each hip into four specialised IUIIme that may be made (and
months, but is often delayed in DDH. The areas. The epiphy&is of lhe femoral head compared with tables detailing average values
position of the capital epiphysis in relation to should D.IKDlB!ly lie within the lower and relatiDg to age aDd sex) when a ~~~DR~ detailed
tbe other pelvic e1emrmbl mullt be cletmmined. inner quadrant (A), but in DDH the bead as~~e~~1111111ml of hip dyspbuia is equimi.
Fmt draw a horizontal line~ moves upwanis aod outwards (as at B).
liae) IICroll tbe pelvia. On each aide 1hil Sllemoa'a line (C) may be diltllrbed.
t.tt. bdlographs (2): Th a11ess joint

developmmll after lrubnent fur DDH the
followiDg may be DOted (a) 1be centre-edge
angle (CE, of WJ.berg); and (b) the acetabular
index (AI angle). (V i1 a vertical, C the came
of 1he femoral head, T an acetabular qe
tangent, M is 1be midpoint of a line joining
1he 8(ldabular margin&, P a vertical drawn
from iL) AdditicB!al information regarding tbe
Mad, aa5tabulum and limbus may be
obtained by MRI sc:ans or contrast
arthrography.
ZOO CLINICAL OR'IHOPAEDIC EXAMINATION
9.100. Component lootenlng•fter toW im:reasc in the distance (6) betwcea. the ~ ce~~~eBt llld bone (8) or between lhe stem. aod
hlp r.piiCIIIIIInt: Tile cup (C)I The wile of the cup md 1be ischium may be llllggeative the cemt:111t. Notr; any chaqc in lhe angle
lllliJbr (I) aUDk within 1be radiolucad. cup of mipiion, although mrors of pollilioniog betwem the lltM of the fanur llllli prollthRic
aida the analym of my ndiognpbic amirs. llllllmbelfilm di~~W~~:es ma.lo= Ibis a little stem. (9), or lillY locallxmt dillturbance (10).
The plaDe {2) of the ~ lief It Ill mg}e ume1iablc. Dcvelopm:Dt of a radiolucaat ~ Clleck for liakiDg of 1be prosthesis, by DOting
(3) to the plaDe of the pelviJ (4), ilhown by I \1) (between eema1t lllld bone) excccdiD& I the diJtaDice betwecD. the UpptZ edge of 1be
line drawn bctwccD 1be UcblaJ. mberoaitics. mm 81111 CD:blling right round the cup u a acetabulum llld tbc greater 1JOChaiDt:r (11).
This angle may be al.tlnd (~ by rotBdon of strcmg iDdH:ator of~- (Note 1hBt the NCIII-UDi.on of the pata" lroc:hantm: (12) md
the cup if it ioolen1. The cup may a1ao appeat"liiiCe of a radioluc:ent line between the wire fracture aDd frqmentalion (13) should
migJale proxilwllly: look for my dilltUitluce cenwnt 1114 a compo!lalt it dilpottie of allo be recorded.
in tbc rclldoDJblp betWCCD 1be wire markt:r loo&c:Ding.) The JteiD. (S): Look for I
md the fixed lwulm• '*' of lhe pelvis.. An mdioluc:ent zoue of IDDnl llum I mm ~
9.101. Component-: 'lbilitJIO'iag

leal of a problem tb.m was CJricjnally
mlicipllllld by boch ~urpou~llllll patients, but
llhould be aueMed.. Wear iDvolve• the lloftr.r
~eeabiiW ~ beld wee is
negligible. To clt4amiDt wear, ~ 1be uoz. RllcllotiNPhl: In 1bil (Dormal) t .10S. Hlp ftldlotnlphs: eampla of
SliP ~ 1be proltbecic beld aDd 1be wile 01am1ey rota~ hip~ 111c mm of pllthologJ (1): Aftr:t a total hip replacement
awtr:r Ill tbrir upprr aDd knwr limits.. Half lhe ~lhmis il well pW:m ThB grmlm" tbe Door of lhe acdabulum bu givm W11Y
1be ~ between 1llele it a lDtAIU1'e of trocbanlr!r is uniti-s in good~ - tbe IUid the cup is beoomina centrally cicplaoed
WCII' in lllc wall of the cup, 3 mm or more wires lllC ialact.. The bead of 1be 1\:monl
be.in&- ~ IIDOQIJt. compoacnt u coacentric with lhe ICCtabular
winl!lllllbr.
THEHIP 201
9.104. Plldlolotf (2): Aften 1Dtal. hip !'-1 05. PldhaiDgJ (3): In tbia case of IDtal 9.106. l'lllhalagJ (4): FollowiDg a
replacement the prosthe1ic deJ:D has fractured, hip rep~ the trochanteric wires have dialooation of the blp which was successfully
with loas of tbe ability to weigbtbear. Note bmlam; the lrol:banta" has dispW:ed reduced, this palilmt cmnplainm of great
the cement, which baa extruded into the proximally and failed to unite. The BWn baa stiffness in the hip. Note the extensive DeW
pelv.il duriDg the iDsertiol1 of the device. loo8e.aed, and it8 diltal CDd i1 in danger of ~ formation around tile joint
There is IIOJ11e evidence of loosening of bolh broaching the femoral cortex. Note the ~ myosilis ossificaDs.
the cup and the slim. extmui.ve tnmal.ucem:y at the !Jone.-agnent
intmace.
9.1 07. l'lldlolotf [5): Note the gro111 distmtion of the pelv.is.
Diagnolil: trlradiate pelv.is, in this cue 8CCOIIdary to ~a.
!t.1 DL PlllhDiogy (e): In the left hip (right af the illuldndion) the
femoral epiphysiJ is smaller 1llan on the otbcr side, and tile slope of
the acclabulum greater. SheDton'a line ia clisrupllld. H Perkin&' aquarea
1118 COII&Inl£ted, the ~phyais of the fmnoral head will be 11e1111 to lie in
the upper and ouler quadrant. (Compare these findinp 'With the other
side.) There is IIOJ11e atrophy af lhe femoral shaft, suggeatiDg a
loDg-atandiDg lesion.
Diagnolil: developmmtal disloc:alion of the left hip.
:Z02 CLINICAL OR'IHOPAEDIC EXAMINATION
t.1ot. PdaalogJ (7): There ia diatorlion of both femoral bead&, t.110. hthDiogJ (I): The left hip U dialoc:ated IIDd the femonll
wbieh have b«:ome l1ut'b Wped, and 1here ia altenlion of the head aJrophic; on the right the tanoraJ. head i• poorly c:ontainecl in the
neclr.---ihaft angie~. ac:etlhalum, and ~ lll'e early ollteolrlllritic cbaDge8 in the joint.
DlapoiiJ: CODgCDital coxa vlltiL BOih aeetabuJa are poorly developed. and 1hclr slope Is markedly
~
Dlaplolil: UDtieated devdopmeDtal dilloc:ltion of the hip.
9.1 11. PdaalotJ It): 'lbcre lll'e 'IIVidelplcad C)'ltkl cbaage• in both
femora IIDd the pelvia.
Diapom: in 1hia c:ue the abuomW appeannc:ea are due to
9.1 1 :a. htholofly (1 O): Thia radiograph of the pelvis of an
hyperparathyroidiam.
ldolctc:eDt boy ahowa grou clcltl'llclion of the right hip joint, with
change• in both the bead of 1hc femur and the acetabulum.
Diapolil: the a~ are typic:a1 of an iD:fec:tiw llrthrilia. In lhi•
c:ase the mpDiam WU the tubercle b.cillDL
THEHIP 203
t.113. Pmhology (1 1): Thisla!mal. 9.115. Pathology (13): The complaint is of

projection of the hip shows displacement of pain and lll:iffness of the hip following a hip
the proximal femoral epiphysis relative to the fraaure 2 years prcvi.oo.sly. The fracture waa
femoral neck. t.114. PllthGICIIJ' {12): The paiDier marb a treated by nailing; the il1temallixalion deville
Diapo&UI: &lipped femonll!piphyBi!l. ringed msa of bone ia the femoral DrJCk with WBll sub&eq111111111y removed, and there 178
a cenlrlll nidus. This waa the source of SllDle very miDm: changes <mly in bone
c:hronk:, niggling bone pain. texlllre ID show its previou1 ptaeDCe.
Dlapo&ls: tile IJiA)ry and. X -ray appearance D~ eollap11e of tile femoraJ. head due
m: typical of oiiiCOid oltCOIDa. to avucular necm&i11. 'There arc lleOOIIdary
ollleoalthritic changes in the hip.
9.116. Pmhology 114): 1bere u marlmd disturbm:e of the bony

textum, maiDly involving the right hemipelvi11. 'Thm! is a desree of
pmttusi.o acetabuli, and there is disturbance of the architecture of the
hcmipelvis, which is ~ cen1rally displaced. t.1 17. htholorw 115): 1bc cpiphyais of die rlgbt femoml bead is
Dlaposil: Paget's disease. IIIIllll and. of increased dcuity. 1bere ia IODle broadeniag of tile
IIIIItllphysis, and thml are IIOIIle cystic changes in the roof of the
acetabulum.
Diqnolil: PerdJcr,' disease.
:Z04 CLINICAL OR'IHOPAEDIC EXAMINATION
9.118. PdMIIogy (te): There iJ ~ued 9.119. PMholagy (17): There is 9.1.:10. ~alagy (1 1): '1."bere ia separation
deDiity of k capital epipbylil llld IOlDe fragmmlldjm of d1e llapitll epiph)'Jia. with aor:l con.pee of k la1ll:nl part of the
cyJtie dwlgc ia tbc metlpbytia. which u 1bc JRICII.Ce of Gqe'l lligo. cpipllytia, will! diaonioa of d1e epipb:yleal
llhowinf sip of brolllleuia& 1'bln are alJo Diqaolil: Pm1hes' d i - . plate ad cyatic cbmgel in the metaphysis,
10111e cyme c:banae• ia the outer balf of tlu: which ia ~ The lxme dmimty, which
acetabulum. Tile Ilea of IIClc:roliJ &loa& k Wll pmiO\IIIy illc1alcd, il rdumiD& to
.inferior margir1 of tile C}'lt u IC.IJ!dime1 normal.
referred IC » tile 'll&liD& rope' alp. ot.polil: loec~ftlhlilbed Pmtbes' di1-.
Diapam: ~· diaeale. Thia would be clacribed. as grade C in the
Herrin& clauificltion of Pertbea' eli-..
9.121. PatM~otJ (tt): There are 9.122. . . . . . . . (20): The floor of the t.12J. PldMIIofrQO): 'lbleis gron
~ chaDges in booe tesan bathe ICCtabulum u projectiag imo tile pelYil. IJ8I:IOWiac of tbe bip joint JpKe.
femur D:l pclYUI, boCilllavia& a moth-ealal 'l'bl:rc il Dlll'01riDg oftbc joint epace,IDila Dilpalll: ~til.
miDor deple of IIIIII:giDalsoiiDiil fanDEoo.
·~IIIIIWbllic boDe diJeue.
J)iapama: Diapalll: 01tl:oaltbritb with prolnuio
acetabuli.
10
The knee

Swelling ofthe knee 208
Extensor mechanism ofthe knee 209
Ligaments ofthe knee 110
Rotatory instability of the knee 212
Lesions of the menisci 113
Patellofemoml instability 114
Retropatellar/anterior knee pain
syndromes/chondromalacia
patellae 115
Osteochondritis dissecans 115
Fat pad injuries 116
L..cose bodies 116
Affections of the articular
surfaces 116
Disturbances of alignment 117
Bursitis 117
How to diagnose a knee
complaint 118
Inspection 221
Testing the quadriceps and extensor
mechanism 222-223
Diagnosing effusion 223-225
Tenderness 225-228
Genu valgum, genu varum and stress
instabilities 128-132
Examining the cruciate
ligaments 233-135
Pivot shift tests 235-236
Menlscal testing 136--238
Patellar assessment 239-240
Radiographs 241-142
Aspiration of the knee 143
Pathology 143--247
Flg. 10.A.
ANATOMICAL FEATURES
The knee joint (Fig. lO.A) combines three articulatiOilll (medial tibiofemorat
(M), lateral tibiofemoral (L) and patellofemoral (P)), which share a common
synovial sheath; anteriorly, this extends a little to either side (1) of the
patella and an appreciable amount proximal to its upper pole (2). This
portion, the suprapatellar pouch, lies deep to the quadriceps muscle.
There is little congruency between the articular swfaces of the tibia and
femur; as a result, there is a well developed system of ligaments to give the
knee stability, and an arrangement of intra-articular menisci to reduce the
contact loadings between femur and tibia.
LIGAMENTS
1. The lateral ligament (3) extends between the lateral cpi.condyle and the
head of the fibu1a
2. The medialliganaent (4), consisting of superficial and deep parts, is
attached above to the medial epicondyle of the femur, and below to the
medial sarface of the tibia on either side of the semimembranosus
groove.
3. The 01lterior C111Ciate ligament (5) runs between the tibial plateau
anteriorly and tbe lateral femoral coodyle posteriorly.
THEKNEE 207
4. The posterior cruciate ligament (6) I1JDS between the tibial plateau
posteriorly and the medial femoral coodyle anteriorly.
Bodl cruciate ligaments lie within the confines of the intercondylar
notch of the femur, thereby avoiding being trapped between the articular
surfaces during movement of the joint.
5. The posterior ligament (J) is attached to posterioc aspects of the femur
and the tibia just outside their articular margins.
Daring 1he last 100 oc so of lmee extension the ligameots of the joint are
twisted taut as a result of medial rotation (8) of the femur on the tibia; at the
start of flexion, this tightening is u.odonc by lateral rotation of the femur,
aided by contraction of the popliteus IllU.IICle.
MENISCI
In plan view the medial (m) and lateral (I) menisci are C-shaped; they are
triangular in cross-section, and formed from denae avascular fibrous tissue.
Their extremities (horns) (9) are attached to the upper surface of the tibia on
which they lie; the posterior hom of the lateral meni8CU8 has an additional
attachment (10) to the femur, whereas both mterior horns are loosely
connected (11). The concave margin (12) of each meniscus is unattached;
the convex margin of the IBt.erlll meniscus is aru:horcd to the tibia by
coronary ligaments (13), whereas the com:sponding part of the medial
meniscus is attached to the joint capsule (14) and thereby loosely united to
both femm and tibia.
During extemion of the knee (15) the menisci slide forwards (16) on the
tibial plateau and become progressively mm: compressed. adapting in shape
to the altering contours of the pu1icular portions of the femur and tibia
between which they come to lie.
Only the peripberal edges of tbe memsci have liD appreciable blood
supply, so that meniscal tears that involve the more central portiODJ have a
poor potential for healing.
BURSAE
Numerous bursae have been described round the Jrnee, but from the practical
point of view only a few are of my real significance.
At 1he front:
(a) The suprapatellar poiiCh (SP) or bursa is a normal extension of the
synovial compartment of the knee; it may become prominent as a result
of a joint effusion, but treatment is always directed at the underlying
cause ratber than this local effect.
(b) A preptJtellar bwsa (PP) may form between the patella and the
overlying skin as a result of repeated local friction, e.g. from kneeling.
(c) An infrapatellar bursa (IP) may form between the skin md the tibial
tubercle m patellar ligament. again Ullually u a result of local friction
from kneeling. Bursae forming deep to the patellar l.i.gament (DIP) also
occur, but are rather uncommon.
At the back:
Buaal enlargements may be encountered in tbe popliteal fossa. and these
are generally refeacd to as Baker '.r cyst.r m eolargcd .remimembTtlliOnu
b11ntuJ. Some are found to communicate with the knee joint (&ametimcs
with a valve-like mechanism), and tend to bep pace in terms of distenaion

with any effusion in the knee.
Others are quite unconnected with the joint The anatomical explanation
is that although the semimembranosus bursa (SM) itself never communicates
with the knee, it is ofren connected to the bursa (G) under the medial head
of gastrocnemius, which does.
SWELLING OF THE KNEE

The knee may become swollen as a result of the accumulation within the
joint cavity of excess synovial fluid, blood or pus (synovitis, haemarthrosis,
pyarthrosis). Much less commonly, the knee swells beyond the limits of the
synovial membrane. This is seen in soft tissue injuries of the knee, when
baematoma formation and oedema may be extenaive. It is also a feature of
fractures, infections and tumours of the distal femm, where confusion may
result either from the proximity of the lesion to the joint or because it
involves the joint cavity directly. Although primary tumours of the knee are
rare, in malignant synovioma there is striking swelling of the joint, and this
often extends beyond the limits of the synovial cavity.
SYNOVITIS, EFFUSION
The synovial membrane secretes the synovial fluid of the joint; excess
synovial fluid indicates some affection of the membrane. Joint injmies cause
synovitis by tearing or stretching the synovial membrane. Infections act
directly by eliciting an inflammatory response which causes the synovial
membrane to secrete more fluid. The membrane itself becomes thickened
and its function disturbed in rheumatoid arthritis and villonodular synovitis;
both conditions are usually accompanied by large effusions. In long-standing
JDelli.scus lesions and in osteoarthritis of the :knee the synovial membrane
may not be directly affected, and consequently no effusion may be present
in cithec of these conditions. Minor injuries of the knee which do not
materially damage any of the main stiUctural clements are in some cases
followed by rather persistent effusions (traumatic synovitis). In spite of
these exceptions, the recognition of fluid in the joint is of great importance.
Effusion indicates damage to the joint, and the presence of a major lesion
must always be eliminated. A tense synovitis may be aspirated to relieve
discomfort.
HAEMARTHROSIS
Blood in the knee is seen most commonly following acute injmies where
there is tearing of vascular structures. The meniaci are avascu1ar, and there
may be no haemarthrosis when a meniscus is tom. Bleeding into the joint
will take place, however, if the meniscus has been detached at its periphery,
or if there is accompanying damage to other structures within the knee (e.g.
the cruciate ligaments). In injuries of the medial ligament, a baematoma
may track distally without involvement of the joint cavity. Nevertheless, the
presenc:e of a hamw:throsi.s generally indicates a substantial injury to the
joint and is a serious finding. Its physical presence alone may give rise to
great discomfort and make diagnosis of its underlying cause rather difficult.
In view of this a tense, painful hacmarthrosis should be aspirated.
THEKNEE 209
PYARTHROSIS
Infectiona of the knee joint are rather uru:ommon, and usually bloodbome.
Sometimes the joint is involved by direct spread from an osteitis of the
femur or tibia; rarely the joint becomes infected following surgery or
penetrating wounds.
In acute pyogenic infections the onset is usually rapid and the knee very
painful; swelling is tense, tendemeas ia widespread, and movement resisted.
There is pyrexia and general malaise. Pyogenic infectiona occmring in
patients already suffering from rheumatoid arthritis often have a much
slower onaet. Although the joint is invariably swollen, other inflammatory
changes are often suppressed, especially if the patient is receiving steroids.
Tuberculous infections of the knee, now uncommon in the UK, have
a slow onset spread over weeks. The knee appears small and globular,
with the associated profound quadriceps wasting contributing to thiJ
appearance.
In gonococcal arthritis, great pain and 1codcmess, often apparently oot of
proportion to the local swelling and other signa, are the striking features of
this condition.
When pus is suspected in a joint, aspiration should always be carried out
to empty it and obtain specimena for bacteriological examination. If
tuberculosis is suspected, synovial biopsy to obtain specimens for culture
and histology is required. All knee infections are treak:d by splintage and an
appropriate antibiotic regimen.
EXTENSOR MECHANISM OF THE KNEE

Extemion of the knee is produced by the quadriceps muscle acting through
the quadriceps ligament, patella, patellar l.igament and tibial tubercle.
Weaknu& of extension leads to instability, repeated joint trauma and
effusion. There is often a vicious circle of pain -+ quadriceps inhibition -+
quadriceps wasting -+ knee instability -+ ligament stretching and further
injury-+ pain. Lrus offtdl uten.rion also leads to instability, as there is
failure of the screwhome mechanism which tightens the ligaments of the
joint at terminal extension.
Rapid wuti.ng of the quadriceps is seen in aU painful and inflammatory
conditions of the knee. Weakness of the quadriceps is also sometimes
found in lesions of the upper lumbar intervertebral discs, u a sequel to
poliomyelitis, in multiple sclerosis and other neurological disorders, and in
the myopathies. Difficulty in diagnosis is common when the wasting is the
presenting feature of a diabetic nemopathy or secondary to femoral nerve
palsy from an i.li.acus baematoma. Maintenance of good quadriceps tone and
breaking the quadriceps vicious cirele is an essential part of the treatment of
virtuaUy aU conditions affecting the knee joint.
Disruption of the extensor mechanism of the knee is seen in a number of
conditious. Fractures of ~ patella seldom give difficulty in diagnosis
provided the appropriate radiographs are taken. Ruptures of the qiiOdriceps
tendon or patellar ligament result from sodden, violent contraction of the
quadriceps and are seen in the middle~ when there has been some
~ying degenerative change in the structures involved Avul&ion of
the tibial fUbero.rity may also be seen as a result of a sudden muscle
contraction. All these acute cooditiona arc generally trca1cd smgically.
There are a number of conditions short of di.mlption which may affect

the patellar ligament and its extremities, with the generic title of jumper's
knee. In the Sinding-l.Antm-Johmtsson rpulro~M, seen in children in the
1(}-14-year age group, there is aching pain in the knee associated with
X-ray changes in the distal pole of the patella. Osgood-Schlatt~r:t diseas~
(which is often thought to be &e to a partial avulsion of the tuberosity)
occars in the 10-16 age group. There is recurrent pain over the tibial
tuberosity, which becomes tender and prominent Radiographs may show
partial detachment or fragmentation of the tuberosity. Pain usually ceues
with closure of the epiphysis, ami the management is usually COiliCIVllti.ve.
In an older age group (16-30) the patellar ligament itself may become
painful ami tender. This almost invariably occars in athletes, ami there may
be a history of giving-way of the knee. cr scans may show changes in the
patellar ligament, which becomes expanded cen1rally. Exploration and
incision of the patellar ligament is usually advised. Rarely, pain ami
tenderness may occur proximal to the upper pole of the patella in
quodric~ps tendinitis.
LIGAMENTS OF THE KNEE
The cruciate, collateral, posterior and capsular ligaments, and the meDisci.
form an integrated stabilising system which prevents the tibia from shifting
or tilting under the femur in an abnormal fashion. The pathological
movements that may occur after ligamentous injury are (a) tilting of the
knee into varus ot valgus, (b) shifting of the tibia dm:dly forwards or
backwatds (anterior ot posterior translation), and (c) rotation of the tibia
under the femut so that the modi.al or lateral tibial condyle subluxes
forwards or backwanls.
Ligament injuries are important to detect as they may account for
appreciable disability, in the form of incidents of giving way of the joint.
recurrent effusion. lack of confidence in the knee, difficulty in undertaking
strenuoas or athletic activities, and sometimes trouble in using stairs or
wal.king on uneven ground.
The diagnosis and interpretation of instability in the knee is difficult and
somewhat controversial. for the following reasons:
1. Several structures may be damaged simultaneously.
2. Each of the main ligamentous structures around the knee baa primary
and secondary supportive functions: if a ligament whose primary role
in averting a certain abnormal movement is tom. that movement may
nevertheless be prevented by other structmes whicb have a secondary
supporting function. Later, however, the secondary structures may
stretch, giving rise to increasing disability. As a result. the symptoms
and clinical signs may be masked during the initial stages, and only
become obvious later.
3. A plethora of terms describing these instabilities makes the interpretation
of the literature somewhat difficult The preaent trend in both examination
and management is to analyse and treat the instability; less emphasis
is placed on the diagnosis of tbe precise anatomical disturbance.
Nevertheless, 1be main supportive structures have certain distinctive
feamres which should be noted.
THEKNEE 211
THE MEDIAL LIGAMENT AND CAPSULE

The medial ligament stretches between the femm and the tibia and has both
superficial and deep layers. Considerable violence (usually in the form of a
valgus strain or a blow on the lateral side of the knee) is required to damage
tbe medial ligament. When the forces are moderately severe a few fibres
ooly may be tom, usually near the upper attacb.mem (sprain of the medial
ligament). Then. when the knee is examined clinically. no inatability will
be demonstrated. but stretching the ligament will cauae pain. Minor tears
of the medial ligament may be followed eventnally by calcification in the
accompanying haematoma, and this may give rise to slwply localised pain
at the upper attachment (Pellegrini-Stieda di11C8Be).
With greater violence the whole of tbe deep part of the ligament ruptures,
followed in order by the superficial part, the medial capsule, the posterior
ligament. the posterior cruciate ligament, and sometimes finally the anterior
cruciate ligament Acute complete tears give rise to serious instability in the
knee, which can move or be moved into valgus. They are uaually dealt with
by immediate surgical repair. Partial tears do well by immobilisati.on for 6
weeks in a pi~stem plaster. Chronic lesiona may be accompanied by tibial
condylar subluxation (liCe later), although there is some doubt as to whether
this is indeed possible without there being some additional damage to the
anterior cruciate ligaJW:J~t. Swgical treatment may be indicated for sw::h
instability. Medial ligament tears may accompany fracturea of the lateral
tibial table, which will require additional attention.
THE LATERAL LIGAMENT AND CAPSULE
This ligament may be damaged by blows on the medial side of the lmee,
throwing it into varus. It most frequently tears at its fibular attachment. As
in the case of the medial ligament. inaeasina violence will lead to tearing
of the posterior capsular Hgament and the cruciates. In addition, the
common peroneal nerve may be stretched and sometimes irreversibly
damaged. These injuries are usually treated by operative repair and. where
applicable, exploration of the common peroneal nerve. Again, any
associated fracture of the medial tibial table may require attention. Chronic
lesiODB may be associated with b"bial condylar subluxations.
THE ANTERIOR CRUCIATE LIGAMENT
Impaired anterior cruciate ligament function is seen most frequently in
association with tears of the medial meniscus. In some cases this is due to
progressive s1retching and attrition IUpture of the ligament. (This may occur
if an attempt is made to obtain full extension in a knee blocked by a
meniscal fragment) In others, the anterior cruciatc ligament tears at the
same time as the meniscus, and in the most severe injuries the medial
ligament may also be affected (O'Donoghue's triad).
Isolated ruptures of the anterior cruciate ligament are uncommon and are
not usually treated surgically unless accomp8Dicd by avulsion of bone at the
anterior tibial attachment. or if there is a strongly positive pivot shift test.
When the tear is acute and accompanies a meniscal. lesion, the Dlaliscus
is preserved if at all possible to reduce the risks of tibial subluxation and
secondary osteoarthritic change. although the damage may be such that
cxcisioo caDDOt be avoided. After attcotion to the meniscus, many would
then advocate direct repair of the anterior cruciate ligament, supplemented
by a ligament reinforcement or a recoDStruction procedure (e.g. using part

of the patellar ligament and its bony attachments). When an acute anterior
cruciate tear is associated with damage to the medial or, less commonly,
the lateral collateral. ligament, a similar approt~Ch may be employed.
Ouonic anterior cruciate ligament Jaxity generally remits from old
injuries, and may cause problems from acute, chronic or recurrent b"bial
mbluxations. There may be a history of giving way of the knee, episodic
pain and functional impairment There is often quadriceps wasting and
effusion, and secondary osteoarthritis may develop. Intense quadriceps and
hamstring muscle building is usually advised as a first mcuure. In resistant
cases, a ligament reconstruction may be advocawl. There is no doubt that
these procedures are often initially vccy 5\lCCessful, but in some the long-
term results are disappointing.
THE POSTERIOR CRUCIATE LIGAMENT

Posterior cruciate ligament tears are produced when in a flexed knee the
tibia is forcibly pushed backwards (as, for example, in a car accident when
the upper part of the shin strikes the dashboard). Most advise immediate
smgical repair if the injury is seen at the acute stage, as persisting instability
and osteoarthritis are common sequelae in the untreated case.
ROTATORY INSTABILITY OF THE KNEE:

TIBIAL CONDYLAR SUBLUXATION$
In this group of conditions, when the knee is stressed the tibia may sublux
forwards or baawards on either the medial or lateral side, giving riae to
pain and a feeling of iDstability in tb: joint. The main fODDS are as
follows:
1. The medial tibiiJJ condyle subhau ~riorly (anteromedial rotatory
instability). In the most severe cases this occun as a result of tears of both
the BDterior cruciate ligament and the medial sbUctures (medial ligament and
capsule). The medial meniscus may also be damaged and con1ribute to the
instability. In the less severe cases there is some controveny regarding
which structures may be spared. Clinically, the condition should be
suspected on the evidence of the BDterior drawer and Lacbman tests, and
the demonstration of instability on applying a valgus stress to the joint
2. 1'he lateral tibial condyle subluxes anleriorly (anterolateral rotatory
instability). In the more severe cases the anrerior cruciate ligamen1 and the
lateral structures are torn. and there may be an associated lesion of the
anterior horn of the lateral meniscus. It may be diagnosed from the results
of the anterior drawer and Lachman tests, and by demonstrating instability
on applying a varus stress to the knee, although a number of specific tests
may afford additional confirmation.
3. The lateral tibial condyle subluxes posteriorly (posterolateral rotatory
instability). This may follow rupture of the lateral and posterior cruciate
ligaments, and be recognised by the presence of instability in the knee on
applying varus stress. in combination with eliciting an abnorma1 posterior
drawer test. There are also specific tests for this instability.
4. Combination.r of these le.Jioru (particularly 1 and 2. and 2 and 3)
may be found. espcciaDy where there is major ligamentous disruption of
tbe knee.
THEKNEE 213
Where symptoms are demanding, and when a firm diagnosis baa been
established, the stability of the joint may be restored by an appropriate
ligamentous reattachment or reconstruction procedure.
LESIONS OF THE MENISCI

CONGENITAL DISCOID MENISCUS
This abnonnality, most frequently involving the lateral meniiiCWJ, commonly
gives rile to presenting symptoms in childhood. The meniscus has not its
usual semilunar form but is D-shaped, with its central edge extending in
towards the tibial spines. It may produce a very pronounced clicking from
the lateral compartment, a block to extension of the joint, and other
derangement signs. It is usually treated by excision.
MENISCUS TEARS IN THE YOUNG ADULT

The commonest cause is a sporting injury, when a twisting strain is applied
to the flexed, weigbtbearing leg. The trapped meniscus commonly splits
longitudinally, and its free edge may displace inwards towards the centre
of the joint (bucket-handle tear). This prevents full extension (with
physiological locking of the joint), and if an attempt is made to straighten
the knee a painful elastic resistance is felt ('springy block to full extension').
In the case of the medi.al meniscus, prolonged loss of full extension may
lead to stretching and eventual rupture of the anterior cruciate ligama1t
The aim in treating meniscal tears is to coacct the mechan;cal problems
that they have created within the joint, while if at all possib1e preserving as
much of each meniscus as is possib1e; this, it is thought, will reduce the
risks of instability and the onset of sccondar:y osteoarthritis. In many cases
the tom part of the meniscus (e.g. the handle of a bucket-handle tear) only
u excised, bot some major menisca1 tem may require total meniscectomy.
In peripheral detachments and certain other lesions, particu.l..arly those near
the periphery of the meniscus, repair by direct suture or other measures is
sometimes attempted. Many surgical procedures are performed
arthroscopically, thereby facilitating early recovery.
DEGENERATIVE MENISCUS LESIONS IN THE MIDDLE-AGED
Loss of elasticity in the menisci through degenerative changes associated
with the ageing process may give rise to horizontal cleavage tears within
the substance of the meniscus; these tears may not be associated with any
remembered traumatic incident, and sharply localised tenderness in the joint
line is a common feature. In an appreciable number of cases symptoms may
resolve without smgery, although this may sometimes be required.
CYSTS OF THE MENISCI

Ganglion-like cysts occur in both menisci, but are much more common in
the lateraL Medial meniscus cysts must be carmuuy distinguished from
ganglions arising from the pes anscrinus (the insertion of sartorius, gracilis
and semitendinosus). In true cysts there is often a history of a blow on the
side of the knee over the meniscus. They are tender, and as they restrict the
mobility of the menisci tbey render them more sosoeptible to tears. They are
geocrally treated by excision. and some1imcs simultaneous :mcoisccctomy
may be required, especially if tbere are problems with recurrence. Some
workers believe that all meniscal cysts have an associated tear, and prefer to
deal with the problem by arthroscopic resection of the tear and simultaneous
decompression of the cyst through the substance of the meniscus.
PATELLOFEMORAL INSTABILITY
The patella hu always a tendency to lateral dislocation as the tibial
tuberosity lies lateral to the dynamic axis of tbe quadriceps (Fig. lO.B); any
tightoess in the extensor mechanism (e.g. from quadriceps contractions or
fibrosis) generates a l.aleral component of force that tends to displace the
patella laterally. Normally, at the beginning of knee ftexion the patella
engages in the groove separating the two femoral condyles (the trochlea),
and this keeps it in pl..ace as flexion continues. This system may be distwbed
in a number of ways. The side thrusts that tend to canse the parella to
sublux laterally may be increased by an abnormal lateral insertion of the
quadriceps, tight lateral structures, or by increases in the angle between the
axis of the quadriceps and the line of the pabillar ligament (e.g. as a result
of knock-knee deformity, or by a broad pelvis). The J.areral condyle which
suppo118 and guides the patella may be deficient, or the patella itself may be
small and poorly formed (hypoplasia). If the patella is highly placed (parella
alta) it may fail to engage in the condylar groove at the beginning of flexion.
Fig. 1o.a. SOIIl8 factlln re1.aias to Jl*lhr (This condition is often associated with genu recurvatum.) Medial to the
instabilily. Becallle the quaddcep• lllld the
J.l*llat 1igamat meet • In qle (Q angle) patella the soft tissues that would normally help prevent an abnormal lateral
tba:e il a lalmal coiDpllDall of fon:e when the excursion of the patella may be deficient, sometinles as a result of stretching
qiWiril:epl COD!ncta, IIIIi thb lmJda to from previous dislocations.
disloc:D the patdJ.a lalrnlly (a). "I"bU is
raimd by the femonJ. l1lk:ul in which the There are a number of conditions ch.aracterised by loss of normal patellar
pueUa liu, - tbe ~ o( the lallnl. alignment
femcnl a.dyle (b). This mech•nii!D may he
iJRdaed. with by m abaonoal t.lrn1 Acute traurutic dislocation of the patella This injury occurs most
iua1im of the quadDI:ept (c).. or m iDcreue frequently in adolescent females during atblelic activity (e.g. playing
mtbe Q mg1e (e.'" in knock bee) (d). The
J.JIIr:ml femonJ. caadyle may he hYJlllPlulic hockey). There may be a history of a direct blow on the inside of the knee.
md. the c:oodylar 1ulcua lba1low (e); ar the The patella dislocates laterally and causes a strlking deformity, which has
pueUa ibelf may be hypoplutic (f). The often reduced by the time the patient is first seen. If still displaced it is
pueUa may be highly pbced. specially in
genu recurndum (g), 10 that it fai.la to ~ reduced, and a period of fixation in a cylinder plastr:r is usually advised in
in 1he amdylar gutlm. all cases. Some advocate exploration, with n~efi.ng of the medial structures
and release of those on the 1atera1. side.
Recurrent l.tenll dislocation Further painful dislocations of the patella
occur. often with increasing :frequency and ease. Surgical stabilisation is
usually adYised in the well established case, to reduoe the risks of seccmdary
patellofemoral. osteoarthritis and prevent the danger that the patient might be
exposed to should the dislocation occur in a hazardous situation. The type of
procedure carried out is aimed at correcting the underlying defect. which
should be established by investigation.
Congenital dislocation of the patell• The patella may be dislocated at
birth in IWociation with congenital abnormalities. The dislocation is
irreducible. Surgical correction is difficult, and the results often poor.
H•bltual dislocation of the patella The patella dislocates every time the
knee flexes, and this is pain free. It often arises in cbildbood and may be
due to an abnormal attachment of the iliotibial tract. In a number of casea in
the neooatal period it result8 from fibrosis in a quadri.ccps muscle wbich bas
THEKNEE 215
been used for intramuscular injections. The COildition also occws in joint
laxity syndromes. In the established case there is usually a severe usociated
deficiency of the trochlea. It may be treaUd by extensive lateral releases,
medial reefing, and sometimes transposition of the tibial tuben:le.
Pennallent clisloation of the pateb This is uncommon, and may

result from an tmtreated childhood or adolesoenl dislocation. The patella is
pennaneotly displaced. and the power of the quadriceps and the strength
of the knee are greatly reduced.
RETROPATELLARIANTERIOR KNEE PAIN

SYNDROMES/CHONDROMALACIA PATELLAE
These are characterised by chronic ill-localised pain at the front of the knee,
often made worse by prolonged sitting, or walking on slopes or stairs. It is
commonest in females in the 15-35-year age group, and the pathology is
often uncertain. In some there is softening or fibrillation of the articular
cartilage liDing the patella (chondromalacia patellae), and some of these
cases progress to develop clear patcllofemoral. osteoartbritis.
Those suffering from retropatellar knee pain (anterior knee pain) may be
divided into two groups: in one no significant cause can be found, whereas
in the other there is evidence of patellar mala.ligmnent. In this latter group
some of the factors responsible for recurrent dislocation may be found to be
present (even although there may be no history of frank dislocation).
Altbougb symptoms are often prolonged. they are usually not severe and
may be dealt with by restriction of the activities known to aggravate the
symptoms, and by physiothaapy. In som.e cases, where symptoms are
particDlarly severe and unresponsive, and where there is evidence of
malalignment. lataal release and patellar debd.dc:ment procedures are often
practised. Where the articular surface of the patella is seriously involved,
patellectomy is sometimes advocated. Anterior knee pain was once thought
to be associated with excessive foot pronation, but this is oo longer
considered to be the case.
OSTEOCHONDRITIS DISSECANS
This occurs most frequently in males in the second decade of life, and most
commonly involves the medial femoral condyle. Possibly as a result of
impingemcnt against the tibial spines or the cruciate ligaments, a segmcnt of
bone undergoes avascular necrosis, and a line of demarcation becomes
established between this area and the Ullderlying healthy bone. Complete
separation may occur so that a loose body is f~ The symptoms are
initially of aching pain and :recurring effuaion, with perhaps locking of the
joint if a loose body is present. Good results generally follow conservative
treatnlalt with quadriceps exercises and continued weigbtbcaring if the
condition is found before epiphyseal closure. If the fngmc:.nt beco~s loose,
it should be fixed surgically. If the lesion is long standing. with a fragment
smaller than its cmer. it should be excised. The cavity may be drilled in an
attempt to eneourage vascularisation of its base. In all cases the damagjng
effects of a loose body must be prevented.
FAT PAD INJURIES

The infrapatellar fat pads may become tender and swollen and give rise to
pain 011 exteusi011 of the knee, especially if they are nipped between the
articulating smfaces of felllllr and bDia. 1'hill may occm 18 a complicati011 of
osteoarthritis, but is seen more frequently in ymmg women when the fat
pads swell in association with premenstrual fluid retention. Excision of the
pads may be required to relieve the symptoms.
LOOSE BODIES
Loose bodies are seen most frequently 18 a sequel to osteoarthritis or
osteochondritis dissecans. Much less commonly, numerous loose bodies are
formed by an abnormal synovial membrane in the condition of synovial
chondromatosis. Loose bodies are treated by excision, but synovectomy
may be required in synovial chondromatosis if massive recurrence is to be
avoided.
AFFECTIONS OF THE ARTICULAR SURFACES

OSTEOARTHRITIS (OSTEOARTHROSIS)
The stresses of weight-bearing mainly involve the DH:dial compart:ment of the
knee, and it is in this area that primary osteoarthritis usually first occurs. 1'hill
is an exc:eedingly common conditi011, arising without any obvious previous
pathology in the joint. Overweight, the degenerative changes accompanying
old age, and overwork are common factors. Secondary osteoartbritis may
follow ligunent and meniliCUS injuries, recmrent dislocati011 of the patella,
osteochondritis dissecans, joint infections and othec previous pathology. It is
seen in association with knock-knee and bow-leg deformities, which throw
additional mecbani~ stresses on the joint.
In osteoarthri.tia the articular cartilage UDdelgoea progressive change,
flaking off into the joint and thereby producing the narrowing that ia a
striking feature of radiographs of this condition. The subarticular bone may
become ebumated, and often small marginal osteophyte& and cysts are
formed. Exposure of bone and free nerve endings gives rise to pain and
crepitus on movement. Distortion of the joint surfaces ia one cause of
progressive loss of movement and fixed flexion deformities. 'I'rea.tmeot is
generally conservative, by quadriceps exercises, short-wave diathermy,
analgesics and weight R:duction. Surgery may be considered in severe cases.
The proc:edules available include joint repbwement, osteotomy (especially in
cases of genu varum and valgum) and arthrodesis.
Characteristically the knee is warm to touch, thele is effusion. limitation of
movements, m.usc1e wasting, synovial thickening, tcndcmess and pain. Fixed
flexion. valgus and (less commonly) varus deformities are quite common.
Generally other joints are also involved, although the monoarticular form is
occasionally seen. Active cases are often treated by synovectomy in an
attempt to avoid or delay the progress of the coodition. An acute fl~up of
symptoms may be treated by temporary splintage. Eitbc:c joint replacement.
osteotomy or arthrodesis may be considered in well selected cases.
THEKNEE 217
REITER'S SYNDROME
This usually presents as a chronic eft'usion accompanied by discomfort in
the joint. It is often bilateral, with an associated conjuru:tivitis. There is
often a history of metbritis or colitis.
ANKYLOSING SPONDYLITIS
The first symptoms of ankylosing spondylitis are generally in the spine. but
occasiooally the condition presents at the periphery, with swelling and
discomfort in the knee joint. Stiffness of the spine and radiographic changes
in the sacroiliac joints are nevertbeless almost invariably present.
DISTURBANCES OF ALIGNMENT
GENU VARUM {BOW LEG)
This commooly oocurs as a growth abnormality of early childhood. and
usually resolves spontaneously. Rarely genu varum is caused by a growth
disturbance involving both the tibial epiphysis and the proximal tibial shaft
(tibia vara), and treatme:nt by osteotomy may be ttquired. In adults this
deformity most frequently results from osteoarthritis, where there is
narrowing of the DXdial joint compartment. It also occun in Paget's disease
and rickets. It is kss common in rheumatoid arthritis unless secondary
osteoarthritic changes su~ in that condition.
GENU VALGUM {KNOCK KNEE)

This is seen most often in young children, where it is usually associated
with flat fooL Nearly all cases resolve spontaneously by the age of 6. It is
also seen in the plump adolescent girl, and it may be a contributory factor in
recmrent dislocation of the patella. In adults it most frequently OCC\ll'!l as
a result of the bone softening and ligamentous stJetching accompanying
rheumatoid arthritis. It occurs after UDCorrected depressed fractures of the
lateral tibial table, and as a sequel to a number of paralytic nemological
disorders where there is ligament stretching and altered epiphyseal growth.
Selected cues may be trea1ed by co.rrective osteotomy.
GENU RECURVATUM
Hyperextension at the knee is seen after ruptures of the anterior cruciate
ligament and in girls where the growth of the upper tibial epiphysis may be
retarded from much pointe work in ballet classes or from the wearing of
high-heeled shoes in early adolescence. In the latter cases there is
corresponding elevation of the patella (patella alta) contributing to a
teDdency to recurrent dislocation. More rarely, the deformity is seen in
congeuital. joint laxity, poliomyelitis and Charcot's disease.
BURSITIS
Cystic swelling occurring in the popliteal region in both sexes is usually
referred to as enlargement of the semimembranosus bursa. In fact, several
of the bursae known to the anatomist may be involved, either singly or
together. The swelling sometimes communicates with the knee joint and
may fllJCtuate in size. Rupture may lead to the appearanc:c of bruising oo tbe
dorsum of tbe foot, and this may help to distinguish it from deep venous
thrombosis or cellulitis. If there is any doubt about the diagnosis, or if the

swelling is persistent and producing symptoms, excision is advised.
Fluctuant bursal swellings may also occur over the pateUa (prepatellar
bursitis or hOWieiiiaid's knee) or the patellar ligament (infrapatellar bursitis
or clergyman's knee). Chronic prepatellar bursitis, with or without local
infection, is common in miners, where it is Mfemd to as 'beat knee'; it is
also associated with other oc:cupatioos where prolonged kneeling is
UDavoidable (e.g. it is common in plumben and carpet layers). If the
swelling is bulky or tense it is aspirated; recummt swellings, if troublesome,
are exciaed.
HOW TO DIAGNOSE A KNEE COMPLAINT

1. Note the patient's age and sex, bearing in mind the following important
distribution of the common knee conditions (Table 10.1).
Table10.1
Aeegroup Miles Feln•lft
Q--12 Discoid lateral meniscus Discoid lateral meniscus

12-18 Osteochondritis dissecans Ant lnddents of recurrent dislocation of
the patella
Osgood-Schlatter's disease Osgood- Schlatter's disease
18-30 L.ongitud inal meniscus tears Recurrent dislocation of the patella
Chondromalacia patellae
Fat pad Injury
30~ Rheumatoid arthrttis Rheumatoid arthritis
40-?5 Degenerative meniscus lesion DegeneratM'! meniscus lesion
45+ Osteoarthritis Osteoartttritis
Infections are comparatively unoommon and occur in both sexes in all

age groups.
Reiter's syndrome occurs in adults of both sexes: ankylosing spondylitis
nearly always occurs in adult males. Both are comparatively rare.
Ligamentous and extensor apparatus injuries occur in both sexes, but are
rare in children.
2. Find out if the knee swells. An e:llusion indicates the presence of
pathology, which must be determined. (Note, however, that the absence of
effusion does not necessarily eliminate significant pathology.)
3. 'I'ly to establish whether there is a mecbanical problem (internal
derangement) accounting for the patient's symptoms. Do this by:
(a) Obtaining a convincing history of an initiating injury. Note the
degree of violence. and its direction. Tbe initial incapacity is
important. For examp]e, a footballer is unlikely to be able to finish a
game with a freshly torn meni.SCllS. Note whether there was bruising
or swelling after the injury, and wbether the patient was able to
weightbear.
(b) A&Jcing if the Jaaee 'g~es way'. 'Giving way' of the knee on going
down stairs or jumping from a height follows cruciatc ligament teara,
loss of full extension in the knee, and quadriceps wasting. 'Giving
THEKNEE 219
way' on twisting movements or walking on uneven ground follows

many meniiiCils injuries.
(c) Aslcing if the we 'loeb '. PatientB often confuse stiffness and true
locking. Ask the patient to show the position the knee is in when and
if it loeb. Remember that tM latee never loeb ill ftill ateMioiL
Locking due to a tom meniscus generally allows the joint to be
flexed fully or nearly fully, but the lut 10-40° of extension are
impossible. Attempts to obtain full extension are aa:ompanied by
pain. Ask what produces any locking. With long-standing meniSCIJS
lesions a slight rotational force, such as the foot catching on the edge
of a clllpet, may be quite sufficient In chronic lesions weightbearing
is not an essential factor, locking not i.nfrequcntly occurring during
sleep. If the knee is not locked at the time of the patient's attendance,
ask how it became free: unlocking with a click is suggestive of a
meniscus lesion. Locking from a loose body may occm at varying
positions of flexion. Locking from a dislocating patella may be noted
to be accompanied by deformity.
(d) Asking about pain. Find out the ciNumstances in which it is present
and ask the patient if he can localise it by pointing to the site with
one finger.
In a high proportion of cases the likely diagnosis will have been established
by this stage, requiring only confirmation by clinical examination.
ADDITIONAL INVESTIGATIONS
Occasioaally a firm diagnosis cannot be made on the basis of the history
and clinical examination alone. The following additional investigations are
often bclpful.
Suspected lnterul derangement
(a) Arthroscopy may give much useful information, and in conjunction with
the clinical &:Tamination will permit a firm, accurate diagnosis to be
made in the majority of cases. lncom:ct diagnoses are most common in
lesions involving the menisci in their posterior thirds. An increasing
number of conditions are amenable to arthroscopic surgery, which can
often follow diagnostic arthroscopy in the !I8IIlC session.
(b) MRJ scans. These can be u!ICful in diagnosing lesions of the menisci and
ligaments, but it has been suggested that they should only be used if
there is diagnostic uncertainty. An accuracy of 90% is claimed.
However, there is often an increase in the sigllal intensity in the region
of the posterior third of the medial meniscus (from the myxoid
degeneration that may occur in the ageing process, or after previous
surgery), and this can lead to false interpretations.
(c) Arthrography may be helpful, although the intelpretation of the
radiographs is specialised and often difficult.
(d) Examination under fJIIMsthesia. If pain prevents full examination (e.g.
by preventing flexion) anaesthesia may be helpful This is frequently
followed by arthroscopy.
(e) Pruvocati'lle uerdses. These are canicd out under the supervision of a
trained physiotbempi.st. They aim to throw considerable stress on the
menisci by applying torsional stJesses to the weigbtbearing knee. If the
meniscus has been damaged. the cx.eroises are likely to be followed by
localised pain, swelling, and sometimes even locking, so that any

doubtful meniscus lesion is likely to declare itself.
Suspected acute infections
(a) Aspiration and culture of the synovial fluid
(b) Blood culture.
(c) Full blood count, including differential white count, and estimation of
the sedflnentation rate and C-reactive protein.
Suspected tuberculosis of the kn•
(a) Chest radiograph.
(b) Synovial biopsy, with specimens of synovial membrane being sent for
both histological and bacteriological e;x-amjnation.. At the same time,
synovial fluid specimens are also sent for bacteriology and sensitivities.
(c) Mantoux test.
Suspected rheumatoid arthritis
(a) Examination of other joints.
(b) Estimations of rheumatoid factor.
(c) Full blood count and lledimentation rate.
(d) Serum uric acid.
Further Investigation of poor mlneraiiAtlon, bone erosions etc..
(a) Estimation of senun calcium. phosphate and alkaline phosphatase.
(b) Estimation of rheumatoid factor.
(c) Serum uric acid.
(d) Full blood count and differential count.
(e) Skeletal survey and cheat radiograph.
(f) Radioisotope scan.
(g) Bone biopsy.
Further imastiglltion of chronic affusion. aspirate I"MMggltiw
(a) Tests as for suspected meumatoid arthritis.
(b) Brucellosis agglutination tests.
(c) Radiography of the chest and sacro:i1iac joints.
(d) Exploration and synovial biopsy.
Further Investigation of savere undlagnOHCI ,_In
(a) Radiography of the chest, pelvis and hips.
(b) Exploration.
THEKNEE 221
10.1. Swelling 11): No!e die praeooe of 1o.2. Swelling (Z): Notr:: whedler lbe 1o.s. Lum,.: NoUI pteeeDl)e of locali8ed
swelling confined to lbe llmill of the ayoovial .welliDg exteads beyolld tbe limits of die 1wdlillp, e.g. (A) preptlllillllr butailiJ
cavity and BUpnlplle1lar pouch. auggelting joint cavity, auggeatiag Wection (of the joim, (boutemalcl'• bee), (B) iDfrlpatellar butailiJ
eflillion. blcmlrthroli1, pyarthrolia or a femur or tibia). mmour or major ~ury. (ckqyman'a bee), (C) mc:aialu1 cylt (ill
space-occ:opyiDg lction in die joint jaint Uao), (D) diaphyeeal adaaiJ (excttotil,
oflca amltipk aad IOIJIC1imca familial). In
belt lmee (a common aflliclion in millers)
there il chnmic ll1ferior bunal enlargemr::Dt,
oflca with tltidmi"' of lbe overlyiDg etin.
10..4. Dlaallomlon: NoUI my bruiaiDs 10.S.. Sldn marks: Nolle (A) scars due to 1D.AL ,._,.,.IIINI1): No~e any iDaeued
wbid! sugeata trmma to the lllptricial pmmua ~ury or suraa:Y: the~ iDW beat aad iU extra, mggelliDs in
tissue• or kmle lipmenb. NoUI tbal bruiaiDs history IDIJSt be obtai.ued.. (B) Simu ~Car~ are particular rbr.nmarnid arthriti1 or infection.
i1 not 1UII.8lJ:y ~een in maailcu1 injuria. N Dill: illdk:ative of previous infectious, oflaJ. of 'Ibr.le IUY alJo be iDcreued local beat as
:my mfDe11 nge&tius lnflaTMDation ~xme. &lid with the po~~:nti.al fot reaaivmon. part of lbe infllllliiiiiiDry l.'elpCIIIJe 110 ~ury.
(C) Bvidra:e of ptoriasis, with lbe ~ll'bility and in !hr. ~ of l'llpidly growing
of piOriatic arthritis. lllaloun. Al-ys CCllllplll'e tbe two aides.
10.7. ,._...,.._ (2): A Wlll'lll kDce aad 1G.I. n. quadriceps (1): lupcct lhe 10.9. n. qadrlceps (2): Bxam!De 1hc
rold foot auggellt a popllical artery block. relaxed quadrklepa 111U1Clc. Slight walltiDg CODI:l'IAlUXI quadrl.cqll. Place: a haDd behlDd
Alwaya make allowaDcc for my wmn aad lou of bulk arc DOI'Dially apparent on the bee amd Ilk the palicnt to prea8 the leg
bandage the pllliaat may haW~ been -m, careful iDapectioa. agaiDat the bllld. Fed the ~ tOIIC wbh
juat prior to the cumlaaliOD, and check the your free lwld.
pedpbetal pQea.
10.10. Th• quMIIkllpl (J): Repeat the Jut 10.11. The q1111drlceps (4): SabllaatW 10.1.:1. The qlllldrlcep& (5): Compare the
- thia time a.UiD.s tbe patient to doni&x waiting, especially in the fat leg, may be clrcumference of the lep Ill the m.arbd
the inver2d :foot. 1'hia ~. the ~by measmema:lt, usumiDg the level&. Wutins of the ~ oa:un 1110t1t
importmlt vailtlla !lllidialia portion of the other limb is 1101111a1. This tat. bei.ll8 :frequmtly u the eaull of disme. g=ally
qtw!rlcepl, wbicb may be involved in objective, may be Vll1uable for repeat from a plinful or 1IIIStable leliml of tbe lmee,
rec:ummt di.aloadi011 of tiJe patella. UIIIIIIDIIDtl 111111 in medicolepl cue1. Begin or from infectioa or rbemnatnid a.rthrilia.
by kx:atillg the lmee joint<-121111' for
cl5aila) and ImlrkiDs it with a ballpoim pen.
Make a lleCODd IIWk on the akin 18 em above
lhil. Repeat c. the other leg.
THEKNEE 223
10.11. Exlllluonp.-mus(1): Lou of 10.14.. IEXtiansor appuatu~ (1)c With the 10.15• ........._apparatus (J): Note~
active exlal&ion of~ lmee (excludinJ patiellt &ittiag widl bia ll:p over the end of poaltion of~ pDlla in relalion to the joint
paralytic cooditiom) follows (I) l1lptllre of the examination couch, ask bim to straightm 1.inrJ ad the tibial tnberollity. If its upper
the quadrlcepl lrlldon, (2) many pDllar the leJ wbile you support the aDkle with one border i.a bi&h. lbi.a IUJPitl that it i.a
fractures, (3) ruptme of~ pD!hr lipmtm, baud. Feel fat qtWiri&:eps contndion and pmimally dispWzd and that you abould
(4) avulsion of the tibi.allllbercle. look fat active exlmSion of the limb. mapect leliOIIs 2, 3 or 4.
I \
10.1 6. l!dln.r . ..-mus (4): H !be 10.17. Extensor •,.,.ntu[S): Look for 10.11. Etfullon (1): Small cffusiolUI are
pe1rlla illl0l1lllll.y pJa=1. lay a fiD&cr alollg gaps IIDII t:elldemcalllt !be other level• to belp ~ molt cuily by inlpcc:tlaa. The lint
its apper border. Lo•• of IIOI'IDilaoft ti.aluc clifiCRI!Iille between leliona 2, 3 and 4. lip lrt bul&iDa at ~ aida of the Jllldlar
rtliltlllee il ~ of • nl]ltllm of the Radiograph& of !be bee 1rt calaltilll. lipmellt and obllicrlltlon of the hollow1 at
q.wlricep& IQdoa (1). ~ llltXIial and lalr:nl. cdaca of the pan:Jla.
10.19. Ethalon (1): Wilh Jl'C8ICI' dfuion 10.20. Effullon (3): paMIIar t.p t.t 10.21. Effullon(4):p8MIIart.p-.t(1):
lDto the Jmce the aupr8plldlar pouch becomca (ballott.ment test) (1): Squee.zc my exceaa Place the dpl of the drumb IUid three finger~
dblended Effiuion iDdlcatca I)'IID'rial aynoviallluid out of the aupt'11ptddlar pouch of the free haDd aquarcly on the pan:.Ua, aad
laiWiOD from ttauma or hrflammatlon. wilh the iDdelt 8lld lhumb, alid fimiJ:y dlatally jed it quiddy dowawarda toward& the fi:mur.
from a point about 15 c:m above the knee to A click u the ptW:Ila Jtrlha the c:oadylu
the level of the opp::r bo.rder of the paiC1la. l.odicalca the prtll':allC of cfl'u8i011. Note that
'lbi1 will allo 'float' the pafdla away from if the petdla ia DOt propcdy alcadied u
the fcmDn1 c:oadylu. delaibcd it will till, givillg a fal.e Depfive.
Note 100 that if the eJl'uJiOD ia rlqhl or tmH,
the lip l'.ett will be IVfG/iw.
10.22. Ethalon (51: tluld dllplae~~~~~ent 10.23. Effullon (6): tluld dilplllcement 10.24. Effusion (7): tluld dltpl--.ent
tiUt (1); Small diUiODII m.y be clefected by tiUt (2): Strob lhe medial side of tile joint t.t (3): Now alrOI!e tile lateral side of the
tbiJ IIIIIIOCVm:. Evlculle tile ~ to displtu lillY Q'l::ell flai4 iD. tile main joint jomt wtlile wa\lcbing tile medial side cloiCiy.
pouch u iD. the pafdlar tllp test before. c:avity to the la2zal side of tbe joint Ally Q'l::ell hid prelellt will be IICCI1 to move
ac:rotf tile joint and diAcn4 tbe IIICdial aide.
'lbia tat will be ~ if the efluaD ia
emu -s =ae.
THEKNEE 225
10.25. Errullon (1): ..-lplble fluid w.w 1CU.. HHMarthrosls: A bamnartbr:osis iJ 10.27. P'y.rthi'GIIs: Tendsnels in
tMt: This c:a be u.mul In tating for lmpr a sip of majoc joint pathology, iJ usually ~· iJ uaually widespread There iJ
etJusi.cma, especially In Cat ~. With the obviou wilhin half an hour of injury, BDd plllftlly a IIIIVtiRI syllmnic: upset, 8lld
thumb em 0118 side of lhD jolnt ad the liDpn gives a doushY feel in the auprapaleilar quadril:tp waJiiDs. If pylll'throm iJ
on the otber (&), compn111 the laHle to empty mpm. A teme humartbrosis should be -pectld. the laHle abouJd always be
lhD bonowa llllbD side of lbD jolnt Now, upiillted to relieve pain and permit a more apinled to relieve painful 8lld dell:rW:tive
with lbD other baud llllmnpt to foroe fluid thorough climc:al (Uid uaually) arthroiCOpic: joilll Jlf"ltme. 8lld to obtain pas for
from thD IU~ pouc:h diatlllly illfD examiDatiOD. eluddalh:IJ the infec:tiq llpl8lld
lhD laHle (b). The fon:e of 111.y fluid beiDa e.tablilb:ina IIDiibiotU: llllllitivities.
lrmlsmilled llwuld be picbd up by lhD
c:omprsaing bad.
10.21. Syncwlal IMiftbran.: Pia up the 1tu9. Tencl•rnus (1 ): It is 6nt eueul:i.al to 10.10. T•ndernel• [3): Joint lin•
akin ad the reluecl quadriceps tmJdon to idallify tbe joint line qlille clarly. Begin by d"'ctu...: Besin by palpating carefully
lbiclme••
1.11e1a tbe of the aynovial 8exing the knee and looking fot tbe hollmn from in from: beck alODS the jolnt line on
IIJalllnDe in the suprllplllellar pow:b. The at the aides of tbe pm:Uar ligameat; tbe&e lie each &ide. Loc:aliled llilldaDess br.re is
aynoviallllalllnoe iJ thidzmd in over the joint line. Then confirm this by mmm!Wllt in mmisc:m. col1almalligameat
infla!IIJM!rKy condition•. e.g. rbtumatnid fee1iDg with the fingen or thumb for the 10ft and fat pad Injuria.
artbritis, ad in vi.llooodlllar synovitia. boUow of the joint. When tbe exmninins
finpr iJ IIIIOVOd proximally itlbould IiBe out
of the joiJil hollow Clll kl the femonl amdyle;
limilady, wt.a mcmd diltlllly it should ridD
over the IIIDiamce of lbD tibia.
1o.31. TenderneR(3):callllterel
llgell'lellb: Now ayltemltlclllly Clll~~Dille die
10.S:t. Tendaneu(4):1fblel-.beKie: In
childJen IDd adoJe8centa, tendemeu is foaDd
10.35.
~ ill m
Ten..__ peteller llpment:
(5):
ltbld:ic patieDt a with
problem
upper IDd lower atllldlmenll af the collallc:nl. over die tibial tubelcJe (a), wbi.ch DillY be tbe patellar )jpmalt iJ IUipCCted, loot for
ligamalll. ANOCiated bruiJiafiDd oedana promiDeDt ill Oagood--Scblatter'a diJeue, md patdllr )i&IIIJlellt telldemcla wbile !be patieat
11e a raame at aoote iajura. after IWU!e IMilBicm illjuriea of the pallellar il llltaiJpda& to Cltll:a4 die leg agaiut
lipmalt lllld ita tibial auacbment. 'l'aldeme1t zeliltlace. '1'10 tat iJ belt pc:;rf'ormtJd wi111
over tile lOMir pole of tile patellA (b) md fbe lee C1'lf:Z fbe en4 of IIJc Cil(IIJ!jD!!IjOD
proxiDW patellar ligament iJ found ill oouch.
SiDdillg--Lanen-Johalaol!. diseue.
Telldcmeat tm:r the quadticep1 UlldOI1 (c) iJ
fOUIIIl iD qllllkioepa t=ldi.Di.til.
10.34. Tendu._ (1): t.mo,.l conclylu: 1o.35. Suspected om.ocMndrltll 10.36. ...._• .,.. (1): atmulon: First
1111pectM Cllleochanclrltll dlllean1 (1): d l - tz): Wilson's tiKt: The aim of the UYb 11n that the k:m!e can be fully
Flex !he bee fully lllld look for tr:lldr:rDc•• tat Ia to cauae preaaun: betwecA !he lllllaior ~ If In doubt, lift bach Jcc• lllld
over !he ftmoral coad.yb. OltCOChondritia ~ l.igamcDt aad the la1aal a8pCCt of the ai&bt alOQ& the &ood aad affected leg. Pull
dlMccan• 11.101t frequently illvol._ the medial
bloJU coadylel, llld pulicular alflclltion
mcclial fc:mDnl coad.yle.. Fb the ~ (a)
llld IDtc:mally rotate lhc foot (b). Now CUC:IId
~ I• recxm~cc~ u o•.
~
Lo••
of run
may be %CCOI'dc:d .. 'The ~
lbould thetc:fole be !Mid to die mcdiallidc. the lmce t'ally (c). If pain oc:cun at run 1acb X" of QICIIIba'.
Cllllallica &Dd Ia re1icvcd by cueaal rotadoD
of lhc fool. tD lhc tat iJ poliJivc.
THEKNEE 227
10.37. Mlmlnlantl (1): ataMIM: If ~here 1D.JL MIMimants (3): atanlllon: Try to 10.39. McMt111ents (4): hyperaxlenlllon
i1 lllillaome doabl, eumioe lhe patient in lhe obtain full extmsion if this is uot obvioul.y (geftU NCUI'WtUIII)! Tbi& is puent if lhe
prone pOOtioD, fully relaxed, and with bia ~t. A &princy block ID (a]l. ext=aion ia bee extr.oda beyond tbe point when the tibia
leg• ~ova: lhe edp of the enmination very lllfPIUve of a backr:t-baDdle meniiiCUa aud femar are in line- Atmmpt to demmutrale
couch. ADy J.osa of ex1r.llslon on one aide tear. A rigid block ID (a]l. extension lbia by 1iflinl tbe leg while al the same time
should be obviou from tbe poaition of the (COIDlDilllly dl=scrlbed u a fixed lleldon preuiDa lw:k on lhe P*lla- If severe, look
heel:l. ddor:mity) ia oftm present in arthritic for other lip of joinllaxity, partK:ularly in
oondjtjoos affecting the bee. the elbow, wriJt aud finpz, keeping in mind
the rare llhl.em-Daalm ayudrome.
10..40. Monmentl (5): ~if 10A1. MCMimants (6): ftalon (1): 1o.G. MIMI111ents (7): ftaiM (1):
pre-a, il rec:onlcd u 'X" bypcreDcDiion'. Meume 1be ~:~~~ge of Beltion in ~. Allallalively, meuwe the bccl-to-butt.ock
It ia Been molt freqacmly in p:la, aud ltarting from the zero potition of normal full diJWice with the leg fully flc1cd. 1bia call be
i1 often uiOC:iallcd with a high ~tr.lla, at=aioa. FlcxioD of 135" aad over ia a very accuraz way of detcctiD& 1111111
choDdroma1acia pOclile, rec:um:at dillocatioD qllded u D.Otlllll, but compete the two aJfc:nltiou in tbe ruae (1 em = 1.5"
of the peteUa. aud 10mctimea 11eara of lhe lkb. 11x:e 1ft maay ~ of Iota of appnllim8tcl.y) lllld ia 1IKflll for cbd:iDg
anlicrior c:nJCilte, mcdiallipmad, or medial flcxiOD, the ~t of wbi.dl. are cffullion daily or weekly prograa. Note that obvioualy
maaiacwl. IDd arthritic ~tionl. llcxioa caa never be ~ta than wbca the
bccl ~ Cbe buttock, IIDd tbat inahility
1D bdn& the bctliD the buttock it IIDt
liCCICtllrily ID iDdil:af« of lk:lioD 1oeJ
(13.5" illut lbllllllil).
10.43. ~ments (1): r.c:ardlng: 'l'bc 11.44. Genu wlgum (knock lin•) In 10.45. Gnu v•lgum In children (2);
f8D&C of moveJDI"Ma in die~ children (1): N~ whether unllaleral or Now briJI& die lep llJgdber to touch lightly
illultrated would be rec:ordcd u foll.owl: bllallnl; the Wn:r l8 more common. Tbe at die kDecl, 1114 meuurc the gap between
(A) 0-135• (Dormal range); (B) s• ICM:Iity of the def'omiliy ie rcc:arded by the malleoli. (Normally the lmce8 tUid
hypt:l""'kmtion - 140" 11cUoD; (C) 10-60" mcuarillg llle inll:rmalleolar gap. Oralp die malleolllbouJd toudl). Serial mcuUIUDeDII,
(or 10" fWxl11cUoD dcfotmity with a fur1llcr child by the 8Dklu alld rotate the lt;p 1lldil ofllen rmsy 6 monlhl, IIIC 11101 to cbcct
50" flexioll). !be patellae are vemw. propt~. N~ that with growth a statit;
~ 18 Ill qu1ar improvellle& In
the 10-l~,ar qe lfOUP < 8 em in femlles
1114 < 4 em in malea is rqmlecl u IIOliJIIl.
10..46. Genu wlgum In edultl (1): 10.47. G•nu wlgum In edultl (2): 1OAI. Gnu nrum (bow leg) (1):
Jn adulU the dafmmity l8 IMII moll otbm in The degnle of valp may be IOJ18hly Meuure the clisbDce betweml the ll.:miea,
usocWiou with J'bmgoatoid llr1hritis. 11 is uMIUed. by~ tbe qle t'ocMd by 1lliq the fi.Daaa u a gmge. ldWly the
abo amJDIOil in fiiiiDap girls. 11 is beat tbe tibial 1114 femon1 shatb.. Allow for tbe ~ sbould be Wlrisbflwrlng. 1114 it i.a
~ by X•rays, IIIII the 1i1mJ sbould be 'nam:al' agle, wbich is ~y 6° in 111-n.l that both ~ sbould be :W:iDg
tKa!. with the palilmt ~BiDs all hi• Wllipt 1111 tbe ldl1t. The lbaded area np-a pnu [orwa:ds to coaDim ay effect d hip rotllian.
tbe affectld lide. valpm. (Note till& the ti:bi.afemom1 qJ.e i.a In tbe 10-l~yesr qe g~UUp, < 4 em in
viitually tbe ame u tbe Q anp uled in the hlalel ad< 5 em ill males i.a mgarded u
..-mall of pdll1lar inllahility.) beiDt within IIOIDIIllimiU.
THEKNEE 229
10..48. Genu urum (2): An uaessment of 10.SO.. Ganu RIUm (J): In cbildrm, 10.51. lnstablllty(1): lbefoliDwing
the cldonDity may alJo be carded out with radiography may be helpful. In (A) rlchrs, potentlll1 ~may be l.oobd far:
X-rays, u in genu vaJaum, with the patitm nom the wide and irregular epiphyseal platzs. (A) valpl (when lbe medialli.pnt:nt is
wdJhtbeariDg durinJ the eltp!»llm of the In (B) ribla van~ (Bimmt'l di.rta~e), nom the tom: severe wben the pcstr:rior CI."IICiale is
films. The debmily is 11ee11 mo.t COIDIDDDiy lhalply dowDiurDed medial metapb.ysea1 a1ao damlpd); (B) - (wben the l..almal
in os~ti• aad Pqet's diseue.. It may bmdr.r. In lbe illfantile form (tmdt:r IF 4) Upment is tom: severe when lbe posterior
occur in dlenmmd arthrilis, llldJ.oush pDil Rmonl disturbance is rare. In the Ia Olllet crucialle i1 II]., tom); (C) tutt6rior
va1gu.m. is COIIIIDOIJe!' in that ccmdi.tion. type (over 5) moral varus is praeat in a dilplatYrrwtt qfthe tibia (antftior mJCiate
number of cues. Note that radiolosicalvanm IarS: wone if medialiDdlor la!r.nl. structures
is IIOI"IIIal till a child is 18 months oJd. tom); (D) pottmor dl~m of the tibia
(p!»la'ior c:ruciJde J.ipment teln).
3 ~~~
4 ,..-·
,,;;........... ·""
·...... ,.- ...
10.52. ln...blllty (2): (E) RDtatlllry:

(1) TM mtulial tibial CONlyZ. .rub/Ku1
fii!Uriorly (an1llromlldial inMability): this is
uaually due to combiDed 11111n of the antmior
cruciaiB aud medialiiiix:IUnll; (2) 1M /sural
CONlyle lllblllu' an1morty (lllll1lmJalmal
instability): 1hi1 is uaually due to 1MB of the 18.53. v.Jt• ...,.ln....,lllty (1 ): 10.54. Ylllgu JtNu lnltllblllty [2.);
anlllrior c:nx:We plu1 the lmn!IIII1K:t'llnl1; Begin by e:Jaminjq the medial lido af the Bztclld the lmcc fillly. Use ODC lumd II I
(3) 1M /sural tibial condyle 1ublllus joint, md die medial ligamall in pWcuJar. fulaom. llld with the other attempt to abduct
pomriorly ~ bulability) or TflltduM11 in injul:i.ea af the mcdial.ligameDt the lq. Look for the joillt opeDiD& up llld the
(4) the medial tibial amdyle aubluul iJ cnmmme4t It the upper (femoral) le& &Oilla illfo vaJau•. On rekue of lbe
pwlllriorly (pollllromedial inatmlity). (3) and !!lt!M'bmen« IIIII in the medial joint line. "Y'Il&u. force 1 COIIIirmaory duDt may be
(4) xedae mainly to INn of the ponmim Bn.ilin& DillY be pme:nt after recent tnuma, fd1. lllod.rat~ wlgua is auggative of 1 major
Cllllciate aod 1anl ar medial~CJUC~Un~1. but illeanartlao8iJ DillY be lbte& (Wbl::re the mr:di.al l!ld pwtftior lipDent ~ (lnde
(.5) Cnmbinarioua of IJ.M inmbilililll. medilllipmeut bel beea ia.juted ad dilplaya l injUtY). Sev./'fl "ftl&uiiiiiiY indi(:lte
1Pniemc8l wifboat laity it DillY be clulificd ldditicoal miCialt (plr&alarly poRczior
I I a gmde I injlny.) CIUCilte) n!pCure (&nde 3 injary).
10.55. V.lgusltNUinltllblllly (1): 10.56. V.lgUIItNUinltliblllty (4): ltNU 10.57. V.lgualtNU lnltllblllly (5): ltNU
If in doubt. 111e the bed of the baud u a lima (1): If thrze is still IOIIle doubt. tben llms (1): Tbe fihm of both sides are dlt.n
fulc:rum aad use the thumb or Index. pbced radiographs of both kHea abould be taken compand Any iulability should be obvious.
in the joiDt tiDe, ID dda:t my opa1ing up of ~ applyins a valps stteu 1D
the joint u it is 1nued. Jf there is still some eacl!joint.
um:ertaimy. I:OIIIpiD the two llldu.
10.58. V.lgUIIINUinltllblllly (6): If DO 10.59. V.lgUIItNUinltllblllty (7): If the 1OJIO. V.lgualtNU lnltllblllly (8): If a
iutabilily b.u ~ demmutrllrd with the kDee is w.ry tellder aad will not pmnit the baemaltllrt»i1 is J!Ielellt (aud tbis is DOt
kDee fully exlaldld. repeat the telb with the p!MIIme of a haDd u a fulcrum. 1111mnpt 1D alwaya the cue) ~ aspira1ion may
kDee flexed 1D 20" ad the foot ialmully alrels the lipment wi1h this crossover mn allow a mare JDelllingful euminalion of the
rotated. Some opening up a£ the joint is grip, with Olle halld plxed ova: the proximal joim..
normal, aod it il •utlflliGJ to tXItlflXD8 tlv part of the tibia jwlt diMal. kl the lmee joint 1D
· · - Danouatn!ion of 1111 dJoorma1 UIIOUIIl
avoid ay local pressure ova: the joim aud itl
of valp 1ugpt1leu exllmlive involvanmt lipmr.ala.
of the medi.alatnK:tllrD (e.-.. partial medial
J.ipmalltear. still clusified u a pde 2
mjmy).
THEKNEE 231
10.61. V.lguut,..IRIUiblllty (9): If the 11.62. Vanu ltrallns1abiii1J (1): 10.6S, V.n11 ltrHSIRIUibllltJ (2):
:kmle l1llllAim too plliuful to pennit Begin by euminiug the latmd aide of the Allmllpt to produce a varna defonnity by
eumimllicm, the joint abould be fully tested joint. 'I'endmness is 111011t rommon ovar the p1a&:lq 011111 band on the midiIll aide of the
Ulldm" IUUIIIIIIhesia; thml abould be pmvWm bead of the fibula or in the lallnl joint line in joiul aDd t'orc:iDg the ankle mldially. Carry
to caay 011 wUh allqic:lll ~ abould acute injuries of the lalmal joiot ~ Olll !be telt u in the cue of valgus stress
~or iDJiabili1y be~ (i.e. wiHn (lalllralli.gamel:ll aDd capsule). inmbllity, :lint in fall utensioo 111111 tbeu in
aeveral ~or ll1l'IICIIIl'CI are involwd), or with 30" flexion, aDd c:ompii'C OIIC llide with !be
BD irtbrolalpy. DCher. Note that wbSl tmting !be 1atenl
lipment, in the DOnllallmee thml is a little
Illln 'pve' Ibm with the IIIIICtiaL
, 0.64. V.ftll *-lnltllbllltJ (3): Apia, 10.65. v.nu snalns1abiii1J (4): AI in 1CU6. VIIIUIIINalnstBIIICJ (5): Always
for a more Mllllitive-•-t of 'live', the
tbumb c:E be pW:ed in the joint !.iDe. If there
the c:ue of 'Y1I1gus snu i.ndability atreu
films may be taken, 8lld if eumimtion ill DOt
clJeck tbl !be patimt is able to doniflex the
foot, to eaaum that !be motor fibres in !be
i1 VmiS instability in exteuion u -n u poiSI"bJe 8WIIl after upiJ:Itima, III:IliiiP to llODIIIIOII penmeaiiiSVII (latmal popliiRl)
flexion, it •uumts turin& of !be polfmior examine the me 111111m pmaa~ -tinia. have IIIC~ cbmlp.
Cllllciate 1ipmeut u well a the blln1
~c:ompiiiL
1o.67. v.- straalnfihblllty (6): In 1CUIL 111e entllrlor drewartiHt (1): Flex the kwle tu 90", with the foot pointing atraigbt
addiiUm, 1st for seoaory diallllbance in the forwards, aod steady il by aitti.DJ cl~ tu it Orup the leg firmly with the dmmbs on the tibial
di.ltaDIItioo of the commoo peroneal arne. tubercle. Oleck that the bamltrlnas - rel.aud, aad jerk the let toward& you. Rqleal with the
knee ftexed tD 70" aad CClDlJIIIle the sides. Note: aigDi&ant dhplllWIIent (i.e. the ~ side
lllllre than the od!er) confu:ma aotmior i.n.mbility of the knee. Nom ai.Jo that in tmn the
endpoinl of the aotmior trallllation il1llllally IOfla: lllld le11 clearly definM than the fum
endpoinl when the lipment i1 intact. Wbeu the dilplacmDimt i1 marhd (aay l.S em or more)
tbr.a the ammor C11lciall: is almDst cr:rtainl.y tam, lllld tlxre il a •troD& pouibilily of usociated
~ tu the medial compla (mediallipmr.ullllld JMdbl caplllle) lllld even the l.akra1
complex. If the displaa=mmt is leas marbd, lllld cme tib1al CODd:yle!DilVes fartbr.r forward than
the od!er, thm the diaposi1 illas clear: it may IUiFit 111 ~ anlmior Cl.'llcilllie lipmr.ul
laxity or a tibial amdyl.ll: sublnuaion (roblmy ilulability).
PC
PC
10..69. 111• enwlor dr...., wt Q): 10.70. 111• entlll'lor dr...., tiHt (3): Now 10.71 . 111• entellor ctr- t.t(4):
Repeat tbe lett wilh the foot in 15° of tum the foot inltl 300 of inlttDal rowioD lllld Beware of the followin& fallacy: a tibia
c:m:anal rowioo. Exceu cxwtlioD of tbe repeal the tst AD!aior mhluxatioo of the .ue.dy dilpW:cd ~ u a ~t of a
meclial tibial amdylc M~CF~tl a clcpc of lateral tibial amdyle auggesta IOIIIC pwtcrior c:raciale lipmalt tear lila)' li~ a
l!lla'Omecllal (rotatory) iDalability, with l!ltaolaecral rotadoaal iDIIabllity, with fallc polid.~ iD thla teat Thia abo appliclltl
poHlbk ilmllvemcDt of tbe medial Upmmt pcaibly d.aml&e to the pottc:rior cruciat.e - the l...acbma tala dcaaibcd in the fo1lolrillc
.. well • the l!llaicr aucillllc 1icamalt the poMierior ~. ftJI.. the .-ocr frlmcl. ~by iDapcc:tiDa the a.llourll «
~ ligiiDellt the kwle pdor tu lsling.
THEKNEE 233
11
ttl 'I auurt \
'I
10.72. The Ladtman tam (1): The 10.73. The Lachman tMtl (2): tile prone 10.74.. The Ladtman tMtl (J): In the tu:tille
LadJman ~ are abo ulled to ddect antmior tat (Feagin and Caolat): This i.a especially IAchmml t•n the reland bee il aupported
tibial inalllbility. In the ~ IAcflmmt Wldul wbt.re the patieDt bas latp thighs at 30° aad the palienl ubd to eDmd it.
1m. the lmee llhouJd be nWiud 111111 in llboul wbicb are diffu:ult to grasp. With the patient Jf the tell Ia positive, them will be antrrior
lS 0 flexion. 0oe hami llabllisea the femur proBe, eocircle tile tibia with both lwlda, IUbJwudion of the lmmll tibial p)atnll U
while the other triu to lift the tibia forwards. placing the index fiDsrn lllld tb.umba in the the quadriceps CODtnlda, aDd pcllltr.rior
The teat i.a poUiive if there illlllllriar libW joint line. Flm: the lmee to 200 aDd Blllmlpt lc 10bJwudion wlum the ~ relaxes. It is
movemeol (~ wilh the thumb in the push the tibia forwan:ls. Anmor trlm.r.l.a!iou comlderM tbal tbia il beltlleeD from the
joint), with lliJIOIIID' mdpoint. The 1M i.a llhouJd be readily ddec:led by the fingen, 111111 Jmdiallide. Repeat, !UiJtins exflmiOD by
ICliMima euier to perlmm with the patimt the :fimmess of the endpoint lb.ould be DOI2d. applying Jll"llle lc the llllkle.
pruDe <- .en f'nmle).
r~( 1. v
10.75. ladlologbleneiJ!b of IIIMIIDr 10.76. Radlalogbl ....lysll (2): 10.77. Po~Drlor dblallnlteblllty: t11111ng
crud... fancdon (1 ): Amcti« au'bhlutioa OD the mm., dmw two liDet pamlld to the tile poiWtllr crucM.IIpiMIIt (1): the
of the tibia in cxtaWon may alto be potllcrior ccn:x of the ~ ~ Ill tile gmlty e-= Rn~. dctadlmcDt or
demallarated with X-raya. 'Ibc lower tbiab il medial. tibial plm:au aDd the medial ftmonl mtdlin& of the polteriar cruciatc ligml=t
aupported by a allldbq. lllld the leg alalded coadyle. Mea~ the dillm:e betweclllbcm. may permit the tibia to IUbiux blckwanb,
apiut the teliiWicc of a 7 q wciabL 'lbc NGIDW = 3.5 111111 i: :1 111111. lluptueA freqaelldy Jivilla rile to a lltriting deformity
limb &bouJd be iD tile DCUtral poaD. with .......... cndat.e = 18.2 - i: 2..7 111111. of the bee whidllllowa the diqzlolit to
tile P*1Ja painting apwlfdl. IUid tile X-ray 'lbc l.atecr ia atilhdY iDctaled if the mcclial be IDidt OQ iMpectioa aloac. 'lbc bee
film~ placed~ tile ll:gJ. IIICaliacul ia tl8o tom. The dU!gnottic lbouJd be 1lc:llod to 1IY', with a JIDdbq
!dilbility il Jqb. Ullder the thiJh.
- -- - __ # __ _
- -- ~ --
li{ J;-- -,-~ ,-
10.78. Pwterlor aucr... llpnlent W: 10.79. PoiWrlor aud*llg1111ent IS): 10.10. Polelrlor aucl.tell•ment (4):
With die leg still in 'JU' flexioD, ut die Pllce die tbumb oa one aide of lbe joint line If die potterior c:mciate .ia lax or tom,
patient to lift die heel from tbc couch v.'l1& 11111 tbc iDdex Oil die other to help you - bot IUblaxatiaD Jlu DOt yet oc:cuaed
you obeerve die kDec from tbe lllerll tide. any tibial movemad. ny to pun tbe tibia (IIDCOIIDDDJl), lheD t.:kwlrd preaeure oa die
Nq posterior IUblaxatioD llloakl narmalJy forwards wiih lbe odl« band. If die potterior tibia williDIDilly produce I detectable,
coaect during thiJ cxfc:DiiOil of tbc lmee, cruciate li.&ament iJ tom aad die tibia CX~:elllive pottai« aaniaD. N~ that a
confirming tbe diagDolil. aublaxed potteriorly, the forward IJIOVCIIIellt Llcllmln ~ in tbe prone poaition may
u lhe tibia reduces will be easily fi:lt alllo be uted to detect poltic'zior c:mciate
luity•
....
'
_... ___ ._ ~ --.. - ----If(
\' II I ,,\
~- __,-.--
!I' '
10.11. Postulor auct•llpnl.nt (5): 10.12. RHiologfal uamlnldlon of 10.13. Redlalogkal ...mlnldlon of
Q~wmlc pOibllar 1hlft tiHt: Flu both the padMior crudatlt llpment fundlan (1): ~raucl... llpi'Mnt fundlan W:
kDee aDd hip to 90". Tbe 1llttK l.eadJ to A saodbag i1 placed bebi.ud tbc 1high IIDd the The lip ~ the llllllllial femoolllllld
lwnJCrlng ~. whidl mthe p n l - proximal tibia preaaed forcibly t.ckwuda tibial c:oadyl.el il meuund, aJ.cma with that
of ligmaJt luity J.da to ~ (with an equiTilent fanJe of 2S kg). 'I'hi1 il betvmm tbe laflnl coodyla. A displacemm!t
diJplaalmmlt of the tibia. Now ex'--1 tbe l'llpllllted, IIDII li'IK the lec:ood pmloading of tbe orda- of 8 mm Oil each a is
lmee: this clisplxs lbe am of lbe pull cycle, ndiograpbs 1n takm wbile the same iDdicacive of 1111 ~ pollerior
mtai.<Jdy, md lbe clbpl-s tibia will nduce. fon:e ia m 1jnhjnewi cruc:iace tee. Eu:enive IIIIMBIIIDt OD tiJe
'IbiJ il mually ~ to c:.eful impec:dcn labnl. Ill' JIJIIdW aide~ iDdicatea posearo1mnl
md i1 iudil:adve of pollllrior laity, with or or poat.ervmeclial iDalability.
wilbout .ddilioual potlm'Dlatenllaxity.
THEKNEE 235
10.14. VI-IIMtl11111 ofdte cruclatll

ligaments: MRliCaDI allow m ICCIIl'II:C
IIMtltmcat of !be Ita~ of tbc crucialc
lipmr.ata ill809& of~. (Note 1hll ill
te:ml8 of llllCIIliCy lhll il iD.fcrior In cliDical
IIMCI&mcat ) (lllu: iatact aJI1'C:rior crucia~
Jigamrr.at.) The a:aciallcl may allo be
iDspected by ardlrotcopy. 'I1Ic ability of tile 10.85. AIHIIIng .-blalsubiUIIIltlons 10.16. MMintosh wt for antllrlor
crucia~ ligamcaU to prevent almoanal tibial (I'GIIItorJ or torslonallnmbllltlu): sublllllllltlon of the lateral tibial conclrfe
movements em be u!ICMe4 mechanically by (I) Look fur medial or Jaleral talderllel• or (the plvut shift test): Pully extelld the lalee
d)'IWDic telliDg rip. oedema. (2) Perform tbc drawer teat~ DOting whllc holding the foot in intaual rotation (1).
varlatioaa. (3) Teat far lnity 011 va1gu& 1tte1a Apply a valgoa atrta1 (2). In 1hla potilion, if
(oilm pollilive in anlai.or aobluxationl of tbc iDitlbillty ia prelalllhc tibia will be in tbc
medial tibial caadylc). (4) Teat far luity 011 IObluxed pollilim. Now ficx !be bee (3):
v - 11treu (uiUilly politive wb.ta tbc lsJrnl rc:duetion ahould occur ll about 30• with an
tibial c:ondylc IUblUJ~tS forward& ar obrioul jerk. A positive ~It J.ndii:afu a
bacbard8). (5) Carty out the following lllliCdor cruc.iab: illlllarmality, with ar without
addil:laul latl. otbcr pathology.
10.17. loMe plwt shift t11st for antllrlor 1o.81. Modlfiocl plvat shift or Joak to1t for 1U9. Postllrolatllrallnltablllty (1): the
subluxation of tho laeonltlblol con.,_ antllrtor sublwadlon of tho latllnltlblal postllrolatllrel d . . - tut: 'I'IIe lr:Dee
'I1Ic patialt ahould be c:omplctel.y n-Jaxed, con.,_ Grup the foot between the mn llbould be 1lc.ml to a little le.1 1lw1 90" and
with no 1allion in 1hc llmlatriJI&t. Apply a IDd tile dleat, IDd apply a valgu& a11et1 (1 ); the toot placed in tDcalal rotatiaD. Apply
valgu& force Ill tile bee (1) It tile - time lean over Ill rotate tbe foot inb'Dally (2). ~~lOft: 0111be tibia. Bxceuive
paahiJia tile fibular IICIId antmiorl.y aJ. Tile Now flex the lmee. If the lett il potitive, IIIII travel 011 the latl:nllide 11 iDdicative of
lalee ahould be pldl.y tl.execl Now cxtald tile becaoJe lhc tibia ia firmly bekl, 1hc lsJrnl poaolJfcrll illltability. Polferolalaal
joillt (3) • .A. full Clttl:mioa il ~ a femoral condyle will appear lio jc:dl: lllteriarly. WUbility i1 uiUilly uiOciated with iJI,juriel
dramalil: clunlr. wi1l CKlQIZ' u the lMcnl ti'bial Now ClteDd the lmec, IDil u !be tibia lio 1he poMczior cniCiate mdllllenlligla:lem
CCXIdyLe IIJblaxet bwllllt (if fOIItary llllblum~ !be femoral CCXIdyle willappe&' lio CCCIIplcx.
inltability il prceeat). Note: lbe ~ llloald ~ becbran1J.
ldak:: IIIia lio 1hc ICilNtioal cxpczieDced iD
ll:ti.vity.
10.10. Posterolaten~lln..-llllJ Q): die 10.91. Poderoletend lnltllbllllJ IS): 10.92. , . . .. . .l'llllnNblllty (4):
eldernaJI'GtatiGII n!CUmltUm tat: Widl JakDb'l rewet'led pivot llhlft tat: Begin by atlmdlnt apprehenllon teat: '!be patiel1t
the patialt in the lupine potltion, ltlnd at the fle.1tiDg tbe knee to 90" (a). Now exlaDally thould be takiDg hit wei&bt through die
end of the e:umiDitioa oouch IDd lift tbe lqa rotate tbe foot (b). apply a valgat sll'ess (c), tlighlly !!sed bee. Grup die k:nee alld with
by tbe great toea. Tbc felt II polilive if die IIIII mend tbe knee (d). If the teat is potltive, tbe thumb at lhc joiDt liae preu lhc llllferior
knee filllJ into exlaDal. rotation (a), Vlnll (b) die potfl:liorly IU'bhJuclla1aal tibial pJMeau pet at tbe lalll te:.nl CODd.yle mtJdiall,y.
an4 rccurvatum (e). saddcaly reduA;:et at about 20". 'lbc tat is politi~ if movement of die
ooadyle OCCUl'l (allowing tbe tibia to slip
poafl:liotly Wider il), IDCl if thiJ is
~by a feeling of gi'lillg way.
10.93. 1'11e menf..:l: (1); Loot for 10.94. 11le menlld QJ: In DCCalt ~ 10.95. 1'11e meniKIIS): pelterlw lelfon1
~~ il1 tlJe joint liDc llld felt for I look for tlelltale oedema in die joiDt 1ille. (1): ~ 1la die bee llld place the thumb
ipliDgy bloclr. to fall ~icla Tbae two Bruilin& is 110t a felton: of JllelliiCil injuria. llld inclc:x abl( die joillt lille. Tbc palm of
lip, in ueocialioo wiCb evidall:e af tbe baDd lbould rea oa lhc patella. You are
quacm.cep. - - II'C the !DOlt CClDiiallc::a DOW ill a politioll to be able to locatle ray
mi rdiablc tigDI d I tom Jllalilcul. clicD enwati'll from lhc joillt.
THEKNEE 237
10.96. The menisci (4): ....-rlor IMions 10.97. Th• menisci (5): anterior lesions: 10••• The - l i d (6): McMurny
(Z): Sweep the beet rouud In a U-lbaped arc, PIMa the dwmb firmly into the joint line at IINIROMWN for the medial m.nlsc:us:
looking aad eeJing fur c1ickl from !be joint the medial aide of the pmllar liprumt. Now PW:e the thnmb and i.ndr.J: along the joint line
m:ompani.ed. by paiD_ Watch !be patient's emnd the joint_ Repeat on the other side of to deti!C:t any clli:b. Flu the leg fully;
fxe, oot the lml!e. wbile caayias out the ligament. A click. m:ompani.ed. by pain, ut.rttQ/Iy rotat. the foot, abdw:t !be lower
Ibis test. is aflr.n fouad in amerior meni.IICIIS l.eliooa. leg. and extrad the joim IIIIOOibly. A clid:
~~rising in the medial jolnlline. aa:ompllllied
by t:Omplaint of pain. is indica!ive of a
medial !IXIIiscul lim.
1O.lt. The meniiCI (7): McMurny 10.100. Th• m•nlscl(8): If any clli:b are 10.101. The menlld (9): If a IIDi1al:mal
m-IIVNforth•IM8J•I-Isass: dmcted, the IIOilDal. limb ahould be eumi.ulld painfal click is obtaiDed, mpea the teet with
~ tbB last teat with lhe foot inlllnlally to blllp elimimde sympfl:lmless, lhe Millin& fiDp£ or tbumb ~ The
rotm!d and tbB leg adl:bM:WtL u., lhe hand k:J DODpathologiall clli:b whi&:b. may be arilin& ca~e of tbB c:.lic:k. wllmbK from IDIIIIiiiCIIS cr
pick up tbB IIOIIr"Ce of any clli:b wbicl! 11111 from 1lllllmu c. other soft tis._ ID&I'I'inl teodou, may be visible 011 close ilupectioD of
~by pmn. A~ IGII8lion over boay pmmi- (e.g. tbB bicepa lhe joint line.
may be felt ia ~ve laioul of tbB tmdaD owr the faDmal. coadyle), or from tbB
~- pWiila clickiiJ& apimt a faDcnl ~le.
10.10:1. The menisci (10): Apl.,. 10.1 OJ. The menisci (11): grinding tMta 10.104. The m•IKI (1l): n-..lytem:
grlndlngtHts (1): In II¥ 1Mb. the auapect {l): 11Im. while stmding 011 a stool, the AI previoully deecribed, lllllmiM:i. are prone to
Dllllliscus ia subjected to ClOIIlpl'lllaion and examiner throws his weisbt aions ~~¥ w. or tear uadl!r almu1tanamaly oa:uniDg
sbeacins ~~res-; lbar:p pain Ia tugellive af the limb, md e.mmall.y roblla the foot. cin:wJuDulcea: the lq moat be aolely
a tor. The patieDt i1 ~ Tile euminrr Sevem sharp pain is iiid.icative af a medial weigblbellrins (I); it Illll8t be 1leud (2); aDd
grasps tbe foot. eDmlally rotma it IIIII fully meoi.lcus tear. Repeat ln a pea1r:r degree of It muat be lllbjedai to a twimng f'on:e (3).
llmes the bee (1). H§ tblllllntanally m1111111 flexion to test the posterior hom. To kist II¥ (A typlW example Ia whim a footballs's
the foot and ulrada the kmle (2). Tile ~idea l.idmlll IlllmiJeus, repeat II¥ tests with the foot rip! foot il ancllotm to the gnnmd with an
are compared. 1b.i. ~~ my forcibly iDtmlally rotated. efJideDl boot, aDd with his rip! kmle lliighliy
J.i.mital:i.oo af rola!iou. Ill" where my pain fleud he twiltl muDd to ped'orm a swiJising
IXCUlL kick with bille:ft.)
fleud to the rcquized IIII!.OUilt (S) and II¥

otbcr liflccl cbr (6); llld the t*ieDt twUb
alowty from lldc to lide. Tbia IDMIOCUYl"C ia
performed 3 timca. lBch dUgnootic accumcy
I
it claimed ln the anle:r oC 9S'lfo (plrticularl.y It
10" fk::ldla), comparlb1c with MRI IICIIIIIlDg
"WIIieh ia aptlllive and not alwaya avallab1c,
and l11hroloopy, whk:b i1 both cxpcD&iYC 1111111
~
~~
r
lavalive. /~!!
Other dyuamlc le8dDg method& lnclacle the
'
lite by phyalothe:rapiata af ao<alltxl l
provocltive earciset and tbdr variatiou. (A \
~
c:ommoD w:tbod ia to - the patient to IICJ1IIIl
and attempt to caldl a medic:iDe bell wbidl ia
~·· · \ II
deli"betately piU:hed to either Jide 10 that be
tw to twist oo hi11lc:red, weigMbearing lmee :ltr 1
to catch it)
@,
~~
\
10.104. amtd. 'lbe 'lbeNaly testa daplh:ate 10.1 05. The m•lld (13): McDiacal cy.u
tbiJ sceuario, and are desc.ribed u being lie ln the joint llnc, fed linn 00 paJpmoa,
~ wben the pltieDt experieDcel and are 1aldct 011 deep ~lllfe. Cyltl of the
joint-lille pain, or ~CD~Itioot of J.odriD&" or mmilci may be uaociated with tearl. Latlcral
c:atr.blng within the laJee lib tbote tqKftd. lllmill:u1 cym are by far the COIDIDOIIelt
s•
Tiley are petf<au:ed It and lo- of~ Cywtic •wcllla&l OD. tbe medial lide are
- lint OD. the pxllide and thea 011 the IOIDdima due to pnglion.l adaiq from the
11111pect ooe (to &lin f.ami1iarity and pcal!llednUI (inic:rti<:a ol nrtmiUI, gra:ilia
cn1fidenao). The eumiuer bolda the pa!ir:nt'a llld lle!Di"'*'i!IOIUt).
haudJ to brp bil bal.ce (4); the br.e ia
THEKNEE 239
i
\/
I
~·
·'- y
I
I
10.106. Thepdllla (1): EumiDe both 10.107. Thepdllla(2): Looldor genu 10.101. The pdllla (J): Ia there any
kneea flexed over the eod of the CXJDCb. recurvatum aDd the position of !be pDIIa knock-k:nlle ddormity? Beca~~~e tbia leads to
Tbi.a may show a tonional defmmity of the relati~ to the femoral c:oruiyl.el. A high an increue in !be Q angle (quadriceps angle)
fem.w or tibia, and a Ulm1llly placed patella palella. (pDIIa alta) is a pmiispo&ing factor it pmiilpO-the k:nlle to ~
(a) ( w!W:b. will be prec~Upolled to inatability in lliCiliiellt lateral dislocation of the pllle]l&. di.llocation, anterior k:nlle pain 111111
(e..s. recuo:eut diab:alion) or cboodmmalacia cbondronWacia JN*Ilae. The ddonnity is
pate.lUle). Now u1t the pallent to emmd !be puticularly 00111I11D11 in adolelcent prls. Tbe
kneea (b), 111111 look for any gross disllllbam:e inllmlal.leolar diJiml:e may be meuunid, or
of pell.ar trading: illbould move IIIIOOihly the Q lllg1.e (wbicll il llimillr to tbe
in !be pDilar groove. ti~Do!ancnllllgl.e) may be ddmnined.
1D.109. The pdllla (4): llndlng the Q 10.110. ..,. , . .... (5): I...ook for 1o.1 , • ..,. patell• (6): DisplJce !be
angle; tbia is tbc angle (IIOl'IDIIly about 6") tlelldcrness 0"/a the anterior surfll:c of the palella medially 1114 palplte ita ~
betwocn (i) a 1iDe joioi.D& the an1Dior AlpCrior P*IJa, lllld DOte wbetber a 1aldc:r, bipartiz llllfll:e. 'ltlldenlcas is foun4 wben tbe
iliac spine witb !be CCidre of tbc ptfdll, an4 ridge is praent I...owet pole tendcmesa ~ llllfll:e is diaeued, e.g. in
(ii) tbe liDe of tbc pUelltr ll&-t Aalr. tbe cx:>cUrJ in Sindillg-LarJen-Iobauon dixuc. ~ paldlle. Repelt 1he tat,
patient (wbo must be l&aDdiJll) to bold the ~ may also occur over the patd1ar dilpbciJll the pazlla lalr.rally. Two-thirds of
eod of a tape measure oa his llllllmior spine lipmrD, qWidricepa 1ZIIdOD. - tibial !be .tialllll' lllrface of the pa2lla are
while you centre tbe olbrr over !be palla. tllbero&ity in olbrr ex1lralar appantul tncliOil oomW.Iy acxnllible in tlri• way.
l'hm alip a~ wkb !be ape and the iajuriea and varimb d 'jll.l:llpa''l bee'.)
Jl*ll-lla-t (Differalcea between the
sexes are more re1Dd to beigbt than pelvic
width.)
10.11:z. Thepaall•(7): Teat the mobility

of the plllella by moviDg it up and down and
10.1 1J. The patllll• (8): Move the patella
proximally and distally, at the llliiiiC time
10.114. The,....,. (9): tlae appNhenslon
tMt: Try ID diJpJace the pm1la lalrnlly
from aide 1D lide. Reduced mobility iJ :found piMsing i1 down lwd apinst the femoral wbile 8exiDg the 1m= from the fully
in mroplllell.ar arlbritia. Tl¥ quadrlc:epa lllDil oondy!M. Pain is produced in cb.oodromalx.ia exteaded polition. If thre is a IIDleocy to
be relaxed for~ peRormaiM:e of this pamllae aDd retroplllellar o*'«ladhri.tis. recummt dial.ocatinn, the palienl will be
lat. Deaeued plllzllar mobility will apprebea.r.i.ve and try ID 1tDp the
obviously impair the pmflliUIIIIMle of the led, pmenilly by puahing the IIXliiiiinm"'s
prmooalnt. hand away.
10.115. Artlcul•uurt.aa (1): PJ.ce the 10.116. Artlcul•uurt.cu ~ Appcent 10.117. Papllteel r.glon (1): Nearly all the
palm of the baDd over the ptfdla, and the brolldcaiDg of the joint md palpeblt 1e1t1 previoual.y dcacriJied bave involved
1lmmb and index a1oD& the joillt 1iDc. Flex ~ OCI.1IIr COIII!DODI.y in otllcotlrlllrilil. cuminatioll af tbc joint/rom rM frrmt. Do
and exlald the joint Tl¥ tourcc of cm:pial1 (Both lidea of the joillt are affected iA the DOt foqet to examiDc the bed of the jomt,
from damqecllldia1llr ~ can thai be lifer lta&e' of tibiafemoral. olteoe1tbritia. but by both inipelltiDD 1111111 ~ If the li:DI:e
de1lccfcd. Compare ODe lide with the other. If iA the early Ragcl of thil 4lOIIditiall the i1 flaecl the roof of the folia iJ rela.ed, 1111111
iA doubt, auc:u~taz the joint !pore ~ IPI.dUzllide of the joint U often lffccted flnt, deep ~on bccomea poaiblc.
pGellar c&b. ('l'bc ahort.-form WOMAC lading to a bow-lq ddarmity tlld fr:eqaently
(ICC p. 178) U Yaluable in AMCMiac the l..uity of the mcdialligamalt.)
depcead~of~ of
the li:DI:e.)
THEKNEE 241
10.118. Popllt.l,..lon (2): 10.119. 111e hlp: Always eumiDe tbc

ScmimembraooBus bunle boc:ome obviou hip, eapecially in tbc pre!ICIII.lC of~
wben tbc blee is em:odcd. Compere tbe undi.aglloled paiD, as bip pain is often
5ides. A bulla may be JDlllllt the time of rUened to tbe lmec joint. The hip may be
examination, lllld trllllillumination is worth aneoed by testiDg rotation at 9(10 flexion tllld
trying altbcqb. DOt al.wt.YJ politi-.e. N~ that noting pain or reslliaion of movcmenta. 10.120. a.dlogn~phs (1): NO!Dllll.
semimanbrauollla ~larue IU)' be •eamdary antaopoltai.or radiograph of tbe knee.
to rbenmatnid artbritil or odler pdlology in
tile joint
10.121. bdlognpbl (2): The COIIIDun of 10.12:1. a.dlogn~phs (4): Note hmlthal:
the fmmlr, tibia ad fibula I n obvious. The lb8laural CDftllylu of the femur aDd of 1b8
pmm1ar shadow i1 uiUlly l'llber faint mKI b.'bla are dn.wn with a bNvy liD8. The /Qts1'fll
difJicull to make oa1. Note 011 the ~ llide tibkll CDftllyu may often be idmtified by 1b8
the two tibial lbadowl f~ by tbe aolmio£ libular 111icularlcm. The llUiliDe of 1b8 tMditJl
E polfmior rimJ of dJe c:Oill:liWI ~ tibkll C'Ofldyu tlmds "' blmd with the aiwiow
tibial pbfMu. ('l'be l.lllnllibial plat9n is 10.122. Rlldlogn1phs (31: Normal lall:nl of 1b8 tibial spma. Note tbe fabella. liD
~ad bu • .mp dudow.) mdiognph of die kaee. Tbc mow poiiiU tx> ~lilt - m d boue lyiac in the lllln1
tile <X81ylopatellar sull:al, wbidl bell" held of ~UI: do IIOt mistlb it for a
idealify tbe lltc::nl t=oal ccalyle. wbich il loote body.
lllp:r llld 1laaet.
J
rf
10.124. 18diC1fNphl (5): N~ my joint 10.125. 18diC1fNphs (6): Look. fur 10.126. laciiOfNplu (7): lolmroadylar
space oau:owinJ (iodiatiug cart1J.aae lo11) al.bmdions in ilclD&I texture (e.g. in P~~iet'a (~) radiographs are ofmn of help in
(N), lipping (L), m.argillalscle.roUa (S). cysts diseue, rbeumaiDid arthritis, osmomalacia, C011fumi.Dg tbe dl.apoail of osteoclwmdritia
(C), loote bodie1 (H), v - or valgua (theae iD1'=1iona). Noll! any bcme dem:la (D) dis.-, u they show the common lites
aze all common in ~1). Do oot augselli'WI of tumour or i.olec:li.oo, or anu of 11101e clearly, eapecially in tbe medial femoral
mistake a bipartite palel1& (B) for !Jw:tme; perio&mal reaaion (P), perbapa iruii.cative of amdyle.. They are also of value in locating
bipartite pamlJa. if preaenl. aft'ec:b the oRr tumoor or illfectioo. Do oot miltak.e loote bodia.
qtwlraal). N ole any almormal cU:ifi.calion, u epiphylealliDes (B) for hairlille or other
in Pellegrlui-5mida diJeue (1), calcified fracturs.
mmUcul (K), aud pleUdogout.
10.127. ladiCifNphl (8): Wblft the 10.1 28. 18diC1fNphs (9): A 200 projection 10.121. laciiOfNplu (10): Apin. in
pam1la U lu.ped. I fiiD8elldal (skyline) view may help in usesains patellar instability. au.pecmd JeCU.mmt dial.oadinn of tbe patella
sbould be obtaiDDd. Thilllm)' show (I) 1 Draw taDpnts to show tbe fatmJ1 tbe bdml1 projection IIIKJuld. be tabn with the
JmrgiDa1 (IMdial) ollllocboodnl frw:ture. pm.UofollloNliJAfls. This i.a poaitive in 97~ :lalllll weishtbearinc aDd held in full
amiiiiOD in I1ICIImlll1 cliak>cwrim of the of DOIJDal. lllbjects (A). In thole l1lffaing IIUm.lion. Thi.a limY c:oofum tbe piMeDCe of
pat.ella. (l) other f'nll:tunls, (3) oa:allim•lly, from IIICIImlllt di.aloadion of the paJ.e1la it i.a 1 highly pW:ed aDd auaceptible J1111e11a
evidax:e of dJondromalacia ~ :rmo in 11M& (B). or oeplive in 20'1. (C). (pDIJa llta).
(4) bi.parti.J.e ptlllllla. This qle may also b& defi.d by cr
Note also whelber the IWcua is sballow
-=-
(>170").
THEKNEE 241
10.110• .AJplrdon(1): AlpirDthelmee 10.131. Aspiration (2): Now ia.liltrate the 10.112. Aspl•tlon (J): Unleu the Jmt.e is
(a) in the preaeru:e of a ten11e lur.mart'bmllia ID' tia~Ue& more deeply down to the levd of the vrsy 1m1e, sqata.e ftaid from the upper
(b) to obWn lpecimrm for badmiology in II}'DilVial membraae of the suprapatellar limits of the npnpa21lar poadJ to IJoat the
suspectrd infec:tioa5. TaldDg fall ueptic pouclL parella. forwards before inlertiDg the
precauliou, begin by rallh!J a skin weal with upind.on ueedle.
local anatathetic j118t ~hove IIIII latr.rai to the
paZlla.
10.1JJ• .AJplrdon (4): Sqaeeze the 10.1J4. Aspiration 15): Un.leaa other
superior upect and &idea of the joint durinJ trea!ment is coo11!mpl.lled., apply a Jones
the ta:minal aae• of upirltion to empty the COIIIpl"ellllion bandage. 'Ibis coolliats of leVInl
joim. Aflr.r wilhdrPtal of the lltledle, apply • l.a.yrn (2-4) of wool in tbe form of wool roll,
sizlrile dre•lh!J over the upinltion life. gampe Ill' couonwool sbt:lets, each held ia
piKe with firmly (but DOt tipaly) applied
calico, c1mnt:t2 or aepe bandagins
Altr:matively, a cklubU: layer af a cin:uWty
woven barld3ce (e.g. '1\lbi.gcip) may be IJied.
10.137. P.thology (3): Tangential (akyliDc)

projection of 1lle previous cue showing tbe
lall:nl. irregularity (to llle rigllt of 1he piclure).
10.111. htbology(4): Tbiaisa

~ lalmal projection of the lmee
in liD adolelamt girl. The palella is in contact
wilh lbD femur proximal to ils articular
10.136. htbology (2): 1'be ~ •wt.:e. aud the joint illryptexllillded.
qtwhaol of lbD patella hu a lepiiiDI amlnl Diapoldl: pm1 niCIIIVIlUm aod patella lll.ta
of ossifil:a!ion. aud delpim DOt lbowing !Wounll:lw.
cleady em. tbe ndiosnrpb tbe ~· 1llltft
well rtlllllded - DOt typka1 of frBctum
ClinK:ally Ibm: wu liD loc:al ~·
DiapaD: bipmifll patella. 'I1Ie comtaacy of
lbD liZ may ot'lla bBlp di.fl'enntiate it from
fiicture.
10.140. P.thologJ (e): There is a well

cle:fum irregularity invclviDg the pmxima1
two-thirda of tbe artiallar: sm&u of tbe
p!ll:ell& in a young WOIIWI.
10.139. PMIMIIogy CJ): 'lbiuwliopph is ......-: d!is iilustrMel a lllaltrxl. degree of
of m acut.e inj!Ky liD lbD lmee ia a 10.141 . ,.., •..,. (7): This localised view
cboadmmlbcia patelbe.
lldolelcmt pt. A1tbousb lbD aMdows of lbD of lbD lmee sbowllllaltrxl.lllllnl'9fill( of the
fanar md tibia .,., thalthe joim hu bem1 joilllapKe ~ the r - IIIJd the pUella,
c:m:rectly poait!OIIIIIl fur the laleDI projection. wilh pUe1lar lipping.
tbe p!ll:ell& is lllp5impoled on tbe fauur. DiapDIII: llfM:I'e relmplllellar ollteolrthritia.
DiapDD: laleDI dialocalion of tbe pa21la.
10.142. Pathology(l): Nomtbcaeparadaa to.ta. Pathology {9}: This radiograph ia
lllld Cragmentalion of the tonguc-llkc an anteropO&tel'icx 'View of lhc bee wblcb IWJ
downward-projecdllg pmximalliblal beea polilicmed to show the iDI:cn1oDdylar
epiphylia. Thla was IIIIOeiated with chroaic, notch (lhc 110-ealled 'tullllcl projectioD'). Note
localiaed bee pain. the puached-out area in the medial femoral 10.144. Pathology (1 D): 1bese radi.oppba
Dlap8sll: OsgoochScb!atter's diacue. condyle, iJidlcaled with the lll'l'OW.
of a )'OUI18 man (note the des- of
Dfaposls: 08tl:ochoDdriti diaeecaDS,
epiphyseal fusion) show aeparation of a larp
typically dl'ectiDg the lat:l:mllide of the
medial femoral condyle.
frasmmt of lloae (lllld articulat cartilage)
from the medial femoral amd.yle.
Dhlpa.la: Jms-ata&diDg osteochnndrilis
clisaa:ans.
10.145. Pathology(11): Tbiais 1he 10.146. Pathology (12}: The amJW8 poiD1 10.147. Pathology (13): Then am sclerotic
Ddiognph of a middle-apd man. The mow to lhMe opacities n!lated to the bee. c:lranps involving 1he poatmor ar1ic:ular
poiDill to a amall spherical loose body lying in Diapam: the uppu arrow poiDill to a surW::e of the plllella. lllld to a lesaer extent
lh8 hdera1 compllllmeDt of 1he joiDt. Them ia llOIIIId fabella. The ~, mow indicates the r:elatal c:oudylar illllfalles of the ftmur.
- lllli1atlnl joiDt lpaalllllliOwiDg. lllld two lootie bodies,Jyins in 1he pclltmior part Thtn is a tilde inegularlty of the b'bial
iimgularity oflha articular surW::e of 1he of the joiol. 1bese IR'l lll!lCOIIdary to spiDea. lllld them ia a la~Je opacity lying
lateni1 femoral amd.yle. osteoarthritis. proximal to lh8 upper pole of lh8 patella.
Diapasia: oateotathrilis oflha a-, with lh8 Diapallilt: osteomthrilis of 1he ~!.Dee, with a
loose body probably sec:oDdaJy to dUll p!XOII. large loose body in the suprapa1ellar poudL
10.1.!10. P..hology (16}: Thil radiograph.

10.148.. Plltholou (14): 1bere are omltiplt IBkiiD foDowin& aru~ tnlllmll, llhow1
lootc bocliel in die kDcc joint widmin& of !be medial joim liDe.
DUpolll: synovial cholldromaiDiia. Di8palill: l:'llpiU!e of the Illlllliallipmlllll of
the !alee. It is UIIOOIDIIIOil to 11e11 sudl a
1G.149. , ..hology (15): There is ptl51 dcpce of dcfumlity wilhout 11tn:11 bc:JDc
dilorpni..sMion of tbe lmec, with moch new ippliccl to tbe joint wbilt the lllma lll'C beiDg
boDe formltion. upoted. The gnlll IIIIIWe of the deCODDity
~: Cllarcot's disease. illdkllllll tb8l !be polterim' J.ipmlm IIIIi
prob.bly both c:nK:iale lipmeatllae also
tum. n.n i• no evidlml:e of an uaociafed
1'rflct1IR of tbe lall:fll tibial plateau.
10.151. P.chalagy (11): 'lbm1l is

10.1 sz. htholou 1111: 1bere I• groea ~ of the maiW joint CODipiii1Illlllt,
10.151. Plllhologr(17): Tbenliubinory IWtCJ'Iriar of tbe joiat !lp8llC with I dqrce of with SOtDe botimntal bciiJe lti:WiODI
of chrouic pm 1111 tbe medial side of !be ~ (Loolar'• -> iDdic8live of ll!plllllld
bee. aDd tbe ~· llilcrn ~ Jllape*: rheu!I!IIO!cl dld1ia. iDI:idmlra o( tanponry powtb. am!lt.
in !be rePm of the llpl8 .......IDII\l of tbe Di8polil: c:brtmK: joiDl illfilction typical of
mediallipDIIIBL tubm:uloai• af the kmle.
DiapaMI: ~eli-.
THEKNEE 247
10.155. Nhology (21): 'lbcre ia

cakificalion iD the 1ate:ral meDiacua.
DlapoiiJ: thia is a common fiDdilla in
pllelldogout.
10.154. Nhology {lO): 1'ht:e Ia

naaowing of lbe medial jo!Dt comparlmr.lll.
with a degree of IDIIq!inallclerolil of bone.
There u • 1iltle raidml cliJbutHiru:e of lbe 10.156. Plllhology {l2): 1br:le iu
lateral tibial pla2au, wbme ~ bu been 111 flllifoan awelling of !be femoral abaft
oJdfrldme. CllaOtdlln& OD lbe kDce joint. Note !be J:ldial
J)fquom: oallioartbrltis of the lalee. ipWulation.
probably -=oudary ID liD old valgus injmy Dlqaolll: !be appe~~UCCI are typi(:ll of
~ Ibm: bu ~ a tibial plaiUIIfral:alre ~IIICOIIIL
(-'. possibly 111 IIIMX:illled meclialligamall
iajmy).
10.157. PatMIOIJ (2J): Tbe proDmal part 10.151. htholotJ (24): CiDicllly tbac
of !be tibial mdaphylilcm its medial side u wu • mark&:d bow-leg clcftrrmi(y. The
beabd, aDd clinically Ibm: wu nwUd ndiogapha coa1ltm lbe tibial bowiJII; IDd
lxlwinl of tbis child'• Jess. lbow 1riclcDiD& af lbe mdapbyiCI dlbe libiJ,
~:tibia. YUL wilh ~ im:plarity Uld capping.
~: licbta UIJOCialicd with ~lamia D
dc&ic::Dcy.
11
The tibia
Common 01uses of pain in the anterior

aspect of the lower leg 250
Osteitis of the tibia 250
Bone tumours 250
Anterior tibial compartment
syndrome 250
s~ fracture of the tibia 250
Medial tibial syndrome/shin
splints 251
Tabes dorsalis 251
Common OJ uses of pain in the
posterior aspect of the lower
leg 251
Deformities of the tibia 251
Guide to commoner causes of leg
pain 252
Inspection 253
Tibial torsion 253-254
Screening tests for leg pain 254
Radiographs 255
Pathology 256--257
COMMON CAUSES OF PAIN IN THE ANTERIOR

ASPECT OF THE LOWER LEG
Note: Knock-knee and bow-leg deformities lll'C included with the knee joint.
OSTEITIS OF THE TIBIA
Osteitis of the tibia occurs predominantly in children. with or without a
history of previous trauma or sore throat. Pain is intense. tendcmcss ia acute
and initially well localised over the meblphyscal area, and there is inability
to weightbear. There is systemic upset with fever and tachycardia, and often
(but not always) a polymmph leukocytosis. Admission and investigation
with repeated blood cultmes is essential. Radiographs of the tibia are
initially normal, often with a lag of 2 weeks or more before any aboonnality
is detectable (although MRI and CT sclll18 may be affected somewhat
earlier). The ESR and C-reactive protein are usually elevated at an early
date. When this condition is suspected, it is customary to administer a
broad-spectrum antibiotic effective against the penicillin-resistant
Staphylococcru, and in large doses to achieve adequate bone levels, prior to
the results of blood cultme. Splintage of the affected area is often helpful,
and in proven cases antibiotics are administered for 4 weeks. Surgical
drainage is seldom necessary and is avoided unless failure of response to
antibiotics, profound toxicity and spread of the infection make it essential.
Cellulitis from insect stings. small woUDda and abrasions and hair follicle
infections may sometime" cause difficulty in di~sis.
Low-grade osteitis of the tibia (Brodie's abscess) may give riae to chronic
upper tibial pain.
BONE TUMOURS
The tibia is a common site for many primary bone tumcun, so that
radiographic examination oftbe tibia is essential in any case of
undi~sed leg pain.
ANTERIOR TIBIAL COMPARTMENT SYNDROME

Thill is a common complication of fractures of the tibial shaft, but may
follow a period of intense lower limb ad:ivity: hence it is common in
athletes. It gives rise to pain in the front of the leg. 'Ibis is due to oedema
and swelling within the confines of the anterior compartment, which lead in
turn to ischaemia in the anterior tibial muscles. In severe cases where
swelling is progressive there may eventually be muscle necrosis. The leg is
diffusely swollen and tender, and the skin bas a glossy appearance. Tibialis
anterior and extensor hallucis longus are first affected. with weakness and
later inability to extend the ankle and great toe. The dorsalis pedis pulse
may be absent, and there may be sensory loss in the first web space due to
ischaemic changes in tile deep peroneal nerve. In high-risk and suspect cases
compartment pressure monitoring is advisable. In severe cases immediate
surgical decompression of the anterior tibial compartment is essential if
muacle necrosis is to be avoided.
STRESS FRACTURE OF THE TIBIA
In this condition the onset of leg pain may be sudden or less acute. 'I'here is
sharply localised bone tendemesa and overlying oedema Radiographic
demonitratioo of 1he hairline fracture may be difficult. and with penistent
THETIBIA 251
pain repeated examination is essential. A radioisotope bone scan may be

helpful in diagnosing a local 'hot spot'. In many cues the diagnosis may
not be firmly established until a small area of tell-tale callus is showing. The
condition is also common in Paget's disease where, of course, there is an
easily identifiable radiological abnonnality.
MEDIAL TIBIAL SYNDROME/SHIN SPLINTS

In this condition pain on the ~ side of the shin in sportsmen may be
severe, and there is usually tc:odcmcss along the postcromcdial border of
the lower part of the tibia. In a number of cases the symptoms may arise
from stress fractures of the tibia, but in others the pathology is less clear.
(Other causes include compartment syndromes, fascial hernias, interosseous
membrane tears, periosteal avulsions, tendinitis, muscle sprains and
periostitis.) Where symptoms are of a chronic nature, and fracture has been
excluded, di\'ision of the attachments of the crural fascia may give relid.
TABES DORSALIS
Severe pain in the shins (lightning pains) is common in tabes dorsalis.
Usually other criteria are present (e.g. Argyll-Robertaon pupi15) and
serological tests will confirm the diagnosis.
COMMON CAUSES OF PAIN IN THE POSTERIOR

ASPECT OF THE LOWER LEG
1. 'Rupttu"ed plantaris tendon'. Sudden pain in the calf during acti\'ity with
diffuse tenderness in the upper and ower part of the calf is now regarded
as being due to tearing of DIWJCJe fibres of soleus or gastrocnemius, rather
than injury to the plantaris muscle wbo6e uame is attached to the
condition. Pain often pcnists for seveql. months and a period of plaster
immobilisation is often helpful in giving relief in the acute initial stages.
2. Thrombophlebitis. Thrombosis in the supe:rficial veins of the calf with
local inflammatory changes is a common CllllSC of recurrent calf pain, and
the presence of tendemcss and other inflammatory signs along the course
of a calf vein make diagnosis easy. Thrombosis in the deep veins is often
silent, and its importance in the postoperative situation is well known.
3. Other causes ofposterior leg pain. Pain in the calf is common in patients
suffering from prolapsed intervertebral discs. Claudication pain is a
feature of vascular insufficiency and spinal stenosis. Leaions of the foot
and ankle that lead to protective muscle spasm on standing and walking
frequently give rise to marked calf and leg pain.
DEFORMITIES OF THE TIBIA

Alteration in the normal curvature of the tibia is not uncommon and may be
a cause for complaint. The bone may curve convex laterally (tibial bowing),
convex anteriorly (tibial kyphosis). or undergo a rotational deformity (tibial
torsion). Deformities of these types are particularly likely to occur in infants
aod young children, when the immah•re bone may yield under the weight of
a relatively heavy c:hi1d. In the majority of cases no other cause is apparent,
and spontaneous correction by the time the child reaches the age of 6 is the
rule. Nevedheless, rickets and other osteodystrophies must be excluded and

continuous observation is essential.
Pseudarthrosis of the tibia is a rare congenital abnormality which leads to
progressive tibial kyphosis. The tibia becomes progressively thinner and
undergoes spontaneous fracture, which proceeds to non-union. It is
particu1arly resistant to treatment. The diagnosis is made on the radiographi<:
findings.
In the adWt, deformity of the tl"bia may be aeen following rickets in
childhood, malunited fractures, Paget's diseue and syphilis.
GUIDE TO COMMONER CAUSES OF LEG PAIN

In children Osteitis or other infections
Bone tumour
Adolescents and young adults Stress fracture tibia
Bone tumours (especially osteoid osteoma,
ostcoclastoma, osteosarooma)
Brodie's abscess
Anterior compartment syndromes
Paget's disease
'Ruptured plantaris tendon'
Painful conditions of the foot
Syphilis
Bone tumours
Adults ProlapiiCd invertcbral disc and spinal
stenosis
VllliCUlar insufficiency
Paget's disease
'Ruptured plantaris tendon'
Painful cooditions of the foot
Syphilis
Bone tumours
THE TIBIA ZSJ
1 1.1. lnspactba (1): softtlsaue aWIIng: 11.2. Inspection (2): locallsad oedame: 11..1. Inspection (J}: loal bone aWIIng:
Nom tbe site aud extad of any lwetlinJ. In Localised oedtma is common over 1bi1 is Jugeative of MDplaam (e.g. osteoid
tbe cue of oedtma, uom particularly if inflammatory lelicms and llreu fracturea. oslrA:Ima) or old fracture. Multiple or lingle
bilafr.ral (~a a-1 rather dian a exot1to1ea commoo.ly occur in tbe tibia in
local ca~~~e). Unilafrzallq oedema in women di.lphyleal. adDis. Tbicboing of the eods of
over 40 is a CODliiiOII lip of intrapelvic the tibia il aeen in rickm and in
omp1.um. omoanhritil.
--
--- - ~~
1 1.4. Inspection (4): geneNI bane 11.5. Inspection (5): tliUisMpe: Noll! , ... nblal tonlon (1): Flex the let!• em!£
tbklllnlnF &teuiw thlckzming of boDe any aboormalantsior cmvatllre (tibial the edp of the Maminatirm cooch. The tibial
is c:lunctaillic: of~·, dileue 111111 k.yphoais), possibly sec:oadm:y toi'3p'• lllba-cles mUll :W:e dinlc:tly fmwards. Place
lq-.a-ling Ollllilia. In lbe ~ cue tiHe dileue, malunited ~ syphilis or the iDdex liDgtn IMir the malleoli. The
~n uiUall.y otbs" lips, Rid! u IK:8Irin& or rillkm. Rkbtl affects the distal. half of both IDIIdial malleoh11 Dml!lally Iiiii 20" ill
.um-. tibia aod fibula, 111111 tiHn - ~ from of the lalllral in the conmal plane) •
llllln1 and tmsicmal. defonnitim.
1 1.7. nblal torsion (2.}: Altl:rllalively, 11.8. nblal torsion (S); (A) MediGl 11.9. ,..nct.mus (1); At thefrontoftlle
eumiDe lhc patient in Chc ptoDC pollition wah torsional deformity (a decreaac in lhc aoglc) leg, tendemeu i1 ~ llill:d in
lhc knees flexed to 90". Tile ankle dloald be 11 uiiOCiatcd wilb &t foot and intoclng. die fol1owiD& COilditionl: (A) O.good-
in the aeutral poti1ion. Note lhc politiaD at (B) Iat.ralloraional cldotmity (an iDa:eaae ScbJatlcr'l dileac, (B) Brodie'• abeceaa,
lhc medial borden at both feet in relmoa to in the llllg]e) il 8CCII in pel CIMI8. Tibial aDd olteitil, (C) IDfcl:ior ti'billl COIDp8dml:llt
lhc midlille: lhil iiiWriDill.y ia tbe n:giaD at femonl torliOD may be rdUibly uae•scd IYJMiromc, (D) ll:ft:11 friA:tmc, (E) IbiD spUIIU.
20", but will be lft:llcr wbere 1bcze il a 1laing ula'uoOJid medloda.
lateral tibial toniollal deformity (illuUifed),
and leiS wheft: ~~!ere il a mcdilll &orliODII
defomlity.
1 1.1 0. Ten--. (2): At !be b.ck of the 11.1 1. ScNenlng tats (1 ): The followiDg , 1. 12.. ~·. . tatsll): The lowm limb
leg, IBidauell il ~tk:ally situated in feltS should be c:mied out in the invt~~tiption ~ abould be elli:iled, and if iDdic:aled,
the followiD&: (A) 'ruphlnld pbmaria IIIIDdon' of any c:ue of leg ptlin. The .night hilt !be papib for I'Adioa to li&bt and
a}'Ddtomt, (B) aver vark:olitlu in aupc:rflcial leg-raiaing ~at abould be carried out aa a ftrlt III)COI!Irmdarioa. Lowu leg pain il a c:omman
tbrombophldlitia, (C) aver die felldocabDcwi - · lD may C:IIQI pelA in tbe leg below tymptom af lale aypbilia. (3) Tbc peripberal
in pmilll tan lllld complcCe ruplm'Ca. lhc knee il rcfarcd from tbc IJiinc. pulla lbould be aoa&bL lacbacmia il an
CX1ft:IDCiy llOIIIIIIOII c:aU8C of leg pm.
THE TIBIA 255
1 1.1 S. Redlogr•phs (1): Tbe lbuldanUlma 11.14. bdlogn!phl (2): Begin by lllJtiD& 11.15. Radlogn1phs (S): Deformity ie
are an anll':ropottmor lllld a lalr%al. whicb die geat:nl 8bape of tbe bone~, dicit ll=XCW:C c:ommon in P~.,., diua~• (A), where dlele
iDclade baCh eodJ of die tibia ll.lld llbula. Fe. and lbeit milleralisatioD. For example, in il diatmbei:e of fmm. and ltlllme, and
better vimalila1ion of a auapect - . rickm duriDg die pba8e of boDe IOfl=iDg, IIOillCfimel IIIIOO!Ditoul change. Ia
localised vicwJ are rcqWrcd. cr and MRI deformity followl weighlbeariDg. Note pH»ttartluo.ril of 1M tibilJ (B) llae il local
ICIUII are aftta uaeful, elpeoially in angulatioD of the pl.alae of the anklt (wbich I1WilliD& and angulaW:Ja of the boDe, wbidl
eval.ultiJI& cyltio dclec1l, ad 1'ldioilotope may llleoreticllly predispoiC 1D ollteo8r1llritia). progreaea 1D tibial diHnlntiOD, die fibula
ICIUII may be belpful in UICIIiJI& loc:al genml1y rc:mailliDg !datively normal
vuculari1y.
1 1.1 6. Redlogr•phs (4): N«* any cmritis, or at tbe site of a bcme tumour. Note lilllla of tbe bcme fur space-occupying leliooa,
localised ddmmity ll1ll:b u in (A) diaphylea! (B) oortU:a1 bcme destruction suggestiJas a IIIICh u (H) a 1lllK:mmnl boDe cyst OCCI1IIiDs
lcl.ui1 (aftta leWDl booea are a1fec:lld); lyti(; III!Opbwn or inm:tioo.. Localiaed in tbe m.t\, (I) an oalleoclutoma OCCI1IIiDs ia
(B) Osgood-SclJlder's clileue; (C) localised tlriclcening of boDe il ICCD. after a healed the epiphym, aud (J) a Brodie's ablcas in
peno.tut xuctiou. ia !be regioa of a nreu fnaure (F) or apia at a tumom lite (e.s. the md:lphyais..
fracture; (D) more exllmDve subpmio&tul ia ollleoid odeoma, where there is oflra a
new boDe formldoa ia !be laJrr atqa of c:emalllidtul (G)). ExamiJJe tbe cavity aud
11.17. ladiOfNphs crf .... tibia:

aampiM crf pMhology {1): The radiograph
showa c:urvllllna of the tibia 8lld fibula. 11.19. P.thology (l); 'lbe arrow poinll to
wbidJ. me convex both lalmally aad an area of pa:iosteal reaction with tbe alight
anaiorly. "fbeee u 1111 ldditicmal tonicmal iDcreue in boDe den8ity It the same level
defmmity wbidJ. u oot obvious in these films. ~ llreu frlclure of tbe tibia.
Diapalil: pamling defonnlty of the tibia 11.11. PllthologJ Ql: r.a die came of the
following rK:bll in clrildbood. film the tibia u 8eeD kl be klcally thicJa:aed,
and just 'Yiaibk u an area of iaL':reued 'boDe
demity lllllllillg downwards from ldt to rigbt.
DlqDalll: ol4 fractla'e of 1be Illidmlft of die
tibia.
11.21. P..hology (5); Ia tile left libala (on tile rigbt of the pictme)
dlere is afenlive bolle del~ lllld IUbpaiolfell- bone
formltion.
Dtllpolll: tile llpllelliDCU Be ~tic of OlllciliaiOIIIC weeD
after the omet, which wu llemlded with fevu, lllllaiae, llld le\'"eR
loc:al. pliiL
11.20. P11111o1otJ (4J: 111e AP m. lboWI •llikill& llicratioa in

belle taiDrc. db 1D iJ1aeae ia ~ a.m:x IBfaiody.lD both
v.icwJ boac tbicJrening and iDc:reucd bone dellaity ~ IPI*=l
Diapalll: Pl&d'• ctiaeuc of tbe tibia. lD lllie cue ~ wu DO
ma!jgnant cl!qc.
THE TIBIA 257
11 .22. hlholou (61: 1b:re i• localiJecl 11.24. PMboiOIIJ (1): This rlldiograph of
thlc'Jrenia& of tile tibia, with a Jaae cavity 1 1.D. htholop (7): There i.a alazp !be femur allows a bony lesion of the abaft with
wbich i1 open on ita laleral upect. cystic spau in tbe tibia, with welii'OIJIIIW a cbaJactmi.atic piiiiCbed.-t ~ IIIJd
Dlapalll: ChrOI1ic oei~ of tile tibia. The llllll'gins. .coadary thic:lumin& of the IIUII'OIIIIdin& boDe.
cavity in lbe bone~ to a linua. No aeqaeatra Dfap&D: uniamJeral. (simple) bone C)'lt ~: !be appearliDall lie c:ham:tmiJtic
IR: lppll'tDt ia t11e ndioaraph. involviJ18 tile medullary caaal. of tbe tibia. of a hi8hlY Jll.lli.inant Bwms'• tumour.
Sucll almonnalilia may oflleu be brought to J..aioas in the tibia are 110t um:ommon 8IId
light by a pd!ological fral:tuie. haw a limilar appearam:e.
1 1.26. htholop (10t: ~ i.a 111. ufmlsive llnlll of oew lxme :famudiOII relabd to !be dDd't
of the fibula. Allhough the lelion iJ more IIISily ~ iD the AP projection, ita stmt is belt
11.25. hlllologJ It): n.e i.a clmtmctioD jadced in tbi.a cue iB the laknl. TIBe wu a hiltmy of 1oc:al trmma aod I'Miilini 1001 weelu
ad grou deb:mily of !be proximal tibala. bcfarc.
»-...:ThD~ ~n~typicalof Dl....,.-: 'lbc aw c•MIIlCI m: typical oflllyOiili1 Ollifican1. Thil -
lbougbt to line
Ollllol:laaiXll The tumour iJl lbi.a CUIIWU occurred in a Jwmatoona wbich bad farmed oo the laJrnl upcct of the leg following a IIDill
Dilly locally malipumt bal wu _.,da!rd with cnck fracture of the fi.ba1a.
a amJIDIIIl pmmealnerve palry md drop foot.
12
The ankle

Soft tissue injuries of the ankle 261
Injuries ofthe lateral ligament 261
Inferior tibiofibular ligaments 261
Medialligament 262
Achilles tendon (tendo
calcaneus) 262
Achilles tendinopathy 262
Acute traumatic Achilles tendon
rupture 262
Insertional tendinitis 262
Other common conditions seen
around the ankle 262
Tenosynovitis 262
Footballet"s ankle 263
Osteochondritis of the talus 263
Snapping peroneal tendons 263
Osteoarthritis 263
Tuberculosis 263
Shortening of the Achilles tendon
(tendo calcaneus) 264
Guide to painful conditions around the
ankle 264
Inspection 265
Tenderness 265
L.ateralligament 265-266
Inferior tibiofibular joint 267
M!M!ments 267-268
Achilles tendon 268
Tenosynovitis 269--270
Peroneal tendons and articular
surfaces 270--272
Radiographs 271-272
Pathology 272-273
Fig. 12.A
ANATOMICAL FEATURES
The ankle joint is basically a simple hinge joint, normally pcrmiUing
movement in one plane (dorsiflexion IIDd plantarfiexion), but in addition,
up to 18° of axial rotation of the talus in the tibial mortice may occur.
Load-bearing sfl"esses (IB) an: taken by the upper articular surface of the
talus and the tibia; the fibula plays no part in this.
Medial displacement (translation) of the talus is prevented by the medial
malleolus (M), and lateral displacement by the 1ateml malleolus (L).
Po.rterior tillar shift is blocked by the downwani-projecting curved articular
surface of the tibia (P) behind, and the corresponding surface in front (A)
prevents anterior subluxation. Any of these bony prominences may be
fractured, resulting in potential instability.
When viewed from above, the articular surface of the talus may be seen
to be wider anteriorly (1) than posteriorly (2). This means that as the ankle
is donifiexed (3), the talus is gripped IDOl'C firmly between the malleoli and
pushes the fibula laterally (4). When the ankle is plantarflexed there is a
greater degree of freedom (and instability) of the talus in the ankle mortice.
The natural congruency of the bony components of the ankle accounts for
its inherent stability and this is reinforced by the disposition and strength of
the associated ligaments. These include the following:
(a) The inferior tibiofibular ligaments (anterior and posterior) (5), which
bind the tibia to the fibula. They an: assisted by the weak imerosseous
membrane (6).
THE ANKLE Z61
(b) The Jateral (external) ligament (7) has three parts which arise from the
fibula; distally the anterior and posterior fuciculi are attached to the
talus, and the central slip is attached to the calcaneus.
(c) The medial ligament (8), immeDJely strong, is triangular in shape
(hence the alternative tenn deltoid ligaulent), and ia attached proximally
to the medial malleolus. Its deep fibres (9) pan to the medial surface of
tbe talus. and its superficial part is attached to tbe navicular (10), tbe
spring ligament (11) and the cakBDeUs (12).
Note that a careful examination of the foot is often also a:quired in the
investigation of many ankle complaints.
SOFT TISSUE INJURIES OF THE ANKLE
Soft tissue injuries of the ankle are extremely common and in more severe
cases difficult to differentiate from undisplaced fractures. Radiographic
examination is essential in all but the most minor lesions, and is also
necessary where symptoms are persistent. When fracture has been excluded
after a significant injury a diagnosis has still to be made, as this manifestly
affects treatment.
INJURIES OF THE LATERAL LIGAMENT
The lateral ligament is damaged through inversion injuries. In an incomplete

tear, some fibres only are ruptured (ankle sprain). Treatment is then
symptomatic and a full early recovery can be expected. When the ligament
is completely tom or detached from tbe fibula. tbe talus is free to tilt in the
mortice of the tibia and fibula. If the lateral ligament fails to heal, chronic
instability of the ankle results. If this injury is diagnosed in the acute stages,
it should be treated by prolonged immobillsation in a plaster cast or
orthosis, or by operative repair. In lafe.di.aano&ed cases good reiJ\Jlts
generally follow lateral ligament reconstruction procedures.
In fimctional instability of the ankk the patient complains of frequent
sensations of the ankle giving way, and pain, stiffness and swelling related
to activity, but no evidence of ligament laxity can be found. It is thought
that in many of these cases there is a degree of motor incoordination arising
from some disorder of proprioception. Most respond to specialised
physiotherapy (using tilt boards and other measures to improve muscular
coordination).
INFERIOR TIBIOFIBULAR LIGAMENTS
When the foot is dorsifiexed the distal end of the fibula moves 1aterally
(and proximally) as it is engaged by the wedge-shaped upper articular
surface of the talus. This movement is restricted by the inferior tibiofibular
ligaments, and to a lesser extent the interosseous membrane. Damage to
these structures may lead to Jateral disp~ment of the fibu1a and lateral
drift of the talus (diastasis). In treablleDl, tbe talus must be realigned with
tbe tibia and any fibular displacement reduced. This reduction may be held
by cross-tereWing of the fibula to tbe tl"bia. or by plaster fixation.
262 CLINICAL ORTHOPAEDIC EXAMINA110N
MEDIAL LIGAMENT
The medial. ligament is immeruely strong, 8IId if stressed in ankle joint
injuries it generally avulses the malial malleolus rather than itself tearing.
Nevertheless, tears do occur, 8IId are seen particularly in conjunction with
lateral malleolar fractures. Meticulous reduction of any associated fracture is
essential, and this often requires an open prooeciure. Operative repair of the
ligament may be required.
ACHILLES TENDON (TENDO CALCANEUS)

ACHILLES TENDINOPATHY
This generally results from excessive repetitive overload of the tendon
to a degree that exceeds its capacity to recover. The preferred term
'tcndinopathy' includes a number of conditions which may only be
differentiated by direct inspection and histological examination of the
tendon or surrounding structures. These iDclude tendinw, whcre there is
a clear in1Jammatory process involving the tendon; tendinosis, where there
is collagen degeneration within the tendon; and paratendinilis, when thele
are inflammatory changes in the sbeath of the tendon.
The condition is common in athletes, particularly runners and jumpers,
but also in footballers, tennis players and ballet dancels. It gives rise to
localised pain which is related to lowec limb activity. In severe cases
of tendinopathy tb.ete may be progressive weakness of plantarflexion,
accompanied by impaired function and, in some cases, spontaneous
rupture of the tendon.
Most cases are treated conservatively by restricting activities,
sapplememed when required by physiotherapy in the form of tendoo
stretching eXCI'Cises, tendon massage, ot1hoUc devices for the shoes, and
therapeutic ultrasound In some resistant cases sargical measures such as the
removal of fibrotic nodules from within the tendon and the release of tendon
adhesions may be required.
ACUTE TRAUMATIC ACHILLES TENDON RUPTURE
Sudden plantarflexion of the foot may rupture the Achilles tendon,
especially when it is weakened as a result of tendinosis and the degenerative
changes often seen in middle age. Surgical repair may be carried out,
although in most cases excellent results may be achieved by conservative
management in a plaster cast or an orthosis.
INSERTIONAL TENDINITIS
This condition affects the tendon at its calcaneal insertion in the calcaneus.
It tends to occur in mi.ddl.e--aged and overweight pati.cmts, and is usually
treated conservatively.
OTHER COMMON CONDITIONS SEEN AROUND THE ANKLE

TENOSYNOVITIS
Inflammatory changes in the tendon shca1hs behind the malleoli may give
rise to pain at the sides of the ankle joint. Thnosynovitis may follow unusual
excessive activity c.: be associated with degenerative changes. Bat foot or
rheomatoid arthritis. There is puffy swelling in the line of the tendoos. with
THE ANKLE Z6J
tenderness extending often for several centimetres along their length.

Tibialis posterior and peroneus longus are most frequently involved. and
stretching of these structures during inversion and eversion of the foot gives
rise to pain. Spontaneous rupture is not uncommon. Symptoms generally
respond to immobilisation for short periods in a below-knee walking plaster
01' an orthosis.
FOOTBALLER'S ANKLE
ill-localised pain in the front of the ankle may follow repeated iDcidents of
forced plantadlexion of the foot which result in tearing of the anterior
capsule of the ankle joint. This occurs frequently in footballen, where this
form of stress is common. Calcification in the resulting areas of avulsion
and haemorrhage leads to the appearance of charactcri.stic exostoses, which
show in J.ate:ra1 radiographic projections of the ankle. These may lead to
mechanical restriction of dorsiflexion.
OSTEOCHONDRITIS OF THE TALUS

Although rather uncommon, this condition, which is seen most frequently in
adolescenta and young men, may give disabling pain in the ankle. It is now
generally agreed that the condition starts as an osteochondral fracture. It is
the frequent source of complaints of chronic disability following a so-called
simple sprain of the ankle. The diagnosis is made on the radiological
:findings, although the site of the pain and local tenderness over the upper
articular surface of the talus may lead one to suspect it. CT and MRI scans
are invaluable in doubtful cases. If loose bodies are produced, they must be
excised The treat:ment of the local lesion follows in principle that of
osteochondritis di.ssecans of the knee.
SNAPPING PERONEAL TENDONS

This is an uncommon cause of ankle pain and is due to tearing of the
superior peroneal retinaculum.. The patient complains of a clicking sensation
in the ankle and is usually able to demonstrate the peroneal tendons riding
over the lateral malleolus. The treatment is by surgical reconstruction of the
retinaculum.
OSTEOARTHRITIS
Primary osteoartbritis of the ankle is rare. Secondary osteoarthritis is
sometimes seen after ankle fractures, avascular necrosis of the talus, or
osteochondritis of the talus.
Rheumatoid arthritis of the ankle is not uncommon but is seldom seen as a
primary manifestation of the disease, so that the diagnosis seldom presents
difficulty.
TUBERCULOSIS
'1\lberculous infections of the ankle joint arc now rare in the UK. When they
occur there is swelling of the joint. wasting of the calf, and the usual signs
of inflammation. 'Ihe patient develops a painful limp, and as the joint is
comparatively supedicial. sinus fonnation is common at a comparatively
early stage.
SHORTENING OF THE ACHILLES TENDON (TENDO CALCANEUS)

Shortening of the Achill.e8 tendon results in p1antarflexion of the foot and
clumsiness of gait as the heel fails to reach the ground. The more severe
degMes of Acbilles tendon shortening are aa:ompanied by a tendency to ftat
foot In many cases ftexion of the knee, by taking the tmiBion off the
g~~Strocnemius, will permit dorsiflexion of the foot. Shortening of the
Achilles tendon may occur as an apparently isolated condition with no
obviOOA predisposing cause, but in a g~eat many cases it is aasociat.ed with
congenital deformities of the foot or neurological disorders, of which
subclinical poliomyelitis iB one of the most common (for talipes deformities
see Chapter 13). Occasionally it may result from ischaemic contracture of
the calf muscles.
GUIDE TO PAINFUL CONDITIONS AROUND THE ANKLE

History of recent Sprain of lateral ligament
injury Complete tear of lateral ligament
(Ankle fracture, fracture of the fifth metatarsal base)
Tibiofibular diastasis
Ruptured Achilles tendon (tendo calcaneus)
History of past CompJete tear of lateral ligament

injury SecOlldary osteoarthritis (e.g. previous ankle f:racture)
No history of injury Osteochondritis tali

Rheumatoid arthritis
Primary osteoarthritis
Footballer's ankle
Secondary osteoarthritis (e.g. from osteochoodriti&
tali)
ThnosynovitiB
Achilles tendinopathy
Snapping peroneal tendons
THE ANKLE Z65
12.1. lntpKtlon(1J: Loall:for(A) 1:u. Inspection (2): Loot for defoanity 12.3. lnJPKtl• (S}: Look for bruiaiag,
defol:mity of shape, tuggcltilla tec:e11t or af poature (e.g. plaDiaJaaiOD owiJI& to llhart IWClllng or oedema. lf 1ll«e i1 ay IWclliDg,
old fracture; (B) limla ~ear~, ~q~ealiDg old teodo ca~a. talipes dc:formity,l.'llptllm! ~ whethrz it ia diff1lae or loclllilled. Note
iDrec:tiaD, pllltil:ullrly tubercuiDiiJ. teodo ~or drop foot). allo whedlcr oedema ia biJaltnl, IUggeltiag
a a}'ltemic nlJx:r than a local Clll*.
12A. Ten--... (1): W1liCII ~ ia 12.5. Tenclern. . (2): After inversion 12... aa...lll. .ment (1): CGIIIplete
tendemeaa localised ~ tbc malleoli
following injury, nd.iogriiJ)Itie enminltion
aprtlina, teDderness ia often diffuse. Swclling
to begin will! lies in tbe line of tbc fuch:uli
......llfpiftent -.r: Swdling ia rapid,
and if leta wilhin 2 llours of injury ia
is oeeesaary to ~ fr1cture. of tbe la11eralligamcat. ecpbtped and pl.:ed OftZ the ltteral
malleolas (MeKcnzie'l lisn).
12.7. l.ateralllpntent 12): ttrus tutlng 12..8. l.ateralllpntent (S): ttrus tutlng 12..9. Ldlnllllgament (4): ltNIS tutlnt
for mmplew ldlralllgament ...rs (1): for mmpletil ....,.lllgament ...rs (2}: for mmplew lewralllgament tars (S):
Orup the heel IDd foroibly ia?m the foot, If in doubt, have a radiognph !aha while If tilfilla of the bllUJ in die ankle lllOrW:e il
llt.liDa for any opaling-up of die lallcnl aide the foot il forcibly inverted demolla1Z'Itcd, rqlCilt the eumiaatioa on the
of lhc IDkle between the tibia IDd tbe tabla. o1Jicr aide ad~ lhc 1llml.
12.10.. Labnlllgamant (J): atNU tutlng 12-1 1_ .....,.. lfpment (6}: strau tastlng 12.12. Lataral Dpment (6): SINM tutlng
for mmplewi.WI'IIIII,.ment tlllln (4): of tha antarlor tllolbulu mmpoMnt fill or ... antellor tlbloftbular llgamMt (2):
If the injury is f:reth ad painful. the IMiatal'llllf,.ment (1 ): Jnstahility may Antr.r:lor di.spb=mr.Dt may be conlinnM by
enmjuatioa may be mare readily~ IIOIIllllima follow tears of lbe liDterior ndiosrapba taha in the pnme pcdim;
after tbe injection of lS-20 mL of O.S'I. bllofiba1ar portion only of lbe lllfela1 alllinWively, with the palimllmpine (aDd
li.docai.oe widely in the region of tbe J.8lmlll J.ipmr.ol. With the paiient pr:ooe, prell prmnbly with loc:al-.thelia), mpport lbe
lipnent. clownwanls Oil the bee!, looting for liDterior heel on a undbq (1) ad preu firmly
dispW:ement of the talus. wbi.cb is oflaJ. downWlll'lil OD the tibia (2) for 30 I«<OIds up
~by dimpling of the lkin Oil to l:liJIOI~ A pp OD the radiograph between
either lide of lbe tendo calc'¥'11 the lab IDd tibia of more than 6 111111 is
repnWu ~ ('3).
THE ANKLE Z67
12.1 S. lnferfOJ dbldbu..r llgamant (1): 12.14. lnr.rlordblofibular llglun.ne W: 12.15. lnr.rlor dblofibular llg~~~n... (S):
In 1un of lhia ligamalt (wllich lw anaior In teara of the iDferior tibiofibular ligamalt Grap the beclmd try lo mme die calaa
and poe1l':rior compoDeDII) tavkmcu iB pain i1 produced by donill.exion of the foot, dirccal.y latt:.rally in tbe llllklt morlic:e. Lateral
prelall over the li.gamcntjut above the line whidl diaplal:ea the fibula lallcrally. diJpJa.clemtN iDdicalct a tear of die lig11111e11t
of the aMic joiDt
12.16. Ankle Joint .......,._..{1): First 11.17. Anlda Joint movements (2): 12.1L AnldeJolnt-ants(J):
confinn that the dle b mobile. and that ay Meume plaDtar:fte.xion from the zero Meume the raqe of donillexion. Always
appareat IIIOVeDlelll b DDt llrisins in the position. This rdera:u::e lies at right qles ID I:OIIlpGe the lidea.
midtarul or mae diltal joillb. Finnly grup lhr: line of the leg. N-.1 r-ae = lSO.
the foot proximal. to the midtarul joint; try ID Nannal r1111J1e = 55".
prochx:e dmliflmon IIIII planbrftexion.
12.19. Ankle Joint mcrwntents (4}: If 12.20. Ankle Joint mGVW~~ents 15): If 12..21. Tendo celceneus (Achlllestllndon):
doniflexioa is remu:ted. beDd the k:nee. If 1brze ia Iota or active doraifleltim (drop foot) suspedlld tendlnopethy (1 ): 'lbc pllti.eal
this restores a DOaDal raJIIC. the Aobillee a tun aeurological n•min•tion is requiiOO. lhould bo proae, with the feet over die edge
leDdoD is tigbL If it mab:IIID ditr-=, 'lbc c:omm011e4t cauaes are lllola:, old or die coadL IDJpect IDd compare die sidea.
joint padlology (IUCh .. 0~ poliomyeJilia, pmlap8ed J.ambar intervnJbnl. Note any IDeal (a) or diffuee IWdliag, reciDeaa
rlx:umalllid udlrili1 or iDfcction) ia tbe di~e:~. IUid local Jeska or the common or die lkiD. or the PfC'CDilC or a HaglaDd
liC1y CIIU8C. perooca1 (lateral poplitul) ~ clc:formity (b): this i1 a aolfoliJ afiectiDg
the~ upcct aftbe heel oa ita
lateral upcct It ia COIIIIIIOIIly Ulociatl:d with
Ill Aobillel imc:rtiODil feDdillilil, although it
cloe1 DDt ~Y iavolve the t=ldon.
I
I
I
'
12.22. Susped8d t8ncllnopetiiJ (2):

~
12.23. Suspect8d tllndlnopatiiJ (3): If 12.24. SuspectMI tllndon ruptuN (1):
Now look for llmdmNM, wblcl! in IIIII cue tmdemN.!! is fOUlld, lillie wb.etbm: the lite Apin lbe patient llboald bo examiiJed with
or a 1IIDdinopatb.y is IIDJlUlly litumd ~~ em or IIIIIXimnm l l m d - chanps with tbe feet CM!I' IIIII tmd of the =h. Dsfa:ts in
pnDimaJ. to lbe IIDioa inMrtloa. Check !or doniflexion IUid p1amadlmjoD of tbe foot. If tbe IXIIItOIIr of IIIII teDdon may bo obviou1.
any iDcmlae iD local but. Plllpm the r-Ica, tbe pain is leCCllldary to paratendjniris tbe life
IIOiiD& any lcx:an-1 or f1ISifmn swellial. aod or !!IIIXimnm 1lmclemNa will rmnain 1Wd (a).
any oodulaity. Gently 11q~ IIIII II!Ddon I! it is doe to tendianPJa aJ.aoe, it willJ~J~~m~
(llb.); uwked p.m is a re~tUn~ of tlllldinosis with IIIII teodca (b). NCJtoe abo 11DY ~
with an anocialed pm11tf!ndlniri1 ofplwi*'Aexklll.
THE ANKLE
12.25. lWido mlmnou112): Tellt the 12..26. Tenclo mlmneu• (3): Palpate the 12.27. Tenclo mlmn•u• (4): Tha~n1011
power of p'laDblrfleldoD by ukiD& the pelient 1l:lldoD while tbe patient COIItimJee remlrld tats Nc:mllllly when tbe calf i1 llqiJIICZed tbe
to press tbe foot apinlt yoar lwld. Compare p!Qhrlle:Don, Compare the tides. Ally pp in foot 1114)\U u the IDide phudar1leJ.ee. Lolt of
one tide with the oChc:t, and DOfc the dlapc of the tendon (ruptmed tau1o calcaDeus) lbould lhia movanent il pgfuognomaaic of an ~CUte
each c:onttlcting calf IIDIIthe prominenl:c of be ObviOUI, The integrity of the tendon may ruplm'C of the tendo~.
each lladoa. aJ8o be tested by m.erting a needle vertically
info tbe llliddk of the calf. NomWly tbe
needle thoold tilt wben the lllltle is puaivdy
don.illexecl and plalltadl.aed
, 2.21. lWioqnovltll (1 ): medl•l(1): IAlok 12..29. Tenoqnovltls (2): m.t..l (2): 12.JO. T__,_.,t111 ()): m.t..l (]):
for teodm~Rs 1110111 !be line of tho loq Look for synoWis in nliation 1D !be flemr I'Uial:arllu and IMirt the foot. ThiJ may
flemr 1IIDdou. Ttmdmueu iiiiiUIIl.ly diffuJe tmdmls. There may be obvious swelliD&· produce pain wbme flmolyDoYiliJ invol'IU
and 1u-r in I*fmD. Note the lite IIIIi allmt Demmmate the JR!ellal of any eJU:a~l !be teadcm of tibialis postmb.
of any local tiJK:buiDi, IJDOVW fluid by lllil.kiDg the 1llldoa ilbNlbl
iD a proximal diiec:Wm.
1231. ~I• (4): m..u.l (4): 12.3:1. THoqnovlds {5): ..... (1): 1:us. lllnoqnowldl (6): ...... (2):
With the foot bc1d in the plalltarllcled IIIIi ElwDille the pet'ODCII1 teDdou for laldenleal Fllll:C the foot into plantullexioa IIDII
evuted politioa, look. for llclldcl'llc11 or PPI 8lld the~ of exceu tynoviallluid in invcniOD. 1bla will give IUe to pain ad
in the Une of the 1lcadoD at tibWia potlaior. lbr2r abeadla. increucd laldenleae aJaag the Une of the
Spontanoou ruptare i1 IICCil matt bqucntly pcronca1 tclldonl if tcno~YJ~Drilia of the
in IIUCCiatiaD with flat foot IIDd dmm.Wd pcronca1 tclldonl il ..-m.
adhlilia.
1234. T•noqnowlds (7): I...,.. [J): Feel 1 2.J5, ftwonMI MndCIIUII Ligblly palpBIB 12.H. Artku..r surr- (1 ): Forcibly
for crqritus 1110111 lbD liue of lhB tmldcm the perooeallelldt:m with the fingen; look. p]anlllrflex the foot to .now paJp.lim of the
aheatbs bebiDd bach ~ u the foot il lllld feel for di~•<WI!CIIt of lhB tmldcml u lllllllrior part of tbe superior artWolar IAIIface
IWIJIII backwmb ami forwvds between the patimlt everu the foot agai.Dst light at the tlll.us. ~~ cxx:urs in arthritic
in~ 8lld cvenioD. Coailml by a.~ DieplaA:emcDt ocean in lbt CODII!Iiont, 8lld in ottcochoadrilll of the tlll.us.
IDI8CU!Wion. COIIditioD kDown u 'lllapplllg petCIIIICal A Tr:alkr cm~tolilzuy be pal~ in cac.
IICIIdolui' • of footbalk:r'a IDldc.
THE ANKLE Z71
12.37. Articular •rr.ms (2): Place a biiDd

acroP the fi:oDl of the IDkle aad puai.vely
danillcx llDd plantarllcx the foot. C:repitu,
wbil:h may be c:on1irmcd by IIIIICO!tatiaa,
auggem articular·~ damqe.
1:1.311. bcllogNplu (1): Normal
12.39. Radlogn~ph• (2): Normallateml
~or radiograph of the IID.kk.
nldio&fll'h of !be llllde.
B
1:uo...dlograph• IJ): In the atllldlrd AP 1:U1. bdfog1"8phl (4): The articular 1Z.Aoa. .._dlograplu (5}: Note any wideDing
aad lateral projecti0111 do DOt miltakc (A) lbe nuqins of tibia llDd ta1.u sboald. appear u of lbe pp (A) between lalw; 1114 medial
common 01 tripmm lloXCIIOfY bone 1114 (B) two congrueot cimllar UQ. If tbere ia - malleolu: tbla ia AJgCJtive of diuWis
lbe epiphylcalli.oe of !be fibula for frlclarca. difficulty in positioning that CllliiOt be (CIOIJIIMR itl lizc will! tile one between the
The IIDOIIDt of tibiofibalar overlap (C) is improved upcm, four arcs will be seen. TWo apper aurha: of talWI m:llbe tibia: !bey
depeudeut on poliaioaini and. any di.uluis. pain lhould be c:ougment, u d!own. If DDt, abould oormally be eqaal). (B) Nom !be
The 01 fibubre (D) is tbouaht ID reprarm an tbrre is a lllblUUlion. para:e of WI cld!da in the articular
aYIIl.lioo of the aalmD lalofilla1u lipnent, surface of the talWI, mgeaive of
m:l may be I.&IClCimd with .i.Mtabllity. ~ti• tali cr • MRI ICaiiS may
belp ia 1lle cblblful cue.
D
12.0. RadiOfNphs (e): (C) Noz my 1l.A4. RadlogNphs (7): Look at the 1:ZA5. Radlogr•phs of tM •Ide:
in'egularity in the joint llllrfKel that may malleoli, where deformity (F) or 1"0IIllded aunpiM of p.thologJ (1}: The uppet
suggest previous fJ:lK:tme, e.g. of the pollterio£ ahadows (H) •UBFst previous avulsion articular aumce of the talns iB dilllm1zd Oil
malleolua; nom my lllllmiar exmlolel of the injuries. Diatmtim of the talus oc:cura in ita llllldlallida.
tibia (aodlor the talus), wbk:h 11111 a fealme of usocial:ion with talipes defmmities (I) aud DiqDaUI: the appearances are typical of
footbal.la'a ankle. (D) Bxamhle the articalar aftm injwillll which have resul!M in avucu1.v Ollt2odloodrilil diueclllll.. More complete
JD.11I1ina for exolklle1, joint ~pea~ llllmlWiDs IIIICro!lis, aod wiHn lhle may be iDaeuea • - - ' of lbe cWect may be obtaiDIId by
and cystic cb.ange. which m:e common in boDe density. a CT or MRI 11C811.
fealmes of oaoartb.rili.J.. If tbeae ae praa11.
look for a po11ible a1111e (lUcia u
Oll~til diuec:as). u primary
Oll~artbrltiJ of tbe lllkle II IIDICOIIIIDOIL
1:ZM. ..thoiOIJ (:Z): Thia invullon film

shows tiJtins of the tllua in the llllde mmtK:e.
'l"ba:e wu 110 til!iDg ~ Ia comparison
6lma of the otla side.
~: 1llli1afera1 r:omplde ~ of tbe 12A7. Pllt:hologJ (3): 'I1Itre it alatgc 12..41. , ..hology (4): 'I1Itre it poll
Jm:ral ligameut. det= in the tahu, wbkh IWo ahowa clcclki1catioa of the ankJ.c followiDg • minor
ilaeued dc:Dsity iafc:riorly. frlctme ill tbe fooC. 'l'bc atle .... lltiff ID:l
Dlapalll: tubcta:lkllia ot the atk with pliDfUl. lid lilac - m&Ibd IWdlia& ot the
grotl involwmelrt ot the 1l1ul. foot llld k& below tbe kDce..
~: Sudcck't ldrollbY (polt-tr.umalic
osteodystrophy, complex regioul paiD
ryDdrome).
THE ANKLE Z7J
12.41. Pathology (4): Tho ndiogmpba ahow groea di~K~rgaiaalion 12.50. Pathology (5): 'lbc taJ.u it groealy mialhapallllld ill upper
of the allllc. articular 8\ll'faa: JlattcDed; cllakally lhia waa aaiiOdatt.d wilb pain,
DtapHII: Ncuropllhic llllk1e joint (Charcot'a dlacuc). In lhia cue 8WC1llng and a1i1fnclt of the aDidc lllld foot. There waa a bi.alllry of a
the pathology wu ayphllitic Ia odgiD. ~tw:rc injury 1n the aDidc llld foot a year prcvioualy.
Dtapolll: c:omprcalim failure of tile talu from avaacular DCC:r08ia,
with ICCOilda:ry oakXJII'thritic cbao&e. 1blt occum:d aa a acquel to a
dislocation of tbe ta1uJ, in 1pite of a aood reduction.
12.52. hthalogy (7): Tile boDt;a of the

aDidc IUid foot mow mdCDile of diau.e
olteoporollia, haviag a grouad-Jlau
appcaran= oullincd with urrow, dade
12.51. Pldhology (61: 'lbele illllaOWi!lg codicalllllflin'. 'l1lc llllk1e jomt •pace ia
abtlali, 1114 lhcre ia bony CODtiDaity betMe:D
of tbe joiDt llpc:c 1114 tlle I'OUDding af tbe
tile talu lllld tile tibia.
upper ldiQilar surfaoe of tile talu (known u
Dilpolll: bony lllkyloli1 of 1llc lllkk
&10-C&llecl 'ballllld SO<:bt' lllldc jcde).
Diapllll: ~a. d tbe aaldc. Tbia
fn1lowiJI& a cbrmlioc joiat illfoctioll (TB).
wu ICOOIIdaly 1X) hcturc, a1tbough all tniCe.l
of lbia iJl tbe AP projeetion h&vc disappeared.
13
The foot
Conditions commendng or seen first in
childhood 279
Talipes equinovarus 279
Talipes calcaneus 280
Skew foot 280
lntoeing 280
Flat foot 280
Pes cavus 281
Kohler's disease 281
Sever's disease 281
Conditions affecting the adolescent
foot 282
Hallux valgus 282
Peroneal (spastic;) flat foot 282
Exostoses 282
Conditions affecting the adult
foot 283
Hallux rigidus 283
Adult flat foot 283
Splay foot 283
Anterior metatarsalgia 284
March fracture 284
Freiberg's diSNse 284
Plantar (digital) neuroma (Monon's
metatarsalgia) 284
Vetruca pedis (plantar wart) 284
Plantar fasciitis 285
Mallet toe, hammer toe. claw toe,
cur1ytoe 285
The nail of the great toe 285
Gout 286
Tarsal tunnel syndrome 286
Diagnosis of foot complaints 286
The mature foot: summary of the key
stages in examination (13-18) 290
Inspection 291-294
Foot posture 294--297
Grculation 297-299
Tenderness 299--300
Plantar neuroma 300
Tarsal tunnel syndrome 301
Movements 302-304
Footprints and shoes 304--306
Radiographs 306--310
Pathology 310--312
ANATOMICAL FEATURES
Rg. 11A. Tltpod action of ttl• raot: To Fig. 1J.8. Plana of mov~~~~•nt (1 ): bt tJw Fig. 1J.C. Plllnuofm-m•nt(:Z): I" tJw
maintain perfect grtllllld cOillact each foot am %-4%U oearly all of the JDOWmeDt occun in z.tUI.J supination (S) OCCUIS wben the soles of
u a tripod. with the lep of tbe tripod being the tlllkk, and this allows balaDce to be the feet are tuiDed inwards to &ce cme
~by the cah:aDeu1 111111 the beads of maintained w'-. going up md down slopea. mother; prmWian (P) involvelllllllVemeDt in
the fint arui fifth u:dmnala. To mainlain (Sclme VrrJ sli&bt DlO'Iallellt in tbe - the !lppl»l~r~ direction. 1'IU. aDowa tbe li!et tc
ba1aDce, the 1Z111m of gravity (ia front of S2) plDe OCCOI'II in the midtanal and adapt to a aurfal:e sloping at ri3bl anglea to
IDJIIt f:a11 witbiD the m:a oovemi by cme or lanomliUillnal joillla, aod minimally in tbe the direc:ticm of travel The majar part of Ibis
both feet, arui to fKil.ilar.e this each foot IIIIUit aubtalar joint.) IIIOVeiJimlt inwlwa the aubtalar joint (bm the
be capmJe of IIIOVeUialt in two plaDes. midmn.lllld tanomebdanal joinllare allo
involwd).
Rg. 1J.D. P I - Dl' m---* (3): hi tJw Rg. 1J.E. lnwrslon: l~~VeniOfl of tJw ltftl Fig. 1 J.F. Sulalar mGWIMIItl (1):
y-axb, ll ri8fJl anps to tbD otb.an, a very DCall1 wben tbe c:alcaJJeus tilis into - · Moftlllelltl in the aubtalar joint, which
limitld Illll8l' of abduction aod adduction of This IIIIIM!IDIIIIt occun in !be lllbCalar joint. ilmllV111 two ..US of~ surf~a~~, ale
the forefoot may occur. Molt of Ibis occun As the heel tilta, it canial !be rst of the foot hi&bly complex. the only joints they :resanble
in tbD midbnal joim, but aome labs piau in with it (tbD foot is dira:tly CODDeCtld to tbD blliDc !bole betwam tbD ndius 111111 uiDa.
the tmoD:IIICmnal joims and in !be lllkle. cak-. through 1he c:.k~ joial), 'Ibn ia, ~~owewr. a rm.n~y fWd axis of
ThU il f1 relatively linle ~ and this rsulll ia ..pnatica of tbD foot. IDIMIIIJIIIIt whic:h ~ lbrnqh !be amt:re af
llthoqb a fiDd ~s adcmctua is a well (\bl.fu lilliDI of the heel. (cmniml) - t i l !be lle8d f11be . . . in freD. and lbroa&b the
bown, Mlf-limiting deCODDily, a-a~Jy of in prollllliolt of !be foot.) pottcrolailcrallllbc:rclc o{ the cak:acal
rJJildhnod behiad.
THEFOOT 277
Fig. 13.G. Subtalar mCMIIftHts (2): The Fig. 1l.H. 1'M midtarsal Joint (1): TbiJ Rg. 11.1. 111• midtarsal joint (2): The joint
complex paamn of c:alcaDilal m.ovemmts lhat 1inb the hiDdfoot with the midfoot. It ia baa in eftect two a.xea of movement. Firat, it
oc:cura in invenlon lllll lllliXI8Iimea comparm fOI"IIled by the bad af the talus (f) aad the lii:U u a biDse. aJJowins s1i.pl doraillexion
with the fhre&.plaoe IOOVflDIIIIIIa of &hips or oavicular (n) on the medial 5ide, aad on the and plantarftexion (lib the lllllde). The axis
aircraft: the ca1caueu rolls (1), pitcbe• (2) larr.ral. by the calcaoeua (C) and the cuboid of thia hinae pu~e~~ through the cemre of the
BDd yaws (tu.ma) (3) ~ the tab. (c). The latmr joint (Cc}, whU:b. penDi.tl only head af the talua, 110 that Ibis ~ is
a limillid range of DlOVt:Uielltl, easurea that coordlulrd with subt:mr movemrm (wbicll
when the heel :mmes the rest of the fuot puae1 tbrough the ume point). The plane af
follows. this ail is tilllid at 45° relali.ve to the
horizomaL
Fig. 13.1. The mldterMI Joint [J): In Fig. U.K. Tai'ICIIl'Mttlrterul mo-..nts: Fig. 1S.L. Heel paltu,. (1 ): Normally, in
addition to IIIOVMIIIIIta in (raqbly) tbe (a) Whmeu the beads of tbe lint aad fifth lhe wai&htbeuinc foot the axis of the 1-r is
x-aD, alimillid IUIIIliiDt of J11011111ion BDd meblanals Conn tbe lllllmi.or limbs of IIIWb. in ~ with the tibia (a). If tbe heel
IUpiJudi.on (Z4D) i1 po11ible; tbll Davicular foot tripod, d:Je other mdatllnlll. beads CID poiCUie U aimoniUil aod tilt& into VDUI, 1hen
1lli1m aDd rotaWI roalld lhe lad of the talus, lldBpt to any imlgulmity in tbe IRDfal:e of the 111111« IIDIUill1 cin:amJtuK:el tbe foot wuald
BDd the cuboid ~ DB tbe ~. TbiJ grouDd. Blevation lllld ~Ilion of tbllfi.nt lllllpinlte aDd lhe tint meblanal head would
wa of rowion a1ao JIIIIC' dlrough the CCIIIrC: metatanal head and of 1hc other~ ~y IIDt contKt the grtNBd (b). To correct lhia,
of 1be bead of tbc tllal. the fourth IUid f!flh (b)) Call conttibute an the foot diatll to tbc llllbular joiDl muat
IIIIJI'CCiable amoaal to OYC:rall oapintrion of pronate, - thi• bda to ICCC::IItUalicG of the
the foot (e.&- llut wllliDC.tllanal ~t medial~ m:b (c).
IIDCUD!a to 15o:J.
Fig. 1:1.0. The •rdtu (l): '1'IN ,..dial arch

ia auppcmd by the apring ligllllHIDt (S),
which abouldln the hMd of the talua; the
plaDlar fucia (1'), which acts u a tie;
abduc:tm hallucia (A) aad :llemr digitmum
lnevil, which act u spring ties; libialis
Fig. 13.M. HMI ,_.... (l): If, on the Fig. 1 J.N. '111e •rdles (1): Tbeae are well
anterior (T), wbicb lifts the amln! of lbe arch
other baad, the heel pc»llll'e Ia one ofv.Jgua !mown feamre& of the foot The medial
(111111, with penmeuslougu (PL), forma a
(d), then to allow all !be mtAalm'Ullada to longitudinal an:h is 1be most important, aod
sliuup-IIP lllpport for it); libialis postmior
contact level pound the foot distal to the the one prlmo.rlly at1i:ctled in pes plaaus aod
(J1>) which adducta the mldllll'lal jolDt lllld
subtal.v joint must aupinaz, leadina to pea cavus. 11 is ti:lr!Md by the calcaoeu (C),
rciDforcc:a tbe aclioa of the aprlag ligament;
ft.allming of !be medi.J m:h (e). Tbe talua (1'), navial1ar (N), ameifomu (Co) aod
aod bor banucia longue (FHL). which acts
importaat pndical points to llOte are that medial. three llll!:tUanals. Flatteaing of the
u aloq llll'iD& tic and hclpa 10p1101t the
voJaus '-11 an auocillr.d with jiDJ foot, m:h is common aad is uaeued clinically,
be.t of the taiaa.
tllld WUIII IIHl wtrh pu cavu1 al.lbough weigbtbearing lateral radiograph•
may be belpfuL
AH~
~
Flg.13.R The •rcha (4): 'J"M lm•ral Fig. 1 S.~ The •rcha {5): 'J"M tran.rvm• Fig. 1S.R. Tile •reM. (6): '1'IN anlnior arch
forlgillldinGI an:h is formed by the caklmeu, arr:h iJ COCIICd by the cuneiform& (c) IIDd lica in 1be coroaal plllle; ita bony COIDpOIICDta
cuboid and fourth and fl1'lh mecatln8la; it iJ cuboid (ca). It lltrdcllea iiCtoSI 1be aok in 1l0111prlee the Jlll:lldmal. hcadl. 11 ie DOt a
vtf'J aballow, IIDd gaarnlly IIJdlala oat Oil 1be conmal pJae. k iJ in fact • balf arcl!: fealm'e of 1be wciptbearing foot, I I UDdtz
~ng. It iJ IUppodcd by the loD& aod 1be whole arch iJ ~by the other foot load 1be mctmnal hadJ flatteD out 'Die
thort planllr 'lipments (LS), the pJaldlr It ia of no particular cliniw aignit!canoc, u IIIICtalln&l beada 11ft: prevc:llted from
Wc:ia (P), flaor di&i1DrwD bftma, flaor and its Jft1C111:C lllld aiu are prec:iJel.y rcldcd to apreadiq oat (qilayiJig) by the
abdllcalr di&iti minimi (aot &own), ptZO!IeUI thole af the mcdialloll&itadinal m:h. The ~ lipmalts (1M) and the
tcdius (Pl1, JICI'OOCII' breYia (PB) and abape of Jlle ~ (likale:d to 1be iDiriMic: lJIIIIClct, eapec:iall.y 1be a - -
pcroacul laD&1II (PL). VOIWOin of.eoac ll'dla) bdpe maiJitaia betd of ldductXJr llai.IDcil (AH).
1be ardl.
THEFOOT 279
FDL
Fig. u.s. '111e toes (1): EmuJor Fig. 11.T. 'l1le toet (2): 1be relative leDgth
digilorum longua (EDL) exteDda the MP of diO toes Ia IIUbject to variatiOIIS, many
(mdatanophalallpl) aod both IP of wbieb are regarded u IIOI'IJla1. 1be
(~) joi.Dts of each toe. Tbe OOIIlDIOIIat ~PT~Dgement iJ the Egyptlalt foot
intr.rosaeous aad lmDbdcal mlllcles (L), (B), wben the grell toe is lonpt aod the
thmup their attachment to the extrmor •ua:eedi.na klel pmpeasively llloiVL In the
expanaiou (B), extend the toes at the 10-Calkd GrHicfoot (G), the leCOIId is the
proximal aDd dislal inll:rphal.aage joinll, 1oDplt. In the rte~ or llltetJMdillte
aod :fte.x the MP joinll; if they bec:ome weak foot (R). the grelll!ld leCOIId toes (aDd ofb:D
or fail, the nnclw:bd pull of flexor disitorum. the tb.ircl) - cqllll in leng1h.
lODpl (fiDL) results in clawing of the toes.
CONDmONS COMMENCING OR SEEN FIRST IN CHILDHOOD

TALIPES EQUINOVARUS (CLUB FOOT)
'Ihi8 is the commonest of the major congenital abnmmalitiea affecting the
foot, and may be detected before birth by ultrasonogmphy. All newly bom
cbildren should be examined to exclude this condilion. It is commoner in
boys than girls, and the aetiology is uncertain. The deformity is a complex
one: characteristically there is a varus deformity of the heel and adduction
of the forefoot, accompanied by some degree of plantarflexion and
supination. MRI scans are regarded as being of value in determining
talonavkular aligo.tDCDt and as a guide to m.anagement.
The best results are obtained with early, aggressive conservative
treal:mcDt, and in particular the long-establislwd Ponseti regimen has been
shown to be particularly successful in the management of this potentially
very disabling condition. It involves manipulative stretching of the tightened
structures (m practice. gently stretclling tbe foot into as near normal
alignment as possibk:) and applying a cast from the toes to the groin. This is
repeated every 5-7 days, to better eacll comction. Once full correction has
been obtained. the child is given an abduction foot orthosis which is worn
full time for 12 weeks - and then at night and nap times. (Possible
pcrcutaDcOus tenotomy of tbe tendocak:aneus and transfer of tibialis anterior
are integral parts of the protocol.)
In some cases, especiatly when there is a delay in starting treatment or

where there is a failure to respond, simple measures may not be enough.
More radical treatments include division of tM plantar fascia at the heel and
procedures that stretch the soft tissues and influence bone growth, especially
those using the Ili.zarov method (this involves the insertion of wires through
bony elements in the leg and foot, connecting them with a frame, and
repeatedly adjusting their spacing and orientation).
In untreated cues the primary anomaly affecting the soft tissues is
followed by alteration in tarsal bone growth. In such cases, wedge excision
of bone and fusion of the midtarsal and subtalar j oints may be required to
obtain a plantigrade foot (Dunn's arthrodesis, triple fusion).
When an incomplete com:ction bas been obtained, the commonest
residual deformities seen in the older child and adult are persistent adduction
of the forefoot, shortening of the Achilles tendon and some stunting in
overall growth of the foot
TALIPES CALCANEUS
This is a much less common congenital abnormality of the foot, in which
the dorsum of the child's foot lies against the shin. There are frequently
associated deformities of the subtalar and midtarsal joints, with the heel
lying in the varus or valgus position (talipes calcaneovarus, talipes
calcaneovalgus). This condition is also treated by stretching and splintage as
soon as the diagnosis bas been made.
SKEW FOOT
In this condition there is adduction of the metatarsals (metatarsus adductwi)
accompanied by a valgus deformity of the hindfoot It may be seen as a
reaidual deformity in cases of club foot wbel'e treatment baa not been
followed by complete resolution. or it may occur on its own. Many cases
resolve spontaneously, but in some it persists, leading to callosities and
foot pain. 'Ireatment is usually by conservative measures, but surgmy may
be required in resistant cases.
INTOEING
After wa1king has commf!D£'1'4, parents may seek advice because the child is
walking with the feet turned inwards (intoeing, hen-toed gait). The feet may
be intemally rotated to such an extent that the child is constantly tripping
and falling. Sometimes this may be due to torsional deformity of the tibiae
(which must always be excluded), or be seen as a complication of cerebral
palsy, but more often it is the result of a post\Ual deformity of the hips
(intcmal rotation) or excessive anteversion of the femmal neck. The
condition generally corrects spontaneously by the age of 6. Continued
observation is advised until correction occurs, but active treatment is
seldom required.
FLATFOOT
The arches of the foot do not start to form until a child starts walking, and
they are not fully fonned until about the age of 10; the young child :t foot is
Mrmally jiJJ1. Nothing is known to speed up the proceaa of arch formation:
orthopaedic shoes, heel cups and plastic moulded insoles have all been
THEFOOT Z81
shown to be valueless. Failure of establ.iahment of the arches is quite rare,

but if this occurs it can lead to awkwardness of gait. rapid. uneven wear and
distortion of the shoes, but seldom pain or other symptoms if joint mobility
is preserved. Persistent flat foot may be associated with valgus deformities
of the heel, knock knees, torsional deformities of the tibiae and shortening
of the Achilles tendon. Rarely it may r:esult from an abnormal talus (vertical
talus) or neuronmacul.ar disorders of the limb (e.g. poliomyelitis, m.uscu1a:r
dystrophies). In the older child, gross deformities with a clear mganic bam
may :require surgery, the nature of which is dependent on the pathology
(e.g. calcaneal osteotomy for severe valgus heels).
PES CAWS
Abnormally high longitudinal arches are produced by muscle imbalance,
which disturbs the forces controlling the formation and maintenance of the
arches. In many cases there is a varus deformity of the heel and a first
metatarsal drop (an increase in the angle between the first metatarsal and
the tarsus). Two distinct groups are seen: those in which subtalar mobility
is maintained. and those in which subtalar movements are decreased or
absent A neurological abnormality should always be sought. and sometimes
this may be obvious (e.g. spastic diplegia or old poliomyelitis). Many
cases are associated with spina bifida occul.ta, which may be confirmed
by cliJlica1 and radiological enmjnation. Rarely fibrosis of the muscles
of the posterior compartment of the leg from ischaemia may be the cause.
In the more severe cases there is weakness of the intrinsic muscles of the
foot, with clawing of the toes; the abnormal distribution of weight in the
foot leads to excessive callus formation under the metatarsal heads and
the heel.
When the deformity is marked, surgery is indicated to relieve symptoolS
aDd lcsseD the chances of ultimate skin breakdown UDder the metatarsal
heads. Wbcre there is a varus deformity of the heeL oorrcction of this defect
alooe may give good results; in some cases a wedge osteotomy of the distal
tarsus or metatarsal bases is required to flatten the highly curved arch and
improve the weight distnbution in the foot Where clawing of the toes is the
most striking finding, proximal intetphalangeal joint fusions of the toes or
transplanting the flexor into the extensor tendons may be helpful.
KOHLER'S DISEASE
This is an osteochondritis of the navicular occurring in cbildren between the
ages of 3 and 10. Pain of a mild character is centred over the medial side of
the foot Symptoms settle spontaneously over a few months and are not
infiuenced by treatment
SEVER'S DISEASE
Chronic pain in the heel in children in the 6-12--year age group generally
arises from the calcaneal epiphysis, which radiologically often shows
increased density and fragmentation. The condition is usually referred
to as Sever's disease which, although originally considered to be an
osteochondritis, is now believed to be due to a traction injury of the
Achilles tendon insertion. Symptoms settle spontaneously without
treatment
CONDITIONS AFFECTING THE ADOLESCENT FOOT

HALWX VALGUS
In adolescence, and particularly in girls, where there is competition between
the rapidly growing foot, tight stoc:tings and often small, high-heeled,
UIISUitable sh<les, valgus deformity of the great toe first appears. In some
cases a hereditary &bort and varus first metatarlal may contribute to the
problem. AJJ the deformity progresses, the drifting proximal pbalanx of the
great toe uncovers the metatarsal head, which presses against the shoe and
leadJ to the formation of a protective bursa (bunion), often associated with
recurrent episodes of infiammation (bursitis). The great toe may pronate, and
further lateral drift results in crowding of the other toes; the great toe may
pass over the second toe or, more commonly, the second toe may ride over
it The second toe may press against the toe cap of the shoe, where there is
little room for it, and develop painful calluses. Later it may dWocate at the
metatarsophalangeal joint The sesamoid bones under the first metatarsal
head may sublux Jaterally, leading to sharply localised pain under the first
metatarsophalangeal joint In the late stages of the condition, arthritic
changes may develop in the metatarsophalanseal joint More commonly,
there is associated disb.lrbance of the mechanics of the forefoot, leading to
anterior metatarsalgia.
A number of surgical procedures are available to correct hallux valgus
deformity. The most popular are (a) fusion of the metatarsophalangeal joint
in a corrected position; (b) Keller's arthroplasty (excision of the prominent
part of the metatarsal bead and removal of the basal portion of the proximal
phalanx); (c) osteotomy of the first metatarsal neck (Mitchell operation);
and (d) in early cases, simple excision of the prominent part of the
metatarsal head may give relief. Silicone replaceme~ of the
metatanopbalang joint is no longer advocaled, as it has been fuund
that a troublesome silicone granuloma almost invariably develops in the
region within 4 years of mrgery.
PERONEAL (SPASTIC) FLAT FOOT

In adolescents (boys in particular), painful flat foot may be found in
association with apparent spasm of the peroneal muscles. The foot is held
in a 1ixOO, everted posUion. Inversion of the foot is not permitted, and there
is often marked disturbance of gail The condition is frequently associated
with ossification in a congenital cartilagi.nous bar bridging the calcaneus
and navicular (tarsal coalition). This anomaly may be demonstrated
radiologically. Swgery in the form of excision of the bar is now the normal
treatment for this condition.
EXOSTOSES
Apart from the exposure and promineix;e of the medial side of the first
metatarsal head commonly seen in WIBOCiation with hallux valgus (and
referred to as a first metatarsal head exostosis), sevcml cxostosea may give
rise to trouble in adolescence:
1. Calcaneal exoJtotis. Prominence of the calcaneus above and to the sides
of the AclJilles tendon insertion may cause problems with frictioo against
THEFOOT ZIJ
the counter of the shoe (blisters, calluses, difficulty in shoe fitting).

Where the exostosis is restricted to the lateral side it is known u a
Haglund deformity.
2. Cuuiform uo.rtosis. An exostosis formed on the dorsum of the foot by
arthritic lipping at the margins of the joint between the first metatarsal
and medial cuneiform may cauae similar difficultiea.
3. Fifth rutatarsalltead. Prominence of the fifth metatarsal head
(buniooette or tailor's bunion) may occur and is often associated with a
V811ll1 defonnity of the fifth toe (quinti varus). All the above conditions
are treated by local excision of the prominence.
4. Fifth metatarsal ba3e. The base of the fifth metatarsal is sometimes
enlarged and unduly prominent, especially in the narrow foot; it may
sometimes cause pressure against the shoe, but surgical treatment is
seldom required.
CONDITIONS .AFFECTING THE .ADULT FOOT

HALLUX RIGIDUS
Primary osteoarthritis of the metamrsophalangeal (MP) joint of the great toe
often commences in adoleacence and gives rise ultimately to pain and
stiffness in this joint. It is commoner in males, and is not associated with
hallux valgus. Sometimes the toe is held in a flexed position (hallux flexus),
and the proximal phalanx and metatarsal bead are thickened following joint
narrowing and circumferential exostosis formation. Treatment is usually by
fusion or Keller's arthroplasty.
.ADULT FLAT FOOT

Gndual flatterring of the medialloDgitudiDal arch (iDcipient flat foot) may
occur in those who spend much of the day on their feeL This is often
usociated with an increase in body weight and the degenerative changes
of ageing in the supporting sbuctures of the arch. When these chmges
are rapid, they give rise to pain ('medial foot strain'). Secondary (tarsal)
arthritic changes may also give rise to pain in long-standing flat foot,
and are associated with loss of movement in the foot (rigid flat foot).
Nevertheless, in two-thirds of cases of fiat foot mobility is preserved in the
8Dkl.e. subtalar and other foot joints (flexible or mobile flat foot), and there
is no cause fur cliDical concern or significant potential for disability. (Ballet
dancers and many professional football.ers have grotesquely fiat feet which
do not interfere with their activities.)
In the early stages incipient flat foot may be helped by weight reduction,
physiotherapy and arch supports. In the la!e.r stages, surgical shoes with
moulded insoles may be the most helpful measure.
SPLAYFOOT
Wulening of the foot at the Jevel of the metatarsal heads is known as splay
foot. This may occur as a variation in the normal pattern of foot growth,
causing no difficulty apart from that of obtaining suitable footwear. Splay
foot may also be seen in association with metatarsus primus varus. hallux
valgus and pes caws.
ANTERIOR METATARSALGIA
In anterior metatarsalgia there is complaint of pain uruJer the metatarsal
heads. The condition is particularly common in middle-aged women and is
also often associated with some splaying of the fmefoot Symptoms may be
triggered by periods of excessive standing or an increase in weight, and
there is often a COilC1J1leOt flattening of the medial longitudinal arch.
Weakness of the intrinsic muaclea is usually present, 110 that there is a
tendency to clawing of the toes; hyperexteuaion of tbe toes at the MP jointB
leads to exposure of the plantar surfaces of the metatarsal heads, which give
high spots of pressure against the underlying akin. In bun thiJ produces pain
and callus formation in the sole. This pathological process is by far the
commonest cause of forefoot pain, but in every cue Maicla fracture,
Freiberg's disease, planblr digital neuroma and VemJca pedis should be
excluded.
The majority of cases of anterior metablrsalgia respond to skilled
chiropodial measures, which may include trimming of ca11uaes and the
provision of supports: these distribute the weightbearing loads more evenly
under the metatarsal heads. Where there is llliWh splaying of the forefoot
and associated toe deformities, swgical shoes may be required. Where there
is a marked hallux valgus deformity an MP joint fusion may improve the
mechanics of the forefoot, with relief of pain.
MARCH FRACTURE
'I'hi8 oCCUI8 in young lldul.ts and involves the second or, less cnmmonly,
the third or fourth metatarsals. The fracture usually follows a period of
11118CC'Witomed activity (tbece is no hi.stmy of injury) and pain settles after
5-6 weeks when the fracture unites.
FREIBERG'S DISEASE
'I'hi8 is an osteochondritis of the second metatarsal head associated with
palpable deformity and pain. Pain may persist for 1-2 years, and in severe
cases excision of the metatarsal head may become necessary. Excellent
results have also been claimed for a dorsi8exion osteotomy of the
metatarsal neck.
PLANTAR (DIGITAL) NEUROMA (MORTON'S METATARSALGIA)

A neuroma situated on one of the planblr digital nerves just prior to its
bifurcation at one of the toe clefts may give rise to piercing pain in the foot.
It mo&t commonly affects the plantar nerve running between the third and
fourth metatarsal heads to the third web space, but any of the digital nerves
may be affected. It most commonly occurs in women. particularly in the
25-45-year age group, and is often treated by excision of the affected nerve.
Division of the intermetatarsalligaments in the affected space without
excising the nerve is said to give comparable results.
VERRUCA PEDIS (PLANTAR WART)

Venucae, thought to be viral in origin, are common in the metatarsal region,
the great toe and the heel They must be differentiated from calluses, and are
most frequently treated by the careful application of caustic preparations
such as salicylic acid. acetic acid and caJbon dioxide snow.
THEFOOT ZIS
PLANTAR FASCIITIS
Pain in the heel due to plantar fuciitis is a common complaint in the
middle-aged. The condition is re1ated to degeneration of the plantar fascia at
ita attachment to the medial calcaneal tuberosity. The condition baa been
descnDed as having three stages. Initially there is a traction periostitis of the
medial band af the plantar fascia, cauaing local heel pain. In the more
advanced secood stage. the posterior tibial nerve may be involved, giving
rise to the symptoms and signa typical of tarsal tunnel syndrome. In the
third stage, the tibialis posterior tendon may be affected, causing the
occurrence of tenderness along the line of its course behind and beneath the
medial malleolus and at its in.acrtion in the navicular. There is &eldom
difficulty in making a diagnosis from the history and clinical findings, but
local thickening of the plantar fascia may be confirmed by MRI scans or
ultrasound examination. Symptoms tend to be prolonged, and the first aim
of treatment is to reduce stress on the plantar fascia. Measures include
weight loss, the wearing of lacing boots with small heels, night splints and
ortho&es. Ext:raoolpon:al shock wave therapy (ESWI) has been shown to be
effective, but the use of NSAIDS and local steroid injections is no longer
advised. In persistent cases, surgery in the form of fasciotomy of the JW:dia1
band of the plantar fascia may be considered.
MALLET TOE, HAMMER TOE, CLAW TOE, CURLY TOE

In a mallet toe the;re is a fixed Oexion deformity of the distal interphalangeal
joint of the toe; in a hammer toe the;re is a fixed flexion deformity of the
proximal interpbal..angeal joint of a toe: the distal IP and MP joints are
extended; in a claw toe both interpbalanp joints are flexed. and the MP
joint extended; and in a curly toe all three joints are flexed.. In all these
conditions coms may develop wberc the defooned. toe presses against the
footwear. Treatment may be conservative, by local chiropodial measures,
or surgical, by means of intc::phalangeal joint fusions or, occasionally,
in the case of mallet toe, by amputation. Simultaocous oorrection of an
accompanying hallux valgus deformity may be required if a straightened
&eeond hammer toe is prevented from lying comctly because of the position
of the hallux. Multiple clawed toes seen in association with pes caVWJ may
be treated by IP joint fusions and flexor/extensor tendon transfers.
THE NAIL OF THE GREAT TOE

Ingrowing of the great toenail gives ri!IC to pain and a tendency to recwrent
infection at the nailfold. If infection is not a problem, skilled chiropody
treatment (e.g. by nail training using a prosthetic device) is usually
successful.
Where infection is marked, avulsion of the nail to permit drainage and
healing is often required. In chrooic ca!ICS, ablation of the nailbed (e.g. by
phenolisation) may give a permanent cure.
Gross thickening and deformity of the nail (onycbogryphoais) may also
be treated by ablation of the nailbed or by xegular chiropody.
Subungual exostosis, often a source of great pain, is treated by surgical
removal of the exostosis.
Deformities of the mUb may result from mycelial infections and are very
resistant to treatment
Abnormal pigmentation of the nail (me1aoonychia) requires investigation,

generally by biopsy, to exclude malignancy.
Irregu1arity of nail growth is a common feature of psoriasis and is usually
associated with skin lesions elsewhere. There may be an accompanying
psoriatic arthritis.
RHEUMATOID ARTHRniS
The foot is commonly involved in Ibeumatoid arthritis and the deformities
are often multiple and severe. They frequently include pes planus, splay
foot, hallux valgus, clawing of the toes, and subluxation of the toea at the
MP joints. Anterior metatarsalgia is often IDlllked. Sometimes a single
deformity, such as a hammer toe, may be the main source of the patient's
symptoms and may be amenable to a simple local surgical procedw-e. Where
there are many deformities, the prescription of surgical shoes with moulded
insoles may be the best treatmeot. Where there is gross crippling deformity,
Fowler's operation, which is an arthroplasty of all the metatarsopbalangea1
joints combined with a plastic reconstruction of the metatarsal weigbtbearing
pad, is often helpful in older patients; the best results may be obtained when
the procedme is combined with fusion of the first MP joint
GOUT
Gout classically affects the MP joint of the great toe, but in se~ cases the
othec MP joints and even the tarsal joints are involved in the arthritic
process. The treatment is mainly medical, but smgical footwear may be
required.
TARSALTUNNELSYNDROME
The posterioc tibial nerve may become c:ompressed as it passes beneath
the ftexor rerinaaJlnm into the &Ole of the foot, giving rise to paraesthesia
and burning pain in the sole of the foot and in the toes. The condition
is uncommon, but is relieved by division of the ftexor retinaculum. The
superficial peroneal nerve may also be compressed as it runs undec the
extensor retinaculum on the dorsum of the foot, giving paraesthesia in
the area of its distribution.
DIAGNOSIS OF FOOT COMPLAINTS

The following tables list the most common disonlers and relate them to the
age groups in which they have the highest incidence.
THEFOOT Z87
'hble 13.1
'-In an dDI'AI•nd
Hlillp11ln med..llkl• flf foae G.-ttMp11ln Fo~p11ln
Children Sever's KOhler's di$6se llgnt shoes Verruca pedis

disease and stockings;
ingrowing toe
nail
Adolescents Calcaneal Ct.nebm ~tosis; Early hallux Ma rcn fracnxe:
exostosis; peroneal flat toot rigidus; bunion Freiberg's disease;
bursitis hallux valgus, pes cavus; ve/T\Ica
nail problems pedis
Adults Plantllr Flat 1001; Hallux valgus Anterior
fasclltls osteoa rthrltls; and bunion; metatarsalgia; plantar
rheu matold arthrltls hallux rlgldus; neuroma; pes cavus;
gout; nan rheu matold arthr1tls;
problems gout; verruca pedis;
tarsal tunnel
syndrome
t.bla 13.2
Faictors In ft.. feat
lnfams 'Normal foot' In all age groups, this Is due to musde

Vertk:al tal us Imbalance often from a neurological
Children Knock knees disorder, e.g. spastic diplegia, poliomyelitis,
Valgus heels Fried reich's ataxia, peroneai i'Tl'JSCie
Nelr'ological disturba nee atrophy, spina blfida (usualy ocx:ulta).
TOfSional deformities of the tibia Many cases are associated \Nith varus heels
Adolescents Continuation of childhood
factors
Peronllill flat foot
Adults Continuation of childhood
factors
Overweight. excessive standing
Degenerative processes
13.1. Oubfoot (1): ullpu t~quiiiGftrus: 13.2. Club foot (2): 'Ibe uewbom clilld 1S.S. Oub fvut (S): If the cbild maintliwl
ID. die Uldleated cue llae l1 (A) penlq ofll:llllolda the foot in plaDCarflexion ll.lld die foot in the invmed poaitiOD, IRippOit die
V8lU8 of the heel. (B) atrophy of die calf inveraiOD, giving a false .i.ll:lpellion of leg aad ll&btlY IC:llroh die tide of die foot.
muscles, (C) callDt where die child walb OD defoanity. Pint oWerve tbe child 88 it ldcka
the la1rnl. border of tbc root It il commaacr to ICC if this potitiOD il mamincd
in males, may be bilatc:ral, ll.lld may be
aaaociated with other IIIIOillllitt.
13.4. Oub foot (4): Ia die ldiDil foot 13.5. Club foot {5): If tbe child does not 13.1. Club foot (61: (A) Note lhllt in the
the cbild will n:lpoad by doni1ltximl of die n:ipODd in • IIOI:!IIal faabioll, geatl.y dorti&x !elf commOD talipea ~ defoanity,
fuot, ewniall, IIDd fannin& of die toe.. 'lbia tbc foot. In tbc noanal cbild, die foot C8D be tbc foot i1 beld in a petition of doni1leliOD.
reactiOD doea DOt ~ pW:c if die dli1d bu brougbt eidxt into cODW:t wi1h the tibiA or (B) Note lhllt in tbc noanal infant die foot
a tllipea deformity. very clole to it can be planlllrfk:ud to llllll1 a clegxee that
tbc foot aad tillla ate in. liDc.
THEFOOT Zit
0 ooOg
DTIITD~
0
13.7. Radlogntpht: • .,..,.,.,...,., ..... 15.8. Rlldlognlplu: .-rvpo.....rvt.w 13.9. bdlogntpht: • .,....,. . . . y ...
(1 ): JntmpretatiOD il difllcu1t owiDg to Che (Z): Tbia liDe lllmDIIlly paseea lhroagh the (3}1 Note (A) !be mai liDe of tile calcaDeus
illcompletelleat of o11ikAtion. CcDil:el for die llrat metatarll1. at 1iea 8lnDg itl medial edge. pueet throu&h or c1oee Ill die :foutlh
talaa. ~•• mdatlrla]j, phalange•. _, N~ lllao !bat the m:t of Che middle dlree mctallnaL (B) Tbc llltel of die talaa IUid
oflm the cuboid arc preacnt lit birth. llqin meiiiW8811 are roughly paraUcl. Now draw call:aJit:ul aubtlc:ad m mgle of 30--SO".
by drawing I IDle througb die lollg WI of I 8CCOIId 1iDe dtrougb die lollg WI of lllc
the talUI. calcm:ua
13.10. Rlldlogr•ph1: ~r 13.1 1. Rlldlogntphl: ....,.,,,,: Draw (A) 13.12. Radlogntpht: ....,.112): In club
wt- (4): Ia clab focM, die previoully au lhroagh 1llos 8.lld calc8111181, IUid (B) root, aotc (A) !be ta1ar IIIIi calcaDeal axea arc
cbcalled %datioa arc alfered owiD& to tallgalfllll lllc c:alc:alatu IUld fifth mdalllnaL Dady ~; (B) die mgle of !be taDgentl
foft::foot adduction. Nofe (A) !be !alar Ilia Note that iD the D.OaUl foot at birth lllat tile illal obttlae; (C) die talar am doelllot pua
doea not cut the flnt mctldlrlll; (B) the talar Ilia JIU'C8 below lllc llrat metatanal below !be &It mdalllnaL ~ malylil
middle tbree mclalaENI. au arc not pamlld; (C); tile iDte:rlxial angle (D) il 25--SO"; the of tile type diiCaiiCd on thil page may be of
(C) !be cakancal W I doe1 not IICriltt the angle bc:tWCCI1 the tqaiU (B) il l S0--175°. bdp iD the doubtful cue ad ia .-.ling
fourth mmtarlll; (D) Che lllik bciWUII Che progea, and MRI ICIDII arc of particular
llllla lllld calc- il redllccd. 'VIIIIe iD cletrzmilling llloaavicular aligrnnm•
13.13. AppM....-: Nollllbe lhape of 13.14.. welghtburlng pos1Uree HnmiDe 1l.15. Pal,..lon: Look for lmlderDeas.
the foot, aod the presem:e of my obvious the weigblhearing foot from above, Cmm. N~ any joillt crepitua. Note any iDcreaae or
ddonnities, almormal callua formation ell:. behind aod from the aide~. dectule in llldn tr:mpr.r'ltllm.
THE MATURE FOOT: SUMMARY OF THE KEY STAGES IN EXAMINATION (FRAMES 13.13-13.18)
13.16. ~ EumiDe lhe mobility 1 3.1 7. G•lt: :&amine !be pit, with IDd 13.1 1. II'MIStlgatlons: Study lbe reiOlta of
of lhe toel, foot alld lllkJc. 'lrilhout llboea. If iDdicatcd. actl'ltZ the anklu, apc:cUl in~ e.g. radioer-pba. ICNII1
:k:Dcca, hlpt 111111 ephle; eummc the 1lrW lcld, ICdimcnlllioll rate, rheumatoid
circ:ulalioD, aDd cary out a aeuroJogk:al f1A:tar CTA1.
eumlnatlon. N~ the footpriat aDd cumiDe
lbe lboea.
THEFOOT 291
13.1 1. lnspacdon: ....,...: N~ 'lll'helbm' 13.10.. lnspectiGft: heel: Ia theM (A) a 1J..21. Inspection: danum (1): lllht:re
lhe foot is IIODDally proportloued. If not, calcane.al prolllillaH:e ( 'calcaaeal ex05tosis') (A)~ of the fifth meta12nal bue?
look at the banda and - the rell of the with overlyillg callas or barai.tis? (Nole tbal (B) ID 'e;mlfOiis' from prominezu:e of the
5bldon. In Marfan'a ayndrome, fur example, where the e:mstolis is primarily l.almal it ia litlh metmna1 bead? (Tbe bllr.r ia &OIIletimel
lhe fKt are J.oas md thin (llflclmocW:tyly, !mown u a Haghmd deformity.) Ia there !mown u a ~ Ol" tailor's extliiDiis.)
spider bmes). ddnrmity of the beet, suggelliDg oJd h:tme Both can be a somce of local pressure
or (B) talipea clefocni.ty? IYDl(lfoml..
13..2::1. lnspacdon: danum (l): b lhr.re (A) 1J.D. Inspection: donurn (J): N~ 13..24. Inspection: giRt toe (1): N~ any
a cuneiform e:mlfolis? (B) a daru1 pnslion? the gemnl state of the Uin and lllli1l.. hallux valsu• deformity. If the defocnily is
If there ia any evideai:e of ilcl!ar:mia, a full 8eWD, the gJat kle IIIli)' uadr.r- or over-ride
cardiovucular examination ia reqWrrd. In all the leCODd, and it IIIli)' prtlllllfle.. The secood
cuea, the pr-=e of the dorulls pedis pat.e toe may aublm at the MP joint. Alwaya
lhau1d be ICRJ&bt rour:iDely. reaua1 my valp defmmity of the pal kle
with the foot we\sJ!Ibearinr.
13..25. lnapectlon: gi'Mt tM (:t): N~ the 1J.l6. lnspectloft: gNIM tM (J): N<* 1:1.27. lns.,.alon: gNIM tDa (4}: Note !be
~of any buna ova the MP joint wbdher (A) the pat toe is thickmed at the p:eiUil& of exceaa callus Wider the great Ule.
(baaion) aod wbdber active lnftammalnry MP joint, ~ ballax rlJidu This lindln& is bighly ~UUestive of baiJax
c:baagu are preKDt (6om friction or (olllrloarllnilis of the firlt meta~ ..:..:..1
._ua.
infection). DiiiCOloration of the joint with joint), or (B) held in a 8t:xed posili.on (ha1lax
acute tr.Dda:nes1 is IIIJPtiW of gout. ftexua), again pll!Dily due ID ollrloartbrilis.
...__ ___ c
0
13.21. Inspection: gNIM m.n•ll (1 ): Note 13.29. lnspectloft: gNIM tMn•ll (2): Nom, 11.:10. lnipHtlan: tMI (1 ): Note the
wb.elhm the great toeuaiJ. is (A) cWorulm if pniiCIIIt. the striking appearliDCO of rela!ive Jastba of the tom. A IICICOIId tDe
(onycbogryphosi1), (B) ingrowUis, po1sibly mebmonychia. This is whle there is loupr tba the :firat ma:y occaairmally become
with aa:ompanyias inf!IJJ!m!di!W!, (C) l.oaptudillal brown or bhd snaking of the clawed or throw llllditiooal. 11ti1111ea on itl MP
~ (lll(plling ~ exoiUJ&is). nail doe tD any cauae. The c:oodition is firlt joint; it may be uacx:iated with Preibq'a
(D) IIMW!II in laUiue aod srowth (qpting 11111111 aftm puberty. and oau.ally only one diP m-.
fuDp1 iDfeaiou. or p•oriuiJ). is lfi'IICIM - Illlllt often the gma toe or the
tlmmb. ~must be excluded, aod all
caM& lllwald be :reRmd witbom delay for
biopsy.
THEFOOT 293
13.31. lnspacdon:tDM(2): Flexthe 13.3:1. Inspection: toes (J): curly tae: In 1J.3J. Inspection: toes (4): d.w toe&: 1be
toea ad J:JOm the relative Jeuatha of lbe lhia deformity a dt:gn:e of fixed ftexion toea are uid to be clawed when they are
mdatanala. Almm:mally short firlt or fifth deveJop& in both IP joiota and the MP joint. It ex1mded lllthe~joinb
mdatanala are a poteDtial caDJe of forefoot i5 poaally Clllled by intr:ro111e0115 IIIIUcle aod. lhrud at the intapbalaogeal joiota. If all
in:lbaWM:e ad pain. Wbr.a both are abort, weakneas. In grtJI/e 1 tbe toe i5 mildly dexed. the tnes are involved, lhia augesta lhlll there
there i5 ofmn paiDfa1 callua UDder the seamd with or wilhoot IIOIIle addaction; in grode 2 mrj be an uaocia!M pes cavua or IIOIIle other
mdatanal.. lhre is a degree of ooder- or over-riding; aod. Cllllle of intrlmic IIIII.M:le inlllffu:ieocy (the
in grode 3 tbe aail i5 oot visible from the lumbricalJ ad immouei.Oex the MP joillll
donum. aod. ex11ead tbe IP joints).
13.34. ln1pacdon: tDM (5): Ia tbc:re a 13.35. lnipKtlon: toes (6): Note the 13.345. lnipKtlon: toH (7): Note the
lu.Jmnwr lw dc:f"ormity, wbeR the toe il fle:ml PRI= of (A) a JfiiJlkt tw deformity ~ of (A) llanl oorru. Theae are IUe88
at the proximal illtelphllaD&ea joint llld (llmoo defoanity at tbc diltal of bypc:zbnloti1 lllat occur over boDy
exlalded Ill tbc MP IDd distal IP joint? 'lbe iDfetpbllaDgell joillt). 'I1Iae i1 Ulllllly callus promi"""""', llld are geucrally e~~~aed by
ICCOil4 toe il molt COIDIIICmly a1liccted, ofti:D UDCier tile tip of the toe or dc:farmity of tile preNute ~t tile llloea. (B) Soft oorru are
owin& to an u.ociallcd blllux vaiau lllil. Note (B) an overlapping tiflll toe ar ~ llypellwllfoli.c lelioaa OCC1llriD&
defoanity. 'lbc:n: il uaually callua over tile q.inti Nl'lU deformity (ofti:D ccqtllital). betweca the toea 1114 are DOt UIOCi.aed with
prominent iDecqJIIalaD&el joillt U I J'CRlt ol l'romiDcDce ot the tiflll JDelltmal bead preNute or tric:tioo.
pre88Uie lglilllt the lllloc. ~ layliar'1 buDioD) may be rdaliccl,
but teldcm Cllllllet probleml.
13.37. 1Mp8dlon: JOie (1): N~ (A) 1J.JL lnspectloft: sole (2): Nole the 1J.J9. lnspectiM: sole (J): Note the
Hyperbidroais. (B) Bvide!K:e of f1mp1 preaeru:e of callus, iDdicatinJ an aaeven or p:aeuce of a verruca (plmlar wart). N~ the
infection or alhl.etr:'1 fool. (C) UJ.cermon reltrictM area of waptbearillg. Be card"uJ. three clualc &ita: at the beet, Ullder the great
of sole, •uuelliD& pe1 emu or DMJrologic.al Ill diJtinauillh betwem almm:m.al, loc:al toe, 1111111 In the forefoot In the region of the
distmbance (trophic uh:emion). tbiclrr:niag, md diffuae, m.oclera2 tbicbning metmrullada. In the •ole they are silll*d
at the heel and Ullder the mt:tatarul. b.eadl betwem the metalarsa1 beads: 1llllh calhuea,
(whicll i.s llllmllll). they do IIOi occw in prunuw anr.u.
1JAO. lnsp«ttanuole(4): vernu:a, 1JA1. lup«ttan: sole (5): Note any U.42. PostuM (1): B1tamin8 tbe ptlliem
Cllldd. A veauca ia a.qui.silely lell&itive to loc:ali.sed fibrous tisme mas~e~ In the sole JtaDdias. Are both tbe heel and. forefoot
silk to silk p11111U111- CalhDel are moch less typical of Dupuytren's conlladllre of tbe feet. tqUandy on the tloor (plantignlde foot)? If the
llmliaive, - cmly to dbwct pnuure.. If thm! 'l'bele 1i~~A~e thirJreninss arise from tbe . . doel not tDuc:h tbe pmmd. IIXlllDine for
i.s any I"IIII1BiDing doabt a map.fyiJis lmiA plantar fucia, and. are auacbed to tbe akin. lhortlming of the ~ or dmrtming of the
may be UMid Ill c:oofu:m the ceolnl Always i11apect tbe banda, u both upper mMI llmdocak:IIIII!IIA.
p!lpillomaloul ltnK:IIInl of tbe VtiD1KlL 1-limbl are often involm IDptbm- iD
this proalll.
THEFOOT 295
13.43. Pollture W: lntDelng: Jf 1bia 13.44.. Podure (J): genu wlgum: Nom the 1JA5. Pa&tun (4): -l'llan: Jf the foot is
defoanity is ptae~~t, examlne for (A) ~of genu valpD. which is hquently evened 1bia suggests (A) prmnea1 spulic llat
torsional deformity of the tibia, (B) iru:reued usocialed with valgus ftat foot. Genu valgu.m fOot, (B) a painful lesion an the IDral side of
iDtrmal rotation of the hipt, or (C) .tdw:tion in tmn is most COilllDDIIl.y seen u a result of the foot, (C) if le11 lllalhd, pes plam:ls.
of the forefOot Moat~ of IDIDeing in a growth clismrtlall&::e about the bee, or u a
children re10lve 11p011taaeoasly by qe 6. complk:alim of rbewnatoid arthrl!U.
13.46. Polltun (5): lnwr1lan: If lhD 1lA7. Postun (6): siMJing: Nom~ 13.41. Posture (7): the too: Reulss 1he
foot ia invedlld 1bia auggem (A) Dlllllcle tbml is any broadming of the forefoot. This toes for curliDi. clawiDg. malhlt toe aDd
imllal-=e from llrob or othar DmJmlogk:al is often the reauh of i.DJ:rinsM: llliUCI.e !Jammer toe. Reulss tbe great toe,
dismler, (B) ball.lu. flexus or rip!Ds. (C) JIM 'MIIIImllu, aDd may be usocialed with Jllll partlcalarly far the ~ of hallux valgus,
caVIII, (D) reaidual taliJIIII defoc:nity, (E) a caVIII, callus 1JIIdM the mellltulal beads, IMII"-rlding of lldj-n toe(s). aDd tomOD.
paiDfu1 coudilion of tbe forefoot. hallux valgus, aDteriot metatuaaJsia, aDd
lrollble wilh moe fitting.
1:1.48. Podura (8}: medial arch (1): Wdh 13.50.. PGstura (9): medial arch (2.1: If 1.1.51. PoltuN (10): medial arch (J): If
the pa1ieut ~look at the medial !be arcb ~ hip aad accealll*d, this pe1 cavu ia plQtllt, c:arry out a full
lnnpndiaal arch and try to u - Jts height. auggeiiB a degree of pes cavaa. Look for ueurologial enmin•rion. Look at tbe lumbar
Try to slip the liDgen Wider !be oavicular. In confirmatory clawing of tbe toes, caDus or lpiDe for dimpJing of !be akin, a hairy pall:h.,
pes cavus, the :1ingrn may ~a ukrn!ion 1llldl:r tbe mdallrul b.eadJ, and or piprntwtim IIJIPDng spiaa bifida or
diii:&Dl:e of 2 em or more from a vrrticalliae a!Jrmdinn of the footprint. ueurolibromato&i&. lbdiological examination
dropped from tbe medial edp of the foot. of the llllllber spiae ia deaiJable..
15.52. PostuN (11 ): nMdl•l•rch (4): In 1s.ss. .,._un (12): medial •rch (5): If 13.54. Postun (13}: medial •rd! (6): lD
pu plaluu, !be mcdilliii'Ch i1 oblitmlttd. Tbc pea pliiDIIs ia suspected. rc-eumiDe the IOJc pes pl.lmu, UKII die mobility of tbe foot
aavicular il often promillellt, ad the IID&f:D for oonfirmamry e'rideDce of call.ua Ullder the flnt by ullin& the pllic:Dt to 111Dd on 1be
caaot be iniCdccl Wider il Alk tbe pafieut to mdatlnal. beads, md - iaaeue in tbe - loci, wllllc at 1be IIDIC time enmjning tbe
11t11::mpt to III'Ch the root lD mobile flat foot of the IOJc involm in weightbearing (i.e. a!D:tltion in die lbpe of tbe foot by figbt
the arch can often be n:.romi voliiD!IIrily. Clttleulion of the DillOW lalz:ral.ltrip). Tbe and feeL 1.-r in die enminatioa cuefully
Nolle that ia cbildn:a the ardlicl ae llow to footprint will be abDormal. in theae ranae
DO(ie 111c of iDvalim IDil evuaion.
become~- B:umiDo die Adlillea ~. Note alJo the PfC8E11CC of any Note Cblt lltbou&h 23~ of Idalia line :ll.lt
teDdcxL, lborteuiD& ol wllicb can cau.e lr:acK:k-lmee deftmDity. feet, lymplaml - IIOt 11Sually preecat tllleu
flit foot. Cb= il &IIOCiDd ICilfne&
THEFOOT 297
B
13.55. Potlture (14}: hMI (1): Look at 1 1.56. Pestura (15): hMI (2): Apia ask 1J..57. Galt: Wak:b tbe patieot walking, fint
tbe foot from bebind. paying partiA:alar the palient 1D staDd. on tbe toes, oblerviDi tbe ~and Ibm in shoes, to aaseas tbe
atlmltion to tbe dope of tbe beela. Notr: brJela. If the heel postu.m couecta, this pia. Bumine from behind, from in fnmt, aDd
(A) valgus '-1s are UIOCimxt with pea indicates a lllObik l1lbtaJar joim. Peniating from tbe ~idea. A child ahoald alJo be made
plamu, (B) varua bee1a are aalllC.iaZd with dmormity 111JP11ing loaa af m.ovemad, to nm. A rdm:Unt cbild can usmlly be
pes cavus. whidl may be t:b 1D arthrilic cbaagea, taru1 coaxed to walk boJding ita J:lllllhrz's baud.
coa1ilion, lou oC spring lipmr.lll or tibiali1 lfiBhly ~ mellmda o{ gait amlylia
posterior f1ml:tioo, or sbm:1ming oC tbe uDlg fan:e piale•, c:ompalm md
1mldoealcanew~. videoeaalylia ell:. are available in some
am!rei.
1:1..51. Skin fllln,.,a&um Grup the foot 1Ut. arculatlon (1): If the foot ia coJd. 1JAO. Circulation (2): Attempt ID palpate
aDd aueu the skin lllmperature. comparing DOte the din tempa:atme gradient aloog the the donalia pedis I!Nry. The veuelliea just
one lid8 with the otbm-. Tlb iDtD IIIXOIIDt tbe length of the limb. You should baYe already llllenliD the tendon of exlmlm h.al.fucis
effiK:ts of loc:al b.nda£iq ..1 tbe llll!bisll oblerved any tropbic cbaops or diaclokmlli.on J.onaus ..t iu pubation llhould be felt by
laDpmltllnl. A wmn foot ia pllltU:ulmty of the skin IOJ!PIIlive of i..lm.....m• llomprellin& it qllinat the :middle ll1lDIIiform.
mggestive of dM-nn !!lnid artlnin1 or pat. A Kooci pube pmnlly exclude~ any
liplificant decree of ii~Cbaemia.
11.61. Circulation (J): Now tl)' to eel 13..62. Circulation (4): The pollledor tl'bial 1.J.U. Circulation (5): Nm seek the
the aateriCB' tibial palJe uear that midline of artmy is oftm diflicu1t to find, arui it is popliiMl artmy. When the palient is supiae it
the aakle, just above the joint liM wbr.re the helpful to iiM:rt the foot while palpating can only be felt by -wJying strong p-esmre
vessel eros- the distal eod of the tibia. behind the lru!dial malleolus. in liD aateriiB' dlm:tim, with the knee flexed
to fun:e tbD veuel aglinat the femoral
coudyh!a. Al1rmatively, i1 may be sought
with the palit;nl pnme..
15.64. Orculllllon (6): 1bc femoral pulJc 1S.65. arculetlon (7): Bumllle the 1JM. Cln:ul.tlon (1): Note any cyanoaia
may be felt a little to the medial aUk: of the lllldomal, paiplliag the abdominll110tt1. Note of the foot wbcn depeDdcnt aad any
midpomt of the gr:oln. wa the B'lr:ry Cll1 be the preacllllC of poleldioa aa it Ia com.pt'l'liiCd ~ on c:lt;vatkm, eagcative of mada:d
compttiiCd apiDat the IUpedor pubic fiDIUI. aplnn the lumbar 8pil1e. arui DOO: any lrU:dal iDaufllcicacy.
cWk:Dce of~ dllatldiaa.
THEFOOT 299
This ia repeated on tile otbclr aide (BI).

Preuure readinp are tben obtlli.ued from tile
antmior 8lld pclllerior tibial artmis (AI, Pl) in
tbe -pect limb. The index ia Ibm nmmally
cak:ulDd by dividins the bi.pclr of the upper
limb RilldiDtl• with tile higba: of the readinp
at the ankle (HAP), aud this ia tbe bail of
IOOit ltlldin. ~y it huM.~
thJit um., tbe Iowa: of the ..., rudinp
(LAP) &iwe - nlli.llble and ISIIilive
J:eMI!ts.) The fiDdiap may be iaaerpmed u
follows:
0.91-1.3 Ncmaal
0.7-0.9 Mild cliscuc
OAl-0.69 Madera~ diseue
0.4 or leu Severe m-
13.67. ClmMIIon (9): ankle bNchlal 11.6&. ,......amus (1): hllel (1):
p - lnda: (AIPI): Thla Ia a simple 1'euderDela muud the heel is pruent in
noo-invuive mdbod of useuJns llltr.rial (A) Sever'a cliaeue; (B) mperior calcaDeal
eflicieru:y within a lower 1Imb by comparins exoltolis and trmdoc:abneus buraitis;
its blood prelllll'e with that in the arms. The (C) pbntar fuciitis and i.nfr:rior cak:aDeal
patient Ia ubd to lie em. tile enminarinn exoltolis; (D) pe• caws.
couch for 10 minutu to allow the blood
pressme to stabilite. The blood prasme in
the right mn (Br) ia tben tU.eo, using a
huJd-beld DoppJrao wtrumW: !low de!Ktor.
13.69. Tend- (2): hMI (2): When! 11.70. T.ndern. . ()): foNt'oal (1): 13.71 . T.ndern- (4): ,.,.,_. (2):
platar fuciilia ia su~ perform Jd'1 Difl'ule trmclemMa under all tbe metmnal 'rtmdeme11 Ulld.r the IMICOIId IIHiCataiUI head
felt. Forcibly donifiN. the par toe to lltretch beads ia COilllllOD in anlai.or ~ aud owr the lleCOIId ~joilll
the planlar fucia. 1'lmdmDe8a IM!I' the ' - l pe1 caws IIIII pea planu1, gout ..._ ia foaDd wbml the lleCOIId toe aublu:ua u a
attx:hmagt of the facia ia diapoai£. .......,,.tnid ll'lhritil. eque1 to hallux vaJau• or rbennuotnjd
BxamiDe the poAII'ior tibial !Min'e aad tbe arthriaiL
libialil ~ laldoa wbk:h may abo be
in"Vdwd.
, :1.72.'llln..._.. (5): faNfoot (J):

Puffy, localiaed swe11iDg on the donum of
1:1.1:1. "Rindam81& (6): faNioot (4}: 1.1.74. "Rindem81& (7}: foNfoot (5}:
suspected plaftter neuroMa (Morlan's
Tenderueas on both plantar aud dorsal
tbe fOOt, palpable thirkmlna of tbe lleCOild aumcea of the secood ar third mda!arBal m.....,..lgla} (1): Sharply defiDed
metatanoph.a1.m joint, pam OD oecb ar abaft& occura in march fracture. ~~~between the mmtanal beads
plaDtarll.exion of the toe, md joint lrlldt:rnen {IIIOat COIDIDDJily between tbe tbird aud
are di.ap.oltil: af Freiberg 'I dUMJfl. foarlh) Ia fouDd in pJantar diJi131 oeumma.
1.1.75. Suspecled j8nt.r nMiniiNI (2): 13.76. Suspectecl plan1• _ . , . . (J}: 1S.77. Sulpected plaftter neunn1a (4};
Compreas tbe m.elldanlll beadJ (a) IUid llDfll SmMilmla lbe patieDt compJains of The sym.ptm11 aud fiDdins• from MP joint
wbetla lhia reproduc:ellhe patient'• ~in the Ules, aod -.cry iDJtabillty in a tee may be oonf1lled with
symptoml of pain al pou.ibly ~ i.mpaiimlmt IIIIDWd be &OUght OD both PI of Mortou's metatanalgia. so always perfocn
(Muldl!r'a lip). ~ wbile Dmnh11111!01JIIl.y the web apu:e ilmllved. Nate that a MK:Ce~l lbe dnwer ti!IL To do 10, Jrlp the metatanal
pr:-mg in a CDDI"CiiJudld Whion from the l"lltll of 9S~ is claimed far lhe w.pm of at the A~Spect level with one b..t (a) IUid
IOle 1llwllnb tbe donallllllflce IIIIi bd: wUh mmrnma by ultruonogrvphy with the otber, while applyq traction to tbe
lhe ather b..t (b). This may remit in a tee (b), attempt to displace it donally (c:).
pllinful c&k, whidl1011111 ~ tD be Pain aud ucen.ive traDS1.aioa 1n1 diagnostic:
IIIIOciad with a mobile IIIIIIUIOIII&. of iallability.
THEFOOT 301
13.71. 'llln.._. (7): ..,.., tuftMI

syndrome (1): Teudemeu may occur over
1 3.79. ~rMIIIII'Inel syndrome (2.): nnll'l 11.10. ~....1tunnel syndrome (J): Telt
5elll&tion over 1he who~ of the soh~ at the
algn: In the tarsal tmmd ll)'lldrome, tapping
the pollrrior tibialJJrZVe In tbe tanal tlmDel over the ~tl!rior tibial nerve foot aDd tbe toea In the area of supply of the
syndrome, where the prell!llltin& I}'JIIptmna may give rise to paraestbe&ia in the sole medial and J.mnl planw nerves (the two
are umall.y at local p.m 111111 pant:~theaia in at the foot. terminal divisiODI at the ~tr.rior tibial
the fOOt. Nom that lr:Ddemeas a tbe IIII!Ie site nra-ve). Compare the ~ Seuory lou ia in
may occur in problam atfec:tlng the tibia& W:t rllber IJIIC.OII!I!MlD in tanal llmDrl
~tr.rior tmJdon (wbicll may be vimalUed. by ayndrome-
inverting the fOOt apimt telli~W~ce).
13.11. Tuul tuftMI syndrome (4): tha 1J.G. Tuail tunnal qndroana (4): 1M 13.13. THd-(l):puttoe(1): In
donllalon....nlon tut (JCin~llll toumlquat tut: In doubtful c:uea, apply a fOIII,IZildeme•• is oftm molt IIICille but is
at •1.}: Maximally doniflex the ankle (a) and !DIImiquet to the calf and im!m to jult lbove di.fJI:IIely lpre8d J1liiDd. tbe wbole
the MP joiub of all the IDM (b); fumly evert tbe l)'lklliA: blood preiiUle.. If Ibis briJisa OD mdl!llnOpbal.anpl joint md oftm tbe eorire
the fOOt (c) md hoJd lbi1 polition. In a tbe patient's I}'JIIptmna in 1-2 lllimlla, the toe. 'l1lem is oftm a reddish-blue
pcmtive cue the palimt'a aymptoms will be diapoli1 is cm1iJmed. Pain aod p~ diiCOJontiOD of the akin rouad the toe.
teprodal:ed. ICIIIIIrtima aflllr ooly a few oo the dor,_ of tbe foot may be
leCCllloliJ. Look abo fol- lnaeued local eucountr:red in 1he much rarrr D~J¥t/lt:itll
peroftiiQJIWI'N ~ ~
~(d) aa:ompayincthe - ·
-
A
13.114. Tender- (9): gNat toe (2): 13..15. Tend.-- (1 D): In usiJJMidltis 1.1.16. Telldamaa (1 1 ): great toenail:
(A) In lttzllta IHilgU6 ~ 11 often there is 1r.lldt:raess ova the lleAIIIOid lxmea, In lllbf1118wal QDIIDAr pain ia produced by
abar.at, or confined to the bunion or ova which are llimalrxl 1lllder the tint mdalllrBal ~ the toe in the vertical pbme. In
paiDful. c:oms on adjacent toel. (B) In lttzllta head, a1.11Jouib they may sablux btmall.y to a btpowillg rfH11QJl pain is produced by
rigldJII there is IUUlly ~ova the l!lll[ked ~. especially in cues of grosa llid&-IIH!de panre.
exoi!Dies that ariJe on the metatarul bead hall~ valgus. ~ain ia ~~~toe ia
aud proximal pha1mx. of'tm on the donal dormlexed while presaure g m•nt.unr.d on
ll1lfxe of the joiDt aa well u the lalrnllide, the seumoid bool!s.
wba:e ~ bunae may farm.
\I
1J.I7. Cnpitul: ~ 1llc pat toe in an 13.11. Movelnentl {1): In uaessiag foot 13.U. ~entl W: IUpinMion: Alii:
up 1114 dowll directioD ~ Pill-liD& the mDVeiiiiZfa, ~ that the 1Dtal.llqC of the patient to tum the IOI.el of the feet
metltarlopbalangell joillt. Jlepctt with the IOpiDitiOD and p!OIIIti.OD ia the foot is made t.owcdl OIIC anotber. 1bc plteilae lbouJ.d be
i.ntelpllal.IDg joild. CrcpiD, indicatiDg that oa:ur i.D. the IUbtalat
1!p of IIIOVelllelll8 w:rtiQI. Tile ~Altin.g angle may be
ollfeolrthritic dlaiJ&c, ia CIODitant iD. 1llc joiDt (A-A), 1llc midtanal joint (B-8), and ~ If 1llc legs are aqurdy pW:ed on
IIJCtltanopb•l•npl joillt in hallux n,klua. the lanomdatanll joiDtl (c-c). In the ~. the c.oudJ, iU end IDl!Y be uacd u a guide.
Inlerpba1.lnaea joiDt crepieus is OOIISiAielecla the mCn movement~ OCCIII in the jointllt the N....a rup"' 35" a~y. Noee
..........,.,iceioo for MP joillt t'usioo. baa: d the fust, foQrth IDd tiftll mctltarlals. lblt thia is a.IUIIII!Ialion of movemcnlll
u.-
OCICUlling at the le¥da prmously
del<:libcd.
THEFOOT 303
13.10. Mlmlnlantl (J): proMtiM: Ask 1he 11.91. MoiNIInaftU (4): If sapin.ation aud 1J.92. . . . . . . . . . (S): Tarn the patient
patient to tmn the feet outwank. The rqe of pronalion are restridled, fix 1he bed wilh oue face dawn wilh the feet over the edge of tbe
movement may be JlleUIIft!Cl in a similar baod aad with the otbr.r assist 1he plllieot to enm!n•tion couch. Evrrt the beel aud ~
fubi.on. repeat theae movr:ments. No further redaction the ~ of J:IIOVmlleDt in tbe subtabr
Ner:maii"IU!p = W a~. in tbe rap ind.icalr:l a Iliff lllbtalar joint. joint by the pollition of tbe heel
The~ o f - mDVelllellt 5howl that Nonul riiJIIC of CfenlGn ul the bed = 141°
·~·
the midtanallllld tanollldaWial joiab
praerve some mobility.
13.9S. ~-ntl [6); Repeat, fm:iDg the 1 J,M. ......,_.. (7): Jn idiop8lllic pel CAVUI, IDil pel CAVUI ICCOIIdary to DCUramllacular
beel illfo invulioD. diJcue, the aubtalar joint iAI generally mobile; ia pel cnu ICCOIIdary to coqc:aitallllipea
Ner:mal raup of IDftnloD of OM laeel• :zo• cquiDovaNI the IUbtalM joint iAI ofti:D Miff. N I :furlller &Uiclc to the difraentiation of tbe8e
lfPruDmately. LoN of IJIOftiDellt ind.iA:Ita cua, mark tbe am of tbe bed with a lkia pcDCillll4 ~ position with tbe patient
w
1 stiff aubtalar joiDt (e.g. okl cak:aoeal MaDding oa a 2 an block of wood, tint aq~y (1 ), IDil !lien with tbe forefoot (M'.l' the IIICclial
fnlctu.te, ~maloicl or~~. spu!U: cciF (2). A cJiall&e in tbc axil (3) ~ a mobile subtalar joint.
flat foot).
13.95. MRem•nb (8): Telt for mobilily in 13.96.. Mcwem•nts (9): , ....... (1): 13.97. Movalll8nts(10):gNattoa(1):
the tint, fourth aud fifth tarwometmnal joints Nolr: the ranp af extauion in the great tne Notm the nmge af ftwon at the
by ltudying the Mel with ODe baud aud at !be metalanoJlbalaaeal joinL mmunopb.aJao&oeal joinL
a!lempling In move the meUillna1 beads Nonaalr.p:W. Nenul rup • W .
individually in a donal aod pl.mtar direction. Metalanopbal.aD movemr:nU are reverely
reltrh:tal aud paiufu1. in ballux !iplus. There
il oftmiiJttle impairmrat in hallwt "Vlllgus
uula1 leCOIIdary arthritic changa are quite
severe.
1.J.tL M--ts(11):gi'Httaa(J): 13.99. Mcwem•nts (12): 1. . .rloM: 1.1.100. Feotprlnt (1): It i1 sometimes
Nolr: the ranp in the iatmphal.anaea1 joint. Ovr.nll IDDbilliy may be roughly IISielled by belpfultn lee tbe pattem of weisbl
Nonulllcldoa = "•. ~y curlinf aad straiJbtminl tbe IDea. dUtz:ibution in the foot: DDir; tbe imprim of
Kdcu.IOD = o•. ~ ~ af i.ndiWiual ranpl is !be •weal)' foot on a vinyl floor, or (A) apply
Restriction is cammoa a:ftr.r fraclllrel aldie aeldmn lllll!ded. Restriction is a6m - . in olive oil eo the •ole aud dlllt the imprint with
1ZIDliiW pMiaux. and is pmeral.ly ~ u prut, dvwn•tnid arllu:iti1, Sudeck's atrophy, talc; (B) me ink on paper (or fix on an X-ray
bei11J a ctlldraindiation In aud i~ cooditiODI aldie foot aud lq. plale and develop it). Varioos specialised
metacarpophal.a jciat fulion. mdmk:a1 md!ods are available. A pedDicope
may a1ao be uel for this purpolll.
THEFOOT lOS
•••
•
-
~D
• + +
A B A
13.101. Footprfnt (l): typlal ,.uarns: 13.102. Shou (1): The palient's only 11.101. Shoes (l):the too-tlhort shoee
(A) Nm::mal. foot. (B) Pea planu. Notr: the complaint may be sboe wear. llllpection is Notr: (A) tbe excessive wear at the toe and
i1x:reue in - of tbe cemral pm:t of llllle expected and may be heJpfal. In the normal heel. (B) A pp may appear above sole.
taking part in weipabeadna. (C) Pea cavua. aoie wear ia fairly ew:o, beinJ muimal. (C) The toe cap may bulge, and the inside
Notr: tbe decrease in - of contact in tbe aaou the tread (a) and at the tip (to tbe of shoe may be marbd by the toe&. (D) Tbe
~ and the 1playins of the antr.rior part lJdma1 aide) (b). At the bade of the heel (c), heel may aive at the seam. n-e may be
of the foot. In extmue CUM lbe lJdma1 m.aximmn wear is also to the latr.nl.lide. blllterlng of the heel. and exceallive lOCk
we.igb.tbe.mg llrip may dl.uppear. wear. (E) A 811(1 may appear between the
qWirll!lr and the ankle..
t
c
1 3.1 04. 5"-t (J): pu planus (1 ): Notr: 11.105. Shoas (4): PM planus (l): Notr: 13.106. Sh- (5): &JIIaY foot: Ne (A)
(A) wear on tbe malial. aide of tbe IOie (A) tbe sboe may be twisted when viewed exce11 wear in the rqion of tbe firlt ar
extr.ading to the tip; (.B) wear on the ou1r:r from bebind (ie. the heel and llllle are on aecond mdataru1 beD. (B) The upper
side of heel; (C) in severe c:uea, wear on the di1ra-ent planea); (.B) ICUff m.arla on medial bulpa Oftt lbe sole &lllierlorly.
di.a&oaal. IXIriW of heel. aide; (C) tbe upper bulges ~ the sole on the
mNallide. Tbe quarter bulp away from
tbe foot (D).
-s
11.107. Shoas(6):pescnua: N~(A) 1J.1OL Shoes (7): hellux valg111: Them iJ 13.109. St.o.(8):h8IIIDI:rlgldus: Note
exce~~oive WHl' Wider the mebdanal bead oflml (A) exceas wear as in splay foot UDder (A) exce1dve W91'11Dder the fint mda!araal
rqi.oo; (B) excesai~ wear .t the back of the the area of the first and seccmd mda!arBal bead and (B) at the tip of !be IIO!e; (C) exceas
heel; (C) rai5iDg of toe; (D) creues; (E) bead~; (B) balgios of the upper to wear on the l.teral side (through walll:ins on
gi.viDJ way of laciDg1. aa:rnmnodate the promiDeat first mdatanal the !~ide of the foot); (D) lateral oveibq. In
bead. llddition, the toe of the llhDe may be upll1l'lled.
H
F
8
11111. Radlognphl (2): An AP view is 1S.112. bdlotll'•plu (J): In the AP view,

roaline, aloog wilh either a bderal or an IIOfe tbe bone lmlllnl lllld typic:aliiDOID.Iliet,
oblique. Note (A) talUI; (B) cak-.; (C) aucb as (A) mm:h fiadure (pmiolleal
~;~>~~;(E)MPmmN J11Ktion oc:c:ura in the healins stap);
(oftm bi- or 1ripartile); (F) c:uhoid. lnamatal (B) Plmbtq's eli-. lfi'ec:tiD8 the seccmd
acceuory booN may be miJaaba fot fiadure IDIII'Manal bead; (C) oateoartbritk: c:banges
13.110. bdlot~nph1(1): Normal or loose badiN, e.g. (G) os tibi.ale allmum; wilh IIXOstoaiJ :fmmJdioa (hallux rigidos).
anta:opoataior ndiogmpb. of the foot. (H) 01 \Maliannm
THEFOOT 307
11.111. bdlographl{4): Note, ifpreaent, 11.114. RlidlotNphs(S): In the child, note

(A) m.elldanlla pimua varus; (B) first any inarJued density of the amcuJ.,
IIIC!IIIbna1 'ao~toaia'; (C) ballmt valgus; suggestive of Kohk.r'& d l - . 'The bone may
(D) joiDt urmwiDg or cyst flli!DliDon, appear redm:ed in a.
a~fPSiive of omoarthritia, rbenmatnid
111brlti1 or gout; (E)~
joiDt subbrud:ion leCOIIdary w hallux valgus
or w rbeumatDid artbr:iU..
1 S.1 15. bdlographl {6): Normalla1!nl radiograph of tbe foot.

13.116. 18dlogr.ph1 (7): In the IJdma1 mdiogmph it is often 13.1 17. 18dlogreplu (1): Noce, if JIRI-'> (A) lhe lWCIIIIOlY os
difficult to tr111:e the oulline of illdlvidoal JDIItlllllnall owiDg to trigvnum (often mis1lllam for a fnwture), (B) CIIDIIifonn exostosis,
superimpoaition, allhougb the tint IIIIi fifth are uiUlly quite clear; (C) IWl'OWiDg of the midlllnBl joint, 111111 other change• qpl4ive
(A) talua, (B) calC~~DeU~, (C) navicular. (D) medial CIIDIIifonn, of midlanal dJ.euuultoid or osteoartbril:i1.
(B) -m.d, (F) cuboid. Now the talonavicular IUid ~
join!I.
11.111. 18dlognphl(tl: Note. if 13.11 '· 18dlogr.phl (10): Cozl&e:nital

Jli'C'CIIt ln lhe ll1uJi, (A) cak1alleal spur, vertical taios. wbich iJ uiOCilb:d with
IOIIIICtiJia IJIOCiallcd with plantar fuciitia, di.alocation of die ta1oDnicullr joill.t, lw
(B) foo1bllla'l ~(C) ln tbe child. a~ radiograpbic appear~~WC. NOlle
i.llcreaed denlity llld frlgmemltion of dle die di%ec:tion of die long WI of b tllas.
calciDetl epiphylia, ICGl ill. Sela'• diaeae. (A) nl.ua; (B) calciDCUI; (F) both cam. of
osllifil:alioo of lbc cuboid. ('lbia COIIdiiioa is
normally treated by Jlll.llipolative rccluction
llld the applicltion of IIC:Iill cutl. Imprcmd
malta Ire c:laimed far IUblequeDt pi.nnillf of
tbe ta1ooavkul8r joillt llld pcrcutllleal
tleadomy of tbc tcu4oc:ak:aneus.)
THEFOOT 309
1J.121 . . .dlognph• (12}:

CalCIIICOJIIIVicuJ. bar or syoostcail (and die
commonest of the lllnal coali!iODS) is belt
aer.n In oblique projections of the foot, aDd is
IUuDd in uaocillion with spulic ft.at foot.
11122. RMIDgnpbi(1J): Anaxial 13.123. Radiographs (14): A 1lUigealial 13.124. Redlognphs (15): A
or lllnglmtial projec:tion of the beet abowl projection may be 1ld wbL':D the -amoid Mli&htbearin& latt:nl projection il of valoe
(A) tlll.us, (B) c:alR!M'U, (J) poltmia£ booea are supect, abowiag, for example. in IIICMiDg dcformiticl ilmllvillg llle ~
1llloc:al~ joim. (K) .~tali, (A) ot~ ci1allp. (B) 11lea1 loqitudiul ardlad llle toc1. 'lbe uea of
(L) bue of fifth mmaan.l. A taJ.oc:alcmeal ~ (C) disloc:ati.ol:llllld a• of 111e ariJta !he talul 11811 &It mctatllnal aoanally
~ten. (M), ~ rDUDd. in spllllic (c), lleell JDDit COIIIl.IIOilly in uiiOCWion wilh coiDcidc, and die bciabt of lhe llrCh may
flat foot, may be~ by dO. view. ldVIJICICd balllll: vaJ&ut. be ultlled by IIOCiJig llle ratio ABICD:
(I) aorma1, (2) pe1 cavu1, (3) pe1 plau1.
13.125. RadiCifNphs (16): In uaeadng 1J.126.. RadiCifNphs e6 tM foot: ...mplu of pdloiOfV (1): N~ the aa:entllalion
haDwr. valgus, J:JOm (A) tbe IIIN~al of both the medial and lallmlllonpudi.ul an:hea of the foot.
tmtle (tbe 'lfl aosJ.e') is IIOlDially 9° or leu ~peacavus.
- more lllJPis mebdanlla piJnaa varu•;
(B) the so-caD.ed ltalliD: valgJU tmtle is
oormally w 01' leu. ~ vaJp af tbe
haDwr. is B-A.) The IIOI1Ila1 diltiJJ~UttJt~Jnal
articllllu and p10%illtlll p}tal~DltHl al'1il:vltlr
tmtlu (C ad D) are rspectivel.y as• md s•
(or lel1).
1:1.1 21. hthology (:1): Note tbl! lllllrbd

iDcnlued density ad llalkm.iDg af the
naviallar.
1).127. , ..hologJ [1): Tbere is ...,.. Diqaa.ia: Kobler's m-. , 3., :tt. hthology (4): 'Ibcre 11 illaeued
dc:formity of tile tarlul, with ~yiD& dcually IDd fra&mcnlldOil of the ~
dc:formity of the foot cplphym.
Dillpolll: untrcmcl club foot Dl8pelk: s-·. dileae..
THEFOOT 311
11.112. PlllhoiOSJ (7): 1biJ oblique

radioaraph lbowJ a thidt bridge of bODe
UDitin& lhe CllciDc:ue with thc navklulat.
The pt.ti=t bad • Jputic flat foot.
1S.1S1. "-'hology (6): 'lbil iun axial DiqDolll: ealcancollaviQJlar I)'IIOstOOJ
1J.1 JO. Pathology (5): '~here il J:ll8lbd
(IIDgeatial) projection of a petient foaDd to (c~coalidoa;
destruction of the ~ metmnal head,
bne a pliDful rigid flat foot The IIIICdial. part clk:aneonavk:alar blr).
with brolldeaing BIJd lm1 of CODUvity in the
bue of the proximal phalmx. af tbe lllbtalar joiDt, between the
IOJ~ tali of die call;- BDd thc
~ Freibr.q'• diJeue.
talu Oil die rigbt side of thc radiograph il DOt
IIIJPimll
Dt.poU: Ulcx:alcaeal ~ (llOilitiOD)
in the regic:a oftbe ~tali.
1J.1SJ. '-'hology (10): ~ wu

complaint of plin on thc po1tler'omedial upcct
of tbe foot, llld thc inferior IUrface af tbe
~ ia eloaptccl.
1S.1 SS. PadlolotJ (1): Tbc pMic:Dr. a 1S.1M. '-'holoiJ IJ): 'l'beze Ui diM.odic:a DiqDalfl: plant. fuciitil UIOdltecl with ..
prob&tioDcr DUne, pvc a s-.a biatory of of the IICalla1. ~ af the c:akueua 1arp es08toliJ or c&k-.I 'PUI'·
ank:dor foot l*D, aad the radiognp1 of Ia aaocia1icd wi!h lbe JII'C'CIDCC of two lqc
foot lbowt DCW bc.c fOI'Jilllka in the ICCCllld cyatic apiCCI in tbe boDe.
IIIIDiablnalllluft. Dlapasll: the appea!'IIIICe& are typical of a
Dlapodl: bcaJmg man:l1 fnctllrc. llmple, multilocular booc cyiL
13.136. hthologJ (11); 1be lmmiDal 13.137. hthoiOD (121: 'Ibe 13.1 Sl hdloiOSJ 113): Tbe lint~
llldallnopbalan joint of the greet toe iJ is short and medially iDdiDCd. 'lbc flnfoot is
phalanx bu vimlally diJippemd. IUid ~
naaowed, md dlere ia ma.rG4 oateoarthritic broaiJtaed. 'Ibe peat toe is tilted laletally,
is grou 10ft U..ue IWClJiD& of tilt toe wbich
lippiD& on bod1 aides of dle joiDt. Little IDd the he.:l of lbe firlt metalllrAl is
wu u.ocia11cd witll pat paiD.
Diapolll: lbe lppCIIIDCCI ate dae to I zmm::ma~t wu pre8alt. UlK10V'Ol'edllld promillalt. Tbe two ]iWm&ea
Dlapolll: ad'VliiiCed baiJ.ux rigidul. of lbe pat IOe - rollfed.
ICvcte aail iDfcction wllich lw ipl'tlld locally,
Diapolll: pctl ballux va1pt deformity
ludiDg li:l 1 datructive otlicitil.
UIOCia11cd witll I l!lelldarlg primol VllUI.
'lbi:R II ~ of the greet toe, llld
apUiyina of lbe forefoot.
13.140. PMhology (15): 'I'Ix%e il evi.ckD;e

of 1 1Uii11cd avaJaon fracture of tilt ltylaid
procelf of the Mil melltatlal bue. 'Iberl: iJ
widelptad ~ ad diatudiCllce of
13.139. htholotJ (14); 'l1lere are valp boac tatan:, witll clinii:ally ma.rG4 awelliDg
dd'uu:ttitiei of all the loci. Tbe MP joinll of llld tti11Det1 af the foot
all lbe Jeuc:r toe. are cliiW<:al, IUid lbe Dlapelll: Sadieck'l atrophy (~
-.moid bolla are diJpllced laecnlly. 'lbc Jqiallal p.a IJIMiromc, ~
boDes ll'C IOIDtWbat ostcoporolie. ~) ICICDildlly to local trauma.
Dllpom: rbtmn•lnid utllriti1.
INDEX
A lateral 261, 265-{i, 270, 272 Arthritis

Abdoorinal aorta 298 DJedUU 261,262,269-70 gonococcal see Gonococcal arthritis
Abdominal examination 293 loose bodies 263 hip 174
in back pain 157 movements 267-8 infective
Abdominal reflexes, testing 156 myotomes 27 hip 202
Abductor l=h 191 osteoarthritis 263, 273 sacroiliac joint 166
Abductor pollicis longus, tenosynovitis 93 osteochondritis dissecans 272 osteoarthritis see Osteoarthritis
Abscess pain 264 rheumatoid see Rheumatoid arthritis
Brodie's 250 pathology 272-3 septic see Septic arthritis
psoas 160 plantarfiexion 267 Arthrognq>hy 219
Acetabulum nuliognophy 271-2 Arthropathy 53
dysphurla 171, 199 rheumatoid arthritis 263 Arthroplasty
Perthe's disease 197, 203 soft tissue injuries 261 Charnley low-friction 176,200
slope 172 sprains 261 Keller's 282
Achilles tendon Sudeck's atrophy 272 Arthroocopy 9,219
insertional tendinitis 262, 268 tenderness 265 Aspiration
rupture 268 tendons elbow 89
shortening 264 Achilles tendon see Achilles hip 192
terulinopathy 262, 268 tendon knee 209, 243
testing 269 perooeal 263, 270 shoulder 73
traumatic rupture 262 snapping peroneal 263, 270 wrist 110
Achondroplasia 144 tenosynovitis 262-3, 269-70 Atlantoaxial joints 44
hand 117 tuberculosis 263, 272 subluxation 47
wrist 107 Ankle brachial pressure index (ABPI) Atlanto-occipital joints 44
Acromioclavicular joint 50 299 Atlas 44
compression beneath 52 Ankylosing spondylitis 138--9 Avascular necrosis
dislocation 56, 72 costovertebral joints 138 femoml head 203
osteoarthritis 54, 70 hip 176, 196 humeral head 71
Adhesive capsulitis, shoulder 53, 63 knee 217,218 scaphoid 107, 108
Adson's test 41 spine 46, 165 talus 273
Age affected joints 138 Axillary artery 14
back complaints 148 diagnosis 160 Axillary brachial plexus 14-15
and hip pathology 181 progression 139 Axillary nerve 15
knee complaints 218 symptoms 138 examination 19
and shoulder pathology 57 testing 156
Aird's test 154 treatmeot 139 B
Allen test 125 Annulus fibrosus 133, 145 Back pain 133--5
American Shoulder and Elbow Surgeons Anterior drawer test 232 abdominal examination 157
scoring system 57-8 Anterior interosseous nerve palsy 26 causes 133
Anaesthetic injections 73 Anterior metatarsalgia 284 circulation 157
Ankle 259--73 Anterior tibial compartment syndrome classification 133
anatomical features 260--1 250-1 diagnosis 134
articular surfaces 270--1 Anterior tibial pulse 298 examination 135
bony ankylosis 273 Anthrax 116 history taking 133-5
Charcot's disease 273 Apical infections, finger 116 mechanical 146-7
dorsiflexion 267-8 Apley's griruting tests 238 radiating to the legs 134
footballer's 263, 308 Apprehension test sedimentation rate 157
functional instability 261 patella 240 Baker's cysts 207-8
infections 273 shoulder 66 Ballottement test 224
inspection 265 standing 236 Bamboo spine 160
ligaments 260--1 AP tomography 8 Barlow's provocative test 193
inferior tibiofibular 260, 261, 267 Arches of the foot see Foot, arches Barlow's test 193
injury 261, 262, 265--6, 272 Arteriovenous fistnla 117 Bart.e-Lieou syndrome 36-7
314 INDEX
Batchelor plaster 171 Calcifying supraspinatus tendinitis 53-4, 70 treatment 35

Beat knee 218 Calf pain 251 vertebral artery involvement 35
Beevor's sign 156 Calve's diBease 138, 159, 165 Chair test, tennis elbow 83
Benediction attitude 25 Capasso's method 163 Charcot's disease
Biceps tendon Capsulitis, idiopathic adhesive 53, 63 ankle 273
mstability 57 Caries sicca 55 knee 246
test 67 Cmpal bones shoulder 73
integrity of long head 67 fractures 106 Charnley low-friction arthroplasty 176,
ruptures 56 instability see Carpal instabilities 200
tendinitis 57, 67 Cmpal mstabilities 96, 105, 108 Children
Bipartite patella 244 dynamic 96 foot conditions 279-81
Bladder, neurological control of 32 static 96 hip radiographs 199
Bone Cmpal tunnel syndrome 25, 94-5 knock knee (genu valgum) 228
cysts see Bone cysts clinical features 94 Choodroma
examination of 6-7 incidence 94 hand 115
tumours see Bone tumours; specific tests 102-4 ossllying, shoulder 70
tumours treatment 94-5 Chondromalacia patellae 215, 244
see also specific bones Cmporuetaoarpal joint Chondromatosis, synovial 2A6
Bone cysts crepitus 12A Chondrosarcoma 72
foot 311 flexion 12A Circulation
shoulder 71 movements 123-4 back pain 157
tibia 257 of the thumb 115, 129 foot 297-9
Bone tumours Catterall grading 197 hand 125
hip 176 Cauda equina syndrome 142 Claudication 251
tibia 250 Cervical osteoarthrosis see Cervical Clavicle 50, 56
see also specific tumours spondylosis Claw hand deformity 17
Bouchard's nodes 115, 120 Cervical rib 44, 47 Claw toe 285, 293
Boutonniere deformity 113--14, 118 Cervical spine 33-47 Clergyman's knee 218
Bow leg (genu varum) 217, 22S-9 ankylosing spondylitis 46 Club foot 279--80, 310
Bowstring test 154 B~-Lieou syndrome 36-7 examination 288
Brachial artery 76 brachial plexus 12-14 incidence 279
Brachial plexus congenital deformity 47 radiography 289
axillary 14-15 congenital fusion 46 treatment 279-80
cervical 12--14 cord compression 41 Cobb method 138, 162
injury crepitus 40 Coccydynia 147
acute trauma 17 curvature 42, 45 Collateral ligaments
assessment 17-18 dislocation 45, 46 elbow 76
in children 19 extension 39 knee 210, 226
long-standing lesions 17 flexion 39 Calles' fracture 107
prognostic signs 19 lateral 39--40 complications after 92
types of 16 inspection 38 inspection 98
complete avulsion 16 Klippel-Feil syndrome 37 malunion 110
nerve root rupture 16 lateml flexion 39--40 Common peroneal nerve
partial avulsion 16 movements 39--40 deformity 30
see also specific nerves myelopathy 41-2,45 motor distribution 29
Brodie's abscess 250 neoplasia 37 sensory distribution 29
Bunion 282, 293 osteitis 37 sites of involvement 30
Bunionette 293 osteoarthritis/osteoarthrosis see Cervical tests 30
Bunnell-Littler test 123 spondylosis Compartment syndrome, anterior tibial 250--1
Bursae osreophyres 45 Complex regional pain syndrome see
knee '1frl-8 palpation 38 Sudeck's attuphy
olecranon 78 pathology 45-7 Compull:d tomography (CT) scans 8
subdeltoid 52 postural pain 34 prolapsed intervertebral disc 164
Bursitis radiography 42-5 Conoid ligament 56, 72
foot 282 range 39 Coracoacromialligament 52
infrapatellar 218 rheumatoid arthritis 36-7, 43, 47 Cord compression mtio 45
knee 217-18 rotation 40 Corns 293
olecranon 78 shoulder abduction 51 Coronoid fossa 76
prepatellar 218 and shoulder examination 65 Costovertebml joints, ankylosing spondylitis
Butcher's wart 116 thoracic outlet syndrome 35, 40--1 138
Buttressing 161, 198 vertebrae 42-3 Coxa valga 183, 195
whiplash 35-6 Coxa vara 174, 175, 183, 191, 195
c Cervical spondylosis 34-5, 45 congenital 202
Caf6-au-lait spots 150 clinical features 35 Crepill!S 5
Caisson disease 71 pain 34 carpometacarpal joint 124
Calcaneal exostosis 282-3 presentation 34 cervical spine 40
Calcaneal spur 308, 311 radiographs 45 foot 302
Calcaneonavicular bar/synostosis 309, 311 shoulder pam s2 shoulder 65
INDEX 315
thumb 124 lateral 244 radiographs 84--6

wrist 102 permanent 215 rheumatoid arthritis 79
CRITOL mnemonic 86 recurrent lateral 214 septic arthritis 87
Cross-body adduction test 65 should.,- 71 and shoulder function 57--8
Cruciate ligaments anterior 55 swelling 80
anterior 206, 211-12, 233 posterior 55 tardy ulnar nerve palsy 78
injury 211-12 recurrent 54-5 tennis see Tennis elbow
posterior 'l1J7, 212, 233-4 sternoclavicular joint 57 tuberculosis 79, 89
visualisation 235 tibial condylar 212-13, 235 ulnar neuritis 78
Cubital tunnel 78 Disposable sharp point 9 ulnar tunnel syndrome 78
Cubitus valgus 77, 80 Distal metatarsal articular angle 310 Electromyography, neurological assessment
Cubitus varus 77, 80 Dorsalis pedis artery 297 18
Cuneiform exostosis 283 Dorsal scapular nerve 13 Elson's middle slip test 126
Cudy toe 285, 293 Dorsiflexion-eversion test 301 Enchondroma
Cyanosis, foot 298 Down's syndrome 117 hand 120, 128
Cysts Drawer test should.,- 70
Baker's 207-8 of Geroe.- and Ganz 66 Eosinophilic granuloma 137, 138, 165
bone see Bone cysts glenohumeral instability 66 Equipment, examination 9
dermoid 115 Drop arm test 62 Erb's palsy 14, 17
hand 115 Duchenne sign 191 Erysipeloid 116
knee menisci 213-14,238 Dunn's arthrodesis 280 Erythrocyte sedimentatioo rate (ESR) 7
mucous 115 Dupuytren's contracture Ewing's tumour 257
foot 294 Examination under anaesthesia, knee 219
D hand 112, 119 Exostoses
DASH (Disabilities of the Arm, Shoulder, Dynamic posterior shift test 234 calcaneal 282-3
Elbow and Hand) questionnaire Dynamometer 128 cuneiform 283
58-9 Dysplastic hip 172 fifth metatarsal head 283
Deformity Index 198 foot 282-3
Deltoid muscle E shoulder 70
power 67 Edinhorgh method 193 subung<UU 285, 302
shoulder abduction 51 Effusion Extensor digitorum communis injury 126
wasting 60 elbow 80 Extensor pollicis brevis tenosynovitis 93
De Quervain's disease 93, 98, 102 knee 208,218,220,223-5 Extensor pollicis longus injury 126
Dermatomes Egyptian foot 279 Extensor tenosynovitis 93
fingers 16 Ehlers-Danlos syndrome 95, 100, 125 External rotation recurvatum test 236
lower limb 28 Elbow 75--89
Dermoid cysts, hand 115 anatomical features 76-7 F
Developmental dislocation of the hip (DDH) aspiration 89 Facet joints 133
170-2 carrying angle 80 dislocation 45, 46
in adults 171-2 congenital radioulnar synostosis 87 Fasciitis, plantar 285, 311
occurrence 170 cubitus valgus 77, 80 Fat pad injuries, knee 216
in older children 171, 193-4 cubitus varus 77, 80 Feagin and Cooke prone test 233
radiography 199, 201, 202 epiphyses 86 Feet see Foot
screening 170-1 extension 81 Femoral condyles, tenderness 226
symptoms 171-2 fiexion 81 Femoral fracture 177
treatment 171 fnK<nre 85, 88, 89 Femoral head
untreated 202 function 77 avascular necrosis 203
Diaphyseal aclasis 243 golfer's see Golfer's elbow density 195
Diffuse idiopathic skeletal hyperostosis gunshot wound 87 shape 195
(DISH) 45, 139 gunstock deformity 80 Femoral neck, anteversion 190
Digital neuroma 284, 300 hyperextension 81 Femoral nerve 28
Discography, prolapsed intervertebral disc important relations 76-7 motor distribution 29
164 inspection 80 sensory distribution 29
Disc prolapse see Prolapsed intervertebral instability 76, 77, 84 sites of involvement 29
disc (PID) loose bodies 85, 88, 89 tests 29
DISH (diffuse idiopathic skeletal Monteggia fracture 85, 88 Femoral polBe 298
hyperostosis) 45, 139 movements 81-2 Fingers
Dislocation/subluxation myositis ossificans 79, 85, 87 abduction 125
acromioclavicular joint 56, 72 myotomes 15 derm.atom.es 16
atlantoaxial joints 47 olecranon bursitis 78 mallet finger 113, 117
cervical spine 45, 46 olecranon fracture 88 movements 121-3, 124
facet joints 45, 46 osteoarthritis 78-9, 88, 89 myotomes 15-16
hip see Developmental dislocation of the osteochondritis dissecans 78-9, 85, 89 opposition 124
bip (DDH) osteophytes 85 trigger 114
patella palpation 82-3 Fixed flexion deformity 4
acute traumatic 214 pathology 87-9 Flat foot 280--1, 287
congenital 214 pronation/supination 81, 82 adult 283
habitual 214-15 pulled 78 footprint 305
316 INDEX
incipient 283 skin temperature 297 Gout 286, 301

peroneal (spastic) 282, 295 sole 294 Gnosp 127
persistent 281 splay 283, 295, 305 Gnnoty test 233-4
posture 296 Sudeck's atrophy 312 ilieat toe
rigid 283 suprnnation 276,302,303 hallux flexus 283
shoes 305 talipes calcaneus 280 hallux rigidus 283, 302, 306, 312
Flexor pollicis longus injury 126 tarsal tunnel syndrome 286, 301 hallux valgus 282, 302, 306, 307, 310, 312
Flip test 154 tenderness 299-300, 301-2 inspection 291-2
Fluid displacement test 224 tripod action 276 movements 304
Fluorodeoxyglucose-positron emission venuca pedis (plantar wart) 284, 294 nails of the 285-6, 292, 302
tomography (FOG-PET) 8 weightbearing posture 290 pain in 287
Foot 275-312 see also Toe(s) tenderness 301-2
abduction 276 Footballer's ankle 263, 308 Grinding tests 238
adduction 276 Footprint 304--5 Grip strengih 128
adolescent conditions 282-3 Forefoot Gunshot wound, elbow 87
adult conditions 283--6 pain 287 Gunstock defonnity, elbow 80
anterior metatarsalgia 284 tenderness 299-300
appearance 290 Forestier's disease 45, 139 H
arches 278 Fracture Haemarthrosis, knee 208, 225
anterior 278 catpal hones 106 Haglund defmmity 283, 291
lateral longitudinal 278 elbow 85, 88, 89 Hallux flexus 283
medial 278, 296 femur 177 Hallux rigidos 283, 302, 306, 312
posture 296 foot 284, 311 Hallux valgus 282, 302, 306, 307, 310, 312
transverse 278 hand 129 Hallux valgus angle 310
bone cyst 311 March 284, 311 Hammer toe 285, 293
childhood conditions 279-81 olecranon 88 Hand 111-29
circulation 297-9 patella 209 achondroplasia 117
club see Club foot scaphoid 108 bilateral function 128
crepitus 302 shoulder 71 Boutonniere defonnity 113--14, 118
cyanosis 298 stress 250--1, 256 chondroma 115
diagnosis 286-7 styloid process 109 circulationl25
Dupuytren's contracture 294 supracondylar 85, 89 Dupuytren's contracture 112, 119
Egyptian 279 tibia 250--1, 256 enchoodroma 120, 128
eversion 295, 303 vertebrae 165 extensor tendon division 114
exostoses 282--3 Freiberg's disease 284, 292, 300, 306, 311 fracture 129
fiat see Flat foot Fr6lich syndrome 174 function assessment 127-8
Freiberg's disease 284, 292, 300, 306, 311 Frozen shoulder 53, 63 ganglioos 115, 120
gait 290, 297 glomus tumours 115
gout 286 G grasp 127
hallux rigidus 283, 302, 306, 312 Gait grip slrengih 128
hallux valgus 282, 302, 306, 307, 310, assessment 182 implantation dermoid cysts 115
312 foot 290, 297 infections 116, 126-7
inspection 291-4 hip 182 inspection 117-20
intoeing 280, 295 Gamekeeper's thumb 123, 129 ischaemic contracture 119
invention 276,295,303 Ganglions joint thickening 125
investigations 290 hand 115, 120 metastatic tumours 115--16
Kobler's disease 281, 307, 310 wrist 92-3, 98 midpalmar and thenar space infections
March fracture 284, 311 Genu recurvatum. 217,239,244 116, 127
movements 276-7,290,302-4 Genu valgum (knock knee) 217, 228,239, movements 121-5
midtarsal 277 295 mucous cysts 115
planes of 276 Genu varum (bow leg) 217, 228-9 myelopathy 42
subtalar 276-7 Gerber and Ganz, drawer test of 66 occupational infections 116
tarsometatarsal 277 Giant cell tumour of bone see Osteoclastoma osteitis 128
pain 287 Gibbus 137, 149 osteoarthritis 115, 129
palpatioo 290 Glenohumeral joint 50 osteoid osteoma 115
pathology 310--12 instability palmar grasp 127
pes caws 281,287,303, 306,310 anterior 66 palpation 121
pes planus see Flat foot inferior 67 pathology 12S-9
plantar (digital) neuroms 284, 300 posterior 66 pinch grip 127
plantar fasciitis 285, 311 osteoarthritis 54, 71 profundus tendon injuries 114
posture 294-7 shoulder abduction 51 radial deviation of the 92
~ation 276, 303 Glomus tumours, hand 115 radiographs 128--9
radiography 306-10 Gluteal muscles testing 192 rheumatoid artluitis 114-15
Iheumatoid arthritis 286, 312 Golfer's elbow 77, 84 swan-neck defonnity 118
sesamoiditis 302 Goniometer 9 swellings 120, 125
Sever's disease 281, 308, 310 Gonococcal artluitis syphilis 116
shoes 305--6 knee 209 tendon and tendon sheath lesions 113-14,
skew 280 shoolder 55 116
INDEX 317
tendon injuries 114, 125--6 osteoid osteoma 203 shoulder 60

tendon sheath infections 116 osteomalacia 201 thoracic/lumbar spine 149--51
thumb to side of index grip 127 pain 176 tibia 253
tuberculosis 116 palpation 186 toes 292-3
tumours 115-16 pathology 200-4 wrist 97-8
vibration syndromes 112-13, 125 pelvic distortion 196 lntennetatlusal angle 310
web space infections 116, 127 Perthe's disease 173-4, 196--8, 203,204 Interphalangeal joints
see also Fingers; Thumb radiography 193, 194-200 distal, movements 122
Hard corns 293 Reiter's syndrome 176 loss of movement assessment 123
Harris System 179 rheumatoid arthritis 175 movements 121, 122
Hatchet head lesion 70 rotation 189--90 osteoarthritis 115
Hawkins-Kennedy impingement sign 65 shortening 181rli proximal, movements 121
Heberden's nodes 115, 120, 129 slipped femoral epiphysis 174-5, 198 Intervertebral discs 132
Heel snapping 176 calcification 158
eversion 276, 303 total joint replacement see Hip replacement lipping 159
inspection 291 transient synovitis 172 narrowing 159
inversion 276, 303 Trendelenburg's test 191 prolapsed see Prolapsed intervertebral disc
pain 285, 287 tuberculosis 174 (PID)
plantar fasciitis 285 Hip replacement protrusion 133
posture 277-8, 297 Charnley low-friction arthroplasty 176, size of 158
Sever's disease 281 200 slipped 133
tenderness 299 conditions associated with 176--8 Intoeing 280
Hemivertebra 160, 168 component failure 177 Inverted radial reflex 42
Hemivertebra cervicalis 47 component loosening and infection Ischaemia, lower limb 254
Herring lateral pillar classification 197 177-8,200 lschaemic contracture, hand 119
High scapula 56 component wear 200 Ischial tuberosity 186
Hill-Sachs lesion 70 dislocation 177
Hip 169-204 femoral fracture 177 J
abduction 188 radiography 200-1 Jakob's reverse pivot shift test 236
acute pyogenic arthritis 174 Histamine test 18 Jerk test 66, 235
adduction 189 Hoffman's test 41 Joint examination 2-3
age distribution of common pathology 181 Homer's syndrome 14, 17 bruising 2, 3
ankylosing spondylitis 176, 196 Housemaid's knee 218 discolourati.on 2
anteversion of femoral neck 190 Hurler's syndrome 117 equipment 9
aspiration 192 Hyperhidrosis 294 movements 4-6
bone tumours 176 Hyperparathyroidism 117, 202 active 5
complete obliteration of joint 196 Hypothenar wasting 22, 41, 97, 104, 120 in an abnormal plane 5
developmental dislocation see passive 5
Developmental dislocation of I restriction 4-5
the hip (DDH) Idiopathic adhesive capsulitis 53, 63 trick 5
Duchenne sign 191 iliopsoas strains 186 oedema 2, 3
dysplastic 172 iliotibial tract 176,214 palpation 3-4
extension 187 llizarov method 280 special tests 6
external rotation 189-90 Imaging techniques 8 swelling 2, 3
flexion 187--8 see also specific techniques temperature change 3-4
function assessment 178--81 Impingement syndrome, shoulder 52-3 tenderness 4
ascending/descending stairs 180 Infection(s) Joint laxity syndrome 55
level of activity 179-80 ankle 273 Jumper's knee 210
pain 179 band 116, 126-7
putting on shoes and socks 180 hip replacement 177--¥. K
sitting to standing 180 knee 209, 220 Keller's arthroplasty 282
time walked 180--1 nails 285, 312 Kienbock's disease 93, 107, 108
walking capacity 180 shoulder 55, 73 Klippel-Feil syndrome 37, 56
work capacity in last 3 months 180 see also specific infections Klumpke's palsy 14
work/level of activity 179 Inferior gluteal nerve 28 Klumpke's paralysis 17
fusion testing 191 Inferior tibiofibular ligament 260, 261, 267 Knee 205-47
gait assessment 182 lnfrapatellar bursa 207 age distribution 218
infective arthritis 202 lnfrapatellar bursitis 218 alignment disturbances 217
inspection 182 Infraspinatus test 65, 68 anatomical features 206--8
internal rotation 189, 190 Inspection 2-3 ankylosing spondylitis 217, 218
irritable 172-4 ankle 265 anterior drawer test 232
joint space, decreased/increased 195 cervical spine 38 anterior pain syndromes 215
and knee examination 241 elbow 80 articular surfaces
movements 187-91 foot 291-4 affections of the 216
myositis ossificans 201 band 117-20 examination 240
myotomes 27 heel 291 aspiration 209, 243
neck·shaft angle 195, 196 hip 182 beat 218
osteoarthritis 175, 196,204 nails 292 bursae 207-8
318 INDEX
bUl'Sitis 217-18 Reiter's syndrome 217,218 r.Htiographs 157-63

chondromalacia patellae 215, 244 retropatellar pain syndromes 215 spondylolisthesis 142
clergyman's 218 rheumatoid arthritis 216, 220, 246 spondylolysis 142
diagnosis of complaints 218-19 rickets 247 see also Back pain; specific conditions
diaphyseal aclams 243 skin marks 221 Lumbosacral articulation, congenital
discoloration 221 swelling 208-9, 218, 221 abnonnality 167
effusion 208, 218, 220, 223-5 synovial membrane 225 Lunotriquetral instability 105
extension 2'lh-7 synovitis 208
extensor mechanism 209--10 temperature changes 221-2 M
disruption 209 tenderness 225--6 Macintosh test 235
examination 223 tibial condylar subluxations 212-13 McKenzie's sign 265
fat pad injuries 216 tuberculosis 209, 220, 246 McMurray manoeuvre 237
flexion 227 Knock knee (genu valgum) 217,228,239 Madelung's defomrity 92, 108
function assessment 178-81 Kohler's disease 281,307,310 Magnetic resonance imaging (MRI) scans 8
genu recurvatum 217, 239,244 Kyphosis 137 knee 219
genu valgum (knock knee) 217,228, angulw- 137, 158 neurological assessment 18
239 inspection 149 prolapsed intervertebral disc 164
genu varum (bow leg) 217, 223--9 regular 137 Mallet finger 113, 117
giving way 218-19 senile 139, 158, 168 Mallet thumb 113, 117
gonococcal arthritis 209 Mallet toe 285, 293
haemarthrosis 208, 225 L March fracture, foot 284, 311
and hip examination 241 Lachman tests 233 Marfan's syndrome
housemaid's 218 active 233 hand 117
hyperextension 217,227 manipulative 233 wrist 95, 100
infections 209, 220 Lateral cutaneous nerve of thigh 32 Medial cutaneous nerve of the arm 14
inspection 221--6 Lateral ligament 261, 265--6, 270, 272 Medial cutaneous nerve of the forearm 14
instability 229-32 injury 261 Medial ligament 261, 262, 269-70
posterolateral 235--6 Lateral patellofemoral angle 242 Medial pectoral nerve 14
rotatory 212--13, 229 Lateral pectoral nerve 14 Medial tibial syndrome 251
valgus stress 229-31 Lateral tomography 8 Median nerve 14, 76
varus stress 231-2 Leg see Lower limb common sites affected 25
internal derangement 219-20 L'hermitte's test 42 examination 25-7
investigations 219-20 Limbs lateral and medial cords 24
joint line structures 225 lower see Lower limb motor distribution 24
jumper's 210 segmental and peripheral nerves sensory distribution 24
Lachman tests 233 11-32 Medical Reoearch Council (MRC)
ligaments 206--7,210--12 upper see Upper limb grading of motor and sensory levels 6
collateral 210, 226 Local anaesthetic injections 73 strength of muscle contraction scale 5-6
cruciate see Cruciate ligaments Long head of biceps integrity 67 Melanonychia 286
injury 210-12, 246 Long thoracic nerve 13, 68 Meniscus see Knee, menisci
lateral 206, 211 Loose bodies Metacarpophalangeal joint 121, 123
medial 206, 211, 246 ankle 263 Metaphyseal aclasis 243
posterior 207 elbow 85, 88, 89 Metatarsalgia
tenderness 226 knee 216, 245 anterior 284
locking 219 Looser's zones 246 Morton's 284, 300
loose bodies 216, 245 Loose shoulder 54-5 Metatarsals
lumps 221 Lordosis 149 base, fifth 283
menisci 207 Losee pivot shift test 235 head
bucket handle tears 213 Lower limb fifth 283
congenital discoid meniscus 213 dermatom.es 28 osteochondritis 284
cysts 213-14, 238 function assessment 178--81 widening of foot at 283
degenerative lesions in the middle-aged inspection 253 march fracture 284
213 ischaemia 254 Metatarsophalangeal (MP) joint 283
examination 236--8 myotom.es 27 Midcarpal inslability 105
lateral 207 oedema 253 Midpalmar infections, hand 116, 127
lesions 213-14, 236-7 pain 250, 251, 252 Midtarsal joint 277
medial 207 peripheral nerves 28-31 Milwaukee brace 137, 138
tears in the young adult 213 segmental nerves 27 Mitchell operation 282
movements 226--8 swelling 253 Monteggia fracture 85, 88
myotomes 27 tenderness 254 Morquio-Brailsford's disease 100
osteoarthritis 216, 244, 245, 247 see also Tibia Morton's metatarsalgia 284, 300
osteochondritis dissecans 215, 226, 245 Lumbar spine 131--68 Motor distributions
pain 219, 220 anatomical features 132-3 common peroneal nerve 29
patellofemoral instability 214-15 curvature 149--50 femoral nerve 29
pathology 243-7 inspection 149--51 median nerve 24
popliteal region 240--1 palpation 151 radial nerve 19
pyarthrosis 209, 225 pathology 165--8 tibial nerve (medial poplileal) 30
r.Htiography 233,241-2 prolapsed inlOrVertebral disc (PID) 145 ulnar nerve 21
INDEX 319
Movements tibia 250, 257 Osteophytes

ankle 267--l! see also specific tumours cervical spine 43, 45
elbow 81-2 Nerve roots 13--14 elbow 85
fingen 121-3, 124 roptw"ed 16 shoulder 69
foot 276-7,290 N<rrVea Osteoporosis, senile kyphosis 139
hand 121-5 peripheml 11-32
hip 187-91 segmental 11-32 p
joint examination 4-6 see also specific nerves Paget's diaeaae 140, 159, 167
knee 226--l! Neurofibromatosis 117 hand 117
restriction of 4-5 Neurological examination 6 radiography 203
scapulothoracic joint 50 Nucleus pulposus 133 tibia 255, 256
shoulder 61-5 Pain
spine see Spine, movements 0 ankle 264
subtalar joint 276-7 Obturator nerve 28 back see Back pain
thoracic spine 133 Occupational infections, hand 116 calf 251
thumb 123-4 Ocular muscle weakness 38 foot 287
vertebrae 132--3 O'Donoghue's triad 211 forefoot 287
wrist 99-101 Odontoid process 44 great toe 287
see also specific joints Olecranon bursitis 78 heel 285, 287
Mucous cysts 115 Olecranon fossa 76 hip 176
Mulder's sign 300 Olecranon fracture 88 knee 215, 219, 220
Muscle contraction strength 5-6 Oilier's disease 128 lower limb 250, 251, 252
Muscle wasting 2, 3 Onychogryphosis 285 neck see Neck pain
elbow 80 Ortolani's test 192 scoliosis 137
wrist 97 Osgood-Schlatter's disease 210, 245 shoulder see Shoulder, pain
Musculocutaneous nerve 14 Ossification, wrist 107 slipped femoral epiphysis 174
Myelography Osteitis tibia 250
neurological assessment 18 cervical spine 37 wrist 98
prolapsed intervertebral disc 164 hand 128 Palmar grasp 127
Myelopathy hand 42 pyogenic, of the spine 141 Palpable :H.uid wave test 225
Myositis ossifi.cans staphylococcal 55 Palpation 3-4
elbow 79, 85, 87 tibia 250, 256, 257 cervical spine 38
hip 201 toes 312 elbow 82--3
tibia 257 wrist 109 foot 290
Myotomes Osteoarthritis hand 121
ankle 27 acromioclavicular joint 54, 70 hip 186
elbow 15 ankle 263, 273 shoulder 60--1
fingen 15-16 cervical see Cervical spondylosis thoracicllumbar spine 151
hip 27 elbow 78-9,88,89 wrist 98-9
knee 27 glenohumeral joint 54, 71 Paraesthesia in carpal tunnel syndrome 94
lower limb 27 hand 115, 129 Paratendinitis, Achilles tendon 262, 268
wrist 15 hip 175, 196, 204 Paronychia 116, 126
Myxoedema, hand 117 interphalangeal joints 115 Patella
knee 216, 244, 245, 247 apprehension test 240
N metatarsophalangeal (MP) joint 283 hipartire 244
Nails spine 142--3, 167 dislocation
conditions affecting 285--6 thumb 129 acute traumatic 214
of the great toe 285--6, 302 wrist 93, 107 congenital 214
infections 116,285,312 Osteochondritis habitual 214-15
ingrowing 285, 302 of the capitnlum 89 Iarera1 244
inspection 120, 292 metatarsal head 284 permanent 215
Narakas classification 19 navicular 281 recurrent lateral 214
Navicular, osteochondritis 281 talus 263 examination 239-40
Neck extension injuries 35--6, 47 Osteochondritis dissecans fracture 209
Neck pain ankle 272 instability 214-15
acute, in the young adult 34 elbow 78-9, 85, 89 mobility 240
postural 34 knee 215, 226, 245 Q angle 239
Neck-shaft angle 195, 196 Osteoclastoma Patella alta 242, 244
Neer impingement sign 65 shoulder 72 Patellar ligament
Neer impingement test 65 tibia 257 rupture 209
Neonatal instability of the hip (Nlll) Osteogenesis imperfecta 95, 100 tenderness 226
170 Osteogenic sarcoma 247 Patellar tap test 224
Neonates, hip radiography 193 Osteoid osteoma Parelloferooral instability 214-15
Neoplasia hand 115 Patrick's test 188
bone see Bone tumours hip 203 Pavlov ratio 45
cervical spine 37 Osteomalacia Paxinos sign 61
hand 115-16 hip 201 Pellegrini-Stieda disease 211, 242, 246
hip 176 senile kyphosis 139 Pelvic distortion 196
320 INDEX
Pelvic tilting 183 Pyogenic arthritis, hip 174 Rib angle assessment 164
Pelvis, triradiate 201 Pyogenic osteitis of the spine 141 Rib hump 150
Performing arts module, DASH questionnaire Rickets
59 Q knee 247
Peroneal nerve, common see Common Q aogie 239 tibia 252. 255, 256
Quadriceps wrist 108
peroneal """'"
Peroneal (spastic) flat foot 282, 295 inspection 222 Risser grading of skeletal maturity 163
Peroneal tendons, snapping 263 rupture 209 Risser jacket 137
Perthe's disease 173-4, 196--8 tendinitis210 Roos test 41
acetabulum 197, 203 wasting 209 Rotator cuff 51
Catterall grading 197 QuickDASH (Disabilities of the Arm, arthropathy 53
Defonnity Index 198 Shoalder, Elbow aod Haod) examination 65--6
Herring lateral pillar classification questionnaire 58-9 impingement syndrome 52
197 Quinti varus deformity 293 lean 52-3
presentation 173
prognosis 173 R s
nodiognq>hy 203, 204 Radial inclination 106 Sacroiliac joint
severity 173 Radial nerve 15, 76 examination 161
treatment 173-4 common sites affected 20 infective arthritis 166
Pes cavus 281, 287, 303, 306, 310 examination 20-1 testing 157
Pes planus see Flat foot motor distribution 19 Saggiog rope sign 204
Phalen test 103 posterior cord 19 Sarcoma, osteogenic 2A7
Phrenic nerve 13 sensory distribution 20 Scaphoid
Pilonidal sinus 116 Radiocarpal joint 102 avascular necrosis 107, 108
Pinch grip 127 Radiography fracture 108
Pivot shift test 235 additional 7 Scapholunate instability 96, 105, 108
Plaotar (digital) neuroma 284, 300 ankle 271-2 Scapola 50
Plantar fasciitis 285, 311 anterior cruciate function 233 high 56
Plantaris tendon rupture 25 1 cervical spine 42-5 shoulder abduction 51
Plantar wart 284, 294 club foot 289 snapping 56
Ponseti regime 279 elbow 84--6 winged 56
Popliteal artery 298 examination 6-7 Scapulothoracic joint 50
Positron emission tomography (PET) 8 foot 306--10 Scheuermann's disease 137-8, 158,
Posterior tibial artery 298 haod 128-9 165
Posterolateral drawer test 235--6 hip 193, 194-200 Schmorl's node 133, 138, 146, 159
Posture 2, 3 knee 241-2 Schober's methcx:l, spine flexion 152
foot 294-7 neurological assessment 18 Sciatic nerve 28
heel 277-8 posterior cruciate function 234 diagnosis 31
neck pain 34 prolapsed intervertebral disc 164 motor loss 31
Ptepa!ellar horsa 207 shoulder 68-70 sensory loss 31
Prepatellar bursitis 218 thoracic/lumbar spine 157--63 sites involved 31
Profundus tendon injuries 114, 125 tibia 255 Scoliosis 135-7
Prolapsed intervertebral disc (PID) 144--6, wrist 105--7 compeosatory 135
166, 168 Radi~s~ 54,56,61, 71 congenital 135--6
in adolescents 145 Radioulnar joint curves 162-3
diagnosis 145 congenital synostosis 87 definition 135
differential diagnosis 146 crepitns 102 deterioration 136
examination 153-4 distal, laxity 104 idiopathic 136, 151, 165
investigation 145, 164 inferior, disruption after Calles' fracture inspection 150-1
lumbar 145 92 investigation 136-7
neurological disturbance 145 Reiter's syndrome maoagemeot 135
"""""'144-5 hip 176 metabolic 136
sequestered 145 knee 217,218 myopathic 136
!eating 15~ Relocation test 66 neuropathic 136
thoracic 145 Retropatellar pain syndromes 215 non-structural 135
treatment 146 Retrospondylolisthesis 159 pam 137
Pronator teres entrapment syndrome 25 Reverse Lasegue test 155 paralytic 136
Prone test (Feagin and Cooke) 233 Rheumatoid arthritis postural 135
Protrusio acetabuli 204 ankle 263 primary curve 136
Provocative exercises, knee 219--20 cervical spine 36-7, 43, 47 prognos~ 136
Proximal phalangeal articular angle 310 elbow 79 sciatic 135
Pseudoadirrosis,tibda 252,255 foot 286, 312 secondary curve 136
Pseudogout 247 haod 114-15 structural 135-6, 136-7, 162
Psoas abscess 160 hip 175 treatment 137
Pulled elbow 78 knee 216, 220, 246 Scotty dog shadows 162
Pulp infections, finger 116, 126 shoalder 54 Screening tests
Pulses 298 spine 143 developmental dislocation of the hip
Pyarthrosis, knee 209, 225 wrist 94, 107 (DDH) 170-1
INDEX 321
tibia 254 recurrent dislocation 54-5 Splay foot 283, 295, 305
wrist 99, 100, 101 rheumatoid arthritis 54 Spondylolisthesis 142, 159, 161, 162, 166
Sedimentation rate 157 rotation 63-4 Spondylolysis 142
Semimembranous bursae 207-8, 217 rotator cuff see Rotator cuff Sports module, DASH questionnaire 59
Senile kyphosis 139, 158, 168 scapula see Scapula Sprengel's shoulder 37, 56, 60
Sensory conduction 18 trapezoid ligament 56, 72 Standing apprehension test 236
Sensory distributions tuberculosis 55, 72 Staphylococcus
common peroneal nerve 29 Silicone granuloma 282 hip arthritis 174
femoral nerve 29 Simian stance 149 osteitis 55
median nerve 2A Simian thumb 25 Sternoclavicular joint
radial nerve 20 Sinding-Larsen-Johansson syndrome 210, dislocation 57
tibial nerve (medial popliteal) 30 239 movements 39
ulnar nerve 21 Single-photon emission controlled Straight leg-raising test 154
Septic arthritis, elbow 87 romngnq>hy (SPECT) 8 sn.ss fracture, tibis 250-1, 256
Sesamoiditis 302 prolapsed intervertebral disc 164 Styloid process fracture 109
Sever's disease 281, 308, 310 Skeletal maturity assessment 163 Subacromial joint compression 52
Sharp point. disposable 9 Skew foot 280 Subdeltoid bursa 52
Shenton's line 195 SLAP lesion 56 Subluxation see Dislocation/subluxation
Shin splints 251 Slipped femoral epiphysis 174-5, 198 Subscapularis testing 63
Shoes 305--6 physeal separation 198 Subscapular nerves 14
Shoulder 49-73 radiognq>hy 203 Subtalar joint movements 276-7
abduction 51, 61-2, 64 Southwick's methiXI of quantifying Subungual exostosis 285, 302
adduction 63 the severity of 198 Sudrek's attophy
age distribution of common pathology 57 Snapping hip 176 ankle 272
anatomical features 50 Snapping peroneal tendons 263 foot 312
apprehension test 66 Snapping scapula 56 wrist 92, 98, 107, 109
aspiration 73 Soft corns 293 Sulcus sign 67
assessment 57-9 Sole inspection 294 Superficialis tendon injury 126
bone cyst 71 Southwick's methiXI 198 Superficial peroneal nerve compression
calcifying supraspinatus tendinitis 53-4 Spastic flat foot 282, 295 syndrome 301
and cervical spine examination 65 SPECT see Single-photon emission controlled Superior gluteal nerve 28
Charcot's disease 73 romngnq>hy (SPECT) Supracondylar fracture 85, 89
chondrosarcoma 72 Speed test 65, 67 Suprapatellar pouch 'llJ7
conoid ligament 56, 72 Spina bifida 14}-4 Suprascapular nerve 14, 67-8
crepitus 65 investigations 160 assessment 18
dislocation 71 Spina bifida occulta 143, 168 Supraspinatus
anterior 55 Spinal cord 14-15 calcifying tendinitis 53-4, 70
posterior 55 compression testing 65, 67
recurrent 54-5 cervical 41 Swan-neck deformity 118
and elbow function 57--8 thoracic 156 Synovial chondrom.atosis 246
elevation and depression 65 Spinal nerves 12 Synovitis
enchondroma 70 Spinal stenosis 143 knee 208
extension 63, 64 acquired 143 transient see Transient synovitis
ftexion 63 congenital 143 Syphilis 116
fracture 71 radiographs 162 Syringomyelia 43, 136
frozen 53, 63 Spina
function assessment 58--9 cervical see Cervical spine T
idiopathic adhesive capsulitis 53 curvature 135 (see also Kyphosis; Tabes dorsalis 251
impingement syndrome 52-3 Scoliosis) Talipes calcaneus 280
infections 55, 73 kissing 143, 159 Talipes equinovarus see Club foot
inspection 60 lipping 159 Talocalcaneal synostosis 309, 311
instabilities 54-5 lumbar see Lumbar spine Talus
joint laxity syndrome 55 metastatic lesions 141-2 anterior subluxation 260
loose 54--5 movements 132-3, 152-3 avascular necrosis 273
mechanical problems 73 extension 133, 153 medial displacement 260
movements 61-5 flexion 133, 152-3 osteochondritis 263
ossifying chondroma 70 lateral flexion 133, 153 posterior shift 260
osteoarthritis 54 rotation 153 see also Ankle
osteoclastom.a 72 osteoarthritis 142-3, 167 Tanner staging 163
osteophytes 69 percussion 151 Tape measure 9
pain 52 pyogenic osteitis 141 Tarsal tunnel syndrome 286, 301
during abduction 62 rheumatoid arthritis 143 Tarsometatarsal movements 277
idiopathic adhesive capsulitis 53 sedimentation rate estimation 157 Taylor-Pelmear scale 113
investigation 73 skeletal maturity assessment 163 Taylor's bunion 293
painful arc syndromes 73 thoracic see Thoracic spine Technetium bone scans 8
palpation 60--1 tuberculosis see Tuberculosis, spine Tenderness
pathology 52, 70--3 vertebrae see Vertebrae ankle 265
radiographs 68-70 see also Back pain; specific disorders femoral condyles 226
322 INDEX
foot 299--300, 301-2 Tihla 249--57 Tourniquet test 301

forefoot 299--300 anterior compartment syndrome Tnmsient synovitis 172
great toe 301-2 250-1 Trapezoid ligament 56, 72
heel 299 bone cyst 257 Trendelenburg lurch 191
joint examination 4 bone tumours 250 Trendelenburg's test 191
knee 225-6 common causes of pain 250 Trigger finger 114
knee ligaments 226 deformities 251-2 Trigger thumb 114
lower limb 254 bowing 251 Trirad.i.ate pelvis 201
patellar ligament 226 kyphosis 251 Trochlea 76
tibia 254 radiography 255 Tuberculosis
tibial tubercle 226 Ewing's tumour 257 ankle 263, 272
Tendinitis fracture 256 elbow 79, 89
Achilles tendon 262 inspection 252 hand 116
biceps tendon 57, 67 medial tibial syodrome 251 hlp 174
caicifymg SUpniSpinatus 5'!-4, 70 myositis ossificans 257 knee 209, 220, 246
quadriceps 210 oedema 253 should..- 55, 72
Tendinosis 262, 268 osteitis 250, 256, 257 spine 140--1
Tendo calcaneus see Achilles tendon osteoclastoma 257 extrinsic causes 140
Tendon hammer 9 Paget's disease 255, 256 featuresl40
Tendon sheath infections, hand 116 pathology 256--7 intrinsic causes 140
Tennis elbow 77 posterior instability 233-4 investigation 140
symptoms 77 pseudoarthrosis 252, 255 onset 140
tests 83-4 radiography 255 radiographs 159, 160, 164, 166
treatment77 rickets 252, 255, 256 symptoms 140
Tenosynovitis screening tests 2S4 treatment 140--1
abductor pollicis longus 93 sbspe 253 wrist 95--6, 107, 109
ankle 262-3, 269--70 shin splints 251 Tumours see Neoplasia; specific tunwurs
de Quervain's 93, 98, 102 stress fracture 250--1, 256 Turner's syndrome 117
extensor 93 subluxations 235
extensor pollicis brevis 93 swelling 253 u
Thenar space infections, hand 116, tabes dorsalis 251 Ulna 76
127 tenderness 254 promineoce 92
Thessaly tests 238 thickening 253 Ulnar nerve 14, 76
Thomas's test 187 torsion 251, 253-4 common sites affected 21
Thomsen's test 84 Tibial condyles examination 22-4
Thomson test 269 lateral 241 motor distribution 21
Thoracic motor root dysfunction 156 medial 241 sensory distribution 21
Thoracic outlet syndrome 35, 40-1 subluxation& 212-13, 235 tardy palsy 78
Thoracic spine 131--68 Tihlal nerve (medial popliteal) tests 84
anatomical featmes 132-3 common sites of involvement 30 ulnar neuritis 78
(axial) rotation 133 diagnosis 31 Ulnar tunnel syndrome 21, 78, 95
convexity 138 motor distribution 30 tests 104
cord compression 156 proximal lesions 31 IDttasound imaging 8
inspection 149-51 sensory distribution 30 Uncovertebral joints, lipping 44
kyphosis 137 Tibial tubercle tenderness 226 Upper limb
movements 133 Tibial tuberosity avulsion 209 function assessment 58-9
palpation 151 Tibia vara 247 peripheral nerve examination 19-27
pathology 165-8 Tinel's sign 18, 103
prolapsed intervertebml disc (PID) Toe(s) 279 v
145 claw 285, 293 Valgus stress instability 229--31
radiographs 157-63 corns 293 Van Rosen method 193
Scheuermann's disease 137-8 curly 285, 293 Varus st:ress instability 231-2
see also Back pain; specific conditions great Verruca pedis (plantar wart) 284, 294
Thoracodorsal nerve 15 inspection 291-2 Vertebrae 132
Thrombophlebitis 251 movements 304 cervical spine 42-3
Thumb nails of the 285--6, 292, 302 displacement 42
abduction 124 pain in 287 fracnJre 165
carpometacarpaljointofthe 115, tenderness 301-2 lateral wedging 44
129 hammer 285, 293 lipping 159
crepitus 124 ingrowing nails 285, 302 movements 132-3
gamekeeper's 123, 129 inspection 292-3 Vertebral artery 35
mallet 113, 117 mallet 285,293 Vertebral bodies 36, 41
movements 123-4 movements 304 erosion 43
opposition 124 nails 285-6 infection 38
osteoarthritis 129 osteitis 312 size 43, 45
trigger 114 overlapping 293 Vibration syndromes
Z-deformity 118 posture 295 bone involvement 112
Thumb to side of index grip 127 Torticollis 38 classification 113
INDEX 323
hand 112-13 carpal instabilities 96, 105 osteoarthritis 93, 107

peripheral blood vessels involvement 112 carpal tunnel syndrome see Carpal tunnel osteogenesis imperfecta 100
peripheral nerve involvement 112 syndrome pain 98
testing 125 Calles' fracture see Colles' fracture palmarllexion 100
Volkmann's ischaemic contracture 119 congenital deformity 107 palpation 98--9
crepitus 102 pathology 107-10
w de Quervain's disease 93, 98, pronation/supination 101
Waiter's tip deformity 17 102 radial deviation 101
Web space infections, hand 116, 127 dorsiflexion 99--100 radiographs 105--7
Whiplash injuries 35--6 Ehlers-Danlos syndrome 95, rheumatoid arthritis 94, 107
causes 36 100 rickets 108
partial 36 extensor tenosynovitis 93 swelling 97, 98
symptoms 36 ganglions 92-3,98 tuberculosis 95--6, 107, 109
Wilson's test 226 hypennobility I 00 ulnar deviation 101
Wmged scapula 56 inspection 97-8 ulnar tunnel syndrome see Ulnar tunnel
WOMAC (Western Ontario and McMaster Kienbock's disease 93, 108 syndrome
Universities Osteoarthritis) Index Madelung's deformity 108
17S-9 movements 99-101 X
Work module, DASH questionnaire 59 muscle wasting 97 X-rays see Radiography
Wrist 91-110 myotomes 15
achondroplasia 107 ossification 107 z
aspiration 110 osteitis 109 Z-deformity of the thumb 118

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With original drawings by the author

C Longman Group Limited 1976, 1983

British IJbrary Catalosuin1 in Pnblicatioa Datil

Library of ColqreA Catalolin1in PnblicatiOD Datil

yaur sourmfor books,

1. General principles in the examination of a patient with an orthopaedic

2. Segmental and peripheral nerves of the limbs 11

3. The cervical spine 33

7. The hand 111

8. The thoracic and lumbar spine 131

9. The hip 169

10. The knee 205

11. The tibia 249

12. The ankle 259

13. The foot 275

In practice, the primary area of interest of the orthopaedic surgeon is in the

In many joints it is also mandatory to look for evidcnc:e of movemenu in

STEP 4: CONDUCTION OF SPECIAL TESTS

STEP 5: EXAMINATION OF RADIOGRAPHS

STEP 6: ARRANGING FURTHER INVESTIGATIONS

2. Pull blood count with differential

ADDITIONAL IMAGING TECHNIQUES

FUNCTIONAL IMAGING TECHNIQUES

The brachial plexus: cervical part 12

sympathetic ~ <> o <>

THE BRACHIAL PLEXUS: CERVICAL PART

MEDIAL CUTANEOUS OF FOREARM

~:=:::;;;;;:;:;;:;:;;:============~====::::J MEDIAL CUTANEOUS OF ARM

CORDS PERIPHERAL NERVES

BRANCHES FROM THE NERVE ROOTS

BRANCHES FROM THE TRUNKS

THE BRACHIAL PLEXUS: AXILLARY PART

3. The thoracodorsal nerve (C6, 7, 8), which supplies latissimus dorsi

' ....... ~ ...

2.7t. O.riMIG-: R.emmnber by !be

2.80. Pertpher•l...,... of the ...., limb:

Postural neck pain 34

Rheumatoid arthritis In the cervical

POSTURAL NECK PAIN

ACUTE NECK PAIN IN THE YOUNG ADULT

CERVICAL SPONDYLOSIS (CERVICAL OST!OARTHROSIS:

In cervical spondylosis the cervical canal may be narrowed by

THORAOC OUTLET SYNDROME

WHIPLASH AND EXTENSION INJURIES OF THE NECK

Whiplash i:Djurics a:re now a common cause of persistent cervical symptoms.

a stationary or slowly moving vehicle strikes another vehicle or object in

RHEUMATOID ARTHRITIS IN THE CERVICAL SPINE

NEOPLASMS IN THE CERVICAL REGION

OSTEITIS OF THE CERVICAL SPINE

J.D. Cord COMpi'MSion Mel CIII'VIal

3.25. c.rvtcal ~hr (1): 3.26. C.I'YICIII ,.,..o~Ntthr 14): My.lopalliy

3.31. Radlogn1phs (12): In the

.3.44. bdlog,..hs (18): Sup.cted cuviall

3.50. PldhoiOD (6): 'lberc: iJ widespread

COMMON PATHOLOGY AROUND THE SHOULDER

ROTATOR CUFF ARTHROPATHY

'Frozen shouldc::r' is a cliDical syndrome characterised by gross restriction

CALCIFYING SUPRASPINATUS TENDINITIS

Degenerative cbanges in tbe shouldec cuff may be accompanied by the local

bursa. Sudden, severe incapacitating pain results; the shoulder becomes

OSTEOARTHRITIS OF THE ACROMIOCLAVICULAR JOINT

OSTEOARTHRITIS OF THE GLENOHUMERAL JOINT