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Essay 1

The document discusses various bone diseases and injuries including osteosarcoma, osteomyelitis, fractures, and tendon injuries. It describes symptoms, examination findings, investigation methods like x-rays, and characteristics of different conditions. The summary focuses on key points like symptoms of pain, examination of affected areas, and using x-rays and other tests to determine the specific condition.

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0% found this document useful (0 votes)
33 views25 pages

Essay 1

The document discusses various bone diseases and injuries including osteosarcoma, osteomyelitis, fractures, and tendon injuries. It describes symptoms, examination findings, investigation methods like x-rays, and characteristics of different conditions. The summary focuses on key points like symptoms of pain, examination of affected areas, and using x-rays and other tests to determine the specific condition.

Uploaded by

Nora Fazira
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Flg.11.18.

- Osteosarcoma affecting the lower

radiological ground alone. The only exception to this can be in

appearance of coagulation when the urine is heated to 55° C,

The articular brnnch - supplies the elbow joint.

Fig. 11.17 .- Osteochondroma.

between 20 and 30 years of age. Primary malignant

the feature except in carcinoma of the prostate where

7. Neighbouring Structures.- While examining a case of bony lesion one must examine

site or by the cubitus valgus deformity as a sequel of malunion. (ii) In fracture of the medial

complaint an d the signs arc similar to the ruph1re of the biceps tendon described above.

osteomyelitis also presents with sinuses. The tuberculous sinus

tumour vary characteristically in all malignant tumours. The vessels become aimless, tortuous

will reveal its characteristic features like undermined edge and

front of the Flexor retinaculum on the lateral side of the pisiform bone and on the medial side

patellar tendinitis, Achilles' tendinitis and plantar fasciitis. Similarly, localized tenderness on

may be seen in case of a tumour of the upper end of the

supplying the raised periosteum. As the tumour spreads into

numerous plasma cells.

determine the causative organism and the most effective antibiotic

concerned, it cannot be tested as this joint is also flexed by the continued action of the Flexor

In this chapter the non-specific diseases such as non-articular rheu matism, pathological

to be a small tear in the attachment of plantar fascia to the os calcis. on-specific in fection from

fracture.

eccentric translucent ga p and at its edges a

multiple myeloma which reveals presen ce of

has originated. The fol lowing points should be noted with details.

The muscles which are involved in ulnar nerve injury anywhere above the wrist are muscles

In chondromn, whether enchondroma or ecchondroma, X-ray shows an osteolytic lesion with

suppuration and abscess forma tion.

DISEASES OF MUSCLES, TENDON AND FASCIAE 143

continued effort he suddenly becomes successful in forcing the swollen tendon through the
of the same name upto the middle of the arm. Here it pierces the medial intermuscular septum

to deviate towards the radial side.

1. In tuberculous osteomyeUtis general examination must be made to exclude pulmonary

joinls along with the lumbricals. Besides these, the dorsal interossei abduct the fingers and the

metastatic bone tu mour. So the scan reflects the metabolic process and a change in mineralisation.

8. Histopathological examination of the tumour, either from

The muscles a re tested as follows :-

pe rforated. A sma ll wedge-shaped area of

F. Cyst.- (i) Solitary cyst; (ii) Cyst associated with generalized osteitis fibrosa; (ijj) Hydatid

fig.11.11.- Exostosis at the

There may be new bone formation which extends outward.

relation with the bony lesion. These arc commonly seen in chronic pyogenic osteomyelitis and

the palmar digital nerves the medial side of the little finger and the adjacent sides of the ring

I Pain. This is the most important complaint in the above conditions. Pain a t the elbow,

injured in fra cture neck of fibula. This nerve supplies the

whereas that of the other bones will reveal generalized involvement of the bones.

and there is flexion deformity of the ring and the little fingers.

HISTORY.-

interossei. (iii) The patient is asked to adduct his fingers keeping straight. A card may be inserte

spic ule type. The cortex is almost a lways

of the ulnar artery and ends by dividing into superficial and deep terminal branches.

"painful arc syndrome". That means when the patient abd ucts his arm, the first 60° is painless.

be pu lsatile e.g. Telangiectatic osteosarcoma, aneurysmal bone cyst, occasionally highly vascular

or lengthened. Shortening will be found when the

must note the character of the pain - whether it is throbbing (characteristic of inflammation) or

zone of hyperaemia. (ii) Circumference of the limb is

disease has affected the kidneys in long continued suppuration

Achondroplasia; (ii) Osteogenesis imperfecta (Brittle

now found to be absolutely theoretical. To give clear decision

Thus positive bone scan is seen before X-ray changes. Only ven; anaplastic tumours and quiescent,

then crosses the hand and supplies branches to tl1e interossei and to the third and tl1e fourth
cases of syphilitic osteitis.

Acute osteomyelitis is common in child ren.

only difference is that the cause is not only thickening of the flexor retinaculum but also some

Paget's disease (osteitis deformans).

MEASUREMENTS.- (i) Length of the l.ong bone.- In osteomyelitis the bone may be shortened

fibula.

signs along the distribution of the median nerve. Flexion movement of the fingers will be painful

probably due to extreme pain and tenderness, is an inflammatory swelling. Peduncula ted

ossification (Codman's triangle) is seen at the spot where the

osphates complex. The patient must empty his bladder before the pelvis is scanned as about

detect a far greater number of counts leading to much better s ta tis tical quality than the whole

the flexor muscles of the forearm take origin. Patient complains of pain when asked to flex the

equinovarus deformity. The sensory loss will affect the anterior

destroyed before a lesion will be seen radiologically. Tomograms

attachment of the extensor muscles of the forearm to the lateral epicondyle or the flexor muscles

cartilage of the femur. Deformed joints are also encow1lered in diaphyseal aclasis.

C. Developmental disorders.- (i)

tendon becomes compressed between the two bones. This condition is popula rly known as

lesion, biopsy is very essential. It gives a clear picture of the

become flexed. This is due to the fact

3. Pain. Pa in is always associated with inflammation. But in bone the peculiar feature

Dupuytren's contracture.- This condition mainly affects the palm and very occasionally

tuberculosis and lymphadenitis. Enquiry must be made whether the patient had cough, evening

DISEASES OF BONE

particularly during walking when the weight of the body is carried by the heel. The cause seems

examination a bulge is detected on the said tendons over the radial styloid process. Pain is felt

i.e. tubercu lous osteomyelilis.

PERCUSSION.- Localized tenderness of chronic osteomyelitis, Brodie's abscess etc. may

breast prostate, kidney, uterus, gastrointestinal tract, testis etc.; or by (ii) direct infiltration

Rupture of the Achilles' tendon. This is due to vascular insufficiency of the tendon and

radiologically. Degenerative process may proceed further as to cause spontaneous mpture of tl1e
phosphatase serves to distinguish p rostatic metastasis in bone

The deep terminal branch - passes between the Abductor digiti minimi and Flexor digi ti

ea r, a ir sinuses, etc.

swellings are generally exostoses. Spherical, ovoid and irregular swellings are generally hrmours

calcaneum. True cystic areas can be seen in the pelvis or long bones.

subcutaneous tissue indicating

Ulnar nerve injury will cause loss of sensation of the medial side of ilie hand, the whole of

widespread diffuse rarefaction with subperiosteal deposition of

sole. So injury to this nerve will make the patient unable to

or dislocation of luna te bone which compresses on the contents of this osseo-fibrous canal, mainly

D. Nutritional, metabolic and endocrinal disorders.- (i) Rickets; (ii) Osteomalacia; (iii)

Carpal tunnel syndrome.- This condition is also an example of stenosing tenovaginitis. TI1e

,. ,, e Ii w In stenosing tenovagin..itis as seen in de Quervain's disease or trigger finger,

(c) Malignant.- PrimanJ - (i) Osteosarcoma; (ii) Chondrosarcoma; (iii) Ewing's tumour;

bluish margin, whereas in chronic pyogenic osteomyelitis Ulere

change. Marrow biopsy should be performed in case of

bone (cf. osteoclastoma).

e.g. the soleus, the gastrocnemius, the popliteus, the plantaris,

Fig.11.6.- Diaphyseal (metaphyseal)

commenced.

patient mus t be asked if there is any other bony swelling in his body or nol.

osteogenesis imperfecta congenita, achondroplasia, diaphysiaJ aclasis,

formation. The tumour has an ill-defined junction with the rest of the shaft. Three types are

in vestigation, which clinches the final diagnosis. X-ray Ag.ll.10.- 05teoma at the lower

a simple tenosynovitis or a stenosing tenosynovitis. Tn de Quervain's disease the patient complains

the forearm between the two heads of the Flexor carpi ulnaris and descends along lhe medial

and can only be forced down through the constricted sheath by the powerful flexor muscle but

In Paget 's disease the bone as a whole is thick and bent; its density in the vascular s tage is

An osteonrn is seen as a pedunculated bony outgrowth from the melaphysis. The growth of

(i.e. of reduced density) as is often seen in tuberculous affection or is sclerosed (i.e. of increas

feature in acute osteomyelitis. Sometimes acute osteomyelitis may destruct the epiphyseal cartilage
148 A MANUAL ON CLINICAL SURGERY

minimi and then perforates the Opponens digiti minimi and supplies all these three muscles. It

dig itorum superficialis and profw1dus. (i) These muscles can be tes ted for Lheir power of extensio

(A) Affected Booe. In the first instance it must be noticed whether the bone is rarefied

There may be even disappearance of the terminal outline with only longitudinal trabeculae

' foot drop' due to paralysis of the external pophteal nerve

Locally there will be swelJing, extreme tenderness, local erythema, limitation of joint

40% of the injected dose is excreted in the urine within firs t 4 hrs. after injection.

downwards through the axilla on the medial side of the axillary artery, between it and the vein

osteomyelitis.

determining the

of skeletal carcinomatosis, leukaemia and rarely in nephritis.

Myositis ossificans; (iv) Subperiosteal haematoma and

with a few spicules projecting from its surface in the metaphysis. (ii) Osteolytic type shows an

Fig.10.1.- A ganglion on the dorsal aspect of the wrist in

visible on X-ray could be detected by radio-isotope scanning.

and Lateral aspect of the leg, dorsum of the foot and the toes.

breaks. Osteogenesis imperfecta (Brittle bones)

osteomyelilis.

form a swelling. ln carpal tunnel syndrome a careful palpation will yield thickening of the flexor

when he flexes his elbow d ue to bunching of the biceps muscle.

in acute osteomyelitis.

ln Rickel, X-ray will show general decakiiication. The epiphysis is widened with delay in

sometimes Pa lmaris brevis.

commonly seen - (i) Sclerotic type, usually found at puberty, shows dense new irregular bone

involves the persons who do not inflict

simullaneously in all primary malignant tumours, but one or the oth er cha nge will be obvious.

the lesion. Depressed, puckered scar indicates previou

Liposarcoma; (ix) Angiosarcoma.

A. INSPECTION.- D ormtt~ In Dupuytren's contractu re inspection is all that is

DIAPHYSIS :
middle phalanges.

the humerus where the extensor group of muscles of the foream1 is attached. The pain is

-1. Bon) irregularity.- A careful palpation of the affected bone is very essential. 1n chronic

On examination, a tense and cystic swelling will be revealed in relation to a capsule of the joint

which has probably drawn the attention of the patient

in diagnosing multiple myeloma in which munerous plasma cells

at the limb distal to the swelling. There may be oedema due to Fig.11.3.-Shows dilated
subcutapressu

which muscle has been involved in rupture. As ganglion is a tense cystic swelling, fluctuation

Rupture of tbc long heud of the bicep hrnchli. This condition also affects elderly individual

ou t.

head of the humerus comes very close to the acromion process and the degenera ted supraspinatus

remaining.

Acute osteomyelitis.- The patients are usually children and the bones are affected mainly

decreased and in the sclerotic stage increased. The trabeculae are coarse an d widely separated.

the little finger and a small part on the medial side of the ring finger.

attachment of the tendon is diagnostic of any type of tendinitis e.g. supraspinatus tendinitis,

in the world can have the privilege to get pathologists of tha t

rupture of the tendons e.g. long head of the biceps, Achilles' tendon etc. In the first two conditio

cases the patients may give a his tory of trauma,

Fig.11.12.- Multiple exostoses are seen

EXAMINATION OF DISEASES OF BONE 151

osteomyelitis. (b) ln multiple myeloma the serum calcium level will be raised. There will be

Brodie's abscess

Fibroma; (ix) Chondromyxoid fibroma; (x) Haemangioma; (xi) Lipoma; (xii) Neurofibroma.

transversely whereas a bone cyst expands along the long axis of the bone.

plantar flexion of the ankle, more so when the patient tries to stand on his toes.

if the thumb is adducted across the palm.

that the extensions of the palmar fascia

nerve should always be performed wherever there is possibility of the ulnar nerve involvement.

the tibia.Lis posterior, the flexor digitorum longus and the flexor
X-ray by an osteolytic lesion affecting the

154 A MANUAL ON CLJNJCAL SURGERY

with a fist.

150 A MANUAL ON CLINICAL SURGERY

the osteoma continues so long Lhe bone grows in length.

(vi) Syphilitic osteit.i s; (vii) Pneumococcal

various types of bone diseases.

will be sprouting granulation tissue which indicates presence

affecting the shaft of the

of the wrist or the palm of the hand.

Multipl.: myeloma

Osteosarcoma occurs between 15 and 30 years of age;

skin over the swelling remains tense, glossy with dilated veins.

Tennis elbow.- In this condition the patient complains of pain on the lateral epicondyle of

in the middle of the arc is the regular feature of supraspinatus tendinitis. Pain on the liga.mentum

there is always the soft tissue shadows in the skiagram d ue to

Fig.4.15). One must try to elicit the history of syphilitic contact.

ganglia wiU be discussed. These conditions affect more or less whole of the body.

and engorged. Sometimes they end abruptly or terminate in pools of contrast which empty

Achilles' tendinitis pain is felt on the attachment of the Achilles' tendon and it is aggravated by

EXAMINATION OF DlSEASF.5 OF BONE

body scanner in a similar time. The great potential value of bone scanning lies in ils ability to

epiphysis and may involve the joint. Osteosarcoma, whid1

6. Shortening or lengthening of the bone - may sometimes be seen following infection of

comparison to the benign bony swellings.

upper end of the humerus.

8. Family history.- A few bony disorders run in families e.g.

mud1 more often than the plantar fascia, is a cha racteristic feature. Contracture of the fascia

patients, epileptics who are having

Sprouting granulation

7. Past history.- A past history of otitis media, pneumonia,


of ilie bone.

imperfecta tarda presents later near 10 years of age.

from decreased blood

5. In secondary carcinoma a thorough examination must be made to exclude primary

Examination o f the neighbouring joints.- The

it may penetrate the articular cartilage. Pathologica l fractures may occur. This tumour expands

EXAMINATION or PERlf>J IFRAL NERVE U'ilQ'-.;S 141

edge is the feature of new growth. As osteosarcoma is a very rapidly growing tumour it loses

cyst; (iv) Aneurysmal bone cyst.

valgurn or genu varum may be the result of asymmetrical destruction of the lower epiphyseal

will find its way out through a sinus and may lead to chronic osteomyelitis.

bone may be irregular. This irregularity will also be present in Brodie's abscess.

contains irregular flecking and the mottling of calcified tissue.

to the bone. The condition is sometimes attributed to the unaccustomed prolonged walking or

trauma so repeatedly in the palm. Its

A. Traumatic.- (i) Excess of callus formation

retinacu lum and will reveal the neurological deficits of the median nerve due to this condition.

sequestrum inside the

144 A MANUAL ON CLINICAL SURGERY

demarcation between the tumour and the W1affected shaft in contradistinction to the sarcomas.

or a tendon sheath. When it originates from a tendon sheath it can be moved sideways slightly but

5. Muscular wasting. This becomes prominent and obv ious in probably one bony lesion

not clearly known. Repeated trauma

relation with the extensor tendon of the finger.

plantar flex his ankle with loss of sensa tion of the whole of the

necessary for the diagnosis. Localized thickening of the fascia, which affects the pal.mar fascia

2. URINE.- (a) Albumin may be present when amyloid

its disappearance by further heat to 80°C and its reappearance

are more sensitive. Osteolysis without formation of new bone is

the adjacent sides of the ring and the little fingers and occasionally the adjoining sides of the

EXAMINATION OF
medial half of the Flexor digitorum profundus.

X-ray is not re liable for early detection of secondary

The muscular branches are two in number which supply the Flexor carpi ulnaris and the

detect ea rly active lesion s in bone before they are visible on X-ray. It might possibly be of valu

osteomyelitis. In chronic osteomyelitis the onset is usually insidious, but acute exacerbation of

involucrum calcium

abduction between his body and the arm initiated by gravity. After this he can continue the

the cause of this condition has been

causes fl exion of the fingers or toes. Most commonly this disease affects the ring finger first and

cavity. Similar cavity is

already clearly visible on X-ray when the patient is first seen. But it is probably more valuable

some external rim. The cavity is traversed by bony trabeculae giving mosaic or soap-bubble

is of great value in

3. X-RAY EXAMINATION.- It goes without saying that

flg.11.13.- A huge osteochondroma.

again on cooling. But this appears in only 50% of multiple

are attached to the proximal as well as

2 Ocfor,, it\. It is the first complaint in conditions like Dupuytren's contracture, ganglia,

unrivalled in surgically difficult regions such as spine (where

typical sinus following

to exclude lymph node enlargement.

mostly the common sheath of the abductor pollicis longus and extensor pollicis brevis (de

(b) Locally malignant.- Osteoclastoma (Giant cell tumour).

1. BLOOD.- (a) Leucocytosis is the feature of bony inflammation, particularly acute

pain subsides as the shoulder is further abducted. The second complaint of the patient is stiffness

that there is practically

which was previously incriminated as

(i) Situation.- A swelling arising from the epiphysis is probably an osteoclastoma. Acute

6. BIOPSY.- To know the exact pathology of the bony

the patient complains of pain and difficul ty in abducting and extending the thumb. On

X-ray features of osteocla.stoma are characteristic. The metaphysio-epiphyseal areas are seen
(iv) Osteoid osteoma; (v) Chondroma; (vi) Chondroblastoma; (vii) Periosteal fibroma; (viii)

sole. As it supplies the plantar muscles through the plantar Fig.9 _31.- A typical example of

wrist against resistance is seen in Golfer's elbow. Pain during abduction of the shoulder particular

osteomyelitis, Brodie's abscess, tuberculous osteomyelitis, bone cyst, osteoma and osteosarcoma

give opinion on small cores of tissues. Marrow biopsy is helpful

it lies behind the medial epicondyle accompanied by the superior ulnar collateral artery. Tt enters

dense sequestrum and

this examination is probably the most important special

expansion occurs along the long axis of the

I. Age. Solitary cyst of a bone is seen in children upto the age of puberty and after tha t

High pyrexia, intense toxaemia with high pulse ra te and leucocytosis are the general signs

A MANUAL ON CLINICAL SURGERY

As has already been discussed the common peroneal part of the sciatic nerve is more often

simila r swelling anywherelse in the body. In d iaphyseal aclasis there

tendon.

changes. Conversely some benign osteoclastomas can show these fea tures. Bu t there are two

Flg.11.1.- Showing the characteristic sites of

as in osteomyelit.is. (b) Presence of Bence Jones p rotein (a

The branches of the ulnar nerve are :-

EXAMINATION OF DISEASES OF BONE 157

movement and effusion of the nearest joint (10% of cases). Later on, subperiosteal pus may find

Examination of the lymph nodes .- See Chapter 8.

sign is inabilihJ to initiate abduction. So the patient leans to the affected side making an angle o

of rupture of the tendon or the muscle concerned. A little thickening of the flexor sheath of the

osteosclerosis is observed. This is due to high level of alkaline

suggests pyogenic osteomyelitis.

The expanding osteolytic lesion can continue to destroy the cortex, although usually it leaves

in the beginning and later on sinus formation. Chronic pyogenic

the nerves and the blood vessels. These structures may be involved by the lesion.

sun-ray spicules due to calcification a long the blood vessels

bone tumours mainly occur in young people;


wrist and fingers against resistance.

SPECIAL INVESTIGATIONS

with pathological fracture. In fact sometimes this fracture becomes lhc first presenting symptom

foot and toes except the s kin between the great and the 2nd toe

Lhe outer covering is thick, it is also bony hard in cons istency. in osteosarcoma ilie consistency

Ewing's t11mo11r g rows from the d iaphysis. There is

(about 25 cm diameter). Using a gamma camera and taking multiple overlapping views, it can

numbness or incoordination or weakness of the muscles innerva ted by median nerve. On

of injury to this nerve is more in this region.

ue to involvement of the nerves by the bony swellings. sarcoma.

lumbricals. It ends by supplying the two heads of the adductor pollicis.

swelling its consistency should also be bony hard, but Lhe condition is so painful and tender

(B) X-ray e, amination of the other bones should be taken in generalized affections of bones.

of hyperparathyroidism, metastatic bone tumours, multiple

Fig, 11. 9 .- Bone cyst. Note that the

is relatively short since the patient had discovered the swelling.

the ulnar artery and supplies the ulnar artery, the skin of the medial aspect of the palm and

of the radio-isotope in a reas of bone with h igh mineral turnover and reflects the metabolic state

globulin) can be demonstrated in the urine of the patient by

its ossification.

and conduction sh1dies on the median nerve will demonstrate a delay at the carpal tunnel.

bone longitudinally - the so-called 'onion effect'.

right side due to involvement of the lateral popliteal nerve by an osteoma at the head of the fibula

6. Presence of fracture. ot infrequently patients with metastatic carcinoma present

towards a s mall swelling which was so long

The gamma camera detects, records and displays the activity within its total field of view

by friction or by involvement of the nerve in callus formation. Anterior transposition of the ulnar

Scanning is performed 1-4 hours after the intravenous injection of 5-10 mci of 99 Ternph

E. Malformation syndromes.- (i) ail-Patella syndrome; (ii) Marfan's syndromes; (iii)

will be multiple swellings ari ing from the metaphyses of different bones

Secondary Carcinoma of bone by (i) primary carcinomas metastasis from thyroid, bronchus,
myeloma cases. Bence Jones protein may also be found in cases

be seen surrounded by

biopsy or from curettage as done in osteoclastoma and bone cyst,

in diaphyseal aclasis.

Tuberculosis

SWELLINGS

Osteoid osteomn is seen as a radiolucent nidus with a surrounding zone of bony sclerosis.

5. RADIOACTIVE SCANNING.- This method depends upon the relatively high uptake

(viii) Cleido-cranial dysostosis; (ix) Fibrous dysplasia.

supply, wh ereas in

DIFFERENTIAL DIAGNOSIS

grade. There is hardly any place of prophylactic small dose

it becomes increasingly rare. Monostotic fibrous dysplasia, though rare, is chiefly a d isease of

carcinoma in the bones. At least 50% of medulla must be

pressure on the neighbouring veins. erves may also be

dense or sclerosed bone.

extent of dissection rather than diagnosis. Diagnosis is easy in these cases.

few primary malignant conditions of bone. (2) Toxic features with fever and malaise are noticed

affecting a young boy.

of the leg and sole and through plantar nerves it supplies the

of the erector spinae muscle or the fascia covering it.

TENDONS AND FASCIAE

bone and cannot be moved. Assessment must be made from which part of the bone the swelling

156

2. In syphilitic osteitis, one should look for other syphilitic stigmas in the body (See

Chronic osteomyelitis; (iii) Brodie's abscess; (iv)

spicule type.

fracture Lhe ulnar nerve should be transposed anteriorly to prevent further damage lo the nerve

Ags.11.4 & 11.5.- The patient is asked to dorsiflex both ankle joints. Note the foot drop on the

is the pnin in the shoulder particula rly felt du.ring abduction and external rotation movements.

arm, but it is often neglected. More commonly Lhe patient compla ins of an abnormal swelling
from other skeletal metastasis. (f) Reduced serum pho phorus

Medial popliteal nerve.- This nerve is rarely injured except

Ganglion.- This is a tense and cystic swelling containing gelatinous material in it. This mostly

Common peroneal nerve.- This nerve itself is liable to be

flo,11.19.- Ewing's tumour

the neighbouring stn.ictures, i.e. the muscles - their power and mobility over the bony lesion,

sodium hydantoin and Peyronie's disease add more to its intricacy.

the diagnosis of bone diseases, is practically valueless in the detection of early stage o

the bone.

is due to decreased

hallucis longus. Through sural nerve it supplies the lateral part

particularly wh.ile extending the wrist and finger , is come across in "Tennis elbow". Similarly

pyogenic osteomyelitis, syphilitic osteomyelitis and even tuberculous osteomyelitis the affected

affecting the femur.

8. PALPATION.- 1 Tendcrne,~. Localized tenderness on the particular point of the

varies - somewhere bony hard, somewhere firm and may be even soft at places. This is a

mixture of osteoporosis, cystic changes and coarsening of the trabecular pattern. Cysts may extend

4. Neie hbouring joints. Sympathetic effusion of the neighbouring joints is a common

of sudden pain in the shoulder while involved in normal activities. The most important physical

chronic osteomyelitis is not uncommon. Malignant tumours grow venJ rapidly and the history

1. Local Temperature. This is best palpated by the back of the fingers and local

valgus i.e. outward deviation of Lhe hand due to the destruction of lower epiphysis of the radius

no p lace of X-ray

abscess.

by sensitivity test. Blood culture may be of use when septicaemia

are diseases of the diaphysis.

Supraspinatus tendinitis.- Degenerative process of the supraspinatus tendon following

10

of the middle and the terminal phalanges. This is tesled by holding the proxin1aJ phalanx and

Fig.11.20.- Secondary carcinoma

Ewing's tumour
the fractured segments or in late cases (Tardy ulnar palsy) by the callus formed at the fractured

not at all along the length of the tendon particularly when the tendon is made taut.

palpation of the swelling of the shea th of the tendon is important. Gradually as consequence of

ln rupture of the tendon and muscles while the muscles concerned are contracting against

and deformities since birth; whereas osteogenesis

which is supplied by its deep peroneal (anterior tibial) nerve.

in clinical p ractice in the early detection of primary osteosarcoma, although usually they are

147

aged and old people and males are predominantly sufferer than the females. The main complaint

differentiation between simple and path ological fracture, to find out the site suitable for biopsy

phosphatase suggests osteoblastic activity as occurs in osteitis

(ii) Size and shnpe.- A swelling, which is d iffuse and very difficult to get al Lhe ma rgins

EXAMINATION

The dorsal branch - supplies the medial side of the little finger and the posterior aspect of

This gives honey-comb appearance. Striated appearance is seen in the pelvis, sacrum and

PALPATION -

from fractured bone; (ii) Ma lunited fracture; (iii)

discarded due to the fact that it often

periosteum is elevated from the shaft. The periosteum may show

Pain becomes very much aggravated during the middle third of the abduction arc when the

(iv) Multiple myeloma; (v) Reticulum cell sarcoma; (vi) Plasmacytoma; (vii) Fibrosarcoma; (viii)

DISEASES OF MUSCLES, TENDONS AND FASCIA£ 145

the normal bone is seen. (iii) The radiating

in detecting bone secondaries to know the spread of the disease, suitability of radical operation,

s lowly. Early venous filling is also seen. But the most important feature is the presence of 'Contr

deformans and some sarcomas. (e) Higher level of senun acid

end of lhe femur with typical sun-ray appearance.

increased vascu la rity of the tumour.

epiphyseal cartilage is destroyed and the bone may be

in the metaphyseal region. Generally the children of the first decade are involved by this disease

commonly start in the metaphysis. Ewing's tumour, multiple myeloma and syphilitic osteomyelitis
demarcated outline.

(1) Anaemia, cachexia and malnutrition are come across in secondary carcinomas and a

X-ray appearance of o.steosarcoma shows a combination of bone destruction and bone

distinct p laces where its value is undeba table - (i) to define the extent of the tumour and (ii)

cases and diagnosis must

test may not be performed, but the swelling is softest at its centre.

median nerve. As this nerve is more superficially placed than the median nerve the possibility

disease and the cellular pattern. It is essential in aU cases, for

Pressure effect .- Different sweIJings of the bone

GENERAL SURVEY

tendon of the finger is the feature of a " trigger finger".

The risk of dissemination which was supposed to be great, is

within the fascia or in the subcutaneous tissue. The overlying skin is more or less fixed to the fas

examina tion in acute

to be seen in cases of bone tumours. But even in these

constricted sheath an d as soon as it is done the finger becomes extended quickly and abruptly

But there are fallacies, e.g. a few malign ant tumours do not show the characteristic arteriographic

sequestrum underneath.

of the forearm to the medial epicondyle indicates 'Tennis elbow" or Golier's elbow respectively.

appearance of centres of ossification . The growth discs are too deep. The metaphysis is splayed

3. Pressure effects. It is always essential to have a look

The pain starts henceforth and continues till the arm reaches an angle of 120°. After this the

asking the patient to straighten his finger against resistance (Fig. 9.17). The patient is asked to

seen in bone cyst, but surrounding sclerosis is

localized pain on the medial epicondyle of the humerus which is aggravated by flexing of the

or the tendon sheath following trauma and subsequent encapsu-lation with fibrous tissue or it may

A MANUAL ON CLI ICAL SURGERY

Paget's disease (osteitis deformans) is a disease of old

Secondary carcinoma of bone is seen in old age above

then the little finger.

(Canon ball metastasis) in a case of osteosarcoma.


B. Inflammatory.- (i) Acute osteomyelitis; (ii)

its way superficially and then fluctuation test will be positive. In more chronic cases the pus

149

Chondroma

mainly starts from the metaphysis, does not invade the

an osteolytic cavity will

On examination localized tenderness is felt on the lateral epicondyle where the extensor muscles

aclasis. Arrows indicate the exostoses.

is that the malignant growth osteosarcoma presents with pain first and swelling later on.

arising from the bone will be fixed to it.

Flg.11.14.- Osteoclastoma

(iii) S11rfnce.- Smooth and lobulated surface are features of benign growth. Irregularity

may occasionally s uffice, Open biopsy is still the popular method.

adolescents but may remain symptomless till the bone

of a rest pain a long the distribution of the median nerve.

calcium indicates generalized osteolysis (which is seen in cases

EPIPHYSIS :

side of the forearm lying in fron t of the Flcxor digitoru m profundus. At the wrist, it passes in

of the hypothenar eminence, the interossci, tl1e third and fourth lumbricals and lhe adductor

patellae particularly during active extension of the knee indicates the diagnosis of patellar tendin

diagnostic feature of osteosarcoma. In acute osteomyelitis, it will pit on pressure. Being a bony

L 1,, (!11,·1, am'.; dt ,b, Women between 40-50 years are the usual victims. In this condition

Fig. l 1. 16.- Osteosarcoma showing the typical radiating

the median nerve, a lso exits. The main complaint of the patient is some sort of difficulty in

lengthened when the metaphysis is included within the

whereas chronic osteomyelitis resents healing for months and even

tendon ruptures, tenosynovitis (simple, suppurative and stenosi.ng), Dupuytren's contracture and

At the elbow this nerve may be injured (i) in su pracondylar fractu re eiU,er in recent injury by

and also a sequel of degenerative process. The rupture commonly takes place in the bicipital

ring finger and less often the little finger

can be both local and general.


Similarly pain in the sole just in front of the calcaneum tuberosity is seen in plantar fasciitis. I

peculiar association with cirrhotic

So injury to this nerve will result in the fool drop and ta lipes

EXAivtlNATION OF DISEASES OF BONE 155

the Flexor carpi ulnaris and the medial half of the Flexor digitorum profundus will be paralysed.

GENERAL EXAMINATION

osteosarcoma, chon drosarcoma, fi brosarcoma or suspected malignant osteocJastoma.

epicondyle of the humerus this nerve is often injured. ln all cases of open reduction of this

the soft tissues its outline becomes indefinite. In bone sarcoma

and increased alkaline phosphatase with high E.S.R. are seen

neighbouring joints may be sympathetically effused in

adult, there will be malaise, fever, headache and backache.

Quervain's disease) and the fibrous sheath of the flexor tendons of the fingers and the thumb

its well-defined edge.

dull aching (characteristic of tumours in their late stages barring

aspect of the knee joint. This is revealed in

trabecular bone and cortex with an expanding lesion which

may be very thin as to yield or break during palpation ('egg-shell crackling'); otherwise when

phosphatase.

is suspected.

ulcer will be undermining with bluish newly growing epithelial edge.

to detect malignant change in Paget's disease, which may be d ifficult on an ordinary X-ray film.

condition mostly affects the medial

This nerve arises from the medial cord of brachial plexus comprising of CB and Tl. lt runs

The palmar cutaneous brnnch - arises from the middle of the forearm, descends in front of

CLASSIFICATION OF BONY

measured if muscular wasting is suspected.

In diaphysenl nclnsis multiple exostoses are seen.

The following points should be particularly noted while taking history :

humerus which leads to pathological

Scurvy; (iv) Hyperparathyroidism (Von-Recklinghausen's disease); (v) Osteoporosis.


(vi) P11/sntio11.- ls ilie swelling pulsatile? Some pathological condition of the bone may

may occur due to violence on the contracted muscle while playing football etc. The presenting

part of the palmar fascia in which the

unnoticed . Acute onset with high rise of temperature and toxaemia is a feature of acute

rise of temperature, pain in the chest, haemoptysis, etc. Neck, axilla and groin must be palpated

Fig.11.2 .- Shows a

of the shoulder, which is popularly known as " frozen shoulder". The natural sequence is that

1. Swelling. The swelling is examined as has been described in chapter 3. All swellings

5. Sinuses.- This may be presen t in chronic osteomyelitis either

to be enlarged and occupied by a cystic tumour. The cortex is thin with a sharp line of

2. ,wellim•. Abnormal swelling of a muscle particularly when it contracts is a feature

bone); (iii) Mucopolysaccharide disorders: (a) Morquio-Brailford disease; (b) Hurler's disease; (c)

on frozen section biopsy is difficult and only a few institutions

thyroid cancer and renal adenocarcinoma.

7. Bacteriological examination of the pus obtained by

2. Tenderness. Inflammatory swellings are always tender. Tumours are generally nontender.

particularly in acute osteomyelitis and osteosarcoma.

etc.

Sometimes degenerative calcification of the tendon may develop which becomes obvious

EXAMINATION OF DISEASES OF BONE

of the bone. It can indicate the p resence of local infection in the same fashion as a primary or

Fig.11.21.- Secondary deposits in the lungs

frequently obtained in many bone di seases

1'

will be red, oedematous and congested. In osteosarcoma the

nerves to cause respective symptoms. Swellings of the

Dupuytren's contracture and ganglia, is mo re informa tive about the type of operation and the

non-specific urethritis or from specific gonococcal in fection may develop th.is condition. Sometime

middle a nd the ring fingers.

mus t be remembe red

mobilization of calcium
Typhoid osteomyelitis; (v) Tuberculous osteomyelitis;

2. Onset and progress. History of trauma is

(1) Flexor carpi ulnari.s.- When Lhe wrist joint is flexed against resistance, the hand tends

DISEASES OF MUSCLES,

On examination, there is thickening of the medial aspect of the palmar fascia with firm nodules

Density of the sequestrum

extensor and peroneal groups of muscles of the leg as also

of the primary carcinoma which may be in the lung, kidney, breast, prostate, thyroid etc.

This is partly due to reluctance on the part of pathologists to

to see the power of adduction of palmar interossei. This test is known as the "card tes t".

con genita presents with multiple fractures, dwarfism

the patient finds difficulty in extending the finger wi th ra ther weak extensor muscle. With

tenosing tenovaginitis.- The cause of this condition is rather unknown, but it involves

5. Ulcers and sinuses. Whenever there is an ulcer or a sinus, it is good practice to hold

and a common cause of low back pain. The pain and tenderness is loca lized at the attachment

cyst) .

Os1eogcnic sarcoma

deficient blood supply seems to be the cause of this condition. It commonly affects the middle

In Osteomyelitis, it

hence retards Lhe growth of the bone.

density) as seen in syphilis, Paget's disease, marble bone or chronic osteomyelitis (sequeslru.m

be nodules in the fascia or in the

Hunter's disease etc.; (iv) Diaphyseal aclasis (Multiple exostoses); (v) Multiple chondromas (Ollier

the base of the ulcer or the sinus and to move it against the bone. Fixity to the bone indicates its

of wide-bore needle has never become popular in this country.

movement of abduction in a normal way. Thus the diagnosis may be escaped by the inexperienced.

occurs transversely (cf. Bone

temperature is raised in acute pyogenic inflammatory conditions and in osteosarcoma.

I,,,\ ·, f111.\cr,- ln this condition Lhe tendon just d istal to the constriction becomes swollen

surrounding involucrum
Ulnar nerve may be injured al the elbow or at the wrist.

(v) Co11siste11cy.- It is bony hard in osteoma. 1n osteoclastoma, the outer bony shell

the muscles concerned contract.

conspicuous by its absence.

pollicis. When the ulnar nerve is injured at the elbow, besides the muscles mentioned above,

Epiphysi tis

may be noticed.

Bone cyst

open biopsy is not possible), biopsy of limb tumours by means

In h1berculous osteomyelitis cold abscess will lead to a swelling

of pain.

Rupture of the supro pinntu~ tendon. Spontaneous rupture of the supraspinatus tendon

tuberculous osteomyelitis. 1n case of the former there will be sprouting granulation tissue al lhe

ma rble bone, cleido-cranial dysostosis, Marfan's syndrome etc.

flexing fingers with pain and neurologica l deficits of the median nerve, e.g. paraesthesia or

of the bony swelling on the veins. There may be paresis neous veins in case of osteod

The superficial terminal brnnch supplies the skin of the medial side of the hand, and through

Acute osteomyeliti s

aggravated when the patient tends to extend U1e wrist and Hte fingers, more so against resistance.

carcinoma in the thyroid, kidneys, lungs, prostate, breasts, uterus, gastrointestinal tract, testis,

acute osteomyelitis. Osteoclastoma generaUy starts in the

examination, slight tenderness can be elicited on the carpal tu1mel. There will be neurological

constriction caused by the tendon sheath the tendon distal to the constriction may bulge out to

irradiation before taking biopsy. Aspiration biopsy though

affecting the lower end of the

duonic osteom yelitis, a

There is h ardly any

Plantar fasciitis.- In this condition the patient experiences unbearable pain under the heel

os teom yeli tis.

age. Nearly all benign bone tumours occur in

and little fingers. IL also supplies the Palmaris brevis.


4. Certain bony lesions involve more than one bone at a time. Diaphyseal (metaphyseal)

E,'{AM.INATlON OF DISEASES OF BONE

groove and mostly spontaneous. The patient sometimes complains of a sudden pain in the upper

Multiple myeloma occurs late - 30 to 50 years.

long-standing lesions fail to show positive results.

of pain when the thumb is extended or abducted. In carpal tunnel syndrome the patient complains

tissue at the mouth of the

of sequestrum at the depth. But boUl these sinuses will be fixed

unaffected.

affected due to pressure effect of the bony swellings and

(C) Lung!> must be X-rayed to exclude secondary deposits in the lungs in cases of

Paget's sarcoma in the elderly, when the signs and X-rays alone

that the clinician hardly reaches ilie bone during palpation and can only palpate the soft tissues

and reaches the posterior comparbnent of the arm in front of the triceps upto the elbow where

excessive fibrous tissue activity. This

epiphyseal cartilage w1til late and hence the joint remains

ulna. Note that the expansion

of the forea rm are attached.

between the two fingers for grasping. The card is now pulled out against the adducted fingers

an arrow).

152

appearance. Mostly the tumoUI grows ecccnlrically, often destroys the epiphyseal cartilage and

abduct his fingers against resistance. This test will reveal the power of abduction of the dorsal

Polymorphonuclear leucocytosis is constant with raised E.S.R. Pus may be sent for culture

4. Duration. 1n acute osteomyelitis the duration is very short

adolescent and in young adults; Osteoclastoma occurs

the presence of a murmur and lo note its character.

Os1eoc las1oma

LOCAL EXAMINATION

pyogenic or tuberculous. History of extrusion of bone chips strongly

3. In osteomyelitis a search should be made for infective foci in the skin, tooth, tonsil,
the plantar fascia There is localized thickening and contracture of the palmar fascia. There may

through its musculocutaneous branch it supplies the anterior

distal limb and venous engorgement may be due to

153

blush', wh ich delineates the extent of the tumour. All these fea tures may not be present

In Multiple myeloma circumscribed areas of rarefaction affect the differen t bones, which may

(Trigger finger).

Spontaneous development of swelling is most likely

myeloma, sa rcoidosis etc.). (d) A rise in serum a lkaline

or involucnun).

will be present.

disease); (vi) Marble bones (Osteopetrosis); (vii) Candle bones, Spotted bones and striped bones;

be made clinically. In

osteosarcoma).

after which stiffness also gradually subsides in next 3 months.

Clwndrosarcoma in skiagram shows frank destruction of the

and its deficient growth which is out grown by the normal development of the ulna. Genu

sometimes d ue to ill-fitting shoes.

originates from the capsule of a joint or a tendon sheath. Tt may be due to a leakage in the capsule

osteoclastoma, very rarely haemangioma of bone and high ly vascular metasta tic carcinomas from

(2) Interossei.- These muscles extend the middle and the terminal phalanges of the fingers

Osteoma

medial side. Pa in and tenderness are locaHzed on the medial epicondyle of the humerus, where

n erves, there w ill be claw foot. "winging of the scapula" .

like a trigger of a pistol.

Golfer's elbow.- This condition is more or less similar to the Tennis elbow, but on the

a bony spur may be seen a t the attachment of the plantar fascia. This may or may not be the cause

may press on the neighbouring blood vessels and the

beyond the confines of the long bones and there may be subperiosteal erosions of the cortex.

ln Brodie's abscess

in osteomalacia. (g) W.R. and Kahn tes ts will be positive in


aclasis, generaljzed osteitis fibrosa, multiple myeloma are the examples of this condition. So the

through the extensor expansions. These are also concerned in flexion of the metacarpophalangeal

and lateral aspects of the leg and whole of the dorsum of Lhe

At the wrist the ulnar nerve may be damaged by the same injury as described under the

Pain is also a regular feature of tenosynovitis when the affected tendon is being used, be it

Syphilitic ostcitis

the pain gradua lly subsides and the stiffness increases. Upto 3 months stiffness remains static,

adjacent growth e.g. Carcinoma of the tongue involving the lower jaw.

40 years.

gradual increase of density compared to that of

other pathology such as rheumatoid arthritis involving the synovial shea ths of the flexor tendons

The aetiology of this condition is

HISTORY

are features of malignant growth and chronic infection.

INSPECTION.-

diagnosis and to exclude possibility of malignant

typhoid fever, multiple boils etc. may be obtained in case of acute

U1e bone which either provokes the growth of the bone or destroys the epiphyseal cartilage and

years. 1n malignant bony tumours the duration is relatively short in

aspiration in cases of acute osteomyelitis is of immense value to

A bony lesion or a swelling is always fixed to the bone and cannot be moved apart from

deformity is obvious whereas in the rupture of tendons deformity becomes obvious only when

Fig.11. 7 .- Chronic

mimic secondary metastasis.

be due to mucoid degeneration of the fibrous sheath. Ganglia are commonly seen on the dorsum

2. Skin overlying the swelling.- In acute osteomyelitis the skin overlying the swelling

and for staging reticulosis. It has been claimed that some 20% bone secondaries which are not

and the incidence considerably comes down after the age of twelve. The symptoms and signs

overlying the bone which pits on pressure.

orifice of the sinus indicating presence of sequestrum in the depth and in case of the latter the

and sensitivity tests. It must be emphasised that radiography, which plays an important role in
G. Tumours.- (a) Benign tumours.- (i) Osteoma; (ii) Osteochondroma; (ill) Osteoblastoma;

Fig.11.15.- Chondroma at the lateral

Fig.11.8.- Brodie's

SCIATIC NERVE

sinus suggests presence of

examination of the affected bone will reveal local pathology, end of the tibia.

lateral condyle of the tibia (indicated by

Tn Osteilis jibrosa (Hyperparatltyroidism; Von Reckli11ghause11 's disease) skfagram shows a

DIFFERENTIAL DIAGNOSIS

in open wounds. Th.is nerve supplies the muscles of the calf

d epos ition has jus t

found in acute fulminating type of osteomyelitis. In chronic type, which is commoner in the

Achilles' tendinitis.- The patient complains of pain at the attachment of tl1e Achilles' tendon

thereby hampering the growth of that particular bone. This may lead to deformities like manus

chronic osteomyelitis.

resistance palpation of the swelling of the muscle will immediately make the diagnosis as to

4. ARTERIOGRAPHY.- The changes of the character of the blood vessels supplying the

Fihro ·itls or fibrositic nodul .- This condition is also a type of non-articular rheumatism

be well elicited by percussion. ln case of spine and pelvis this can be elicited by gently striking

The ma in sign is the loca lized tenderness over the insertion of the supraspinatus tendon.

6. Similar swellings.- An enquiry must be made if Ulere is any

)cf r 1 1h Palpation of the deformity, which is come across in conditions like

1 S\,clling.- It has already been emphasized that nl/ bony swellings will be fixed to the

affected than the medial tibial part in injury to the sciatic nerve.

palmar interossei adduct the fingers. So far as the flexion of the metacarpophalangeal joint is

AUSCULTATION.- In case of pulsatile swellings, this examination wiJJ be required to detect

hyperproteinaemia, the globulin (pa rticularly gamma globulin) being raised. (c) A rise in serum

METAPHYSI S :

Otherwise the tumours whether they are benign or malignant are painless to start with. One

may occur due to degenerative change in the tendon in elderly individuals. The patient complains

Tuberculous osteomyelitis may be seen at any age.


to the bone. Sometime there may be scar on the skin overlying

one cannot with certainty make the diagnosis on clinical or

(iv) Edge.- Ill-defined edge is the feature of inflammatory swelling and welJ-defined

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