Essay 1
Essay 1
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.
tumour vary characteristically in all malignant tumours. The vessels become aimless, tortuous
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
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.
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
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
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.
F. Cyst.- (i) Solitary cyst; (ii) Cyst associated with generalized osteitis fibrosa; (ijj) Hydatid
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,
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
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
must note the character of the pain - whether it is throbbing (characteristic of inflammation) or
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.
only difference is that the cause is not only thickening of the flexor retinaculum but also some
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
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
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.
tendon becomes compressed between the two bones. This condition is popula rly known as
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
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.
Ulnar nerve injury will cause loss of sensation of the medial side of ilie hand, the whole of
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
(c) Malignant.- PrimanJ - (i) Osteosarcoma; (ii) Chondrosarcoma; (iii) Ewing's tumour;
commenced.
patient mus t be asked if there is any other bony swelling in his body or nol.
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
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
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
with a few spicules projecting from its surface in the metaphysis. (ii) Osteolytic type shows an
and Lateral aspect of the leg, dorsum of the foot and the toes.
osteomyelilis.
form a swelling. ln carpal tunnel syndrome a careful palpation will yield thickening of the flexor
in acute osteomyelitis.
ln Rickel, X-ray will show general decakiiication. The epiphysis is widened with delay in
commonly seen - (i) Sclerotic type, usually found at puberty, shows dense new irregular bone
simullaneously in all primary malignant tumours, but one or the oth er cha nge will be obvious.
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
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,
rupture of the tendons e.g. long head of the biceps, Achilles' tendon etc. In the first two conditio
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.
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
with a fist.
Multipl.: myeloma
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
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
body scanner in a similar time. The great potential value of bone scanning lies in ils ability to
mud1 more often than the plantar fascia, is a cha racteristic feature. Contracture of the fascia
Sprouting granulation
it may penetrate the articular cartilage. Pathologica l fractures may occur. This tumour expands
edge is the feature of new growth. As osteosarcoma is a very rapidly growing tumour it loses
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.
to the bone. The condition is sometimes attributed to the unaccustomed prolonged walking or
retinacu lum and will reveal the neurological deficits of the median nerve due to this condition.
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
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
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.
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
causes fl exion of the fingers or toes. Most commonly this disease affects the ring finger first and
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
2 Ocfor,, it\. It is the first complaint in conditions like Dupuytren's contracture, ganglia,
mostly the common sheath of the abductor pollicis longus and extensor pollicis brevis (de
pain subsides as the shoulder is further abducted. The second complaint of the patient is stiffness
(i) Situation.- A swelling arising from the epiphysis is probably an osteoclastoma. Acute
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
it lies behind the medial epicondyle accompanied by the superior ulnar collateral artery. Tt enters
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
As has already been discussed the common peroneal part of the sciatic nerve is more often
tendon.
changes. Conversely some benign osteoclastomas can show these fea tures. Bu t there are two
movement and effusion of the nearest joint (10% of cases). Later on, subperiosteal pus may find
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
The expanding osteolytic lesion can continue to destroy the cortex, although usually it leaves
the nerves and the blood vessels. These structures may be involved by the lesion.
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
(about 25 cm diameter). Using a gamma camera and taking multiple overlapping views, it can
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.
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
its ossification.
and conduction sh1dies on the median nerve will demonstrate a delay at the carpal tunnel.
right side due to involvement of the lateral popliteal nerve by an osteoma at the head of the fibula
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
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
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
supply, wh ereas in
DIFFERENTIAL DIAGNOSIS
it becomes increasingly rare. Monostotic fibrous dysplasia, though rare, is chiefly a d isease of
few primary malignant conditions of bone. (2) Toxic features with fever and malaise are noticed
of the leg and sole and through plantar nerves it supplies the
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
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
Ganglion.- This is a tense and cystic swelling containing gelatinous material in it. This mostly
the neighbouring stn.ictures, i.e. the muscles - their power and mobility over the bony lesion,
the diagnosis of bone diseases, is practically valueless in the detection of early stage o
the bone.
is due to decreased
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
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
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.
10
of the middle and the terminal phalanges. This is tesled by holding the proxin1aJ phalanx and
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
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
(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 -
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)
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
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
distinct p laces where its value is undeba table - (i) to define the extent of the tumour and (ii)
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
GENERAL SURVEY
within the fascia or in the subcutaneous tissue. The overlying skin is more or less fixed to the fas
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
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
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
its way superficially and then fluctuation test will be positive. In more chronic cases the pus
149
Chondroma
On examination localized tenderness is felt on the lateral epicondyle where the extensor muscles
is that the malignant growth osteosarcoma presents with pain first and swelling later on.
Flg.11.14.- Osteoclastoma
(iii) S11rfnce.- Smooth and lobulated surface are features of benign growth. Irregularity
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
the median nerve, a lso exits. The main complaint of the patient is some sort of difficulty in
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
So injury to this nerve will result in the fool drop and ta lipes
the Flexor carpi ulnaris and the medial half of the Flexor digitorum profundus will be paralysed.
GENERAL EXAMINATION
epicondyle of the humerus this nerve is often injured. ln all cases of open reduction of this
Quervain's disease) and the fibrous sheath of the flexor tendons of the fingers and the thumb
may be very thin as to yield or break during palpation ('egg-shell crackling'); otherwise when
phosphatase.
is suspected.
to detect malignant change in Paget's disease, which may be d ifficult on an ordinary X-ray film.
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
may occur due to violence on the contracted muscle while playing football etc. The presenting
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
to be enlarged and occupied by a cystic tumour. The cortex is thin with a sharp line of
bone); (iii) Mucopolysaccharide disorders: (a) Morquio-Brailford disease; (b) Hurler's disease; (c)
2. Tenderness. Inflammatory swellings are always tender. Tumours are generally nontender.
etc.
Sometimes degenerative calcification of the tendon may develop which becomes obvious
of the bone. It can indicate the p resence of local infection in the same fashion as a primary or
1'
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
mobilization of calcium
Typhoid osteomyelitis; (v) Tuberculous osteomyelitis;
(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
of the primary carcinoma which may be in the lung, kidney, breast, prostate, thyroid etc.
to see the power of adduction of palmar interossei. This test is known as the "card tes t".
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
density) as seen in syphilis, Paget's disease, marble bone or chronic osteomyelitis (sequeslru.m
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
movement of abduction in a normal way. Thus the diagnosis may be escaped by the inexperienced.
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
pollicis. When the ulnar nerve is injured at the elbow, besides the muscles mentioned above,
Epiphysi tis
may be noticed.
Bone cyst
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
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,
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
Plantar fasciitis.- In this condition the patient experiences unbearable pain under the heel
groove and mostly spontaneous. The patient sometimes complains of a sudden pain in the upper
of pain when the thumb is extended or abducted. In carpal tunnel syndrome the patient complains
unaffected.
(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
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
Os1eoc las1oma
LOCAL EXAMINATION
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
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).
or involucnun).
will be present.
disease); (vi) Marble bones (Osteopetrosis); (vii) Candle bones, Spotted bones and striped bones;
be made clinically. In
osteosarcoma).
and its deficient growth which is out grown by the normal development of the ulna. Genu
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
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
beyond the confines of the long bones and there may be subperiosteal erosions of the cortex.
ln Brodie's abscess
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.
other pathology such as rheumatoid arthritis involving the synovial shea ths of the flexor tendons
HISTORY
INSPECTION.-
U1e bone which either provokes the growth of the bone or destroys the epiphyseal cartilage and
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
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
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.11.8.- Brodie's
SCIATIC NERVE
examination of the affected bone will reveal local pathology, end of the tibia.
DIFFERENTIAL DIAGNOSIS
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.
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
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
(iv) Edge.- Ill-defined edge is the feature of inflammatory swelling and welJ-defined