attachment of ligamentum patella.

after tuberculous arthritis becomes secondarily infected. This condition signifies formation of

counl and E.S.R. in acute arthritis and

way, which are featmes of loose body in the joint. In the elbow generally the capitulum or radial

and tender spots. When the tendons are made taut against resistance the pain increases. On Xray

The patients present with painless lump which may give rise to slight ache and weakness. This

becomes one of the s light flexion, slight

avoid pain. On the other hand the patient lurches on the affected side (Trendelenburg's gait) in

this portion may be detached forming loose body

localized in the shoulder joint or radiating from the acromion process down the outer side of

patient stands on the affected side, the pelvis

obliterate the lumbar lordosis and this manoeuvre should not be forcibly continued as this will

haemoglobin, total count, differential

ulnaris. This condition may be due to osteoarthritis of the elbow joint and the ulna r nerve is

be elicited. Similarly in compo1111d pa/mar ganglion cross fluctuation

Acute arthritis rarely affects a shoulder

connection with the tendon sheath.

calc ification above the greater

common) or on the ventral aspect of the wrist is nothing but a ganglion.

according to the existing deformity till the interspinous line becomes horizontal. Now the angle

(De Quervain's disease).

On examination there is tenderness at the point of insertion of

of elevation of the arm, the gleno-humeral joint contributes 10° and the scapular movemen t

Secondly the different movements must be compared

Fig.15.25.- It is shown that even with the 'fixed flexion'

PaJpa tion will revea l considerable tenderness over the latera l epicondyle of the lrnmerus

infra-articular synovial membrane (in ferior aspect of the synovial membrane) and the capsule to

complain of referred pai n in the

osteoarthritis if the arm is made to sway a little the palpating hand al the shoulder joint will

stenosed in stenosing tenosynovitis

completes the full range of abduction. The supraspinatus muscle is concerned to begin the process

of the range) it impinges upon the u.nder surface of the acromion

complains of aching pain and recurrent effusion.

and adduction deformities it will no longer be horizontal. fn the former, the anterior superior

of the biceps near its insertion may become inflamed giving rise to a condition known as

rotation of U1e scapula and the clavicle.

does not go beyond the margins of this muscle.

) "l m nt" of the joint viz. the lower part of the humerus and the upper parts

A MANUAL ON CLINICAL SURGERY

Wh en the mechanism fa ils, Trendelenburg's

diaphragm which is supplied by the same segments i.e. C3, 4 & 5).

of defonnihj is estimated by the amount of abduction or adduction made in relation to the normal

motor neurone disease; (ii) in congenital or

as the sy:novial cavity is nearest to the surface at this region and the posterior ligament is thin

of the common

In arthritis of acromioclavicular joint sharp pain is felt when

this group. Rarely excessive callus forma tion and displaced fragments may be responsible for

toes.

Subdeltoid (Subacromial) bursitis.- Fluid in the subdeltoid bursa will present as cystic and

radio-ulnar joints. The humero-ulnar joint permits flexion and extension. The fu ll range of

marked rotation deformities there will be corresponding change in the direction of the anterior

of movement due to the movement of the scapula as

1n standing position it should be noted

becomes positive (i) when lhe abductors are

nothing but olecranon

PALPATION.- l 1 n.._ I ter:,pcrature. This will be increased in acute arthritis, olecranon

"Caries Sicca" i.e. without abscess formation is often

quite uncommon in

scoliosis of the lumba r spine with

lengthening, as the pelvis is tilted

Perthes' d isease etc. when the lever system

Fixed Intern/ or medial rotation deformity.- This deformity cannot conceal itself by

process sometimes gets

INSPECTION.- The patient must be stripped upto the waist and stand in front of the

l• Swellings around the elbow joint are palpated a long the usual lines of the

Age of onset of symptom often suggests the diagn osis. From birth to 5 years - congenital

is commonly seen at the back (dorsal aspect) of the wrist but may occur in front of the joint,

shoulder joint due to cervica l

as soon as the concerned tendon is made taut due to its intimate

arm is carried backwards and inwards. Flexion and extension take place at right angle to this

the arm upto its middle. The students must remember a fallacy in this respect that pain in the

acute supraspinatus tendinitis.

Limp is the second complain t and this is more often d iscovered by the clinician or the

biceps tendon or may be due to rnbbing against osteophytes in an osteoarthritic shoulder. The

should be deep high in the axilla to detect any fullness

and occasionally locking. One thing must be noted that pain in the elbow may be referred from

So during abduction the arm is carried forwards and outwards while during adduction the

region of origin of the common extensor muscles at the lateral epicondyle. In Golfer's elbow the

injured by the osteophytes.

Fig.IS.IS.-The ganglion on

deformity the patient can extend his hip joint fully by bending

previous one. IL is the

DIFFERENTIAL

disease: (i) increasing pain and increasing stiffness, (ii) decreasing pain wiU1 persistent stiffnes

sound side because he tries to take the weight off the affected side as quickly as possible to

and lax. When more fluid accumulates, a swelling is noticed on the posterolateral aspect of the

convexity towards the affected side.

hands firmly in apposition. The angle formed by the hand and the forearm of the aifected side

will reveal the tear.

elbow joint, this joint is held in semiflexion position - the position of ease or greatest capacity.

PALPATION.- J ,ellil!li:; ls the swelling fluctuant?

head of the radius. Note the dense epiphysis of the

-N

Fig.15.14.- Mill's manoeuure. Note that the clinician's left thumb is palpating

median nerve as it passes benea th the flexor re tinaculum.

demons trated with the patient lyin g on the bed .

will disappear as soon as the wrist is straightened. This is

capsule of the shoulder joint to give additional strength to it. These four muscles are - anteriorly

damage to the cartilages leading to limitation of movements.

INSPECTION.- t P<, 11 n. The patient is asked to stand stra ight with his arm at the

p rovides most of the required

passively adducted or the thumb is ulnar deviated, the patient winces with pa.in. With the

severe pain due to the manoeuvre.

epicondylitis).-

through the deltoid. fullness, however,. can be discovered in the

Student's (or

and when the shoulders are braced

of the medial femoral condyle is involved and the patient complains of vague aching,

or epitrochlear lymph nodes one must flex the elbow to the right angle to relax the surrounding

pathological dislocation of U1e hip where the

atrophy which may result from long

slight abduction and lateral rotation

tendinitis but is sometimes come across in conditions like (a) subdeltoid bursitis, (b) incomplete

anteriorly.

joint which may be missed.

beneatl1 the finger and thumb. If the elbow is kept extended the enlarged lymph node may not

The corresponding axilla should be always palpated

tibial (Osgood-Schlatter's disease) tubercle and at the heel where the tendo-achillis is attached

and external rotation which are often affected in different

movements are best examined when the elbow joint is kept flexed at 90° and the arm is kept by the

fluctuating swelling beneath the acromion process. J.n this condition the humeral head can be

not in the coronal plane of the body but is slightly

the fa lse ankylosis.

affected side, the pelvis being tilted down causing apparent lengthening of the limb. Similarly a

between the pelvis and the femur. This test

repeated movement of

in front rather than in the buttock. The pa in often radiates to the knee thus misleading the

adhere to one another. Patients between 45-60 years are commonly affected. Females seem to

posterior margins of the deltoid and along the long tendon of the biceps due to existence of

arthritis. Tenderness along the tendon sheath indicates

Flg. 15 .2 .-- Codman' s method of

fluctuation above and below the flexor retinaculum.

De-Quervain's disease (Stcnosing tenosyno\itis).- This is a condition in which the common

LOCAL EXAMINATION

The range permitted in each movement is as follows : h

in the joint.

so far as th e attitude of the patient is

This is due to narrowing of the osseo-fibrous tunnel (Carpal

of tuberculous arthritis, acute arthritis, gonococcal a rthritis and rarely rheumatoid arthritis. As

also the acromioclavicular and sternoclavicuJar joints.

be palpated. While unilateral enlargement of this lymph node indicates some infective lesions

Abduction - 180°; flexion - 90°; extension - 45°; •. :.;

does occasiona lly affect the elbow joint. The

swolJen with prominent knuckles. In t11berc11lous tenosynovitis of the 11/nnr bursa (compound
palmar

over the olecranon and

by gluteal folds and itiac crest. It indicates a

is s itu ated in the

joint, the a tt·itude is typical and differs

and a hard lump at the root of the neck. C. In the shoulder- (i) Musculo-tendinous cuff lesions.

and the lateral epicondyle - form a triangle when the elbow is flexed. But these three bony

compensation at the lumbar spine. It always remains revea led and is determined by noting the

infec ted and leads to

smface of the patella or the tips of lhe

it with that of the sound limb. This angle is the outward deviation of the extended and supinated

joint, whereas flexion and abduction take place in rrudcarpal joint. Normal range of flexion is

mphire of supraspinatus tendon. In this condition if the patient is made to abduct his shoulder

tenderness is situated on the common flexor origin from the medial epicondyle.

optimum position i.e. slight Hexion,

Stenosed Sheath

inclines towards the weigh t bea ring leg

(1) Abduction, (2) Adduction, (3) Flexion, (4) Extension, (5) External

other side. N & D indicate normal and diseased sides respectively.

(i ii) in fracture neck of femur, coxa vara,

friction is caused while

In tuberculous arthritis of the hip

- 1 "' Any swelling near about the elbow joint is noted. Normal hollows on either

osteoarlhrit is, but also s hows

compared (Fig. 15.27). The details of

complete rupture of supraspinatus tendon. This muscle is

d efec t in th e osseo-muscul a r mecha n ism

Figs.lS.16 & 15.17.- Showing the methods of testing the ranges of extension and flexion of the

Fig.15.26.- Thomas' test is demonstrated. The normal hip is

thenar and the hypothenar muscles. There may be some interfering with the movements of the

and (ii) the inferior radioulnar joint. Pronation and supination movements occur at the inferior

234

the chest wall with one hand and with the other hand lo palpate the shoulder joint from all

fig.15 .11.- Shows calci -

a complica tion of Colles' fracture or idiopathic (which by far

limb till the interspinous line becomes horizontal.

on the opposite (n ormal) side sinks as shown

explanations which the students should keep in mind.

leads to rapid swelling and tension wjth often calcium deposition

bursitis and is caused by

of the shoulder joint, which is not very common, the swelling extends beyond the anterior and
starts here in case of joint effusion.

both the radiocarpal and the midcarpal joints. Extension and adduction mostly occur in radiocarpal

the abduction and adduction movements occur. This is

capitulum affecting its articular surface. La ter on

(v) Bone.- Myositis ossificans traumatica is probably the commonest condition of

the previous cond ition

is pain on the radial styloid process where the sheath enclosing the said two lendons exists.

Th.is conilition affects the ulnar nerve whereas the latter condition affects the median nerve. The

INSPECTION.- The patient is first inspected in tlte standing posture both from front and behind.

effu sion extends upwards and downwards beyond the extent of the joint and a long the

filled so tight that it feels solid.

palpated. The examiner's right hand is used to palpate patient's

A man can only keep his sh irts on. In case of females some cover for genitals is provided with.

along the sensory dis tribution of the median nerve are also

head is affected, and the signs and symptoms are simi lar to the knee joint. In the ankle commonly

lumbar spine and the bed. This manoeuvre will automatically bend up the hip upto the angle in

the shoulder movement occurs at the shoulder joint proper

unilateral congenital dislocation and coxa vara. This is to cou nteract the tendency of the pelvis

practically all movements - especially abduction are limited. After

or tuberculous arthritis, rheumatoid or

easily demonstrated in case of chi ldren

of the scapula is not in the

syndrome. The cyst contains crystal-clear gelatinous fluid. When on dorsal aspect of the wrist,

which lies the superior aspect of shoulder and (c) Greater

abduction remain painless.

weak as in poliomyelitis, muscle dystrophies or

clenched fis t against resistance, considerable pain is experienced a t U1e lateral epicondyle. Mill

Extensor PoUlcis

flexion of the affected hip joint. A good

and deformity. The joints are palpated for local tenderness, temperature and to assess the

Fixed flexion deformity.- This is usually made good by lordosis of the lumbar spine. In
Rupture of the supraspinatus tendon.- Degeneration of the supraspinatus tendon is again

very painful and is always held in semi-flexion position (optimum position). On both sides of

elderly men between 45-65 years are affected. The patient usua lly gives a history of trauma in

one cm above the base of the medial epicondyle. When enlarged, the node will be found s]jpping

Fig.15.10.- Testing passive movements of

effusion in it. Th is is

du ll ache wh.ich quickly gets worse leading to agonizing pain and

simply increase the flexion of the affected hip showing an exacerbated deformity.

Figs.15.4 to 15.9.- Showing movements of the shoulder joint :

bursitis and bicipitoradial bursitis.

(iv) Cord or root tumour. B. Tn the neck-arm junction.- (i) Cervical rib, (ii) Pancoast's syndrome

joint tends to bear most of his weight

into the subdeltoid bursa.

ACTIVE MOVEMENTS.- The patient is asked to carry out

affects the elbow.

sufferers of th is condition have never played

humerus.

THE WRIST AND OTHER JOINTS OF THE HAND

formation may result. X-ray shows narrowing and irregularity of the radiocarpal and midcarpal

1. Attitude.- The clinician must

outnumbers the other conditions). The majority of the patients

upwards resulting in scoliosis of th

'1 rrr dcrnc . Tenderness exactly on the joint line indicates

be stripped upto the waist and these movements should

or s p lenic ruplure. These are also

(ii) Muscles and tendons - due to adhesion to the bone following fracture (e.g.

Flg.15.3 .- In painful arc

the way of Lifting weight or protecting himself from falling. The pain is felt immediately radiating

common nerves viz. the femoral, obturator and the sciatic. With destruction of the articular

Chronic supraspinatus tendinitis (painful arc syndrome).- This

Carpal tunnel syndrome.- This is nothing but a type of compression neuropathy of the
The patient mus t be s tripped upto the waist. The joints are inspected for any redness, swelling

(iv) Capsules and ligaments - in prolonged immobilization, which is a common cause

about 60°, that of extension is about 70°, adduction about 35° and abductjon about 25°.

writing between the skin

process. Commonly older men in the age group of 45-60 years are the victims. The most important

ankylosed gleno-humeraJ j oint will show some range

taking measurements of the limbs are

MOVEMENTS.- The elbow joint has got two components - humero-ulnar and superior

known as the 'Wrist jlexion Test' (Pha/en's sign). Electrical nerve

Effusion of the wrist, ganglion and the compound palmar ganglion

revealed in X-ray.

Arromiod'I icular and sternocla, icular joint,. These joints arc bes t examined from the front.

I . <. • le 1 I 1 ~ -- This is an important part of examination which will often

or wilhout deposition of calcium is the main underlying pathology of this condition. Degenera tion

which is detected by the fact that the hand of the clinician cannot be insinuated between the

th e pull exerted by the abd uctors of the hip.

epicondyle. Fig.15.13.- Cozen's test. See the text.

placement olf the clinician's fingers on the

stiffness and the hands feel weak. The wrist becomes swollen with wasting of lhe forearm,

impairment of fine movements. Pain, tingling and numbness

discussed later in this chapter.

to the calcaneum (Sever's disease). In both these conditions the patient presents with swollen

Observe the gait carefully.

shouJder of the patient. The thumb lies along the depression

(ii) Arthritis - any a rthritis of the joint, be it rheumatoid, osteoarthritis, tuberculosis etc.

diseases of the shoulder joint.

EXAMINATION OF

wasting of the thena r eminence. When the patient is asked to

is normally horizonta l and at right angles to the midline of the body. In presence of abduction

palpation of the shoulder joint. Note the

the flexor retinacu.lum. Rheumatoid arthritis and tuberculosis are incriminated for this condition.
the bicep muscle is made to contract, belly of the biceps looks prominent and rounder with a

the swelling becomes tense and prominent when the wrist is flexed. The gelatinous fluid is

Compound palmar ganglion. This is nothing but chronic inflammation of the common

This is a very rare

comparison to th e

Tennis elbow (Lateral epicondylitis).- This is

> {., t ma~ r 1 ·tl11 I This is another method of palpating

EXAMINATION OF INDIVIDUAL JOINT PATHOLOGIES 229

anterior to the acromion to feel the superior aspect (at the

normal side is n oted. The important movements are abduction

spondylosis or cervical rib or irritation

This is called "night pain".

feel the crepilus. Three bony joints are important to palpate in the shoulder joint - (a) Tip of

Acute Arthritis.- Acute arthritis often leads to effusion of the elbow joint. The joint becomes

finding is that the mid-abduction (60° - 120°) is painfu l. This is the range of abduction in which

determine the range of flexion the backs of lhe hands are placed in contact and the elbows are

In painful arc syndrome pressure just below the acromion will elicit tenderness if the arm is

side of the olecranon and obliterated in effusion of the joint. Olecranon bursitis (miner's or

the wrist when the extensor muscles are put in action, such as during pouring oul tea in a cup

of the diaphragm fo llowing gallstone

Moreover there will be wasting of muscles of the thighs and this associated with interstitial

which leads to tremendous pain. Young individuals between 25-45

degeneration. This is a case of

not concentrate on the hjp joint alone

Acute supraspinatus tendinitis.- Localized degeneration of the supraspinatus tendon with

thumb. The hand is U1en pushed passively to the medial (ulnar) side. Pain is experienced at

there is very little space between the greater tuberosity and the acromion and the thickened

shoulder joint may be referred from the neck, chest or the abdomen (from irritation of the

* 'Rotator cuff' is a cuff comprised of tendons of the four muscles which fuse with the

differences. Thirdly the clinician must have a clear idea

the supraspinatus on greater tuberosity just beneath the acromion

Fig.15.1.- Note that the plane

surgeon for proper inspection not only of the affected joint but also to compare with the soW1d

is not uncommon.

Acute arthritis.- This will lead to pain, tenderness and effusion of the joint.

i.e. Bronchial carcinoma affecting the apical lobe of the lung giving rise to Homer's syndrome

In arthritis of the wrist joint all the movements of the wrisl are painful and limited.

recumbent position the patient is asked to extend the limbs. He will be able to do so in expense

Longus """"".,..""''

On examination there is local tenderness and a localized swelling may or may not be present.

Th is condition is

mcdiaJ counterpart of

supraspinatus tendon becomes nipped between the e two bones. The beginning and the end of

Longus

Adduction is corrected by tilting the pelv is

backwards or drawn forwards.

arthritis is also occasiona lly seen in shoulder joint and

by flexing both the hip joints as well as

one corner of the upper surface of the talus is affected. The symptoms are aga in similar to those

pelvis forwards. Abduction is corrected

aspects. In supraspinatus tendinitis pressure just below the acromion process will elicit tenderness

which is accentuated by flexion and supination (movement caused by the biceps muscle at the

which it is fixed flex.ion. So Lhc angle between the affected thigh and the bed is the angle of fixe

the shoulder joint. Note that the scapula is

, ~~t:llinp Effusion in the joint is difficult to palpate

standing disease of the hip. Lastly one

insertion of the supraspinatus) and slJghtly anterior aspect of

commonly seen after fracture of the shaft of the femur when quadriceps adhere to the fractured

e.g. radia l club hand, Madelung's deformity etc.

swelling such as caused by ganglion or deformHy such as tuberculous affection of the wrist or

the following way: The pa tient stands on the

belong to this group, (2) from the synovial membrane numerous cartilaginous loose bodies
make an angle of 20° to 30° when the deltoid muscle takes over the process of abduction and

E,'v\MJNATION OF INDIVIDUAL JOINT PAI HOIOGIES 231

to cause Limitation of movements of the joint. From superficial to deep, the causes are :-

seeds. The patient presents with the swelling mostly wiU1ou t pain but wiU1 some wasting of the

This means extra-articular structures are involved in such a way as

This is ca used by

and the patient's am1 is moved gently backwards (extension)

on the sound leg. Thus the p a tient

where the extensor muscles originate. Cozen's test i.e. when the patient is asked to extend his

230

of effusion of the elbow joint first there is filling up of the concavity on each side of the olecra

is fixed by the clinician from behind and the patient is asked to abduct the shoulder.

of the knee joints, without very suggestive cause. That the patient is a bleeder will confirm the

Osteochondritis dissecans.- This condition,

nerve (median nerve) concerned. In la te cases there may be

INDIVIDUAL JOINT

PASSIVE MOVEMENT.- The importance of this movement is not much except in complete

looks longer than its fellow. IN STAGE

join t, but occasionally seen in children. R11e11matoid

alongwith their common sheath

coracoid, below which is the anterior aspect of the shoulder, (b) Tip of the acromion, below

8 months and the whole process takes about 2 years.

of the humerus.

swelling. The patient is asked if the joints become painful in different movements of the shoulder

Tuberculosis.- This is rarely seen in the wrist. The patient complains of gradual aching,

DIFFERENTIAL DIAGNOSIS

at the me d ia l

ankylosis of the joints will result.

On X-ray there w ill be a d ense s pot in the

developing within villous synovial processes (osteochondromatosis), (3) from the bone resulting

the arm is raised above right angle. Determine how much of

of lumbar lordosis, which is detected by passing a hand behind the lumbar spine. The angle of

supraspinatus following

site resulting in Limitation of extension of the knee joint), Volkmann's ischaemic contracture, etc.

sh ould look for any scar or sinus near

left shoulder.

patients are usually over 50 years of age. A history of trauma is almost inevitable in the form of

the affected bone looks more dense and fragmented.

the joint is lax and redundant accumulation of fluid

points come to a straight horizontal line when the elbow is extended.

fication in the tendon of

\ 11 1 (i) Fibrous variety.- Fibrous ankylosis is commonly seen as a sequel

fixed adducted limb is brought parallel to its fellow by scoliosis with convexity towards the

Abductor Pollicis

takes the entire weight and the trunk

damaged and sub equent adhesion binds tom to

Extensor Poll1cis

examination. Fluctuant swelling will be seen in effusion of the elbow and in all bursitis. 1n case

elbow).

informations regarding diseases of the

Brachia! Neuralgia.- This term signifies pain extending over a large part of the upper limb.

S'<AMINATlON OF INDIVIDUAL JOINT PATHOLOGI ES 235

Arthritis of the shoulder joint.-

will be some sensory change and motor impairment of the

student's elbow) will give rise to swelling over the olecranon process. Great effusion of the

outnumber the male pa tients. The patient sometimes gives a history of trauma. The patient first

lowered as far as possible. The angle between the hand and forearm is the range of flexion

fixed with one hand.

arthritis of the joint and in frozen shoulder.

occur at right angles to that plane.

and (iii) disa ppearance of stiffness with return of a ll the movements. Each phase lasts from 4 to

sheath of the tendons of abductor pollicis longus and extensor pollicis brevis becomes
pain on the attachment

elbow joint will also show fulJ.ness in the antecubital fossa. Sometimes a bursa beneath the tendon

Presence of fixed deformities are usually

Sometimes it is felt as hard as a bone. The ganglion becomes fixed

whereas flexion and extension

tennis. Probably the common extensor origin is

A MANUAL ON CLINICAL SURGERY

movements, which is very pain ful. So the attitude

confirmatory as destructive lesions of tuberculosis will be obvious in "Caries Sicca".

seen both anteriorly and posteriorly. In rheimwtoid arthritis the metacarpophalangeal joints become

the name suggests this condition signifies fibrosis between the two articular surfaces following

The painful arc syndrome is definitely the pathognomonic feature of chronic supraspinatus

can be elicited above and below the flexor retinaculum. ln ganglion,

This condition means stiffness of a joint e ither by intra-articular lesions (True ankylosis) or

beyond the flexor retinaculum. A small circumscribed swelling either on the dorsal (more

thumb in the palm, the patient is asked to make a fisl by superimposing the fingers over the

with greater ranges of movement.

con fused with "frozen shoulder". Previously many

the s tudents and the

tendons of the abductor pollicis

sequestra from acute arthritis secondary to acu te osteomyelitis, but most important in this group

ususa lly the young adu lt females are the victims.

be examined not only from in front but also from

of biceps becomes

cases which were diagnosed as "Caries Sicca" were

years are the common victims. The first complaint is obviously a

sign becomes positi ve. The test is p erformed in

either by muscular spasm or by fibrosis

deltoid muscle.

when the whole of the movement takes place at the shoulder joint. For every subsequent 15°

condition mainly affects

(ii) Bony variett;.- Bony ankylosis occurs following suppurative arthritis and occasionally

longus and extensor pollicis brevis

side.

capitulurn is generally involved. The head of the

HISTORY.- Patients with elbow disorders mostly complain of pain, stiffness, deformity

rupture of the supraspinatus tendon and (c) crack fracture of the greater tuberosity of the

D r, rmil). Obvious deformitjes of the wrist are rare and

236 A MANUAL ON CLINICAL SURGERY

Trendelenburg's test.- Norma lly

and swelling over the medial aspect of the olecranon. This sign distinguishes an effusion of the

PATHOLOGIES

nipping of a synovial fringe a nd entrapment of a

(idiopathic). Tuberculosis of the hip may occur at an y age.

affected side automatically rises. Next the

by extra-articular involvement (False Ankylosis).

5°. To note exactly how much movement is contributed by the gleno-humeral joint, the scapula

PAINFUL ARC

from the shoulder to the middle of the outer side of the arm. The patient soon di ·covers tha t he

Miner 's) elbow.- The

condition in which the

experiences a pain which becomes worse at night and prevents the patient from sleeping on the

radioulnar joint. All other movements i.e. flexion, extension, adduction and abduction occur in

ganglion), a swelling is present on the palmar aspect and extends both proximally and distally

226

Bicipitoradial bursitis.-

Rotation of the shoulder joint is restricted, particularly the external rota tion in different

is made good by the mobili ty of the

movement.

THE ELBOW JOINT

condition is a lso due to a process of degenera tion of the

the hip joint.

radius is also affected (Fig.15.12). The patient

particularly in rheumatoid arthritis.

and forwards (flexion) and the sho ulder joint is carefully

joint and note if there is any tenderness. Posteriorly also the joint is palpated similarly. In

(the commonest site).

fingers. Paraesthesia due to median nerve compression may occur. The swelling shows cross

Fig.15.12.- Osteochondritis dissecans affecting the

joints with rarefaction of the adjacent bones.

the stemoclavicular joints to exclude any organic disease there.

common flexor origin

pathology and is so situated that on abduction (during the midd le

joint and the bony configuration is such as to sacrifice

affected. The main complaint is progressive weakness and

Brevis

extension means when the e lbow joint becomes straight. The full range of flexion is 180° from

according to the stage of the disease. TN STAGE 1 (Synovitis) - there is effusion into the joint

hold it. Examiner's right hand grasps the patient's flexed elbow

and should be differentiated from effusion of the tendon shea ths. In the laller condition the

and the pelvis tilts raising that side of Lhe pelvis which is n ot taking the weight. This is due to

the table.

INSPECTION.- In aU affections of the wrist joint this joint will remain in

inclined forwards a bout 30° with this plane (fig.15.1).

I ti. 9 r c I To examine for enlarged supratrochlear

Fixed abduction or adduction deformity.- A limb when fixed in abduction position is brought

ANKYLOSIS

symmetrical synovitis with boggy fluid distension of both the knee joints suggests this condition.

cartilage pain becomes wor e at night d ue to disappearance of the protective muscular spasm.

unaffected lower limb first, the buttock on the

111« , A child is completely stripped for exammation of hip joints.

Figs.15.21 & 15.22.- Diagrammatic representation

fluctuation on both anterior and posterior aspects of the joint can

' ·,.._

the ca use of this condi tion. The injury which causes tear is rather trifle in that way. Usually

this position that means when the soft tissues of the anterior aspect of the joint come to

tuberosity, its prominence.

Charcot's joint.- This condition occasionally

take place in the plane of the

thigh of the patient is bent with the flexed knee till the lumbar lordosis completely disappears,

will limit its function.

fixed jlexion deformihj is accurately measured by Hugh Owen Thomas' test. In this test the sound

Figs.15.19 & 15.20.- Trendelenburg's test. NormaJly when

shoulder at the beginning of the act or not. This indicates

involvement of the ulnar nerve occurs when it passes between the two heads of the flexor carpi

of Trendelenburg's test.

about a vertical axis; circumduclion - results from succession

forearm from the axis of the arm. This angle disappears when Lhe forearm is flexed or pronated.

(Finkelstein's test).

from injury, e.g. fracture of the tibial spine, detached osteophytes in the case of osteoarthritis,

ca refully. If a patient with a painful hip is using stick, he usually holds it in the opposite hand

the shoulder and down the arm with painful and restricted neck movements. X-ray will show

lumbar spine and the pelvis as a whole.

ls the affected limb shortened? This is

with those of the normal side to exactly assess the

1 v ting- This will be obvious in any affection of the elbow joint which

elbow joint over the radiohumeral joint. Crossed fluctuation can be elicited between this area

vertical to bring interspinous line horizontal.

W1accustorncd over use. The patients a re usually women in their forties. The main complaint

remains straight. This deformity disappears when the joint is flexed. J.n case of effusion of the

gradually lessens and the disease recovers spontaneously. Thus there are three phases of th is

Ganglion.- This is a cystic swelling caused by mucoid or myxomatous degeneration of the

ax ill a. Subdeltoid bursitis may give rise to swelling and

the knees. The levels of the knees are

subscapularis, superiorly supraspinatus and posteriorly infraspinatus and teres minor.

EXAMINAl ION OF INDIVIDUAL JOINT PATHOLOGIES 227

15

laterally. Fourthly in the movement of abduction the shoulder joint itself moves for 100°- 120°,

while exami.ning the affected shoulder. This palpation

flex the wrist there will be exacerbation of the symptoms

more often seen among the tennis players and

the median nerve at the wrist.

to sink on the sound side when the leg of that side is raised off the ground. l.n bilateral congenit

lurches on the sow1d side with slight

barring rheumatoid arthritis they are mostly congenital deformities

flexed position and characteristic ulna r deviation is noticed in wrist and the finger joints

iliac spine on the affected side will be at a lower level, whereas in the latter it will be found at

vara); 20 to 40 yea rs - osteoarthritis due to previous disorders; over 40 years - osteoarthritis

which La ter on bursts into the subdeltoid bursa relieving pain.

HISTORY.- The most common symptom of the hip disorders is pain, which is mostly felt

repeated throwing of a ball. The patient complains of pain over the insertion of the biceps tendon

By this time the muscles around the shoulder how signs of disu e atrophy. Months later stiffness

hence the name. But quite a number of the

affected side. Gradua l stiffness of shoulder follows. In a matter of months all movemen ts

When one leg is lifted, the other leg

Th is is ca lled the stage of apparen t

Frozen shoulder. The underlying pathology is that an exudate causes the layers of the

bony trabeculae between the two articular ends following severe destruction of the articular

The affected limb is he ld just above the ankle and is gradually adducted or abd ucted

Patients comp lain of pain on U1e latera l aspect of the elbow, accentuated by dorsiflexion of

behind (particularly during abducton to see the scapular

DIAGNOSIS

222 A MANUAL ON CLINICAL SURGERY

llefonnil). By palpation the actual deformity is noted.

will flex the affected thigh to the extent of 'fixed flex.ion· deformity.
There are numerous causes of this condition and careful examination will reveal the exact cause

nature of the deformity, a line is drawn connecting the two anterior superior iliac spines. This lin

fluid impulse between the two sides of olecranon posteriorly and at the bent of the elbow

supraspinatus tendon which is probably triggered by an injury or

of limitation of movements following trauma. Contracture of these structures are held responsible.

which becomes thickened and

concerned in starting the movement of abduction. 1n chronic

the neck or shou Ider disorders.

relatives of the patient than the patient himself. The gait of the patient must be noticed very

about the plane of the body of the scapula along which

This leads to spasm of the power ful

shoulde r joint. Tuberculous affection of the joint is

tenosynovitis.

X-ray appea rance is widely nccepted ns normnl, which differentiates this condition from othe rs.

of salutation). Now he is asked to lift both the elbows gradually as far as he can keeping the

is attached to an epiphysis or apophysis. The possible exception is probably Johansson-Larsen's

SPECIAL INVESTIGATIONS

the dorsal aspect of the wrist

or turning a door handle.

this is practically nil in bony ankylosis. Yet a good range of abduction is possible because of the

While examining for the ranges of different

is painful, the extremes are painless.

elbow joint from enlargement of bursa beneatl1 the triceps tendon.

tuberculous arthritis of the joint.

The elbow tunnel syndrome. Thjs condition is by fa r rarer than carpa l tunnel syndrome.

stage it is very difficult to differentiate this condition from tuberculous arthritis.

A MANUAL ON CLI ICAl.. SURGERY

PALPATION.- The shoulder joint is best palpated by keeping the arm by

if the patella or the toes point up to the ceiling, it indicates slight medial rotation. In presence

Golfer's (or Baseballer's)

dislocation and bilateral coxa va ra the d1aracteristic waddling gait is seen.

Cr , This is important. It may be flattened due to wasting of the deltoid muscles

of the ulna and the radius are carefully paJpated for any thickening or irregularity - the evidence

the origin of the common extensor tendons where the patient is experiencing

th e s kin over the

a higher level. Now the angle of deformity is estimated in the following way :-

(iii) Fascia - in Dupuytren's contracture and occasionally in gonococcaJ fibrofascitis,

the stability of the joint to certain extent to compromise

cartilages.

to the ground by lateral flexion of the lumbar spine i.e. scoliosis with convexity towards the

are painless. The whole range of abduction is painful in acute

the joint and other three fingers a re )Placed on the clavicle to

EXAMINATION OF INIJI\'IDUAL JOINT PATHOLOGIFS 233

coronal plane of the body but is

i.e. the tenderness

a few days pain subsides once the calcified substance has erupted

thenar and hypothenar muscles. The joinl is kept flexed a little, later on cold abscess and sinus

corresponding tendon sheath, while the former is limited within the extent of Lhe joint and is

are all fluctuant swellings. In effusion of the wrist joint cross

of the knee joint.

rise to tremendous

of the hand, wrist and forearm, but bilateral enlargement suggests a generalized disease e.g.

and the articular cartilage is involved.

are women between the ages of 40-60 years. This condition

medially rotated and sligh tly flexed. Very often the arm is being supported by the other hand

Flexion is concealed as discu ssed earlier.

loses its intactness; (iv) when it h urts the

DIFFERENTIAL DIAGNOSIS

below the spine of the scapula to palpate the posterior aspect

disease in which this condition affects the lower pole of the patella (a sesamoid bone) a t the

olec ranon b ursa. This

of the foregoing movements.

the olecranon normal concavity will disappear. Effusion of the e lbow joint will elicit transmitted

rotations - both medial and la teral - one quarter of a circle

lifting weight or saving himself from a fa ll. The clinical picture is unmistakable - i.e. whenever

structures. The node will be palpated on the anterior surface of the medial intermuscular septum

the other side. The test is positive if the pelvis drops on the

flexion deformihJ- It must be remembered that the sound thigh is flexed only upto the point lo

swelling and tenderness in the affected a rea. The patient may present with locking and giving

seen at the level between C6 & C7. Patient will complain of pain radiating from the neck towards

effusion of the shoulder joint.

THE HIP JOINT

the shoulder joint. The left hand is used to palpate the right

syphilis and calls for biopsy of the gland.

may be bilateral but more often the more active side is

Flex.ion and extension can be tested in lhe following way : to determine the range of extension

more commonly of the joints of the fingers.

bursa beneath the tendon

In affection of the shoulder joint the arm is held by the side of the chest,

that the patient with arthritis of the hip

adducted, but not if the arm is abducted as the tender spot will disappear under the acromion

Fig.15.18.- Diagrammatic

It must be noted that va rus or valgus deformity of the elbow is only obvious when this joint

adductors and flexors of the hip to protect its

upwards and may mislead the clinician. On examination there

elbow (Medial

within the joint and is obtained by the

in a particular case. The common causes are - A. Tn the neck.- (i) Disc prolapse commonly

gap proximal to it.

indicate the diagnosis by itself. 1n tennis elbow a localized tenderness will be elicited in the

the mid-range of abduction (60°-120°), the extremes of the range

movement). This is because of the fact that a n

of the clavicle. But these movements occur a lmost simultaneously except in the initial 25°-30°
30°). Abduction and adduction

SHOULDER JOINT & SHOULDER GIRDLE

shoulder joint. See the text.

syndrome, the midrange abduction

'

comparison) one after another and the difference from the

supraspinatus tendinitis and an y a rthritis of the shoulder joint.

radial head.

sheath of U1e flexor tendons leading to swelling of this sheath (ulnar bursa) above and below

concerned. Any fixi ty of the hip joint

be prominent with rotmded fullness seen in subdeltoid bursitis or effusion of the joint. ln effusion

2 (Arthritis) - the effusion subsides

HISTORY.- The patients with the problems of the wrist may present wilh either pain,

Chronic arthritis. All the usuaJ forms of chronic arthritis may be seen in the elbow joint.

diagnosis.

inflamed and effused .

distinctly palpated below the acromion process which differentiates this condition from the

MOVEMENTS.- The wrist joint, like the elbow has got two components : (i) the radiocarpal

bicipitoradial bursitis. This condition also gives rise to a slight swelling in front of the elbow

MOVEMENTS.- The shoulder joint is a very mobile

tunnel) either due to rheumatoid arthritis or pregnancy or as

is loose body from osteochondritis dissecans.

sinus forma tions (florid type) are not uncommon, but

(i) Skin and subwtaneous tissue - in bums following contracture.

process. Similarly in front just below the coracoid process one can feel the anterior aspect of the

the radial styloid process which shoots down to the thumb or upwards towards the elbow

Rupture of the biceps tendon.- This condition is a sequel of avascular degeneration of the

of abduction which is later carried on by the deltoid muscle. Palpation will reveal a gap just

representation of the positions of the

connective tissue of the joint capsule or the tendon sheath. Usually young adults are affected.

when it may compress the median nerve leading to symptoms simulating carpal tunnel
which demands maximum capacity

a ll the movements simultaneous ly on both sides (for

which is often a tense swelling fluctuation can be seldom elicited.

the presenting fea tures. Occasionally the pajn may shoot

is unable to lift the arm or abduct his shoulder. But if he bends to the affected side a little to

from tuberculous arthritis, rheumatoid arthritis, osteoarthritis, rotator cuff* lesions etc. It may

is compared with that of the sound side. This angle is the range of extension movement. To

But these are uncommon. Tuberculosis occu rs in adults more often than in children.

slightly inclined forwards (about

the weight of the body is taken on one leg the pelvis rises on

Cluttoo's joint.- This is a manifestation of the congenital syphilis. Symptomless and

though more often seen in the knee joint, yet it

by tilting the pelvis downwards and

manoeuvre i.e. the patient's wrist is passively flexed when his forea rm is pronated. This gives

(Fig. 15.28). Flexion is concealed by

direction of the anterior surface of the patella or of the toes when the foot is held at right angle

disloca tion; 5 to 10 years - Perthes' disease; 10 to 15 years - slipped epiphysis (adolescent coxa

HISTORY.- In diseases of the shoulder joint the patients usually complain of pain - either

tenderness just beneath the acromion process.

232 A MANUAL O CLINICAL SURGERY

anterior superior iliac spine. The angle of fixed adduction deformity is measured by adducting the a

the leg. Normally, the lower limb remains with a slight latera l rotation. So in recumbent position

Lmtorn fibres and to the joint caps uJe. Tendinitis,

Similarly, osteoarthritis is also not commonly seen in the

whether the joinl is involved by acute

particularly paraesthesia within 1 minute and the symptoms

(c) Tmctio11 osteochondritis.- This condition occurs only in those places where the tendon

(gleno-humeral joint) and how much is contributed by rotation

bursa over the olecranon

especially abduction and external rotation are restricted. As the process con tinues the pain abates

patien t as in different arth ri tis of the hip.

for the initial 30°, he will be able to complete the whole range of abduction with the help of the

extensor tendons.

Haemophilic joint.- Haemophilic patients sometimes p resent with sudden bila teral effusion

side of the chest. When tile elbow joint is extended these movements will be mixed with rotation

side of the body with the palms looking forwards that means in anatomical position. Observe

of previous osteomyelitis. The three bony points - the tip of the olecranon, the medial epicondyle

each leg bears half of the body weight.

keratitis will confirm the diagnosis. This condition often commences in one joint and at this

EXAMJNATION OF INDIVIDUAL JOINT PATHOLOGIES 237

supraspinatus tendinitis (painful arc syndrome), pain is felt at

tuberosi ty in acu te su praspina tus

228 A MANUAL ON CLINICAL SURGERY

conduction s tudy wiU elicit a delay in motor conduction of

is examined for

nothing but " frozen shoulders". X-ray examination is

wrist joint. Note that there is restriction of both the movements on the affected left side.

.. ~in ,~ In tuberculosis of the wrist joint sinus formation

beneath the acromion process. Straight X-ray will not give much in formation, but arthrography

and kept slightly raised.

downwards and the affected limb

the lumbar spine forwards.

During abduction it is noted whether the patient shrugs his

clinician. This is because of the fact that both the hip and the knee joints are supplied by the

ls he lurching on to the sound s ide or to the affected side? In arthritis the patient lurches on th

the patient is asked to place his palms and fingers of both the hands in contact (lndian method

muscles do not have stable fulcrum to act on;

the additional 60°-80° is obtained by the forward rotation of the scapula and some movement

chronically inflamed, thickened and later on stenosed as a result of degenerative changes or

sound side, the pelvis being tilted up causing apparent shortening of the limb. To ascertain the

joint. It is useful to note tha t the movements of these joints occur during elevation of the arm

the carrying angle (normally it is 10° in case of males and 20° in case of females) and compare
In this condition also the adolescents are affected and the two places are notoriously involved

by over-use. The swelling of the tendon is again the underlying

Figs.15.23 & 15.24.- In the first figure fixed adduction deformity has been concealed by raising the

SweUing may be due to effusion of the wrist joint which i rather uncommon

EXAMINATION OF INDIVIDUAL JOIN'I PATHOLOGIES 225

shoulder joinl. It not only shows

ten dinitis. Sometimes the patients

lumbar lordosis and by tilting the

there to indicate joint effusion. As the inferior aspect of

branch of the radia l nerve may be the other

224 A MANUAL ON CLINICAL SURGERY

Loose bodies.- They may arise (l) from the synovial fluid, e.g. fibrinous loose bodies resulting

movements of shoulder joint, firstly the patient must

from haemorrhagic or inflammatory effusion - 'melon-seed' bodies found in tuberculous joints

diminished disc space. (ii) Tuberculosis of the cervical vertebrae. (iii) Vertebral body tumour.

by this condition. These are the knee joint where the ligamentum patellae is attached to the

body of the scapula (A-A)

synovial sac. But in subdeltoid bursitis fullness is only seen just beneath the deltoid muscle and

The synovial membrane becomes thick and villous. The fluid contains fibrin particles and melon

look is made to detect any muscular

flexed to the limit to obliterate the compensatory lordosis. This

It is a good practice to feel the acromioclavicular as well as

or osteomyeliti.s. ln th is condition cold abscess and

adduction and medial rota tion (fig. 15.29).

rotation and (6) Internal rotation.

plane i.e. in flexion the arm is carried forwards and medially and in extension backwards and

approxima tion. The radio-ulnar joint permits pronation and supination movements and these

The pain is aggravated when the patient extends her thumb against resistance. tf the wrist is

of the shoulder joint. The tip of the index finger is placed just

occasionaUy seen and the disease starts as a synovitis

of the scapula and the clavicle. In frozen shoulder proper abduction is very much Limited and
process. Skiagram will revea l calcification of supraspinatus tendon