Introduction to Limb Arthrology 9789814877992, 9781003372769

Table of contents :
Cover
Half Title
Title Page
Copyright Page
Dedication
Table of Contents
Foreword
Acknowledgements
Section I
Introduction to General Arthrology
I.1: Classification Based on Structure
I.2: Classification Based on Function
I.3: Types of Joints/Articulations
I.4: Basic Structure and General Anatomy of Joints
I.5: Development of Limb Buds
I.6: Upper Limb
I.6.1: Physical Examination
I.6.2: Paralysis of the Upper Limb
I.6.3: Arterial Blood Supply to the Upper Limb
I.6.4: Venous Drainage of the Upper Limb
I.6.5: Lymphatics
I.6.6: Muscles of the Scapular Region
I.6.6.1: Deltoid
I.6.6.2: Teres major
I.6.6.3: Triceps brachii
I.6.6.4: Supraspinatus
I.6.6.5: Infraspinatus
I.6.6.6: Teres minor
I.6.6.7: Subscapularis
I.6.7: Nerves of the Scapular Region
I.6.8: Arteries of the Scapular Region
I.6.9: Topographic Anatomy of the Scapular Region
I.6.10: The Human Breast
I.6.10.1: Introduction
I.6.10.2: Anatomy of human breast
I.6.10.3: Vessels and nerves
I.6.11: Muscles of the Upper Limbs
I.6.11.1: Anterior compartment
I.6.11.2: Posterior compartment
I.6.11.3: Forearm
I.6.12: Nerves of the Upper Limbs
I.6.12.1: Radial nerve
I.6.12.2: Median nerve
I.6.12.3: Ulnar nerve
I.6.13: Hand and Wrist Anatomy
I.6.13.1: Bones of hand
I.6.13.2: Compartments of the hand
I.6.13.3: Dorsum of the hand
I.6.13.4: Palm
I.6.13.5: Anatomical snuff box
I.6.13.6: Ligaments of the upper limb
I.6.13.7: Synovial membrane
I.6.13.8: Flexor tendon zones of the hand
I.6.13.9: Flexor muscles of the digits
I.6.13.10: Digital flexor sheath
I.6.13.11: Extensor tendon zones of hand
I.6.13.12: Muscles of the hand
Chapter 1: Examination of the Shoulder
1.1: Inspection
1.2: Palpation
1.3: Range of Movements
1.4: Neurologic Examination
1.4.1: Reflex Testing
1.4.2: Sensation Testing
1.5: Special Tests
1.5.1: Ossification of the Bones of the Shoulder
1.6: Special Tests for the Shoulder
1.6.1: Stability of the Shoulder
1.6.2: Biceps Tests
1.6.3: Impingement Tests
1.6.4: Other Tests
1.7: Examination of Related Areas
1.7.1: Sternoclavicular Joint
1.7.2: Acromioclavicular Joint Arthritis
1.7.2.1: Shoulder separation
1.7.3: Dislocation of the Glenohumeral or Shoulder Joint
1.7.4: Scapular Disorders
1.7.5: Frozen Shoulder
1.7.6: Tuberculosis of the Shoulder
1.7.7: Rotator Cuff Tears
1.7.8: Biceps Tear
1.7.9: Biceps Bursitis/Tendinitis
1.7.10: Brachial Neuralgia
Chapter 2: Examination of the Elbow
2.1: Inspection
2.1.1: Ligaments
2.1.2: Fat Pads
2.1.3: Bursae
2.1.4: Blood and Nerve Supply
2.1.5: Structures
2.2: Physical Examination
2.3: Inspection of Elbow
2.4: Palpation
2.5: Neurologic Examination
2.6: Special Tests
2.7: Important Lines and Angles
2.8: Examination of Related Areas
Chapter 3: Examination of the Wrist and Hand (Fingers)
3.1: Anatomy of the Wrist
3.2: Functions of Wrist Complex
3.3: Inspection of the Hand
3.4: Palpation of the Hand
3.4.1: Bony Palpation
3.4.2: Soft Tissue Palpation
3.5: Range of Motion
3.5.1: Active Range of Motion
3.5.2: Passive Range of Motion
3.6: Neurologic Examination
3.6.1: Muscle Testing
3.6.2: Sensation Testing
3.7: Special Tests
3.7.1: Surface Anatomy
3.7.2: History
3.8: Examination of the Hand
3.8.1: Examination of the Joints
3.8.2: Examination of the Musculo-tendinous Units [10: and 11]
3.8.3: Examination of the Nerves [10: and 11]
3.8.3.1: Motor testing
3.8.3.2: Sensory testing
3.9: Functional Tests
3.10: Clinical Examination
3.11: Differential Diagnosis: Special Tests
3.12: Examination of Related Areas
3.12.1: Wrist Deformities
3.12.2: Stiffness of the Wrist
3.12.3: Swellings Around the Wrist
3.12.4: Deformities of the Tendons
3.12.5: Other Deformities: Dupuytren’s Contracture
3.12.6: Tunnel Syndromes
3.12.7: Open Injuries of the Hand
Section II
Introduction to Lower Limb Arthrology
II.1: Pelvic Girdle
II.2: Sacroiliac Joint
II.2.1: Ligaments of the SIJ
II.2.2: Movements of the SIJ
II.2.3: Clinical Signs of SIJ Dysfunction
II.2.3.1: Hypomobility lesions
II.2.3.2: Degenerative changes at the SI joint
II.2.3.3: Osteitis condensans ilii
II.2.3.4: Inflammatory diseases and infections
II.3: Sacroiliac Joint Syndrome
II.3.1: Extra-articular Manifestations
II.3.2: Physical Examination
II.3.3: Tests for SIJ
II.4: Ankylosing Spondylitis
II.4.1: Epidemiology
II.4.2: Pathogenesis
II.4.3: Pathology
II.4.4: Clinical Features
II.4.5: Laboratory Findings
II.4.6: Radiological Evaluation
II.4.6.1: CT scan
II.4.6.2: MRI
II.4.6.3: Bone scintigraphy
II.4.7: Complications of Ankylosing Spondylitis
II.4.8: Differential Diagnosis
II.4.9: Management
II.4.9.1: Medical line of management
II.4.9.2: Surgical line of treatment
II.4.10: Juvenile Ankylosing Spondylitis
Chapter 4: Examination of the Hip and the Pelvis
4.1: Inspection
4.2: Palpation
4.3: Range of Motion
4.4: Special Tests
4.4.1: Introduction
4.4.2: Anatomy of the Hip
4.4.3: Biomechanics of the Hip Joint
4.4.4: Examination of the Hip Joint
4.4.5: Special Tests
4.4.6: Special Tests in the Pediatric Patient
4.4.7: Investigations
4.4.8: Examination of Related Areas
Chapter 5: Examination of the Knee
5.1: Inspection
5.2: Palpation
5.2.1: Soft Tissue Palpation
5.3: Tests for Joint Stability
5.4: Range of Motion
5.5: Neurologic Examination
5.6: Special Tests
5.7: Examination of Related Areas
Chapter 6: Anterior Cruciate Ligament Injuries of the Knee
6.1: Introduction
6.2: Incidence
6.3: Anatomy and Biomechanics
6.4: Clinical Presentation
6.5: Special Tests
6.6: Natural History
6.7: Treatment
6.7.1: Timing of Surgery
6.7.2: Graft Selection
6.7.3: Graft Placement
6.7.4: Graft Tensioning
6.7.5: Graft Fixation
6.7.6: Graft Failure
6.7.7: Rehabilitation
6.7.8: Results
6.7.9: Complications
6.8: Recent Advances in ACL Reconstruction
Chapter 7: Examination of the Foot and Ankle
7.1: Inspection of the Foot
7.2: Palpation
7.2.1: Palpation of Bony Points
7.2.1.1: Medial aspect
7.2.1.2: Lateral aspect
7.2.2: Palpation of Soft Tissue
7.3: Tests for Ankle Stability
7.4: Range of Motion
7.4.1: Active Range of Movements
7.4.2: Passive Range of Movements
7.4.3: Movements of the Lesser Toes
7.5: Neurologic Examination
7.6: Special Tests
7.6.1: Gait
7.6.1.1: Common types of gait
7.6.1.2: Walking aid
7.6.2: Inspection
7.6.3: Palpation
7.6.4: Range of Movement
7.6.5: Vascular Examination
7.6.6: Neurological Examination
7.6.6.1: Forefoot
7.6.6.2: Midfoot
7.6.6.3: Hindfoot
References
Chapter 8: Examination of the Foot
8.1: Regions of the Foot
8.2: Features of the Dorsal Region of the Foot
8.3: Features of the Plantar Region or Sole
Chapter 9: Uncommon Injuries of the Limbs
9.1: CMC Joint Arthritis of the Base of the Thumb
9.1.1: The Trapezium
9.1.2: The CMC Joint of the Thumb
9.1.3: The Intercarpal Joints
9.2: Pediatric Trigger Thumb
9.3: Bennett’s Fracture
9.3.1: Reverse Bennett’s Fracture
9.3.2: Pseudo Bennett’s Fracture
9.4: Rolando’s Fracture
9.5: Ulnar Collateral Ligament Injury
9.5.1: Classification Ulnar Collateral Ligament Injuries
9.6: Jersey Finger
9.7: Lisfranc Injury
9.7.1: Anatomy of the Ligament
9.7.2: Mechanisms of Injury
9.7.3: History and Examination Findings
9.7.4: Management
9.8: The Wrist: Radiocarpal and Midcarpal Joints
9.8.1: Functions of the Wrist Complex
9.8.2: CMC Joints of Fingers
Index

Citation preview

Introduction to

Limb Arthrology

Introduction to

Limb Arthrology

edited by

K. Mohan Iyer

Published by Jenny Stanford Publishing Pte. Ltd. 101 Thomson Road #06-01, United Square Singapore 307591

Email: [email protected] Web: www.jennystanford.com British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library.

Introduction to Limb Arthrology Copyright © 2023 by Jenny Stanford Publishing Pte. Ltd. All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system now known or to be invented, without written permission from the publisher.

For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy is not required from the publisher.

ISBN 978-981-4877-99-2 (Hardcover) ISBN 978-1-003-37276-9 (eBook)

I write this dedication with a very heavy heart, full of fond memories for my respected teacher, late Mr. Geoffrey V. Osborne, without whose constant encouragement and freedom, I could not have written this book. Such teachers are extremely rare to find these days, when the turmoil of the daily life overtakes one’s ambitions, duties, and career aspirations. I have a remarkable store of personal and academic memories of the four long years I spent with him at the University of Liverpool, UK, during which I rarely looked upon him as my teacher because he was more of a close friend and father to me. I also dedicate this book, with loving thanks, to My wife, Mrs. Nalini K. Mohan My daughter, Deepa Iyer, MBBS, MRCP (UK), FAFRM (RACP) [Honorary adjunct assistant professor, Bond University, Queensland, and senior lecturer, Griffith University and University of Queensland, Australia] My son-in-law, Kanishka B. My son, Rohit Iyer, BE (IT) My daughter-in-law, Deepti B.U. My grandsons, Vihaan and Kiaan My grandchild, Nisha Iyer

Contents

Foreword xv Acknowledgements xvii

Section I Introduction to General Arthrology 3 I.1 Classification Based on Structure 3 I.2 Classification Based on Function 4 I.3 Types of Joints/Articulations 5 I.4 Basic Structure and General Anatomy of Joints 6 I.5 Development of Limb Buds 7 I.6 Upper Limb 9 I.6.1 Physical Examination 9 I.6.2 Paralysis of the Upper Limb 9 I.6.3 Arterial Blood Supply to the Upper Limb 10 I.6.4 Venous Drainage of the Upper Limb 11 I.6.5 Lymphatics 11 I.6.6 Muscles of the Scapular Region 12 I.6.6.1 Deltoid 12 I.6.6.2 Teres major 12 I.6.6.3 Triceps brachii 12 I.6.6.4 Supraspinatus 13 I.6.6.5 Infraspinatus 13 I.6.6.6 Teres minor 13 I.6.6.7 Subscapularis 13 I.6.7 Nerves of the Scapular Region 14 I.6.8 Arteries of the Scapular Region 15 I.6.9 Topographic Anatomy of the Scapular Region 17 I.6.10 The Human Breast 17 I.6.10.1 Introduction 17 I.6.10.2 Anatomy of human breast 18 I.6.10.3 Vessels and nerves 19

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I.6.11 Muscles of the Upper Limbs I.6.11.1 Anterior compartment I.6.11.2 Posterior compartment I.6.11.3 Forearm I.6.12 Nerves of the Upper Limbs I.6.12.1 Radial nerve I.6.12.2 Median nerve I.6.12.3 Ulnar nerve I.6.13 Hand and Wrist Anatomy I.6.13.1 Bones of hand I.6.13.2 Compartments of the hand I.6.13.3 Dorsum of the hand I.6.13.4 Palm I.6.13.5 Anatomical snuff box I.6.13.6 Ligaments of the upper limb I.6.13.7 Synovial membrane I.6.13.8 Flexor tendon zones of the hand I.6.13.9 Flexor muscles of the digits I.6.13.10 Digital flexor sheath I.6.13.11 Extensor tendon zones of hand I.6.13.12 Muscles of the hand

1. Examination of the Shoulder 1.1 Inspection 1.2 Palpation 1.3 Range of Movements 1.4 Neurologic Examination 1.4.1 Reflex Testing 1.4.2 Sensation Testing 1.5 Special Tests 1.5.1 Ossification of the Bones of the Shoulder 1.6 Special Tests for the Shoulder 1.6.1 Stability of the Shoulder 1.6.2 Biceps Tests 1.6.3 Impingement Tests 1.6.4 Other Tests

21 21 22 23 27 27 28 31 32 32 32 32 33 33 34 34 34 35 35 36 37 45 45 46 48 50 53 53 54 54 59 59 61 63 64

Contents



1.7

Examination of Related Areas 1.7.1 Sternoclavicular Joint 1.7.2 Acromioclavicular Joint Arthritis 1.7.2.1 Shoulder separation 1.7.3 Dislocation of the Glenohumeral or Shoulder Joint 1.7.4 Scapular Disorders 1.7.5 Frozen Shoulder 1.7.6 Tuberculosis of the Shoulder 1.7.7 Rotator Cuff Tears 1.7.8 Biceps Tear 1.7.9 Biceps Bursitis/Tendinitis 1.7.10 Brachial Neuralgia

2. Examination of the Elbow 2.1 Inspection 2.1.1 Ligaments 2.1.2 Fat Pads 2.1.3 Bursae 2.1.4 Blood and Nerve Supply 2.1.5 Structures 2.2 Physical Examination 2.3 Inspection of Elbow 2.4 Palpation 2.5 Neurologic Examination 2.6 Special Tests 2.7 Important Lines and Angles 2.8 Examination of Related Areas

3. Examination of the Wrist and Hand (Fingers) 3.1 Anatomy of the Wrist 3.2 Functions of Wrist Complex 3.3 Inspection of the Hand 3.4 Palpation of the Hand 3.4.1 Bony Palpation 3.4.2 Soft Tissue Palpation 3.5 Range of Motion 3.5.1 Active Range of Motion 3.5.2 Passive Range of Motion

70 71 73 76

82 99 106 115 116 126 130 135 141 141 142 142 142 143 145 147 148 149 156 157 160 161 165 165 170 172 173 173 176 180 181 182

ix

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3.6 3.7 3.8



3.9 3.10 3.11 3.12

Neurologic Examination 3.6.1 Muscle Testing 3.6.2 Sensation Testing Special Tests 3.7.1 Surface Anatomy 3.7.2 History Examination of the Hand 3.8.1 Examination of the Joints 3.8.2 Examination of the Musculotendinous Units [10 and 11] 3.8.3 Examination of the Nerves [10 and 11] 3.8.3.1 Motor testing 3.8.3.2 Sensory testing Functional Tests Clinical Examination Differential Diagnosis: Special Tests Examination of Related Areas 3.12.1 Wrist Deformities 3.12.2 Stiffness of the Wrist 3.12.3 Swellings Around the Wrist 3.12.4 Deformities of the Tendons 3.12.5 Other Deformities: Dupuytren’s Contracture 3.12.6 Tunnel Syndromes 3.12.7 Open Injuries of the Hand

Section II

Introduction to Lower Limb Arthrology II.1 Pelvic Girdle II.2 Sacroiliac Joint II.2.1 Ligaments of the SIJ II.2.2 Movements of the SIJ II.2.3 Clinical Signs of SIJ Dysfunction II.2.3.1 Hypomobility lesions II.2.3.2 Degenerative changes at the SI joint

183 183 185 186 186 190 192 196 196 198 199 201 204 205 208 211 211 212 213 213 214 215 217 223 223 224 224 225 225 226 227

Contents





II.2.3.3 Osteitis condensans ilii 227 II.2.3.4 Inflammatory diseases and infections 227 Sacroiliac Joint Syndrome 228 II.3.1 Extra-articular Manifestations 228 II.3.2 Physical Examination 229 II.3.3 Tests for SIJ 230 Ankylosing Spondylitis 232 II.4.1 Epidemiology 232 II.4.2 Pathogenesis 233 II.4.3 Pathology 233 II.4.4 Clinical Features 234 II.4.5 Laboratory Findings 236 II.4.6 Radiological Evaluation 236 II.4.6.1 CT scan 238 II.4.6.2 MRI 238 II.4.6.3 Bone scintigraphy 238 II.4.7 Complications of Ankylosing Spondylitis 239 II.4.8 Differential Diagnosis 239 II.4.9 Management 240 II.4.9.1 Medical line of management 241 II.4.9.2 Surgical line of treatment 242 II.4.10 Juvenile Ankylosing Spondylitis 244



Dipen Menon, Vidhi Adulkia, and Kunal Kularni 4.1 Inspection 247 4.2 Palpation 248 4.3 Range of Motion 251 4.4 Special Tests 254 4.4.1 Introduction 254 4.4.2 Anatomy of the Hip 254 4.4.3 Biomechanics of the Hip Joint 262 4.4.4 Examination of the Hip Joint 266 4.4.5 Special Tests 268 4.4.6 Special Tests in the Pediatric Patient 275 4.4.7 Investigations 277 4.4.8 Examination of Related Areas 282



II.3 II.4

4. Examination of the Hip and the Pelvis

247

xi

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5.

Examination of the Knee 5.1 Inspection 5.2 Palpation 5.2.1 Soft Tissue Palpation 5.3 Tests for Joint Stability 5.4 Range of Motion 5.5 Neurologic Examination 5.6 Special Tests 5.7 Examination of Related Areas

293 293 294 295 299 300 301 302 314



6.1 Introduction 6.2 Incidence 6.3 Anatomy and Biomechanics 6.4 Clinical Presentation 6.5 Special Tests 6.6 Natural History 6.7 Treatment 6.7.1 Timing of Surgery 6.7.2 Graft Selection 6.7.3 Graft Placement 6.7.4 Graft Tensioning 6.7.5 Graft Fixation 6.7.6 Graft Failure 6.7.7 Rehabilitation 6.7.8 Results 6.7.9 Complications 6.8 Recent Advances in ACL Reconstruction

327 328 328 329 330 334 335 336 337 338 338 339 339 340 340 341 341

6. Anterior Cruciate Ligament Injuries of the Knee Abhishek Vaish and Raju Vaishya

7. Examination of the Foot and Ankle 7.1 Inspection of the Foot 7.2 Palpation 7.2.1 Palpation of Bony Points 7.2.1.1 Medial aspect 7.2.1.2 Lateral aspect 7.2.2 Palpation of Soft Tissue 7.3 Tests for Ankle Stability

327

343 343 344 344 344 345 347 358

Contents



7.4 7.5 7.6

Range of Motion 7.4.1 Active Range of Movements 7.4.2 Passive Range of Movements 7.4.3 Movements of the Lesser Toes Neurologic Examination Special Tests 7.6.1 Gait 7.6.1.1 Common types of gait 7.6.1.2 Walking aid 7.6.2 Inspection 7.6.3 Palpation 7.6.4 Range of Movement 7.6.5 Vascular Examination 7.6.6 Neurological Examination 7.6.6.1 Forefoot 7.6.6.2 Midfoot 7.6.6.3 Hindfoot

8. Examination of the Foot 8.1 Regions of the Foot 8.2 Features of the Dorsal Region of the Foot 8.3 Features of the Plantar Region or Sole 9. Uncommon Injuries of the Limbs 9.1 CMC Joint Arthritis of the Base of the Thumb 9.1.1 The Trapezium 9.1.2 The CMC Joint of the Thumb 9.1.3 The Intercarpal Joints 9.2 Pediatric Trigger Thumb 9.3 Bennett’s Fracture 9.3.1 Reverse Bennett’s Fracture 9.3.2 Pseudo Bennett’s Fracture 9.4 Rolando’s Fracture 9.5 Ulnar Collateral Ligament Injury 9.5.1 Classification Ulnar Collateral Ligament Injuries 9.6 Jersey Finger

359 359 359 360 361 362 362 364 364 365 369 369 374 374 374 378 379 401 401 401 403 413

413 417 417 418 432 434 436 436 437 439 440 442

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Contents



9.7

9.8

Index

Lisfranc Injury 9.7.1 Anatomy of the Ligament 9.7.2 Mechanisms of Injury 9.7.3 History and Examination Findings 9.7.4 Management The Wrist: Radiocarpal and Midcarpal Joints 9.8.1 Functions of the Wrist Complex 9.8.2 CMC Joints of Fingers



443 443 445 447 450 456 460 460

477

xv

Foreword

It gives me immense pleasure to write the foreword for Dr. K. Mohan Iyer’s book Introduction to Limb Arthrology. There are certainly many textbooks on the topic but there are not many that cover clinical examination in such detail. The book explains the special tests for each joint well and retains original figures from the authors. It has a global appeal and is suitable for practitioners at every level, befitting different healthcare settings. It is particularly useful for orthopedic trainees preparing for exams around the world. Dr. Iyer is an accomplished orthopedic and trauma surgeon who has worked, taught, and collaborated across the world. His experience adds a timeless dimension to the book that builds on the basic principles, critically analyzing the current trends. Anyone who has written a book of this magnitude would certainly appreciate that selecting high-proficiency international authors and coordinating with them for the different chapters, editing the content to ensure the central idea of the book is retained, getting relevant permissions, and bringing out an outstanding book like this is a mammoth task. I congratulate Dr. Iyer for managing this colossal task with such patience and dedication. I hope the readers also would enjoy reading the book. Vikas Khanduja MA (Cantab), MSc, FRCS, FRCS (Orth), PhD Consultant Orthopaedic Surgeon & Research Lead (Elective) Addenbrooke’s – Cambridge University Hospital Chair | SICOT Education Academy & ESSKA Hip Arthroscopy Committee President Elect | British Hip Society 2021 Royal College of Surgeons Hunterian Professor

Acknowledgements

I am extremely happy to have the foreword of this book from consultant orthopedic surgeon Vikas Khanduja. He specializes in hip and knee surgery and has a special interest in arthroscopic (keyhole) surgery of the hip. He has been instrumental in setting up the tertiary referral service for young adult hip surgery in Cambridge, UK. Complementing his clinical practice, Vikas’ research focuses on femoroacetabular impingement (FAI), a condition in which there is an abnormal contact between the rim of the acetabulum (hip socket) and femoral head–neck junction (ball of the hip), during movement of the hip. This results in pain, labral and cartilage damage, and in some cases arthritis of the hip. In particular, he has been working on disease stratification of FAI using novel imaging techniques, better pre-operative planning tools using dynamic analysis of the hip, and optimization of arthroscopic management of FAI via precision surgery using navigation to improve outcomes. He has authored over 145 peer reviewed articles and 3 books and has received the American and British Hip Society Travelling Fellowship in 2011, Royal College of Surgeons of England’s Arnott Medal in 2013, and the Insall Fellowship from the American Knee Society and Insall Foundation in 2014. I thank Mr. Jose, Mr. Menon, Mr. Raju Vaishya, and Mr. Maneesh Bhatia for kindly providing their special clinical photographs, which will help the target audience to clearly understand the importance of conventional clinical signs in orthopedics. I would also like to thank Mr. Mohan Kumar, graphics designer, Bangalore, India, for his immense help in developing the line diagrams for this book. I am extremely grateful to Mr. Magdi E. Greiss (MD, MCh Orth, FRCS, senior consultant orthopedic surgeon, North Cumbria University Hospitals, and former president, BOFAS, UK) for sharing his invaluable photographs, which he had shot during his training and early years after becoming a consultant in orthopedics.

xviii

Acknowledgements

I am also grateful to Dr. Rajesh Botchu (MBBS, MS Orth, MRCSI, MRCS Ed, FRCR, consultant musculoskeletal radiologist, the Royal Orthopaedic Hospital, Birmingham, UK) for kindly granting permission to use some of his images, including X-ray and MRI images in this book. I also thank Jenny Rompas and Stanford Chong, the directors and publishers, for guiding me throughout the publishing process and the editorial and production teams at Jenny Stanford Publishing for their invaluable support in bringing the book to its final form. Above all, I highly appreciate the help of my son, Mr. Rohit Iyer, in the presentation and publication of this book. I would also like to share that my grandchild was born during the making of this book, adding a beautiful personal moment to my memories. K. Mohan Iyer MBBS (Mumbai), MCh Orth. (Liverpool), MS Orth. (Mumbai) FCPS Orth. (Mumbai), D’Orth. (Mumbai) Bengaluru, Karnataka, India

Section I

Introduction to General Arthrology

Arthrology is the scientific study of joints and articulations. The word articulation is derived from the Greek words “arthro” meaning “joint” and “logos” meaning “science.” Therefore, an articulation is a site where rigid elements of the skeleton meet. The classification of joints can be done either on the basis of their structure or their function.

I.1 Classification Based on Structure

This type of classification involves the material that binds the bones together and the presence or absence of a joint cavity:

(a) Fibrous Joints: These joints are fixed and immovable and the bones are connected by fibrous tissue with no joint cavity, such as (i) Sutures in the skull in which a thin layer of dense fibrous connective tissue unites the bones. The joints have irregular/interlocking edges that give added strength to the joint and prevent fracture. Such a joint is also called “synarthrosis” because it is immovable or “synostosis” because this type of suture fuses completely and gets replaced by the bone. Introduction to Limb Arthrology Edited by K. Mohan Iyer Copyright © 2023 Jenny Stanford Publishing Pte. Ltd. ISBN 978-981-4877-99-2 (Hardcover), 978-1-003-37276-9 (eBook) www.jennystanford.com

4

Introduction to General Arthrology





(ii) Syndesmoses are present where there is a greater distance between articulating bones and have more fibrous connective tissue than sutures. These arrangements of connective tissue are in the form of bundles called ligaments or in the form of sheets called interosseous membranes. This amphiarthrosis has limited movement, for example, the anterior tibiofibular joint and the interosseous membranes in the forearm and leg. (iii) Gomphoses are dentoalveolar joints that are coneshaped pegs in a bony socket called “synarthrosis.” The only example of this is teeth in the alveolar processes of the maxillae and mandible.

(b) Cartilaginous Joints: These joints are slightly movable or semi-movable and the bones are united by cartilage with no joint cavity, such as (i) Synchondroses: In these joints, hyaline cartilage is the material that connects the bones, and the joints are called synarthroses (e.g., epiphyseal plates and articulation of the first rib with the manubrium of sternum when they finally become synostoses when bone replaces cartilage). (ii) Symphyses: In these joints, fibrocartilage is the material that connects the bones, and the joints are called amphiarthroses. Here, the ends of the articulating bones are covered with hyaline cartilage and thin disks of fibrocartilage connect the bones occurring in the midline of the body (e.g., intervertebral disk and pubic symphysis).

(c) Synovial Joints: These joints are the most movable in the body and have a joint cavity (synovial cavity with synovial fluid). They have two layers: articular cartilage, which covers the ends of the opposing bones, and articular capsule, which encloses the joint cavity. They have reinforcing ligaments with bursae that provide movement and stability.

I.2 Classification Based on Function

Based on their function, joints can be classified as (a) synarthroses, (b) amphiarthroses, and (c) diarthroses. While synarthroses and amphiarthroses are largely restricted to the axial skeleton, diarthroses are predominantly found in the limbs.

Types of Joints/Articulations

(a) Synarthroses: These are immovable joints, or sutures, such as fontanelles. These joints are also called “synostoses” or “syndesmoses” because there is bone-to-bone union. However, in the formation stage, the joint has a fibrous membrane between the two bones. Sometimes they are also fibrous or ligamentous. (b) Amphiarthroses (cartilaginous joints): These are slightly movable joints with fibrous connections, such as intervertebral disks. They are movable and immovable. Because there is cartilage between two bones in these joints, they allow some movement while still providing protection. (c) Diarthroses (synovial joints): These are freely movable joints and have three features:

(i) Synovial membrane: A serous membrane that produces synovial fluid that reduces friction and absorbs shock (ii) Articular cartilage (iii) Capsule: Dense connective tissue covering the joint

I.3 Types of Joints/Articulations

(a) Ball-and-socket joint: It involves triaxial movement that allows maximum freedom of movement, including flexion, extension, abduction, adduction, circumflexion, and rotation. (b) Hinge joint: It involves uniaxial movement that allows movement in only one direction, including back-and-forth movement and flexion and extension only in one plane (sagittal). Many times the articular surfaces of such joints will have a distinct shape (e.g., the spool-shaped trochlear surface of the humerus). (c) Pivot joint: It involves uniaxial movement that allows rotation when the bone has a rounded, pointed, or conical surface, which fits into a ring of another bone. (d) Saddle joint: It involves biaxial movement that allows flexion, extension, abduction, adduction, and circumduction. The bone surfaces in this type of joint are inverted with respect to each other.

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(e) Condyloid joint: It involves biaxial movement that allows flexion, extension, abduction, and adduction but not rotation. In this type of joint, one bone is concave (hollowed-out depression) and the other is convex (rounded or elliptical). (f) Sliding or gliding joint: It involves biaxial movement that allows side-to-side and back-and-forth movements. In this type of joint, the bones have two flat surfaces that slide over each other but there is no angular motion. Table I.1

Types of joints (articulations)

Joint Type

Example

1. Ball-and-socket

Hip

4. Hinge

Elbow

2. Pivot

3. Saddle

5. Condyloid 6. Gliding

Back of the neck (atlas and axis) Thumb Knee

Intercarpal joints of foot

I.4 Basic Structure and General Anatomy of Joints (a) Articular capsule: It encloses the joint cavity, is continuous with the periosteum, and is lined by the synovial membrane. (b) Synovial fluid: It is a slippery fluid that feeds cartilages. (c) Articular cartilage: It is made up of hyaline cartilage and covers the joint surfaces and their articular disks and menisci. For example, the jaw, wrist, sternoclavicular, and knee joints absorb shock, guide bone movements, and distribute forces. (d) Tendon: It attaches the muscles to bones (e) Ligament: It attaches a bone to another bone. (f) Bursa: It is a sac-like extension of a joint capsule and allows nearby structures to slide more easily past each other. (g) Tendon sheaths: These are cylinders of connective tissue lined with the synovial membrane and are wrapped around a tendon.

Development of Limb Buds

I.5 Development of Limb Buds There are four stages of limb bud development: ∑ The bud stage (initial outgrowth) ∑ The paddle stage (dorsoventral flattening) ∑ The plate stage (relative expansion of the distal end) ∑ Rotation stage (rotation around the proximodistal axis)









The important features of limb bud formation are: ∑ The upper limb buds develop at the lower cervical and upper thoracic levels C5–C8. The lower limb buds develop at the lumbar and upper sacral regions L3–L5. The upper limb buds are visible by day 26 or 27 of the embryonic stage and the lower limb buds appear 1 or 2 days later. ∑ The limb buds become visible as outpocketings from the ventrolateral body wall of the embryo at the beginning of the 5th week of the embryonic stage. ∑ Each limb bud consists of an outer ectodermal cap and an inner mesodermal core. The ectodermal cells at the end of each limb bud proliferate to form the apical ectodermal ridge (AER). ∑ Initially, the limb buds consist of a mesenchymal core. Mesenchyme, or the embryonic connective tissue, is a gelatinous substance with ‘star-shaped’ mesenchymal cells. These mesenchymal cells migrate and differentiate into many different types of primitive cell lines, such as (a) Fibroblasts (adult connective tissue forming cells) (b) Chondroblasts (cartilage-forming cells) (c) Osteoblasts (bone-forming cells) ∑ As the mesoderm within the limb proliferates, the limb elongates and the mesenchyme segregates into superficial, intermediate, and deep regions. Mesenchymal cells aggregate throughout the cores of the elongating limb buds to form the limb skeleton. Chondrification centers appear and initially, the entire limb skeleton is cartilaginous. Osteogenesis, mostly by the endochondral process, begins with the clavicle and extends throughout the fetal life and childhood. Primary

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∑



∑



∑



∑



∑



∑



∑



∑

ossification centers start in the shaft of long bones; an epiphyseal plate of cartilage occurs between the primary and secondary (epiphyseal) ossification centers. The mesenchyme in the somatopleuric mesoderm will transform into osteoblasts that will form the pelvic and pectoral girdles and also the bones of the upper and lower limbs. The process of bone formation is known as ossification. The mesenchyme in the buds begins to condense, and by the end of the 6th week, the first hyaline cartilage models, foreshadowing the bones of the extremity can be recognized. Intra cartilaginous ossification, which is one of the two methods of bone development, begins during intrauterine life. In this type of ossification, the mesenchymal tissue first gives rise to a hyaline cartilage model of the bone and then the osteoblasts convert that model into a bone (e.g., long bones, irregular bones like vertebrae). There is evidence that the limb muscles develop from somites and that the cells migrate into the limb bud. Generally, the muscles differentiate on the flexor and extensor sides of the axial skeleton of the limbs, in the proximo-distal direction. The upper extremity rotates laterally through 90 degrees on its longitudinal axis. As a result, the elbow joint is located dorsally and operates in the ventral direction. The flexor and extensor compartments are located ventrally and dorsally, respectively. In the lower limb, the rotation of almost 90 degrees occurs in the medial direction. The patella comes to lie anteriorly and the knee operates in the dorsal direction. The flexor and extensor compartments are located in the dorsal and ventral aspects of the lower limb, respectively. It is this type that is mostly seen in the long bones of limbs. First, a hyaline cartilage model is formed in the mesenchyme. Then a primary ossification center appears in the ‘diaphysis’ of the model. Thereafter, bone formation and laying start from the center in both the upward and downward directions. Almost all primary centers of ossification appear before birth. Most of the secondary centers appear after birth. The part of a long bone ossified from the primary center is the ‘diaphysis,’

Upper Limb

while the part of a long bone ossified from a secondary center is the ‘epiphysis.’ The fusion between the diaphysis and the epiphysis does not occur until puberty.

I.6 Upper Limb

I.6.1 Physical Examination Chapters 1 to 3 discuss in detail the examination of the shoulder, elbow, wrist, and fingers, respectively. C5

C6

C7

C8

T1

Figure I.1 The anatomy starts with the brachial plexus.

I.6.2 Paralysis of the Upper Limb (a) Erb’s paralysis: It occurs due to an injury in C5 and C6 during birth or later in life. In this paralysis, the arm hangs by the side and rotates medially, the forearm is pronated and extended, and the wrist and fingers are flexed. (b) Klumpke’s paralysis: It occurs due to a birth injury in C8 and T1. In this, the intrinsic muscles and long flexors of the hand are paralyzed, resulting in a claw hand with extension at the metacarpophalangeal (MCP) joint along with flexion at the interphalangeal joint (IPJ).

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Note: A cervical rib with a post-fixed brachial plexus can also cause klumpke’s paralysis. (c) Winging of the Scapula: It occurs due to an injury to the long thoracic nerve and, in turn, paralysis of the serratus anterior muscle. (d) Humeral fracture at the surgical neck can cause paralysis of the axillary nerve with loss of abduction.

I.6.3 Arterial Blood Supply to the Upper Limb

The axillary artery begins at the lateral border of the first rib as a continuation of the subclavian artery. The artery has the following six primary branches: (i) Supreme thoracic artery (ii) Thoracoacromial artery (iii) Lateral thoracic artery (iv) Subscapular artery (v) Anterior humeral circumflex artery (vi) Posterior humeral circumflex artery For purposes of description, these primary branches can be categorized as follows into three parts with respect to their relation to the pectoralis minor muscle. (i) Brachial: The supreme thoracic artery falls in this category and is between the lateral border of the first rib and the medial border of the pectoralis minor. (ii) Radial (radial recurrent, superficial radial, and deep radial): The thoracoacromial and lateral thoracic arteries fall in this category and are behind the pectoralis minor. Ulnar (anterior ulnar recurrent, posterior ulnar recurrent, common interosseous, posterior interosseous, anterior interosseous): The subscapular and the anterior and posterior humeral circumflex arteries fall in this category and are between the lateral border of the pectoralis minor and the inferior border of the teres major (superficial branch and deep branch). The superficial branch is formed mainly from the ulnar artery and is completed by the superficial branch of the radial artery, which may or may not be complete or be even extremely small. The deep arterial is formed by manly the deep branch of the radial artery and is completed by the deep branch of the ulnar artery.

Upper Limb

I.6.4 Venous Drainage of the Upper Limb

∑ Tributaries of the cephalic vein drain on the lateral side of the dorsal venous arch of the hand ∑ Superficial veins of the forearm drain into the axillary vein, draining the superficial parts of the lateral hand and lateral forearm. (Note: The median cubital vein usually shunts some of the blood collected by the cephalic vein to the basilic vein. (Latin/ Greek, kephale = head) ∑ The axillary vein lies along the medial side of the artery and is a continuation of the basilic vein. ∑ The basilic vein begins at the inferior border of the teres major muscle and ends at the lateral border of the first rib, where it becomes the subclavian vein. ∑ It also receives tributaries that are parallel to the branches of the axillary artery. ∑ The cephalic vein joins the axillary vein just before it becomes the subclavian vein. Hence, penetrating wounds in the larger upper part are serious because air might enter the venous system. ∑ The veins that run with their corresponding arteries are frequently multiple (2 or 3 interconnected veins). This interconnected venous network is called the vena commitantes.

I.6.5 Lymphatics

The lymph nodes of the axilla are as follows: (i) Central axillary nodes [15 to 20 lymph nodes], adjacent to the axillary vein (ii) Lateral axillary nodes [15 to 20 lymph nodes], also adjacent to the axillary vein (iii) Posterior axillary nodes [15 to 20 lymph nodes], just alongside the subscapular vein (iv) Apical axillary nodes [15 to 20 lymph nodes] (v) Anterior axillary nodes [15 to 20 lymph nodes], just below the pectoralis major

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I.6.6 Muscles of the Scapular Region I.6.6.1 Deltoid Origin: Lateral one-third of the clavicle, acromion, the lower lip of the crest of the spine of the scapula Insertion: Lateral one-third of the clavicle, acromion, the lower lip of the crest of the spine of the scapula

Action: Abducts arm; anterior fibers flex and medially rotate the arm; posterior fibers extend and laterally rotate the arm Innervation: Axillary nerve (C5, C6) from the posterior cord of the brachial plexus Artery: Posterior circumflex humeral artery

I.6.6.2 Teres major

Origin: From the dorsal surface of the inferior angle of the scapula Insertion: Into the crest of the lesser tubercle of the humerus

Action: Adducts the arm, medially rotates the arm, assists in arm extension

Innervation: Lower subscapular nerve (C5, C6) from the posterior cord of the brachial plexus Artery: Circumflex scapular artery

I.6.6.3 Triceps brachii

Origin: Long head from the infraglenoid tubercle of the scapula; the lateral head from the posterolateral humerus and the medial head from the surface of the inferior ½ of the humerus Insertion: Into the olecranon process of the ulna

Action: Extends the forearm while the long head extends and adducts the arm Innervation: By the radial nerve

Artery: Supplied by the deep brachial (profunda brachii) artery

Upper Limb

I.6.6.4 Supraspinatus Origin: From the supraspinatus fossa

Insertion: It is inserted into the greater tubercle of the humerus (highest facet)

Action: It abducts the arm (initiates abduction); the supraspinatus initiates abduction of the arm, then the deltoid muscle completes the action; a member of the rotator cuff group Innervation: By the suprascapular nerve (C5, C6) from the superior trunk of the brachial plexus Artery: Supplied by the suprascapular artery

I.6.6.5 Infraspinatus

Origin: From the infraspinatous fossa

Insertion: Into the greater tubercle of the humerus (middle facet)

Action: Laterally rotates the arm; the infraspinatus, supraspinatus, teres minor, and subscapularis are the rotator cuff muscles Innervation: By the suprascapular nerve

Artery: Supplied by the suprascapular artery

I.6.6.6 Teres minor

Origin: From the upper 2/3 of the lateral border of the scapula

Insertion: Into the greater tubercle of the humerus (lowest facet)

Action: It laterally rotates the arm; it fixes the head of the humerus in the glenoid fossa during abduction and flexion of the arm; a member of the rotator cuff group Innervation: By the axillary nerve (C5, C6) from the posterior cord of the brachial plexus Artery: Supplied by the circumflex scapular artery

I.6.6.7 Subscapularis

Origin: From the medial two-thirds of the costal surface of the scapula (subscapular fossa)

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Insertion: Into the lesser tubercle of the humerus

Action: It medially rotates the arm; assists extension of the arm; the subscapularis, supraspinatus, infraspinatus, and teres minor are the rotator cuff muscles Innervation: By the upper and lower subscapular nerves (C5, C6) Artery: Supplied by the subscapular artery

I.6.7 Nerves of the Scapular Region 1. Axillary nerve Source: It originates from the posterior cord of the brachial plexus. Branches: Superior lateral brachial cutaneous nerve Action: Motor to the deltoid, teres minor Sensory: It supplies the skin of the upper lateral arm. It may be endangered by surgical neck fractures.

2. Lower subscapular nerve Source: It originates from the posterior cord of the brachial plexus. Branches: It gives off some unnamed muscular branches. Action: Motor to the subscapularis and teres major muscles; the subscapularis and teres major are synergists (medial rotation of the humerus) Sensory: It has no cutaneous branches. 3. Middle subscapular nerve Source: It originates from the posterior cord of the brachial plexus (C7, C8). Branches: It also has some unnamed muscular branches. Action: It supplies the latissimus dorsi muscle. It is also called the thoracodorsal nerve. Sensory: It has no cutaneous branches.

4. Suprascapular nerve Source: It originates from the superior trunk of the brachial plexus (C5, C6). Branches: It has no named branches. Action: It mainly supplies the supraspinatus and the infraspinatus. The suprascapular nerve passes through the scapular notch inferior to the superior transverse scapular ligament.

Upper Limb

Sensory: It has no cutaneous branches.

5. Thoracodorsal nerve Source: It originates from the posterior cord of the brachial plexus. Branches: It has some unnamed muscular branches. Action: It mainly supplies the latissimus dorsi muscle. It is also called the middle subscapular nerve. Sensory: It has no cutaneous branches.

6. Upper subscapular nerve Source: It originates from the posterior cord of the brachial plexus (C5, C6). Branches: It has some unnamed muscular branches. Action: It is motor to only the subscapularis muscle, which is a strong medial rotator of the humerus. Sensory: It has no cutaneous branches.

I.6.8 Arteries of the Scapular Region

1. Anterior circumflex humeral artery Source: Axillary artery, 3rd part Branches: Unnamed muscular branches Supply to deltoid muscle; arm muscles near the surgical neck of the humerus; anterior circumflex humeral artery anastomoses with the posterior circumflex humeral artery 2. Posterior circumflex humeral artery Source: Axillary artery, 3rd part Branches: Unnamed muscular branches Supply to deltoid; arm muscles near the surgical neck of the humerus. The posterior circumflex humeral artery anastomoses with the anterior circumflex humeral artery. It passes through the quadrangular space with the axillary nerve. 3. Axillary artery Source: Subclavian artery (axillary artery is the continuation of the subclavian lateral to the 1st rib) Branches: 1st part, superior thoracic artery; 2nd part, thoracoacromial artery, lateral thoracic artery; 3rd part, anterior humeral circumflex artery, posterior humeral circumflex artery, subscapular artery. The

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pectoralis minor crosses anterior to the axillary artery and is used to delineate the three parts mentioned on left. Supply to pectoral region, shoulder region, and upper limb.

4. Circumflex scapular artery Source: Subscapular artery Branches: Unnamed muscular branches Supply to Teres major muscle, Teres minor muscle, Infraspinatus muscle. The circumflex scapular artery anastomoses with the suprascapular artery and the dorsal scapular artery to form the scapular anastomosis.

5. Dorsal scapular artery: Source: Subclavian artery, 3rd part Branches: Unnamed muscular branches Supply to Levator scapulae muscle, rhomboideus major muscle, rhomboideus minor muscle. The dorsal scapular artery anastomoses with the suprascapular artery and the subscapular artery to form the scapular anastomosis. The dorsal scapular artery is a branch of the transverse cervical artery in ~30% of cases.

6. Subscapular artery Source: Axillary artery, 3rd part Branches: Circumflex scapular artery and thoracodorsal artery Supply to subscapularis muscle, teres major muscle, teres minor muscle, infraspinatus muscle The circumflex scapular branch of the subscapular artery anastomoses with the suprascapular artery and the dorsal scapular artery in the scapular anastomosis. 7. Suprascapular artery Source: Thyrocervical trunk Branches: It has a few muscular branches. Supply to supraspinatus and infraspinatus, and the shoulder joint 8. Thoracodorsal artery Source: Subscapular artery

Branches: Unnamed muscular branches

Upper Limb

Supply to Latissimus dorsi muscle. Thoracodorsal artery accompanies the thoracodorsal nerve

I.6.9 Topographic Anatomy of the Scapular Region (i) Quadrangular space: It is the space bounded by the teres minor muscle superiorly, the teres major muscle inferiorly, the long head of the triceps brachii muscle medially, and the humerus laterally. Significance: The axillary nerve and the posterior circumflex humeral artery pass through this space. (ii) Triangular interval: It is the interval between teres major muscle superiorly, long head of the triceps brachii muscle medially, and humerus laterally. Significance: The radial nerve passes through this interval to get from the axilla to the posterior surface of the humerus. (iii) Triangular space: It is the space bounded by the teres minor muscle superiorly, the teres major muscle inferiorly, and the long head of the triceps brachii muscle laterally. Significance: The circumflex scapular vessels are located in this space as they pass from the axilla to the dorsum of the scapula.

I.6.10 The Human Breast I.6.10.1 Introduction

It is made up of suspensory ligaments, lobe, lactiferous sinus, alveoli, lactiferous ducts, lobule, areolar gland, nipple, and areola and consists of 10 to 20 simple glands. The presence of more than two nipples is known as polythelia and the presence of more than two complex mammary glands as polymastia. (i) Embryologically: Belongs to integument (ii) Functionally: Part of the reproductive system (a) Respond to sexual stimulation (b) Feed babies (iii) Modified apocrine sweat glands: It is the apex of cell, becomes part of secretion, and breaks off (iv) Present in males and females

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I.6.10.2 Anatomy of human breast A. Position and attachment (i) Lateral aspect of the pectoral region (ii) Located between ribs 3 and 6/7 (iii) Extend form sternum to axilla (iv) Surrounded by superficial fascia (v) Rest on the deep fascia (vi) The breast is fixed to the overlying skin and the underlying pectoral fascia by fibrous bands known as Cooper’s ligaments. Note: The left breast is usually slightly larger with its base circular, either flattened or concave, and is separated from the pectoralis major muscle by fascia, retromammary space.

B. Structure (i) Its outer surface is convex and is covered by skin. (ii) Nipple (a) It is usually located in the 4th intercostal space. (b) It has a small conical/cylindrical prominence below the center. (c) It is surrounded by an areola, which is a pigmented ring of skin. (iii) Areola ∑ It is a thin-skinned region, lacking hair and sweat glands. ∑ It contains areolar glands. ∑ The areolar pigment darkens in pregnancy. ∑ It has radial smooth muscle fibers and can cause nipple erection. (iv) Lobes and lobules (a) Excretory (lactiferous) ducts converge toward the areola ∑ They form ampullae (collection sites of lactiferous sinuses) ∑ Ducts become contracted at the base of the nipple (b) Secretory epithelium ∑ They change with hormonal signals, usually at the onset of menstruation. ∑ During pregnancy, the glands begin to enlarge in 2nd month.

Upper Limb









∑ After birth, the 1st secretion is called colostrum and it contains antibodies. (c) “Tail of Spence” or the axillary tail ∑ It is the prolongation of the upper, outer quadrant in the axillary direction. ∑ It passes under the axillary fascia, which may be mistaken for axillary lymph nodes. (d) Fatty tissue ∑ It surrounds the surface and fills spaces between lobes. ∑ It determines the form and size of the breast. ∑ It has no fatty deposit under the nipple and areola.

I.6.10.3 Vessels and nerves

A. Arteries: These are derived from the thoracic branches of three pairs of arteries: (i) Axillary arteries: These are continuous with the subclavian artery that gives rise to the external mammary (lateral thoracic) artery. (ii) Internal mammary (thoracic) arteries: These are the first descending branch of the subclavian artery that supply intercostal spaces and the breast. These arteries are used in coronary bypass surgery. (iii) Intercostal arteries: These are the numerous branches that emerge from the internal and external mammary arteries.

B. Veins: They form a ring around the base of the nipple, called the “circulus venosus.” Large veins pass from the circulus venosus to the circumference of the mammary gland, and then to (i) the external mammary vein to the axillary vein or (ii) the internal mammary vein to the subclavian vein. C. Innervations: These are derived from (i) the anterior and lateral cutaneous nerves of the thorax or (ii) spinal segments T3 – T6.

D. Lymphatics: These are clinically significant. (i) Glandular lymphatics drain into the anterior axillary (pectoral) nodes and subsequently into the central axillary nodes, the apical nodes, the deep cervical nodes, and the subclavicular (subclavian) nodes.

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(ii) Medial quadrants drain into the parasternal nodes. (iii) The superficial regions of the skin, areola, and nipples form large channels that drain into the pectoral nodes. Note: Axillary nodes also drain lymph from the arm.

Routes of Metastasis (i) From medial lymphatics to parasternal nodes and then to mediastinal nodes (ii) Across the sternum in lymphatics to the opposite side via cross-mammary pathways and then to the contralateral breast (iii) From sub-diaphragmatic lymphatics to nodes in the abdomen and then to the liver, ovaries, and peritoneum (Fig. I.2)

Figure I.2 Breast cancer secondaries. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

The arteries supplying the mammae are derived from the thoracic branches of the axillary, the intercostals, and the internal mammary. The veins describe the anastomotic circle around the base of the papilla, called by Haller the circulus venosus. From this, large branches transmit the blood to the circumference of the gland and end in the axillary and internal mammary veins.

Upper Limb

I.6.11 Muscles of the Upper Limbs I.6.11.1 Anterior compartment 1. Coracobrachialis Origin: Coracoid process of the scapula with biceps brachii Insertion: Upper half medial border of the humerus Action: Flexes and weakly adducts arm

Nerve: Musculocutaneous nerve (C5, 6, 7) (from the lateral cord)

2. Musculus brachialis Origin: From the anterior surface of the humerus, particularly the distal half of this bone Insertion: Coronoid process and the tuberosity of the ulna Artery: Radial recurrent artery

Nerve: Musculocutaneous nerve

Action: Flexion at elbow joint The biceps are tri-articulate, meaning that it works across three joints. The most important of these functions is to supinate the forearm and flex the elbow. These joints and the associated actions are listed as follows in the order of importance: (i) Proximal radioulnar joint (ii) Humeroulnar joint and (iii) Glenohumeral joint

3. Musculus biceps brachii Origin: Short head – coracoid process of the scapula; Long head – supraglenoid

Insertion: Radial tuberosity and bicipital aponeurosis into deep fascia on the medial part of the forearm Artery: Brachial artery

Nerve: Musculocutaneous nerve (C5–C7)

Action: Flexes elbow and supinates forearm Antagonist: Triceps brachii muscle

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I.6.11.2 Posterior compartment 1. Triceps muscle Origin: Long head – scapula; Lateral head – posterior humerus; Medial head – posterior humerus Insertion: Olecranon process of the ulna Artery: Profunda brachii Nerve: Radial Action: Extends the forearm Antagonist: Biceps brachii

2. Anconeus Origin: Lateral condyle of humerus Insertion: Lateral surface of the olecranon process and superior part of the ulna Artery: Profunda brachii (recurrent interosseous artery) Nerve: Radial (C7, C8, and T1) Action: Partly blended in with the triceps, which it assists in extension of the forearm; also stabilizes the elbow and abducts the ulna during pronation

3. Cubital fossa The cubital fossa is the region of the upper limb in front of the elbow joint. It is a triangular area with the following boundaries: ∑ Laterally: brachioradialis muscle ∑ Medially: pronator teres muscle ∑ Superiorly: an imaginary line from the medial and lateral epicondyles (i) Muscular floor: (a) supinator, (b) brachialis, and (c) biceps tendon (ii) Bony floor: (a) humerus, (b) radius, and (c) ulna (iii) Artery–nerve layer: (a) brachial artery and (b) median nerve (iv) Aponeurotic layer: (a) bicipital aponeurosis and (b) biceps tendon (v) Venous layer: (a) cephalic vein, (b) basilic vein, and (c) median cubital vein

Upper Limb

I.6.11.3 Forearm I.6.11.3.1 Anterior compartment 1. Flexor carpi radialis Origin: From the common flexor tendon from the medial epicondyle of the humerus Insertion: Into the base of the second and third metacarpals Action: Flexes the wrist and abducts the hand Nerve supply: Median nerve

2. Flexor carpi ulnaris Origin: From the common flexor tendon and (ulnar head) from the medial border of the olecranon and upper 2/3 of the posterior border of the ulna Insertion: Into the pisiform, hook of hamate, and base of 5th metacarpal Action: Flexes the wrist and adducts the hand Nerve supply: Ulnar nerve 3. Flexor digitorum profundus Origin: From the posterior border of the ulna, proximal two-thirds of the medial border of the ulna and the interosseous membrane Insertion: Into the base of the distal phalanx of the digits 2 to 5

Action: Flexes the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints Nerve supply: From the median nerve via anterior interosseous branch (radial one-half) and the ulnar nerve (ulnar one-half)

4. Flexor digitorum superficialis Origin: Humeroulnar head from the common flexor tendon and the radial head from the middle 1/3 of the radius Insertion: Into the shafts of the middle phalanges of the digits 2 to 5 Action: Flexes the metacarpophalangeal and proximal interphalangeal joint Nerve supply: Median nerve 5. Flexor pollicis longus Origin: From the anterior surface of radius and interosseous membrane

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Insertion: Into the base of the distal phalanx of the thumb

Action: Flexes the metacarpophalangeal and interphalangeal joints of the thumb Nerve supply: Median nerve via anterior interosseous branch

6. Pronator quadratus Origin: From the medial side of the anterior surface of the distal onefourth of the ulna

Insertion: Into the anterior surface of the distal one-fourth of the radius Action: Pronates the forearm

Nerve supply: From the median nerve via the anterior interosseous branch 7. Cubital fossa Origin: From the medial epicondyle of humerus

Insertion: Into the distal half of flexor retinaculum and palmaris aponeurosis

Action: Flexes the hand (at the wrist) and tightens palmar aponeurosis Nerve supply: From the median nerve (C7 and C8) ulnar artery

8. Pronator teres Origin: From the common flexor tendon and (deep or ulnar head) from the medial side of the coronoid process of the ulna

Insertion: Into the midpoint of the lateral side of the shaft of the radius Action: Pronates the forearm Nerve supply: Median nerve

9. Supinator Origin: From the lateral epicondyle of the humerus, supinator crest and fossa of the ulna, radial collateral ligament, annular ligament Insertion: Into the lateral side of proximal one-third of the radius Action: Supinates the forearm

Nerve supply: Deep radial nerve

Upper Limb

I.6.11.3.2 Posterior compartment 1. Abductor pollicis longus Origin: From the middle one-third of the posterior surface of the radius, interosseous membrane, mid-portion of posterolateral ulna Insertion: Into the radial side of the base of the first metacarpal Action: Abducts the thumb at the carpometacarpal joint Nerve supply: Radial nerve, deep branch

2. Brachioradialis Origin: From the upper two-thirds of the lateral supracondylar ridge of the humerus Insertion: Into the lateral side of the base of the styloid process of the radius Action: Flexes the elbow and assists in pronation and supination PS: The brachioradialis, flexor of the forearm, is unusual in that it is located in the posterior compartment, but it is actually in the anterior portion of the forearm. Nerve supply: Radial nerve 3. Extensor carpi radialis longus Origin: From the lower one-third of the lateral supracondylar ridge of the humerus Insertion: Into the dorsum of the second metacarpal bone (base) Action: It extends the wrist; abducts the hand Nerve supply: Radial nerve 4. Extensor carpi radialis brevis Origin: From the common extensor tendon (lateral epicondyle of humerus) Insertion: Into the dorsum of the third metacarpal bone (base) Action: Extends the wrist; abducts the hand Nerve supply: Deep radial nerve 5. Extensor carpi ulnaris Origin: From the common extensor tendon and the middle one-half of the posterior border of the ulna Insertion: Into the medial side of the base of the 5th metacarpal Action: Extends the wrist; adducts the hand Nerve supply: Deep radial nerve

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6. Extensor digiti minimi Origin: From the common extensor tendon (lateral epicondyle of the humerus) Insertion: Joins the extensor digitorum tendon to the 5th digit and inserts into the extensor expansion Action: Extends the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints of the 5th digit Nerve supply: deep radial nerve 7. Extensor digitorum Origin: From the common extensor tendon (lateral epicondyle of the humerus) Insertion: Into the extensor expansion of digits 2 to 5 Action: It extends the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints of the 2nd–5th digits; extends wrist deep Nerve supply: Radial nerve

8. Extensor indicis Origin: From the interosseous membrane and the posterolateral surface of the distal ulna Insertion: Its tendon joins the tendon of the extensor digitorum to the second digit; both tendons insert into the extensor expansion Action: It extends the index finger at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints Nerve supply: Deep radial nerve 9. Extensor pollicis brevis Origin: From the interosseous membrane and the posterior surface of the distal radius Insertion: Into the base of the proximal phalanx of the thumb Action: Extends the thumb at the metacarpophalangeal joint Nerve supply: Deep radial nerve

10. Extensor pollicis longus Origin: From the interosseous membrane and middle part of the posterolateral surface of the ulna Insertion: Into the base of the distal phalanx of the thumb Action: Extends the thumb at the interphalangeal joint Nerve supply: Deep radial nerve

Upper Limb

I.6.12 Nerves of the Upper Limbs The radial, median, and ulnar nerves are the main nerves of the upper limbs.

I.6.12.1 Radial nerve

The radial nerve originates as a terminal branch of the posterior cord of the brachial plexus. It goes through the arm, first in the posterior compartment of the arm, later in the anterior compartment of the arm, and continues in the posterior compartment of the forearm.

Arm ∑ In the arm, the radial nerve arises from the brachial plexus and travels posteriorly through what is often called the triangular interval (US) or the triangular space of the axilla (UK). ∑ It enters the arm behind the axillary artery/brachial artery, and it then travels posteriorly on the medial side of the arm. ∑ After giving off branches to the long and medial heads of the triceps brachii, it enters a groove on the humerus, the radial sulcus. ∑ Along with the deep brachial artery, the radial nerve winds around in the groove (between the medial and lateral heads of the triceps) toward the forearm, running laterally on the posterior aspect of the humerus. ∑ While in the groove, it gives off a branch to the lateral head of the triceps brachii. The radial nerve emerges from the groove on the lateral aspect of the humerus. At this point, it pierces the lateral intermuscular septum and enters the anterior compartment of the arm. ∑ It continues its journey inferiorly between the brachialis and brachioradialis muscles. When the radial nerve reaches the distal part of the humerus, it passes anterior to the lateral epicondyle and continues in the forearm. Branches/Innervations The following are the branches/innervations of the radial nerve (including the superficial branch of the radial nerve and the deep branch of the radial nerve/posterior interosseous nerve). Cutaneous innervation is provided by the following nerves: ∑ Posterior cutaneous nerve of arm (originates in the axilla)

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∑ Inferior lateral cutaneous nerve of arm (originates in the arm) ∑ Posterior cutaneous nerve of forearm (originates in the arm)

The superficial branch of the radial nerve provides sensory innervation to much of the back of the hand, including the web of skin between the thumb and index finger.

Forearm ∑ In the forearm, it branches into a superficial branch (primarily sensory) and a deep branch (primarily motor). ∑ The superficial branch of the radial nerve descends in the forearm under the brachioradialis. ∑ It eventually pierces the deep fascia near the back of the wrist. ∑ The deep branch of the radial nerve pierces the supinator muscle, after which it is known as the posterior interosseous nerve. Motor (i) Muscular branches of the radial nerve: triceps brachii, anconeus, brachioradialis, and extensor carpi radialis longus (ii) Deep branch of the radial nerve: extensor carpi radialis brevis and supinator ∑ The posterior interosseous nerve is a continuation of the deep branch after the supinator for the following muscles: extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis.

I.6.12.2 Median nerve





∑ It is derived from the lateral and medial cords of the brachial plexus. ∑ Disk herniations in the cervical spine (at the level of C5–C8 and T1) can cause numbness and/or decreased grip strength in the hand. ∑ The median nerve courses with the brachial artery on the medial side of the arm between biceps brachii and brachialis at the first lateral to the artery. ∑ It then crosses anteriorly to run medial to the artery in the distal arm and into the cubital fossa.

Upper Limb









∑ The median nerves arise from the cubital fossa and pass between the two heads of the pronator teres. ∑ It then travels between flexor digitorum superficialis and flexor digitorum profundus, before emerging between flexor digitorum superficialis and flexor carpi radialis. ∑ The unbranched portion of the median nerve innervates muscles of the superficial and intermediate groups of the anterior compartment except for flexor carpi ulnaris. ∑ The median nerve gives off two branches as it courses through the forearm: (a) The anterior interosseous branch courses with the anterior interosseous artery and innervates all the muscles of the anterior compartment of the forearm except the flexor carpi ulnaris and the medial (ulnar) half of flexor digitorum profundus. Its ends with its innervation of the pronator quadratus. (b) The palmar cutaneous branch of the median nerve arises at the distal part of the forearm. It supplies sensory innervation to the lateral aspect of the skin of the palm (but not the digits).

Distribution Arm: The median nerve has no voluntary motor or cutaneous function in the (upper) arm. It gives vascular branches to the wall of the brachial artery. These vascular branches carry sympathetic fibers. Forearm: It innervates all of the flexors in the forearm except flexor carpi ulnaris and that part of flexor digitorum profundus that supplies the medial two digits. The latter two muscles are supplied by the ulnar nerve (specifically the muscular branches of the ulnar nerve). The main portion of the median nerve supplies the following muscles: ∑ Superficial group, namely pronator teres, flexor carpi radialis, and palmaris longus ∑ Intermediate group, namely flexor digitorum superficialis muscle

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The anterior interosseus branch of the median nerve supplies the following muscles: ∑ Deep group: Flexor digitorum profundus (only the lateral half), flexor pollicis longus, and the pronator quadratus Branches in the hand

∑ The median nerve enters the hand through the carpal tunnel, deep into the flexor retinaculum along with the tendons of flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus. From there it sends off several branches: (i) Recurrent branch to muscles of the thenar compartment (the recurrent branch is also called “the million-dollar nerve”) [1] (ii) Digital cutaneous branches to the common palmar digital branch and the proper palmar digital branch of the median nerve, which supply the: (a) lateral (radial) three and a half digits on the palmar side and the (b) index, middle, and ring fingers on the dorsum of the hand ∑ In the hand, the median nerve supplies motor innervation to the 1st and 2nd lumbrical muscles. ∑ It also supplies the muscles of the thenar eminence by a recurrent thenar branch. ∑ The rest of the intrinsic muscles of the hand are supplied by the ulnar nerve. ∑ The muscles of the hand supplied by the median nerve can be remembered using the mnemonic “LOAF” – L for lumbricals 1 and 2, O for opponens pollicis, A for abductor pollicis brevis, and F for flexor pollicis brevis. ∑ The median nerve innervates the skin of the palmar side of the thumb, the index and middle finger, half the ring finger, and the nail bed of these fingers. ∑ The opponens pollicis muscle is innervated exclusively by the median nerve. ∑ The inability to firmly hold an object between the index finger and thumb is a classic sign of median nerve pathology.

Upper Limb





∑ The lateral part of the palm is supplied by the palmar cutaneous branch of the median nerve, which leaves the nerve proximal to the wrist creases. ∑ This palmar cutaneous branch travels in a separate fascial groove adjacent to the flexor carpi radialis and then superficial to the flexor retinaculum. It is therefore spared in carpal tunnel syndrome.

I.6.12.3 Ulnar nerve

Arm ∑ The ulnar nerve comes from the medial cord of the brachial plexus and descends on the posteromedial aspect of the humerus. ∑ It goes behind the medial epicondyle, through the cubital tunnel, at the elbow. Forearm ∑ It enters the anterior (flexor) compartment of the forearm through the two heads of flexor carpi ulnaris and runs alongside the ulna. ∑ There it supplies one and a half muscles (flexor carpi ulnaris and medial half of flexor digitorum profundus). ∑ It soon joins with the ulnar artery, and the two travel inferiorly together, deep to the flexor carpi ulnaris muscle. ∑ In the forearm, it gives off the following branches: muscular branches of the ulnar nerve, the palmar branch of the ulnar nerve, and the dorsal branch of the ulnar nerve.

Hand ∑ After it travels down the ulna, the ulnar nerve enters the palm. ∑ The ulnar nerve and artery pass superficial to the flexor retinaculum, via the ulnar canal. ∑ The course of the ulnar nerve through the wrist contrasts with that of the median nerve, which travels deep to the flexor retinaculum of the hand and therefore through the carpal tunnel. ∑ In the hand, the ulnar nerve gives the superficial branch of the ulnar nerve and the deep branch of the ulnar nerve.

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I.6.13 Hand and Wrist Anatomy I.6.13.1 Bones of hand There are a total of 27 bones in the hand and wrist, which are grouped into carpals, metacarpals, and phalanges. (i) Carpal Bones ∑ All carpal bones participate in wrist function except for the pisiform. ∑ The scaphoid serves as a link between each row, therefore, it is vulnerable to fractures. ∑ The distal row of carpal bones is strongly attached to the base of the second and third metacarpals, forming a fixed unit. (ii) Metacarpals ∑ The hand contains five metacarpals. ∑ The first metacarpal articulates proximally with the trapezium. ∑ The other four metacarpals articulate with the trapezoid, capitate, and hamate at the base. (iii) Phalanges ∑ The hand contains 14 phalanges. ∑ All four distal carpal bones articulate with the metacarpals at the carpometacarpal (CMC) joints.

I.6.13.2 Compartments of the hand

There are 11 separate osteofascial compartments: (i) Dorsal (ii) Interossei (4 compartments) (iii) Palmar (iv) Interossei (4 compartments) (v) Adductor pollicis (vi) Thenar (vii) Hypothenar

I.6.13.3 Dorsum of the hand

The posterior antebrachial cutaneous supplies the skin of the dorsum of the wrist. The radial nerve supplies the skin of the dorsum of the

Upper Limb

thumb and 2½ digits as far as the distal interphalangeal joint. The ulnar nerve supplies the ulnar 1½ digits and the adjacent part of the dorsum of the hand.

I.6.13.4 Palm

(i) The ulnar nerve supplies sensation to the skin of ulnar 1½ digits and motor to muscles of the hypothenar eminence and motor to ulnar two lumbricals, motor to seven interossei, motor to adductor pollicis muscle. (ii) The median nerve supplies the sensory to the skin of the palmar aspect of the thumb and 2½ digits including the skin on the dorsal aspect. It also supplies the distal phalanges, motor to muscles of the thenar eminence, and motor to radial two lumbrical muscles.

I.6.13.5 Anatomical snuff box

The anatomical snuffbox, or radial fossa (Foveola radialis in Latin), is a triangular deepening on the radial, dorsal aspect of the hand at the level of the carpal bones, specifically, the scaphoid and trapezium bones forming the floor. The name originates from the use of this surface for placing and then sniffing powdered tobacco, or “snuff.”

The boundaries ∑ The medial border of the snuffbox is the tendon of the extensor pollicis longus. ∑ The lateral border consists of the tendons of the extensor pollicis brevis and the abductor pollicis longus. ∑ The proximal border is formed by the styloid process of the radius. ∑ The distal border is formed by the approximate apex of the schematic snuffbox isosceles triangle. ∑ The floor of the snuffbox varies depending on the position of the wrist, but both the trapezium and primarily the scaphoid can be palpated. ∑ Deep to the tendons that form the borders of the anatomical snuff box lies the radial artery, which passes through the anatomical snuffbox on its course from the normal radial

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pulse detecting the area to the proximal space in between the first and second metacarpals to contribute to the superficial and deep palmar arches. ∑ The cephalic vein arises within the anatomical snuffbox, while the dorsal cutaneous branch of the radial nerve can be palpated by stroking along the extensor pollicis longus with the dorsal aspect of a fingernail.

I.6.13.6 Ligaments of the upper limb



∑ The acromio-clavicular ligament joins the acromion process to the clavicle. ∑ The coracoclavicular ligament joins the coracoid process to the clavicle as well as to the acromion process. ∑ The ligaments of the shoulder joint are (i) capsular, (ii) coracohumeral, (iii) gleno-humeral, and (iv) glenoid. ∑ The ligaments of the elbow are in the form of a capsule that surrounds the joint on all sides, which are as follows: (i) external lateral, (ii) internal lateral, (iii) anterior, and (iv) posterior. ∑ The ligaments of the wrist are (i) anterior, (ii) posterior, (iii) internal lateral, and (iv) external lateral.

I.6.13.7 Synovial membrane

The pisiform and the upper metacarpal joint of the thumb each have a separate synovial membrane. The other carpal and metacarpal joints have a single synovial membrane.

I.6.13.8 Flexor tendon zones of the hand

There are five flexor tendon zones in the hand: (i) Zone I: It consists of the profundus tendon only and is bounded proximally by the insertion of the superficialis tendons and distally by the insertion of the flexor digitorum profundus (FDP) tendon into the distal phalanx. (ii) Zone II: It is often referred to as “Bunnell’s no man’s land.” Proximal to zone II, the flexor digitorum superficialis (FDS) tendons lie superficial to the flexor digitorum profundus (FDP) tendons. Within zone II and at the level of the proximal third of the proximal phalanx, the FDS tendons split into two

Upper Limb

slips, collectively known as Camper chiasma. These slips then reunite on the dorsal aspect of the FDP, inserting into the distal end of the middle phalanx. (iii) Zone III: It extends from the distal edge of the carpal ligament to the proximal edge of the A1 pulley. Within zone III, the lumbrical muscles originate from the FDP tendons. The distal palmar crease superficially marks the termination of zone III and the beginning of zone II. (iv) Zone IV: It includes the carpal tunnel and its contents (i.e., the nine digital flexors and the median nerve). (v) Zone V: It extends from the origin of the flexor tendons at their respective muscle bellies to the proximal edge of the carpal tunnel.

I.6.13.9 Flexor muscles of the digits

The forearm can be divided anatomically into anterior and posterior compartments. The anterior compartment contains the flexorpronator group of muscles, most of which arise from a common flexor attachment on the medial epicondyle of the humerus. The eight muscles of the anterior compartment may be divided further into three distinct functional groups as follows: (i) Muscles that rotate the radius on the ulna (ii) Muscles that flex the wrist (iii) Muscles that flex the digits: These muscles include the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and the flexor pollicis longus (FPL)

I.6.13.10 Digital flexor sheath



∑ The digital flexor sheath is a closed synovial system consisting of both membranous and retinacular portions. ∑ The membranous portion comprises visceral and parietal layers that invest the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons. ∑ In the distal aspect of the hand, the retinacular component consists of tissue condensations arranged in cruciform, annular, and transverse patterns that overlie the membranous, or synovial, lining.

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∑ The digital flexor sheath has been proposed to have a threefold function as follows: (i) It facilitates smooth gliding of the tendons. (ii) The retinacular component acts as a fulcrum, adding a mechanical advantage to flexion. (iii) It is a contained system, or bursa, with synovial fluid bathing the tendons and aiding in their nutrition. ∑ The membranous portion of the sheath appears macroscopically as a number of cul-de-sacs, or plicae, that interdigitate between both the tendons and the retinacular tissue condensations. ∑ The first cul-de-sac is located approximately 10–14 mm proximal to the distal metacarpal head and represents the point of transition between the parietal and visceral layers of the synovium. ∑ This outpouching occurs for each separate tendon, in effect forming two separate plicae. Note that this is true only for the middle three rays of the hand. ∑ In most instances, both the first-digit and fifth-digit synovial layers begin much more proximally at the level of the wrist and are referred to as the radial and ulnar bursa, respectively. ∑ Distally, the parietal layer of synovium forms plicae between each of the retinacular elements of the pulley system. ∑ The synovium ends distally, forming a final single cul-de-sac prior to the insertion of the FDP tendon on the distal phalanx.

I.6.13.11 Extensor tendon zones of hand

The dorsum of the hand, wrist, and forearm are divided into eight anatomic zones: (i) Zone 1: Distal interphalangeal (DIP) joint (ii) Zone 2: Middle phalanx (iii) Zone 3: Proximal interphalangeal (PIP) joint (iv) Zone 4: Proximal phalanx (v) Zone 5: Metacarpophalangeal (MCP) joint (vi) Zone 6: Dorsum of hand (vii) Zone 7: Wrist (viii) Zone 8: Dorsal forearm

Upper Limb

I.6.13.12 Muscles of the hand The muscles of the hand can be divided into two groups: extrinsic and intrinsic muscles. A. Extrinsic Muscles

(i) Extrinsic extensors All extensors are extrinsic and supplied by radial nerve, except for the interosseous-lumbrical complex.

(a) Wrist extensors These are a larger group of thumb and digit extensors. The extensors of the wrist are on the dorsal side of the forearm. A majority of the wrist extensors begin at the lateral epicondyle of the humerus. The main extensors at the wrist are 1. Extensor carpi radialis brevis (ECRB) Origin: Lateral epicondyle of humerus Insertion: Base of 3rd metacarpal Action: Extends and radially deviates the wrist Innervation: radial nerve (C7 and C8)

2. Extensor carpi radialis longus (ECRL) Origin: Lateral supracondylar ridge of humerus Insertion: Base of 2nd metacarpal Action: Extends and radially deviates at the wrist Innervation: Radial nerve (C6 and C7)

3. Extensor carpi ulnaris (ECU) Origin: Lateral epicondyle of humerus Insertion: Base of 5th metacarpal Action: Extends and ulnar deviates hand at wrist joint Innervation: Radial nerve (b) Digit extensors At the digits, the extension occurs due to 1. Extensor digitorum communis Origin: Lateral epicondyle of humerus

Insertion: Extensor expansions of medial four digits

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Action: Extends the four digits and the wrist Innervation: Posterior interosseous nerve 2. Extensor indicis proprius

Origin: Posterior surface of ulna and interosseous membrane Insertion: Extensor expansion of 2nd digit

Action: Extends 2nd digit and helps to extend the hand Innervation: Posterior interosseous nerve 3. Extensor digiti minimi

Origin: Lateral epicondyle of humerus Insertion: 5th digit

Action: Extends 5th digit at metacarpophalangeal and interphalangeal joints Innervation: Posterior interosseous nerve (c) Thumb extensors

Extension at the thumb is brought about by 1. Abductor pollicis longus

Origin: Posterior surfaces of ulna Insertion: Base of 1st metacarpal Action: Abducts thumb

Innervation: Radial nerve

2. Extensor pollicis brevis Origin: Posterior surface of radius and interosseous membrane Insertion: Base of proximal phalanx of thumb

Action: Extends proximal phalanx of thumb at the carpometacarpal joint Innervation: Posterior interosseous nerve 3. Extensor pollicis longus

Origin: Posterior surface of middle 1/3 of ulna Insertion: Base of distal phalanx of thumb

Action: Extends distal phalanx of thumb at carpometacarpal and the interphalangeal joints Innervation: Posterior interosseous nerve

Upper Limb

(ii) Extrinsic Flexors The muscles that flex the wrist are on the palmer side. A group of them begin at the medial epicondyle of the humerus at the elbow. (a) Wrist Flexors

A larger group of thumb and digit flexors are innervated by the median nerve except for the FCU and the FDP to the small and ring finger, which are innervated by the ulnar nerve. There are three main flexors at the wrist joint: 1. Flexor carpi radialis

Origin: Medial epicondyle of humerus Insertion: Base of 2nd metacarpal

Action: Flexes and radial deviates the hand (at the wrist) Innervation: Median nerve (C6 and C7) 2. Flexor carpi ulnaris

Origin: medial epicondyle of humerus

Insertion: Pisiform bone, the hook of hamate bone, and 5th metacarpal bone Action: Flexes and ulnar deviates hand (at the wrist) Innervation: Ulnar nerve (C7 and C8) 3. Palmaris longus

Origin: Medial epicondyle of humerus

Insertion: Distal half of flexor retinaculum and palmar aponeurosis Action: Flexes hand at the wrist

Innervation: Median nerve (C7 and C8) (b) Digit Flexors

1. Flexor digitorum superficialis Origin: Medial epicondyle of humerus

Insertion: Middle phalanges of digits 2–5

Action: Flexes middle phalanges at proximal interphalangeal joints; also flexes proximal phalanges at metacarpophalangeal joints and hand Innervation: Median nerve (C7, C8, and T1)

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2. Flexor digitorum profundus Origin: Proximal 3/4 of ulna Insertion: Base of the distal phalanx of digits 2–5 Action: Flexes distal phalanges at distal interphalangeal joints Innervation: Medial part by the ulnar nerve and the lateral part by the median nerve

3. Flexor pollicis longus Origin: Anterior surface of radius and adjacent interosseous membrane Insertion: Base of distal phalanx of thumb Action: Flexes phalanges of 1st digit (thumb) Innervation: Anterior interosseous nerve from median nerve (C8 and T1) (c) Forearm Flexor

1. Pronator quadrates Origin: Distal 1/4 of the anterior surface of ulna Insertion: Distal 1/4 of the anterior surface of radius Action: Pronates forearm Innervation: Median nerve

2. Pronator teres Origin: Medial epicondyle of humerus Insertion: Middle of the lateral surface of radius Action: Pronates Innervation: Median nerve (C6 and C7) B. Intrinsic Muscles

These muscles are situated totally within the hand. The intrinsic muscles of the hand can be arranged into three groups according to either the region they appear in or their depth.  Regional groups of muscles are the thenar and hypothenar groups: ∑ The thenar muscles are three in number and act on the thumb. ∑ The hypothenar group are three in number and act on the little finger.

Upper Limb





The remainder muscles can be arranged from superficial to deep, as shown in Fig. I.3.

Figure I.3 Volar aspect of the hand showing surface anatomy of various structures. Image courtesy: Dr. Jose Tharayil, Kerala, India.



∑ Once the palmar aponeurosis is removed, the first layer is made up of the tendons of the FDS. ∑ The superficial arterial arch is formed mainly from the ulnar artery and is completed by the superficial branch of the radial. This completion is not always present or may be extremely small. ∑ The deep arterial arch is formed mainly by the deep branch of the radial artery and is finished by the deep branch of the ulnar artery. ∑ The dorsal venous plexus of the hand and the ensuing cephalic and basilic veins drain the superficial aspects of the hand. ∑ The cephalic vein ends up in the axillary vein just before it becomes the subclavian vein and the basilic vein joins the brachial vein to become the axillary vein. These muscles can also be grouped as: (i) thenar, (ii) hypothenar, (iii) lumbricals, and (iv) interossei muscles.

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(i) Muscles of the thenar group 1. Abductor pollicis brevis Origin: Scaphoid and trapezium Insertion: Lateral side of the base of proximal phalanx of thumb Action: Abducts thumb Innervation: Median nerve (C8 and T1)

2. Flexor pollicis brevis Origin: Flexor retinaculum and tubercles of scaphoid and trapezium Insertion: Lateral side of the base of proximal phalanx of thumb Action: Flexes thumb Innervation: Recurrent branch of the median nerve (C8 and T1)

3. Opponens pollicis Origin: Flexor retinaculum and tubercles of scaphoid and trapezium Insertion: Lateral side of 1st metacarpal Action: Draws 1st metacarpal laterally to oppose thumb toward the center of the palm Innervation: Recurrent branch of the median nerve (C8 and T1)

4. Adductor pollicis It has two heads that are separated by a gap through which the radial artery passes. Origin: Oblique head from the bases of 2nd and 3rd metacarpals, capitate and adjacent carpal bones, transverse head from the anterior surface of the body of 3rd metacarpal bone Insertion: Medial side of the base of proximal phalanx of thumb Innervation: Ulnar nerve Action: Adducts thumb toward middle digit (ii) Muscles of the hypothenar group

1. Opponens digiti minimi Origin: Hook of hamate and flexor retinaculum Insertion: Medial border of 5th metacarpal Action: Brings little finger (5th digit) into opposition with thumb Innervation: Deep branch of the ulnar nerve (C8 and T1)

2. Abductor digiti minimi The most superficial of the hypothenar muscles forming the hypothenar eminence

Upper Limb

Origin: Pisiform bone Insertion: Medial side of the base of proximal phalanx of 5th digit Action: Abducts 5th digit

3. Flexor digiti minimi brevis Origin: Hook of hamate and flexor retinaculum Insertion: Medial side of the base of proximal phalanx of the little finger Action: Flexes proximal phalanx of little (5th) finger Innervation: Ulnar nerve

4. Palmar brevis It lies in the fascia deep to the skin of the hypothenar eminence; a relatively unimportant muscle except that it covers and protects the ulnar nerve and artery Origin: Flexor retinaculum and palmar aponeurosis Insertion: Skin on the medial side of the palm Action: Wrinkles the skin on the medial side of the palm and deepens the hollow of the palm, as in cupping of the hand, thereby aiding the grip (iii) Lumbrical muscles

They consist of four muscles. Origin: Lateral and adjacent side of tendons of FDP of each finger (2nd–5th) Insertion: Lateral side of the tendon of extensor digitorum on proximal phalanges of each finger (2nd–5th) Action: Flexion each finger at MCP and extend each finger at the IP joint. Innervation: Median and ulnar nerve (iv) Interossei muscles

1. Palmar Interossei They consist of four muscles. Origin: Sides of shafts of metacarpals of all digits (except the middle one) Insertion: Side of bases of proximal phalanges of all digits (except the middle finger)

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Action: Adducts each finger at MCP, assists in flexion of each finger at the MCP joint Innervation: Ulnar nerves 2. Dorsal Interossei They consist of four muscles. Origin: Adjacent side of metacarpals Insertion: Proximal phalanx of each finger Action: Abducts fingers 2–4 at the MCP joint and assists in flexion of fingers 2–4 at MCP and extension at IP at the same finger. Innervation: Ulnar nerve

Reference

1. Olave E, Prates JC, Del Sol M, Sarmento A, Gabrielli C. Distribution patterns of the muscular branch of the median nerve in the thenar region. J Anat. 1995, 186: 441–446.

Chapter 1

Examination of the Shoulder

The shoulder girdle consists of three joints and one articulation, namely (i) (i) (ii) (iii)

The sternoclavicular joint The acromioclavicular joint The glenohumeral or shoulder joint The scapulothoracic articulation

1.1 Inspection

Asymmetry of the shoulder is very obvious when examined by bilateral compression of the two shoulder joints. This may be very easily noticed when the arm is hanging down the side, if it is internally rotated and adducted, as in Erb’s palsy, like a waiter receiving a tip. The deltoid region is next inspected as it is normally full and round but may be vacant as in cases of anterior shoulder dislocation. The arm is then held slightly away from the trunk. The deltopectoral groove is located just medial to the shoulder mass, between the anterior fibers of the deltoid and the pectoralis major, and it contains the cephalic vein which can be used for a venous cutdown. It is also a very important site for incisions in the shoulder region. Introduction to Limb Arthrology Edited by K. Mohan Iyer Copyright © 2023 Jenny Stanford Publishing Pte. Ltd. ISBN 978-981-4877-99-2 (Hardcover), 978-1-003-37276-9 (eBook) www.jennystanford.com

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Over the posterior aspect of the shoulder girdle is the most prominent part which is the scapula. This is very easy to locate as it is situated over the ribs two to seven in the resting position, and its medial border is nearly 2 inches away from the spinous processes. Occasionally the scapula has only partially descended from the neck to the thorax resulting in a Sprengel’s deformity. Occasionally the midline spinous processes may show a lateral scoliotic deformity resulting in elevation or depression of the shoulders. Very rarely do the spinous processes show a rounded kyphotic deformity due to Scheuermann’s disease in adolescents.

1.2 Palpation

Bony landmarks can be palpated systematically by beginning from the suprasternal notch. The joint that is immediately lateral is the sternoclavicular joint which is best appreciated when palpated bilaterally. The clavicle is normally slightly superior to the manubrium sternum, and it rises from it. Dislocations of the sternoclavicular joint are frequently seen when the clavicle has shifted over the manubrium sternum. Proceeding with the palpation laterally, the clavicle represents a medial convex smooth surface that is well felt in its full length, becoming concave at its lateral end. The lateral end of the clavicle forms the coracoid process which faces anterolaterally and lies deep under the cover of the pectoralis major muscle. The acromioclavicular joint lies immediately lateral to the coracoid process and can be easily felt by asking the patient to flex and extend his or her shoulder several times. This joint may be prominent and tender in dislocations of the lateral end of the clavicle. Palpating just lateral to the acromioclavicular joint, one finds the acromion process. Continuing palpation just lateral to the acromion and slightly inferiorly, one reaches the greater tuberosity of the humerus. The bicipital groove is located just medial and anterior to the greater tuberosity. It is best felt when the arm is externally rotated when the tendon of the long head of the biceps can be rolled. Palpating posteriorly and medially, one finds the acromion tapering into the spine of the scapula as one continuous arch. The medial

Palpation

border of the scapula is about 2 inches from the spinous process of the thoracic vertebrae, and the triangle at the medial end of the spine of the scapula is at the L3 level. The soft tissue palpation is mainly into four regions, namely (1) the rotator cuff, (2) the subacromial and subdeltoid bursa, (3) the axilla, and (4) the muscles around the shoulder girdle.

1. The rotator cuff This cuff is composed mainly of three muscles that form an insertion into the greater tuberosity of the humerus – namely, the supraspinatus, the infraspinatus, and the teres minor. The fourth muscle is the subscapularis which is located anteriorly. The rotator cuff is clinically important because the supraspinatus is the most commonly ruptured muscle near its insertion. 2. The subacromial bursa It has two main components, namely the subacromial and the subdeltoid parts. This is a frequent pathologic finding causing tenderness and limitation of shoulder movements.

3. The axilla It is a pyramidal space through which nerves and vessels pass into the upper arm. Enlarged lymph nodes can be well palpated in this space. The axilla is formed anteriorly by the pectoralis major muscle and posteriorly by the latissimus dorsi muscle, while its medial wall is formed by the second to sixth ribs with its overlying serratus anterior muscle, and the lateral wall is limited by the bicipital groove of the humerus. The shoulder joint is the apex of the pyramid, and the axilla is supplied by the brachial plexus and the axillary arteries. 4. The muscles of the shoulder girdle ∑ The sternocleidomastoid is palpated on the side opposite to which the head is turned and is mainly important for hematomas in the muscle which can cause a wry neck, swollen lymph nodes due to infection, and may frequently be traumatized in injuries of the neck, such as a whiplash injury. ∑ The pectoralis major muscle is very important clinically as it may be absent congenitally, most frequently either in whole or in part. The costochondral junctions which lie just next to the sternum are the frequent site of costochondritis when they are tender on palpation.

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∑ The biceps muscle is palpated with the elbow in resisted flexion and can be seen curled up in the midarm when the long head of the biceps is torn. The long head of the biceps may be involved in tenosynovitis when it is tender or may be dislocated in the bicipital groove which is well palpated when the shoulder is laterally rotated. ∑ The deltoid may be atrophied in cases of axillary nerve damage usually because of shoulder dislocations. The deltoid muscle converges down to the midpoint of the lateral aspect of the arm to a bony prominence known as the deltoid tuberosity. ∑ The trapezius is a fan-shaped muscle that extends from the occiput along with the spinous processes of the cervical spine into the clavicle, acromion, and the spine of the scapula where it merges into the origin of the deltoid. ∑ The rhomboids retract the scapulae and run from the spinous processes of the cervical spine vertebrae obliquely downward and laterally, to insert into the medial border of the scapula. They can be palpated by asking the patient to put his arm behind his back with the elbows flexed and the arms internally rotated when the patient pushes posteriorly as this movement is resisted. ∑ The latissimus dorsi has a broad origin at the iliac crest and twists upon itself toward the shoulder before being inserted into the floor of the bicipital groove of the humerus. ∑ The serratus anterior muscle prevents winging of the scapula by anchoring the medial border of the scapula to the thoracic cage.

1.3 Range of Movements

The range of movements that are possible in the shoulder girdle is mainly abduction, adduction, flexion, extension, internal rotation, and lateral rotation. These movements are tested both actively and passively. The Apley’s scratch test evaluates all the ranges of movements of the shoulder girdle. Firstly, ask the patient to touch the superomedial angle of the opposite scapula behind her head. This tests abduction and lateral rotation. Next ask the patient to touch the opposite acromion in front of her head, which tests internal rotation

Range of Movements

and adduction. Finally, further test adduction and internal rotation by asking the patient to touch the opposite scapula at its inferior angle, from behind. Another way in which all of these movements are tested is by asking the patient to abduct his arm to 90 degrees while keeping the elbows extended. Then, with his forearms supinated, ask him to carry on abduction at the shoulders until the palms touch each other over the top of the head, which tests full bilateral abduction at the shoulders. Next, ask the patient to keep his hands behind his neck and push his elbows posteriorly which tests abduction and lateral rotations. Finally, ask the patient to keep his hands behind his back as high as they will go to test for adduction and internal rotations. The glenohumeral joint is tested passively through its full range, but when it has a full passive range but is limited in its active range, that signifies that muscular weakness is the problem. To differentiate between extra- and intra-articular block, feeling at the point of blockage will determine which is involved: It is rubbery in cases of soft tissue extra-articular block, as compared with a bony block which is abrupt and bony in nature.

(i) Abduction/adduction: This occurs in a ratio of 2:1 at the glenohumeral joint and the scapulothoracic joint. It is normally 180 degrees and 45 degrees at both the joints. Another way to test this is by firmly anchoring the scapula and then testing for abduction when the pure glenohumeral movement is about 90 degrees at which point the scapula begins to move, which can be felt. Full abduction is completed when the arm is externally rotated to increase the articulating surface of the humeral head. In cases of a frozen shoulder, the movement occurs mainly by scapulothoracic movement and never in the glenohumeral joint. (ii) Flexion/extension: Normal movement is about 90 degrees for flexion and 45 degrees for extension. These movements may be limited in cases of bursitis of the shoulder or bicipital tendinitis. (iii) Internal rotation/external rotation: This is best tested by keeping the elbows close to the waist which prevents substitutions of rotation and flexing the elbows to 90 degrees

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and then rotating the arm laterally and medially. The normal range of internal rotation is about 55 degrees, and the normal range of external rotation is about 45 degrees. The alternative technique to test for internal and external rotations is by asking the patient to abduct both her shoulders to 90 degrees with bent elbows to 90 degrees and then test for rotations with palms facing upward and downward.

1.4 Neurologic Examination

This is mainly done through tests in the shoulder girdle: namely, flexion, extension, abduction, adduction, external rotation, internal rotation, scapular elevation, scapular retraction, and shoulder protraction.

1. Flexors (a) Primary flexors ∑ Anterior fibers of the deltoid ∑ Axillary nerve – C5 ∑ Coracobrachialis – musculocutaneous nerve – C5, C6 (b) Secondary flexors ∑ Pectoralis major (clavicular head) ∑ Biceps ∑ Anterior fibers of the deltoid Flexion is tested by flexing the elbow to 90 degrees and then starting flexion of the shoulder. Gradually and slowly increase resistance as flexion at the shoulder begins (Table 1.1).

2. Extensors (a) Primary extensors ∑ Latissimus dorsi – thoracodorsal nerve – C6, C7, C8 ∑ Teres major – lower scapular nerve – C5, C6 ∑ Posterior fibers of the deltoid – axillary nerve – C5, C6 (b) Secondary extensors ∑ Teres minor ∑ Triceps (long head) Test for an extension by gradually increasing resistance to flexion over the posterior aspect of the distal humerus (Table 1.1).

Neurologic Examination

Table 1.1

Muscle grading chart

Muscle Gradations

Description

5: Normal

Complete range of motion against gravity with full resistance

3: Fair

Complete range of motion against gravity

4: Good 2: Poor

1: Trace 0: Zero

Complete range of motion against gravity with some resistance

Complete range of motion with gravity eliminated Evidence of slight contractility No joint motion No evidence of contractility

3. Abduction (a) Primary abductors ∑ Middle fibers of the deltoid – axillary nerve – C5, C6 ∑ Supraspinatus-suprascapular nerve – C5, C6 (b) Secondary abductors ∑ Anterior and posterior fibers of the deltoid ∑ Serratus anterior This is tested by asking the patient to abduct his arm against gradually increasing resistance.

4. Adduction (a) Primary adductors ∑ Pectoralis major-medial and lateral anterior thoracic nerve – C5, C6, C7, C8, T1 ∑ Latissimus dorsi-thoracodorsal nerve – C6, C7, C8 (b) Secondary adductors ∑ Teres major ∑ Anterior fibers of the deltoid This is tested by adduction of a slightly abducted arm against gradually increasing resistance offered on the medial side of the arm. 5. External rotators (a) Primary external rotators ∑ Infraspinatus-suprascapular nerve – C5, C6 ∑ Teres minor – branch of the axillary nerve – C5

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(b) Secondary external rotators ∑ Posterior fibers of the deltoid This is tested by holding a flexed elbow at the waist with the forearm in a neutral position and asking the patient to rotate the arm outward against gradually increasing resistance.

6. Internal rotators (a) Primary internal rotators ∑ Subscapularis – upper and lower subscapular nerves – C5, C6 ∑ Pectoralis major – medial and lateral anterior thoracic nerves – C5, C6, C7, C8, T1 ∑ Latissimus dorsi – thoracodorsal nerve – C6, C7, C8 ∑ Teres major – lower subscapular nerve – C5, C6 (b) Secondary internal rotator ∑ Posterior fibers of the deltoid The test is carried out in the same way as above, and the patient is asked to rotate his arm inward against gradually increasing resistance. 7. Scapular elevation (a) Primary elevators ∑ The trapezius-spinal accessory nerve or cranial nerve XI ∑ Levator scapulae – C3, C4 along with branches from the dorsal scapular nerve, C5 (b) Secondary elevators Rhomboid major Rhomboid minor Ask the patient to shrug his shoulders against gradually increasing resistance.

8. Scapular retraction (a) Primary retractors ∑ Rhomboid major – dorsal scapular nerve – C5 ∑ Rhomboid minor – dorsal scapular nerve – C5 (b) Secondary retractors ∑ The trapezius This can be tested by asking the patient to throw his shoulders back against gradually increasing resistance, whereby the patient assumes a position of attention.

Neurologic Examination

9. Scapular protraction (a) The primary protractor is the serratus anterior – long thoracic nerve – C5, C6, C7 This is tested by asking the patient to reach forward when the scapula moves anteriorly on the thorax. Winging is seen when the patient pushes against a wall or when doing a push-up when the serratus anterior is weak.

1.4.1 Reflex Testing

Both the muscles, biceps, and triceps which cross the shoulder joint should be tested.

1.4.2 Sensation Testing

These can be tested by well-delineated dermatomes as follows: (i) The lateral arm – C5 nerve root, which is examined by a rounded area just on the lateral aspect of the deltoid muscle – axillary nerve. (ii) The medial arm, which is supplied by the T1 nerve root. (iii) The axilla, which is supplied by the T2 nerve root. (iv) The area from the axilla to the nipple is supplied by the T3 nerve root. (v) The nipple, which is supplied by the T4 nerve root.

Figure 1.1 Fracture of the neck of the humerus treated by ORIF. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

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Abnormal sensations (paresthesia) may either be increased (hyperesthesia) or decreased (hypoesthesia) or may be completely absent (anesthesia). The axillary nerve is frequently damaged in shoulder dislocations and fractures of the neck of the humerus (Fig. 1.1) when it leaves an anesthetic patch over the lateral aspect of the deltoid muscle.

1.5 Special Tests

The shoulder joint is made up of four bones namely, the scapula, clavicle, humeral head, and the posterior rib cage. It also consists of four joints namely, sternoclavicular, acromioclavicular, glenohumeral, and the scapulothoracic joints. The shoulder girdle is made up of two bones three joints, namely the scapula and the clavicle along with three joints namely, glenohumeral, acromioclavicular, and the sternoclavicular joints. The sternoclavicular joint is synovial and of saddle variety. The acromioclavicular is synovial and plane variety. The main glenohumeral synovial is multiaxial and of the ball and socket variety.

1.5.1 Ossification of the Bones of the Shoulder

1. Clavicle: It is the 1st bone to ossify. It has no medullary cavity. It occurs by intramembranous ossification. Secondary ossification centers via endochondral. The medial epiphysis ossifies at 12–19 years and fuses at 22–25 years. The lateral epiphysis ossifies and fuses at 19 years. Cleidocranial dysostosis (Fig. 1.2) affects the development of the bones, skull, and teeth. Its signs and symptoms include underdeveloped or absent collarbones (clavicles), dental abnormalities, and delayed closing of the spaces between the skull bones (fontanels). 2. Scapula: The body and spine [posterior] ossify at birth. The coracoid process [anterior] atavistic epiphysis center at 1 year, base at 10 years. The acromian [lateral projection] fuses by 22 years via 2–5 centers form at puberty. The glenoid-upper 1/4th ossify at 10 years while the lower 3/4th appear at puberty and fuse by 22 years.

Special Tests

Figure 1.2 Cleidocranial dysostosis. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

3. The proximal humerus: The humeral head ossifies at 6 months while greater tuberosity ossifies at 1 to 3 years and the lesser tuberosity ossifies at 4 to 5 years. All physis close at 14–17 years girls and 16–18 years boys. The ligaments of the sternoclavicular joint are mainly (1) capsular ligament, (2) sternoclavicular ligament-anterior and posterior, (3) interclavicular ligament, (4) costoclavicular ligament consisting of the anterior lamina and the posterior lamina, and (5) the articular disk is mainly fibrocartilaginous. The ligaments of the acromioclavicular joint are made up of (1) fibrous capsule, (2) acromioclavicular ligament, and (3) coracoclavicular ligament which is made up of two parts namely the conoid part and the trapezoid part, (4) coracoacromial ligament. The ligaments of the shoulder joint (glenohumeral joint) are made up of (1) fibrous capsule, (2) glenohumeral ligament consisting of the superior band, middle band, and the inferior band, (3) coracohumeral ligament, and (4) transverse humeral ligament. The glenohumeral joint is made up of 25% humeral head surface in contact with the glenoid and this joint space thinning is seen with OA of the Shoulder. The humeral head coverage is increased to 75% with the glenoid labrum. The glenoid labrum has a (1) fibrocartilaginous rim and is (2) triangular in cross-section, which

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is (3) attached to the peripheral margin of the glenoid cavity except above. (4) It also deepens the glenoid fossa and forms a pliable cushion for the ball to roll. Relations of joints (Fig. 1.3)

Figure 1.3 Line diagram of the front of the shoulder.

(i) Above: Deltoid, supraspinatus, subacromial bursa, and coracoacromial arch. (ii) Below: Quadrangular space transmitting axillary nerve and posterior circumflex humeral vessels, long head of triceps. (iii) In front: Subscapularis, coracobrachialis, and the short head of biceps. (iv) Behind: Infraspinatus and teres minor. (v) Within the capsule-long head of the biceps. (vi) Deltoid muscle covers the joint in the front, behind, and laterally. (vii) The long head of the biceps originates from the supraglenoid tubercle of the scapula. It is intracapsular but extrasynovial.

Special Tests

The tendon passes through the shoulder joint and emerges below the transverse humeral ligament inside the joint, the tendon is surrounded by a separate tubular sheath of the synovial capsule.

Rotator cuff muscles (i) Supraspinatus, infraspinatus, teres minor, and subscapularis form a cuff around the humeral head. (ii) Keep humeral head within the joint (counteract deltoid) (iii) Abduction, external rotation, internal rotation. Functions of the muscles of the rotator cuff (i) The four major muscles of the rotator cuff rotate the humerus and properly orient the humoral head in the glenoid fossa (socket) (ii) The tendons of these four muscles merge, forming a cuff around the glenohumeral joint (iii) Supraspinatus: abducts the humeral head and acts as a humeral head depressor (iv) Infraspinatus: externally rotates and horizontally extends the humerus (v) Teres minor: externally rotates and extends the humerus (vi) Subscapularis: internally rotates the humerus

Factors maintaining the stability of shoulder joint (i) The glenoid labrum deepens the socket. (ii) Supraspinatus, the tension of the upper part of the capsule and coracohumeral ligament prevent its downward displacement. (iii) Tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor blend with fibrous capsule to form the musculo-tendinous rotator cuff and act as guardians of the joint. (iv) The long head of the biceps and coracoacromial arch prevents upward dislocation of the humerus. Bursae in relation to the shoulder joint (a) Communicating – Subscapular bursa and the infraspinatus bursa (b) Noncommunicating – (1) Subacromial-largest bursa of the body, (2) above acromion process, (3) between capsule and

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coracoid process, (4) behind coracobrachialis, (5) between teres minor and long head of triceps, and (6) In front and behind the tendon of latissimus dorsi.

Blood supply and nerve supply

(i) Vascular supply: Anterior and posterior circumflex humeral, suprascapular, and circumflex scapular vessels (ii) Nerve supply: The capsule is supplied by the suprascapular nerve (posterior and superior parts), axillary nerve (anteroinferior), and the lateral pectoral nerve.

Movements of the shoulder ∑ They are (1) flexion, (2) extension, (3) abduction, (4) adduction, (5) external rotation, (6) internal rotation, and (7) circumduction. ∑ The most important aspect is the plane of movements, such as (1) abduction and adduction occur at the plane of the scapula and (2) flexion and extension occur 90 degrees to the plane of the scapula. ∑ The three mutually perpendicular axes around which the principal movements of flexion-extension (A), abduction/ adduction (B), and medial and lateral rotation (C) occur at the shoulder. 1. Flexion: It is a 90-degree movement and the muscles involved are (a) deltoid (anterior fibers), (b) pectoralis major (clavicular fibers), (c) coracobrachialis, and (d) biceps.

2. Extension: It is of 45 degrees and the muscles involved are (a) deltoid (posterior fibers), (b) teres major, (c) latissimus dorsi, and (d) pectoralis major (sternocostal fibers). 3. Adduction: It is of 45 degrees and the muscles involved are (a) pectoralis major, (b) latissimus dorsi, (c) teres major, and (d) coracobrachialis. 4. Abduction: It is of 180 degrees and the muscles involved are (a) supraspinatus, (b) deltoid, (c) serratus anterior, (d) infraspinatus, and (e) trapezius.

5. External Rotation: It is 80–90 degrees and the muscles involved are (a) infraspinatus, (b) teres minor, and (c) deltoid (posterior fibers).

Special Tests for the Shoulder

6. Internal Rotation: It is 55 degrees and the muscles involved are (a) subscapularis, (b) pectoralis major, (c) latissimus dorsi, (d) teres major, and (e) deltoid (anterior fibers).

7. Circumduction: This is a movement in which the distal end of the humerus moves in a circular motion while the proximal end remains stable. It is formed by flexion, abduction, extension, and adduction, successively.

1.6 Special Tests for the Shoulder 1.6.1 Stability of the Shoulder

1. Apprehension Test (Crank Test): With the patient seated, the shoulder is abducted 90⁰ and externally rotated, the positive sign is one of pain and apprehension and is indicative of traumatic instability problems. It is elicited by slowly applying lateral rotation on the shoulder.

2. Jobe Relocation Test (Fowler Sign): With the patient supine the shoulder is abducted 90⁰ and externally rotated when a positive sign is seen as a relief of pain and apprehension and is indicative of posterior internal impingement/traumatic instability problems. It is elicited by applying a posteriorly directed force to the head of the humerus when further external rotation becomes possible. It is also called the Fowler Sign.

3. Rockwood Test: It is done with the patient sitting. A positive sign is marked apprehension at 90⁰ with some uneasiness and pain at 45⁰ and 120⁰. It is indicative of anterior Instability. It is elicited by stabilizing the elbow and humerus and then grasping the humeral head and lifting it forward.

4. Rowe Test for Anterior Instability: It is done with the patient supine. The arm is abducted 80⁰–120⁰, flexed 20⁰, externally rotated 30⁰, with a hand on the patient’s axilla when a positive sign of apprehension (pain) or a click sound is heard indicative of anterior instability and/or anterior labral tear. It is elicited by stabilizing the scapula when pushing the spine forward using the index and middle finger. Apply a counter pressure on the coracoid then draw the humerus forward.

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5. Rowe Test for Multidirectional Instability: The patient stands forward flexed 45⁰ at the waist with arms pointing to the floor. A positive sign is a sulcus sign which is indicative of multidirectional instability. It is elicited as follows: Place the hand on the patient’s shoulder with the index and middle finger (anterior) and the thumb (posterior). The signs of multidirectional instability are seen anteriorly when the shoulder is extended 20⁰–30⁰, then push anteriorly; posteriorly when the shoulder is flexed 20⁰–30⁰, then push posteriorly; and inferiorly when the shoulder is flexed 20⁰–30⁰, then push posteriorly and apply traction [1]. 6. Fulcrum Test: With the patient supine the shoulder is abducted 90⁰ and externally rotated when a positive sign is pain and apprehension which is indicative of traumatic instability problems. It is elicited by placing a hand under the glenohumeral joint and then applying lateral rotation. It is also a modification of the Crank Test.

7. Anterior Drawer Test: It is done with the patient supine. The arm is abducted 80⁰–120⁰, flexed 20⁰, externally rotated 30⁰, with a hand on the patient’s axilla when a positive sign of apprehension (pain) or a click sound is heard indicative of anterior instability and/ or anterior labral tear. It is elicited by stabilizing the scapula when pushing the spine forward using the index and middle finger. Apply a counter pressure on the coracoid then draw the humerus forward. 8. Posterior Apprehension Test: This is done with the patient supine when a positive sign of apprehension is experienced when the shoulder is elevated to 90⁰ indicative of posterior shoulder instability. It is elicited by applying a posterior force on the elbow and then horizontally adducting and internally rotating the shoulder. It is also called stress test.

9. Feagin Test: It is done with the patient standing when the shoulder is abducted 90⁰ on the physiotherapist’s shoulder. This is positive when there is a presence of sulcus on the coracoid process or apprehension which is indicative of multidirectional instability. It is elicited by closing hands over the humerus and pushing down and forwards. 10. Clunk Test: This is done with the patient supine when a positive sign is heard as a clunk/grinding sound indicative of a Tear of the Labrum (Bankart). It is elicited as follows: Place one hand on the posterior aspect of the shoulder, when one hand holds the humerus above the elbow. Fully abduct arm over the patient’s head. Push

Special Tests for the Shoulder

anteriorly with the hand over the humeral head (place a fist under the glenohumeral joint) when the other hand rotates the humerus into lateral rotation. 11. Compression Rotation Test: Patient supine, elbow flexed and abducted 20 degrees, the examiner pushes up on the elbow and rotates the humerus medially and laterally. Snapping or catching is positive for a labral tear.

1.6.2 Biceps Tests

1. Speed’s Test: This is done with the patient standing. A positive sign is pain on the bicipital groove with pain and weakness which is indicative of bicipital tendonitis or SLAP II or a rupture of the biceps (Fig. 1.4). It is elicited as follows: Resist shoulder extension by the patient first in supination then in pronation with elbow extension. (The other names for this test are Biceps Test/Straight Arm Test.)

Figure 1.4 Line diagram of Speed’s Test.

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2. Yergason’s Test: This is done with the patient sitting/standing. The elbow is at 90⁰ with the forearm pronated when a positive sign is indicated by pain/tenderness or popping out of groove which indicates bicipital tendonitis or a torn transverse humeral ligament. It is elicited when there is resistance to supination while the patient externally rotates the shoulder (Fig. 1.5) [2].

Figure 1.5 Line diagram of Yergason’s Test.

3. Bicep Saw Test: Patient flexes elbow to 90 degrees places fist in examiners hand. Patient’s fist if forced down while making a saw motion FE to and from –30 and + 30. Pain in bicipital groove suggestive of bicipital tendinitis.

4. Biceps Tension Test: This is done with the patient standing, the shoulder is abducted 90⁰, elbow extended, and the forearm supinated when a positive sign is indicated by reproduction of symptoms and is indicative of a SLAP lesion. It can be elicited by applying an eccentric adduction force.

5. Biceps Load Test: This is done with the patient supine. The shoulder is abducted 90⁰ and externally rotated; the elbow flexed 90⁰, and the forearm supinated when a positive test is indicated when the apprehension does not disappear. This is diagnostic of the integrity of superior labrum. It is elicited as follows: Fully externally rotate shoulder until apprehension, stop external rotation and hold the position. Then the patient resists elbow flexion at the wrist.

Special Tests for the Shoulder

1.6.3 Impingement Tests 1. Neer Impingement Test: This is done with the patient sitting when a (+) sign is pain which indicates overuse injury to the supraspinatus muscle. It can be elicited when the patient’s arm is passively and forcibly fully elevated and the shoulder is internally rotated (Fig. 1.6).

Figure 1.6 Line diagram of Neer’s Test.

2. Hawkins–Kennedy Impingement Test: This is done with the patient standing or sitting when a (+) sign is pain, which is indicative of supraspinatus tendonitis. It can be elicited by flexing the shoulder to 90⁰ and then medially rotating the shoulder (Fig. 1.7).

Figure 1.7 Line diagram of the Hawkins–Kennedy Test.

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3. Impingement Test: Arm is abducted to 90 and full lateral rotation, positive if painful.

1.6.4 Other Tests

1. Scapular Thoracic Glide Test (Lateral Scapular Slide Test): This is done by the patient sitting/standing with arms at the side. The sign is positive when there is >1–1.5 cm difference from the original measure which is indicative of a scapular instability. To elicit this, measure the distance from spine to scapula to T2/T3, inferior angle to T7–T9, or superior angle to T2. (Also test the patient in shoulder abduction: 45⁰, 90⁰, 120⁰, and 150⁰.) 2. O’Brien Test: Patient flexes arm to 90 degrees with the elbow fully extended and then adducts the arm 10–15 degrees medial to the sagittal plane. Maxi pronation with FE against resistance— repeated in supination. Pain with pronation and not supination is AC or labral lesion. 3. Codman’s (Drop Arm) Test: This is done with the patient standing and the shoulder abducted 90⁰ when a (+) sign is the inability to return the arm to the side slowly, indicative of a rotator cuff tear. It is elicited by asking the patient to slowly lower his arms to the side with some arc movements. It is also known as the Codman’s test. 4. Military Brace (Costoclavicular Syndrome) Test: Palpate the radial pulse as the shoulder is drawn down and back. Positive if a decreased pulse and indicates possible thoracic outlet syndrome. 5. Adson Maneuver: It is done with the patient sitting with head on the ipsilateral side. A (+) sign: the disappearance of pulse indicative of thoracic outlet syndrome. It can be elicited as follows: locate a radial pulse, external rotate and extend the shoulder and instruct the patient to take a deep breath and hold it.

6. Allen Test: This is done with the patient sitting with his head on the contralateral side. A (+) sign: the disappearance of pulse indicative of thoracic outlet syndrome. It can be elicited as follows: the elbow is flexed to 90⁰, the shoulder is extended and externally rotated horizontally, palpate the radial side. 7. Halstead Maneuver: This is done when the neck is hyperextended rotated on the contralateral side. When a (+) sign of the

Special Tests for the Shoulder

disappearance of the radial pulse is indicative of thoracic outlet syndrome. It can be elicited as follows: Find the radial pulse, and apply downward traction on the extremity.

8. Tinel’s Sign at the Shoulder: It is done with the patient sitting. A (+) sign of tingling sensation is indicative of a peripheral nerve injury. It can be elicited by tapping on the scalene triangle in the area of the brachial plexus.

9. Yocum Test: This is done with the patient standing or sitting. A (+) sign of pain, is indicative of supraspinatus tendonitis. It can be elicited when the patient places a hand on the opposite shoulder then the physiotherapist elevates the elbow. It is also a modification of the Hawkins–Kennedy Test.

10. Coracoid Impingement Test: This is done with the patient standing or sitting when a (+) sign: pain, indicative of supraspinatus tendonitis. It can be elicited by flexing the shoulder to 90⁰, horizontally adducting to 10⁰–20⁰, and then medially rotate the shoulder. It is also known as a modification of the Hawkins–Kennedy Test. 11. Lift-Off Sign: This is done with the patient standing and the dorsum of the hand on the back pocket. A (+) sign is the inability to lift the hand off the back, which is indicative of a subscapularis Lesion. It can be elicited by asking the patient to lift the hand away from the back.

12. Pectoralis Major Contracture Test: This is done with the patient supine and his hands clasped behind his head when a (+) sign is that the elbows do not reach the table which is indicative of a tight pectoralis major. It is elicited by lowering the arm until the elbows touch the table.

13. Teres Minor Test: This is done with the patient prone, with one hand on the iliac crest, when a (+) sign of pain and weakness is indicative of a teres minor strain. This can be elicited by asking the patient to extend and adduct the shoulder against resistance. 14. Infraspinatus Test: It is done with the patient standing with the arm on the side with the elbow 90⁰ when a (+) sign is seen as pain with an inability to resist internal rotation. This is indicative of an infraspinatus strain. It can be elicited by applying an internal rotation force that the patient resists.

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15. Hornblower’s Test: This is done with the patient standing and the shoulder flexed to 90⁰, with the elbow flexed to 90⁰, when a (+) sign is the inability to externally rotate the shoulder, which is indicative of a tear on the teres minor. It is elicited when the patient externally rotates with resistance. 16. Lateral Rotation Lag Sign: It is done with the patient seated or standing and with the arms at the side. A (+) sign is when the patient cannot hold the position due to pain with an increased internal rotation on the affected side. This is indicative of a torn supraspinatus, infraspinatus, and subscapularis. This can be elicited as follows: When the patient passively abducts shoulder to 90⁰, elbow flexed to 90⁰ and externally rotate when the Patient holds the position. This is also called the Infraspinatus “Spring Back” Test.

17. Supraspinatus Test: This is done with the patient standing when the shoulder is abducted 90⁰, a (+) sign: pain or weakness is felt indicative of a torn supraspinatus or neuropathy of the suprascapular nerve. It is elicited when the shoulder is internally rotated and angled forward 30⁰, thumb pointing to the floor, then resist. It is also called Empty Can Test or Jobe Test. 18. Heuter’s Sign: This is done with the patient sitting and forearm pronated. A (+) sign: absence of elbow supination which is indicative of a ruptured distal biceps tendon. It is elicited by resistance to elbow flexion with the forearm pronated. 19. Lippman’s Test: The patient is sitting/standing. A positive sign is a sharp pain on the bicipital groove indicative of Bicipital Tendonitis. It is elicited as follows: Hold the patient’s arm and flex to 90⁰ with one hand, while the other hand palpates the biceps tendon 7–8 cm below the glenohumeral joint. Then move the biceps tendon side to side. 20. Gilchrest’s Test: It is done with the patient standing. The positive sign is pain on the bicipital groove indicative of bicipital paratendonitis. It is elicited as follows: Ask the patient to lift 2–3 kg/5–7 lbs of weight over the head with the arm in external rotation.

21. Ludington’s Test: This is done with the patient sitting hands clasped behind the head. A positive sign indicated by no contraction evident/palpable is indicative of a torn long head of biceps. It is elicited by asking the patient to contract the biceps.

Special Tests for the Shoulder

22. Ellman’s Compression Rotary Test: This is done with the patient side-lying on the unaffected side when the positive sign of pain reproduction is indicative of glenohumeral arthritis. This can be elicited by compressing the humeral head while the patient rotates the shoulder medially and laterally.

23. Acromioclavicular Shear Test: This is done with the patient sitting. The sign is positive with an abnormal movement at the AC joint indicative of acromioclavicular joint pathology. It is elicited as follows: Cup hands over the deltoid, one on the clavicle, and one on the scapula. Squeeze both hands together. 24. Wall Push-Up Test: This is done with the patient standing at an arm’s length from the wall. A positive sign is indicated by winging within 5–10 reps of a push-up. This is indicative of the weakness of scapular muscles. This is elicited by asking the patient to do 15–20 wall push-ups.

25. Closed Kinetic Chain Upper Extremity Stability Test: This is done with the patient prone on the floor at an arm’s length with hands 36 inches apart. The positive sign is winging of the scapula which is indicative of the weakness of scapular muscles. This can be elicited as follows: The patient touches the other hand and then returns to the original position. This is done for 15 seconds while the physiotherapist counts how many reps the patient is able to do. 26. SLAP Prehension Test: This is done with the patient sitting. The sign is positive when it is first = painful followed by second = relief of pain, which is indicative of a SLAP (superior labrum anterior to posterior) lesion. It is elicited as the patient actively abducting the shoulder at 90⁰; the forearm pronates and then horizontally adducts. The patient abducts the shoulder at 90⁰; the forearm supinates and then horizontally adducts. 27. Inferior Shoulder Instability Test: This is done with the patient standing relaxed. A positive sign is seen as a sulcus sign [+1 = 2 cm] which is indicative of inferior instability/ glenohumeral laxity. It is elicited by grasping the patient’s elbow and then pulling it distally. It is also known as Sulcus Sign.

28. Jerk Test: This is done with the patient sitting when the shoulder is flexed 90⁰ and internally rotated and a positive sign is seen as a sudden jerk or clunk, indicative of recurrent posterior instability. It is elicited as follows: Grasp the patient’s elbow and axially load the

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humerus proximally. Maintain the axial load and then move the arm to a horizontal arm to horizontal adduction with internal rotation.

29. Push-Pull Test: This is done with the patient supine. A positive sign of >50% translation, pain/apprehension is seen when the shoulder abducted 90⁰, flexed 30⁰ and this is indicative of Posterior Instability. It is elicited by holding the patient’s arm on the wrist and humerus when a pull on the arm at the wrist while pushing down on the humerus with the other hand.

30. Dugas Test: This is done with the patient sitting. A positive sign is seen as pain/inability to do the command of the physiotherapist which is indicative of anterior dislocation. It is elicited by asking the patient to place one hand on the opposite shoulder and to lower the elbow to the chest [3]. 31. Protzman Test: It is done with the patient sitting. The arm is abducted 90⁰, supported on the patient’s hip when a positive sign of pain is experienced indicative of anterior instability. It is elicited by palpating the anterior head with one hand, while the other hand is on the patient’s axilla and the humerus is pushed anteriorly and inferiorly [4]. 32. Surprise Test: It is done with the patient supine. A positive sign of pain and forward translation of the humeral head when the shoulder is abducted 90 degrees and externally rotated is indicative of traumatic instability problems. It can be elicited by performing “Fowler’s Sign,” after further external rotation, releasing the posterior force. It is also called as anterior release test.

33. Load and Shift Test: This is done with the patient sitting relaxed on the chair. A positive sign may be as follows: (a) Normal laxity = 1–25%; (b) Grade 1 = head rides over the glenoid rim (25–50%); (c) Grade 2 = head overrides the rim but reduces (>50%); and (d) Grade 3 = head overriding the rim and remains dislocated. This test mainly indicates traumatic problems at the glenohumeral joint. It is done as follows: Grasp the humeral head and stabilize the shoulder. Seat the humerus on the glenoid fossa and push it anteriorly and posteriorly to check for instability. 34. Tinel’s Sign: It is done with the patient sitting with the neck slightly flexed. A positive sign is indicated by localized pain indicative of a cervical plexus lesion. It is elicited by tapping the area of the

Special Tests for the Shoulder

Brachial Plexus with a finger along the nerve trunks [5, 6]. [It takes its name from French neurologist Jules Tinel (1879–1952).]

35. Brachial Plexus Compression Test: This is done with the patient sitting. A positive test is indicated if the pain radiates into the shoulder and signifies mechanical cervical lesions having a mechanical component. This is done by applying firm compression to the brachial plexus by squeezing the plexus under the thumb or fingers. 36. Valsalva Test (Valsalva Maneuver): A positive sign of increased pain is indicative of increased intrathecal pressure. It is elicited by when the patient takes a deep breath and holds it while bearing down as if moving bowels [7]. (The physician Antonio Maria Valsalva first described the technique in the 1700s as a way to clear pus out of the ears.)

37. Scalene Cramp Test: This is also carried out with the patient sitting. A positive sign indicated by an increase in the pain is indicative of thoracic outlet syndrome. It is elicited when the patient actively rotates the head to the affected side and pulls the chin down into the hollow above the clavicle by flexing the cervical spine [8].

38. Jackson’s Test: This is also done with the patient sitting. A positive sign indicted by pain radiating into the arm is indicative of cervical nerve root compression. It is done by rotating the patient’s head to one side and applying downward pressure on the head. 39. Lhermitte’s Sign: This is done with the patient in the long sitting position. A positive sign of pain radiating down the spine is indicative of dural or meningeal irritation. It is done by flexing the patient’s head and one hip simultaneously while the leg is kept straight [9]. (Lhermitte’s sign was first described by Marie and Chatelin in 1917. This sign is mostly described as an electric shock-like condition by some patients with multiple sclerosis. This sensation occurs when the neck is moved in the wrong way or rather flexed. It can also travel down to the spine, arms, legs, and sometimes the trunk. Demyelination and hyperexcitability are the main pathophysiological reasons depicted for the Lhermitte’s sign.) 40. Distraction Test: This is done with the patient sitting. A positive sign indicated by relief of pain is indicative of pressure on the nerve roots. This is done by placing one hand under the patient’s chin and

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the other around the occiput. Then slowly lift the head, by applying traction to the cervical spine.

41. Shoulder Abduction Test: This is also done with the patient sitting. A positive sign indicated by relief of symptoms is indicative of nerve root compression. This is done by abducting the patient’s arm and then resting the hand or forearm on top of the head.

42. Shoulder Depression Test: This is done with the patient sitting. A positive test with increased pain indicates a positive test indicative of nerve root compression. This is done by side flexing the patient’s head on the unaffected side and then applying downward pressure on the opposite shoulder (affected side).

43. Naffziger’s Test: This is done with the patient sitting. A positive test is when there is pain, indicative of a nerve root problem or a space-occupying lesion. It is done by compressing the patient’s jugular veins for 30 seconds and then asking the patient to cough [10].

1.7 Examination of Related Areas

The shoulder joint area is the site for referred pain in certain conditions, which must be borne in mind. Shoulder symptoms due to an irritated diaphragm being supplied by the same nerve root innervations (C4, C5) may be seen in myocardial infarction. Certain problems such as a prolapsed cervical disk may be referred to as the medial angle of the scapula. Occasionally a spinal fracture may have radiation to the shoulder along its muscle inserted into the scapula. Sometimes the pain may radiate retrograde proximally in cases of injuries to the distal humerus or the elbow. Certain specific conditions affecting the shoulder joint should be borne in mind, such as: (i) (ii) (iii) (iv)

The sternoclavicular joint The acromioclavicular joint The glenohumeral or shoulder joint Scapular disorders: ∑ Sprengel’s shoulder

Examination of Related Areas

(v) (vi) (vii) (viii) (ix) (x)

∑ Winged scapula ∑ Grating Scapula Frozen shoulder Tuberculosis of the shoulder Rotator cuff tears Biceps tear Biceps bursitis/tendinitis Brachial neuralgia

1.7.1 Sternoclavicular Joint

The sternoclavicular joint is a saddle type of synovial joint between the sternal end of the clavicle and the manubrium of the sternum with the articulation of 1st costal cartilage (Fig. 1.8).

Figure 1.8 Line diagram of the sternoclavicular joint.

Capsule properties: It has a strong joint capsule that consists of the sternal end of the clavicle, the manubrium of the sternum, and part of the 1st costal cartilage. The articular surfaces are covered with fibrocartilage. The joint is separated into two compartments by a fibrocartilaginous articular disk (Fig. 1.9). The capsule reinforces mainly the subclavius muscle. It originates in the costal cartilage of the first rib and gets inserted into the inferior aspect of the clavicle. Ligaments: The ligaments of the sternoclavicular joint provide much of its stability. There are four major ligaments: (i) Sternoclavicular ligaments (anterior and posterior): These strengthen the joint capsule anteriorly and posteriorly. (ii) Interclavicular ligament: This spans the gap between the sternal ends of each clavicle and reinforces the joint capsule superiorly.

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(iii) Costoclavicular ligament: The two parts of this ligament (often separated by a bursa) bind at the 1st rib and cartilage inferiorly and to the anterior and posterior borders of the clavicle superiorly. It is a very strong ligament and is the main stabilizing force for the joint, resisting elevation of the pectoral girdle.

Figure 1.9 Line diagram of the sternoclavicular joint showing capsule and articular disk.

The neurovascular supply: (a) Arterial supply to the sternoclavicular joint is from the internal thoracic artery and the suprascapular artery. The veins of the joint follow the major arteries. The veins of the joint follow the major arteries. (b) The joint is supplied by the medial supraclavicular nerve (C3 and C4) and the nerve to the subclavius (C5 and C6). Table 1.2

Movements of the sternoclavicular joint

Movements Muscles (A) Elevation

Upper Trapezius, Levator Scapulae

(D) Abduction (Protraction)

Serratus Anterior

(B) Depression

(C) Adduction (Retraction) (E) Upward Rotation

(F) Downward Rotation

Lower Trapezius, Pectoralis Minor Middle Trapezius, Rhomboids

Upper & Lower Trapezius, Serratus Anterior

Rhomboids, Pectoralis Minor, Levator Scapulae

Examination of Related Areas

Movements of the joint: The sternoclavicular joint has a large degree of mobility (Table 1.2). Several movements are involved in this joint movement namely (1) elevation, (2) depression, (3) retraction, (4) protraction, and (5) rotation.

Physiological importance: The sternoclavicular (SC) joint is important because it helps to support the shoulder. The SC joint links the bones of the arms and shoulder to the vertical skeleton. Pathologic abnormality of the sternoclavicular joint (SCJ) is rare. Those with osteoarthritis may benefit from local steroid injection to ameliorate the inflammation and subsequent pain associated with this process. For those who fail conservative treatment, surgical excision of the joint is curative in this noninfectious process. SCJ septic arthritis is a rare clinical entity, accounting for only 1% of cases of septic arthritis in the general population. It can, however, result in life-threatening complications if not treated adequately. Although mild cases may respond to antibiotics and surgical debridement, more serious cases require SCJ joint resection. Although the sternoclavicular joint is an unusual site for infection, thoracic surgeons may preferentially be called on to coordinate management of cases refractory to antibiotic therapy because of the anatomic relationship of this joint to major vascular structures. Most cases of early sternoclavicular joint infections will respond to conservative measures. However, when radiographic evidence of infection beyond the sternoclavicular joint is present, en bloc resection, although seemingly aggressive, results in immediate eradication of all infection with negligible functional morbidity. The sternoclavicular joint (SCJ) is commonly affected by rheumatological conditions. The sternoclavicular (SC) joint is a true diarthrodial joint that can be involved during the course of RA; however, its clinical implications appear to continue to be underestimated by the rheumatology community. There is ultrasound evidence that reveals a higher prevalence of SC joint involvement in patients with RA than in age‐ and sex‐matched healthy controls. The SCJ is capable of referring pain to areas distant from the joint.

1.7.2 Acromioclavicular Joint Arthritis

Definition Acromioclavicular (AC) joint arthritis is a progressively degenerative disease in which there is degeneration of joint cartilage and the underlying bone which causes pain and stiffness.

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Etiology The combination of three factors underlies the frequency of problems of the AC joint: (i) First, because it is a diarthrodial joint, it is vulnerable to the same processes affecting other joints in the body, such as degenerative osteoarthritis, infections, and inflammatory and crystalline arthritis. (ii) Second, its superficial location and its relationship to the shoulder girdle predispose it to traumatic injury. (iii) Third, the biomechanics of the shoulder girdle require the AC joint to transmit large loads across a very small surface area, which can result in failure with repetitive activity or overuse. Risk factors (i) Age (>45 yrs) (ii) History of the previous injury to AC joint (especially previous trauma and sports injury) (iii) Weight-lifting activities particularly those transmitting huge loads across the shoulder joint like bench press and military press. Causes There are three common causes of acromioclavicular joint arthritis: 1. Primary osteoarthritis 2. Post-traumatic osteoarthritis 3. Distal clavicle osteolysis

1. Primary Osteoarthritis In comparison to the rate of occurrence in the knee and hip, primary osteoarthritis in the shoulder is relatively rare. However, primary involvement of the AC joint is much more common than primary involvement of the glenohumeral joint and is, in fact, the most common cause of pain in the AC joint. Degenerative changes are seen by the fourth decade in the majority of AC joints. In one study, 54% to 57% of elderly patients demonstrated radiographic evidence of degenerative arthritis. In another study, magnetic resonance (MR) imaging demonstrated evidence of arthritic changes in 48% of the AC joints in over 300 older asymptomatic patients. Despite its seeming prevalence by radiologic criteria, symptomatic primary osteoarthritis is a relatively uncommon clinical entity.

Examination of Related Areas

2. Posttraumatic Arthritis Acromioclavicular arthritis following trauma is even more common than primary osteoarthritis, due to the frequency of injury to this vulnerable joint. The incidence of posttraumatic arthritis symptoms after injury or surgery is highly variable and depends on the degree of injury and the type of operative procedure. Arthritis also occurs, although less commonly, after distal clavicle fractures, particularly those with intra-articular extension. Operative procedures for AC joint dislocations in which the AC joint is preserved or transfixed have been associated with a higher incidence of arthritis than those in which the joint is sacrificed (i.e., the Weaver-Dunn procedure). 3. Distal Clavicle Osteolysis An increasingly recognized but still infrequent entity that causes AC joint symptoms is distal clavicle osteolysis. Osteolysis related to repetitive microtrauma has recently been receiving more attention, particularly among weight-lifting athletes. This condition is thought to be growing in frequency due to the of weight training and its incorporation into fitness programs and training regimens for other sports. The proposed mechanism of this form of osteolysis is that repetitive stresses to the subchondral bone of the distal clavicle lead to fatigue failure, which initiates resorption. Grading of the severity of osteoarthritis is done by the Kellegren Lawrence Classification (Table 1.3) [11]. Table 1.3

Kellegren Lawrence Classification

Grade

Description

0

No radiographic features of osteoarthritis

2

Possible narrowing of joint space with definite osteophytes

1 3 4

Doubtful narrowing of the joint space with possible osteophytic lipping Definite narrowing of the joint space, moderate multiple osteophytes, subchondral sclerosis, and possible deformity of the bone ends Marked narrowing of joint space, large osteophytes, severe subchondral sclerosis, definite deformity of the bone ends

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1.7.2.1 Shoulder separation A shoulder separation is not truly an injury to the shoulder joint. The injury involves the acromioclavicular joint (also called the AC joint). The most common cause of separation of the AC joint is from a fall directly onto the shoulder. The fall injures the ligaments that surround and stabilize the AC joint.

Types of Separation Mild shoulder separation: This involves a sprain of the AC ligament that does not move the collarbone and looks normal on X-rays. A more serious injury tears the AC ligament and sprains or slightly tears the coracoclavicular (CC) ligament, putting the collarbone out of alignment to some extent. Severe separation: The most severe shoulder separation completely tears both the AC and CC ligaments and puts the AC joint noticeably out of position. Symptoms Pain at the end of the collar bone. Pain may feel widespread throughout the shoulder until the initial pain resolves, following this it is more likely to be a very specific site of pain over the joint itself. Swelling often occurs. AC joint injuries are graded from 1–6 using the Rockwood scale [12] which classifies injuries in relation to the extent of ligament damage and the space between the acromion and clavicle. The Rockwood classification of acromioclavicular injuries in adults is as follows: Type I: Minor sprain of the acromioclavicular ligament, intact joint capsule, intact coracoclavicular ligament, intact deltoid and trapezius Type II: Rupture of the acromioclavicular ligament and joint capsule, sprain of the coracoclavicular ligament but intact coracoclavicular interspace, minimal detachment of the deltoid and trapezius Type III: Rupture of the acromioclavicular ligament, joint capsule, and coracoclavicular ligament; elevated clavicle (≤100% displacement); detachment of the deltoid and trapezius Type IV: Rupture of the acromioclavicular ligament, joint capsule, and coracoclavicular ligament; posteriorly displaced clavicle into the trapezius; detachment of the deltoid and trapezius

Examination of Related Areas

Type V: Rupture of the acromioclavicular ligament, joint capsule, and coracoclavicular ligament; elevated clavicle (>100% displacement); detachment of the deltoid and trapezius Type VI (rare): Rupture of acromioclavicular ligament, joint capsule, and coracoclavicular ligament; the clavicle is displaced behind the tendons of the biceps and coracobrachialis Evaluation and Diagnosis

1. Presentation Isolated AC joint arthritis presents with discomfort or aching over the anterior and/or superior aspect of the shoulder. Pain is often brought on by activities of daily living, such as washing the opposite axilla, and reaching back to retrieve a wallet. Symptoms are often exacerbated by more demanding activities, such as pushing or overhead work in the case of laborers and weight-lifting, golfing, swimming, or throwing in athletes. Patients may note pain at night, with nocturnal awakening when rolling onto the affected shoulder. There may be associated symptoms of popping, catching, or grinding.

2. Physical Examination ∑ Careful examination of the entire shoulder girdle combined with cervical spine examination is essential to rule out any contribution from cervical lesions. ∑ Inspection of the affected extremity may reveal swelling, deformity, joint prominence, or asymmetry which may indicate AC joint instability. Palpation over the AC joint may elicit tenderness, which is anecdotally sensitive but nonspecific. ∑ Dynamic stability of the AC joint can be assessed by placing the patient supine and affected extremity in 90 degrees of flexion. With one hand on the affected joint, the examiner assesses the movement of the clavicle with respect to acromion while applying a downward force on the patient’s flexed arm. 3. Specific Tests (i) Provocative maneuvers, such as reaching across to touch the opposite shoulder or placing the hand behind the back, may elicit discomfort. The provocative tests include: (a) Cross-body adduction test: The most reliable provocative physical examination is the cross-body adduction test, in

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which the arm on the affected side is elevated 90 degrees of forward flexion and the examiner then grasps the elbow and adducts the arm across the body. Reproduction of pain over the AC joint is suggestive of an AC joint lesion. This test may also be positive in patients with subacromial impingement and may cause discomfort posteriorly in patients with posterior capsular tightness. The sensitivity is 77% and the specificity is 79%. (b) AC resisted extension test: The patient is seated with the examiner standing behind him/her. The patient’s shoulder is positioned into 90 flexion and internal rotation, with the elbow placed into 90 flexion. The examiner places his/her hand on the patient’s elbow and asks him/her to horizontally abduct the arm against isometric resistance. A positive test is pain in the AC joint. This test sensitivity is 72% and specificity 85%. (c) O’Brien active compression test: In this test, the affected arm is brought into 90 degrees of forward flexion and 10 degrees of adduction. The patient then performs resisted shoulder flexion with the arm in maximum internal rotation and then in maximum supination. Pain with the former maneuver is consistent with a SLAP lesion and pain with the latter maneuver indicates AC joint abnormality. The sensitivity of this test is 41% and the specificity is 95%. The overall accuracy of these provocative tests in diagnosing AC joint arthritis is 93%. (ii) Painful arc sign: In this test, the affected shoulder is abducted and if the patient experiences pain during the last 30 degrees of abduction, it is consistent with AC joint arthritis. The sensitivity of this test is 50% and the specificity is 47%. (iii) Paxinos sign: With the patient sitting and the symptomatic arm by the side, the examiner’s thumb is placed under the posterolateral aspect of the acromion and the index and middle fingers of the same (or contralateral) hand are placed superior to the midclavicle. If we are examining the left shoulder right hand is to be used for eliciting this sign and vice versa. The examiner provides pressure to the acromion in an

Examination of Related Areas

anterosuperior direction with the thumb, while also applying pressure in an inferior direction to the midclavicle with the index and middle fingers. If pain is elicited or increased in the region of the acromioclavicular joint, the test is considered positive.

4. Radiological examination

(i) X-rays (a) Shoulder AP view: The AP projection is usually obtained with the patient in the upright or supine position and with the coronal plane of the body parallel to the cassette. The beam is directed in a true AP direction relative to the body. This results in a slight overlap of the glenoid rim and the humeral head as the glenohumeral joint is tilted anteriorly approximately 40 degrees. (b) Zanca view: Zanca described a modified technique that provides a clear, unobstructed view of the distal clavicle and AC joint. This projection is obtained by angling the X-ray beam 10 to 15 degrees superiorly and decreasing the kilovoltage to about 50% of that used for a standard glenohumeral exposure. Findings: Patients with primary or posttraumatic degenerative arthritis will have findings of arthritic changes which include (a) sclerosis, (b) osteophyte formation, (c) subchondral cysts, and (d) joint space narrowing. (c) Supraspinatus outlet view: The supraspinatus outlet view is useful for evaluating the acromion process and subacromial abnormalities such as osteophytes that may cause impingement. It is similar to the Y view but with caudal tube angulation. This view is taken with the patient turned as for the Y projection and the cassette perpendicular to the body of the scapula and parallel to the glenoid fossa. The X-ray is taken from a mediolateral projection along the axis of the scapular spine, with an X-ray beam angled 10–15 degrees craniocaudally and centered on the acromioclavicular joint. (ii) Ultrasonography Ultrasonography can be used to assess joint space and detect osteophytes or other bony erosions, although the usefulness

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of this technique is dependent on the skill of the technician and is limited to superficial soft tissue. (iii) MRI Magnetic resonance imaging is very sensitive in identifying abnormalities of the AC joint, but these changes often do not correlate with physical findings. In one study of asymptomatic volunteers, findings indicated that AC joint arthritis was present in 75% of shoulders. The nonspecificity of MR imaging precludes it from being useful in the evaluation of patients with AC joint symptoms. However, MRI can help rule out other causes of shoulder joint pain which can be concomitantly present with AC joint arthritis. (iv) Joint injection A joint injection can be used both diagnostically and therapeutically. A combination of local anesthetic and corticosteroid is used.

Technique: Palpate the bony landmarks and mark the site of injection. Prepare the skin using a sterile technique. A 23-gauge needle is directed into the joint from a superior approach. The needle is then slowly advanced perpendicular to the articulation while palpating for a tactile pop through the capsule. The mixture can then be easily injected and noted to flow freely into the joint. The joint can be injected under sonographic guidance. ∑ Despite the subcutaneous nature of the joint, intra-articular injections can sometimes be difficult where the accuracy can be improved with the use of ultrasound guidance. ∑ Elimination of pain within a few minutes of the injection confirms the AC joint as the source of the patient’s symptoms and is considered by many authors to be the most valuable diagnostic tool. ∑ Relief after an injection is also considered the most accurate prognostic indicator of success with distal clavicle resection. 5. Treatment Whether treated conservatively or with surgery, the shoulder will require rehabilitation to restore and rebuild motion, strength, and flexibility. The main treatment depends on the type of injury. The initial treatment of a separated shoulder consists of controlling the inflammation and resting the joint.

Examination of Related Areas

(i) Icing the injury: The inflammation from a separated shoulder can be controlled with ice placed on the joint every four hours for 15 minutes. Icing can be done for the first several days until the swelling around the joint has subsided. (ii) Rest the AC joint: A sling to rest the joint can be worn until the pain has subsided and you can begin some simple exercises. Resting the joint will help minimize painful symptoms and allow healing to begin. (iii) Anti-inflammatory medication: Anti-inflammatory medication will also help to minimize the pain and inflammation. (iv) Grade I and II injuries: It has been underestimated and may lead to more chronic disability than previously recognized, especially in athletes and heavy laborer’s who stress their shoulders daily. Some late surgery such as AC joint resection arthroplasty may be needed. However, more than 50% of the patients have a good or excellent shoulder 6 years after injury. (v) Surgery: It is not in most cases. Type I and type II shoulder separations are by far the most common types of separated shoulders, and these types of injuries rarely need surgery, and only if there are problems with nonoperative treatment. Type IV, V, and VI shoulder separations almost always require surgery (Fig. 1.10), but these are very uncommon injuries. The difficult decisions arise with patients with a type III shoulder separation. There is controversy among orthopedic surgeons as to how to best manage patients with a type III shoulder separation. As may be expected, there is no ‘right answer’. Surgical treatment can also be considered if pain persists or the deformity is severe. A surgeon might recommend trimming back the end of the collarbone so that it does not rub against the acromion. Where there is significant deformity, reconstructing the ligaments that attach to the underside of the collarbone is helpful. This type of surgery works well even if it is done long after the problem started. (vi) Non-surgical treatment for type III shoulder separations: Most evidence suggests that patients with type III shoulder separations do just as well without surgery, and avoid the potential risks of surgical treatment. These patients return to sports and work faster than patients who have surgery for this type of injury.

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(vii) Type III and IV: AC joint instability symptoms may persist, with impingement symptoms secondary to the drop-down of the shoulder and the abnormal biomechanics. A patient may complain of severe deformity in the AC joint and traction symptoms with neck pain and neural brachial plexus symptoms. There is a significant decrease (24%) in horizontal abduction strength at fast speeds. However, overall 87% with type III dislocation showed satisfactory outcomes with conservative treatment of ‘skillful neglect.’ (viii) Surgery for type III shoulder separations: Recent studies have suggested that some athletes and heavy laborers may benefit from early surgical treatment of type III shoulder separations. These include athletes who participate in sports that require overhead throwing such as baseball. The potential benefit of early surgical treatment for type III shoulder separations remains unproven.

Figure 1.10 Complete dislocation of the AC joint treated by a Bosworth screw. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

1.7.3 Dislocation of the Glenohumeral or Shoulder Joint Shoulder dislocation is well documented in Egyptian tomb murals as early as 3000 BC, with a depiction of manipulation for glenohumeral dislocation resembling the Kocher method. In a painting in the tomb of Ipuy, 1300 BC, the sculptor of Ramses II shows a physician reducing a dislocated shoulder, using a similar technique.

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Epidemiology It occurs in approximately 1.7% population. It occurs in both sexes, men in 20–30 years (M:F = 9:1) and women in 61–80 years (M:F = 1:3). It occurs less in children as their epiphyseal plate is weaker and tends to fracture before dislocating. It is seen more commonly in the elderly as the collagen fibers have fewer cross-links and hence a weaker capsule or tendons or ligaments.

Anatomy Glenohumeral stability depends on both passive and active mechanisms: (i) Passive, such as joint conformity, vacuum effect of limited joint volume. Adhesion and cohesion owing to the presence of synovial fluid, a scapular inclination of zero to 30 degrees, and glenoid labrum. The bony restraints are the coracoid, acromion, and glenoid fossa, along with ligamentous and capsular restraints such as the joint capsule, superior, middle, and inferior glenohumeral ligaments along with the coracohumeral ligament. (ii) Active, such as biceps, long-head, rotator cuff, and scapular stabilizing muscles.

Pathoanatomy of shoulder dislocations These may vary from (1) stretching or tearing of capsule, (2) avulsion of glenohumeral ligaments usually off the glenoid, (3) labral injury, (4) Bankart lesion, (5) impression fracture, (6) Hill–Sachs lesion, and (7) rotator cuff tear. A Bankart lesion is usually (a) seen in anterior dislocation, with (b) stripping of glenoid labrum along with periosteum usually at the (c) anteroinferior surface of glenoid and scapular neck. The avulsion of the anteroinferior glenoid rim causes a bony Bankart lesion. A Hill–Sachs lesion is usually due to (1) depression on the humeral head in its posterolateral quadrant caused due to (2) impingement by the anterior edge of the glenoid on the head as it dislocates. Dislocation of the shoulder is usually seen as follows: (i) Mostly anterior in more than 95% of dislocations. (ii) Posterior dislocation occurs in less than 5%. (iii) An inferior dislocation, occurring in less than 1%, is commonly referred to as luxatio erecta (Latin for “erect dislocation”),

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deriving its name from the classical presentation of an arm that is elevated and abducted and held overhead, unable to be lowered. The vast majority of cases of luxatio erecta will be successfully managed with closed reduction and postreduction immobilization. Cases of an irreducible inferior dislocation in the emergency room setting usually occur secondary to the humeral head buttonholing through the inferior capsule. Usually a beach chair position, and a reduction utilizing a deltopectoral approach. Alternatively, one can use a strap incision to utilize both the deltopectoral interval and if necessary, a deltoid-splitting interval. (iv) Habitual: It is a non-traumatic dislocation that may present as multidirectional dislocation due to generalized ligamentous laxity and is usually painless by nature. Mechanism of injury The commonest is a fall on an outstretched hand with the shoulder abducted and externally rotated. Posterior dislocation is usually by a direct blow from the front of the shoulder or epileptiform convulsions or electric shock. Clinical features There is pain, and the patient holds the injured limb with the other hand close to the trunk. The shoulder is abducted and the elbow is kept flexed. There is a loss of the normal contour of the shoulder which appears as a step. The anterior bulge of the head of the humerus may be visible or palpable along with an empty glenoid socket.

Radiographic evaluation (i) Trauma series of the injured shoulder (Figs. 1.11A & B) includes: (a) Anteroposterior (AP) shoulder view (b) Scapular-Y view (c) Axillary views taken in the plane of the scapula. ∑ Velpeau axillary view: If a standard axillary view cannot be obtained because of pain, the patient may be left in a sling and leaned obliquely backward 45 degrees over the cassette. The beam is directed caudally, orthogonal to the cassette, resulting in an axillary view with magnification.

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(d) West point axillary view: This is taken with the patient prone with the beam directed cephalad to the axilla 25 degrees from the horizontal and 25 degrees medial. It provides a tangential view of the anteroinferior glenoid rim. (e) Stryker notch view: Here the patient is supine with the ipsilateral palm on the crown of the head and the elbow pointing straight upward. The X-ray beam is directed 10 degrees cephalad, aimed at the coracoid. This view can visualize 90% of posterolateral humeral head defects.

(A)

(B)

Figure 1.11 (A) Anterior dislocation of the shoulder. (B) Anterior fracturedislocation of the shoulder. Image courtesy: Dr. Rajesh Botchu, Consultant MSK Radiologist, Royal Orthopaedic Hospital, Birmingham, UK.

(ii) Computed tomography may be useful in defining humeral head or glenoid impression fractures, loose bodies, and anterior labral bony injuries (bony Bankart lesion). (iii) Single- or double-contrast arthrography may be utilized to evaluate rotator cuff pathologic processes. (iv) Magnetic resonance imaging may be used to identify rotator cuff, capsular, and glenoid labral (Bankart lesion) pathologic processes. Management It is an emergency and should be reduced in less than 24 hours or else AVN of the head of humerus sets in. It is immobilized strapped

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to the trunk for 3–4 weeks and rested in a collar and cuff. The reduction maneuvers available are the follows: (i) (ii) (iii) (iv) (v) (vi)

Traction-countertraction method Hippocrates method Stimpson’s technique Kocher’s technique Milch technique Scapular manipulation

Stimpson’s technique: The patient is placed prone on the stretcher with the affected shoulder hanging off the edge. Weights (10–15 lbs) are fastened to the wrist to provide gentle, constant traction (Fig. 1.12).

Figure 1.12 Line diagram showing Stimpson’s technique.

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Kocher’s technique: It is carried out in four steps as follows: (i) traction, with the elbow flexed at right angle, steady traction applied along the long axis of humerus, (ii) external rotation, (iii) adduction, and (iv) internal rotation.

Milch technique: The arm is abducted and the physician’s thumb is used to push the humeral head into its proper position. Gentle traction in line with the humerus is provided with the physician’s opposite hand. Scapular manipulation:  The patient sits upright and leans the unaffected shoulder against the stretcher. The physician stands behind the patient and palpates the tip of the scapula with his thumbs and directs a force medially. The assistant stands in front of the patient and provides gentle downward traction on the humerus. The patient is encouraged to relax the shoulder as much as possible. Postreduction: The orthopedic follow-up is roughly every week. Complications Recurrent dislocation of the shoulder:  The shoulder is one of the most unstable and frequently dislocated joints in the body, because of its greatest range of motion at expense of stability, it accounts for nearly 50% of all dislocations and has a 2% incidence in the general population. The factors that influence the probability of recurrent dislocations are age, return to contact or collision sports, hyperlaxity, and the presence of a significant bony defect in the glenoid or humeral head. It is approximately 50–90% of patients under 20 and approximately 5–10% of patients over age 40. Ways to prevent redislocation:  The position of immobilization, increasing the duration of immobilization, physical therapy, and operative repair. Mobilization:  30 Æ begin mobilization after one week. Position: Internal rotation and adduction vs. 10 degrees external rotation (anatomically sound but the evidence does not support benefit).

Normal functional anatomy of the shoulder joint The glenoid fossa is a flattened, dish-like structure. Only one-fourth of the large humeral head articulates with the glenoid. The glenoid is deepened by 50% by the presence of the glenoid labrum. which

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increases the humeral contact up to 75 %. Superiorly biceps attaches to the supraglenoid tubercle which blends with the posterior part of the labrum. The labrum may serve as a “chock block” to prevent excessive humeral head rollback. The joint capsule is lax and thin and, by itself, offers little resistance or stability. Anteriorly, the capsule is reinforced by three capsular thickenings or ligaments that are intimately fused with the labral attachment to the glenoid rim. Glenohumeral Ligaments

(i) Superior glenohumeral ligament: It attaches to the glenoid rim near the apex of the labrum conjoined with the long head of the biceps. On the humerus, it is attached to the anterior aspect of the anatomical neck. The restraint to inferior, anterior, and posterior stress at 0 degrees of abduction is a tightening of the rotator interval (which includes the superior glenohumeral ligament) and decreases posterior and inferior translation; external rotation also may be decreased. (ii) Middle glenohumeral ligament: It has a wide attachment extending from the superior glenohumeral ligament along the anterior margin of the glenoid down as far as the junction of the middle and inferior thirds of the glenoid rim. On the humerus, it is also attached to the anterior aspect of the anatomical neck. It limits external rotation when the arm is in the lower and middle ranges of abduction but has little effect when the arm is in 90 degrees of abduction.

(iii) Inferior glenohumeral ligament: The glenoid margin from the 2- to 3-o’clock positions anteriorly to the 8- to 9-o’clock positions posteriorly humeral attachment is below the level of the horizontally oriented physis into the inferior aspect of the anatomical and surgical neck. The anterosuperior edge of this ligament usually is quite thickened. There is a less thick and distinct posterior part and a thin axillary recess which create a hammocktype model. In external rotation, the hammock slides anteriorly and superiorly. The anterior band tightens, and the posterior band fans out. With internal rotation, the opposite occurs. The anteroinferior glenohumeral ligament complex is the main stabilizer of anterior and posterior stresses when the shoulder is abducted 45 degrees or more.

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Muscles around shoulder joint They dynamically position the scapula to place the glenoid opposite the humeral head as the shoulder moves. The ligaments work in a static fashion to limit translation and rotation, their stiffness and torsional rigidity are increased with concomitant muscle activity. The intrinsic and extrinsic muscle groups serve as fine-tuners of motion and power movers by working in “force couples.” The force couples control and direct the force through the joint, contributing to stability. Importance of synchronous movement of the scapula The glenoid has the ability to remain in the most stable position in relation to the humeral head with movement. Many studies show the importance of this dynamic balance to appropriate positioning of the glenoid articular surface so that the joint reaction force produced is a compressive rather than a shear force. Strengthening rehabilitation of the scapular stabilizers (serratus anterior, trapezius, latissimus dorsi, rhomboids, and levator scapulae) is especially important in patients who participate in upper extremity-dominant sports. The glenoid also has the ability to “recoil.” This ability to “recoil” lessens the impact on the shoulder as the scapula slides along the chest wall. Scapular dyskinesia is an alteration of the normal position or motion of the scapula during coupled scapulohumeral movements and can occur after overuse of and repeated injuries to the shoulder joint. Other stabilizing factors: Version of glenoid; Cohesion of joint fluid; Vacuum effect produced by negative intra-articular pressure; Ruffini end organs and Pacinian corpuscles in the shoulder capsule.

Pathoanatomy Acute shoulder dislocation occurs (1) when the humeral head is forced through the capsule where it is weakest or (2) when the humeral head is forced anteriorly out of the glenoid and tear labrum from an almost entire half of the rim of the glenoid and also capsule and periosteum called Bankart lesion. A Hill-Sach’s lesion is an impaction fracture on the humeral head on the posterolateral aspect that can be produced as the shoulder is dislocated due to impaction of the humeral head against the glenoid rim. Instability results when the defect engages the glenoid rim in the functional arc of motion at 90 degrees abduction and external

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rotation. The defects of 35% to 40% of the head were shown to decrease stability. Capsular laxity: Excessive laxity can be caused by a congenital collagen deficiency, shown by hyperlaxity of other joints, or by plastic deformation of the capsuloligamentous complex from a single macro traumatic event or repetitive micro-traumatic events. The primary deficiencies, secondary deficiencies like erosion of the anterior glenoid rim, stretching of the anterior capsule and subscapularis tendon, and fraying and degeneration of the glenoid labrum all can occur with repeated dislocation. An arthroscopic study of anterior shoulder dislocations found that 38% of the acute injuries were intrasubstance ligamentous failures, and 62% were disruptions of the capsuloligamentous insertion into the glenoid neck. The “circle concept” of structural damage to the capsular structures was suggested by cadaver studies that showed that humeral dislocation does not occur unless the posterior capsular structures are disrupted in addition to the anterior capsular structures. Posterior capsulolabral changes associated with recurrent anterior instability often are identified by arthroscopy. Classification Following are the three types of shoulder instability based on the (i) direction of instability ∑ unidirectional ∑ bidirectional ∑ multidirectional (ii) degree of instability ∑ subluxation ∑ dislocation (iii) duration of instability ∑ acute ∑ subacute ∑ chronic if greater than 6 weeks In addition to these types, there is a fourth type of instability termed the ‘habitual’ dislocation of the shoulder. One must also take into consideration the following factors:

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(i) Type of trauma ∑ macro trauma ∑ micro trauma ∑ secondary trauma (ii) Age of initial dislocation ∑ 40 years (10% recurrence)

Matsen’s simplified classification system [13, 14]

(i) TUBS (Traumatic Unidirectional Bankart Surgery) (ii) AMBRII (Atraumatic, Multidirectional, Bilateral, Rehabilitation, Inferior capsular shift, and Internal closure). Micro-traumatic or developmental lesions fall between the extremes of macro-traumatic and atraumatic lesions and can overlap these extreme lesions.

History It mainly depends on the amount of initial trauma (high or low energy). Recurrence with minimal trauma in the midrange of motion—and/or with the bony lesion. It also depends on the position in which the dislocation or subluxation occurs. If dislocations occur during sleep or with the arm in an overhead position—a/w with a significant glenoid defect with the ease with which the shoulder is relocated is determined. There may be associated nerve injury or physical limitations caused by this instability. Be careful about subluxation which is commonly overlooked by the physicians because the symptoms are vague and there is no history of actual dislocation. The patient may complain of having a “dead arm” as a result of stretching of the axillary nerve or secondary rotator cuff symptoms: Posterior shoulder instability may present as posterior pain or fatigue with repeated activity (e.g., blocking in football, swimming, bench press, rowing, and sports requiring an overhead arm movement). Mental status: Some patients with posterior instability learn to dislocate their shoulder through selective muscular contractions. Although voluntary dislocation does not indicate pathological overlay, some of these patients have learned to use voluntary dislocation for secondary gain, and in these patients, surgical treatment is doomed to failure.

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Physical examination: Both shoulders should be thoroughly examined, with the normal shoulder used as a reference for atrophy, asymmetry, tenderness, active and passive ROM, power of muscle, and also winging or dyskinesia of scapula. Stability of shoulder joint

1. Shift and load test With the patient sitting with the arm slightly abducted placing one hand along the edge of the scapula to stabilize it by grasping the humeral head with the other hand and applying a slight compressive force. The amount of anterior and posterior translation of the humeral head in the glenoid is observed. Easy subluxation of the shoulder indicates loss of the glenoid concavity.

2. Sulcus test With the arm in 0 degrees and 45 degrees of abduction. This test is done by pulling distally on the extremity and observing for a sulcus or dimple between the humeral head and the acromion that does not reduce with 45 degrees of external rotation. The distance between the humeral head and acromion should be graded from 0 to 3 with the arm in 0 degrees and 45 degrees of abduction, with 1+ indicating subluxation, less than 1 cm, 2+ indicating 1 to 2 cm of subluxation, and 3+ indicating more than 2 cm of inferior subluxation, which does not reduce with external rotation. Subluxation at 0 degrees of abduction is more indicative of laxity at the rotator interval, and subluxation at 45 degrees indicates laxity of the inferior glenohumeral ligament complex. 3. Apprehension test (a) In an anterior dislocation, the shoulder is in 90-degree abduction and the elbow in 90-degree flexion, resulting in external rotation with anterior stress applied. (b) In a posterior dislocation, the shoulder is in 90-degree and the elbow in 90-degree flexion resulting in a forward flexed, internally stress applied rotated with posterior stress. Thus, in both the types of dislocation a and b, apprehension or instability is produced. 4. Drawer test (a) In an anterior dislocation, anterior stress is applied in various degrees of abduction and external rotation, whereas

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(b) In a posterior dislocation, posterior stress is applied at 90 degrees of abduction and in various degrees of flexion + IR. Combining the results of a and b, Grade 1 means that the humeral head slips up to the rim of the glenoid, Grade 2 means that it slips over the labrum but then spontaneously relocates, and Grade 3 indicates dislocation.

5. Jobes relocation test (i) This test is used mainly in used for evaluating instability in athletes involved in sports requiring overhead motion. (ii) A bony deformity of the glenoid or humerus is indicated by apprehension or instability at low ranges of motion ( 7 mm; poor prognosis < 5 mm) (ii) Y-lateral for the shape of the acromion, axillary for Os acromiale, AP of ACJ for osteophytes, and AP in the abdomen for rotator cuff dysfunction

Radiographic features The subchondral sclerosis of the humeral head or flattening of the greater tuberosity or sclerosis of the acromion-sourcil sign. Calcifications are located in the presumed area of rotator cuff tendon, acromion spurs, or acromion types 2 and 3. Subchondral sclerosis of the humeral head with acromiohumeral space less than 6 mm is indicative of chronic full-thickness tear. A bony spur on the inferior surface of the acromion.

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Arthrogram It is good for the diagnosis of complete rotator cuff tear and is costeffective. It is invasive but does not give information about the size of the tear. A channel between the articular capsule and the subacromial-subdeltoid bursa in a complete rotator cuff tear and a presence of contrast medium in the subdeltoid-subacromial bursa signs the presence of a complete rotator cuff tear. Ultrasound is cheap and quick to perform and gives a good definition of the rotator cuff. It allows dynamic examination and is operator-dependent. The finding of nonvisualization of the cuff, localized absence, discontinuity, or focal abnormal echogenicity is an indication for an MRI, which is the best diagnostic aid and defines the site of cuff damage. It also demonstrates fatty changes in muscle indicative of a poor-quality cuff. It also defines the exact size, shape, and location of the tear and is non-invasive.

Conservative management ∑ McLaughlin in 1962 advanced reasons to avoid early repair as 25% of cadavers had torn cuff-most of them were asymptomatic. 50% of patients would recover comfortably but the results of early and late repair are similar and repair did not always permit anatomic restoration. Hence early diagnosis is difficult. A review of the literature indicates that the success rate of nonoperative treatment ranges from 33% to 92% [44]. ∑ Bartolozzi et al. reported 66–75% good or excellent results (mean follow-up of 20 months). Unfavorable prognostic factors were tear >1 cm with symptoms >1 year and significant functional impairment [45]. ∑ Hawkins and Dunlop (1995) reported >50% satisfactory results at an average follow-up of 4 years [46]. ∑ Bokor et al. reported 74% satisfactory results over a period of 7.6 years in 53 patients (average age of 62 years). 86% of those present within 3 months responded favorably while only 56% of those presented after 6 months were satisfactory [47]. ∑ Itoi and Tabata reported 82% satisfactory results in 62 shoulders followed over 3.4 years [48].

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Orthotherapy The term used by Michael Wirth (OCNA 1997) means an interactive exchange between patient and orthopedic surgeon directed at creating an exercise regimen that gradually improves motion and strength in the shoulder girdle. There are three phases: Phase 1: Restore full, painless range of motion; Codman pendulum exercise followed by passive movements in all direction Phase 2: Designed to strengthen the remaining muscles of the rotator cuff, deltoid, and scapular muscles Phase 3: Gradual reinstitution of normal activities including work, hobby, and sport

Subacromial corticosteroid injections It is a combination of local anesthetic and steroid (5–10 ml) given in a course of a maximum of 2 to 3 injections. Method: It is given sitting with arms hanging by side and the needle inserted just under acromion from anterolateral, lateral, or posterolateral aspect. They should have an easy unrestricted flow of fluid. Benefits: They are a short-term benefit in reducing pain and increasing ROM with risks being a decreased tendon strength and risk of rupture into tendon due to subcutaneous atrophy with effects on articular cartilage and may have detrimental effects on results of subsequent repair. Operative treatment

Patient selection Samilson and Binder: The patient is physiologically younger than 60 years and clinically or arthrographically demonstrates full-thickness cuff tear. A failure to improve on nonoperative management for a minimum of 6 weeks will need to use shoulder in overhead elevation with full passive range of motion with the ability and willingness to cooperate. Poor prognostic factors are as follows: (i) Old age group (ii) Long history (iii) No history of trauma (iv) Smoker

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(v) Multiple steroid injections, and (vi) Diffuse osteopenia

Gartsman has classified rotator cuff tear on basis of size as follows: (i) (ii) (iii) (iv)

Small: 5 cm



Tear repair procedures available are:



Neer described the four major objectives of tear repair as

(i) Open or arthroscopic: Tendon to tendon or tendon to bone (ii) Arthroscopic debridement and acromioplasty with mini-open repair (i) Closure of cuff defect (ii) Elimination of impingement lesions of the coracoacromial arch (iii) Preservation of origin of deltoid and rehabilitation to prevent postop stiffness

Technique of open repair Approach by a 5 to 7 cm incision extending from the lateral aspect of ant third of acromion to the lateral tip of coracoids. Then proceed to the subacromial decompression for coracoacromial ligament release, anterior acromioplasty, and modified acromioclavicular arthroplasty. For rotator cuff repair: Assess the nature of the tear. The mobilization will release the adhesion with the release of the coracohumeral ligament. Then with interval slide subscapularis tendon, transfer and repair the tendon to tendon or tendon to bone (McLaughlin technique). Mobilization is the release of the capsule from the labrum and the release of cuff tendons from the coracoids. The rotator cuff is repaired by transosseous repair. Advantages of open repair It is easy to do with no special equipment required. It allows direct visualization of cuff repair and acromioplasty with good long-term follow-up.

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Disadvantages Deltoid detachment is required and false-positive studies (arthrogram 2%, MRI 10%) will lead to unnecessary open exploration leading to an unrepairable tear being opened. Significant intra-articular pathology may be missed.

(i) Arthroscopic repair of rotator cuff Advantages: Lesser morbidity with the ability to identify and treat other pathology. It is truly an outpatient procedure and allows to address small undetected tears with a considerable lot of patient acceptance. Disadvantages: It is technically difficult and the implant cost needs an anchor. There is an increased OR time with a high failure rate during the learning curve. (ii) Arthroscopic assisted mini-open repair It is usually done by a lateral portal is expanded and is useful for small and moderate shape tears and its results are comparable to open repair. Advantages: It is easy to do with modest arthroscopic skills and allows for arthroscopic correction of intra-articular pathology with well-established improvement in perioperative morbidity. It is usually done in two large studies with no increase in complication or compromise in the outcome as it is cost-effective and easy to “bail out” to a full open procedure if desired and avoids opening patients with false-positive studies and hence avoid opening patients with unrepairable defects.

Postoperative plan It depends on the size of the tear, type of repair, degree of retraction, intraoperative motion limits, and the age of the patient. (i) Open: Proceed slowly (deltoid detached), avoid active flexion or abduction for 4 weeks and it requires 1–2 additional months. (ii) Arthroscopic: Immediate active and passive ROM, avoid active abduction >60 degrees for 3–4 weeks and then electrical stimulation, resisting exercises for 3–4 months. There is a high demand for activities within 4–6 months.

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Phase 1 requires protective, protecting repair but regaining movement and prevention of muscle weakening Phase 2 requires strengthening when healing is secure, and 2/3 normal range of movement achieved Phase 3 requires a return to work and sport, entry requirements, full ROM, no pain or tenderness Partial-thickness tear: There are three subtypes of tears (Codman), namely bursal-side, articular surface tears, and the intratendinous. The surgical options vary between debridement alone, debridement with arthroscopic subacromial decompression, open repair with acromioplasty, arthroscopic repair, and arthroscopic repair with the mini-open repair. The Ellman classification is based on the depth of tear [49]: Type 1: 0–3 mm Type 2: 3–6 mm Type 3: >6 mm Arthroscopic debridement and acromioplasty versus repair: Gartsman (1995) took into consideration the size and depth of tear (more or less than 50 %) depending on the patient’s activity level and bone structure, but currently lesions with 50 % require excision and repair. Bursal lesions with type 2 or type 3 acromions require decompression only [50]. Irreparable tears: During pre-operative diagnosis, if AHI 60 years with good external rotation and good flexion would give a good relief with subacromial LA injection.

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(ii) Tendon transposition involves transferring part of subscapularis or infraspinatus superiorly, which disrupts the coupling force of subscapularis and infraspinatus. Partial repair of a massive rotator cuff tear, as advocated by Burkhart et al., is considered a “functional rotator cuff tear” in which the force couples are intact with stable fulcrum kinematics and edge stability, constituting an intact “suspension bridge.” A balanced force couple being the inferior half of the infraspinatus posteriorly and the subscapularis anteriorly. In the case of an irreparable cuff, Burkhart et al. reported the results on partial rotator cuff repair, which preserves normal mechanics as compared to tendon transfer, as 2 excellent, 6 good, 5 fair, and 1 poor [51]. (iii) Muscle transfers: The main indication being the symptomatic rotator cuff defect that has a low probability of repair. Here two parameters are used namely static subluxation of the humeral head and the degree of degeneration and atrophy of rotator cuff muscles. Thus, transfers for substitution of individual muscles such as subscapularis for trapezius (acromial portion), pectoralis major, pectoralis minor, supraspinatus for trapezius (acromial portion), deltoid and infraspinatus for latissimus dorsi, teres major. The latissimus dorsi transfer was described by Gerber in 1992 with the indication being an irreparable rotator cuff tear involving the supraspinatus and infraspinatus with a functioning subscapularis and deltoid. A review of 16 cases over 33 months showed the following results: with an average gain of flexion by 52 degrees and abduction by 50 degrees, external rotation of 13 degrees, with an overall excellent 8, good 5, fair 2, poor 2, and patients with subscapularis tear did poorly. Teres major transfer was described by Celli in 1998 with an indication of an isolated infraspinatus tear along with a functional supraspinatus. He reported 6 cases with good results [52]. Complications of rotator cuff repair (i) Retear or failure of repair (ii) Infection (iii) Adhesions (iv) Fracture of acromion (v) Denervation of deltoid

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(vi) (vii) (viii) (ix)

Injury to the suprascapular nerve Greater tuberosity fracture Stiffness, frozen shoulder Reflex sympathetic dystrophy

Cuff tear arthropathy This is the end stage of rotator cuff disease (4%) in patients of age 70–80 years with severe shoulder pain. They have an active elevation of 40–60 degrees with severe wasting of supraspinatus and infraspinatus showing an effusion anteriorly with superior subluxation of the humerus. A radiograph shows a superior translation of the head of the humerus with loss of articular cartilage due to direct articulation of the head with the coracoacromial arc. This is called as “femoralization” of the proximal humerus or “acetabularization” of the upper glenoid. Their treatment for intractable pain, unresponsive to conservative treatment, is the strongest indication for surgery having the option of shoulder arthrodesis. Hemi replacement arthroplasty or total shoulder replacement: ∑ The prerequisites for arthroplasty being an adequate deltoid power and a preserved or reconstructed coracoacromial arch ∑ Diagnosis is based on a good review of the history and examination ∑ Nonoperative management remains the standard initial care ∑ Surgery in selective active individuals ∑ Arthroscopy with early mobilization and decreased morbidity ∑ Treatment according to patients’ functional needs

1.7.8 Biceps Tear

The biceps is a two-headed muscle that lies on the upper arm between the shoulder and the elbow. Both heads arise on the scapula and join to form a single muscle belly that is attached to the upper forearm. (i) Short head: coracoid process of the scapula (ii) Long head: supraglenoid tubercle

Artery: It is supplied by the brachial artery and its nerve supply is by the musculocutaneous nerve action.

Examination of Related Areas

Action: It flexes the elbow as well as flexes and abducts the shoulder. It also supinates the radioulnar joint in the forearm. A biceps rupture is a condition characterized by complete tearing of one or more tendons or muscle bellies of the biceps muscle. Rupture of the biceps tendon often occurs after a sudden contraction of the biceps with resistance to flexion and supination of the forearm intrinsic degeneration of the tendon release and frictional wear of the tendon belly may have an impact. Proximal biceps tendon rupture This is when one of the two biceps tendons in the shoulder is torn away from the bone. There is sudden shoulder pain and an oddshaped bulge is seen in the biceps. When the proximal biceps tendon ruptures, the muscle moves toward the elbow and becomes a big ball of muscle called the Popeye muscle. A rupture of the distal biceps tendon occurs around the elbow joint and usually occurs in men. A proximal rupture of the biceps tendon can be left alone, especially in the elderly. However, a distal rupture of the biceps tendon should be repaired. Distal biceps tendon rupture A tear of the biceps tendon at the forearm is unusual. The symptoms are a sudden pain over the front of the elbow and weakness in the forearm. The rupture typically occurs in athletes, such as bodybuilders, or in people who perform manual labor. Rupture of the tendon involves flexion of the elbow against resistance with eccentric loading and sudden tearing of the tendon. The patient will feel a pop with pain, swelling, and weakness of the elbow. The biceps muscle may retract into the upper arm causing a bump or “Popeye” sign.

Predisposing factors ∑ Age: Older people who have put more years of wear and tear on their tendons than younger people. ∑ Heavy overhead activities with shoulder overuse. ∑ Smoking: Nicotine use can affect nutrition in the tendon. ∑ Corticosteroid medication: Using corticosteroids has been linked to increased muscle and tendon weakness. ∑ Gender: Men suffer from biceps rupture more commonly than women, but this difference may result primarily from vocational or avocational factors.

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Signs and symptoms (i) Sudden sharp acute pain in the upper arm with tenderness and weakness (ii) Sometimes an audible pop or snap may be heard (iii) Bicep muscle cramp (iv) Bruising from the middle of the upper arm down toward the elbow (v) Difficulty turning the arm palm up or palm down a bulge in the upper arm above the elbow (Popeye muscle) may appear, with a dent closer to the shoulder Examination

(i) There may be a weakness in flexion and supination. The biceps will migrate proximally (Popeye sign). (ii) A Hook test may be seen as follows: A complete biceps tendon tear is detected by performing the hook test. Supinate the flexed elbow and palpate the tendon from the lateral side. If no tendon can be hooked with the finger, then this is an abnormal hook test, indicating the tendon ruptured distally. (iii) The patient will lose 40% of supination and 30% of flexion. Investigation An X-ray with an ultrasound may be necessary. An MRI may clinch the diagnosis. Differential diagnosis A differential diagnosis from acromioclavicular joint separations gout, rotator cuff disease, and septic arthritis must be kept in mind to rule out these conditions. Treatment (i) Medical management (conservative): NSAID, ice with rest, and physical therapy (ii) Surgical: Incision with tenodesis and acromioplasty

Physiotherapy and rehabilitation management Nonoperative rehabilitation: In this choice of treatment, the strength is 20% lower than before. The treatment takes 4–6 weeks if done 2–3 times a week.

Examination of Related Areas

Phase1: Acute phase Week 1 Clinical modalities as needed with glenohumeral ROM: apply appropriate joint mobilization to restrictive capsular tissues and implement hand stretching as indicated. Additional supplements with the home program a cross-arm stretch, sleeper stretch, or early scapular strengthening and begin scapular stabilization with instruction in lower trapezius facilitation. Phase 2: Subacute phase, early strengthening Week 2 Continue with modalities and ROM. Begin rotator cuff strengthening along with sports cord internal/external rotation in 30 degrees abductee. The sports cord low rows (prone, scapular plane abduction ( 100 cm.

7. Finger-to-floor distance It is an expression of spinal column mobility when bending over forward. The measured distance is between the tips of the fingers and the floor when the patient is bent over forward with knees and arms fully extended.

8. Cervical rotation This is tested with the patient supine, head in the neutral position, and forehead horizontal. If necessary, place the head on a pillow or foam block to allow this. The gravity goniometer/bubble inclinometer is placed centrally on the forehead. The patient rotates his head as far as possible, keeping his shoulders still, ensuring no neck flexion or side flexion occurs. Normally 70–90.

II.3.3 Tests for SIJ

1. Straight Leg Raise (SLR) Test: Here the clinician passively extends the patient’s knee. If there is pain when the hip is at 0 to 30

Sacroiliac Joint Syndrome

degrees, it indicates hip pathology or nerve root pathology. If there is pain at 30 to 50 degrees, it indicates sciatic nerve involvement. There is a limited range of movement of less than 70 degrees with hamstring tightness. Pain between 70 to 90 degrees indicates sacroiliac involvement. 2. Gaenslen Test: With the patient supine and both legs extended, the uninvolved knee is brought to the chest, while the involved hip remains extended. Overpressure is applied to the involved side. If the test is positive, it indicates SIJ involvement. 3. Thigh Thrust Test: With the patient supine and the involved hip in flexion and adduction, a posterior shearing force is applied through the femur in varying degrees of adduction and abduction. The test is positive if there is buttock pain, indicating SIJ involvement.

4. FABER or Patrick Test: The patient is supine with the hip positioned in flexion, abduction, and external rotation. The clinician applies overpressure at the knee toward the table while stabilizing the opposite anterior and superior iliac spine (ASIS). The test is positive when there is pain, indicating SIJ pathology. If the patient exhibits a decrease in pain, an outflare should be suspected.

5. Gapping or Distraction Test: With the patient supine, the clinician applies crossed-arm outward pressure on the ASIS. The test is positive when there is pain, indicating SIJ pathology. If the patient reposts relief, then an outflare should be considered.

6. Compression Test: The patient is positioned supine or sidelying. The clinician applies medial pressure over the iliac crests to compress the ASIS. The test is positive if there is pain, and when there is relief of pain, an outflare should be considered. 7. Apparent Leg-Length Measurement: Measured umbilicus to medial or lateral malleolus is indicative of innominate rotation.

8. True Leg-Length Measurement: Measurements between the ASIS and medial or lateral malleolus is indicated bony differences between the two lower extremities.

9. Laguerre Test: With the patient supine, the examiner flexes, abducts, and laterally rotates the patient’s affected leg and applies gentle pressure at the end range of motion. The test is positive if there is ipsilateral sacroiliac pain, indicating SIJ pathology (ligamentous sprain, instability, sacroiliitis).

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10. Gillet Test: The examiner palpates the inferior aspect of the PSIS of the tested side with one hand and the S2 spinous process with the other. The patient flexes the hip at 90 degrees. The examiner should feel the PSIS move inferiorly and laterally relative to the sacrum. The test is positive when this motion is absent. The examiner should then compare this to the opposite side. An alternate method for this test is to palpate both PSISs at the same time and compare the end position [1]. 11. Yeoman’s Test: The patient is prone, with the knee flexed at 90 degrees. The examiner raises the flexed leg off the examining table, hyperextending the hip. This test places stress on the posterior structures and anterior sacroiliac ligaments. Pain suggests a positive test.

II.4 Ankylosing Spondylitis

AS is usually bilateral and symmetric and involvement of the SIJs is the hallmark (Fig. II.1). AS is a chronic inflammatory disorder of unknown etiology that primarily affects the spine, axial skeleton, and large proximal joints of the body. It is also called as Marie-Strumpell or Bechterew’s disease or Poker’s Back. The term ankylosing spondylitis is derived from the Greek word “ankylos” (bent or crooked) and spondylitis (inflammation). Therefore, it means the spine that can lead to stiffness and fusion of the back. Extra-articular involvement is also seen in this condition. ∑ Irish physician Bernard Conner was the first to describe AS. ∑ Bechterew was the first to give a clinical description of AS. ∑ Strumpell published many clinical reports on AS. ∑ Pierre published the earliest X-ray examinations of AS in 1899. ∑ Krebs was the first to describe the characteristic obliteration of the SI joint in 1934. ∑ Vander Under et al. proposed Modified New York Criteria for AS in 1984.

II.4.1 Epidemiology

∑ The worldwide prevalence of AS is around 0.9%.

Ankylosing Spondylitis







∑ It mainly affects young people around 26 (15–45) years. About 80% of patients develop the first symptoms at an age of 30 years, and less than 5% of patients develop symptoms older than 45 years. ∑ The male to female ratio is 2:1 to 10:1. The male patients have more structural changes, including bamboo spine, than do female patients. ∑ The HLA-B27 is positive in around 90% of patients with AS. ∑ AS may follow after infection of bacteria Klebsiella pneumoniae and some other Enterobacteria such as Salmonella, Escherichia coli, and Yersinia pestis.

II.4.2 Pathogenesis

There are two theories for the pathogenesis of AS: (i) Receptors theory: HLA B27 is a receptor for etiologic factors (bacteria, virus, etc.). The resulting complex provokes the production of cytotoxic T cells, which cause damage to cells with the HLA B27 molecule. So, urinary or bowel infections can be a trigger for AS. (ii) Molecular mimicry theory: Bacterial antigen (or other damaging factors) in complex with other HLA molecule becomes similar to HLA B27 properties and gets recognized by cytotoxic T cells as HLA B27 or decreases the immune reaction at pathologic peptide (immunological tolerance).

II.4.3 Pathology



∑ The enthesis, which is the site of ligamentous attachment to bone, is thought to be the primary site of pathology in AS, particularly in the lesions around the pelvis and spine (Fig. II.1). ∑ Sacroiliitis is usually one of the earliest manifestations of AS, with features of both enthesitis and synovitis. ∑ Synovitis follows and may progress to pannus formation with islands of new bone formation. The eroded joint margins are gradually replaced by fibrocartilage regeneration and then by ossification. Ultimately, the joint may be totally obliterated.

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∑ In the spine, early in the process, there is inflammatory granulation tissue at the junction of the annulus fibrosus of the disk cartilage and the margin of vertebral bone.

Figure II.1 Ankylosing spondylitis and bamboo spine. Reprinted with the kind permission of Mr. Magdi E. Greiss, Whitehaven, Cumbria, UK.

II.4.4 Clinical Features (i) The symptoms of the disease are usually first noticed in late adolescence or early adulthood. The initial symptom is usually dull pain, insidious in onset, felt deep in the lower lumbar or gluteal region, accompanied by low-back morning stiffness of up to a few hours’ duration that improves with activity and returns following periods of inactivity. (ii) Within a few months of onset, the pain has usually become persistent and bilateral. Nocturnal exacerbation of pain forces the patient to rise and move around. In some patients, bony tenderness (presumably reflecting enthesitis) may accompany back pain or stiffness, while in others it may be the predominant complaint. (iii) Common sites include the costosternal junctions, spinous processes, iliac crests, greater trochanters, ischial tuberosities, tibial tubercles, and heels.

Ankylosing Spondylitis

(iv) Arthritis in the hips and shoulders (root joints) occurs in 25 to 35% of patients. (v) Arthritis of peripheral joints other than the hips and shoulders, usually asymmetric, occurs in up to 30% of patients and can occur at any stage of the disease. (vi) Neck pain and stiffness from the involvement of the cervical spine (Fig. II.2) are usually relatively late manifestations. (vii) Occasional patients, particularly in the older age group, present with predominantly constitutional symptoms such as fatigue, anorexia, fever, weight loss, or night sweats. Flexion contractures of the hip are compensated by flexion at the knees.

Figure II.2 Ankylosing spondylitis of the cervical spine. Reprinted with the kind permission of Mr. Magdi E. Greiss, Whitehaven, Cumbria, UK.

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II.4.5 Laboratory Findings

∑ No laboratory test is diagnostic of AS. ∑ HLA B27 is present in approximately 90% of patients with AS. ∑ Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are often, but not always, elevated. ∑ Mild anemia may be present. ∑ Patients with severe disease may show an elevated alkaline phosphatase level. ∑ Elevated serum IgA levels are common. ∑ Rheumatoid factor and antinuclear antibodies are largely absent unless caused by a coexistent disease. ∑ Synovial fluid from peripheral joints in AS is nonspecifically inflammatory. ∑ In cases with restriction of chest wall motion, decreased vital capacity and increased functional residual capacity are common, but airflow measurements are normal and ventilator function is usually well maintained.

II.4.6 Radiological Evaluation

Sacroiliitis grading can be achieved using plain radiographs according to the New York criteria: (i) Grade 0: normal (ii) Grade I: some blurring of the joint margins – suspicious (iii) Grade II: minimal sclerosis with some erosion (iv) Grade III: definite sclerosis on both sides of the joint along with severe erosions with the widening of joint space with or without ankylosis (v) Grade IV: Complete ankylosis (vi) Star sign: Ossification of the capsuloligamentous structure at the superior part of the SI joint. Spine (i) Earliest D-L vertebrae, then L-S vertebrae (ii) Disco vertebral junction and apophyseal and costal articulations are affected (iii) Disco vertebral changes in order

Ankylosing Spondylitis

History (i) Romanus lesion: This shows the anterior vertebral body erosion due to enthesopathy. (ii) Shiny corner sign: Shows erosion often surrounded by reactive sclerosis. (iii) Anterior squaring of vertebrae: In the lumbar spine, progression of the disease leads to loss of lordosis and reactive sclerosis, caused by osteitis of the anterior corners of the vertebral bodies with subsequent erosion, which leads to the “squaring” of the vertebral bodies. (iv) Syndsemophytes: Inflammation of the annulus fibrosus and the corners of the vertebral bodies; erosion of the vertebral bodies is followed by ossification of the annulus fibrosus, which bridges the disk space (marginal syndesmophytes). (v) Bamboo spine: The ultimate fate is the ossification of all the ligaments of the spine and the complete fusion of the vertebral column. The anteroposterior (AP) radiograph of the lumbar spine reveals three vertically oriented radiodense lines. (i) Trolley track sign: Capsular ossification about the apophyseal joints (lateral lines) (ii) Dagger sign: Ossification of interspinous and supraspinous ligaments (central line) (iii) Dural ectasia: It refers to ballooning or widening of the dural sac which can result in posterior vertebral scalloping and is associated with herniation of nerve root sleeves.

Other Joints 1. Hip involvement is generally bilateral and symmetric, with uniform joint space narrowing, axial migration of the femoral head sometimes reaching a state of protrusio acetabuli and a collar of osteophytes at the femoral head-neck junction. 2. Pelvis involvement is in the bridging or fusion of pubis symphysis. 3. Knees demonstrate uniform joint space narrowing with bony proliferation. 4. Hands are generally involved asymmetrically, with smaller, shallower erosions and marginal periostitis. 5. Shoulder joint involvement is not uncommon and demonstrates a large erosion of the anterolateral aspect of the humeral head, producing a “hatchet deformity.”

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II.4.6.1 CT scan



∑ It may be useful in selected patients with normal or equivocal findings on SIJ radiographs. ∑ Joint erosions, subchondral sclerosis, and bony ankylosis are better visualized on CT. ∑ Some normal variants of the SI joints may mimic features of sacroiliitis. ∑ It supplements scintigraphy in evaluating areas of increased uptake. ∑ It is superior to radiographs and MRI in demonstrating injuries. ∑ It provides imaging modality of choice in patients with advanced AS in whom there is suspicion of a cervical spine fracture. ∑ Sagittal reformats should be obtained as axial images poorly assess the transverse fracture plane.

II.4.6.2 MRI



∑ It may have a role in the early diagnosis of sacroiliitis. ∑ Synovial enhancement on MR correlates with disease activity measured by inflammatory mediators. ∑ Enhancement of the interspinous ligaments is indicative of enthesitis. ∑ Increased T2 signal correlates with edema or vascularized fibrous tissue. ∑ It is superior to CT in the detection of cartilage inflammation and destruction, bone erosions, and subchondral bone changes. ∑ It is useful in following treatment results in patients with active AS.

II.4.6.3 Bone scintigraphy

∑ It may be helpful in selected patients with normal or equivocal findings on SIJ radiographs. ∑ Qualitative assessment of accumulation of radionuclide in the SI joints may be difficult due to normal uptake in this location; thus, quantitative analysis may be more useful.

Ankylosing Spondylitis



∑ Ratios of SI joint to sacral uptake of 1.3:1 or higher are abnormal.

II.4.7 Complications of Ankylosing Spondylitis

(i) A spinal fracture is the most serious complication of AS, which may occur after even minor trauma to the rigid, ankylosed spine, especially in the cervical region, e.g., chalk stick, also carrot stick, fracture. (ii) Anderson lesion inflammatory spondylodiscitis that occurs in association with AS and results in a disk pseudarthrosis. (iii) Cauda equina syndrome due to nerve root traction by bony overgrowth or arachnoiditis occurs rarely. (iv) Atlanto-axial subluxation: Osteoporosis of the vertebral bodies is very common in AS and contributes to fracture risk. Early predictors of severe disease include hip involvement, ESR greater than 30 mm, limitation of lumbar spine movement, unresponsiveness to nonsteroidal anti-inflammatory drugs (NSAIDs), and age of onset less than 16 years. Premature atherosclerosis occurs in AS and is related to the systemic inflammatory process.

II.4.8 Differential Diagnosis

The inflammatory back pain of AS is usually distinguished by the following five features: (i) The age of onset is below 40. (ii) It has an insidious onset. (iii) Its duration is three months before medical attention is sought. (iv) There may be morning stiffness. (v) There is improvement with exercise or activity. The most common causes of back pain other than AS are primarily mechanical or degenerative rather than inflammatory and do not show these features. (i) Rheumatoid arthritis (ii) Paget’s disease (iii) Metastatic diseases

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(iv) Gout (v) Infections (brucellosis, staphylococcal, etc.): unilateral involvement (vi) Ochronosis

Diffuse idiopathic skeletal hyperostosis (DISH): There is marked calcification and ossification of paraspinous ligaments, usually most prominent in the anterior spinal ligament, that gives the appearance of “flowing wax” on the anterior bodies of the vertebrae. Intervertebral disk spaces are preserved, and sacroiliac and apophyseal joints appear normal, helping to differentiate (fine calcification of annulus fibrosus in AS).

II.4.9 Management

The essence of management of spondylitis is summarized by Dixon as “It’s the doctor’s job to control the pain and it’s the patient’s job to keep moving.” Effective therapy, therefore, includes an appropriate choice of pharmacological agents backed by physiotherapy and surgery. Patient education: Proper posture in standing, sitting, and lying; sleeping on a firm mattress without a pillow; stop smoking.

Physiotherapy: The aim of exercise is to maintain joint movement and to build up muscles that oppose the direction of the deformity with particular emphasis on the spinal extensors and intercostal and hip extensor muscles. Therefore ∑ Patients should be encouraged to take up regular sports like swimming, badminton, squash, etc. ∑ Patients should be encouraged to practice full rib cage expansion using manual resistance. ∑ Prone lying for a period of 15 minutes or more should be performed on a daily basis. ∑ Rotation of the spine and pelvis should be encouraged.

∑ Work habits should be modified to avoid single prolonged sitting.

Ankylosing Spondylitis

II.4.9.1 Medical line of management NSAIDs ∑ They are the first choice of medication and are given continuously or during the onset of the disease. ∑ The individual response depends on the agent and often several different medications have to be tested. ∑ Indomethacin, naproxen, celecoxib, and phenylbutazone have proved to be efficacious in various RCTs. ∑ They reduce the pain and morning stiffness but have no role in slowing the course of the disease. ∑ Phenylbutazone can cause severe adverse effects such as suppression of white blood cell production and aplastic anemia. ∑ 50% of patients report insufficient control of the symptoms with NSAIDs alone. ∑ When NSAIDs fail, DMARDs like sulfasalazine or methotrexate may be used as an alternative. ∑ Sulfasalazine has shown to be useful against peripheral joint pain but it has not shown to be beneficial in spinal diseases. TNF-α Inhibitors







∑ Currently, etanercept, infliximab, and adalimumab are available for clinical use. ∑ Under the effect of these drugs, monoclonal antibodies show a significant improvement in function, spinal mobility, and quality of life. ∑ The usage of these drugs results in the significant reduction of spinal inflammation, which in turn, delays the structural damage of bony structures. ∑ Leukopenia, aplastic anemia, liver disease, vasculitis, lupus like autoimmune disease, multiple scleroses like demyelinating disease, infections like an opportunistic bacterial infection, reactivation of tuberculosis, and systemic fungal infections are the adverse effects of these drugs. ∑ Concomitant use of methotrexate decreases the frequency of use of monoclonal antibodies.

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Interleukin-17A Inhibitor Secukinumab is an option for the treatment of active AS that has responded inadequately to TN-α inhibitors.

II.4.9.2 Surgical line of treatment











∑ Severe hip and knee arthritis can be managed by total knee replacement (TKR) and total hip replacement (THR), respectively. ∑ If the flexion deformity is severe, the patient’s field of vision is limited to a small area near the feet and walking is extremely difficult. This is evident by looking at the chin-brow vertical angle. ∑ Respiration becomes almost completely diaphragmatic. ∑ Gastrointestinal symptoms resulting from the pressure of the costal margin on the contents of the upper abdomen are common; dysphagia or choking may occur. ∑ In addition to improvement in function, the improvement in appearance made by correcting the deformity is important to the patient. ∑ If extreme, the deformity should be corrected in two or more stages because of contracture of soft tissues and the danger of damaging the aorta, the inferior vena cava, and the major nerves to the lower extremities. ∑ According to law, 25 to 45 degrees of correction usually can be obtained, resulting in marked improvement functionally and cosmetically.

A. Spine Osteotomy

1. Smith-Peterson Osteotomy ∑ This osteotomy is an excellent option for the correction of smaller degrees of spinal deformity. The bone is removed through the pars and facet joints. Symmetric resection is necessary to prevent creating a coronal deformity. ∑ Removal of the underlying ligament is also helpful in preventing buckling of the dura or iatrogenic spinal stenosis. ∑ Approximately 10 degrees of correction can be obtained with each 10 mm of resection. Excessive resection should

Ankylosing Spondylitis



be avoided because it may result in foraminal stenosis. In patients with degenerative disks, decreased flexibility may limit the amount of correction that can be obtained. ∑ The osteotomy is closed with compression or with in situ rod contouring, and a bone graft is applied.

2. Pedicle Subtraction Osteotomy (Thomasen) ∑ Pedicle subtraction osteotomy is best suited for patients who have a significant sagittal imbalance of 4 cm or more and immobile or fused disks. ∑ Pedicle subtraction osteotomy is inherently safer than the Smith-Petersen osteotomy because it avoids multiple osteotomies. ∑ Typically, 30 degrees or more of correction can be obtained with a single posterior osteotomy, preferably at the level of the deformity. ∑ If the deformity is at the spinal cord level, pedicle subtraction osteotomy can be used, but manipulation of the cord must be avoided.

3. Eggshell Osteotomy The eggshell osteotomy requires anterior and posterior approaches and usually is reserved for severe sagittal or coronal imbalance of more than 10 cm from the midline. This is a spinal shortening procedure with anterior decancellation, followed by removal of posterior elements, instrumentation, deformity correction, and fusion.

Complications 1. Anesthetic 2. Rupture of the aorta and spinal nerves of the inferior vena cava 3. Post-operative ileus 4. Pulmonary complications 5. Cauda equina syndrome with paraplegia 6. Osteomyelitis 7. Perforated gastric ulcer

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B. Cervical Spine Osteotomy In patients with chin on chest deformity, often the mandible is so near the sternum that the opening of the mouth and chewing properly becomes difficult. Cervical osteotomy may be indicated in the following cases: (i) To elevate the chin from the sternum and to improve the appearance, ability to eat, and ability to see ahead (ii) To prevent atlantoaxial and cervical subluxations and dislocations, which result from the weight of the head being carried forward by gravity (iii) To relieve tracheal and esophageal distortion, which causes dyspnea and dysphagia (iv) To prevent irritation of the spinal cord tracts or excessive traction on the nerve roots, which causes neurologic disturbances The appropriate level for osteotomy is determined by the deformity and the degree of ossification of the anterior longitudinal ligament. Complications 1. Thrombosis of spinal cord vessels 2. Quadriplegia

II.4.10 Juvenile Ankylosing Spondylitis







∑ Juvenile ankylosing spondylitis (JAS) is the term used for AS starting before the age of 16 years, most commonly in boys (60% to 80%). ∑ The prevalence of HLA B27 in this condition, which has been termed the seronegative enthesopathy arthropathy (SEA) syndrome, is approximately 80%. ∑ Axial skeletal involvement is seen in only 12% of cases and peripheral arthropathy enthesopathy can be seen in 78–85% of cases. ∑ The lower limb joint is frequently affected. ∑ 5–10% of patients may have constitutional symptoms with anemia, increased ESR, and hypergammaglobulinemia. ∑ Cardiovascular and pulmonary diseases are uncommon.

Reference



∑ Subluxation of the atlanto-occipital joint leads to severe cervico-occipital pain. ∑ High levels of IgM and IgG are found in both the patients and their first-degree relatives and selective deficiency of IgA has been reported.

Reference

1. Meijne, W., van Neerbos, K., et al. (1999) Intraexaminer and interexaminer reliability of the Gillet test. J Manipulative Physiol Ther, 22, 4–9.

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Chapter 4

Examination of the Hip and the Pelvis

Dipen Menon,a Vidhi Adulkia,b and Kunal Kularnia

aKettering General Hopital, NHS Foundation Trust, Kettering, Northamptonshire, UK bUniversity Hospitals of Leicester, Leicester, UK

The pelvic girdle is formed by three main joints, namely, the hip joints, sacroiliac joints, and the symphysis pubis.

4.1 Inspection

This is done as the patient enters the examining room and the patient has completely removed his clothes to make this inspection quite simple. Observe for any abrasions, discolorations, birthmarks, sinuses, scars, and swellings. Also, observe the patient’s gait and stance to see if both the anterior superior iliac spines are on the same horizontal plane, and some impression may be had by this observation for any tilted pelvis due to limb length discrepancy. An inspection may also be made from the side, which gives an idea of the normal lumbar lordosis which is seen. The absence of this may be seen in cases of spasms of the paravertebral muscles in disk pathology. Introduction to Limb Arthrology Edited by K. Mohan Iyer Copyright © 2023 Jenny Stanford Publishing Pte. Ltd. ISBN 978-981-4877-99-2 (Hardcover), 978-1-003-37276-9 (eBook) www.jennystanford.com

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An inspection is also carried out from the posterior aspect to see if the two gluteal folds are symmetrical on both sides. In infants, asymmetrical folds may be seen in congenital dislocation of the hip, muscular dystrophy, or limb length discrepancy. When viewed from the posterior aspect, two dimples are also seen which overlie the posterior superior iliac spines just above the buttocks.

4.2 Palpation

Bony palpation is carried out anteriorly and posteriorly.

(A) Anterior Aspect Anterior superior iliac spines: In most patients, these bony prominences are subcutaneous, being palpated on the sides of the waist.

(i) Iliac crest: The Iliac crest is subcutaneous in most of its course, and both the crests are level with each other. Iliac tubercle: This is felt as a bony prominence on the outer wall of the iliac crest when palpating posteriorly along the iliac crest. (ii) Greater trochanter: These can be palpated by the hand moving down from the iliac tubercles. Normally both the trochanters are on the same horizontal level, but this relation is disturbed in cases of congenital dislocation of the hip or a fracture of the hip.

(iii) Pubic tubercles: Palpation is then continued medially toward the midline where the pubic tubercles can be felt as bony prominences under the pubic hair. (B) Posterior Aspect This is best examined with the patient lying on his side.

(i) Posterior superior iliac spines: These are easily palpable over the dimples which are just above the buttocks. The spines are easily palpable and subcutaneous in nature. (ii) Greater trochanter: Palpating downwards from the posterior superior iliac spine, the posterior border of the greater trochanter can be felt.

(iii) Ischial tuberosity: This is easily palpated when the hips are flexed when the gluteus maximus moves upwards and the ischial tuberosity is felt. Both the tuberosities lie on the same horizontal plane as the lesser trochanters.

Palpation

(iv) Sacroiliac joint: This joint is not usually palpable, because of the overhanging ilium and its ligaments. This soft tissue palpation is carried out in five zones as follows:

Zone I Femoral Triangle: The femoral triangle has its base at the inguinal ligament which extends between the anterior superior iliac spines and the pubic tubercles. Any unusual bulges seen and felt along this may indicate an inguinal hernia. The femoral artery is normally felt as a strong pulse beneath the midway point of the anterior superior iliac spine and the pubic tubercle. Just beneath the femoral artery is the femoral head. The femoral nerve lies just lateral to the artery though it is not palpable. The femoral vein lies just medial to the artery and is a common site for venous puncture. (i) Sartorius muscle: This is the longest muscle in the body and forms the lateral border of the femoral triangle. It is usually palpable at its origin just inferior to the anterior superior iliac spine. (ii) Adductor longus muscle: This muscle can be palpated as a distinct ridge when the legs are abducted. In spastic children, this muscle may be tenotomized to release the limb from severe adduction and thus prevent dislocation of the hip. The femoral triangle is palpated for lymph nodes that may be enlarged in infection from the lower limb or the pelvis. These are usually located most medially in the femoral triangle. Zone II

This mainly consists of the greater trochanter and the gluteus medius muscle. (i) Greater trochanter: Palpate the greater trochanter for any tenderness, and usually a bursa is felt over the bone as a boggy swelling. (ii) The gluteus medius muscle: It is usually inserted into the lateral part of the greater trochanter. Occasionally when the hip is flexed and adducted, the tensor fascia lata may ride anteriorly over the greater trochanter and may give an audible click when it returns to the neutral position.

Zone III Sciatic nerve: This is located exactly midway between the greater trochanter and the ischial tuberosity. This is covered by the gluteus maximus with the hip in extension, which moves away when the

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hip is flexed. Tenderness over the nerve may be seen in a herniated lumbar disk, spasm of the piriformis, or in cases of direct trauma over the nerve as in nerve injections. Similarly, the bursa covering the ischial tuberosity may be inflamed giving rise to ischial bursitis. Zone IV

Iliac crest: The cluneal nerves supply the skin over the iliac crest between the posterior superior iliac spines and the tubercles, and these are cut when taking a bone graft. Therefore, this area should be palpated for any neuromas in the cluneal nerves.

Zone V Hip and pelvic muscles: These are mainly arranged in four quadrants: (i) (ii) (iii) (iv)

Flexor group, which is the anterior quadrant. Abductor grouping, which is the lateral quadrant. Adductor grouping, which is the medial quadrant. Extensor grouping, which is the posterior quadrant.

(i) Flexor grouping: The iliopsoas muscle is primarily a hip flexor. The iliopsoas bursa lies deep beneath the muscle, and infection may result in painful iliopsoas bursitis.

(a) Sartorius muscle: This is a long strap-like muscle that runs along the anterior aspect of the thigh. (b) Rectus femoris: This muscle crosses the hip and the knee joints, thereby acting as a flexor of the hip and an extensor of the knee. This muscle has its origin in two heads, and both these heads may be pulled or torn from their heads in sports injuries. (ii) Abductor grouping: This group consists of two main muscles: namely, the gluteus medius and the gluteus minimus. Of these, the gluteus minimus lies deep under the gluteus medius and is therefore not palpable. The gluteus medius is the main hip abductor and is palpable at its insertion along the anterior and lateral aspects of the greater trochanter. Weakness of this muscle results in a characteristic “gluteus medius lurch.” (iii) Adductor grouping: This group is formed by five muscles: namely, the gracilis, pectineus, adductor longus, adductor brevis, and the adductor magnus. Of these muscles, the adductor longus is the most superficial and can be palpated.

Range of Motion

(iv) Extensor grouping: This mainly consists of the gluteus maximus and the hamstrings. The gluteus maximus is easily palpable when the patient is lying prone with hip extended and buttocks squeezed together. The hamstring muscles consist of the biceps femoris on the lateral side with the semitendinosus and the semimembranosus on the medial side. Generalized spasm of the hamstrings (“pulled hamstring”) is commonly seen after athletic activity or may be seen in spondylolisthesis or a herniated lumbar spinal disk.

4.3 Range of Motion

(A) Active Range of Movements (i) Abduction: This is tested by asking the patient to stand and spread his legs wide apart. The normal range possible is around 45°. (ii) Adduction: This is tested by asking the patient to cross his legs and should be about 20°. (iii) Flexion: This is tested by asking the patient to flex his hips toward the chest, and this should be around 135°. (iv) Flexion and adduction: This is tested by asking the patient to sit on a chair and cross one thigh over the other. (v) Flexion, abduction, and external rotation: This is tested by asking the patient to place the lateral side of his foot on his opposite knee. (vi) Extension: This is tested by asking the patient to get up from the sitting position with his back straight and his arms across his chest. (vii) Internal and external rotation: These are tested by the patient lying supine and prone.

(B) Passive Range of Movements (i) Flexion (Thomas’) test: This is a specific test designed to assess flexion contracture of the hip joint in addition to the range of flexion in the hip joint. Test the flexion as flexing the hip on the patient’s chest to see if it is possible to touch the thigh to the chest. When the knee is at the chest wall, have the patient hold this limb with his hand and allow the other limb to fall straight onto the examining table. If this is not fully possible, then the patient has a fixed flexion contracture of that hip. (ii) Extension: This is tested by asking the patient to lie prone. The pelvis and hip are stabilized with one hand on the pelvis while the

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other hand flexes the knee to relax the hamstrings. Then the hip extension is tested by extending the thigh, which should extend to around 30°. (iii) Abduction: This is tested with the patient lying supine and the pelvis stabilized at the iliac crests. The lower limb is held at the ankle and abducted in one piece, normally to around 45°. This is more often limited by pathology than adduction. (iv) Adduction: This is tested by continuing the above maneuver from full abduction until the limb returns to the normal position, which is normally around 30°.

(v) Internal/external rotation: These are tested in two ways: with the hips flexed and extended. In the first approach, with the patient lying supine, both limbs are held just above the malleoli and rotated to examine the angle at which the patella faces. The normal angle of internal rotation is 30°, while the normal angle of external rotation is 45°. In the other approach, keeping the patient supine, let his legs hang down from his flexed knees. In this position, the tibia is the pendulum that measures the angles of internal and external rotation at the hip joints. Yet another method to test these movements with the patient supine and the knees extended is to observe the upward direction of both big toes, which can be used as a marker for these angles. This also takes into account the normal angle of anteversion at the neck of the femur, when the patient is lying flat. Any decrease in the angle of internal rotation may lead one to suspect a slipped upper femoral epiphysis in the growing child. In an adult, osteoarthritis may cause limitation to these movements, though internal rotation is more frequently limited in that condition. Neurologic Examination (A) Muscle Testing (i) Flexors

(a) Primary flexor: iliopsoas – femoral nerve – L1, L2, L3 (b) Secondary flexor: rectus femoris

This is tested by the patient sitting at the edge of the table with her legs hanging over the edge. The patient is asked to raise her thigh against gradually increasing resistance (Table 4.1).

Range of Motion

Table 4.1

Muscle grading chart. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

Muscle Gradations

Description

5: Normal

Complete range of motion against gravity with full resistance

3: Fair

Complete range of motion against gravity

4: Good 2: Poor

1: Trace 0: Zero

(ii) Extensors

Complete range of motion against gravity with some resistance

Complete range of motion with gravity eliminated Evidence of slight contractility No joint motion No evidence of contractility

(a) Primary extensor: gluteus maximus – inferior gluteal nerve – S1 (b) Secondary extensor: hamstrings

This is tested with the patient lying prone with the leg flexed at the knee to relax the hamstrings. The patient is asked to extend his thigh during this maneuver. (iii) Abductors

(a) Primary abductor: gluteus medius – superior gluteal nerve – L5 (b) Secondary abductor: gluteus minimus This is tested by the patient lying on his side. The patient is asked to abduct her leg. Alternatively, this can be tested by the patient lying supine, with the legs abducted against gradually increasing resistance. (iv) Adductors

(a) Primary adductor: adductor longus – obturator nerve – L2, L3, L4 (b) Secondary adductors: adductor brevis, adductor magnus, pectineus, and gracilis. In continuation with the above test, this test is carried out by placing the hand over the medial side of the thigh. The patient is asked to pull her limb back toward the midline, or the patient may be asked to adduct her legs with gradually increasing resistance over the medial aspect of the knees.

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(B) Sensation Testing The dermatomes of the anterior abdominal wall run in oblique bands, with the umbilicus being supplied by the T10 dermatome. The strip just above the inguinal ligament is supplied by the T12 dermatome, and the area in between this and the umbilicus is supplied by the T11 dermatome. The dermatome just below the inguinal ligament is supplied by the L1, while the dermatome just above the knee joint is supplied by the L3. The area in between these two regions is supplied by the L2 dermatome. The posterior primary divisions of the cluneal nerves L1, L2, and L3 cross over the posterior iliac crest and supply sensation to (1) the area just over the iliac crest, (2) the area between the posterior superior iliac spine and the iliac tubercle and (3) the area over both the buttocks. The posterior cutaneous nerve of the thigh (S2) supplies a longitudinal area along the posterior aspect of the thigh, while the lateral cutaneous nerve (S3) of the thigh supplies a broad area over the lateral aspect of the thigh. The dermatomes around the anus are arranged in three concentric rings with the innermost being supplied by S1 and the outermost being the S3, while the S2 supplies the intermediate ring.

4.4 Special Tests 4.4.1 Introduction

The hip (femoroacetabular) joint, is a ball-and-socket synovial joint comprising the articulation between the acetabulum and femoral head. It is the primary connection between the lower limb and the axial skeleton. The main functions of the hip joint are to bear the weight of the body during stance and gait. Static stability is provided by the osseous anatomy, alongside the labrum, capsule, and ligamentous attachments. Dynamic stability is conferred through the contraction of the various muscle groups around the hip [1].

4.4.2 Anatomy of the Hip

Acetabulum Named after a Roman ‘vinegar cup,’ this is a hemispherical cavity formed by three bones—the ilium, ischium, and pubis. Fusion occurs

Special Tests

at the triradiate cartilage, a ‘Y’ shaped growth plate, between 12– 16 years. Radiographically, this point is known as the “teardrop,” which can be identified on an anteroposterior (AP) radiograph of the pelvis (Fig. 4.1). At the lip of the acetabulum, a horseshoeshaped fibrocartilaginous ring called the labrum serves to deepen the acetabulum and provide a larger articular surface to aid the articulation and prevent dislocation [2]. This attaches to the edge of the transverse acetabular ligament (TAL), which is a useful surgical landmark in guiding acetabular component orientation during a total hip arthroplasty (THA). Important reference angles to consider when planning a THA are [3]: (i) Acetabular inclination: measured in the coronal plane; approximately 45° (ii) Acetabular anteversion: measured in the sagittal plane; approximately 15–20°

Figure 4.1 AP radiograph of the pelvis indicating the “teardrop” (white arrow) and acetabular inclination measuring approximately 41° in this example. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

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Femur The femoral head is spherical and sits within the acetabulum. Distally, it is connected to the shaft by the neck. The medial portion of the femoral neck is partly formed by the calcar femorale, a dense plate of bone that ascends vertically from the posteromedial aspect of the shaft to the neck. This provides structural support and allows for the distribution of stresses from the femoral head to the shaft. At the lateral aspect of the junction of the femoral neck and shaft, the greater trochanter (GT) projects superiorly, providing attachments to multiple muscle groups [1] The lesser trochanter (LT) is a projection from the posteromedial aspect of the femoral shaft. The intertrochanteric line, a ridge on the anterior surface of the femoral shaft, connects the two trochanters [2] (Fig. 4.2).

Figure 4.2 AP radiograph of the pelvis demonstrating the intertrochanteric line (white dashed line) and the NSA. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

The femoral neck-shaft angle (NSA), usually ranges between 120–140° (average 127°) (Fig. 4.2). An increased NSA angle is termed coxa valga, whereas a reduced NSA angle is termed coxa

Special Tests

vara. The femoral neck is itself anteverted by 15° to 20° with respect to the femoral shaft. Excess anteversion or retroversion must be considered in both, lower limb deformity analysis (as it may contribute to more distal signs such as in- or out-toeing gait), or other conditions (slipped capital femoral epiphysis) [3, 4]. Hip joint capsule The capsule consists of circular and longitudinal fibers attached to the acetabulum, labrum, and TAL proximally. Distally, the fibers form a collar around the femoral neck, attaching to the intertrochanteric line anteriorly, and somewhat more proximally on the posterior aspect of the femoral neck. Ligaments Four main ligaments surround the hip joint [2]. Three are extracapsular (iliofemoral, pubofemoral, and ischiofemoral), and one is intracapsular (ligamentum teres). These ligaments play a role in the static stability of the hip. (i) Iliofemoral ligament: Also known as the ligament of Bigelow, this is one of the strongest ligaments in the body. It arises from the anterior inferior iliac spine (AIIS) and acetabular margin. It bifurcates, resulting in an inverted ‘Y’ shaped appearance, inserting onto the intertrochanteric line. (ii) Pubofemoral ligament: This is a triangular ligament that arises from the superior pubic ramus and obturator crest. It inserts onto the intertrochanteric line, reinforcing the hip capsule anteriorly. (iii) Ischiofemoral ligament: Spirals from the ischium toward the posterior aspect of the femoral neck, where it attaches to the GT and merges with the hip capsule. It strengthens the capsule posteriorly. (iv) Ligamentum teres: Triangular shaped, arising from the acetabular notch to insert into a depression on the femoral head called the fovea. Although it confers some stability, its primary function is to provide a conduit for the artery of the ligamentum teres (more relevant in childhood). Blood supply The femoral head and proximal femur have a complex blood supply system, which alters with age. This can broadly be divided into three groups (Fig. 4.3).

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Artery of Ligamentum Teres

Obturator Artery

Retinacular Arteries Ascending branch of LFCA

Lateral Femo ral Circumflex Artery (LFCA) Descending branch

Femoral Artery

Medial Femoral Circumflex Artery (MFCA) Profunda Femoris

of LFCA

Figure 4.3 A line diagram of the blood supply of the proximal femur. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

(i) Intraosseous circulation: This comprises the nutrient artery of the femur, which most commonly arises from the second perforating branch of the profunda femoris. The profunda femoris (deep artery of the thigh) in turn arises from the femoral artery and subdivides into the medial femoral circumflex artery (MFCA), lateral femoral circumflex artery (LFCA), and three perforating branches. The MFCA is the primary supply to the adult femoral head [5]. The perforating arteries (3 perforators) are so named because they penetrate the adductor magnus tendon. The nutrient artery is usually a branch of the second perforator or branches from the first and third perforator if there are two nutrient arteries. The nutrient artery enters the medullary canal through the posterior cortex and then subdivides into ascending and descending blood vessels to form the femoral intraosseous circulation.

Table 4.2

Different groups of muscles acting on the hip joint Reprinted with the kind permission of Mr. Menon, Kettering, UK.

Muscle

Origin

Psoas major

Transverse processes of T12 – L5

Iliacus

Gluteus medius Gluteus minimus

Iliac fossa

Outer surface of ilium between the posterior and anterior gluteal line

Lesser trochanter

Greater trochanter

Blood supply

Innervation

Anterior branch of Iliolumbar artery

Ventral rami of lumbar spinal nerves L1 – L3

Iliac branch of Iliolumbar artery

Femoral nerve (L2 – L3)

Primary action on hip

Flexor

Superior gluteal artery Superior gluteal nerve (L4 – S1) Abductor

(Continued)

Special Tests

Outer surface of ilium between the anterior and inferior gluteal line

Insertion

259

Piriformis

Obturator internus

Origin

Ischial spine

Obturator externus

Obturator membrane

Quadratus femoris Rectus femoris

Vastus medialis

Vastus intermedius Vastus lateralis

Ischial tuberosity

Ischial tuberosity

Straight head – AIIS Reflected head – capsule of hip joint

Greater trochanter Trochanteric fossa Trochanteric crest

Intertrochanteric line, Base of patella linea aspera via quadriceps Anterolateral surface tendon of femoral shaft Intertrochanteric line linea aspera,

Blood supply

Innervation

Primary action on hip

Superior gluteal artery Nerve to piriformis (S1, S2)

Sacrum

Ischiopubic ramus

Gemellus superior Gemellus inferior

Insertion

Internal

Nerve to

MCFA

Nerve to quadratus femoris (L4 – S1)

Pudendal artery

Obturator and MCFA

Inferior gluteal, MFCA Artery of the quadriceps

Femoral artery Artery of the quadriceps

LCFA, artery of the quadriceps, profunda femoris

obturator internus (L5, S1)

Nerve to obturator internus (L5, S1) Obturator (L3, L4)

External rotator

Nerve to quadratus femoris (L5 – S1) Femoral (L2 – L4)

Knee extensor, Hip flexor

Examination of the Hip and the Pelvis

Muscle

260

Table 4.2 (Continued)

Muscle

Origin

Adductor longus

Pubis

Adductor brevis

Adductor magnus Pectineus

Gluteus maximus Semitendinosus

Semimembranosus Biceps femoris

Posterior gluteal line of ilium

Ischial tuberosity

Linea aspera Iliotibial tract and gluteal tuberosity

Medial proximal tibia

Horizontal line on posterior aspect of medial tibial condyle

Head of fibula and lateral tibial condyle

Blood supply

Innervation

Profunda femoris

Obturator (L2 – L4)

MCFA

Femoral (L2 – 3)

Perforating arteries

Sciatic (L5 – S2)

Inferior gluteal artery

Primary action on hip

Adductor

Inferior gluteal (L5 – S2)

Extensor

Special Tests

Long head – ischial tuberosityShort head – linea aspera

Insertion

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(ii) Retinacular circulation: This is formed by the retinacular arteries, which arise from an extracapsular arterial ring formed by the anastomosis of the MFCA posteriorly and LFCA anteriorly. While the superior and inferior gluteal arteries also provide a small contribution toward this anastomosis, the majority of the blood supply is from the MFCA. The retinacular arteries pierce the hip capsule as they ascend the femoral neck to supply the femoral head, forming a sub-synovial intra-articular ring. An intracapsular neck of femur fracture can therefore result in disruption of this source of blood supply to the femoral head, resulting in osteonecrosis (commonly referred to as ‘avascular necrosis’, AVN). (iii) Artery of ligamentum teres: This is derived from the posterior branch of the obturator artery, but can occasionally arise as a branch of the MFCA. As the name suggests, it travels with the ligamentum teres to supply the femoral head. However, its contribution diminishes with age, and it is, therefore, a much more important source of blood supply to the pediatric femoral head. The various groups of muscles acting on the hip joint are shown in Table 4.2 [2].

4.4.3 Biomechanics of the Hip Joint

A functional hip joint is a key component of locomotion, as this joint must support the significant forces that are exerted upon it. For example, supine straight leg raise can result in joint reaction forces (JRF) two times the body weight, whereas running can result in a JRF that is 10 times the body weight [6]. The JRF is a biomechanical concept that can help explain how forces are distributed across the joint through a combination of muscle pull and body weight (Fig. 4.4). Consideration of the JRF plays an important role in understanding and managing the pathology of the hip joint; a reduction in JRF can result in a concurrent decrease in a patient’s symptoms. Strategies to reduce the JRF can therefore include (i) Reducing body weight [7] (ii) Decreasing the lever arm (B in figure) by medializing the axis of rotation or using a Trendelenburg gait (iii) Increasing the abductor lever arm by increasing the offset, using a walking stick in the opposite

Special Tests

Abductor Force

A

Joint Reaction Force (JRF)

B

Body weight (BW) A – Abductor lever arm B – Body weight lever arm

Figure 4.4  A line diagram showing the joint reaction force on the hip joint. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

History taking and symptoms A detailed history is key, as a diagnosis can often be reached from the patient’s symptoms alone. Clinical examination and investigations can then be directed toward confirming or refuting the provisional diagnosis. Moreover, the history will illustrate exactly how a patient’s symptoms are affecting their quality of life and help guide the management plan.

Patient-reported outcome measures In recent years, particularly with the global advent of national arthroplasty joint registries, there is a growing emphasis on patient-reported outcome measures (PROMS), following major joint replacement. The Oxford Hip Score (OHS) is a 12-question validated and commonly utilized questionnaire (maximum score 48, with 48 being best and 0 being worst), designed to ascertain the impact of hip pain on a patient’s quality of life (QoL) [8]. A low score is strongly suggestive of hip disease severely affecting QoL, and these patients are therefore more likely to benefit from surgical intervention. The score can be repeated after such an intervention (e.g., a THA) to demonstrate any improvement or deterioration in symptoms.

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Hip pain This is the most common symptom that patients present with. The location of the pain can be varied, ranging from the ipsilateral groin to the thigh, buttock, GT, and knee. Buttock and thigh pain could be referred from co-existing lumbar spine pathology and present as “hip pain”. Similarly, knee pain could be secondary to underlying knee OA or be referred from the hip joint above (via the obturator nerve). Hip pain, especially when secondary to osteoarthritis (OA), tends to be exacerbated by movement, relieved with rest, and is often associated with varying degrees of stiffness. Inflammatory arthritides commonly exhibit morning stiffness and more symmetrical patterns. Patients often complain of the pain gradually worsening over time, which is accompanied by a steady decline in their ability to carry out their activities of daily living. The mnemonic ‘SOCRATES’ can be helpful in ensuring that a thorough pain history is taken (Table 4.3). In conjunction, note the patient’s analgesic requirements. In addition, patients need to be asked about any history of trauma, diseases affecting the hip in childhood, and any previous treatment/surgery. Remember to ask about any walking aids or adaptations. Relevant past medical history is important in assessing risk prior to considering any intervention. Table 4.3 Pain history using the mnemonic ‘SOCRATES.’ Reprinted with the kind permission of Mr. Menon, Kettering, UK. Hip Pain History Component

Hip relevance

S

Site

Where is the pain located (i.e., groin – hip joint; GT – bursitis)

C

Character

Sharp, burning, ache (mechanical vs neurological)

O

R

Onset

Radiation

What starts the pain (e.g., activity in young patient – femoro-acetabular impingement; start-up pain with existing hip replacement – loosening) History of trauma Does it spread anywhere (e.g., buttock/leg - coexisting spinal pathology; thigh – OA, loose arthroplasty femoral component; knee - co-existing knee arthritis)

Special Tests

Hip Pain History Component

Hip relevance

A

Associated symptoms

E

Exacerbating Movements make it worse (e.g., psoas tendon and relieving resisted flexion; internal rotation – osteoarthritis) Rest pain associated stiffness factors Worse toward end of the day Anti-inflammatories make it better Functional assessment: Able to climb stairs/use transport/wash/dress independently/Do shopping/ job/housework

T

S

Temporality

Severity

Weakness (sciatic nerve injury), dysesthesia, fevers (infected joint)

Is it getting better or worse Any pain in childhood pain (dysplasia, SCFE, Perthes sequelae)

Visual Analog Scale: 0 to 10 (0: no pain, 10: worst imaginable pain)

Stiffness Hip stiffness is common and often accompanies pain. It is often worse first thing in the morning, tending to ease with activity. Alternatively, patients may complain of difficulty getting in and out of cars or chairs or bending down (deep hip flexion) to put their shoes on. This occurs due to numerous reasons; for example, loss of joint space and osteophyte formation in OA results in the femoral head impinging on the acetabulum during hip movements. Furthermore, inflammation around the hip capsule causes contractures or fibrosis, resulting in hip stiffness. Limp This often occurs due to hip pain and stiffness. Pain causes patients to mobilize with an antalgic gait, which helps them reduce the JRF on the hip joint by reducing the time spent in the stance phase of gait on the affected side. Stiffness often results in an arthrogenic gait in which the pelvis on the affected side elevates significantly, and is associated with a circumduction movement of the leg to clear the ground during the swing phase of gait. Similarly, a Trendelenburg gait (where the pelvis sags on the unaffected side) is observed by the healthy ‘lifted leg lagging’ due to abductor muscle weakness on the contralateral affected side, forcing patients to lean toward the affected side to maintain their balance (abductor lurch).

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Deformity Deformities in the hip can be masked by compensatory tilting of the pelvis. A fixed flexion deformity of one hip can be compensated by increased forward pelvic tilt resulting in an increase in the lumbar lordosis in the spine (sagittal plane compensation). Similarly, fixed adduction and abduction deformities of the hip can be compensated by the pelvic tilt in the coronal plane resulting in apparent shortening or lengthening of the affected leg respectively. These deformities can be unmasked by performing special tests that will be discussed in detail later in this chapter. Swelling Swellings in and around the hip joint are difficult to detect due to the deep-seated location of the hip joint. However, occasionally patients might present with lumps around the trochanter or groin that could be indicative of an underlying abscess or tumor. Do not forget alternative (non-orthopedic) pathologies such as hernia, which may also present with groin pain!

4.4.4 Examination of the Hip Joint

This follows the basic sequence of ‘look, feel and move,’ with a few additional special tests that can be applied to the examination of any joint. Practice is key to ensuring a slick and efficient examination, which is especially important for those preparing for postgraduate examinations. It is mandatory to keep the patient comfortable and avoid causing undue pain or distress—remember to look at the patient’s face at all times and clearly explain every step. Adequate exposure of the lower back, down to the feet is required (underwear may be kept on), albeit taking care to preserve the patient’s dignity with the judicious use of sheets. A chaperone should be offered for examinations if appropriate [9]. Look As discussed earlier, gait can be significantly altered in patients with the underlying hip disease and should therefore be commented upon. Patients can try to alleviate their symptoms by using walking aids and/or a shoe raise, which should be noted. The patient should then be asked to expose the hip and the knee joint, at which time leg length discrepancy, muscle wasting, thigh

Special Tests

crease asymmetry, scars (indicating previous surgery or infections), swellings, erythema, and sinuses may be observed. It is important to examine the patient from the front, side, and back to ensure that such abnormalities are not missed. Remember that some scars may be well hidden, including beneath the underwear (e.g. pelvic surgery in the groin, or the scar of a medial hip approach in the inner thigh).

Feel Palpation of the GT may elicit tenderness indicating underlying trochanteric bursitis. Similarly, palpation around the groin may cause some tenderness, however, it is difficult to truly palpate the hip joint simply due to its deep location. Move Active and passive hip movements should be checked both on the affected and unaffected side with the patient supine, and include hip flexion, abduction, adduction, internal rotation, and external rotation. Hip extension is best tested with the patient prone, although this is not routinely tested in the older patient in whom hip OA is suspected. Internal and external rotation of the hip can be tested with the hip extended or flexed. Table 4.4 shows the normal ranges of motion of the hip joint. It is important to remember that age, sex, and ethnicity can also have an impact on what the ‘normal’ range of movement is for the hip. The normal range of hip movement decreases with age, especially in men, and studies have shown that Asian populations can have an increased ‘normal’ range of motion of the hip joint for external and internal rotation. In patients with severe hip OA, internal and external rotation especially may be significantly limited by pain and stiffness. Table 4.4 An approximation of normal ranges of motion for the hip joint. Reprinted with the kind permission of Mr. Menon, Kettering, UK. Normal ranges of motion for the hip joint Flexion

0–125°

Adduction

0–30°

Extension

Abduction

External rotation Internal rotation

0–15° 0–45° 0–45° 0–35°

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4.4.5 Special Tests 1. Trendelenburg test This test is performed to assess a patient’s abductor mechanism [10]. The examiner should stand facing the patient, placing his/her hands on the patient’s iliac wings with the thumbs on each anterior superior iliac spine (ASIS) (right thumb on the patient’s left ASIS and the left thumb on the patient’s right ASIS, see reason below). The patient needs to hold onto the examiner’s forearms. The patient should then flex their knee in order to stand on one leg, first on the affected side, followed by the unaffected side. The abductors on the weight-bearing side will elevate the contralateral hemipelvis in order to maintain balance as shown in Fig. 4.5. The test is considered

Figure 4.5 Trendelenburg’s test in a patient with normally functioning hip abductors. The white dashed line represents the line joining the 2 ASIS. The picture on the right demonstrates the rising hemipelvis as the patient is asked to weight bear on a single leg. In patients with weak abductors, when asked to bear weight on the affected leg, the hemipelvis on the ‘sound’ side will sag. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

Special Tests

to be positive, i.e., the patient has a weakened abductor mechanism when the pelvis on the unaffected side drops (“lifted leg lags”) with the patient standing on the affected leg due to contralateral abductor weakness. This rise and fall of the hemipelvis can often be quite subtle, and we, therefore, advocate the examiner also place his hands lightly on both ASIS of the patient in order to improve the accuracy of the test (Fig. 4.6).

Figure 4.6 Clinical photograph showing a positive Trendelenburg’s test. with the examiner placing their arms lightly on the patient’s ASIS bilaterally in order to feel the rise of the hemipelvis as the patient weight bears on one leg. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

2. Leg length measurement Hip disorders such as OA, SCFE, or developmental dysplasia of the hip (DDH) can result in significant leg length abnormalities, which can have an impact on the surgical management of the disorder. It is important therefore to delineate the presence of leg length discrepancies, along with where the shortening has occurred. With the patient lying supine on the examination couch, the examiner should place a forearm along both the patient’s ASIS, ensuring that their forearm is perpendicular to the side of the couch (to ascertain that the pelvis is square) (Fig. 4.7). The next step is to measure the distance between each ASIS and ipsilateral medial malleolus to determine the true leg length (Fig. 4.8).

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Figure 4.7 The pelvis is squared using the examiner’s forearm to line up both ASIS. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

Figure 4.8 Measurements are taken from the ASIS to the medial malleolus with a tape measure for each limb to determine the true leg length. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

Any discrepancies in the true leg lengths should prompt the examiner to move on to the Galeazzi’s test in order to determine if the shortening is in the femoral or tibial segment of the affected leg (Fig. 4.9). For this, the patient is asked to flex their knees to 90° with both heels equidistant from the buttocks, and the legs in contact with one another. Proximal positioning of the knee on the affected side indicates femoral shortening, whereas an inferior positioned knee indicates tibial shortening of the affected limb.

Special Tests

Figure 4.9 Galeazzi’s test. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

If the shortening is due to a femoral abnormality, further tests can be carried out to determine if the abnormality is proximal, i.e., above the level of the GT, or whether the abnormality lies in the femoral shaft below the GT. Anterior Superior Iliac Spine (ASIS)

Line B Line A 90° Line C

Greater Trochanter

Figure 4.10 A line diagram showing the Bryant’s triangle. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

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One such test is drawing the iliofemoral triangle, also known as Bryant’s triangle, with the patient supine, as illustrated in Fig. 4.10. The base of this triangle is formed by a line joining the ASIS and the top of the GT (line A). The two sides of the triangle are made up of a line dropped down perpendicular to the bed from the ASIS (line B), with the third line perpendicular to line b, going down to the GT (line C). Bryant’s triangle is drawn on both the affected and unaffected sides, and the lengths of line C on the two sides are compared. Shortening on one side indicates that the femur has migrated proximally due to disease in the hip joint. As this test compares the affected limb with the contralateral side, it cannot be used in patients who present with bilateral hip disorders. In these cases, Nelaton’s line can be used [Figure 4.11]. This is a line that is drawn from the ischial tuberosity to the ASIS. The position of the GT is then noted in relation to this line. In patients without the hip disease, the GT will lie on the line or distal to it, whereas in patients with femoral shortening due to underlying hip pathology, the GT will lie proximally, indicating migration of the femur proximally. In clinical practice, plain radiographs of the pelvis and femur are used to determine any leg length discrepancies. Anterior Superior Iliac Spine (ASIS)

Greater trochanter

Ischial tuberosity

Figure 4.11 A line diagram showing Nelaton’s line. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

3. Thomas’ test Patients with underlying hip disorders can develop a fixed flexion deformity (FFD), which can be difficult to elicit due to the patient compensating with a forward tilt of the pelvis and a resultant increase in lumbar lordosis. Thomas’ test is performed to determine the degree of FFD present in the affected hip joint. With the patient

Special Tests

supine, the examiner should place a hand underneath the patient’s lower back, at the level of the lumbar lordosis (Fig. 4.12), and ask them to bring the unaffected leg close to their chest, by fully flexing at the hip and knee joint. This should result in complete obliteration of the lumbar lordosis (Fig. 4.13). The examiner should then inspect the straight (affected) limb to see if there is any residual flexion at the hip joint, indicating an FFD.

Figure 4.12 Picture illustrating the lumbar lordosis present when the patient lays flat on the examination couch. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

Figure 4.13 Obliteration of the lumbar lordosis occurs as the patient flexes their hip and knee. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

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This can then be repeated for the opposite leg. The examiner checks this by placing their hand underneath the lumbar lordosis of the patient to ensure complete obliteration. Any flexion of the contralateral hip would be due to an FFD. 4. Anterior impingement test This test, as the name suggests, is used to determine the presence of underlying intra-articular hip disease. The examiner should flex the affected hip to 90° with the patient supine. The hip is then passively adducted and internally rotated in this position of 90° of flexion (Fig. 4.14). The test is positive if the movement combination results in the patient experiencing pain in the groin. Classically, the FABER (flexion, abduction, and external rotation) maneuver can be used to elicit femoroacetabular impingement (FAI).

Figure 4.14 Anterior impingement test which involves hip flexion, adduction, and internal rotation. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

Special Tests

Examination of the hip joint should always be completed by (a) performing a neurovascular examination of the limb and (b) examining the joint above (spine) and below (knee). Overall assessment of lower limb alignment is also of importance in practice, particularly when considering lower limb deformity. Figure 4.15 summarizes the examination of the hip joint and the sequence in which we recommend that the tests be carried out. Introduce yourself Gain consent Wash hands

Inspect front, side and back

Lie patient on couch and square the pelvis

Palpation

Leg length measurements

Thomas' test

Perform active and passive range of motion

Anterior impingement test

Neurovascular exam

Examination of spine and knee

Assess gait

Trendelenburg test

Figure 4.15 Flowchart summarizing the hip examination. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

4.4.6 Special Tests in the Pediatric Patient The Ortolani and Barlow tests are special tests used most commonly to exclude DDH in a pediatric patient. In the UK, these tests are performed on the newborn child as part of a screening program for DDH. They are not useful after the age of 3–6 months, as hip contractures develop in the older patient which makes eliciting the ‘clunk’ and the ‘click’ of the Ortolani’s and Barlow’s tests difficult. In this older age group, leg length discrepancy and loss of abduction are more helpful findings.

1. Ortolani’s test This test attempts to reduce a dislocated hip and is performed with the newborn baby supine. The examiner passively flexes both the patient’s hips to 90° and then abducts the hips, all the while applying

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a gentle force over the hips, attempting to push them anteriorly and into the acetabulum (Fig. 4.16). The test is positive when a clunk is palpated, as the dislocated hip moves over the neolimbus and reduces into the acetabulum.

Figure 4.16 Ortolani’s test. The examiner places his/her fingers over the posterior aspect of the hip, with the thumbs anteriorly while attempting to reduce the dislocated hip. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

2. Barlow’s test This test is performed after a positive Ortolani’s test to check whether the hip is unstable and can be re-dislocated. With the newborn baby supine and the hips held in 90° flexion, the examiner adducts the hips and applies a gentle depressing force, attempting to dislocate the hips posteriorly (Fig. 4.17). The test is positive when the hip redislocates with a ‘click’. This is the exact opposite of Ortolani’s test in essence. The examiner places his/her fingers over the postero-lateral aspect of the flexed hip in the supine patient, with the thumbs over the proximal thigh anteriorly, while gently adducting and depressing the hip in order to redislocate the joint.

Special Tests

Figure 4.17 Barlow’s test. Reprinted with the kind permission of Mr. Menon, Kettering, UK.

4.4.7 Investigations 1. Blood tests Following history taking and examination, basic investigations are conducted. Blood tests can be helpful in evaluating certain underlying pathologies. For patients with OA who are due to undergo arthroplasty, routine blood tests, including full blood count, hemoglobin, renal function, and clotting, are a useful pre-operative baseline. Depending upon local hospital policy, the patient may also require a group and save blood test before surgery.

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If septic arthritis is the suspected diagnosis, in addition to the above blood tests, a C-reactive protein test (CRP) and erythrocyte sedimentation rate (ESR) is helpful. CRP is a reliable marker when monitoring the response of a patient to the treatment of an infection. Other blood tests used in patients presenting with hip pathologies also include adjusted serum calcium and phosphate levels, rheumatoid factor, and serum electrophoresis, which are mainly used to screen for metabolic and neoplastic hip disorders. 2. Radiographs

Plain radiographs of the pelvis are usually the first line of imaging conducted for patients presenting with symptoms around the hip joint (Fig. 4.18). Commonly, anteroposterior (AP) pelvis and lateral views (frog lateral views in the pediatric patient) are obtained for the majority of hip pathologies, but special views such as Judet views may be helpful if the patient presents with a history of trauma and fractures of the acetabulum are suspected. Advantages of this imaging modality are that it is readily available, inexpensive, and associated with low radiation exposure. However, a plain radiograph is a 2-dimensional representation of a 3-dimensional structure; if a patient remains symptomatic with a normal pelvic radiograph, then further investigations should be considered. 3. Ultrasound scan (USS)

This is commonly used for pediatric patients with suspected DDH or septic arthritis. In infants below the age of 6 months, ultrasound is the mainstay of hip imaging for DDH. In infants and children above this age, an X-ray may be more helpful, as the ossific nucleus appears. USS can demonstrate hip joint effusion that would raise the suspicion of an underlying hip disorder (including septic arthritis). It confers no radiation risk. However, it is an operator-dependent modality (due to inter-observer variability) and could be difficult to access in individual hospitals due to the lack of adequately trained personnel.

Special Tests

Figure 4.18 Plain AP radiograph of the pelvis which typically includes both hips and sacroiliac joints. This radiograph demonstrates bilateral hip osteoarthritis (narrowing of joint spaces, osteophytes, subchondral sclerosis, and cysts). Reprinted with the kind permission of Mr. Menon, Kettering, UK.

4. Bone scintigraphy Commonly referred to as a ‘bone scan,’ scintigraphy of the hip joint involves the use of a radioactive tracer such as technetium or gallium, which is injected intravenously into the patient, after which images are taken using a gamma camera (Fig. 4.19). Uptake of the tracer tends to be directly proportional to osteoblastic activity, and therefore bone scans can help diagnose multiple conditions such as infections, fractures, and osseous metastases. While a bone scan is a sensitive test, it is not very specific and therefore the underlying diagnosis needs to be made based on the history and examination taken by the clinician [11]. The disadvantage of a bone scan is its significant radiation exposure (6.3 mSv approximately: equivalent to about 120 chest X-rays).

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Figure 4.19 A whole body bone scan in a patient diagnosed with prostate cancer demonstrating metastases to the spine, right ilium and left proximal femur (arrows).Reprinted with the kind permission of Mr. Menon, Kettering, UK.

5. Computed tomography (CT) CT is an investigative tool that produces computer-generated crosssectional images using multiple X-rays (Fig. 4.20). Currently, CT scans have become essential in everyday clinical practice. They are used routinely in trauma cases to demonstrate fractures, especially those involving the pelvis or acetabulum, as well as in the staging of cancers and monitoring response to treatment. Furthermore, 3-dimensional reconstructive images obtained from modern-day CT scanners can be used for pre-operative planning of complex fracture patterns [12]. However, the disadvantage is that the patient is exposed to a higher dose of radiation, and therefore CT

Special Tests

scans are associated with an increased lifetime relative risk of cancer [13]. It is particularly important to reduce the use of CT scans when possible, in infants and children.

Figure 4.20 A CT scan demonstrating a displaced left, intracapsular neck of femur fracture (arrow). Reprinted with the kind permission of Mr. Menon, Kettering, UK.

6. Magnetic resonance imaging (MRI) Another form of cross-sectional imaging used routinely in orthopedics is MRI. MRIs are useful in depicting soft tissue structures and bony edema, and can therefore help diagnose and stage multiple conditions such as AVN of the femoral head, SCFE, and Perthes disease [14]. They are even used to detect fractures of the femoral neck that are not visible on CT scanning (MRI is the gold standard for clinically suspected fractures with normal-looking X-rays). Moreover, MRIs are better than CT scans in demonstrating intramedullary lesions and are therefore used to grade tumors around the hip joint. While MRI scans do not expose the patient to any radiation, they are expensive and not as easily accessible as CT scanning.

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7. Arthrogram Commonly performed to investigate intra-articular hip pathologies such as femoro-acetabular impingement (FAI) and labral tears, arthrograms are invasive procedures compared to CT and MRI scanning. They are two-stage procedures, usually involving the injection of contrast or air into the hip joint [12], followed by imaging in the form of either fluoroscopy, CT, or MRI. Arthrograms allow the investigator to obtain both static and dynamic images, and this is useful in diseases such as Perthes disease and FAI [15].

4.4.8 Examination of Related Areas

The hip and pelvis examination is completed with a proper rectal examination. While testing, the gloved finger first examines the superficial anal reflex (S2, S3, S4) to touch. While doing a rectal examination, palpate the inner surface of the rectal wall which should be smooth and not fixed and immobile. During palpation, the internal sphincter is felt to grip your finger in a contraction which is the deep anal reflex (S5). Also, the prostatic groove can be palpated clearly before proceeding to palpate the sacroiliac joint and the bony coccyx which is normally mobile in bimanual palpation. The following very specific conditions must always be kept in mind: (i) Congenital dislocation of the hip: This is a condition that can be diagnosed early in life, and various tests are very helpful in its diagnosis in addition to early radiographs. A hip with a positive Barlow’s or Ortolani sign may become normal with time, without any treatment. Treatment before weight-bearing consists of an abduction napkin or a von Rosen splint. Treatment after weightbearing is by gradually increasing vertical traction, followed by a plaster or a Dennis Brown splint. Surgical treatment is considered when the closed treatment fails, and an open reduction is considered with or without a Salter’s osteotomy or derotation osteotomy to keep the reduction stable. (a) Subluxation of the hip: This is commonly seen in acetabular dysplasia when the femoral head is not displaced but subluxated upwards over the innominate bone. Radiographs taken at this stage are diagnostic (Fig. 4.21).

Special Tests

Figure 4.21 DDH. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Treatment is by traction and a Dennis Brown splint to be worn until the acetabular roof looks normal. In older children, surgical treatment is directed toward providing a good acetabular roof by a Salter’s innominate osteotomy or Chiari’s pelvic osteotomy, or by constructing a massive shelf (Fig. 4.22).

Figure 4.22 Derotation osteotomy of the hip. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

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(b) Pathological dislocation of the hip: This may result from early pyogenic arthritis (Fig. 4.23) giving rise to a dislocation, and radiographs are diagnostic.

Figure 4.23 Septic arthritis L hip. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

This is usually treated by aspiration under anesthesia, along with systemic antibiotics and a Dennis Brown splint for 3 months. (c) The irritable hip: This is usually seen in nonspecific synovitis with pain and limp. Treatment is by bed rest with traction and analgesics. Blood investigations help in establishing the diagnosis, and certain conditions such as transient synovitis, tuberculosis, chronic synovitis, Perthes disease, and slipped upper femoral epiphysis must be considered in the differential diagnosis. (ii) Tuberculosis of the hip: This usually starts as synovitis, and the destruction of the hip is very rapid with muscle spasms and wasting. Healing leaves an unsound hip with fibrous ankylosis characterized by limb shortening and deformity. Secondary infection may occur, with the development of bony ankylosis (Fig. 4.24). Initial treatment is by antituberculous drugs with traction. Later on, surgical treatment is done by an osteotomy or arthrodesis, or a combination of both.

Special Tests

Figure 4.24 Sequelae TB R hip. Note OA L hip. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

(iii) Perthes disease: This is a condition seen in the first few years of life due to partly or wholly avascular necrosis of the head of the femur (Fig. 4.25). Gradually this dead head is replaced by creeping substitution, resulting in revascularization of the femoral head along with varying degrees of flattening and coxa vara. The various stages of the disease are clearly recognizable on serial radiographs. Treatment is by traction, avoiding weight-bearing, and containment of the femoral head within the acetabulum.

Figure 4.25 Bilateral Perthes disease. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

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(iv) Slipped upper femoral epiphysis: This condition may be seen due to trauma, and sometimes an underlying abnormality is strongly suggested such as an endocrine imbalance. In the majority of the cases, it is bilateral (Fig. 4.26), although unilateral cases are also known in about 30% of cases. Clinically, the limb shows diminished abduction along with medial rotation and an increased lateral rotation. Radiographs are diagnostic by Trethovan’s and Capener’s signs, and indications on lateral radiographs are very obvious from the very start of the condition. Treatment is by fixing the displaced femoral head in situ with multiple pinning without any attempt at reduction. In some cases, a geo-metric fixation osteotomy or subtrochanteric osteotomy is carried out to correct the deformity in order to make the growth plate more horizontal.

Figure 4.26 Pediatric hip (frog-leg lateral view). Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

(v) Coxa vara: Here the NSA is reduced. This may be congenital or acquired (Fig. 4.27). Radiographs may be helpful in some cases when a separate triangular piece of bone may be seen in the inferior part of the metaphysis. This is usually treated by a corrective subtrochanteric osteotomy.

Special Tests

Figure 4.27 Congenital coxa vara. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

(vi) Osteoarthritis: This is a condition where the articular cartilage is worn away in pressure areas, while in non-pressure areas, the cartilage may become dense and thicker, giving rise to osteophytes and lipping. Concurrent synovial hypertrophy also occurs, and clinically the condition is diagnosed by rest pain at night along with decreased painful movements of the hip in its extreme degrees. There is an obvious shortening of the limb with an elevation of the GT, and radiographs are very helpful in its diagnosis. Initial treatment is usually conservative in the form of heat, manipulation, and an injection of hydrocortisone. Eventually, surgical treatment is indicated, including any of three main operations, namely, osteotomy, arthrodesis, and arthroplasty (Fig. 4.28). A McMurray’s displacement osteotomy is valuable in the early stages if the disease is segmental. The femur is divided in the subtrochanteric region, and the displacement is fixed using a compression plate. Arthrodesis is a certain way of achieving a pain-free joint, but this has been discarded these days with the evolution of arthroplasty. With the advent of total joint arthroplasty, Girdlestone’s arthroplasty of an excision of the hip joint (Fig. 4.29) has been reserved as a salvage operation for failed cases of total joint

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arthroplasty. THA or low friction arthroplasty was revolutionized by Charnley five decades ago. Nowadays, uncemented total hip replacement is in vogue, because of the shorter operating time involved, avoiding the complications postoperatively of using bone cement. Another form of arthroplasty which is done nowadays is the surface replacement of the femoral head, whereby an excision of the femoral head is avoided as is done in THA. The latter can be reserved for any future salvage operations, such as revision of the surface replacement by its conversion to THA.

Figure 4.28 Bilateral OA requiring a bilateral THR with precautions. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Figure 4.29 Girdlestone resection arthroplasty. Reprinted with the kind permission of Dr. Rajesh Botchu, Consultant MSK Radiologist, Royal Orthopaedic Hospital, Birmingham, UK.

Special Tests

(vii) Fracture neck of femur: This is a very common condition and is frequently seen in the elderly. In the past, it was well known “to be the beginning of the end.” Considerable interest still prevails in this condition, and it is now called “the unsolved fracture.” The most important point to note is whether the fracture is intracapsular or extracapsular. It must be diagnosed as early as possible so that necessary treatment can be started as early as possible. Various forms of treatment have been tried in the past, and it has been universally agreed that these fractures should be treated as early as possible. The basic aim of early treatment is to put the patient on their feet again as soon as possible. (viii) Avascular necrosis of the hip: This is a condition that must be kept in mind for differential diagnosis where an early decrease in rotations of the hip joint is seen. It results in an area of avascularity of a segment of the hip, and the patient complains of pain only. It may be bilateral in alcoholics. This condition may also be seen in liver disorders or may be seen as an idiopathic variety.

Figure 4.30 Stage II osteonecrosis of the right hip [16]. A: minor radiolucency especially in the weight-bearing area of the head without any collapse. B: T1 coronal image (no collapse). C: axial MRI shows the involvement of the anterior half of the head. D and E: multiple drilling with exact locations of the small drills toward the necrotic area.

(ix) Traumatic subluxation of the Hip with a fracture of the lip of the acetabulum: This has to be kept in mind as these two injuries are present in the same single case (Fig. 4.30).

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Figure 4.31 Traumatic subluxation of the Hip with a fracture of the lip of the acetabulum. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

(x) Extensive Paget’s disease of both hips with pelvis: It must be kept in mind for differential diagnosis (Fig. 4.32).

Figure 4.32 Extensive Paget’s Disease of both hips with the pelvis. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

References

Acknowledgments The authors would like to thank Mr. Milan Muhammad (Trauma and Orthopaedic registrar at Leicester Royal Infirmary Hospital) and Alex Wilcockson (3rd-year medical student at Leicester Medical School) for kindly acting as models for our hip examination.

References

1. Lu Y, Uppal HS. Hip fractures: relevant anatomy, classification, and biomechanics of fracture and fixation. Geriatr Orthop Surg Rehabil [Online], 2019 Jul [Accessed 2019 Jul 16]; 10: 2151459319859139. Available from URL: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6610445/ 2. Standring S (ed.). Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 41st Ed., Elsevier, 2016.

3. Tonnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. J Bone Joint Surg Am, 1999 Dec, 81(12): 1747–1770. 4. Gelberman RH, et al. The association of femoral retroversion with slipped capital femoral epiphysis. J Bone Joint Surg Am, 1986 Sep, 68(7): 1000–1007.

5. Dewar DC, et al. The relative contribution of the medial and lateral femoral circumflex arteries to the vascularity of the head and neck of the femur: a quantitative MRI-based assessment. Bone Joint J, 2016 Dec, 98–B(12): 1582–1588. 6. Bulstrode C, et al. (ed.). Oxford Textbook of Trauma and Orthopaedics. 2nd Ed., Oxford: Oxford University Press, 2011.

7. Mullins M, Youm T, Skinner J. Biomechanics and joint replacement of the hip. In: Ramachandran M (ed.), Basic Orthopaedic Sciences, 2nd Ed., Great Britain: CRC Press, 2017. 8. Wylde V, Learmonth ID, Cavendish VJ. The Oxford hip score: the patient’s perspective. Health Qual Life Outcomes, 2005 Oct, 3: 66.

9. Harris N, Ali F (eds.). Examination Techniques in Orthopaedics, 2nd Ed., Cambridge: Cambridge University Press, 2014.

10. Ugland TO, et al. High risk of positive Trendelenburg test after using the direct lateral approach to the hip compared with the anterolateral approach: a single-centre, randomised trial in patients with femoral neck fracture. Bone Joint J, 2019 Jul, 101–B(7): 793–799.

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11. Agrawal K, Tripathy SK, Sen RK, Santhosh S, Bhattacharya A. Nuclear medicine imaging in osteonecrosis of hip: old and current concepts. World J Orthop, 2017 Oct, 8(10): 747–753.

12. Lang P, Genant HK, Jergesen HE, Murray WR. Imaging of the hip joint. Computed tomography versus magnetic resonance imaging. Clin Orthop Relat Res, 1992 Jan, (274): 135–153.

13. Wylie JD, et al. Computed tomography scans in patients with young adult hip pain carry a lifetime risk of malignancy. Arthroscopy, 2018 Jan, 34(1): 155–163.

14. Rajeev A, Tuinebreijer W, Mohamed A, Newby M. The validity and accuracy of MRI arthrogram in the assessment of painful articular disorders of the hip. Eur J Orthop Surg Traumatol, 2018 Jan, 28(1): 71–77. 15. Shahid M, et al. Efficacy of using an air arthrogram for EUA and injection of the hip joint in adults. J Orthop, 2014 Jul, 11(3): 132–135.

16. Gharanizadeh K. Advances in avascular necrosis of the hip joint. In: Iyer KM (ed.), Hip Joint in Adults: Advances and Developments, ISBN: 978-81-4474-72-7, Jenny Stanford Publishing: Singapore, 1998.

Chapter 5

Examination of the Knee

The knee is the largest modified hinge joint in the body, which provides the greatest range of movement in flexion of the joint.

5.1 Inspection

Inspect the patient’s gait while asking him to undress to expose the knee joints. Examine the patient standing up when the normal knee has a slight degree of valgus in the leg with respect to the femur. An increase in this angle is called genu valgum, and it results in both the knees touching one another to produce a knock knee. Obliteration of the normal valgus ankle results in a genu varum called bow legs. When seen sideways, the knee joint is extended, which can be exaggerated, and this may be bilateral, as in females due to hyperlaxity of ligaments resulting in a genu recurvatum. Inspect the quadriceps muscles just above the knee joint. These may be decreased in size or atrophied following knee surgery. Intraarticular hemorrhage and synovitis with synovial thickening may be seen as a generalized swelling that obliterates the normal contour of the knee joint. Above all, look for any localized swellings around the knee. A bursal swelling is commonly seen in front of the patella and is Introduction to Limb Arthrology Edited by K. Mohan Iyer Copyright © 2023 Jenny Stanford Publishing Pte. Ltd. ISBN 978-981-4877-99-2 (Hardcover), 978-1-003-37276-9 (eBook) www.jennystanford.com

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known as prepatellar bursitis, or it may be seen inferiorly over the tibial tubercle, which is known as infrapatellar bursitis. Occasionally a localized swelling may be seen in the popliteal fossa, such as a Baker’s cyst, or it may be located just over the medial aspect of the tibial tubercle, which is known as a Pes Anserine bursa.

5.2 Palpation

The bony components of the knee joint are best palpated with the knee in slight flexion as they all disappear in full extension of the knee. Furthermore, the muscles, tendons, and ligaments are lax in the flexed non-weight-bearing position, thus facilitating examination of the bony landmarks and joint margins.

A. Medial Aspect This is best palpated by the thumbs over the joint line. (i) Medial tibial plateau: Move your thumb just inferiorly, and the sharp ridge of the medial tibial plateau can be palpated, which is also the attachment of the medial meniscus. (ii) Tibial tubercle: Continue with the inspecting finger inferiorly until it reaches the bony tibial tubercle. The area just medial to this is of importance as the insertion to the tendon of the Pes Anserine and the bursa. (iii) Medial femoral condyle: This is palpated just medial to the patella, and a greater area can be palpated by increasing knee flexion to more than 90 degrees. Sometimes a bony defect may be palpated in cases of osteochondritis dissecans. Osteophytes may be palpated at the edges of patients with osteoarthritis. (iv) Adductor tubercle: This can be identified by proceeding upward and posteriorly up the medial femoral condyle, in the distal part of the natural depression between the vastus medialis and the hamstrings. B. Lateral Aspect

(i) Lateral tibial plateau: This is a sharp ridge just between the junction of the tibia and the femur. (ii) Lateral tubercle: This is a large bony prominence immediately below the lateral tibial plateau.

Palpation

(iii) Lateral femoral condyle: More of the articulating articular surface is palpable with the knee flexed more than 90 degrees, as the finger moves upward. The amount of the lateral femoral condyle available for palpation is much less than the medial femoral condyle because most of the surface of the lateral femoral condyle is covered by the patella. (iv) Lateral femoral epicondyle: This lies just lateral to the lateral femoral condyle. (v) Head of the fibula: Proceeding with palpation slightly inferiorly and posteriorly along the joint line, the fibular head is palpated at the same level as the tibial tuberosity.

C. Trochlear Groove and Patella The trochlear groove is the path along which the patella tracks, and it can be palpated by both thumbs along the medial and lateral joint lines to the highest point of the patella—just above that a depression of the trochlear groove. The patella is fixed in flexion of the knee joint and is mobile in full extension when it is easier to push the patella to the medial side than the lateral side.

5.2.1 Soft Tissue Palpation

This is carried out in the following four zones: anterior, medial, lateral, and posterior.

Zone I: Anterior Aspect (i) Quadriceps: This is a massive muscle that is formed of three parts—the medialis, intermedius, and lateralis—and together with the rectus femoris, it forms a common tendon inserting into the superior and medial borders of the patella and carrying on as the infrapatellar tendon to be finally inserted into the tibial tubercle. The muscle mass of the medialis extends further distally than the lateralis. Observe for any defects just proximal to the patella. These may be seen in ruptures that are transverse in nature. Signs of atrophy may be seen in the vastus medialis frequently following knee surgery or an effusion. The actual measurements of atrophy of the quadriceps muscle may be taken at similar points in both the thighs, with the tibial tubercle or the tibial plateau being taken as reference points for this.

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(ii) Infrapatellar tendon: This is inserted into the tibial tubercle which may be tender in children, in which case it is called Osgood– Schlatter’s syndrome. The infrapatellar tendon may be avulsed from its insertion when it does not feel rigid and a palpable defect can be felt. The infrapatellar region is palpated for any signs of bursitis, which is fairly common. These bursae are mainly located in the anterior aspect of the knee joint and they may be superficial or deep to the patellar tendon. The superficial infrapatellar bursa lies between the patellar tendon and the skin and may become inflamed with constant kneeling. Another common site is the tendon of the Pes Anserine where the bursa lies just beneath the tendon of the Pes Anserine. This is known as the Pes Anserine bursa. The prepatellar bursa is located just over the anterior part of the patella, and it may be involved after constant kneeling in what is referred to as “housemaid’s knee.” Zone II: Medial Aspect

(i) Medial meniscus: This is located just above the medial tibial plateau and is anchored by coronary ligaments. It may be tender (Fig. 5.1) when involved in tears. The medial meniscus is mobile as compared with the lateral meniscus. When the tibia is rotated externally the anterior margin of the medial meniscus is palpable in the joint space. Tears of the medial meniscus are more frequent than tears of the lateral meniscus. (ii) Medial collateral ligament: This is a broad fan-shaped ligament that has two portions and lies between the medial femoral condyle and the upper tibia. The deep part extends to the edge of the upper tibial plateau and the medial meniscus, while the superficial part extends more distally over the flare of the upper tibia. This medial collateral ligament is intimately blended with the joint capsule and is frequently torn in valgus injuries, as seen in football. In cases of avulsion from the medial epicondyle, a small chip of the bone may be taken with the ligament when the point of origin is tender on palpation. (iii) Sartorius, gracilis, and semitendinosus muscles: These are three tendons situated on the posteromedial side of the knee, which insert into the lower portion of the medial tibial plateau. They mainly provide stability to the medial side of the knee joint during valgus stress. These tendons are like a goat’s foot and therefore called Pes

Palpation

Anserine. The semitendinosus tendon is the most posterior and inferior of the lot, with the gracilis tendon lying anterior and medial to it. The sartorius muscle is a wide, thick strap-like band just above the gracilis tendon. At the common insertion of these tendons is seen a bursa which lies beneath it called the Pes Anserine bursa, which may be inflamed giving rise to pain. The semitendinosus muscle is sometimes used as a graft to reinforce the medial compartment of the knee joint.

Figure 5.1 Clinical photograph demonstrating eliciting joint line tenderness. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

Zone III: Lateral Aspect (i) Lateral meniscus: This is situated on the lateral aspect of the joint and is less frequently torn as compared with the medial meniscus. The meniscus is attached to the popliteus muscle and not to the lateral collateral ligament, thus making it more mobile than the medial meniscus. The lateral meniscus is a common site for the

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development of a cyst which can be felt as a firm and tender mass. (ii) Lateral collateral ligament: This is a stout cord that originates from the lateral femoral condyle to be inserted into the head of the fibula. This is palpated easily when the knee is flexed to 90 degrees and the hip is abducted and laterally rotated to relax the iliotibial tract. (iii) Anterior superior tibiofibular ligament: This lies in the interval between the tibia and the fibular head. It is rarely pathologically involved. (iv) Biceps femoris tendon: This is palpated when the knee is flexed at which point it becomes taut and can be felt on the lateral side at its insertion into the fibular head. (v) Iliotibial tract: This tract is situated just anterior to the lateral aspect of the knee joint and is inserted into the lateral tibial tubercle. This is neither a muscle nor a tendon but a thick band of fascia, and contractures of this can result from paralytic cases like poliomyelitis and meningomyelocele. (vi) Common peroneal nerve: This nerve can be palpated by rolling it beneath the finger as it winds around the neck of the fibula. Excessive pressure on it may cause a foot drop.

Zone IV: Posterior Aspect The posterior aspect is marked by the popliteal fossa, which is bordered by the biceps tendon on its lateral side. The medial border is formed by the tendons of the semitendinosus and semimembranosus at its superior medial border, while the inferior borders are formed by the origin of the heads of the gastrocnemius muscle. A group of neurovascular structures crosses beneath it to the leg. (i) Posterior tibial nerve: This is a branch of the sciatic nerve and is the most superficial structure in the popliteal fossa. (ii) The popliteal vein: This vein lies directly beneath the nerve. (iii) The popliteal artery: This lies very deep in contact with the joint capsule of the knee joint. It is quite commonly seen in the popliteal fossa is the popliteal cyst or Baker’s cyst which is a painless mobile swelling seen on the medial side of the fossa and is a distention of the gastrocnemius-semimembranosus bursa. (iv) Gastrocnemius muscle: Both the heads of the muscle are palpable at its origin when the knee is flexed against resistance.

Tests for Joint Stability

5.3 Tests for Joint Stability (i) Collateral ligaments: These are tested by the patient lying supine with knees extended. The collaterals are tested with the knees in 10 degrees of flexion. The knee to be tested is held with the limb straight, and the other hand is placed over the lateral side of the joint over the head of the fibula. This hand is pushed medially while the limb is pulled laterally to create valgus stress. During this maneuver, the joint space can be palpated for a slight widening. Releasing that pressure may elicit a clunk which is felt in the tibia and femur closing against each other. This test can be done conversely for a varus stress of the knee, which will demonstrate the instability of the lateral side of the knee joint. Since the medial collateral ligament is more important to stability than the lateral one, an isolated tear there may cause joint instability, whereas a similar isolated tear of the lateral collateral ligament may not be enough to cause joint instability. This is the reason most tears occur on the medial side of the knee joint. (ii) Cruciate ligaments: Both these ligaments are very important in preventing anterior and posterior dislocations of the knee joint, and they both are intracapsular originating on the tibia and inserted onto the inner sides of the femoral condyles. These are tested by the patient lying supine on the bed with feet kept flat and the knees flexed to 90 degrees. The hamstrings are then tested over the posterior aspect of the knee to ensure that they are not taut. The hands are placed on the knee so that the tibia is pulled anteriorly when it may slide forward under the femur giving a positive anterior drawer sign. This indicates a tear of the anterior cruciate ligament. This test is now repeated with the foot held in internal and external rotation to keep the capsule tight. External rotation of the leg holds the posteromedial capsule tight, and the anterior slide is diminished even if the anterior cruciate is torn. If there is an anterior slide demonstrable, which is equal to that seen with the leg in the neutral position, then both the anterior and posterior cruciates are torn, along with the posteromedial capsule. In such cases, the medial collateral ligament may also be torn. Similarly, internal rotation of the leg tightens the posterolateral capsule, and forward movement of the leg is reduced when compared with the forward movement, which is reduced when the leg is in the neutral position. This indicates that both the cruciates are torn along with the posterolateral capsule of

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the knee joint. The anterior cruciate ligament may be torn with tears of the medial collateral ligament. Similar tests can be carried out on the posterior cruciate ligament when the tibia is pushed backward to elicit a positive drawer sign in tears of the posterior cruciate ligament. Isolated tears of the posterior cruciate ligament are very rare. The incidence rate of anterior cruciate tears is more than that of posterior cruciate tears.

5.4 Range of Motion

Three basic movements are seen in the knee joint: namely, flexion, extension, and rotation, including internal and lateral rotations. Flexion and extension are mainly the results of movement between the femur and the tibia. Rotations involve displacement of the menisci on the tibia, along with movement between the tibia and the femur. The extension is performed by the quadriceps, while flexion is performed by the hamstrings along with gravity. Internal and external rotations are done when the knee is slightly flexed by the semimembranosus, semitendinosus, gracilis, and sartorius on the medial side. It is done on the lateral side by the biceps. A. Active Range of Movement

(i) Flexion: Ask the patient to squat down on the floor. He should be able to do this with his knees flexed. (ii) Extension: Ask the patient to stand up from the sitting position and he should be able to do this standing up. Also, ask the patient to sit on the table and extend his knee fully. Normally he should be able to extend his knee fully, but in some cases, this movement may not be complete for the last 15 degrees, in which case it is called an “extensor lag”—something that is commonly seen in quadriceps weakness. It is important to note that some amount of external rotation of the tibia on the femur occurs when the knee is fully extended. This is explained by the anatomic configuration of the knee joint, with the medial femoral condyle being half an inch longer than the lateral femoral condyle. This can be seen in the screw home movement which is seen from a pencil dot over the midpoint of the patella and the tibial tubercle. Now ask the patient to bend and extend the knee joint. The tibial tubercle turns slightly laterally on full extension, and this may be prevented by a torn meniscus.

Neurologic Examination

(iii) Internal and external rotations: Ask the patient to rotate his foot medially and laterally, which should be possible to 10 degrees on either side. B. Passive Range of Movement

Flexion is possible to 135 degrees when the heel touches the posterior aspect of the thigh. The extension should be full in both the knees to 0 degrees, but occasionally slight hyperextension may be seen. Internal and external rotations are possible to 10 degrees and are tested with both knees held straight with the hands on the ankles rotating the legs.

5.5 Neurologic Examination A. Muscle Testing

Extension – primary extensor – quadriceps – femoral nerve – L2, L3, L4 Flexion – primary flexor: (i) Semitendinosus-tibial portion of the sciatic nerve – L5 (ii) Semimembranosus-tibial portion of the sciatic nerve – L5 (iii) Biceps femoris-tibial portion of the sciatic nerve – S1 These are tested by asking the patient to lie supine on the examining bed and to flex the knee. Then ask the patient to extend her knee with gradually increasing resistance to test the quadriceps muscle. To test the flexors, mainly the biceps on the lateral side, externally rotate the leg while flexing the knee against resistance. B. Sensation Testing

The sensory dermatomes of the knee run in long oblique bands as follows:

(i) L4 crosses the anterior aspect of the knee continuing down the medial side of the leg. This is the infrapatellar branch of the saphenous nerve, which supplies the skin over the medial femoral condyle. It is commonly cut during medial meniscectomy. (ii) L3 supplies the anterior aspect of the thigh just at and above the knee joint. This is mainly supplied by the femoral nerve. (iii) L2 supplies the anterior aspect of the middle of the thigh, by the femoral nerve.

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(iv) S2 supplies a strip of the middle of the posterior thigh and the popliteal fossa by the posterior cutaneous nerve of the thigh. C. Reflex Testing

The only reflex to be tested is the patellar reflex – L2, L3, L4. For clinical purposes, the patellar reflex is considered to be an L4 reflex. This reflex is tested by asking the patient to be seated with his legs dangling free on the side or with one leg crossed over the other. When the patient is lying down, the knee joint is held in slight flexion while testing this reflex. The tendon is tapped to elicit the reflex, and reinforcing this may be helpful.

5.6 Special Tests

Diagnosing an anterior cruciate ligament (ACL) tear clinically requires some special tests, which are described below. Hence, these are given in detail in the next Chapter 6. There are several special tests for clinical diagnosis of the knee. Some most commonly performed tests are: 1. Tests for isolated ACL injuries (a) Anterior Drawer Test: It is performed with the knee flexed to 90 degrees (Fig. 5.2). It is crucial to feel the relaxation of the hamstrings with two fingers to avoid false-negative tests. With both hands placed behind the tibial condyles, the tibia is pulled forward [1]. In a positive test, there is an increased translation of the upper tibia anteriorly, compared to the opposite knee. Translation can be graded into three gradings:



∑ Grade I: Translation less than 5 mm compared to the opposite limb ∑ Grade II: Translation between 5–10 mm compared to the opposite limb ∑ Grade III: Translation more than 10 mm compared to the opposite limb

The drawback with the anterior drawer test is that in an acute setting when the knee is swollen and painful, it is often difficult for the patient to flex the knee to 90 degrees. Also, a mechanical block due to a torn meniscus may cause a ‘door stopper’ effect leading to a false-negative test.

Special Tests

Figure 5.2 Anterior drawer test. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

(b) Lachman Test: It is performed with 30-degree flexion of the knee (Fig. 5.3); there is increased anterior excursion compared to the opposite knee. In acute injuries, there is a soft mushy endpoint. This test has the benefit that it can be performed easily in acute settings and also with concomitant meniscal injuries. (c) Pivot Shift Test: It is a dynamic test that is more diagnostic of ACL tear than the other described tests. However, intactness of medial collateral ligament and cooperation of the patient with full muscle relaxation are prerequisites to perform this test. In this test, the patient lies in the supine position, and a combination of an axial load and valgus force is applied by the examiner, during a knee flexion from an extended position. In a positive test (ACL tear), there is a subluxation of the lateral tibial condyle [2].

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Figure 5.3 Lachman test. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

2. Tests for isolated posterior cruciate ligament (PCL) injuries (a) Posterior Sag Test: Place both knees at 90-degree flexion on the examination table and look tangentially from the sides to appreciate a posterior sag of the tibia compared to the unaffected opposite side. A definite posterior sag is suggestive of insufficiency in the posterior cruciate ligament. (b) Posterior Drawer Test: This test is also referred to as the reverse anterior drawer test. It is performed with the knee in 90-degree flexion, thumbs supporting the medial and lateral tibial condyles, and the rest of the three fingers posteriorly on the hamstrings to feel the relaxation. Compare the posterior excursion of the tibia more than 5 mm compared to the opposite side. It is essential to check the start point in this test. In cases where both anterior and posterior cruciate ligaments are insufficient, it is easy to make clinical errors between positive anterior and posterior drawer tests. (c) Quadriceps Active Test: This test is performed to assess the integrity of the PCL. With the patient in the supine position, the patient’s involved limb is placed in a position of 45 degrees hip flexion and 90 degrees of knee flexion [3]. Look for the tibia to

Special Tests

“sag” compared to the position of the femur. The examiner should then sit on the foot of the affected limb to stabilize it. Next, have the patient actively contract their quad muscle. A positive test occurs if the patient’s tibia shifts forward. The importance of this test is that the posterior cruciate ligament is responsible for resisting the excessive posterior translation of the tibia on the femur, due to its attachments on posteriorly on the tibial plateau and anteriorly on the lateral side of the medial femoral condyle. In the position of 45 degrees of hip flexion and 90 degrees of knee flexion, gravity places a force on the tibia that pulls the tibia posteriorly but is blocked by an intact PCL. In the absence of a PCL, the tibia appears to “sag.” When the quad contracts, an anterior translation of the tibia on the femur occurs due to the attachments of the quadriceps muscles. The most common mechanism for PCL injury is a posterior translation at 90 degrees of knee flexion. While the PCL can be ruptured through hyperextension and hyperflexion as well, it is unlikely that it is the only ligament torn in these injuries. The ACL is stressed more than the PCL in both hyperflexion and hyperextension. 3. Tests for menisci (a) Mc Murray’s Test: With the patient supine, place the patient’s tested leg in maximal hip and knee flexion. While palpating the joint line, apply a valgus force to the knee, while simultaneously externally rotating and extending the knee completely. Place the tested leg back in maximal hip and knee flexion. While palpating the joint line, apply a varus force to the knee, while simultaneously internally rotating and extending the knee completely. A positive test occurs when pain or clicking/thudding is produced [4]. The importance of this test is that the menisci are crescent-shaped structures that help increase the concavity of the tibia for acceptance of the femoral condyles. They attach anteriorly and posteriorly to the intercondylar area of the tibia. Laterally, they adhere to the tibia loosely via the coronary ligaments (this allows some sliding of the menisci). With its concave shape, the meniscus acts to decrease compressive forces of the knee by increasing the force distribution of the femoral condyles onto the tibia. Due to decreased blood supply to the inner aspects of each meniscus, an injury in this area is less likely to heal. This test stresses each meniscus by adding a rotary force to a flexion/extension pattern. When the tibia is externally rotated, the medial meniscus is primarily being assessed, while the

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posterior portion of the lateral meniscus may be assessed as well. When the tibia is internally rotated, the lateral meniscus is being tested. These motions stress the structure, and when combined with palpation of the joint line, clicking can be felt. The meniscus is usually injured through twisting motions on a slightly bent knee or sometimes through muscular contractions of the semimembranosus, quadriceps, or popliteus, due to their attachments to the menisci. Whenever an injured meniscus is present, or a meniscus is removed, the force distribution characteristic is lost and increased compressive forces are placed on the knee. These individuals have been found to have increased development of knee osteoarthritis. (b) Apley’s Grinding Test: With the patient lying down on the stomach, flex the knee under examination to 90 degrees and with one hand press the foot down toward the examination table but at the same time giving internal and external rotation forces [5]. Notice if the patient winces in pain or complains of sudden catch suggestive of a meniscal tear. (c) Thessaly Test: Have the patient stand on the test leg with the knee bent to 20 degrees of flexion (the opposite leg is flexed behind the patient). The patient may place his/her hands on the hands of the examiner for balance during the test. The patient then rotates the knee medially and laterally three times in each direction. A positive test occurs when the patient experiences joint line discomfort or if locking/catching occurs.

4. Tests for patellofemoral joint (a) Patellar Tap/Fluctuation: The patient is lying supine with the leg extended. The examiner puts pressure on the proximal side of the knee to squeeze the fluid out of the suprapatellar pouch (Fig. 5.4). The fluid can be moved under the patella while maintaining the pressure on the suprapatellar pouch; the examiner uses his/her other hand to press upon the medial and lateral recesses forcing the fluid under the patella [6]. Tapping down the patella with the finger/thumb to create an upward and downward movement and a palpable ‘click’ as the patella hits the underlying femur (Fig. 5.5). If the test is negative, the femur and the patella are already in contact. A positive test is when the patella can be felt to move down through the fluid and rebound on the patella. The test can be falsely positive; therefore, we must always test both the knees to compare.

Special Tests

Figure 5.4 Cross fluctuation test for knee effusion. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

Figure 5.5 Patellar tap test for knee joint effusion. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

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(b) Apprehension Test: This is a test that is designed for the clinical identification of lateral patellar instability. The moving patellar apprehension test is performed in two parts. Part 1 is a provocationoriented test. The examiner places the knee to be examined into full extension. A lateral force is applied to the patella with the examiner’s thumb (Fig. 5.6).  The examiner then moves the knee from full extension to 90 degrees of flexion and then returns to full extension while maintaining the laterally applied force on the patella. The second aspect of the test (Part 2) consists of a symptom alleviation maneuver.  The examiner repeats Part 1 of the test with a medially applied force on the patella.   The examiner places the knee to be examined into full extension. A medial force is applied to the patella with the examiner’s index finger. The examiner then moves the knee from full extension to 90 degrees of flexion and then returns to full extension while maintaining the medially applied force on the patella. A positive test consists of orally expressed apprehension or apprehensive quadriceps recruitment on the provocation test (Part 1), and alleviation of these symptoms with normal ROM within the test ROM in Part 2 of the test [7].

Figure 5.6 Patella apprehension test. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

Special Tests

(c) Patellar Grind Test: This test is performed to elicit signs of patellofemoral arthritis, patella femoral syndrome, and chondromalacia. The patient is positioned supine or long sitting with the involved knee extended. The examiner places the web space of his hand just superior to the patella while applying pressure (Fig. 5.7). The patient is instructed to gently and gradually contract the quadriceps muscle. A positive sign on this test is pain in the patellofemoral joint.

Figure 5.7 Patella grind test. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

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5. Tests for mediolateral stability (a) Varus Stress Test: Performed to assess the integrity of the lateral collateral ligament (LCL). The patient’s leg should be relaxed for this test. The examiner should passively bend the affected leg to about 30 degrees of flexion. While palpating the lateral joint line, the examiner should apply a varus force to the patient’s knee. A positive test occurs when pain or excessive gapping occurs (some gapping is normal at 30 degrees). Be sure to not include rotation of the hip in your application of force. Next, the examiner should repeat the test with the knee in neutral (0 degrees of flexion). A positive test occurs when pain or gapping is produced. There should be no gaping at 0 degrees. The lateral collateral ligament is vital for resisting varus force at the knee due to its attachments along the femur and fibular head. With the fibular nerve also located around the fibular head, any injury with a mechanism of a varus force to the knee could potentially stress the fibular nerve as well. Other tissues at risk with these injuries include the PCL and arcuate complex, especially if the injury varus force is combined with extension. At 0 degrees, there is usually no gapping that occurs when a varus stress is applied, so if gapping occurs during the test, severe injury is suspected, i.e., ACL, PCL, LCL, capsule. In the position of 30 degrees, some gapping occurs, because the LCL and other structures are no longer stressed maximally. The LCL is a very thick, fibrous ligament that can be palpated with position stress in the figure-4 position (think of the attachments!). Due to the difficulty of varus forces being an injury mechanism (because of the shielding by the opposite lower extremity), isolated LCL injuries are relatively rare [8]. (b) Valgus Stress Test: This test helps to assess the integrity of the medial collateral ligament (MCL). The patient’s leg should be relaxed for this test. The examiner should passively bend the affected leg to about 30 degrees of flexion. While palpating the medial joint line, the examiner should apply a valgus force to the patient’s knee (Fig. 5.8). A positive test occurs when pain or excessive gapping occurs (some gapping is normal at 30 degrees). Be sure to not include rotation of the hip in your application of force. Next, the examiner should repeat the test with the knee in neutral (0 degrees of flexion). A positive test occurs when pain or gapping is produced. There should be no gaping at 0 degrees.

Special Tests

Figure 5.8 Valgus stress test. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

The MCL is vital for resisting valgus force at the knee due to its attachments along the femur, meniscus, and tibia. The MCL also plays a significant role in restraining tibial external rotation. The surgical severing of the superficial portion of the MCL was shown to increase tibial external rotation at 90 degrees by about three times [9]. According to Neumann, the MCL attaches to the medial epicondyle proximally and posterior to the distal attachment of the Pes Anserine distally on the anteromedial tibia. The deeper fibers

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of the MCL are shorter than the superficial fibers and also attach to the posteromedial capsule, meniscus, and semimembranosus tendon. Because the deeper fibers are shorter than the superficial fibers, they are more likely to be injured when stressed with a valgus force, even though the superficial fibers provide the primary resistance to valgus force. The superficial fibers, on the other hand, are more likely to be stressed with external rotation of the tibia on the femur (or internal rotation of the femur on the tibia). With the attachment of the MCL to the meniscus, whenever the mechanism of injury affects the MCL, be sure to check the meniscus for injury as well. At 0 degrees, there is usually no gapping that occurs when a valgus stress is applied, so if gapping occurs during the test, severe injury is suspected, i.e., ACL, PCL, MCL, capsule (no gapping because the MCL, posteromedial capsule, hamstrings, oblique popliteal ligament, and parts of the  ACL are most taut in full extension). In the position of 30 degrees, some gapping occurs, because the MCL and other structures are no longer stressed maximally, but the MCL is the primary stabilizer in this position. The MCL overall is one of the most essential ligaments for the stability of the knee. With a hypermobile knee, due to a sprained MCL, it is essential to take extra precautions to decrease the risk of further injury. With a lax MCL, the ACL becomes increasingly stressed with valgus forces, especially at 45 degrees of flexion [9]. Remember the MCL is the primary valgus restraint in the flexed knee; without it, the ACL is prone to injury.

6. Tests for posterolateral instability (a) External Rotation Recurvatum Test: In this test, the examiner determines if there is an increased amount of knee hyperextension compared to the contralateral side. The test is performed while applying a stabilizing force to the distal thigh while one lifts the great toe to assess the amount of knee recurvatum present. This is usually measured by the amount of heel height in cm. In general, it is measured on the medial aspect of the foot and compared to the healthy contralateral knee. Studies have demonstrated in the face of a posterolateral knee injury, an increased amount of recurvatum is usually indicative of a combined anterior cruciate ligament tear. (b) Dial Test in 30 and 90 Degrees: The test can be done with the patient either in the prone or supine position. The goal of the test is

Special Tests

to inspect the external rotation (foot–thigh angle, best measured in a clinical setting at the knee joint while the knees are at 30 degrees and 90 degrees of flexion. The clinician flexes the patient’s knees to 30 degrees and places both hands on the feet of the patient, cupping his heels. A maximal external rotation force is then applied, and the foot–thigh angle is measured and compared with the other side. The knees are then flexed to 90 degrees, and again an external rotation force is applied (Fig. 5.9), and the foot–thigh angle is measured again. The test is positive when there are more than 10 degrees of external rotation in the injured knee compared to the uninjured knee [9]. Two types of different injuries can be identified: (i) An isolated injury to the PLC: More than 10 degrees of external rotation in the injured knee is present at 30 degrees of flexion, but not at 90 degrees of flexion. (ii) Instability of the PCL: More than 10 degrees of external rotation in the injured knee is present at 90 degrees of flexion, but not at 30 degrees of flexion.

A combined injury: More than 10 degrees of external rotation in the injured knee is present at 30 degrees and 90 degrees of flexion. This is an injury to the PCL and the PLC. (c) Reverse Pivot Shift Test: The reverse pivot shift test helps to diagnose acute or chronic posterolateral instability of the knee. A significantly positive reverse pivot shift test suggests that the PCL, the LCL, the arcuate complex, and the popliteal fibular ligament are all torn. The reverse pivot shift test begins with the patient supine with the knee in 90 degrees of flexion. Valgus stress is then applied to the knee with an external rotation force. Bring the knee from 90 degrees of flexion to full extension. The tibia reduces from a posterior subluxed position at about 20 degrees of flexion. A shift and reduction of the lateral tibial plateau can be felt as it moves anteriorly from a posteriorly subluxed position. A “clunk” occurs as the knee is extended. This is called reverse pivot shift because the shift of the lateral tibial plateau occurs in the opposite direction of the real pivot shift (seen in ACL tears). If the tibia is posterolaterally subluxed, the iliotibial band will reduce the knee as the IT band transitions from a flexor to an extensor of the knee. It is imperative to compare this test to the contralateral knee.

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Figure 5.9 Dial test in 90 degrees flexion. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

5.7 Examination of Related Areas Examination of the lower limb is complete with an examination of the joints above and below, which should be complete and thorough for any referred pain at the knee. Certain specific conditions affecting the knee joint should be kept in mind while examining the knee joint.

Examination of Related Areas

1. Deformities of the knee (i) Knock knee or genu valgum: This is the commonest deformity of the knee and is usually bilateral and idiopathic, and may be seen in rickets, rheumatoid arthritis, and other neurologic disorders. Radiographs are very helpful in this condition, and the child is usually seen at an interval of 3 months to monitor progress. Raising the inner heel may be helpful in some cases to relieve the strain, and stapling the inner side of the knee epiphysis may help in arresting the disorder. A low femoral osteotomy may be worth considering in cases where a caliper has been tried.

Figure 5.10 Bilateral genu varum (bow leg) deformity in both knees. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

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(ii) Bow legs (genu varum): This is usually seen as idiopathic (Fig. 5.10) or in rickets and certain epiphyseal injuries of the upper tibia. A special variety called Blount’s disease (Fig. 5.11) is seen in the West Indies when the posteromedial aspect of the proximal tibial epiphysis fails to grow normally. Clinically the deformity is the only symptom, and radiographs are very useful in these cases. Usually, these cases recover untreated, but sometimes closed osteoclasis of the tibia, stapling the outer side of the lower femoral epiphysis, or even an upper tibial osteotomy may be considered in certain cases.

Figure 5.11 Blount’s disease. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Examination of Related Areas

(iii) Hyperextension of the knee (genu recurvatum): This condition may be congenital or may be seen in rickets or cases of lax ligaments. The condition is mainly symptomless, and deformity is the main complaint. Treatment for this condition is done using calipers and treatment of the underlying cause. 2. Swellings of the knee (i) Traumatic synovitis: Here the fluid pushes the patella forward, which is seen very clearly on radiographs, and treatment is usually by quadriceps exercises along with a crepe bandage or back splint if necessary. (ii) Nontraumatic synovitis: Here the synovitis occurs without any injury. This may be seen in acute or chronic cases of inflammation or transient synovitis (Fig. 5.12).

Figure 5.12 Knee swelling, with obliteration of all the normal depressions around the knee and muscle wasting of the thigh. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

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(iii) Hemarthrosis: Without any obvious injury, this represents a case of hemophilia. The knee joint is filled within a matter of hours. Aspiration under sterile conditions will confirm the diagnosis. Quadriceps exercises and a crepe bandage or a back splint may be helpful in certain cases. (iv) Tuberculosis of the knee joint: This is usually the result of bloodborne infection and starts as synovitis which may progress to arthritis with fibrosis. Sinuses are fairly common as the knee joint is superficial. In the early stages, radiographs may show rarefaction. Gradually the joint space decreases when arthritis supervenes. In the early stages of the active disease, traction on a Thomas’ splint is very useful. In the healing stages, a weight-relieving caliper or a removable polythene splint is helpful. In the healed stage, Charnley’s arthrodesis (Fig. 5.13) using compression clamps is the method of choice.

Figure 5.13 TB Rt knee treated by Charnley’s arthrodesis. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

3. Ligament injuries Most ligament injuries occur when the knee is bent, and various classifications are given for this injury depending on which quadrant of the knee joint is involved. These injuries may be complete or partial tears and the knee is examined in three main ways: sideways tilting with the knee bent to about 30 degrees of flexion, anteroposterior gliding with the leg rotated medially, and laterally, and finally, rotation of the flexed knee tested in all directions. All of these movements are then compared with those of the other knee. Radiographs are very

Examination of Related Areas

useful when the ligament is avulsed with a piece of bone, and stress films are carried out when necessary. Partial tears are treated by aspiration of the hemarthrosis and a plaster cast or a back splint, to permit regular examination at weekly intervals. Complete tears are usually treated by operative intervention. The operative procedure may be carried out in 2 weeks with a generous incision. Repair of every torn structure is carried out, which is finally protected by an above-knee plaster with the knee joint kept in about 30 degrees of flexion. Various surgical operations are known for ligament injuries, and most importantly adhesions and instability are avoided by these procedures.

4. Meniscal injuries (i) Torn medial meniscus: This is the most commonly torn meniscus, and the tear may be in the anterior horn, posterior horn, or both. This torn part may be displaced inward into the knee joint, resulting in locking of the knee joint when the knee is extended, thereby blocking extension. An accurate history of a twisting force on a bent knee as seen commonly in footballers is of vital importance. Radiographs are normal, but arthrography may reveal the tear. It is very important to differentiate between true locking and pseudo-locking. Treatment is mainly conservative in the first instance by quadriceps exercises and manipulation when the knee is locked. Surgical treatment in the form of excision of the medial meniscus is indicated when the symptoms are recurrent or if the joint cannot be unlocked. (ii) Other meniscal lesions: These lesions must be kept in mind as they are seen less frequently. A torn lateral meniscus is less often seen on account of its greater mobility. An immobile meniscus is seen in the elderly, and a discoid lateral meniscus which is usually recognized by its characteristic loud clunk noise may occasionally be seen. Meniscal cysts are sometimes seen, and they most often occur in the lateral meniscus, where they are treated by excision of the lateral meniscus. 5. Extensor mechanism lesions

(i) Strains, avulsions, and ruptures: These may be seen in the resisted extension of the knee, and this presents in different ways depending on the age of the patient. When it is above the patella in the elderly, a transverse fracture of the patella in the middle-aged is indicated, and a torn patellar ligament in the younger age groups. Osgood–

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Schlatter’s disease is a commonly seen entity in children and is a variety of osteochondritis, when a tender bony lump may be felt over the tibial apophyses, and radiographs show fragmentation of the apophyses. Spontaneous recovery is often seen by restricting strenuous activity for a short period.

Figure 5.14 Habitual patellar dislocation due to multiple quad injections (note the absent groove). Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Examination of Related Areas

(ii) Recurrent dislocation of the patella (Fig. 5.14): This is commonly seen in adolescent children due to lax ligaments, weak muscles, or anatomic abnormalities. The dislocation is always to the lateral side, and treatment is usually conservative in the first few instances by rest and quadriceps exercises. Only when the dislocation is recurrent is an operation considered. Surgical treatment by lateral release and medial reefing is a soft tissue procedure with excellent results, and in some cases, realignment of the patellar tendon or even a patellectomy can be considered. Recurrent subluxation of the patella is more common than a recurrent dislocation, and it is treated along similar lines. (iii) Chondromalacia patellae: This is commonly seen in young adolescent girls with tenderness behind the patellae and is usually caused by softening of the articular cartilage behind the patellae. Skyline radiographs of the knee may be helpful in diagnosing the condition. Treatment is initially conservative by avoiding violent activity, with quadriceps strengthening exercises along with heat in the form of short-wave diathermy. In refractory cases, an operation can be considered.

(iv) Quadriceps contracture: Here the quadriceps muscle becomes fibrosed and shortened. This may be seen in children following injections into the anterior aspect of the thigh. The vastus intermedius is commonly involved, and treatment is by division of the affected muscle. 6. Other disorders of the knee

(i) Bursae: These are commonly seen in the prepatellar bursa (housemaid’s knee) or infrapatellar bursitis (clergyman’s knee) or semimembranosus bursa may occur due to constant repetitive friction.

(ii) Loose bodies: These may occur due to injury, degeneration, or inflammation and may be symptomless in many cases. Treatment by surgical removal is only considered when they cause symptoms such as locking (Fig. 5.15).

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Figure 5.15 Loose bodies of the right knee. Reprinted with the kind permission of Dr. Rajesh Botchu, Consultant MSK Radiologist, Royal Orthopaedic Hospital, Birmingham, UK.

(iii) Osteochondritis dissecans: This is usually caused by trauma when an osteochondral fracture remains ununited. The medial surface of the femoral condyle is a very common site for this to occur and is clearly seen on radiographs (Figs. 5.16 and 5.17). With time, spontaneous healing can occur, but when the healing is uncertain, then surgical drilling of the crater after excision of the loose fragment is advocated.

Figure 5.16 Osteochondritis dissecans. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Examination of Related Areas

Figure 5.17 Osteochondritis dissecans (classic site). Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

(iv) Osteoarthritis of the knee: This is fairly common, with the lower limb having a varus deformity along with pain and tenderness along the medial joint line. Radiographs (Fig. 5.18) are very useful in determining the extent of medial compartment narrowing, and conservative treatment is usually not satisfactory. When conservative treatment does fail, surgical treatment in the form of an osteotomy, arthrodesis, or arthroplasty can be carried out. In some select cases where the arthritis is mainly confined to the patellofemoral joint, a patellofemoral replacement may be carried out to relieve pain. (v) Charcot’s disease: This is usually caused by repetitive trauma to an insensitive joint when the joint becomes disorganized and lax with calcified masses in the capsule. Arthrodesis is usually very difficult in these cases, and a caliper is the treatment of choice, because of instability. (vi) Synovial osteochondromatosis: This is a condition that is seen in men above the age of 40 years. It usually affects bigger joints such as the knee. It presents as synovitis, and X-rays taken may show the condition (Fig. 5.19), but when not seen in the early stages, magnetic resonance imaging is useful for its diagnosis.

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Figure 5.18 Osteoarthritis of the knee. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Figure 5.19 Synovial osteochondromatosis. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

References 1. Sanders TL, Maradit Kremers H, Bryan AJ, et al. Incidence of anterior cruciate ligament tears and reconstruction: A 21-year populationbased study. Am J Sports Med, 2016, 44(6): 1502–1507.

References

2. Sanders TL, Pareek A, Barrett IJ, et al. Incidence and long-term followup of isolated posterior cruciate ligament tears. Knee Surg Sports Traumatol Arthrosc, 2017, 25(10): 3017–3023.

3. Kambhampati SBS, Vaishya R. Trends in Publications on the Anterior Cruciate Ligament Over the Past 40 Years on PubMed. Orthop J Sport Med, 2019, 7(7): 1–8. 4. Vaishya R,  Vijay V, Vaish A, Agarwal AK. A critical review of the management of partial tears of ACL. J Clin Orthop, 2017, 2(1): 27–30. 5. Vaishya R, Hasija R. Joint hypermobility and anterior cruciate ligament injury. J Orthop Surg (Hong Kong), 2013, 21(2): 182–184.

6. Lorenzzoni P, Radswiki T,  et al. Anterior cruciate ligament tear. Radiopedia, https://radiopaedia.org/articles/anterior-cruciateligament-tear.

7. Vaishya R,  Esin Issa A, Agarwal A, et al. Anterior cruciate ligament ganglion cyst and mucoid degeneration: A review. Cureus, 2017, 9(9): e1682. DOI 10.7759/cureus.1682 8. Desai VS, Wu IT, Camp CL, Levy BA, Stuart MJ, Krych AJ. Midterm outcomes following acute repair of grade III distal MCL avulsions in multiligamentous knee injuries. J Knee Surg, 2020, 33(8): 785–779. 9. Ellenbecker TS (ed.). Knee Ligament Rehabilitation, New York: Churchill Livingstone; 2000, 92–93.

10. Vaishya R, Agarwal AK, Ingole S, Vijay V. Current practice variations in the management of anterior cruciate ligament injuries in Delhi. J Clin Orthop Trauma, 2016, 7(3): 193–199.

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Chapter 6

Anterior Cruciate Ligament Injuries of the Knee

Abhishek Vaish and Raju Vaishya

Department of Orthopedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India

6.1 Introduction Sports injuries in the younger population are rising due to the increasing popularity of sports and an increase in awareness about health. An anterior cruciate ligament (ACL) is the most commonly injured ligament of the knee. It may be associated with other internal structural injuries of the knee, such as the meniscus, cartilage, and other ligaments. As ACL injuries mostly produce a dramatic and significant instability of the knee and affect the younger population, these have to be dealt with in time to restore the knee function and to restore their activities of daily living. We shall discuss the importance of ACL injuries, its burden, biomechanics of this ligament, and the management of its injuries, in this chapter. The importance of rehabilitation after an ACL injury is crucial for an excellent Introduction to Limb Arthrology Edited by K. Mohan Iyer Copyright © 2023 Jenny Stanford Publishing Pte. Ltd. ISBN 978-981-4877-99-2 (Hardcover), 978-1-003-37276-9 (eBook) www.jennystanford.com

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functional outcome and to avoid avoids knee stiffness. As these are the injuries involving young and active individuals, reinjury or failure of previous ligament reconstructions is also known and hence the rate of revision ACL surgeries has seen an increase recently. Chronic ACL insufficiency can cause damage to the articular cartilage and thus early degenerative arthritis, meniscal tears, and stretching of secondary stabilizers such as collateral ligaments.

6.2 Incidence

ACL injuries are much more common than posterior cruciate ligament (PCL) injuries. The age- and sex-adjusted annual incidence of ACL tears was 68.6 per 100,000 person-years [1], whereas the annual incidence of isolated, complete PCL tears was 1.8 per 100,000 [2]. There has been a steady increase in the interest and understanding of ACL injuries in the last four decades [3]. Mostly there is a complete tear of an ACL after a twisting injury of the knee and the partial tears of ACL are relatively rare and their incidence ranges from 10–28%. It is reported that there is a 15% to 66% chance of this lesion progressing to a complete tear and hence the partial tear must be managed appropriately [4].

6.3 Anatomy and Biomechanics

The ACL is composed of collagen fibers that are longitudinally oriented. It is an extra synovial but an intra-articular structure of the knee. Its blood supply comes primarily from the middle geniculate artery, and its nerve supply is through the posterior articular nerve (a branch of the tibial nerve). The approximate length of an ACL is 35 mm and has two principal bundles comprising an anteromedial (AM) bundle and a posterolateral (PL) bundle. The AM bundle provides anteroposterior stability to the knee whereas the PL bundle provides rotational stability to the knee. The AM bundle is tight in flexion, and the PL bundle is tight in extension. The AM and PL bundles are parallelly aligned in extension and cross each other in flexion. At 30-degree flexion, the tension is least on the ACL.

Clinical Presentation

The ACL can bear an ultimate load of 1700 ± 250 N, according to biomechanical studies. Risk factors: Risk factors for ACL tears include excessive demands on unconditioned knees, knee flexion angle during landing, limb alignment, notch size, and hormonal fluctuations. Joint hypermobility is also considered a contributor. Its prevalence is higher in females and Africans (than Caucasians) and decreases with age. Joint hypermobility is reported to be more common in patients with an ACL injury compared to the normal population, and hence, predisposes them to ACL injuries [5].

6.4 Clinical Presentation

A. History Most commonly patient presents with a history of an injury after playing sports. There is a history of twisting of the knee, classically as a sudden deceleration or cutting movements leading to hyperextension. The patient describes hearing or feeling a pop sound, followed by an inability to stand up immediately after this injury. There is immediate swelling of the knee and an inability to weight bear fully, on the injured knee. In chronic cases, the typical history of giving way of the knee and intermittent locking of the knee is seen.

B. Examination The injured knee is swollen with hemarthrosis, after acute injuries and the knee may be in an attitude of flexion. In chronic cases, there is often wasting of the thigh muscles, with or without knee swelling. Palpation of the knee may reveal mild raised local temperature, and the signs of fluid in the knee (e.g., cross fluctuations, ballottement, and patellar tap) may be positive. The knee movements are restricted in acute injuries and usually not in chronic cases. The ACL originates from deep within the notch of the distal femur. Its proximal fibers fan out along the medial wall of the lateral femoral condyle. The first ACL reconstruction surgery is attributed to Hay Groves in 1917 [6] (Fig. 6.1).

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Figure 6.1 ACL reconstruction. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

6.5 Special Tests To diagnose an ACL tear clinically requires some special tests, which are described below: 1. Lachman test It is performed with 30-degree flexion of the knee (Fig. 6.2). There is increased anterior excursion compared to the opposite knee. In acute injuries, there is a soft mushy endpoint.

Figure 6.2 Clinical photograph demonstrating the Lachman Test. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

Special Tests

2. Anterior drawer test It is performed with the knee flexed to 90 degrees (Fig. 6.3). With both hands placed behind the tibial condyles, the knee is pulled forward. In a positive test, there is an increased translation of the upper tibia anteriorly, compared to the opposite knee.

Figure 6.3 Clinical photograph demonstrating the Anterior Drawer Test. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

Figure 6.4 Clinical photograph demonstrating the pivot shift test. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

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3. Pivot shift test It is a dynamic test that is more diagnostic of ACL tear than the other described tests. However, intactness of medial collateral ligament and cooperation of the patient with full muscle relaxation are its prerequisites to perform this test. In this test, the patient lies in the supine position, and a combination of during a knee flexion from an extended position (Fig. 6.4). In an axial load and valgus force is applied by the examiner, a positive test (ACL tear), there is a subluxation of the lateral tibial condyle. 4. Objective tests

The laxity related to ACL tears can be objectively tested and recorded by various instruments like a knee ligament arthrometer KT-1000/ KT-2000 (Fig. 6.5), which can precisely quantify the ACL injuries and grading.

Figure 6.5 Clinical photograph demonstrating the knee ligament arthrometer. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

5. Radiological investigations (i) Plain radiographs are usually not helpful in the diagnosis of an ACL injury. However, associated fractures (avulsion, lateral femoral condyle, and Segond fractures) could be diagnosed and may provide a clue to the tear of the ACL.

Special Tests

(ii) Computed tomography (CT) is very useful and accurate in the diagnosis of avulsion bone fragment and undisplaced fractures of the condyles. (iii) Magnetic resonance imaging (MRI) is the most accurate investigation tool to diagnose an ACL injury, with a specificity and sensitivity of more than 90%. It is considered a gold standard test (Fig. 6.6). Several primary and secondary signs to diagnose an ACL tear on the MRI have been described [8]. A discontinuity in the ligament or an abnormal contour of the ACL, along with an empty notch sign are characteristics of an ACL tear. Mucoid degeneration of the ACL sometime resembles an ACL tear on the MRI and hence must be carefully evaluated [7].

Figure 6.6 An MRI image showing complete disruption of the ACL. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

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6.6 Natural History The intra-substance tear of the ACL rarely heals on its own, and the symptomatic instability often requires ACL reconstruction using a graft. However, the bony avulsion injuries, especially in adolescents, may heal spontaneously. The course of healing in ACL injuries is determined by many factors such as age, activity level, the extent of the injury, physiotherapy, and time since injury. People who do not give these injuries adequate time and environment to heal usually suffer from concomitant injuries (Figs. 6.7 and 6.8) to other structures in due time, such as cartilage (21–31%) and menisci (50– 70%). The other commonly associated injuries with ACL tears are O’Donoghue’s unhappy triad, Segond fracture, posteromedial corner injury of the knee, and meniscocapsular separation.

Figure 6.7 Arthroscopic view of a bucket handle tear of the medial meniscus in an untreated case of an ACL tear. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

Figure 6.8 Arthroscopic view of a posterior capsular tear in a chronic ACL tear. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

Treatment

6.7 Treatment The treatment of an ACL injury depends on the pre-injury activity level of the patient, age, and amount of instability. The treatment may range from conservative to operative management. A. Conservative Treatment

It includes aggressive rehabilitation, pain management, and counseling about activity levels. The patient’s motivation regarding physiotherapy should be assessed beforehand, and compliance should be checked on regular follow-up. Various specialized braces (Fig. 6.9) are available to provide stability to the knee.

Figure 6.9 Photograph of ACL knee brace. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

B. Operative The ACL reconstruction is an accepted and established surgical technique for ACL injuries and is now considered a gold standard in

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the management of symptomatic ACL tears. ACL reconstruction has been shown to restore joint stability, and improve functional outcomes. 1. Repair (isolated with or without augmentation) (i) Mid-substance tear: The results of a direct repair procedure are not very good, because the healing capacity of ACL is limited. Hence, some people have tried to augment the healing of a partially torn ACL by using an injection of mesenchymal cells (MSCs) and plateletrich plasma (PRP). (ii) Bony avulsion: Most commonly bony avulsion injuries of ACL occur in adolescent individuals, with an open physes, through the tibial attachment. These can be repaired using screws, staples, and sutures with good functional outcomes. This procedure can either be performed by an open or arthroscopic procedure. 2. Extra-articular reconstruction procedures There are various extra-articular procedures (McIntosh, Andrew, Losee). However, these procedures are not very popular nowadays. These are reserved mainly for children with ACL insufficiency, where an intraarticular procedure cannot be done due to open physes.

3. Intra-articular reconstruction procedures Surgeon preferences in ACL reconstruction differ considerably among arthroscopic surgeons. There is a majority consensus for using hamstring autograft (single bundle) with a suspensory fixation on the femoral side and an aperture fixation on the tibial side. Transportal technique of making the femoral tunnel and preservation of amputation stump are the preferred methods. However, differences exist over the timing of surgery, rehab after surgery, pain management, etc. [9, 10].

6.7.1 Timing of Surgery

It was earlier believed that the functional outcomes of ACL reconstruction are best achieved if the surgery is performed after the resolution of initial inflammation and achievement of the full range of motion. However, nowadays, there has been a change in this trend, and many ACL reconstructions are being performed soon after the initial injury. The only important factor which determines an excellent functional outcome is proper rehabilitation after an ACL reconstruction. It avoids the development of knee stiffness.

Treatment

6.7.2 Graft Selection Autografts have better chances of incorporation, revascularization, and healing compared to Allografts and are therefore preferred. The synthetic grafts that were popular in the 1980s have mostly gone into disrepute and are only being used infrequently. The most commonly used autografts are hamstring (Fig. 6.10) and bone-patellar-tendonbone graft (BPTB). Peroneal longus, tibialis anterior, quadriceps, and Achilles tendon grafts are the other lesser commonly used options. It has been documented that BPTB grafts have lesser chances of failure and laxity. However, this graft is associated with a high incidence of anterior knee pain, and there could be a fracture of the patella during its harvesting. Allografts are excellent alternatives; however, their availability is still not universally present and are expensive, and there could be a risk of disease transmission.

Figure 6.10 Clinical photograph of harvested hamstring tendons for ACL reconstruction. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

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Single vs. double bundle reconstruction: The majority of ACL reconstructions are being done using a single bundle of quadrupled hamstring grafts (fig. 11). However, some surgeons prefer to recreate the two native bundles of ACL (AM and PL bundles) by using the double bundle of the hamstring grafts for their reconstruction.

Figure 6.11 Clinical photograph of quadrupled hamstring tendon graft for ACL reconstruction. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

6.7.3 Graft Placement Accurate graft placement is crucial in ACL reconstruction (Fig. 6.12) surgery to achieve satisfactory functional outcomes and avoid failure. If the femoral tunnel is too anteriorly placed it reduces flexion and early failure of the graft and if made too posteriorly placed it causes the graft to be taut in extension and lax in the flexion leading to poor stabilization of the knee. Hence, an isometric placement of the graft provides the best outcomes. Most surgeons advocate placement of graft posterior to native ACL tibial insertion (near PL bundle) as the maximum stress on ACL is on the extension.

6.7.4 Graft Tensioning

Graft tensioning is important to avoid graft failure and for better joint kinematics. The tension is graft specific. However, this tension

Treatment

should be just sufficient to negate the Lachman test. If the graft is not cyclically preconditioned, it has shown to have a reduction in force by approximately 30 percent after fixation.

Figure 6.12 Arthroscopic view of reconstructed ACL using hamstring tendons. Clinical photograph reprinted with the kind permission of Raju Vaishya, Delhi, India.

6.7.5 Graft Fixation A sound fixation of the ACL graft is essential during its reconstruction surgery. It can be achieved either by:

(i) Direct fixation, using interference screws, staples, washers, cross pins (ii) Indirect fixation, using polyester tapes, suture post, titanium button

6.7.6 Graft Failure

A reconstructed ACL graft can fail through several mechanisms and reasons:

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(i) Fixation device failure: E.g., screw divergence, graft tunnel length mismatch, and slippage (ii) Auto/allograft failure: Creep, reduced strength, immune response (iii) Impingement (iv) Non-anatomical location of tunnels (v) Too aggressive rehabilitation, causing stretch out (vi) Infection

6.7.7 Rehabilitation

Functional outcomes after ACL surgery depend primarily on postoperative rehabilitation. The goal in the first two weeks after surgery is to attain full extension, flexion up to 90 degrees, and attain good quadriceps strength. The next two weeks are reserved to attain full flexion. Further two weeks are for attaining isotonic and isometric strengthening of quadriceps. Return to sports is usually aimed at six months.

6.7.8 Results

The results of ACL reconstruction surgery depend on numerous factors such as obesity, concomitant injuries, and the timing of surgery. Obesity leads to increased loading over the medial compartment leading to excessive shearing along with rotations. The articular cartilage wears out quicker as well as the reconstructed graft may stretch out faster. The ACL injuries are often associated with medial meniscal injuries. Although most patients get good to excellent results in the short-term after ACL reconstruction, its consequences in the long-term in prevention or acceleration of knee osteoarthritis (OA) are not yet well-defined. Most surgeons, therefore, prefer not to wait long after an ACL injury to do an anterior cruciate ligament reconstruction (ACLR), as delayed reconstruction is associated with secondary damages to the intra- and periarticular structures of the knee [11]. Chronic ACL insufficiency may sometime be associated with varus malalignment of the knee due to coexisting osteoarthritis (OA). A combined ACL reconstruction along with high tibial osteotomy (HTO) needs to be done in these cases to achieve success [12].

Recent Advances in ACL Reconstruction

An ACL reconstruction should be performed either in an acute setting or after the edema subsides and the patient gains a full passive range of motion for the best results. Chronic tears, after ACLR, have shown poor results compared to acute reconstructions as the latter is seldom associated with secondary injuries and degeneration.

6.7.9 Complications A. Intraoperative (i) (ii) (iii) (iv)

Inadequate length of the graft Blow out of posterior femoral condyle Graft Amputation Incorrect tunnel placement

B. Postoperative

(i) Extension lag (ii) Anterior knee pain (mainly with bone-patellar tendon-bone, or BTB, graft) (iii) Arthrofibrosis (joint stiffness) (iv) Recurrent or residual instability of the knee Revision ACL surgery: Revision ACL reconstruction may be required if the primary ACL reconstruction fails early or late due to various reasons. Early failure has been reported in about 10% of cases, within six months of the surgery and the late failures occur after one year, mainly due to recurrent or repeat injury.

6.8 Recent Advances in ACL Reconstruction

Biologics are the way ahead in medicine. There are various new modifications that have been tried along with the regular ACL reconstruction to enhance healing. This augmented ACL reconstruction has not shown significantly better results. Various newer substances used are bio-scaffolds such as hyaluronan, PRP, and mesenchymal stem cells. All these theoretically have proven to deliver growth factors such as platelet-derived growth factor (PDGF), transforming growth factor (TGF), and vascular endothelial growth factor (VEGF) to the injury site.

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References 1. Sanders TL, Maradit KH, Bryan AJ, et al. Incidence of anterior cruciate ligament tears and reconstruction: A 21-year population-based study. Am J Sports Med, 2016, 44(6): 1502–1507.

2. Sanders TL, Pareek A, Barrett IJ, et al. Incidence and long-term followup of isolated posterior cruciate ligament tears. Knee Surg Sports Traumatol Arthrosc, 2017, 25(10): 3017–3023.

3. Kambhampati SBS, Vaishya R. Trends in publications on the anterior cruciate ligament over the past 40 years on PubMed. Orthop J Sport Med, 2019, 7(7):1–8. 4. Vaishya R, Vijay V, Vaish A, Agarwal AK. A critical review of the management of partial tears of ACL. J Clin Orthop, 2017, 2(1): 27–30. 5. Vaishya R, Hasija R. Joint hypermobility and anterior cruciate ligament injury. J Orthop Surg (Hong Kong), 2013, 21(2):182–184.

6. Burnett QM, 2nd, Fowler PJ. Reconstruction anterior cruciate ligament reconstruction: historical overview. Orthop Clin North Am, 1985, 16(1), 143–157. 7. Radswiki T, Roberts D, et al. Anterior Cruciate Ligament Tear. Radiopedia. https://radiopaedia.org/articles/anterior-cruciateligament-tear

8. Vaishya R, Esin IA, Agarwal A, et al. Anterior cruciate ligament ganglion cyst and mucoid degeneration: a review. Cureus, 2017, 9(9): e1682. DOI: 10.7759/cureus.1682 9. Vaishya R, Agarwal AK, Ingole S, Vijay V. Current practice variations in the management of anterior cruciate ligament injuries in Delhi. J Clin Orthop Trauma, 2016, 7(3), 193–199.

10. Vaishya R, Agarwal AK, Ingole S, Vijay V. Current trends in anterior cruciate ligament reconstruction. Cureus, 2015, 7(11): e378, DOI: 10.7759/cureus.378 11. Vaishya R, Agarwal AK. Does anterior cruciate ligament reconstruction prevent or initiate knee osteoarthritis? A critical review. J Arthros Jt Surg, 2019, 6(3): 133–136. https://doi.org/10.1016/j.jajs.2019.04.001. 12. Vaishya R, Agarwal AK, Vijay V, Jha GK. Prospective study of the anterior cruciate ligament reconstruction associated with high tibial opening wedge osteotomy in knee arthritis associated with instability. J Clin OrthopTrauma, 2016, 7(4): 265–271.

Chapter 7

Examination of the Foot and Ankle

7.1 Inspection of the Foot This is done from the moment a patient enters the examining room. A deformed foot may be seen in a deformed shoe when the patient walks into the examining room. Certain examples are as follows: The shoes of a patient with a drop foot show scuffed toes due to scrapping the floor in the swing phase. Similarly, a patient with a toe-in shows excessive wear over the lateral border of the sole. Inspection is started in the normal manner with the counting of the toes, as in some cases an extra toe may be seen (supernumerary toe or digit). A disproportionately large great toe may be seen which is swollen or as a congenital anomaly. The normal foot when seen at rest has some degree of plantar flexion and inversion as opposed to spastic feet which show dorsiflexion and eversion. The normal foot has a dome due to the medial longitudinal arch, which extends between the first metatarsal and the calcaneus. This arch is abnormally high in pes cavus or may be absent in pes planus. Occasionally in children, the forefoot is seen to be deviated medially on the hindfoot to cause a forefoot adductus deformity. Introduction to Limb Arthrology Edited by K. Mohan Iyer Copyright © 2023 Jenny Stanford Publishing Pte. Ltd. ISBN 978-981-4877-99-2 (Hardcover), 978-1-003-37276-9 (eBook) www.jennystanford.com

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Observe if there are any changes in the color of the foot in weightbearing and non-weight-bearing positions. Diagnosis of arterial insufficiency may be thought of when the foot which was light pink when elevated is beet red on being lowered (dependent rubor). The skin of the foot is normally thick in weight-bearing areas such as the base of the first metatarsal head or the calcaneus. This may be increased in pathologic conditions when it is called a callosity as is seen in weight-bearing regions of the foot. The foot and the ankle are also examined for either unilateral or bilateral swelling. This may be seen in trauma, or cases of bilateral swelling may be seen in lymphatic obstruction in cardiac or pelvic pathology. This is normally seen just above the medial malleolus as pitting edema.

7.2 Palpation

7.2.1 Palpation of Bony Points 7.2.1.1 Medial aspect The head of the first metatarsal and the first metatarsophalangeal joint are palpable as the ball of the foot. Occasionally bony prominences may be palpated over the metatarsal head in certain conditions such as gout and bunions. The first metatarsal bone extends proximally as a flare at its base until the first metatarsocuneiform bone. Continuing proximally is the navicular bone which articulates distally with the three cuneiform bones, laterally with the cuboid bone, and proximally with the talus. Occasionally aseptic necrosis of the navicular may be seen as a tender area in children, and in some, an additional bone that is prominent and tender may be felt attached to the navicular. This is known as the accessory navicular bone. The head of the talus lies just proximal to the navicular, which becomes more prominent on the eversion of the ankle. Continuing with palpation over the medial side, the medial malleolus is felt as a prominence that articulates with one-third of the medial side of the talus. Continuing plantarward is the sustentaculum tali, which is a bony prominence providing attachment to the spring ligament and may cause pes planus, if deficient. The medial tubercle of the talus is a small bony prominence situated immediately posteriorly to the medial malleolus and serves as a point of insertion for the medial collateral ligament of the ankle.

Palpation

7.2.1.2 Lateral aspect The fifth metatarsal bone and the metatarsal joint are situated on the lateral side of the ball of the foot. The proximal part of the bone ends in a flare called the styloid process into which is inserted the tendon of the peroneus brevis. Just behind the styloid process is a groove on the cuboid in which the tendon of the peroneus longus runs to the medial plantar aspect of the foot. The calcaneus can be easily palpated subcutaneously just proximal along the lateral border of the foot. The peroneal tubercle is a bony prominence on the lateral surface of the calcaneus and lies just distal to the lateral malleolus. It separates the tendons of the peroneus brevis and peroneus longus as they pass around the lateral surface of the calcaneus. The lateral malleolus which is the distal end of the fibula is situated slightly distally and posteriorly compared with the medial malleolus. It contributes to the medial malleolus to form the ankle mortise which points 15 degrees laterally and is commonly involved in fractures. (i) Sinus Tarsi Area This is a depression that lies just anterior to the lateral malleolus and is filled with the extensor digitorum brevis and a pad of fat. The dome of the talus is palpated with the foot in plantarflexion and inversion (Fig. 7.1). A greater part of this dome is felt on the lateral side as compared with the medial side. Very rarely a defect may be palpable, as in osteochondritis dessicans. The inferior tibiofibular joint is located just proximal to the talus with the anterior tibiofibular ligament overlying this joint.

(ii) Area of the Hindfoot The bare part of the dome of the talus protrudes posteriorly from behind the ankle joint. The medial tubercle of the calcaneus which lies on the medial plantar surface of the calcaneus and is large and broad gives attachment to the abductor hallucis longus muscle medially and the flexor digitorum brevis and the plantar aponeurosis anteriorly. It may occasionally be seen as a bony spur that is tender on palpation. The medial tubercle of the calcaneum is weight-bearing while the lateral tubercle is not. In children, the posterior aspect of the calcaneus is tender, which is known as Sever’s epiphysitis.

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Figure 7.1 Brodie’s abscess talus. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

(iii) Plantar Surface

This is examined with the plantar surface of the foot facing the examiner. This surface is difficult to examine because of the fascial bands from the palmar aponeurosis which limit palpation of the bony prominences. Palpating from the calcaneus distally along the medial longitudinal arch of the foot toward the great toe, beneath the first metatarsal head is the flexor hallucis brevis tendon which has two sesamoid bones which may be inflamed in some cases giving rise to a sesamoiditis which is tender. Continuing palpation just lateral to the first metatarsal head, the transverse arch of the foot lies and is felt from the first to the fifth metatarsal head. Occasionally tenderness may be felt over the second metatarsal head in fractures which are quite common in the second metatarsal neck. Occasionally a callosity may be palpated over the fifth metatarsal head. At times a condition characterized by infarction and fracture of the metatarsal head also known as Freiberg’s infraction most often seen in the 2nd metatarsal (MT) head (Fig. 7.2).

Palpation

Figure 7.2 Freiberg’s disease. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

7.2.2 Palpation of Soft Tissue This is carried out in various zones:

Zone I: Head of First Metatarsal Bone This area is the site of a common deformity namely the hallux valgus and bunion. It is a deformity characterized by lateral deviation of the big toe, which in some cases may be so excessive that the big toe may overlap the second toe. In some cases, the first metatarsal may be deviated medially, in a condition called metatarsus primus varus. This may also form a projection of bone over the medial area of the first metatarsal head, and constant friction over this area may result in the development of a bursa. Sometimes gouty crystals (Fig. 7.3) may be deposited in the tissues about the joint, which can cause pain and deformity.

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Figure 7.3 Gouty tophus. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Palpation

Zone II: Navicular Tubercle and Talar Head As described previously, the plantar portion of the talar head articulates with the sustentaculum tali and the anterior part of the posterior aspect of the navicular. A Shepherd’s fracture. Fracture of the lateral tubercle of the posterior process of the talus (Fig. 7.4). The talar head which lacks support between these two articulations is supported by the tibialis posterior tendon and the spring ligament which extends from the sustentaculum tali to the navicular. An accessory navicular bone is an accessory bone of the foot that occasionally develops abnormally in front of the ankle toward the inside of the foot. This bone may be present in approximately 2–21% of the general population and is usually asymptomatic. When it is symptomatic, surgery may be necessary (Fig. 7.5).

Figure 7.4 Shepherd’s fracture. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

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Figure 7.5 OS naviculare screwed to the parent bone. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

This is clearly seen in the pes planus when this support is lost and the talar head displaces medially and plantarward stretching the spring ligament and the tibialis posterior to result in a loss of the longitudinal arch. This is clearly seen as a callosity that develops over the prominent talar head and results in a valgus angle of the calcaneus especially when viewed from the posterior aspect of the foot. Köhler disease is a rare bone disorder of the foot found in children between six and nine years of age. The disease was then found to belong to a group of conditions called  osteochondroses, which disturb bone growth at ossification centers and occurs during bone development (Fig. 7.6).

Palpation

Figure 7.6 Köhler disease. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Zone III: Medial Malleolus The deltoid ligament is a broad and strong ligament that lies on the medial side of the medial malleolus. Below the deltoid ligament is the medial collateral ligament of the ankle joint. In the depression between the posterior aspect of the medial malleolus and the tendoachilles are the following structures from anterior to posterior: tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial artery, and tibial nerve, and flexor hallucis longus tendon. The tibialis posterior tendon is very prominent when the patient inverts and plantarflexes the foot when it is visible as it passes behind and inferior to the medial malleolus. In cases of spasticity in poliomyelitis or meningomyelocele in which the other muscles around the ankle are weak, the tibialis posterior stands out as a strong chord causing a plantarflexion and inversion deformity of the foot. The flexor digitorum longus tendon lies just behind the tibialis posterior tendon which can be seen when the toes are flexed. The flexor hallucis longus tendon lies on the posterior aspect of the ankle

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joint where it forms a groove on the posterior aspect of the talus between the medial and lateral tubercles as it crosses the ankle joint. All of these tendons pass very close to each other and are protected by a synovial lining which causes pain when inflamed behind the medial malleolus. The posterior tibial artery normally runs between the tendons of the flexor digitorum longus and the flexor hallucis longus and is of clinical importance as it is the main blood supply to the foot. The tibial nerve runs just immediately posterior and lateral to the posterior tibial artery and is of clinical importance as it is the main nerve to the sole. The nerve and the artery are held to the tibia to form the tarsal tunnel which can be compressed to create neurovascular problems in the foot. The long saphenous vein is seen visibly anterior to the medial malleolus. This may be used for an intravenous infusion when the veins in the upper limb are inaccessible.

Zone IV: Dorsum of the Foot Between the Malleoli The important structures passing from the medial to the lateral side are as follows: the tibialis posterior tendon, the extensor hallucis longus tendon, dorsalis pedis artery, and extensor digitorum longus tendon. The tibialis anterior tendon is the most medial structure and also the strongest dorsiflexor and invertor of the foot. Weakness in it causes a foot drop. This can be tested easily by asking the patient to dorsiflex his foot when it becomes prominent as it inserts to the medial aspect of the base of the first metatarsal and the first cuneiform bone. The extensor hallucis longus tendon lies just lateral to the tibialis anterior tendon and is palpated by asking the patient to dorsiflex her great toe. This tendon is very useful in tendon transfers for a foot drop when it is transferred to the dorsum of the foot. The extensor digitorum longus tendon lies just lateral to the extensor hallucis longus as it lies at the ankle joint. Distally it splits into four slips each of which inserts into the dorsal part of the base of the distal phalanx of the toes. These tendons can be palpated when the toes are extended. The dorsalis pedis artery: This artery lies between the extensor hallucis longus and the extensor digitorum longus tendons as it passes to supply the foot. This artery may be affected by vascular disease. The tibialis anterior, extensor hallucis longus and extensor digitorum longus originate from the anterior compartment of the leg between the tibia and the fibula. This anterior compartment is

Palpation

enveloped by a strong anterior fascia covering the posterior tibia, the fibula, and the interosseous membrane, thus rendering it rigid. Sometimes in fractures of the tibia and fibula, a hematoma within the muscles may collect which causes pain within the anterior compartment of the leg causing necrosis of the muscles, nerves, and vessels and resulting in a foot drop. This is also called the anterior compartment syndrome.

Zone V: Lateral Malleolus The lateral collateral ligament lies on the lateral side and is not as strong as the medial deltoid ligament. It mainly consists of three parts: The anterior talofibular ligament is the first part of the ligament that is involved in an inversion sprain of the ankle joint. The second part of the ligament is the calcaneofibular ligament which is inserted into the lateral wall of the calcaneus. This part is involved only after the first part is also torn in injuries. If both these parts are affected it may lead to ankle instability. The third part is the posterior talofibular ligament which is inserted into the small posterior tubercle of the talus. This third part is very strong and prevents forward slippage of the fibula on the talus and is only involved in severe injuries of the ankle. Peroneus longus and brevis tendons: These two tendons pass over the lateral aspect of the calcaneus with the peroneal tubercle in between them. They are strong primary evertors of the ankle and are covered by a retinaculum that keeps them in place. When the retinaculum is deficient, it may result in snapping of the tendons and the snap is seen and felt audibly. The peroneus brevis tendon passes below the tubercle and is inserted into the tuberosity of the base of the fifth metatarsal, which may be pulled along with a flake of bone or may fracture when it is tender. Zone VI: Sinus Tarsi The sinus tarsi is commonly affected in ankle sprains, rheumatoid arthritis, or spastic paralysis. The extensor digitorum brevis tendon may be felt bulging out of the sinus tarsi when the patient extends his toes.

Zone VII: Head of the Fifth Metatarsal Os vesalianum is a rare accessory bone located proximal to the base of the fifth metatarsal in the peroneus brevis tendon (Fig. 7.7). A bursa is present just overlying the lateral side of the fifth metatarsal.

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This may be inflamed giving rise to a callosity called a “tailor’s bunion.”

Figure 7.7 Os Vesalius. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Zone VIII: Calcaneus The gastrocnemius and the soleus muscles form a common tendon called the tendoachilles, which is the strongest tendon in the body. This can be ruptured by a sharp blow or a laceration, which is painful and tender and in which case, the patient is unable to perform plantar flexion. The ruptured ends may retract leaving a palpable defect just above the posterior calcaneus. The tendon is tested by asking the patient to lie prone. The calf is squeezed to see if there is any plantarflexion. If it is diminished or absent, the tendon is ruptured. Osteoid Osteoma/Calcaneus: Osteoid osteoma of the calcaneus is rare and frequently misdiagnosed as arthritis because of similar symptoms. In addition, radiographic findings may be nonspecific,

Palpation

and magnetic resonance imaging (MRI) may show bone marrow edema and changes in adjacent soft tissue. MRI scans in all cases of calcaneal osteoid osteoma reported till 3 months after the injury exhibited a nidus (Fig. 7.8). The retrocalcaneal bursa lies between the tendoachilles and the posterior superior angle of the calcaneus. This can be inflamed in bursitis due to excessive friction over the bursa, such as with ill-fitting shoes.

Figure 7.8 Calcaneal osteoid osteoma treated by CT-guided curettage. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

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Calcaneal bursa: This is located superficially between the tendoachilles and the skin of the heel. This can be located by pinching the bursa between the examining fingers. Tarsal coalition: The most common coalitions occur across a joint between the navicular and calcaneus bones and talus and calcaneal bones (Figs. 7.9 and 7.10).

Figure 7.9 Calcaneonavicular bar. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Zone IX: Plantar Surface of the Foot The central bony prominence that is felt in the hindfoot is the medial tubercle of the calcaneus. Most of the muscles of the foot originate from it, and it should be examined for the presence of a bony prominence called a calcaneal spur, which is tender on palpation.

Plantar aponeurosis (plantar fascia): These are strong bands of fascia which originate at the medial tubercle of the calcaneus splaying out into the sole to be attached to the ligamentous structures near the metatarsal heads in the forefoot. The sole is normally smooth to palpation but may be nodular in plantar fascitis when it is painful. Continued palpation between the metatarsal heads for nodules or tenderness. An area of tenderness between the heads of the third and fourth metatarsals is commonly seen. It is called Morton’s neuroma.

Palpation

Figure 7.10 Talocalcaneal bar. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

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Zone X: Toes Certain pathological conditions that are commonly seen in the toes are as follows: (i) Claw toes: This is a condition that is commonly seen in pes cavus when the metatarsophalangeal joint is hyperextended along with hyperflexion of the proximal and distal interphalangeal joints. In this condition, callosities may develop over the dorsum of the toes and the metatarsal heads on the plantar side. (ii) Hammer toes: This is usually seen in the second toe and consists of hyperextension of the metatarsophalangeal and distal interphalangeal joints along with hyperflexion of the proximal interphalangeal joint. This is usually seen in patients with ill-fitting shoes. (iii) Corns: Soft corns are usually found due to the excessive moisture between the toes, especially between the fourth and fifth toes. Hard corns are usually felt on the dorsum of the flexed interphalangeal joint, usually the fifth toe. (iv) Ingrown toenails: The anterior corners of the lateral and medial sides of the toenail may dig into the surrounding skin resulting in pain, redness, and tenderness of the soft tissue.

7.3 Tests for Ankle Stability

Stability of the ankle joint depends on the integrity of structures on the medial and lateral sides (Fig. 7.11).

Figure 7.11 Unstable ankles. Reprinted with the kind permission of Mr. Magdi Greiss Whitehaven, Cumbria, UK.

Range of Motion

The most common stress affecting the ankle joint is inversion stress because of two reasons: (1) the medial malleolus is shorter than the lateral malleolus, thus permitting the talus to invert farther than it can evert, and (2) the ligamentous structures on the lateral side are three separate structures as compared with the deltoid ligament on the medial side. The anterior and posterior stability is tested by the drawer’s sign, making the patient sit down with his legs dangling down the edge of the table. One hand is placed over the distal tibia firmly, and the other hand is placed over the calcaneus. The distal tibia is pushed posteriorly while the calcaneus is pulled anteriorly to elicit the anterior drawer sign. Normally the anterior talofibular is tight in all positions, and the anterior drawer sign should be positive if there is an anterior forward movement of the talus on the tibia. Conversely, the ankle is tested for posterior stability.

7.4 Range of Motion

The normal range of movements at the foot and ankle are:

(i) Ankle movements: plantar flexion and dorsiflexion (ii) Subtalar movements: inversion and eversion (iii) Midtarsal movements: forefoot adduction and forefoot abduction (iv) Toe movements: flexion/extension

7.4.1 Active Range of Movements

Ask the patient to walk on his toes to test for dorsiflexion and ask him to plantarflex his foot and move his toes. Test for inversion by asking him to walk on the outer border of his foot, and to test for eversion ask him to walk on the inner border of his foot. These are quick active tests in the foot and ankle and the inability to perform any of these should make one test the passive range of movements.

7.4.2 Passive Range of Movements

(i) Ankle: Dorsiflexion –20 degrees and plantarflexion –50 degrees This is tested with the patient sitting at the edge of the table with

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the knees flexed so that the gastrocnemius is relaxed. Then the movements are tested between the talus and the tibia and fibula. To perform this, first, lock the subtalar joint onto the hindfoot in inversion and then plantarflex and dorsiflex the foot to get an idea of whether this movement is occurring at the ankle joint only. A decrease in the range of ankle movements may be seen in an extraarticular swelling such as edema following trauma or due to cardiac failure. An intra-articular swelling can also cause restriction of ankle movements such as fusion of the ankle joint or an ankle joint capsular contracture. (ii) Subtalar joint: Inversion –5 degrees and eversion –5 degrees

This is tested by holding the distal tibia with the patient sitting on the edge of the table and the calcaneus is held with the other hand and inverted and everted by holding the heel. (iii) Forefoot: Adduction –20 degrees and abduction –10 degrees

This is tested at the midtarsal joints, namely, the talonavicular joint and the calcaneocuboid joints. This is done by holding the calcaneus with one hand while the other moves the forefoot medially and laterally. Normally these movements are tested independently, though they can be tested in conjunction with inversion and eversion. When forefoot adduction is tested with inversion of the ankle, it is called supination, and when eversion is tested with forefoot abduction, it is called pronation. (iv) First metatarsophalangeal joint: Flexion –45 degrees and extension –80 degrees

This joint is extremely important in ambulation in the toe-off phase of gait. This movement may be markedly restricted in certain conditions such as a hallux rigidus or when the joint is fused.

7.4.3 Movements of the Lesser Toes

Claw toes may cause restriction of extension in the proximal and distal interphalangeal joints and flexion at the metatarsophalangeal joints, while hammer toes cause restriction of flexion in the distal interphalangeal joint, extension at the proximal interphalangeal joint, and flexion at the metatarsophalangeal joint.

Neurologic Examination

7.5 Neurologic Examination 1. Muscle Testing Dorsiflexors (i) Tibialis anterior – deep peroneal nerve – L4 (L5) This is tested by the patient sitting over the edge of the table. The patient tries to force his foot into plantarflexion and eversion with resistance is offered against the first metatarsal and shaft, during which, the muscle is palpated. (ii) Extensor hallucis longus – deep peroneal nerve – L5 This is tested by the resistance offered by the extension of the interphalangeal joint of the great toe over the distal part of the interphalangeal joint. If the finger is placed across the interphalangeal joint, then the extensor hallucis brevis is also tested. (iii) Extensor digitorum longus – deep peroneal nerve – L5 This is tested by asking the patient to sit over the edge of the table. The calcaneus is stabilized with one hand, and the other hand tests for extension of the toes against gradually increasing resistance. (iv) Extensor digitorum brevis: This muscle is tested as before along with the extensor digitorum longus. Its muscle belly can be palpated in the sinus tarsi where it bulges out. Plantar Flexors

(i) Peroneus Longus and brevis – superficial peroneal nerve – S1 Ask the patient to walk on the medial borders of her feet. This tests the function of both muscles simultaneously since they are evertors of the foot and the ankle. Passively they are tested by opposing plantar flexion and eversion, gradually increasing resistance against the fifth metatarsal head and shaft. (ii) Gastrocnemius and soleus – tibial nerve – S1, S2 The common tendon is tested by asking the patient to walk on his toes. (iii) Flexor hallucis longus – tibial nerve – L5 To actively test this muscle, observe the patient’s gait. This muscle functions in a smooth toe-off. Alternately, ask the patient to sit at the edge of the table, then ask her to bend or

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(iv) (v)

curl her great toe, while opposing this action with a gradually increasing resistance. Flexor digitorum longus – tibial nerve – L5 This test is carried out as above by asking the patient to bend or curl her toes. Tibialis posterior – tibial nerve – L5 This is tested by asking the patient to plantarflex and invert when he is sitting at the edge of the table. This motion is resisted when the tibialis posterior being stronger can deform the foot.

2. Sensation Testing

The L4 dermatome, crossing the knee joint, supplies the medial side of the leg to cover the skin medial to the crest of the tibia, medial malleolus, and medial side of the foot. The L5 dermatome covers the lateral side of the leg lateral to the crest of the tibia and the dorsum of the foot. The S1 dermatome covers the lateral border of the foot. 3. Reflex Testing

The main reflex to be tested is the Achilles tendon reflex. This is supplied by S1, which is a deep tendon reflex and is mediated through the gastrocnemius muscles. This is tested by reinforcing the reflex and asking the patient to clasp his hands while the test is carried out. If the patient is bedridden, then ask the patient to keep the leg on the opposite leg with the knee hanging. The tendon is put on stretch by dorsiflexion of the foot while the tendon is tapped at the ankle, which elicits the reflex. When the patient is lying prone in bed, flex the knee to 90 degrees and dorsiflex the foot while testing the reflex. If the ankle is swollen or too painful to test this reflex by tapping it, the patient can be asked to lie prone. The ball of the foot is held dorsiflexing the foot, and the reflex can be tested by striking the hammer on the fingers of the hand.

7.6 Special Tests 7.6.1 Gait

The simple definition of gait is “the person’s manner of walking.” It is the progression of the body from one point to another in an energy-efficient process involving synchronous joint and muscle

Special Tests

movements. The bipedal gait has enabled humans to use their hands and be stable in an upright position. Gait is divided into stance and swing phases which comprise 60% and 40%, respectively. The stance phase is further divided into: (i) (ii) (iii) (iv) (v)

Initial contact Loading response Mid-stance Terminal stance Pre-swing

The swing phase is divided into:

(i) Initial swing (ii) Mid-swing (iii) Terminal swing

There are five prerequisites of normal gait described by Perry in 1985 [1], and they include: (i) (ii) (iii) (iv) (v)

Stability instance Adequate foot clearance in swing Adequate step length Appropriate pre-positioning of the foot in terminal swing Energy conservation

These subdivisions of the gait cycle are difficult to differentiate in the clinical setting; however, the focus should be on the three rockers. Perry further described muscle actions during the stance phase by combining the initial contact and loading response as the first rocker. During the first rocker, the fulcrum and ground reaction force (GRF) is at the heel and progressively moves anteriorly by eccentric contraction of the anterior compartment muscles of the leg. The second rocker is the mid-stance phase and the GRF moves forward to become anterior to the knee; there is eccentric contraction of the plantar flexors. The third rocker is the terminal stance. As the heel begins to lift as a result of concentric contraction of the gastrocnemius and soleus complex the pivot point moves forward toward the metatarsal heads. Start by asking the patient to walk in their shoes with walking aid in their usual manner and note foot, knee, and hip movements. Pay attention to Perry’s rockers and note changes in normal gait phases. Ask the patient to walk on their tiptoes, heels, and inner and outer

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borders. Inability to walk in this fashion may correlate to various pathologies which will be described later in the chapter.

7.6.1.1 Common types of gait

(i) Antalgic: This is by far the most common gait pattern seen in orthopedic clinics. It is secondary to pain. There is a shortening of the stance phase on the affected side and shortened swing phase on the contralateral side. (ii) Equinus: Walking on tiptoes, e.g., plantarflexion contracture. (iii) Trendelenburg: Observed on the coronal plane. The hip abductors are either inactivated due to pain in the hip joint or are weak resulting in a drop of the pelvis on the contralateral side. This could further be confirmed by performing the Trendelenburg test. (iv) Stepagge/high step: The forefoot is the initial contact point and there is usually a slap as there is no eccentric contraction of the anterior leg compartment muscles resulting in uncontrolled plantarflexion of the foot, e.g., foot drop secondary to peroneal nerve palsy or tibialis anterior tendon rupture. (v) Short leg: Pelvic drop: The pelvis droops on the affected side. (vi) Scissoring: Legs cross over each other, e.g., adductor contracture in spastic cerebral palsy.

7.6.1.2 Walking aid

The type of walking aid and the side on which it is held should be noted. Gait should be assessed with and without walking aid if possible. You should also observe whether the walking aid is the right height for the patient and maintains the patient’s coronal and sagittal balance. (i) Shoes: Assess whether shoes are standard off-the-shelf or custom-made. Look for the pattern of wear, which is normally on the lateral aspect of the heel. Abnormal wear patterns including wear over the metatarsal heads may suggest an abnormal initial contact, e.g., leg-length discrepancy or tight Achilles tendon. Other abnormal patterns may be medial wear where there is excessive pronation, e.g., pes planus deformity. Always compare to the other side. Look inside the shoes for insoles and whether the patient bought them or a health professional recommended them.

Special Tests

(ii) Orthoses: Note the type of orthoses and whether it is corrective or accommodative. Describe the orthoses as seen and whether there are hinges or not.

7.6.2 Inspection

Always look for scars noting their locations and how well they have healed. Assess the quality of the skin and any signs of active infection or skin irritation. Look for discharging sinuses or weeping skin. 1. From the front

(i) Alignment: Assess alignment of the lower limbs and whether there is any pelvic obliquity suggestive of leg-length discrepancy. If there is a leg-length discrepancy then a screening of the spine should be done for deformities followed by the Galeazzi test to determine the site of discrepancy. (ii) Symmetry: Is the deformity bilateral and symmetrical suggestive of a systemic or global pathology or is it unilateral suggestive of previous trauma. (iii) Swelling and skin changes: If symmetrical could be secondary to systemic diseases such as Rheumatoid arthritis or peripheral vascular disease. If unilateral changes are present this could be due to trauma, venous thromboembolism (VTE), infection, stress fracture, or stress response (usually confirmed on an MRI scan). (iv) Callosities: Note the site and whether it is unilateral or bilateral. It is indicative of areas of abnormally increased pressure. (v) Ecchymosis: Observe it, especially on the plantar surface which is suggestive of Lisfranc injuries. (vi) Signs of peripheral vascular disease: Look for loss of hair, shiny skin, discoloration, or dusky toes. (vii) Active or healed ulcers: Note the depth and size as well as clinical signs of infection which may be present in patients with diabetic neuropathy. (viii) Inspection of toes: Look between the toes for areas of moisture, skin breakdown, or active infection suggestive of poor hygiene, vitamin D deficiency, fungal infections, and peripheral neuropathy. (ix) Hallux varus or valgus: Note the position of the great toe in relation to the lesser toes. Note whether there is an overlying bunion and whether the overlying skin is irritated or breaking down.

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(x) Overall width of the forefoot: This increases bunion and bunionette deformities. (xi) “Peek-a-boo sign”: Looking from the front, the medial heel pad is not normally seen; when seen it is a feature of cavovarus deformity. (xii) Increased intermetatarsal space: It can especially be observed between the second and third toes, indicating an enlarged bursa. 2. From the side

(i) Lesser toe deformities: Make a note whether there is overriding of the second toe over the great toe. Evidence of under-riding or overriding fifth toe suggests tightness of the extensor or flexor tendons, respectively. Look for a hammer deformity (flexion of the PIPJ), mallet toe (flexion of the DIPJ), or claw toe (hyperextension of the MTPJ, flexion of PIPJ, and DIPJ). It is of vital importance to note whether the deformities are flexible or rigid as this will impact whether a bony procedure will need to be added to a soft tissue procedure. (ii) Medial longitudinal arch: Flattening would suggest pes planus or a high arch (Fig. 7.12), which could be a feature of pes cavus. (iii) Position of the first ray: Note whether there is a plantar-flexed ray that could be driving hindfoot varus as in cavovarus deformity.

Figure 7.12 Clinical photograph showing the medial longitudinal arch flattening—pes planus. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Special Tests

3. From the back (i) Note whether the calves are of equal size suggestive of muscle atrophy in cases of neglected Achilles rupture or history of clubfoot.

(ii) First note the heel position, which is normally neutral. When the heel is in varus, an assessment of flexibility should be performed using the Coleman block test (described below under cavovarus foot). If the hindfoot is in the valgus, ask the patient to stand on tiptoes holding onto the wall for support; normally the heel should go into varus (Fig. 7.13) [2].

(iii) Observe if there are too many toe signs. Normally the lateral 1½ toes are seen from behind; however, if more toes are seen this is indicative of increased heel valgus angle as seen in acquired tibialis posterior insufficiency (Fig. 7.14). (iv) Observe metatarsus adductus in which there is increased lateral curvature of the foot.

Figure 7.13 Heel rise: Clinical photograph showing heel levels swing into varus in physiological flat feet. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

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Figure 7.14 Too many toes: Clinical photograph showing the right foot with five toes. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Figure 7.15 Anatomical landmarks: Clinical photograph of the lateral side showing 5 = 5th tarsometatarsal joint; PT = tertius; ST = sinus tarsi; PB = peroneus brevis; PL = peroneus longus. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Special Tests

7.6.3 Palpation Palpation starts with the assessment of temperature, always comparing to the other side. Temperature is increased in Charcot arthropathy and decreased in peripheral vascular disease (Figs. 7.15–7.17). Start palpation away from the area of maximum tenderness in an orderly manner ensuring all parts of the foot and ankle are examined. Having a system that is reproducible and organized is important for foot and ankle examination and comes with practice and experience.

Figure 7.16 Anatomical landmarks: Clinical photograph of the dorsum of the ankle and foot showing 1st TMTJ; 2nd TMTJ; 3rd TMTJ; TA = tibialis anterior; PT = peroneus tertius. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

7.6.4 Range of Movement Both active and passive movements are important to note. It is a good practice to compare them to the contralateral side as the normal range of motion varies between individuals but these are broad ranges of reference. Ankle dorsiflexion is usually about 0–20 degrees; this value is reduced in cases of tight Achilles tendon or anterior ankle impingement secondary to osteophytes. Ankle

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plantarflexion is usually about 0–45 degrees; this is usually reduced secondary to anterior capsule tightness seen in osteoarthritis.

Figure 7.17 Anatomical landmarks: Clinical photograph of the medial side showing M = medial malleolus; TP = tibialis posterior; N = navicular; 1 = first metatarsal. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Inversion and eversion normally take place at the subtalar joint. Inversion has been reported as a wide range of 0–35 degrees; this could be increased in lateral ligament laxity or reduced in cases of stiffness following injury or surgery. Eversion of 0–15 degrees on the other hand could be increased in medial ligament (deltoid) injury. Both inversion and eversion may be reduced in cases of tarsal coalition or advanced hindfoot arthritis. To test for passive ankle dorsiflexion (Fig. 7.18) and plantarflexion hold the lower leg just above the ankle joint with one hand, hold the heel in the other palm and place the foot on the forearm and push upward and downward. The measurements are from the neutral position and should always be compared to the other side. To passively assess subtalar movements (Fig. 7.19), place the index and thumb over the Tatar neck while cupping the heel with the other hand, moving the heel in the coronal plane to assess for inversion and eversion.

Special Tests

Figure 7.18 Clinical photograph showing passive dorsiflexion of the ankle. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Figure 7.19 Clinical photograph showing passive subtalar joint movement. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

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Movement of the first ray MTPJ should be assessed in cases of suspected arthritis and compared to the other side. Make a note of whether plantarflexion and dorsiflexion are painful through the range of movement or only at the extremes suggesting dorsal osteophytes or early degenerative disease. Assess the strength of the tibialis anterior by palpating the tendon and asking the patient to dorsiflex and invert against resistance (Fig. 7.20). The strength of the tibialis posterior can be assessed by palpating the tendon behind the medial malleolus and asking the patient to invert foot in plantarflexion against resistance (Fig. 7.21). Assess the strength of the peroneal tendon by asking the patient to evert against resistance while keeping the ankle in a neutral position (Fig. 7.22).

Figure 7.20 Clinical photograph showing the power of the tibialis anterior tendon. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

The power of the muscles should be documented using the Medical Research Council (MRC) grading system: Grade 0: No contraction or muscle movement Grade 1: Trace of contraction, but no movement at the joint Grade 2: Movement at the joint with gravity eliminated Grade 3: Movement against gravity, but not against added resistance Grade 4: Movement against an external resistance with less strength than usual Grade 5: Normal strength

Special Tests

Figure 7.21 Clinical photograph showing the power of the tibialis posterior tendon. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Figure 7.22 Clinical photograph showing the power of the peroneal tendon. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

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7.6.5 Vascular Examination A thorough vascular examination is required to assess the extent of potential risk secondary to peripheral vascular disease or diabetes. The presence of current or healed ulcers is a poor prognostic feature. Clear documentation of distal pulses must be made. If the dorsalis pedis or posterior tibial pulses cannot be palpated then a Doppler should be employed to assess flow (triphasic waveform is normal). The dorsalis pedis pulse can be palpated on the dorsum of the foot just lateral to EHL or medial to EDL. The posterior tibial artery is located just posterior to the medial malleolus. ABPI should be performed where normal is 0.9 to 1.3, a reading of higher than 1.3 is indicative of calcified vessels and poor flow, and 1.3. Toe pressures are more reliable and a systolic >40 mmHg is a predictor of healing.

7.6.6 Neurological Examination

It is of vital importance to assess the neurological status of the foot with clear documentation before and after any intervention. Loss of protective sensation as in diabetic neuropathy can lead to devastating ulceration that could become infected and lead to loss of limb. Loss of sensation that does not follow a dermatomal distribution and instead a stocking distribution is more in the keeping of diabetic or alcoholic neuropathy. Inability to feel the Semmes–Weinstein monofilament 5.07 is consistent with peripheral neuropathy [3]. Dull aches across the medial aspect of the foot with associated loss of sensation or tingling could be a sign of tarsal tunnel syndrome requiring further investigation. The five main sensory nerves to test are superficial peroneal, deep peroneal, tibial, sural, and saphenous.

7.6.6.1 Forefoot

(i) Medial and lateral sesamoiditis

∑ Localized tenderness over the medial and lateral sesamoids. ∑ Medial sesamoiditis may be a result of overload due to excessive pronation which might resolve with orthotics.

Special Tests

(ii) Morton’s neuroma (Fig. 7.23)





∑ Thumb index squeeze test: There is tenderness of the 3rd and/or 2nd intermetatarsal spaces when pressed using the index and thumb.

∑ Mulder’s click test (Fig. 7.24): Although commonly performed it is not very reliable. ∑ Dorsiflex the foot and squeeze the metatarsal head, a positive test is an audible click [4].

∑ Look for associated conditions such as lesser toe deformities, callosities, and tenderness on palpation of the MTPJ indicating synovitis. ∑ It is important to check for sensations at the tip of the toes and on the plantar aspect of the foot as this could be diminished in Morton’s neuroma.

Figure 7.23 Clinical photograph showing how to test for Morton’s neuroma by squeezing the third web space. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

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Figure 7.24 Clinical photograph showing how to elicit a Mulder’s click. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

(iii) Hallux valgus

∑ There is lateral deviation of the big toe. ∑ Assess for medial prominence and state of overlying skin changes from shoe pressure resulting in erythema or bursa. ∑ The big toe could be over or under-riding the second toe. ∑ Callosities at the IPJ indicate hyperpronation of the big toe when pushing off. ∑ Assess whether the deformity is correctable. ∑ Look for deformities of the lesser toes.

(iv) Hallux varus

∑ This could be idiopathic or iatrogenic. ∑ There is medial deviation of the big toe. ∑ Look for scars that may indicate overcorrection of previous hallux valgus. ∑ Range of movement is usually painless unless there is associated degenerative joint disease.

(v) Hallux rigidus

∑ Assess for dorsal prominence suggestive of dorsal osteophytes.

Special Tests





∑ Note the range of movement, crepitus, and pain. ∑ Pain could be throughout all ranges of motion or at the end of dorsiflexion or plantarflexion. The normal range of motion can be as high as 65–75 degrees and plantarflexion 5–15 degrees. ∑ It is very important to always compare to the contralateral side. ∑ Grind test: Axial compression and rotation of the big toe will result in pain.

(vi) Freiberg’s disease



∑ Although not very common, this condition should be suspected in young females complaining of forefoot pain centered on the second metatarsal head. ∑ Pain worsens on weight-bearing or on squeezing the second MTPJ (Fig. 7.25). ∑ In the early stages of the disease, pain is worsened with the distraction of the 2nd MTPJ while in the late stages it is worsened with compaction.

Figure 7.25 Clinical photograph showing tenderness in Freiberg’s disease. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

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(vii) Lesser toe deformities





∑ You should first identify the deformity and then assess whether it is flexible or fixed. ∑ Flexible deformities can be managed with tenotomies, fixed deformities require fusion and subluxed MTP joint requires osteotomies to reduce pressure on the metatarsal head. ∑ Dorsiflex the foot and re-assess flexibility of the toe deformities to relax the extrinsic muscles of the foot. (a) Mallet: MTPJ and PIPJ are normal, DIPJ flexion. This is indicative of a tight flexor tendon. (b) Hammer: MTPJ normal, PIPJ flexion, and DIPJ extension.

(c) Claw: MTPJ hyperextension, PIPJ, and DIPJ flexion. ∑ Anterior draw or digital Lachman test for plantar plate: Over time the plantar plate becomes insufficient and should therefore be assessed. Hold the proximal phalanx in 20–25 degrees of dorsiflexion relative to the metatarsal head, and apply dorsal translation in an attempt to sublux the MTPJ. A positive test is defined as 2 mm of dorsal displacement or 50% joint subluxation.

7.6.6.2 Midfoot (i) Arthritis



∑ This includes tarsometatarsal joints, naviculocueniform joint, talonavicular joint and calcaneocuboid joint. ∑ The patient will have tenderness overlying the respective joints with movement. ∑ To assess the midfoot (Fig. 7.26), grasp the ankle and proximal foot still with one hand, supinating and pronating the distal metatarsals with the other hand. ∑ Alternatively, move the metatarsal shafts up and down in the coronal plane while stabilizing the hindfoot and ankle.

(ii) Accessory navicular: Tenderness over the navicular bone in young females, which becomes inflamed at the site of the tibialis posterior insertion site.

Special Tests

Figure 7.26 Clinical photograph showing how to test for the ROM (range of movement) of the midfoot joint. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

7.6.6.3 Hindfoot 1. Ankle (i) Ankle impingement



∑ Look for antalgic gait, effusion, and pain on range of movement.

∑ In late stages or when secondary to previous trauma there may be associated deformity.

∑ Anterior impingement test (Fig. 7.27): Ask the patient to squat; a positive test will result in reduced ankle dorsiflexion compared to the contralateral side. ∑ Posterior impingement test: Pain on the posterior aspect of the ankle on passive plantarflexion (Fig. 7.28) is a positive test.

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Figure 7.27 Clinical photograph showing anterior impingement. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Figure 7.28 Clinical photograph showing passive dorsiflexion of the ankle will result in ankle pain posteriorly. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Special Tests

(ii) Plantar fasciitis

∑ Palpate for tenderness over the plantar medial aspect of the calcaneum.

∑ It is very important to assess for gastrocnemius complex tightness.

∑ Silfverskiold test (Figs. 7.29 and 7.30): This test can be done with the patient supine or prone, although if the patient is able to lie prone it is easier to compare to the other side. Note the degree of ankle dorsiflexion with knees extended and flexed. If there is a reduction in ankle dorsiflexion with the knee extended and flexed then gastrocnemius and soleus are both tight and Achilles tendon release is required to regain motion. If dorsiflexion is limited with knee extended but improves with knee flexion then the gastrocnemius only is tight [5].

Figure 7.29 Clinical photograph showing Silverskiold test to assess ankle dorsiflexion with the knee extended. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

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Figure 7.30 Clinical photograph showing Siverskiold test with the knee flexed to 90 degrees. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

(iii) Cavovarus deformity



∑ Look for tibialis anterior weakness during the swing phase of the gait assessment. ∑ Look for toe deformities and recruitment of EHL resulting in cock up toes. ∑ Assess the strength of the muscles (weak tibialis anterior and peroneal muscles). ∑ Shoes would have excessive lateral wear. Look for hindfoot alignment from behind, which will be in varus, and the “peeka-boo” sign. ∑ Look for plantarflexion of the forefoot by examining the foot with the patient supine. ∑ Coleman block test (Fig. 7.31): With the patient standing, a one-inch block is placed on the lateral aspect of the foot freeing up the plantar-flexed first ray and eliminating the contribution of the forefoot pronation. A flexible hindfoot will correct to neutral or valgus. A spine examination is also required to be completed to look for scoliosis and signs of spine dysraphism.

Special Tests

Figure 7.31 Clinical photograph showing Coleman block test. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

(iv) Pes planus







∑ From the side: The medial longitudinal arch is reduced (Fig. 7.12), inability to introduce the first palmar crease of the index finger under the arch. ∑ From behind: “Too many toes” sign, more than the normal 1½ toes (Fig. 7.14). The hindfoot will be in valgus, ask the patient to stand on tiptoes while holding onto the wall and see if the hindfoot (Fig. 7.13) corrects to the neutral or varus position. If the patient is able to stand on both tip toes then ask them to stand on each tip toes of each foot to assess the strength of the tibialis posterior tendon. Inability to perform single heel rise is indicative of tibialis posterior insufficiency. Patients may be able to stand on tiptoes but are unable to repeat more than five times in quick succession which would mean weak tibialis posterior muscle. ∑ Jack’s test (Fig. 7.32): Assess the flexibility of pes planus. The patient’s weight-bearing passive dorsiflexion of the big toe MTPJ (Fig. 7.33) will result in an increase in the medial longitudinal arch concavity enabling you to insert the distal phalanx of the index finger under the medial arch. ∑ Perform the Silfverskiold test (described above) to look for Achilles tendon tightness.

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Figure 7.32 Clinical photograph showing Jack’s test, which demonstrates the inability to pass more than the tip of the index finger under the medial arch of the foot. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Figure 7.33 Clinical photograph showing Jack’s test by dorsiflexing the big toe the examiner is able to pass distal phalanx under the medial arch of the foot. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Special Tests

(v) Achilles rupture

∑ Feel for a palpable gap and check for bruising. ∑ In chronic ruptures, active ankle plantar flexion will be weak and passive ankle dorsiflexion will be increased. ∑ With the patient in prone position, assess for increased resting ankle dorsiflexion and perform the Thompson test (Fig. 7.34). ∑ Thompson test: It is performed with the feet off the edge of the couch the calf is squeezed halfway up the leg and lack of ankle plantarflexion indicated a positive test and rupture [6].

Figure 7.34 Clinical photograph showing how to elicit the Thompson test. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

(vi) Tarsal coalition

∑ Loss of internal rotation of the subtalar joint results in rigid movement during the gait cycle. ∑ Patients are unable to walk on the outer border of their feet. ∑ From the side look for flattening of the medial longitudinal arch. ∑ From behind look for hindfoot alignment (valgus) and “too many toes” sign.

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∑ There is a reduction of subtalar joint movement. ∑ Jack’s test: Arch does not reconstitute. Hindfoot does not correct on tiptoeing. ∑ Perform the Silfverskiold test to look for contracture of the Achilles tendon.

(vii) Ankle instability





∑ Assessment should start by performing the Beighton score to assess for generalized laxity: a score of 5 or more out of 9 is considered a sign of generalized laxity. A point is awarded for each of the following:  Passive dorsiflexion and hyperextension of each fifth MCP joint beyond 90 degrees  Passive apposition of each thumb to the flexor aspect of the forearm  Passive hyperextension of the elbow beyond 10 degrees  Passive hyperextension of each knee beyond 10 degrees  Active forward flexion of the trunk with the knees fully extended so that the palms of the hands rest flat on the floor ∑ Ask the patient to flex their knee to 90 degrees to relax the gastrocsoleus complex. To test the competency of the ATFL (anterior talofibular ligament, Fig. 7.35) plantarflex the ankle to 10 degrees; grip the distal tibia with one hand to stabilize and grasp the heel with the other hand, while stabilizing the tibia pull the foot forwards and note the degree of forward translation. A positive test is when there is no firm endpoint or increased anterior translation compared to the uninjured side. A dimple sometimes is seen (dimple or suction sign) indicating ATFL compromise. To test the competency of the CFL (calcaneofibular ligament), repeat the test with the ankle in a dorsiflexion position. ∑ Talar tilt test: Ensure the gastrocsoleus complex is relaxed by flexing the knee to 90 degrees, tilting the talus from side to side, and comparing it to the uninjured side. The absence of a firm endpoint is indicative of a combined injury to ATFL and CFL.

Special Tests

Figure 7.35 Clinical photograph showing the anterior draw test. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

(viii) High ankle sprain: Look for bruising and swelling. There are multiple tests to assess for a syndesmosis injury.









∑ Cotton’s test: There is an excessive translation of the talus from medial to lateral in the ankle mortise. ∑ Crossed-leg test (Fig. 7.36): Ask the patient to sit with the middle of the injured leg across the top of the opposite knee. Pressure is applied to the medial aspect of the proximal tibia and fibula at or near the knee to apply shear strain to the distal syndesmosis ligaments. A positive test will result in pain in the ankle. ∑ External rotation test (Fig. 7.37): Ask the patient to sit at the edge of the couch with the knee and hip flexed to 90 degrees. With one hand stabilize the leg halfway down the shin and with the other hand externally rotate the ankle. A positive test will result in pain in the ankle. ∑ Fibula translation (Fig. 7.38): With the patient in a supine position, hold the fibula with the thumb and index finger while translating anteriorly and posteriorly in the sagittal plane. ∑ Squeeze (Hopkin’s) test: with the patient supine squeeze the middle of the lower leg between the palms of both hands (Fig. 7.39).

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Figure 7.36 Clinical photograph showing the crossed-leg test. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Figure 7.37 Clinical photograph showing the external rotation test. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Special Tests

Figure 7.38 Clinical photograph showing fibular translation. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

Figure 7.39 Clinical photograph showing squeeze (Hopkins) test. Reprinted with the kind permission of Mr. Maneesh Bhatia, Leicester, UK.

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(ix) Systemic conditions



∑ Diabetic neuropathy: It is of vital importance to thoroughly assess the neurovascular status of the foot and look for ulcerations. In the presence of an ulcer, you must note any clinical signs of infection and depth. Look for asymmetrical deformities suggestive of Charcot arthropathy. ∑ Rheumatoid arthritis: Start the examination from the ankle first and proceed distally. Assess skin condition for fragility and presence of rheumatoid nodules. Look for symmetrical deformities; hindfoot alignment (valgus) and forefoot pronation and abduction. Medial and lateral malleoli swelling secondary to tenosynovitis of the tibialis posterior and peroneal tendons. Note the presence of hallux valgus and lesser ray deformities e.g. hammer or claw toes and any callosities over the joints or on the plantar aspect. Assess movement of the ankle and subtalar joints noting any restrictions.

2. Ankle Joint

The ankle joint is a hinged synovial joint and it connects the distal ends of the tibia and fibula with the proximal end of the talus. The articulating surface is the trochlea of the talus, which is formed by the lateral and medial malleolus of the tibia and the fibula. The proximal articular outermost layer of the ankle joint is made by the articular facets of the lower end of the tibia consisting of its medial malleolus and the lateral malleolus which are bound by the inferior transverse tibiofibular ligament. These three together create a deep tibiofibular socket (also termed “tibiofibular mortise”). The distal articular outermost layer of the ankle joint is composed of the articular facets on the upper, medial, and lateral aspects of the body of the talus. The articulating surfaces are formed by the body of the talus which fits snugly into the mortise formed by the bones of the leg. The body of the talus presents three articular surfaces: A superior pulley-shaped articular surface (trochlear surface) that articulates with the inferior aspect of the lower end of the tibia. The medial comma-shaped articular surface articulates the lateral aspect of the medial malleolus forming the lateral triangular articular surface which articulates the medial aspect of the lateral malleolus. The wedge-shaped body of the talus fits into the socket above. The socket

Special Tests

provides flexibility to the tibiofibular ligaments and the fibula, which permits slight movements of the fibula at the superior tibiofibular joint. A. Solidity of the ankle joint

The trochlear surface on the superior aspect of the body of the talus is wider in front than behind. During dorsiflexion, the ankle joint of the anterior wider part of the trochlea moves posteriorly and fits correctly into the tibiofibular mortise, thus joint is stable. During plantar flexion, the narrow posterior part of the trochlea does not fit correctly in the tibiofibular mortise, thus the joint is unstable during plantar flexion. Variables that keep the solidity of the ankle joint are as follows:

(i) Close interlocking of its articular surfaces (ii) Strong medial and lateral collateral ligaments (iii) Deepening of tibiofibular socket posteriorly by the inferior transverse tibiofibular ligament (iv) Tendons (4 in front and 5 behind) crossing the ankle joint (v) Other ligaments of the joint The depth of the superior articular socket is contributed to the downward projection of the medial and lateral malleoli and the transverse tibiofibular ligament. Anatomically, two factors tend to displace the tibia and fibula forward over the talus: (i) The forward pull of tendons passes from the leg to the foot (ii) Pull of gravity, when the standing line of gravity falls in front of the ankle joint However, the following factors are responsible for the prevention of displacement:

(i) The talus is wedge-shaped, being wider anteriorly (ii) The posterior border of the lower end of the tibia is prolonged downward (iii) Ligamentous structures B. Joint capsule

The articular capsule surrounds the joints and is attached (a) above to the borders of the articular surfaces of the tibia and malleoli and (b) below to the talus around its upper articular surface.

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∑ Anteriorly: The joint capsule is a broad, thin, and fibrous layer. ∑ Posteriorly: The fibers are thin and run mainly transversely, blending with the transverse ligament. ∑ Laterally: The capsule is thickened and attaches to the hollow on the medial surface of the lateral malleolus.

The joint capsule is thin in the front and behind to enable hinge movements and thick on either side where it combines with the collateral ligaments. It encompasses the joint entirely. It is connected to the articular margins of the joint all around with two exceptions:



∑ Posterosuperiorly: It is connected to the inferior transverse tibiofibular ligament. ∑ Anteroinferiorly: It is connected to the dorsum of the neck of the talus at some distance from the trochlear surface.

C. Synovial membrane

∑ The synovial membrane extends superiorly between the tibia and fibula as far as the interosseous tibiofibular ligament. ∑ The synovial membrane lines the inner surface of the joint capsule but ends at the periphery of the articular cartilages. ∑ A small synovial process goes upward into the inferior tibiofibular syndesmosis.

D. Ligaments

The essential ligaments of the ankle joint are the capsular ligament and the medial and lateral collateral ligaments. (i) Medial ligament







∑ The medial ligament (or deltoid ligament) is attached to the medial malleolus (a bony prominence projecting from the medial aspect of the distal tibia). ∑ The deltoid ligament is an extremely triangular ligament on the medial side of the ankle, compensating for the shortness of the medial malleolus. ∑ It consists of an apex attached to the tip and margins of the medial malleolus and a base, which fan out, attaching to three tarsal bones, namely the talus, calcaneus, and navicular bones. ∑ The primary action of the medial ligament is to resist overeversion of the foot.

Special Tests





∑ It splits into two parts, superficial and deep. Above, both the parts have a common connection to the apex and margins of the medial malleolus while below, the connection of superficial and deep parts differs. ∑ The superficial part has its fibers split into three parts:

(a) The anterior fibers (tibionavicular) are connected to the tuberosity of navicular bone and the medial (b) The middle fibers (tibiocalcanean) are connected to the entire length of sustentaculum tali (c) The posterior fibers (posterior tibiotalar) are connected to the medial tubercle and the adjoining part of the medial surface of the talus

(ii) Lateral collateral ligament

The lateral collateral ligament is composed of three parts:

(a) Anterior talofibular ligament (ATFL) ∑ Description: Flat weak band that extends anteromedially and is the most commonly damaged ligament of the ankle ∑ Proximal attachment: Lateral malleolus ∑ Distal attachment: Neck of the talus ∑ Role: Restrain anterior displacement of the talus with respect to the fibula and tibia (b) Posterior talofibular ligament (PTFL) ∑ Description: Thick, fairly strong band that runs horizontally medially; is under greater strain in full dorsiflexion of the ankle; and is rarely injured because bony stability protects ligaments when the ankle is in dorsiflexion ∑ Proximal attachment: Malleolar fossa of the fibula ∑ Distal attachment: Lateral tubercle of the talus ∑ Role: Forms the back wall of the recipient socket for the talus’ trochlea. It also resists posterior displacement of the talus. (c) Calcaneofibular ligament (CFL) ∑ Description: Round cord that passes posterioinferiorly ∑ Proximal attachment: Tip of lateral malleolus ∑ Distal attachment: Lateral surface of the calcaneus ∑ Role: (a) Aids talofibular stability during dorsiflexion;

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(b) Restrain inversion of the calcaneus with respect to the fibula; also prevents talar tilt into inversion

(iii) Anterior tibiotalar ligament

∑ Proximal attachment: Medial malleolus ∑ Distal attachment: Head of the talus ∑ Role: Reinforces ankle joint control of eversion and plantarflexion

(iv) Posterior tibiotalar ligament

∑ Distal attachment: Talus posteriorly ∑ Role: Control dorsiflexion

(v) Tibionavicular ligament

∑ Description: Forms most anterior part of the deltoid ligament ∑ Distal attachment: Dorsomedial aspect of navicular ∑ Role: Reinforces ankle joint

(vi) Tibiocalcaneal ligament

∑ Description: Very thin ligament ∑ Distal attachment: Sustentaculum tali ∑ Role: Reinforces ankle joint

The Ankle ‘Ring’ The ankle joint and associated ligaments can be visualized as a ring in the coronal plane:

∑ The upper part of the ring is formed by the articular surfaces of the tibia and fibula. ∑ The lower part of the ring is formed by the subtalar joint (between the talus and the calcaneus). ∑ The sides of the ring are formed by the medial and lateral ligaments.

A ring, when broken, usually breaks in two places (the best way of illustrating this is with a polo mint—it is very difficult to break one side without breaking the other). E. Relations of the ankle joint

Anteriorly, from the medial to the lateral side, the ankle joint is related to these structures:

Special Tests



∑ Tibialis anterior ∑ Extensor hallucis longus ∑ Anterior tibial artery ∑ Deep peroneal nerve ∑ Extensor digitorum longus ∑ Peroneus tertius

Mnemonic: The Himalayas Are Not Dry Tablelands. Posteriorly, from the medial to the lateral side, the ankle joint is related to these structures: ∑ Tibialis posterior ∑ Flexion digitorum longus ∑ Posterior tibial artery ∑ Posterior tibial nerve ∑ Flexor hallucis longus Mnemonic: The Doctors Are Not Here. F. Muscles

(i) Posterior compartment (superficial) (a) Gastrocnemius Action: Plantarflexion when the knee is extended; flexion of the knee raises the heel during walking Proximal attachment: The lateral head is from the lateral aspect of the lateral femoral condyle; the medial head is from the posterior surface of the femur superior to the medial femoral condyle Distal attachment: To the posterior surface of the calcaneus via the calcaneal tendon (Achilles tendon) Innervation: Tibial nerve (S1–S2) (b) Soleus

Action: Plantar flexion and steadying of the leg on the foot Proximal attachment: Posterior aspect of the head of the fibula, superior ¼ posterior surface of the tibia, soleal line and medial border of the tibia (c) Plantaris

Action: It weakly assists gastrocnemius in plantarflexion

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Proximal attachment: Inferior end of the lateral supracondylar line of the femur and the oblique popliteal ligament (ii) Posterior compartment (deep) (a) Tibialis posterior

Action: Plantarflexion and inversion; it supports the medial longitudinal arch Proximal attachment: Interosseous membrane and the posterior surface of the tibia inferior to the soleal line at its posterior surface Distal attachment: The navicular tuberosity, cuneiform, cuboid, and the bases of the 2nd to 4th metatarsals Innervation: Tibial nerve (L4–L5) (b) Flexor digitorum longus

Action: Plantarflexion and flexion of the lateral four digits; it also supports the longitudinal arch Proximal attachment: Medial part of the posterior surface inferior to the soleal line and the broad tendon to the fibula Distal attachment: Into the bases of the distal phalanges, 2nd to 4th digits Innervation: Tibial nerve (S2–S3) (c) Flexor hallucis longus

Action: Weak plantarflexion along with flexion of the big toe at all its joints; it also supports the medial longitudinal arch Proximal attachment: Inferior ⅔ of the posterior surface of the fibula along with the inferior part of the interosseous membrane Distal attachment: Base of the distal phalanx of the big toe (iii) Lateral compartment (a) Peroneus brevis

Action: Weak plantarflexion and eversion Proximal attachment: Inferior ⅔ of the lateral surface of the fibula Distal attachment: Dorsal surface and tuberosity of the base of the 5th metatarsal Innervation: Superficial peroneal nerve (superficial fibular nerve) (b) Peroneus longus

Action: Weak plantarflexion, eversion, and also supports the transverse arch

Special Tests

Proximal attachment: Head and superior ⅔ of the lateral surface of the fibula Distal attachment: Base of the 1st metatarsal and medial cuneiform Innervation: L5–S2 (iv) Anterior compartment (a) Tibialis anterior

Action: Dorsiflexion, inversion, and support of the medial longitudinal arch Proximal attachment: Lateral condyle of the tibia and superior ½ of the lateral surface of the tibia and the interosseous membrane Distal attachment: Medial and inferior surfaces of the medial cuneiform and the base of the 1st metatarsal Innervation: Deep peroneal nerve (deep fibular nerve), L4–L5 (b) Extensor digitorum longus

Action: Dorsiflexion and extension of the lateral four digits Proximal attachment: Lateral condyle of the tibia along with the superior ¾ of the anterior surface of the interosseous membrane Distal attachment: Middle and distal phalanges of the lateral four digits (c) Extensor hallucis longus

Action: Dorsiflexion of the big toe Proximal attachment: Middle part of the anterior surface of the fibula and the interosseous membrane Distal attachment: Dorsal aspect of the base of the distal phalanx of the big toe Innervation: L5–S1 (d) Peroneus tertius

Action: Dorsiflexion and aids eversion Proximal attachment: Inferior ⅓ of the anterior surface of the fibula and the interosseous membrane Distal attachment: Dorsum of the base of the 5th metatarsal G. Arterial and nerve supply

(i) Arterial supply: It is by the malleolar branches of anterior tibial, posterior tibial, and peroneal arteries.

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(ii) Nerve supply: It is by the branches of deep peroneal and tibial nerves (the segmental innervations are by L4, L5; S1, S2 spinal sections). H. Movements

(i) Dorsiflexion

Principle muscles: Tibialis anterior Accessory muscles: (a) Extensor digitorum longus, (b) extensor hallucis longus, and (c) peroneus tertius (ii) Plantar flexion

Principle muscles: (a) Gastrocnemius and (b) soleus Accessory muscles: (a) Plantaris, (b) tibialis posterior, (c) flexor hallucis longus, and (d) flexor digitorum longus Note: The ankle joint is stable in dorsiflexion and shaky in plantar flexion. The dorsiflexion is restrained by the L4 and L5 spinal segments and plantar flexion by the S1 and S2 spinal sections. 3. Ankle Sprains

Excessive stretching and/or tearing of ligaments of the ankle joint is known as an ankle sprain. Ankle sprains are normally caused by falls from height or spins of the ankle. When the plantar-flexed foot is excessively inverted, the anterior and posterior talofibular and calcaneofibular ligaments are stretched and torn. The ATFL is most commonly torn. When the plantar-flexed foot is excessively everted, the deltoid ligament does not get torn; however, it results in an avulsion fracture of the medial malleolus. Inversion sprains are much more common than eversion sprains. 4. Dislocations of the Ankle

Dislocations of the ankle joint are uncommon as it is quite a stable joint because of the tibiofibular mortise. However, whenever a dislocation takes place, it is constantly escorted by a fracture of one of the malleoli.

A. Pott’s fracture (fracture dislocation of the ankle) It takes place when the foot is caught in a rabbit hole and everted forcibly. There will be

∑ Oblique fracture of the lateral malleolus because of internal rotation of the tibia

Special Tests



∑ Transverse fracture of the medial malleolus as a result of pull by the powerful deltoid ligament ∑ Fracture of the posterior margin of the lower end of the tibia (third malleolus) because it is carried forward

These phases are also referred to as first, second, and third degrees of Pott’s fracture, respectively. The third degree of Pott’s fracture is also termed trimalleolar fracture. Optimum position of the ankle: The optimum position of the ankle is one where the ankle joint is in slight plantar flexion. Understanding this position is important for using a plaster cast in the ankle region. B. Superior and inferior tibiofibular joints









∑ The superior joint is the synovial plane joint whereas the inferior joint is a syndesmosis. ∑ The proximal tibiofibular articulation (also called the superior tibiofibular joint) is an  arthrodial  joint  between the  lateral condyle of the tibia and the head of the fibula. ∑ The contiguous surfaces of the bones present flat, oval facets, covered with  cartilage  and connected by an  articular capsule and the anterior and posterior ligaments. ∑ When the term  tibiofibular articulation  is used without a modifier, it refers to the proximal, not the distal (i.e., inferior) tibiofibular articulation. ∑ Injuries to the proximal tibiofibular joint are uncommon and usually associated with other injuries to the lower leg.

C. Types of dislocations

Dislocations can be classified into the following five types:

(i) Anterolateral dislocation (most common) (ii) Posteromedial dislocation (iii) Superior dislocation (uncommon, associated with shortened tibia fractures or severe ankle injuries) (iv) Inferior dislocation (rare, associated with lengthened tibia fractures or avulsion of the foot, usually extensive soft tissue injury and poor prognosis) (v) Chronic instability (subluxation)

As there are often concomitant fractures and ligamentous injuries (e.g.,  ankle fracture), anterolateral and posteromedial dislocations may be overlooked on the first examination, with

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the potential to cause chronic instability. If the dislocation is recognized and treated properly, the prognosis is typically good, although injury to the common peroneal nerve may occur. Inferior dislocations are exceptional as they usually only occur in avulsion (traumatic  amputation) injuries. Subluxation may also occur in diseases with ligamentous laxity (e.g.,  Ehlers–Danlos syndrome), muscle weakness (e.g.,  muscular dystrophy), or secondarily to degeneration (e.g., in rheumatoid arthritis).

References

1. Peterson MJ, Perry J, Montgomery J. Walking patterns of healthy subjects wearing rocker shoes. PTJ, 1985, 65(10): 1483–1489. https:// doi.org/10.1093/ptj/65.10.1483 2. Paulos L, Coleman SS, Samuelson KM. Pes cavovarus. Review of a surgical approach using selective soft-tissue procedures. J Bone Joint Surg Am, 1980, 62(6): 942–953.

3. Kanji JN, Anglin RE, Hunt DL, Panju A. Does this patient with diabetes have large-fiber peripheral neuropathy? JAMA, 2010, 303(15): 1526– 1532. doi:10.1001/jama.2010.428.PMID 20407062

4. Waldman S (ed.). The mulder test for morton neuroma, in: Physical Diagnosis of Pain: An Atlas of Signs and Symptoms, Philadelphia, PA: Elsevier Saunders, October 2005, p. 381, https://doi.org/10.1016/ B978-0-323-71260-6.00287-2

5. Singh D. Nils Silfverskiöld (1888–1957) and gastrocnemius contracture. Foot Ankle Surg, 2013, 19(2): 135–138. doi:10.1016/j. fas.2012.12.002 6. Simmonds FA. The diagnosis of the ruptured Achilles tendon. Practitioner, 1957, 179 (1069): 56–58.

Chapter 8

Examination of the Foot

8.1 Regions of the Foot The regions of the foot include the following:

1. 2. 3. 4.

The dorsal region of the foot The plantar region (sole): the part in contact with the ground The heel region: the sole under the calcaneus The ball of the foot: the sole beneath the medial two metatarsal heads

8.2 Features of the Dorsal Region of the Foot

(i) Skin The skin on the dorsum of the foot is thin, hairy, and freely mobile on the underlying tendons and bones. (ii) Cutaneous nerves 1. The sensory nerve supply 2. The superficial peroneal nerve 3. The deep peroneal nerve 4. The saphenous nerve and 5. The sural nerve Introduction to Limb Arthrology Edited by K. Mohan Iyer Copyright © 2023 Jenny Stanford Publishing Pte. Ltd. ISBN 978-981-4877-99-2 (Hardcover), 978-1-003-37276-9 (eBook) www.jennystanford.com

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(iii) Dorsal venous arch (or network) The dorsal venous arch lies in the subcutaneous tissue over the heads of the metatarsal bones and drains on the medial side into the great saphenous vein and on the lateral side into the small saphenous vein. (iv) Anterior muscles of the leg 1. Tibialis anterior Origin: Lateral condyle and proximal half of lateral tibia

Insertion: Medial plantar surfaces of the medial cuneiform and the base of the first metatarsal Innervation: Deep fibular nerve (L4L5)

Action: Dorsiflexes the foot and inverts the foot 2. Extensor hallucis longus

Origin: Middle half of the anterior surface of the fibula and the interosseous membrane Insertion: Base of the distal phalanx of the great toe Innervation: Deep fibular nerve (L5S1)

Action: Extends the great toe and dorsiflexes the ankle 3. Extensor digitorum longus

Origin: Lateral condyle of the tibia and proximal three-quarters of the anterior surface of the interosseous membrane Insertion: Middle and distal phalanges of toes 2 to 5 Innervation: Deep fibular nerve (L5S1)

Action: Extends toes 2 to 5 and dorsiflexes the ankle 4. Fibularis tertius

Origin: Distal thirds of the anterior surface of the fibula and interosseous membrane Insertion: Dorsum of the base of the 5th metatarsal Innervation: Deep fibular nerve (L5S1)

Action: Dorsiflexes the ankle and aids in eversion of the foot

Features of the Plantar Region or Sole

8.3 Features of the Plantar Region or Sole The sole is the bottommost region where the human foot comes in contact with the earth. In various ways, the structure of the foot and palm is comparable and similar to the palm of the human hand. The foot is meant for the transfer of body weight and movement of the body. Different parts of the foot are in contact with the earth during different types of activities like running, walking, and standing. (i) Skin

The skin of the sole presents the following features:

1. 2. 3. 4.

It is thick and hairless. There are no sebaceous glands present in it. It includes a large number of sweat glands. It is bound to the underlying deep fascia (plantar aponeurosis) by the many fibrous bands. 5. The above features boost the efficiency of the grip of the sole on the earth.

(ii) Superficial fascia

It contains subcutaneous fat in fibrous meshwork formed by irregular septa. Fibrous meshwork connect skin with deep fascia. The superficial fascia is thick over some points of the sole, such as at the posterior tubercle of calcaneus, heads of metatarsal bones, and pulp of digits. These are weight-bearing points of the sole. (iii) Cutaneous nerve supply

This takes place with the help of the following nerves:

1. Medial calcaneal branches of the tibial nerve 2. Cutaneous branches of the medial plantar nerve 3. Cutaneous branches of the lateral plantar nerve

(iv) Deep fascia

It is formed by bundles of collagen fibers longitudinally arranged in the sole. It divides the sole into three parts: central, medial, and lateral. The central part is very thick forming plantar aponeurosis. The medial and lateral parts are thin, forming plantar fascia, which covers the flexor digitorum brevis. The medial part covers abductor hallucis. The lateral part covers the abductor digiti minimi.

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(v) Fibrous flexor sheaths The inferior surface of every toe from the head of the metatarsal to the base of the distal phalanx is provided with a solid fibrous sheath originating from the deep fascia of the toes. It is connected to the sides of the phalanges. The proximal end of every sheath gets the deeper part of the slickness of the plantar aponeurosis. The distal end of the sheath is closed and is connected to the base of the distal phalanx. The sheath, together with the inferior surfaces of the phalanges and interphalangeal joints, creates a blind tunnel via which passes the long flexor tendon/tendons of the toes. (vi) Plantar aponeurosis

It is a thick central part of the deep fascia which is triangular in shape and narrow posteriorly. The posterior part shows attachment on the medial tubercle of the calcaneus proximal to the flexor digitorum brevis. The anterior end divides into five bands, one for each toe. Transverse fibers hold together five bands. The plantar digital vessels and nerves pass between the bands protected by transverse fibers. Near the head of the metatarsal, digital bands divide into superficial and deep slips. The superficial slip shows attachment on the skin and blends with superficial transverse metatarsal ligaments. The deep slip divides into two parts that embrace flexor tendons. Then it blends with fibrous flexor sheaths and deep transverse metatarsal ligaments. The lateral and medial intermuscular septa pass vertically from the medial and lateral aspects of the central part. The transverse septa arising from vertical septa divide the muscles of the sole into four layers. Morphologically the plantar aponeurosis represents the degenerated tendon of the plantaris muscle, which has been divided by the enlarging heel during development. Functions of the plantar aponeurosis





∑ It fixes the skin of the sole and maintains the longitudinal arch of the foot. ∑ It helps to preserve the longitudinal arches of the foot by acting as a tie beam and protects vessels and nerves from compression. ∑ It gives origin to muscles of the first layer of the sole. ∑ It divides the sole into different compartments.

Features of the Plantar Region or Sole

Clinical significance: plantar fasciitis and calcaneal spur The plantar aponeurosis is stretched during the standing position. Consequently, splitting or inflammation (plantar fasciitis) frequently takes place in people who do a lot of standing or walking, viz. traffic police staff. It causes pain and tenderness in the sole particularly underneath the heel during standing. The continued episode of the plantar fasciitis results in calcification in the posterior connection of the plantar aponeurosis creating a calcaneal spur. (vi) Deep transverse metatarsal ligaments

All these are four short, flat, bands of fibrous tissue, which attach to the plantar ligaments of the adjoining metatarsophalangeal joints. They are linked dorsally to interossei, and ventrally to lumbricals and digital nerves and vessels. (vii) Muscles

The muscles acting on the foot can be divided into two distinct groups: extrinsic and intrinsic muscles. The extrinsic muscles arise from the anterior, posterior, and lateral compartments of the leg. They are mainly responsible for actions such as eversion, inversion, plantarflexion, and dorsiflexion of the foot. The intrinsic muscles are located within the foot and are responsible for the fine motor actions of the foot, for example, the movement of individual digits. There are 10 intrinsic muscles in the sole. They act collectively to stabilize the arches of the foot, and individually to control the movement of the digits. There are four layers of the muscles of the foot: A. First Layer

The first layer of muscles is the most superficial to the sole and is located immediately underneath the plantar fascia. There are three muscles in this layer: 1. Abductor hallucis

Location: On the medial side of the sole, where it contributes to a small soft tissue bulge

Origin: Medial tuberosity of calcaneum, flexor retinaculum, and the plantar aponeurosis Insertion: Base of the proximal phalanx of the big toe Nerve supply: Medial plantar nerve

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Nerve root: S23

Action: Flexes and abducts the big toe and braces the longitudinal arch 2. Flexor digitorum brevis

Location: Lateral to the abductor hallucis; sits in the center of the sole, sandwiched between the plantar aponeurosis and the tendons of flexor digitorum longus (FDL) Origin: Medial tubercle of the calcaneum and the plantar aponeurosis Insertion: Four tendons to the four lateral toes; inserted into the borders of the middle phalanx; tendons perforated by those of FDL Nerve supply: Medial plantar nerve Nerve root: S23 Action: Flexes lateral four toes; braces medial and lateral longitudinal arches 3. Abductor digiti minimi

Location: lateral side of the foot; is homologous with the abductor digiti minimi of the hand Origin: Medial and lateral tubercles of the calcaneum and the plantar aponeurosis Insertion: Base of the proximal phalanx of the fifth toe Nerve supply: Lateral plantar nerve Nerve root: S23 Action: Flexus and abducts fifth toe; braces lateral longitudinal arch Features: They cover the entire sole. B. Second Layer

The second layer contains two muscles: the quadratus plantae and the lumbricals. In addition, the tendons of the FDL (an extrinsic muscle of the foot) pass through this layer. 1. Flexor digitorum accessorius or quatratus plantae

Location: Superior to the FDL tendons; is separated from the first layer of muscles by the lateral plantar vessels and nerve Origin: Medial and lateral plantar surface of the calcaneum Insertion: Tendons of the FDL Nerve supply: Lateral plantar nerve

Features of the Plantar Region or Sole

Nerve root: S23

Action: Assists the FDL in flexing the lateral four toes 2. Lumbricals

There are four lumbrical muscles in the foot. Location: Medial to their respective tendon of the FDL Origin: Tendons of the FDL Insertion: Dorsal extensor expansion; bases of the proximal phalanges of the lateral four toes Nerve supply: First lumbrical by the medial plantar nerve and the remainder by the lateral plantar nerve Actions: Flexes at the metatarsophalangeal joints, while extending the interphalangeal joints 3. Tendons The following two tendons are present in the second layer: (a) Tendon of FDL

Origin: Arises from the posterior surface of the body of the tibia, from immediately below the soleal line to within 7 or 8 cm of its lower extremity, medial to the tibial origin of the tibialis posterior; also arises from the fascia covering the tibialis posterior Insertion: Finally divides into four tendons, which are inserted into the bases of the last phalanges of the second, third, fourth, and fifth toes, each tendon passing through an opening in the corresponding tendon of the flexor digitorum brevis opposite the base of the first interphalangeal joint. Actions: To plantarflex and invert the foot Variation: Flexor accessorius longus digitorum, not infrequent, origin from the fibula, tibia, or the deep fascia and ends in a tendon which, after passing beneath the laciniate ligament, joins the tendon of the long flexor or the quadratus plantae Nerve supply: Tibial nerve (L5, S1, S2) (b) Tendon of flexor hallucis longus

Origin: Distal ⅔ of the posterior surface of fibula along with the adjacent interosseous membrane Insertion: Base of distal 1st phalanx (along the plantar surface) Actions: Flexes phalanx and plantar flexes foot

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Nerve supply: Tibial nerve (L5, S1, S2)

Note: Flexor digitorum accessorius and lumbricals are attached to the tendon of FDL. C. Third Layer

The third layer contains the following three muscles: 1. Flexor hallucis brevis

Location: On the medial side of the foot; originates from two places on the sole. Origin: Cuboid and lateral cuneiform, and tibialis posterior insertion Insertion: Medial tendon into the medial side of the base of the proximal phalanx of the big toe; lateral tendon into the lateral side of the base of the proximal phalanx of the big toe Nerve supply: Medial plantar nerve Nerve root: S23 Action: Flexes the metatarsophalangeal joint of the big toe; also supports the medial longitudinal arch. 2. Adductor hallucis

Location: Laterally to the flexor hallucis brevis; consists of an oblique and transverse head Origin: Oblique head of the bases of the 2nd, 3rd, and 4th metacarpal bones; transverse head from the plantar ligaments of the metatarsophalangeal joints Insertion: Lateral side of the base of the proximal phalanx of the big toe. Nerve supply: Deep branch of the lateral plantar nerve Nerve root: S23 Action: Flexes the metatarsophalangeal joint of the big toe; also holds together the metatarsal bones. Features: (a) They are confined to the metatarsal region of the sole. (b) Two of these muscles act on the big toe and one on the little toe. 3. Flexor digiti minimi brevis

Location: On the lateral side of the foot, underneath the metatarsal of the little toe; resembles the interossei in structure Origin: Base of the 5th metatarsal bone

Features of the Plantar Region or Sole

Insertion: Lateral side of the base of the proximal phalanx of the little toe Nerve supply: Superficial branch of the lateral plantar nerve Nerve root: S23 Action: Flexes the metatarsophalangeal joint of the little toe D. Fourth Layer 1. Interossei

The plantar and dorsal interossei comprise the fourth and final plantar muscle layer. The plantar interossei have a unipennate morphology, while the dorsal interossei are bipennate.

(a) Plantar interossei There are three plantar interossei. Location: Between the metatarsals; each arises from a single metatarsal Origin: Inferior surfaces of the 3rd, 4th, and 5th metatarsal bones Insertion: Medial sides of the bases of the proximal phalanges of the lateral three toes Nerve supply: Lateral plantar nerve Nerve root: S23 Action: Adduction of digits three to five; flexes the metatarsophalangeal and metatarsophalangeal joints and extends the interphalangeal joints (b) Dorsal interossei

There are four dorsal interossei. Location: Between the metatarsals; each arises from two metatarsals Origin: Adjacent sides of the metacarpal bones Insertion: Bases of the proximal phalanges—first: medial side of the second toe; remainder: lateral sides of the second, third, and fourth toes; also the dorsal expansion Nerve supply: Lateral plantar nerve Nerve root: S23

Action: Abduction of digits two to four; flexes the metatarsophalangeal and extends the interphalangeal joints. Mnemonic: Plantar interossei adduct (PAD) the toes and originate from a single metatarsal as unipennate muscles; dorsal interossei

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abduct (DAB) the toes and originate from two metatarsals as bipennate muscles. 2. Tibialis posterior tendon

Origin: It originates on the inner posterior borders of the tibia and fibula and is also attached to the interosseous membrane, which attaches to the tibia and fibula.

Action: It produces inversion and assists in the plantar flexion of the foot at the ankle. Insertion: It inserts into the tuberosity of the navicular and the plantar surface of the medial cuneiform. The plantar portion inserts into the bases of the second, third, and fourth metatarsals, the intermediate and lateral cuneiforms, and the cuboid. The recurrent portion inserts into the sustentaculum tali of the calcaneus. Nerve supply: Its innervation is via the tibial nerve. 3. Peroneus Longus

Origin: The muscle, the longest and most superficial of the three  peroneus muscles, arises from the  head of the fibula and its ‘belly’ runs down most of this bone. It becomes a tendon that goes posteriorly around the lateral malleolus of the ankle, then continues under the foot. Insertion: The medial cuneiform and first metatarsal. Action: It plantarflexes the foot, in conjunction with the  tibialis posterior, and also everts the sole. Innervation: Superficial peroneal nerve (L5, S1) Functions: An important agent in the maintenance of the transverse arch of the foot. Features: They fill up the intermetatarsal spaces. (viii) Neurovascular planes of the sole

There are two neurovascular planes between the muscle layers of the sole: 1. Superficial neurovascular plane between the first and second layers: In this plane, the trunks of medial and lateral plantar nerves and the arteries are located. 2. Deep neurovascular plane between the 3rd and fourth layers: In this plane, the deep branches of the lateral plantar nerve and artery are located.

Features of the Plantar Region or Sole

Note: All the muscles are innervated either by the medial plantar nerve or the lateral plantar nerve, which are both branches of the tibial nerve. Clinical Relevance

Contusion of extensor digitorum brevis: Tearing of the extensor digitorum brevis muscle fibers will result in a hematoma. This produces a characteristic swelling anteromedial to the lateral malleolus – differentiating it from a sprained ankle (for which it is often confused). Medial Plantar Nerve Entrapment: The medial plantar nerve can become compressed and irritated as it passes deep to the abductor hallucis muscle. This can cause aching, numbness, and paresthesia on the medial side of the sole. The muscle can become compressed during repetitive eversion of the foot, which may occur in some sports such as gymnastics.

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Chapter 9

Uncommon Injuries of the Limbs

Some uncommon injuries of the limbs are

1. Carpometacarpal (CMC) joint arthritis of the base of the thumb 2. Pediatric trigger thumb 3. Bennett’s fracture 4. Rolando fracture 5. Ulnar collateral ligament injury 6. Jersey finger 7. Lisfranc injuries 8. The wrist (radiocarpal and midcarpal joints) injuries

9.1 CMC Joint Arthritis of the Base of the Thumb

Osteoarthritis of the CMC joint of the thumb was recognized and studied long back by French neurologist Jean-Martin Charcot (1825–1893), and was later studied by Leri (1926), Robert (1936), Forestier (1937), and Huc and Badie (1941) [1–4]. Robert (1936) demonstrated the value of placing the hand in forced pronation to aid Introduction to Limb Arthrology Edited by K. Mohan Iyer Copyright © 2023 Jenny Stanford Publishing Pte. Ltd. ISBN 978-981-4877-99-2 (Hardcover), 978-1-003-37276-9 (eBook) www.jennystanford.com

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in the radiographic diagnosis of CMC arthritis of the thumb. Lasserre, Pauzat, and Derennes (1949) stated that two main movements occur at the CMC joint namely anteroposterior flexion which is visible but difficult to analyze on radiographs, and lateral movements allowing abduction and adduction which is easy to interpret from radiographs made in forced pronation [5]. During abduction, the base of the first metacarpal completely fills the transverse hollow of the trapezium, while in adduction it slides laterally to leave the medial part. The amount of sliding is very little but in rare instances, the metacarpal is subluxated even during abduction and this physiological subluxation is called the “step sign” of Forestier, “le signe de la marche d’escalier,” which mainly consists of a deformity of the base of the thumb caused by radial subluxation of the first metacarpal. Muller (1949) stated that osteoarthritis of the CMC joint of the thumb could result from occupations due to repetitive use of the thumb and advocated arthrodesis of the trapezio-metacarpal joint for relief of pain while preserving power and grip of the thumb [6]. Gervis dominates treatment for this condition and most people accept his views. He was the first to describe the technique of excision of the trapezium through an incision made parallel to the extensor pollicis brevis in the anatomical snuff box. Using careful dissection, the ligaments are then dissected off the bone and the trapezium excised in one piece taking care to protect the radial artery and sensory branches of the radial nerve along with the tendon of the flexor carpi radialis. In 1949, he reported 15 patients with 18 trapezia excised with uniformly good results in 16 wrists and slightly inferior results in two cases due to general arthritic changes [7]. In 1973, he reported on his experience of excision of the trapezium for osteoarthritis of the CMC joint of the thumb after 25 years and was so pleased with the results that he had his own trapezium excised [8]. Following this, he returned to practice orthopedic surgery and could operate as well as before the operation. He described 12 cases followed up from 6 years to 22 years with satisfactory results without exception. He also stated that his 30 years of experience in excising the trapezium for osteoarthritis of the CMC joint of the thumb has shown that this simple operation is entirely satisfactory. Murley (1960) reported 36 out of 39 wrists with good results and also noted that the power of abduction was more reduced by the operation than was the active range of abduction [9]. He also

CMC Joint Arthritis of the Base of the Thumb

noted that opposition was less affected than abduction and no patient had any deterioration or recurrence in the pseudoarthrosis once it had been satisfactory. He advocated a Z-shaped incision with the transverse limb of the incision centered over the dorsum of the trapezium, to protect the sensory branches of the radial nerve to leave a longer scar and be able to dissect with ease. Postoperatively he recommended a plaster for three weeks with the thumb held in abduction. Goldner and Clippinger (1959) emphasized the value of excision as an adjunct to the mobilization of the thumb in cases of adduction contracture of the first web space [10]. They advocated excision of the trapezium piece-meal after having split the trapezium into three segments with an osteotome which were then removed. They also resected the bases of the first and second metacarpals along with tenolysis of the extensor pollicis longus and abductor pollicis longus as need be. Sims and Bentley (1970) reviewed the results of 27 trapeziectomies with excellent results in 15, good in 6, and 5 having moderate discomfort with normal activities regarded as fair with one poor result [11]. They concluded that both arthrodesis of the CMC joint of the thumb and excision of the trapezium give good results but noted an incidence of 53% of patients with associated trapezio-scaphoid arthritis as well. They stated that excision of the trapezium is particularly valuable in cases of associated trapezioscaphoid arthritis. Marmor and Peter (1969) reported 12 cases of CMC arthritis of the thumb, 5 treated by arthrodesis and 7 treated by excision of the trapezium, with good or excellent results in 5 of the 7 cases, with relief of pain and improved function of the thumb [12]. They concluded that excision of the trapezium gave an equally good pain relief as arthrodesis of the CMC joint of the thumb. Iyer (1981) reported on 26 wrists with 25 good results. He also carried out arthrograms on his 26 wrists along with a per-operative arthrogram to study the evolution of the pseudojoint so formed after excision of the trapezium [13, 14]. Arthrodesis of the trapezio-metacarpal joint has been recommended by Muller (1949) and Brittain (1952) for relief of pain along with preservation of power and grip of the thumb. However, Muller and others have also discussed the difficulty in obtaining a successful fusion of this small joint [6, 15].

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Dickson (1976) using silicone rubber sponge interpositional arthroplasty reported excellent early results in 15 of the 16 wrists with complete relief of pain and crepitus at the time of removal of sutures following the operation [16]. He postulated that silicone rubber interpositional arthroplasty promotes the development of repair fibrous tissue from the subchondral bone without any deleterious effects of the sponge in normal joints confirming the safety of this implant material. Implant arthroplasty of the CMC joint has been advocated by Swanson with total dissection of the affected trapezium and replacement with a heat-molded, intramedullary-stemmed silicone rubber implant [17]. The short-term results of silicone rubber implants are not encouraging and the main complication of this procedure appeared to be dislocation of the prosthesis. This has been modified by the advancement of the insertion of the abductor pollicis longus with reinforcement of the capsule with a tendon slip, usually from the flexor carpi radialis. With the long-term results of silicone rubber implants and arthrodesis of the CMC joint unsatisfactory, excision of the trapezium appears to have the primary place in the treatment of osteoarthritis of the CMC joint of the thumb. Excision of the trapezium is particularly preferable as a simple, rapid, and effective way of relieving and restoring function though some amount of residual weakness of opposition grip and pinch grip after trapeziectomy does exist. It is particularly the procedure of choice in patients who also have associated trapezio-scaphoid arthritis. The normal wrist has four separate joint compartments: (i) The radiocarpal joint between the proximal row of carpal bones and distal radius, which is separated by the triangular cartilage from the inferior radioulnar joint; (ii) the inferior radioulnar joint; (iii) the midcarpal joint, which is separated by synovial reflections and interosseous ligaments; and (iv) the isolated CMC joint of the thumb. The CMC joint of the thumb is a single separate joint enclosed by a tough capsule and does not communicate with the other joints of the carpus [18]. The integrity of this tough capsule is maintained even in rheumatoid arthritis when there may be free communication between all other joints [19].

CMC Joint Arthritis of the Base of the Thumb

9.1.1 The Trapezium The trapezium has six surfaces and four articulations. The six surfaces are (i) Palmar surface: This is characterized by a groove and a tubercle. The groove lodges the tendon of flexor carpi radialis and its lips give attachment to the flexor retinaculum. The tubercle which is covered by the thenar muscles gives origin from proximally to distally to the abductor pollicis brevis, opponens pollicis, and flexor pollicis brevis. (ii) Dorsal surface: This is rough in nature and is related to the radial artery. (iii) Lateral surface: This is large and rough and gives attachment to the radial collateral ligament of the wrist joint and the capsular ligament of the CMC joint of the thumb. (iv) Medial surface: This has a concave facet for articulation with the trapezoid. (v) Proximal surface: It has a hollowed-out facet for articulation with the distal scaphoid. (vi) Saddle-shaped distal surface: This is for articulation with the base of the thumb metacarpal. In addition to these surfaces, the trapezium has a distal projection that extends between the bases of the first and second metacarpals and has a facet directed medially for articulation with the base of the second metacarpal.

9.1.2 The CMC Joint of the Thumb

This is a saddle-shaped separate single joint between the base of the first metacarpal and the trapezium, surrounded by a fibrous capsule lined by a synovial membrane that is distinct from that of the other CMC and intercarpal joints. The fibrous capsule is thickest laterally and dorsally. The joint has three sets of ligaments: A lateral ligament which is relatively large extending from the lateral surface of the trapezium to the radial side of the base of the first metacarpal, and dorsal and palmar ligaments which are oblique bands converging on the base of the first metacarpal.

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9.1.3 The Intercarpal Joints The intercarpal joints can be subdivided into the following:

(i) Joints between the bones of the proximal row of the carpal bones. (ii) Joints between the bones of the distal row of the carpal bones. (iii) The midcarpal joint between these two rows of bones.

The bones constituting the intercarpal joints are connected by an extensive system of ligaments. The synovial membrane of the carpus is very extensive. The cavity so formed extends between the distal surfaces of the proximal row and the proximal surfaces of the bones of the distal row to form an S-shaped cavity between the two rows of bones. From this cavity are two projections proximally between the scaphoid and lunate on one hand, and the lunate and triquetral on the other. It sends three prolongations distally between the four bones of the distal row. From this anatomical arrangement, it is clear that the distal articular surface of the trapezium contributes to the formation of a single separate synovial joint with the base of the first metacarpal, whereas the proximal surface of the trapezium contributes to the formation of the midcarpal joint which has a synovial cavity continuous with the intercarpal joints. Fisk (1970) stressed the importance of the scaphoid which bridges the radial side of the midcarpal joint and together with the trapezium acts as a jointed strut that plays a small part in midcarpal movements [20]. The stability of the carpus is mainly dependent on the structures on the volar aspect of the wrist, namely (i) interosseous ligaments, (ii) joint capsules, and (iii) carpal ligaments. As a whole, the carpus is more stable in ulnar deviation and dorsiflexion. He concluded that carpal instability may occur with or without fracture of the scaphoid and is often associated with hypermobility of the scaphoid at its proximal or distal poles which may itself be the cause of carpal arthritis. The CMC joint of the thumb is a saddle joint with free movements occurring in three planes namely axial rotation, abduction–adduction, and flexion-extension. A wide range of gliding movements occurring at the opposing surfaces subjected to repetitive use results in rapid wear in this joint.

CMC Joint Arthritis of the Base of the Thumb

The sequence of pathological events can be divided into the following four stages: Stage I

The medial part of the trapezium is the first to show wear [5] as it is the part used least, as the thumb is usually abducted when subjected to pressure. This presents as initial synovitis with local swelling, pain, and effusion into the joint (Fig. 9.1), which greatly limits movements of the thumb, and local pressure on the radial side of the first metacarpal base produces pain [21]. The joint space is distended and can be seen on radiographs as joint space widening. It is this first stage when seen and treated with local steroid injections that help to alleviate the symptoms and many cases settle without the necessity for further treatment.

Figure 9.1 X-rays taken at this stage shows distention of the joint space. Courtesy: K. Mohan Iyer, Bangalore, India.

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Stage II In a small proportion of patients, the process extends into the second stage with medial osteophyte formation accompanied clinically by increased pain (Fig. 9.2). It is in this stage as the articular surfaces are denuded of the cartilage, that joint space narrowing occurs. Circumduction of the thumb with axial compression produces a painful crepitus-the “grind test” [17]. Loss of strength and motion thereby continues and pain is exacerbated by pinching or wringing movements.

Figure 9.2 Stage II of the CMC osteoarthritis of the base of the thumb, showing a decrease of the joint space with medial osteophyte. Courtesy: K. Mohan Iyer, Bangalore, India.

Stage III As the disease progresses, the first metacarpal subluxates dorsoradially which brings the base of the first metacarpal dorsally and its head abducted toward the plane of the palm. In an attempt to overcome this disability, there is associated compensatory hyperextension occurring at the metacarpophalangeal joint, in order to restore thumb abduction. In this stage, clinically the pain decreases leaving the patient with an unstable thumb (Fig. 9.3).

CMC Joint Arthritis of the Base of the Thumb

Figure 9.3 Stage III of CMC osteoarthritis of the base of the thumb, showing subluxation of the thumb. Courtesy: K. Mohan Iyer, Bangalore, India.

Stage IV Further progress of the disease renders the subluxated CMC joint fixed by superimposed fibrosis and contracture. Also, there is marked hyperextension at the metacarpophalangeal joint along with flexion at the interphalangeal joint to complete the typical Z deformity (Fig. 9.4). However, clinically, by this time the pain decreases, leaving the patient with a fixed adducted thumb.

Figure 9.4 Stage IV of CMC osteoarthritis of the base of the thumb, showing a typical Z-shaped deformity of the thumb. Courtesy: K. Mohan Iyer, Bangalore, India.

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A series of clinical photographs (Figs. 9.5–9.15) show the results obtained following the excision of the trapezium.

Figure 9.5 Function of the hand showing extension of the thumb following excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

Figure 9.6 Function of the hand showing the abduction of the thumb following excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

CMC Joint Arthritis of the Base of the Thumb

Figure 9.7 Function of the hand showing circumduction of the thumb following excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

Figure 9.8 Function of the hand showing opposition of the thumb following excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

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Figure 9.9 Function of the hand showing the abduction of the thumb following excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

Figure 9.10 Function of the hand showing opposition of the thumb following excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

CMC Joint Arthritis of the Base of the Thumb

Figure 9.11 Function of the hand showing extension of the thumb following excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

Figure 9.12 Function of the hand showing opposition of the thumb following excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

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Figure 9.13 Function of the hand showing opposition of the thumb after excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

Figure 9.14 Function of the hand showing grip strength after excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

CMC Joint Arthritis of the Base of the Thumb

Figure 9.15 Function of the hand showing pinch grip after excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

An arthrogram was performed on all wrists reviewed to which patients willingly consented. The purpose of arthrography was to demonstrate the residual joint space (Figs. 9.16 and 9.17) between the base of the first metacarpal and scaphoid following excision of the trapezium, and in particular, was intended to assess the configuration of this space and relate the appearances with respect to the clinical result.

Figure 9.16 An arthrogram being performed. Courtesy: K. Mohan Iyer, Bangalore, India.

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Figure 9.17 An arthrogram being performed. Courtesy: K. Mohan Iyer, Bangalore, India.

Under sterile conditions, the skin just proximal to the base of the thumb was infiltrated with 2% lignocaine. Using an image intensifier, the tip of a 22-gauge needle was inserted through the anatomical snuff box into the joint space between the base of the first metacarpal and scaphoid. The needle could be maneuvered easily into position once it penetrated the thick capsule; however, in cases where the pseudojoint was small, the joint space could be widened by applying traction on the thumb. Metrizamide, in a concentration of 280 milligrams of iodine per milliliter, was injected into the pseudojoint till resistance was met to indicate the complete filling of the pseudojoint. Thereafter radiographs of the wrist (Fig. 9.18) were repeated immediately in the anteroposterior and lateral projections and also the anteroposterior projection in stress views with the wrist in full radial and ulnar deviation. Excision of the trapezium for osteoarthritis of the CMC joint of the thumb is regarded as a successful operation in most patients for whom it is done with relief of pain and restoration of movements. Little or no mention has been made in the literature of the form of the pseudojoint which results between the base of the first metacarpal and the distal scaphoid. After the operation, granulation and fibroblastic tissue must fill the cavity of the trapezium and leave only an irregular small capacity joint space (Fig. 9.19). In time, the

CMC Joint Arthritis of the Base of the Thumb

capacity of the joint increases and extends between the opposing surfaces, and the contour changes into a fairly regular pattern (Fig. 9.20).

Figure 9.18 Arthrogram of the pseudojoint taken in stress views of the wrist. Courtesy: K. Mohan Iyer, Bangalore, India.

Figure 9.19 Arthrogrogram taken immediately after excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

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Figure 9.20 Arthrogrogram of the pseudojoint taken a long while after excision of the trapezium. Courtesy: K. Mohan Iyer, Bangalore, India.

Arthrogram of the wrist joint has been used in the evaluation of trauma by Kessler and Silberman and Ganel et al. and also of rheumatoid arthritis of the wrist by Harrison et al. and Ranawat et al. [19, 22–24]. Arthrography of the metacarpo-scaphoid joint proves with certainty the success of the arthroplasty procedure by the presence of a distinct joint space [25]. Some of the arthrograms showed a larger joint than others but this fact did not appear to be related to the clinical end result. The evolution of this condition has resulted in by advancement of the insertion of abductor pollicis longus with reinforcement of the capsule with a tendon slip (Fig. 9.21) usually from the flexor carpi radialis. Even silicone rubber implants (Fig. 9.22).

CMC Joint Arthritis of the Base of the Thumb

Figure 9.21 Postoperative oblique X-ray of trapeziectomy with LRTI procedure. X-rays reproduced with kind consent from Guus M. Verneuleum, MD, PhD, plastic surgeon, Xpert Clinic, Amsterdam, Netherlands [26].

Figure 9.22 Postoperative X-rays of TJA (Guepar prosthesis). X-rays reproduced with kind consent from Guus M. Verneuleum, MD, PhD, plastic surgeon, Xpert Clinic, Amsterdam, Netherlands [26].

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Arthrodesis of the CMC joint (Fig. 9.23) has been tried with unsatisfactory results. It is particularly the procedure of choice in patients who also have associated trapezio-scaphoid arthritis.

Figure 9.23 Postoperative oblique X-ray of the arthrodesis with plate and screws. X-rays reproduced with kind consent from Guus M. Verneuleum, MD, PhD, plastic surgeon, Xpert Clinic, Amsterdam, Netherlands [26].

9.2 Pediatric Trigger Thumb The problem of triggering in children occurs usually in the thumb. It may be noticed soon after birth; hence, it is also sometimes called congenital trigger thumb but a better diagnosis would be pediatric trigger thumb. In adults, it may accompany rheumatoid arthritis. The Sugimoto classification [27] involves four stages: Stage 1: Palpable nodule

Stage 2: Active triggering Stage 3: Passive triggering

Stage 4: Fixed flexion deformity

Pediatric Trigger Thumb

Most patients present at Stage 2 and later, as children do not usually complain of a nodule. The pathophysiology is the same as in adults and other trigger fingers—a thickening of the flexor tendon (flexor pollicis longus, FPL, in the case of trigger thumb), a thickening of the tendon sheath, or both. In all cases, a nodule at the A1 pulley can be felt. In about 30% of cases, the triggering resolves spontaneously and many studies have shown that it is reasonable to continue with observation until the child is 3 years old or unless there is painful triggering or a fixed flexion deformity of the IPJ.

Management: Initial management consists of observation, active and passive motion exercises, and splinting at night. Children with trigger thumbs rarely complain of pain. They are usually brought in for evaluation when aged 1–4 years when the parent first notices a flexed posture of the thumb IP joint. These children often demonstrate bilateral fixed flexion contractures of the thumb by the time they present to the physician. The diagnosis is made instantaneously as the appearance is classical. One is unable to passively straighten the fixed contracted thumb. A nodule can be felt at the stenosed site. The cause of a trigger thumb is the same as in the finger. There is mechanical obstruction of the tendon of FPL through a tight A1 pulley. Apart from being congenital, there may be an element of unnoticed trauma. Treatment is usually surgical but one must not always rush into surgery as in some studies there is a spontaneous recovery in 30% of cases. Recovery is unlikely if the child is more than 2 years (Fig. 9.24). In children, the procedure is performed under a general anesthetic under a tourniquet. A transverse or curvilinear incision centered over the MCP joint of the thumb was made on the volar aspect. This is centered over the nodule. The A1 pulley is cleanly divided longitudinally. The tendon of the FPL is then delivered to the wound with a curved hemostat. The edges of the pulley may be excised. Full excursion of the thumb is then observed to make sure no secondary adhesions are present. It is obvious to say that the neurovascular structures are protected. Skin is closed with absorbable sutures and thumb movements are encouraged as soon as possible.

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Figure 9.24 Trigger thumb deformity in a 3-year-old child with surgical release of A1 pulley and complete correction of the deformity. Reprinted with the kind permission of Mr. Siddiqui, consultant orthopedic surgeon, Kettering General Hospital, Kettering, UK.

9.3 Bennett’s Fracture Bennett’s fracture is a fracture of the base of the first metacarpal bone which extends into the CMC joint. It is the most common type of intra-articular fracture of the thumb, which is nearly always accompanied by some degree of subluxation or frank dislocation of the CMC joint. The fracture is named after Edward Hallaran Bennett, who said that his fracture “passed obliquely across the base of the bone, detaching the greater part of the articular surface,” and “the separated fragment was very large and the deformity that resulted there-from seemed more a dorsal subluxation of the first metacarpal.” Mechanism of injury: It is an axial force directed against the partially flexed metacarpal. This type of compression along the metacarpal bone is often sustained when a person punches a hard object, such as the skull or tibia of an opponent, or a wall. It can also occur as a result of a fall onto the thumb. The proximal metacarpal fragment remains attached to the anterior oblique ligament, which in turn is attached to the tubercle of the trapezium bone of the CMC joint. This ligamentous attachment ensures that the proximal fragment remains in its correct anatomical position. The distal fragment of the first metacarpal bone possesses the majority of the articular surface

Bennett’s Fracture

of the first CMC joint. Unlike the proximal fracture fragment, strong ligaments and muscle tendons of the hand tend to pull this fragment out of its correct anatomical position.

Specific feature: Tension from the abductor pollicis longus (APL) muscle subluxates the fragment in a dorsal, radial, and proximal direction and rotates the fragment into supination while tension from the adductor pollicis (ADP) muscle displaces the metacarpal head into the palm. Clinical features: Characteristic signs include pain, swelling, and ecchymosis around the base of the thumb and thenar eminence, especially over the CMC joint of the thumb. Instability of the CMC joint of the thumb can be observed, accompanied by pain and weakness of the pinch grasp. X-rays posteroanterior and lateral radiograph: Traction X-rays are advisable and a computed tomography (CT) scan is rarely indicated in case of doubt. Treatment: The following treatments are indicated:

(i) Conservative treatment for undisplaced fractures (ii) Closed reduction and internal fixation for reducible fractures (iii) Open reduction internal fixation (ORIF) for fractures that are not reducible in a closed manner. ORIF is also indicated in highdemand patients and those who need immediate restoration of the full range of motion. However, ORIF is possible only if the anterior marginal fragment is large enough for internal fixation (>20% of the articular surface). A. Closed reduction and POP application: Reduction is performed by a combination of longitudinal traction, pronation of the metacarpal along with pressure at the thumb metacarpal base. This is then confirmed by the correct restoration of the articular surface using image intensification. B. Closed reduction and internal fixation: The most common are transfixion of the base of the first metacarpal to the trapezium or transfixion of the thumb base to the second metacarpal or a combination of both. C. Wagner technique for closed pinning D. Open reduction and internal fixation (Fig. 9.25)

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Figure 9.25 Lateral view showing Bennett’s fracture. K-wire fixation of Bennett’s fracture or ORIF of Bennett’s fracture. Reprinted with the kind permission of Mr. Shahrier Fazal Sarker, consultant orthopedic hand and wrist surgeon, Broomfield Hospital, Mid and South Essex NHS Foundation Trust, UK.

9.3.1 Reverse Bennett’s Fracture It is a fracture-dislocation of the base of the 5th metacarpal bone which is pathologically and radiographically analogous to Bennett’s fracture of the thumb. It is quite unstable due to unopposed extensor carpi ulnaris force on the fracture fragment, which causes migration and subluxation of the fragment. Frequently need K-wire stabilization to counteract the strong force of extensor carpi ulnaris (ECU).

9.3.2 Pseudo Bennett’s Fracture

It is a two-piece fracture of the proximal first metacarpal bone that usually results from longitudinal axial loading. They are usually stable and depending on the degree of displacement, and often do

Rolando’s Fracture

not require surgery. It is important to distinguish them from intraarticular fractures, which are usually unstable and require surgery.

9.4 Rolando’s Fracture

It is an intra-articular fracture of the base of the first metacarpal bone which extends into the CMC joint. The differentiating feature from Bennett’s T- or Y-shaped fracture patterns can occur either in the frontal or in the sagittal plane. It was described by Silvio Rolando in 1910, this fracture is a 3-part intra-articular fracture of the base of the thumb metacarpal. Today the term “Rolando’s fracture” is often misused to describe multifragmentary intra-articular fractures of the thumb metacarpal base. The mechanism of injury, clinical evaluation, radiographic evaluations, and treatment are the same as Bennett’s fracture. A. Closed Reduction and POP application: As there is usually a flexion deformity, the reduction can be performed with axial traction on the thumb and simultaneous pressure over the dorsal aspect of the basal diaphysis near the fracture. Maintaining reduction during the application of the cast, it is important to exert pressure over the dorsal aspect of the first metacarpal diaphyseal base, and from the palmar aspect over the first metacarpal head. Note: An important pitfall is the palmer pressure. Avoid pressing from the palmar aspect over the base of the proximal phalanx. This results in redisplacement of the fracture and hyperextension of the MCP joint. B. Open Reduction and Internal Fixation (Fig. 9.26): Choice of approach: For Y- or T-shaped patterns in the frontal plane, a straight dorsal approach is preferred as opposed to a Y- or T-shaped fracture pattern in the sagittal plane, the radiopalmar approach is the preferred choice. Kirschner Wire Fixation The following are the advantages and disadvantages of this technique: Advantages (i) No cut (ii) Less dissection of muscle

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(iii) Less risk of infection (iv) Smaller procedure Disadvantages (i) (ii) (iii) (iv)

Plaster for 6 weeks Must keep it dry Increased stiffness Increased risk of late infection along the wire

Figure 9.26 Rolando fracture with intraoperative images of ORIF of Rolando’s fracture. Reprinted with the kind permission of Mr.  Shahrier  Fazal  Sarker, consultant orthopedic hand and wrist surgeon, Broomfield Hospital, Mid and South Essex NHS Foundation Trust, UK.

Open Reduction The following are the advantages and disadvantages of this technique: Advantages 1. Allows accurate alignment of the joint surface under direct vision 2. Gentle movements may be started early if screw fixation is noted to be strong at the time of surgery

Ulnar Collateral Ligament Injury

Disadvantages (i) Exposure of the joint (ii) Increased risk of injury to skin nerves, early infection (iii) A need for expertise in dissection

Complications: Stiffness of the MC along with Stiffness of the 1st MCP joint, wrist joint, etc. with post-traumatic arthritis and open surgeryrelated complications.

9.5 Ulnar Collateral Ligament Injury

It is an injury to the metacarpophalangeal joint ulnar collateral ligament of the thumb. A tear or avulsion of the ligament may occur at the site of insertion into the phalanx of the thumb. A Skier’s thumb is an acute condition while a gamekeeper’s thumb is a chronic condition as a result of repeated episodes. C. S. Campbell, an orthopedic surgeon originally coined the term gamekeeper’s thumb in 1955, after he observed this condition in a series of Scottish gamekeepers. Gamekeepers kill small animals by forcefully extending the neck while Skiers fall onto the extended thumb, hyperabduction. The capsule is thickened medially and laterally to form the ulnar and radial collateral ligaments which are static stabilizers of the MCP joint. The ligament is a proper accessory called the ulnar collateral ligament. The capsule is thin over its dorsolateral aspect between the extensor pollicis brevis (EPB) and abductor pollicis. There is a rupture of the ulnar collateral ligament caused by forcible abduction due to a fall onto an outstretched hand, while the gamekeeper’s fracture is an avulsion fracture. There are two types, namely (i) Partial rupture when only the ligament proper is torn. The thumb is unstable in flexion. (ii) Complete rupture when the thumb is unstable in all the positions.

The Stener lesion consists of the interposition of the adductor pollicis aponeurosis between the ends of the torn ligament which prevent healing of the ligament resulting in chronic instability which is present in about 80% of complete ruptures.

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9.5.1 Classification Ulnar Collateral Ligament Injuries The following are the clinical features of ulnar collateral ligament injuries (Palmer and Louis) (Table 9.1):





∑ There is swelling and tenderness over the ulnar side of the thumb metacarpophalangeal joint. There is also a bruise-like discoloration around the joint. ∑ Interference in pinching activity, grasp along with laxity of the joint and there will be a lump (Stener lesion). ∑ On abduction stress testing the joint in full extension and 30 degrees of flexion should be compared with the uninjured thumb. ∑ The stress test in extension with the abduction of more than 40 degrees indicates a complete injury. When compared to the other side, the difference of more than 15 degrees.

Table 9.1

Classification of injuries and suggested treatments

Type Injury 1

2

3

4

5

6

Fracture undisplaced

Fracture displaced

Ligamentous tear, stable

Ligamentous tear, unstable

Volar lip fracture

Ulnovolar fracture and ligamentous tear

Treatment Conservative Surgical

Conservative Surgical

Conservative

Surgical

The following investigations are suggested for examining the injuries:



∑ X-ray – To exclude a fracture, or to observe an avulsion fracture or subluxation ∑ Fragment from the base of the proximal phalanx. A stress view examination shows a minimally displaced ( ulnar collateral). Flexion/ extension of IP joints of the index finger—proximal (100°–110°) > distal (80°). The range of PIP and DIP joint flexion increases ulnarly with 5th PIP and DIP having flexion ranges of 135 degrees and 90 degrees, respectively. Additional range to ulnarly fingers also favors angulation of fingers toward the scaphoid and opposition with the thumb. Extrinsic finger flexors: These muscles of the fingers and thumb have proximal attachment above the wrist. Two muscles contribute to finger flexion namely flexor digitorum superficialis (FDS) and FDP. FDS: It flexes the proximal IP joint and MCP joint which produces more torque than FDP. It crosses fewer joints and is superficial to FDP at the MCP joint which has a greater moment arm for the MCP joint. FDP: It flexes the MCP, PIP, and DIP joints. During finger flexion with wrist flexion, the FDS and FDP work together. At the proximal phalanx (proximal to PIP), FDP emerges through the split in FDS (camper’s chiasma) and FDS attaches to the base of the middle phalanx. Both FDS and FDP are dependent on wrist position for optimal length– tension relationship. Counterbalancing extensor torque at the wrist is provided by extensor carpi radialis brevis (ECRB) or sometimes by extensor digitorum communis (EDC).

Mechanism of finger flexion: The optimal function of FDS and FDP depends on the following: (i) stabilization by wrist musculature

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Uncommon Injuries of the Limbs

and (ii) intact flexor gliding mechanism. The gliding mechanism consists of flexor retinacula, bursae, and the digital tendon sheaths. The fibrous retinacular structures (proximal flexor retinacula, transverse carpal ligament, and extensor retinaculum) tether the long flexor tendons to the hand, preventing bowstringing of tendons. The bursae and tendon sheaths facilitate friction-free excursion of tendons on the retinacula. Both the FDS and FDP tendons cross the wrist and pass beneath the proximal flexor retinaculum through the carpal tunnel and ulnar bursa (all). The FPL pass through the carpal tunnel with FDS and FDP and then the radial bursa encases it. The FDS and FDP tendons of each finger pass through a fibro-osseous tunnel which comprises five transversely oriented annular pulleys (vaginal ligaments) and three obliquely oriented cruciate pulleys. Annular pulleys (i) A1 is at the head of MC (ii) A2 is at the volar midshaft of proximal phalanx (iii) A3 is at the distal-most part of the proximal phalanx (iv) A4 is centrally on the middle phalanx (v) A5 is at the base of the distal phalanx

The base of each pulley is longer than the roof superficially and the roof has slight concavity volarly. This prevents the pulleys from pinching each other at extremes of flexion and minimizes the pressure on the tendon when it is under tension. The three cruciate pulleys are as follows: (i) C1 is located between A2 and A3 (ii) C2 is between A3 and A4 and (iii) C3 is between A4 and A5 A4, A5, and C3 contain only the FDP tendon and no FDS. The thumb has a different pulley system. The function of annular pulleys are as follows:

(i) To keep the flexor tendons close to the bone (ii) To allow only a minimum amount of bowstringing and migration volarly from the joint axes (iii) To enhance tendon excursion efficiency and work efficiency of long tendons. Extrinsic finger extensors: The extrinsic finger extensors are EDC, extensor indicis proprius (EIP), and extensor digiti minimi (EDM).

The Wrist: Radiocarpal and Midcarpal Joints

It passes from the forearm beneath the extensor retinaculum which maintains the proximity of tendons to the joints and improves excursion efficiency. At the MCP joint level EDC tendon of each finger merges with broad aponeurosis known as the dorsal hood or extensor hood. The EIP and EDM tendons insert into the EDC tendon of the index and little finger at or just proximal to the extensor hood. EDC, EIP, and EDM perform an extension of MCP joints of fingers via connection to extensor hood and sagittal band and also causes wrist extension. Distal to the extensor hood, the tendon splits into three bands; the central tendon inserts on the base of the middle phalanx while the two lateral bands rejoin as the terminal tendon, which inserts into the base of the distal phalanx. Extensor mechanism: It is formed by EDC, EIP, EDM, extensor hood, central tendon, and the lateral bands that merge into the terminal tendon. The passive components are the bands on the triangular ligaments which helps in the stabilization of the fingers and sagittal bands which help to connect the volar surface of the hoods to the volar plates and the deep transverse MC ligament which helps to prevent bowstringing of the extensor tendons. The dorsal interossei (DI), volar interossei (VI), and lumbrical (intrinsic musculature) are active components of the extensor mechanism. The passive element is the oblique retinacular ligament (ORL). Intrinsic finger musculature: With all attachments distal to the radiocarpal joint, the dorsal and volar interossei muscles arise between the MC and are an important part of the extensor mechanism. There are 4 DI and 3–4 VI muscles. The DI and VI are alike in their locations and some of their actions; characterized by their ability to produce MCP joint abduction and adduction, respectively. The interossei muscle fibers join extensor expansion in two locations; some fibers attach proximally to the proximal phalanx and extensor hood; some attach more distally to lateral bands and central tendons. The 1st DI has the most consistent attachment into the bony base of the proximal phalanx and extensor hood while the 2nd and 3rd DI have both proximal and distal attachments. The 4th DI is not actually present with the abductor digiti minimi (ADM) playing that role. There are 3 VI muscles that have distal attachment only (lateral band/central tendon).

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Uncommon Injuries of the Limbs

The proximal interossei have a predominant effect on MCP joint only, but distal interossei will produce their predominant action at IP joints and some effect on the MCP joints. All DI and VI muscles pass dorsal to transverse MC ligament but volar to the axis of MCP joints flexion/extension.

Role of interossei at MCP joint in extension: They are effective stabilizers and prevent clawing due to flexion torque and they also balance passive tension in the extrinsic extensors at MCP joint at rest. The interossei muscles are effective abductors and adductors at the MCP joint when the MCP joint is in extension. The proximal insertion muscles are more effective than the distal insertion muscles. So abduction is stronger than adduction. Role of interossei at MCP joint in flexion: From extension to flexion these tendons and action lines of interossei muscles migrate volarly away from the coronal axis of the MCP joint which increases the moment arm for MCP flexion as the action line is nearly perpendicular to the moving segment. It also increases the flexion torque at MCP joint as it approaches full flexion. The volar migration of interossei is restricted by deep transverse MC ligament, prevents loss of active tension, and serves as an anatomical pulley. In full MCP flexion, abduction/adduction is restricted due to tight collateral ligaments, the shape of condyles on MC heads, and active insufficiency of fully shortened interossei muscles.

Role of interossei at IP joint in IP extension: The ability to cause IP extension is influenced by its attachments. The IP joint extension produced by distal interossei is stronger than MCP abduction/adduction during MCP extension. The index and little fingers have weaker IP extension than the middle and ring fingers (fewer distal interossei muscles). Overall, proximal components are effective in MCP flexion and distal component in IP extension. So the most consistent activity of interossei is when the MCP joints are flexed and the IP joints are extended, an advantage of optimal biomechanics for both DI and VI. Lumbrical muscles: They are the only muscles in the body that attaches to the tendons of other muscles. Each muscle originates from the tendon of the FDP muscle in the palm volar to the deep

The Wrist: Radiocarpal and Midcarpal Joints

transverse MC ligament which attaches to the lateral band of the extensor mechanism on the radial side. It crosses MCP joint volarly and IP joints dorsally. The difference between interossei and lumbricals is the more distal insertion of lumbricals, origin at FDP, great contractile range of lumbricals, and effective IP extensors than the MCP joint position. Deep transverse MC ligament prevents lumbricals from migrating dorsally and losing tension as MCP and IP extend. Lumbrical contraction increases tension in the lateral band and FDP tendon too. They act as both agonists and synergists for IP extension. As lumbricals activate to cause IP extension, there is the effective release of passive tension in the FDP tendon. They also assist FDP indirectly during hand closure. Functionally MCP joint flexion is weaker in lumbricals than interossei. A large range of lumbricals prevents active insufficiency when shortening over MCP and IP joints. CMC or trapezio-metacarpal (TM) joint between trapezium and base of 1st metacarpal head has been dealt with separately. MCP joint: This is located between the head of 1ST MC and the base of the proximal phalanx. It is a condyloid joint with 2 degrees of freedom—flexion/extension and abduction/adduction. The joint capsule, volar plates, and collateral ligaments are similar to other MCP joints. Its main function is to provide additional flexion range to the thumb in opposition and to allow the thumb to grasp and contour objects. Though the structure is the same flexion/extension ranges are half of the other fingers. Abduction/adduction is extremely limited. IP joint: This is located between the head of the proximal phalanx and the base of the distal phalanx. It is similar to other IP joints of the fingers. Musculature of the IP joint

A. Extrinsic thumb muscles: The four extrinsic thumb muscles are

1. FPL: It inserts on distal phalanx and correlates to the FDP. In the wrist, it is invested by the radial bursa, which is continuous with its digital tendon sheath. It is unique as it functions independently. It is the only muscle responsible for thumb flexion at the IP joint. It sits between the sesamoid bones and derives some protection from the bones.

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Uncommon Injuries of the Limbs

2. Extensor pollicis longus (EPL) 3. EPB 4. APL The EPL, EPB, and APL are located dorso-radially. The EPB and APL follow a common course from the dorsal forearm to the 1st dorsal compartment on the radial aspect of the wrist. The ABL inserts on the base of the MC joint. EPB inserts on the base of the proximal phalanx and abducts the CMC joint with slight radial deviation of the wrist, while the EBP is for extension of the MC joint. The EPL inserts on the base of the distal phalanx at the proximal phalanx and the EPL is joined by expansion from APB, 1st volar interossei, and adductor pollicis (ADP) which extends the thumbs IP joint to neutral but no hyperextension, extends and adducts 1st CMC joint.

B. Intrinsic thumb muscles: Five thenars muscles originate from carpal bones and flexor retinaculum. The opponens pollicis (OP) is the only intrinsic muscle having distal attachment on 1st MC on the lateral side which is very effective in positioning the MC in an abducted, flexed, and rotated posture. The APB, FPB, ADP, and 1st volar interossei insert on proximal phalanx. The FPB has two heads of insertion: the first one is a large lateral head that attaches to ABL, producing abduction, and the second one is a medial head that attaches to ADP, resulting in adduction. The 1st dorsal interossei which though not considered as a thenar muscle contributes to thumb function like CMC joint distraction and assists thumb adduction. The thenar muscles are active in most grasping activities and the activity of the extrinsic thumb muscle in grasp is partially the function of helping to position the MCP and IP joints, the main function being returning the thumb to extension from its position. Prehension: Prehension activities involve grasping or taking hold of an object between any two surfaces of the hand. The thumb participates in most, but not all, prehension activities. The power grip results in flexion of all the finger joints, while prehension is the skillful placement of an object between fingers or between the fingers and the thumb. The phases of both these movements are in phases such as the opening of the hand, then positioning of the fingers, bringing the fingers to the object, and then maintaining the static phase. Prehension involves the opening of the hand, followed

The Wrist: Radiocarpal and Midcarpal Joints

by positioning of the fingers followed by bringing the fingers to the object. Power grip: The fingers function to clamp on or hold an object into the palm and they sustain the flexion position that varies in degree with the size, shape, and weight of the object with the palmar arches around it. The thumb serves as an additional surface to the finger palm by adducting against the object. The different power grips are as follows: (i) (ii) (iii) (iv)

Cylindrical grip Spherical grip Hook grip Lateral prehension

(i) Cylindrical grip: It involves the use of all finger flexors with the FDP working predominantly and the interossei muscles acting as primary MCP flexors, abductors/adductors. The FPL and thenar muscles assist in flexion and adduction of thumb. The hypothenar eminence acting to flex and abduct the MCP joint, typically with the wrist in neutral/extension and slight ulnar deviation, e.g., turning a door knob. (ii) Spherical grip: Mostly cylindrical grip but a greater spread of fingers to encompass the object as more activity of interosseous, e.g., holding a ball. (iii) Hook grip: It is a specialized form of prehension with function primarily of fingers. There is a major activity of FDP and FDS and the load is more distally FDP, proximally (FDS), and the thumb is moderate to full extension, e.g., carrying a briefcase.

(iv) Lateral prehension: When the contact is between two fingers, the extensor musculature predominates. The MCP and IP joints, in extension as contiguous MCP joint, simultaneously abduct and adduct, e.g., holding a paper. Precision handling: It requires much finer motor control and is more dependent on intact sensation. In a “two-jaw chuck,” one jaw is the thumb (abducted and rotated) and the second jaw is by the distal tip, the pad, or the side of the finger. There are three varieties of prehensions: (a) Pad-to-pad prehension (b) Tip-to-tip prehension

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Uncommon Injuries of the Limbs

(c) Pad-to-side prehension

Pad-to-side prehension: It involves opposition of pad or pulp of thumb to pad or pulp of the finger. The pad has the greatest concentration of tactile corpuscles. The MCP and proximal IP joint of the finger are partially flexed with the distal IP joint being extended or slightly flexed. The thumb has CMC flexion, abduction, and rotation; MCP and IP joints are partially flexed or extended, e.g., holding forceps.

Tip-to-tip prehension: The muscle activity is almost the same as pad-to-pad prehension with some key differences like the IP joint of the fingers and the thumb have range and force to create full flexion. The MCP joint of the opposing finger deviates ulnarly, e.g., holding a pen. Side-to-side prehension: It is a key grip or lateral pinch between the thumb and side of the index finger. The thumb is more adducted and less rotated least precise form of precision handling.

Functioning position of the wrist and hand: The wrist complex in slight extension (20 degrees) and slight ulnar deviation (10 degrees) and the fingers are moderately flexed at the MCP joint (45 degrees) and proximal IP joint (30 degrees) and slightly flexed at distal IP joint.

References

1. Leri, A. (1926) Etudes sur les affections des os et des articulations, Paris: Masson et Cie. 2. Robert, P. (1936) Bulletins et memoires de le Sociate de Radiologie medical de France, 24: 687–690. 3. Forestier, J. (1937) L’osteoarthrite seche trapezometacarpienne (rhizarthrose du pouce). Presse Medicale, 45: 315–317. 4. Huc, G. and Badie, M. (1941) Déformations des doigts et des mains dans les arthrites chroniques. Revue du Rheumatisme , 8(3): 12–26.

5. Lassere, C., Pauzat, D. and Derennes, R. (1949) Osteoarthritis of the trapezio-metacarpal joint, Journal of Bone and Joint Surgery, 31B: 534–536.

References

6. Muller, G. M. (1949) Arthrodesis of the trapezio-metacarpal joint for osteoarthritis, Journal of Bone and Joint Surgery, 31B: 540.

7. Gervis, W. H. (1949) Excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint, Journal of Bone and Joint Surgery, 31B: 537–539.

8. Gervis, W. H. (1973) A review of excision of the trapezium after osteoarthritis of the trapezio-metacarpal joint after twenty-five years, Journal of Bone and Joint Surgery, 55B: 56–57. 9. Murley, A. H. G. (1960) Excision of the trapezium in osteoarthritis of the first carpo-metacarpal joint, Journal of Bone and Joint Surgery, 42B: 502–507.

10. Goldner, J. L. and Clippinger, F. W. (1959) Excision of the greater multangular bone as an adjunct to mobilization of the thumb, Journal of Bone and Joint Surgery, 41A: 609–625.

11. Sims, C. D. and Bentley, G. (1970) Carpometacarpal arthritis of the thumb, British Journal of Surgery, 57(6), 442–448. 12. Marmor, L. and Peter, J. E. (1969) Osteoarthritis of the carpometacarpal joint of the thumb, American Journal of Surgery, 117: 632.

13. Mohan Iyer, K. (1981) The results of excision of the trapezium. The Hand, 13(3), 246–250. 14. Mohan Iyer, K. and Whitehouse, G. H. (1981) Arthrography of the Metacarpo-scaphoid joint following excision of the trapezium, The Hand, 13(3), 251–256. 15. Brittain, H. A. (1952) Architectural Principles in Arthrodesis. Edinburgh and London: Livingstone. 16. Dickson, R. A. (1976) Arthritis of the carpometacarpal joint of the thumb. Treatment by silicone sponge interposition arthroplasty. An experimental and clinical study. Hand, 8, 197–207. 17. Swanson, A. B. (1972) Disabling arthritis at the base of the thumb, Journal of Bone and Joint Surgery, 54A: 456.

18. Kuczynski, K. (1974) Carpometacarpal joint of the human thumb, Journal of Anatomy, 118: 119–126.

19. Harrison, M. O., Feiberger, R. H., and Ranawat, C. S. (1971) Arthrography of the rheumatoid wrist, American Journal of Roentgenology, 112: 480–486.

20. Fisk, G. R. (1970) Carpal instability and the fractured scaphoid, Annals of the Royal College of Surgeons of England, 46(2): 63–76.

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21. Eaton, R. G. and Littler, J. W. (1969) A study of the basal joint of the thumb, Journal of Bone and Joint Surgery, 51A: 661.

22. Ganel, A., Engel, J., and Ditziam, R. (1979) Arthrography as a method of diagnosis of soft tissue injuries of the wrist, Journal of Trauma, 19: 376–380.

23. Kessler, I. and Silberman, Z. (1961) An experimental study of the radiocarpal joint by arthrography, Surgery, Gynaecology and Obstetrics, 112: 33–40. 24. Ranawat, C. S., Harrison, M. O., and Jordan, L. R. (1972) Arthrography of the wrist joint, Clinical Orthopaedics, 83: 6–12. 25. Patterson, R. (1953) Carpo-metacarpal arthroplasty of the thumb, Journal of Bone and Joint Surgery, 15: 240.

26. Vermeulem, G. M. (2014) ‘Thumbs Up’ Surgical Management and Outcome of Primary Osteoarthritis at the Base of the Thumb, Thesis submitted for the PhD on 29th January 2014 to the University of Erasmus MC, The Netherlands. 27. Wolfe, S., Hotchkiss, R., Pederson, W., and Kozin, S. (2011) Green’s Operative Hand Surgery, 6th Edition, Elsevier Churchill Livingstone, 2011.

28. Fischer L-P. (2005) [Jacques Lisfranc de Saint-Martin (1787–1847)], Histoire des sciences médicales, 39(1): 17–34. 29. Stavlas, P., Roberts, C. S., Xypnitos, F. N., Giannoudis, P. V. (2010) The role of reduction and internal fixation of Lisfranc fracture-dislocations: a systematic review of the literature. International Orthopaedics, 34(8): 1083–1091. 30. English, T. A. (1964) Dislocations of the Metatarsal Bone and Adjacent Toe. Journal of Bone and Joint Surgery (British Volume), 46B(4): 700– 704. 31. Aitken, A. P. and Poulson, D. (1963) Dislocations of the tarsometatarsal joint. Journal of Bone and Joint Surgery, 45(2): 246–383.

32. Rammelt, S., Schneiders, W., Schikore, H., Holch, M., Heineck, J., and Zwipp, H. (2008) Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture-dislocation. Journal of Bone and Joint Surgery (British Volume), 90B(11): 1499–1506. 33. Root, M. I. (1973) Biomechanical examination of the foot. Journal of the American Podiatry Association, 63(1): 28–29.

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34. Kalia, V., Fishman, E. K., Carrino, J. A., Fayad, L. M. (2012) Epidemiology, imaging, and treatment of Lisfranc fracture-dislocations revisited. Skeletal Radiology, 41(2): 129–136. 35. Welck, M. J., Zinchenko, R., Rudge, B. (2015). Lisfranc injuries. Injury, 46(4): 536–541.

36. Solan, M. C., Moorman, C. T., Miyamoto, R. G., Jasper, L. E., Belkoff, S. M. (2001) Ligamentous restraints of the second tarsometatarsal joint: a biomechanical evaluation. Foot and Ankle International, 22(8): 637– 641. 37. Myerson, M. S., Fisher, R. T., Burgess, A. R., Kenzora, J. E. (1986) Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot and Ankle International, 6(5): 225–242.

38. Myerson, M. (1989) The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthopedic Clinics of North America, 20(4): 655–664. 39. Bloome, D. M. and Clanton, T. O. (2002) Treatment of Lisfranc injuries in the athlete, Techniques in Foot and Ankle Surgery, 1(2), 94–101.

40. Ly, T. V., Coetzee, J. C. (2006) Treatment of primarily ligamentous Lisfranc joint injuries: Primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. Journal of Bone and Joint Surgery, 88: 514–520. 41. Myerson, M. S. (1999) The diagnosis and treatment of injury to the tarsometatarsal joint complex. Journal of Bone and Joint Surgery (British Volume), 81(5):756–763.

42. Aronow, M. S. (2006) Treatment of the missed Lisfranc injury. Foot and Ankle Clinics, 11(1): 127–142.

43. Quénu E, Küss G. Etude sur les luxations du metatarse. Reb Chir, 1909(39): 281.

44. Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W (1982) Injuries to the tarsometatarsal joint. Incidence, classification and treatment. Journal of Bone and Joint Surgery (British Volume), 64: 349–356. 45. Ross, G., Cronin, R., Hauzenblas, J., Juliano, P. (1996) Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. Journal of Orthopaedic Trauma, 10(2): 119–122.

46. Nunley, J. A., Vertullo, C. J. (2002) Classification, investigation, and management of midfoot sprains. American Journal of Sports Medicine, 30(6): 871–878.

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47. Haapamaki, V., Kiuru, M., Koskinen, S. (2004) Lisfranc fracturedislocation in patients with multiple trauma: diagnosis with multidetector computed tomography. Foot and Ankle International, 25(9): 614–619. 48. Raikin, S. M., Elias, I., Dheer, S., Besser, M. P., Morrison, W. B., Zoga, A. C. (2009) Prediction of midfoot instability in the subtle Lisfranc injury. Journal of Bone and Surgery (American Volume), 91(4): 892–899.

49. DeOrio, M., Erickson, M., Usuelli, F. G., Easley, M. (2009) Lisfranc injuries in sport. Foot and Ankle Clinics, 14(2): 169–186. 50. Desmond, E. A., Chou, L. B. (2006) Current concepts review: Lisfranc injuries. Foot and Ankle International, 27(8): 653–660.

51. Cosculluela, P. E., Ebert, A. M, Varner, K. E. (2009) Dorsomedial bridge plating of Lisfranc injuries. Techniques in Foot and Ankle Surgery, 8(4): 215–220. 52. Alberta, F. G., Aronow, M. S., Barrero, M., Diaz-Doran, V., Sullivan, R. J., Adams, D. J. (2005) Ligamentous Lisfranc joint injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation. Foot and Ankle International, 26(6): 462–473. 53. Lee, C. A, Birkedal, J. P, Dickerson, E. A., Vieta, P. A, Webb, L. X., Teasdall, R. D. (2004) Stabilization of Lisfranc joint injuries: a biomechanical study. Foot and Ankle International, 25(5): 365–370.

54. Coetzee, J. C, Ly, T. V. (2007) Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. Surgical technique. Journal of Bone and Surgery (American Volume), 89(1): 122–127.

55. Henning, J. A, Jones, C. B., Sietsema, D. L., Bohay, D. R., Anderson, J. G. (2009) Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot and Ankle International, 30(10): 913–922. 56. Smith, N., Stone, C, Furey, A. (2016) Does open reduction and internal fixation versus primary arthrodesis improve patient outcomes for Lisfranc trauma? a systematic review and meta-analysis. Clinical Orthopaedics and Related Research, 474(6): 1445–1452.

57. Kuo, R. S., Tejwani, N. C., Digiovanni, C. W., Holt, S. K., Benirschke, S. K., Hansen, S. T., et al. (2000). Outcome after open reduction and internal fixation of Lisfranc joint injuries. Journal of Bone and Joint Surgery (American Volume), 82(11): 1609–1618.

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58. Rajapakse, B., Edwards, A., Hong, T. (2006) A single surgeon’s experience of treatment of Lisfranc joint injuries. Injury, 37(9): 914– 921. 59. Aune, S. (1955) Osteoarthritis of the first carpo-metacarpal joint, Acta Chirurgica Scandinavica, 109: 449–456. 60. Napier, J. R. (1955) Form and function of the carpometacarpal joint of the thumb, Journal of Anatomy, 89: 362–369.

61. Weilby, A. (1971) Surgical treatment of osteoarthritis of the carpometacarpal joint of the thumb, Scandinavian Journal of Plastic and Reconstructive Surgery, 5: 136–141.

62. Weinman, D. T. and Lipscomb, P. R. (1967) Degenerative arthritis of the trapezio-metacarpal joint: arthrodesis or excision? Mayo Clinic Proceedings, 42: 276–287.

63. Resnick, D. (1974) Arthrography in the evaluation of arthritic disorders of the wrist, Radiology, 113: 321–340. 64. Linscheid, R. L., Dobyns, J. H., Beabout, J. W., and Bryan, R. S. (1972) Traumatic instability of the wrist, Journal of Bone and Joint Surgery, 54A: 1612–1632.

475

Index

abduction 5, 6, 13, 48–51, 57–59, 88, 92, 93, 103, 104, 110, 111, 113, 114, 116–118, 180–182, 184, 231, 251, 252, 267, 274, 275, 414, 415, 461–463, 466–468 active 95, 123, 181 bilateral 49 diminished 286 excessive 460 forcible 439 forefoot 359, 360 isometric 95 MPC joint 465 scapular plane 129 abductor 253, 259, 268, 466 abductor digiti minimi (ADM) 42, 177, 184, 186, 403, 406, 465 abductor digiti quinti 178 abductor hallucis 403, 405, 406 abductor hallucis muscle 345, 411 abductor pollicis 439 abductor pollicis brevis 30, 42, 167, 178, 184, 200, 417 abductor pollicis longus (APL) 25, 28, 33, 38, 167, 176, 184, 187, 197, 415, 416, 430, 435, 468 abnormality 80, 99, 108, 267, 271, 286 AC joint 78 anatomic 321 bony 105 dental 54 femoral 271 leg length 269 pre-existing 190 scars and nail 191 abrasion 191, 247

AC joint see acromioclavicular joint ACL see anterior cruciate ligament ACL injury 327–329, 332–335, 340 ACLR see anterior cruciate ligament reconstruction ACL tear 303, 313, 328–330, 332–334, 336 acromioclavicular joint (AC joint) 45, 46, 54, 55, 64, 67, 70, 73–82, 128 acromion 12, 46, 48, 76–78, 81, 83, 92, 95, 111, 116, 119, 121, 122, 124, 125 acromion process 34, 46, 57, 79 activity athletic 251 osteoblastic 279 pinching 440 provocative 96 weight-lifting 74 adduction 5, 6, 48–51, 58, 59, 87, 113, 114, 117, 180–182, 231, 251, 252, 267, 414, 463, 465, 466, 468, 469 cross-body 118 dorsal 183 excessive 142 forefoot 359, 360 horizontal 68, 95, 96 severe 249 adduction contracture 415 adductor 253, 261, 466 adductor longus 249, 250, 253 adductor magnus 250, 253, 261 adductor pollicis 32, 42, 187, 199, 435, 468

478

Index

adhesion 83, 109, 114, 115, 122, 125, 319, 433 adhesive capsulitis 106, 107, 111, 119 ADM see abductor digiti minimi AER see apical ectodermal ridge AIIS see anterior inferior iliac spine alcohol withdrawal 190 amphiarthroses 4, 5, 223 amputation 190, 214, 215, 217, 443, 455, 456 analgesics 112, 213, 284 anconeus 22, 28, 145, 148, 156 anesthesia 54, 99, 101, 113, 191, 284 ankle dorsiflexion 369, 370, 379, 381, 385 ankle instability 353, 386 ankle mortise 345, 387 ankylosing spondylitis 162, 228, 232, 233, 235, 239 ankylosis 181, 229, 236, 238, 284 annulus fibrosus 234, 237, 240 anterior aspect 88, 142, 149, 152, 154, 175, 177, 248, 250, 295, 296, 301 anterior compartment 21, 23, 27, 29, 35, 145, 352, 353, 397 anterior cruciate ligament (ACL) 299, 300, 302, 305, 310, 312, 327–342 anterior cruciate ligament reconstruction (ACLR) 330, 334–338, 340, 341 anterior inferior iliac spine (AIIS) 257, 260 anterior instability 59, 60, 68, 96 anterior muscle 10, 47, 48, 100, 104, 105, 402 anterior superior iliac spine (ASIS) 231, 247–249, 268–272 apical ectodermal ridge (AER) 7 APL see abductor pollicis longus

apprehension 59, 60, 62, 92, 93, 159, 209 apprehension test 59, 92, 308 arch 116, 134, 170–172, 343, 366, 383, 386, 405, 444, 460, 461 continuous 46 dorsal venous 11, 144, 402 medial 383, 384 midfoot 445 O-type 185 transverse and longitudinal 170, 459 artery 10–15, 19–22, 28, 72, 168, 172, 175, 177, 249, 257, 258, 260, 352, 410, 417 femoral 249, 258, 260 intercostal 19 nutrient 258 obturator 258, 262 perforating 258 peroneal 397 popliteal 298 retinacular 258, 262 arthritis 73–75, 77, 78, 80, 131, 133, 235, 318, 323, 372, 378, 456 carpal 418 crystalline 74 hindfoot 370 patellofemoral 309 psoriatic 214 pyogenic 284 reactive 132 rheumatoid 119, 159, 162, 164, 176, 177, 179, 212–216, 390, 400, 430, 432 septic 73, 128, 278, 284 trapezio-scaphoid 415, 416, 432 arthrodesis 212, 284, 287, 323, 414–416, 432, 442, 455 arthrogram 120, 123, 282, 415, 427–430, 458, 461 arthrography 93, 111, 319, 427, 430

Index

arthroplasty 81, 122, 126, 162, 255, 263, 264, 277, 287, 288, 323, 416 arthroscopy 90, 93, 99, 126, 134 articular capsule 4, 6, 120, 391 articular disk 6, 55, 71, 72, 459 articular surface 5, 71, 98, 117, 162, 168, 390, 391, 394, 434, 435, 457, 462, 463 articulation 4, 6, 71, 80, 144, 145, 166, 170, 175–177, 254, 255, 417, 459, 460 costal 236 hamatolunate 166 humeroradial 145 humeroulnar 145 intercarpal 170, 459 midcarpal 166 scapulothoracic 45 triquetrum-hamate 170, 459 wrist’s 175 ASIS see anterior superior iliac spine avascular necrosis 212, 262, 285, 289 avulsion 83, 163, 213, 296, 319, 332, 336, 399, 400, 439, 440, 449 avulsion fracture 398, 439, 440 axillary vein 11, 19, 41, 144

Baker’s cyst 294, 298 Bankart lesion 83, 85, 89 Barlow’s test 275–277 Baumann angle 161 Bennett’s fracture 413, 434–437 biceps 46, 48, 50, 53, 56–58, 61, 62, 66, 83, 88, 126–129, 154, 156, 300, 301 biceps brachii 22, 28, 144, 145 biceps tendon 22, 66, 94, 114, 117, 127, 154, 157, 298 bicipital groove 46–48, 61, 62, 66, 110, 116

bicipital tendonitis 61, 62, 66 bone 4–6, 8, 9, 32, 54, 73, 75, 100, 122, 130, 133, 145, 165, 166, 173, 174, 206, 207, 223–225, 344, 345, 349, 350, 418 calcaneal 356 carpal 32, 33, 166–171, 173, 175, 207, 209, 416, 418, 456, 458, 460, 461, 468 collar 76 cuboid 344 cuneiform 344 hamate 23, 32, 39, 42, 43, 166, 168–173, 175, 177, 187, 457, 459, 460 innominate 223, 282 innominate/hip 223 omovertebral 100, 101, 104 pelvic 225 pubic 223 scaphoid 33, 42, 165, 166, 168–170, 173, 174, 178, 187, 188, 207, 209, 418, 427, 428, 457–460, 463 skull 54 subchondral 75, 238, 416 tarsal 392 vertebral 234 bony architecture 96, 444 bony defect 87, 294 bony deformity 93, 206 bony landmarks 46, 80, 151, 294 bony prominence 48, 175, 188, 248, 294, 344–346, 356, 392 brachial artery 21, 22, 27–29, 126, 143, 144, 154 brachial plexus 9, 10, 12–15, 27, 28, 31, 47, 65, 69, 143, 144 brachioradialis 25, 28, 145, 147, 153, 154, 156 branches 10, 11, 14–16, 19, 25, 27–31, 41, 42, 51, 52, 143, 258, 262, 408, 410, 411 anterior 156, 259

479

480

Index

anterior interosseous 23, 24, 30, 183 circumflex scapular 16 digital 30 dorsal 31 dorsal sensory 201 infrapatellar 301 malleolar 397 posterior 262 sensory 157, 171, 414, 415 subscapular artery 16 superficial 10, 27, 28, 31, 41, 409 superficial sensory 203 terminal 27, 176 thenar 30 thoracic 19, 20 vascular 29 breast 17–19, 230 brevis 154, 361 adductor 250, 253, 261 extensor carpi radialis 25, 28, 37, 153, 167, 176, 183, 198, 463 extensor hallucis 361, 452 flexor digiti minimi 43, 408 flexor digitorum 345, 403, 404, 406, 407 flexor hallucis 408 peroneus 345, 368, 396 Bryant’s triangle 271, 272 bursa 4, 6, 130–134, 142, 145, 147, 151, 249, 250, 294, 296, 297, 353, 355, 356, 464 calcaneal 356 gastrocnemiussemimembranosus 298 iliopsoas 250 prepatellar 296, 321 retrocalcaneal 355 semimembranosus 321 subacromial 47, 56, 115, 118 subacromial-subdeltoid 120 subdeltoid 47

subscapular 57, 111 superficial infrapatellar 296 bursitis 49, 130–134, 153, 264, 296, 355 infrapatellar 294, 321 ischial 250 painful iliopsoas 250 trochanteric 267 buttocks 228, 229, 248, 251, 254, 264, 270

calcaneum 345, 381, 405, 406 calcaneus 343–346, 350, 353–356, 359–361, 392–395, 401, 403, 404, 410 calcification 119, 163, 240, 405 callosity 172, 176, 344, 346, 350, 354, 358, 365, 375, 376, 390 carpal tunnel 30, 31, 35, 168, 171, 178, 202, 460, 464 carpal tunnel syndrome 31, 135, 202, 208, 209, 215 carpometacarpal joint (CMC joint) 32, 38, 166, 170, 171, 180, 182, 184, 413–418, 432, 434, 435, 437, 456, 459, 461, 462, 467, 468 carpus 165, 168, 173, 174, 207, 211, 416, 418, 459 cartilage 4–6, 8, 72, 100, 287, 327, 334, 399, 420, 454 articular 4–6, 121, 126, 287, 321, 328, 392 costal 71 hyaline 4, 6 joint 73 triradiate 255 cauda equina syndrome 229, 239, 243 circumduction 5, 58, 59, 114, 420 clavicle 7, 12, 34, 46, 48, 54, 67, 69, 71, 72, 76, 77, 104 CMC joint see carpometacarpal joint

Index

Codman’s test 64 compression 69, 133, 160, 178, 208, 243, 404, 434 axial 159, 377, 420 bilateral 45 carpal tunnel 179 ulna nerve 208, 209 compressive force 92, 226, 305, 306, 462 computed tomography (CT) 85, 93, 98, 102, 105, 238, 280–282, 333, 435, 450 condyle 141, 160, 162, 261, 333, 397, 399, 402, 466 coracobrachialis 21, 50, 56, 58, 77, 144 coracoid 59, 60, 83, 85, 94, 114, 122 Cozen’s test 158 Crank test 59, 60 C-reactive protein test 278 CT see computed tomography cubital fossa 22, 24, 28, 29, 143, 144, 154, 157 cuff 47, 57, 86, 117, 120 irreparable 125 posterior 116 cuff tear 116, 120–122, 125 cuneiform 396, 397, 402, 408, 410, 443–445 cutaneous branch 14, 15, 29, 31, 34, 403 DDH see developmental dysplasia of the hip defect 85, 89–91, 98, 123, 295, 296, 345, 354 deformity 101, 102, 147, 148, 161, 162, 179, 192, 196, 213, 214, 242–244, 266, 315–317, 347, 365, 366, 375, 376, 378, 379, 434 anatomical 191 boutonniere 193, 213

bunionette 366 buttonhole 179 cavovarus 366, 382 chest 244 concomitant 102 coronal 242 gunstock 142, 148, 161 hammer 366 hatchet 237 spinal 242 swan neck 179, 192 degrees of flexion 77, 93, 114, 118, 183, 299, 306, 308, 310, 312, 313, 318, 319 degrees of freedom 170, 459, 461–463, 467 deltoid 12, 14, 15, 45, 48, 50–52, 56–59, 76, 77, 94, 96, 107, 116, 121–123, 125, 126 deltoid muscle 13, 15, 48, 53, 54, 56 dermatome 53, 110, 254, 301, 362 developmental dysplasia of the hip (DDH) 269, 275, 278, 283 diabetes 106, 107, 131, 190, 374 differential diagnosis 102, 111, 119, 128, 204, 207, 208, 239, 284, 289, 290 DIP joint see distal interphalangeal joint disease 212, 214, 234, 235, 237, 241, 264, 272, 282, 285, 287, 420, 421 autoimmune 109, 241 Bechterew’s 232 Charcot’s 162, 323 degenerative joint 376 demyelinating 241 De Quervain’s 176, 213 Freiberg’s 347, 377 inflammatory bowel 229 Kienbock’s 170, 205, 212, 458 Köhler 350, 351 liver 241

481

482

Index

neurological 190 Paget’s 239, 290 Parkinson’s 109 peripheral vascular 365, 369, 374 Perthes 281, 282, 284, 285 spinal 241 systemic 365 thyroid 131 vascular 352 dislocation 46, 82, 83, 87, 91–93, 96, 99, 244, 249, 255, 321, 398–400, 446 anterior 68, 83, 85, 92 anterolateral 399 congenital 248, 282 dorsal 177 erect 83 habitual 90, 97, 99 humeral 90 multidirectional 84 non-traumatic 84 radial head 152 traumatic 97 voluntary 91 disorder 107, 110, 135, 163, 269, 315, 321 bone 350 chronic inflammatory 232 liver 289 muscle-pain 226 neurologic 315 distal humerus 50, 70, 142, 160, 161 distal interphalangeal joint (DIP joint) 23, 26, 33, 36, 176, 179, 182, 183, 192, 193, 195, 213, 358, 360, 366, 442, 463 distal phalanges 33, 176, 396, 397, 402 distal phalanx 23, 24, 26, 34, 36, 38, 40, 396, 397, 402, 404, 442, 464, 465, 467, 468 distal tibia 95, 359, 360, 386, 392

dorsiflexion 212, 359, 362, 371, 372, 377, 378, 380, 381, 383, 391, 393, 397, 398, 405

ECRB see extensor carpi radialis brevis ECRL see extensor carpi radialis longus ECU see extensor carpi ulnaris EDC see extensor digitorum communis edema 116, 117, 149, 238, 281, 341, 344, 355, 360, 447 EDM see extensor digiti minimi EIP see extensor indicis proprius EPB see extensor pollicis brevis EPL see extensor pollicis longus Erb’s palsy 45 Erb’s paralysis 9 extensor carpi radialis brevis (ECRB) 25, 28, 37, 153, 167, 175, 176, 183, 198, 463 extensor carpi radialis longus (ECRL) 25, 28, 37, 153, 154, 167, 177, 183, 198 extensor carpi ulnaris (ECU) 25, 28, 37, 167, 168, 169, 175, 177, 183, 198, 436 extensor digiti minimi (EDM) 26, 28, 38, 168, 177, 183, 198, 464, 465 extensor digitorum communis (EDC) 37, 177, 183, 198, 463–465 extensor digitorum longus 352, 361, 397, 398, 402 extensor hallucis longus 352, 361, 397, 398, 402 extensor indicis proprius (EIP) 38, 198, 464, 465 extensor pollicis brevis (EPB) 26, 28, 38, 167, 176, 188, 197, 213, 414, 439, 468

Index

extensor pollicis longus (EPL) 26, 28, 34, 38, 157, 167, 176, 188, 197, 197, 415, 468 extensor tendon 25, 26, 167, 175, 176, 179, 187, 192, 213, 465

FAI see femoro-acetabular impingement FCR see flexor carpi radialis FCU see flexor carpi ulnaris FDL see flexor digitorum longus FDP see flexor digitorum profundus FDS see flexor digitorum superficialis Feagin test 60 femoral condyles 295, 299, 305, 322 lateral 295, 298, 300, 329, 332, 395 medial 294–296, 300, 301, 305, 395 posterior 341 femoral head 237, 249, 254, 256–258, 262, 281, 282, 285, 288 femoro-acetabular impingement (FAI) 264, 274, 282 FFD see fixed flexion deformity Finkelstein’s test 176, 208, 209 fixed flexion deformity (FFD) 180, 266, 272–274, 432, 433 Fleck sign 449, 450 Flesche test 229 flexor carpi radialis (FCR) 29, 31, 150, 153, 156, 168, 178, 183, 187, 197, 200, 414, 416, 417 flexor carpi ulnaris (FCU) 23, 29, 31, 39, 150, 153, 168, 175, 177, 183, 187 flexor digitorum longus (FDL) 352, 362, 396, 398, 406–408

flexor digitorum profundus (FDP) 23, 29–31, 34–36, 39, 40, 43, 168, 183, 196, 199, 200, 442, 463, 464, 466, 467, 469 flexor digitorum superficialis (FDS) 23, 29, 30, 34, 35, 39, 41, 168, 168, 183, 196, 442, 463, 464, 469 flexor hallucis longus 352, 361, 396, 398 flexor pollicis brevis 30, 42, 178, 185, 417 flexor pollicis longus (FPL) 23, 30, 35, 40, 157, 168, 184, 197, 433, 467, 469 flexor retinaculum 24, 30, 31, 39, 168, 171, 172, 213, 405, 417, 464, 468 Fowler’s sign 59, 68 FPL see flexor pollicis longus fracture 53, 54, 115, 117, 149, 151, 174–176, 206, 207, 238, 239, 278–281, 289, 290, 345, 346, 353, 434, 435, 437, 440 boxer’s 176 Colles’ 177, 181, 205, 211 concomitant 399 coronoid 161 distal clavicle 75 distal radius 170, 458 gamekeeper’s 439 glenoid impression 85 humeral 10 intraarticular 437 neck 14 olecranon 149 osteochondral 322 radial head 161 spinal 70, 239 tibia 399 transverse 319, 399 trimalleolar 399 two-piece 436 volar lip 440

483

484

Index

Freiberg’s infraction 346 frozen shoulder 49, 71, 106–109, 111, 112, 114, 115, 126 fungal infection 173, 241, 365

gait 247, 254, 265, 266, 293, 360–364 antalgic 265, 379 arthrogenic 265 bipedal 363 out-toeing 257 Galeazzi’s test 270, 271, 365 gastrocnemius 354, 360, 361, 363, 381, 395, 398 genu valgum 293, 315 genu varum 293, 316 Gilchrest’s test 66 Gillet test 232 glenoid 34, 55, 83, 87–89, 92, 93, 95, 97, 98, 100, 117, 126 glenoid fossa 13, 56, 57, 68, 79, 83, 87 glenoid labrum 55, 83, 87, 90 glenoid rim 68, 79, 83, 85, 88–90, 94, 117 gluteus maximus 248, 249, 251, 253 golfer’s elbow 131, 149, 158, 163 gout 128, 131, 159, 164, 214, 240, 344 gravity 51, 244, 253, 300, 372, 391 greater trochanter (GT) 226, 234, 248–250, 256, 257, 259, 264, 267, 271, 272, 287 GT see greater trochanter Guyon’s canal 168, 201 Guyon’s tunnel 172, 175, 177–179 hamstrings 251–253, 294, 299, 300, 302, 304, 312, 337 Hawkin–Kennedy test 63, 65 Hawkins test 118 hemarthrosis 318, 319, 329 hematoma 47, 149, 353, 411

hemipelvis 268, 269 Hill–Sachs lesion 83, 98 Hornblower’s test 66 humeral head 54, 57, 59, 61, 67, 68, 79, 83, 85, 87, 89, 92, 93, 116, 117, 119 humerus 12–15, 17, 21–27, 35, 46–48, 53, 54, 57, 59–61, 68, 87, 88, 126, 131, 132, 142–144, 151, 160, 161 lateral epicondyle 142 posterior 22 posterolateral 12 proximal 55, 126 supracondylar 149

iliac crest 48, 65, 141, 231, 234, 248, 250, 252, 254 ilium 224, 249, 254, 259, 261, 280 impingement 79, 83, 93, 116–118, 132, 264, 274, 282, 340, 380 impingement test 63, 64 incision 45, 84, 94, 103, 122, 128, 185, 217, 319, 414, 415, 452 infection 73, 74, 131, 133, 134, 179, 181, 206, 211, 212, 217, 228, 233, 240, 241, 249, 250, 278, 279, 365, 438, 439 inflammation 73, 80, 81, 112, 116, 117, 130–134, 158, 164, 228, 229, 232, 237, 241, 317, 321 injury 9, 10, 75, 76, 80, 81, 84, 85, 131–134, 190, 192, 194, 196, 303–305, 310, 312, 313, 317, 318, 327–330, 334, 399, 400, 439, 440, 442, 443, 445–447 ankle 399 athletic 445 bony avulsion 334, 336 crush 193, 445 epiphyseal 141, 316 flexor tendon 442 jersey finger 442 labral 83

Index

lunotriquetral 210 nail gun 192 neurovascular 446 posteromedial corner 334 soft tissue 399 syndesmosis 387 traction nerve 114 traumatic 74 traumatic brain 194 whiplash 47 innervation 12–14, 19, 29, 38–40, 42–44, 157, 395–397, 402, 410 abducts thumb 38, 42 distal interphalangeal joints 40 flexes thumb 42 joint 37 medial cuneiform 397 motor 143, 144 pronates forearm 40 segmental 398 sensory 28, 29, 143, 144 wrist 37–39 interphalangeal joint (IP joint) 38, 39, 172, 176, 179, 180, 184– 186, 191–195, 197–200, 404, 407, 409, 456, 463, 466–470 intrinsic muscle 9, 30, 37, 40, 173, 198, 405, 468 IP joint see interphalangeal joint Jackson’s test 69 Jack’s test 383, 386 Jobes relocation test 59, 93 Jobe test 66, 118 joint 4–6, 21, 54, 56, 145, 182, 183, 185, 187, 192, 194–196, 237, 238, 390, 391, 416, 418, 456 apophyseal 237, 240 ball-and-socket 5, 6, 254 calcaneocuboid 360 cartilaginous 4, 5 dentoalveolar 4 dislocated 87

distal radioulnar 166, 169, 210, 457 glenohumeral 45, 49, 54, 55, 57, 60, 61, 66, 68, 70, 74, 79, 82 hip 252, 262, 266 immovable 5 inferior tibiofibular 345, 399 intercarpal 6, 166, 417, 418, 461 midcarpal 166, 167, 170, 171, 413, 456–461, 463, 465, 467, 469 midtarsal 360 movable 5 peripheral 235, 236 proximal 232 radiocarpal and midcarpal 171, 413, 456, 457, 459–461, 465, 467 root 235 sacroiliac 223–225, 227, 279 scapulothoracic 54 sternoclavicular 6, 45, 46, 54, 55, 70–73 synovial 4, 5, 461 tarsometatarsal joint 368, 378, 444, 445, 447 joint capsule 71, 76, 77, 83, 88, 111, 112, 296, 298, 391, 392, 457, 463, 467 joint reaction forces (JRF) 262, 263, 265 joint space 75, 79, 236, 265, 279, 296, 299, 318, 419, 420, 427, 428, 430 JRF see joint reaction forces junction 88, 234, 256, 294 femoral head-neck 237 lumbosacral 230 musculotendinous 442 vertebral 236 Kaplan’s line 187 Kennedy test 63, 65 Kirk-Watson test 209

485

486

Index

Klippel–Feil syndrome 100, 101 Kocher method 82 Kocher’s technique 86, 87

Lachman test 303, 304, 330, 339, 378 Laguerre test 231 lateral collateral ligament (LCL) 154, 159, 297–299, 310, 313, 353, 391–393 lateral epicondyle 22, 24–27, 37, 147, 149, 152, 154, 157, 158, 161, 163 lateral femoral circumflex artery (LFCA) 258, 262 lateral malleolus 231, 345, 353, 359, 390–393, 398, 410, 411 lateral rotation 48, 49, 58, 61, 64, 286, 300 latissimus dorsi 48, 50, 58, 59, 89, 100, 107, 125 LCL see lateral collateral ligament lesion 67, 97, 112, 117, 124, 135, 162, 233, 319, 328 atraumatic 91 bony 91 bursal 124 cervical plexus 68 extensor mechanism 319 joint 78 labral 64 mechanical 226 meniscal 319 motor neuron 157 posterior 95 space-occupying 70 LFCA see lateral femoral circumflex artery ligament 34, 55, 71, 72, 76, 88, 145, 146, 159, 167–172, 177, 178, 181, 196, 224, 257, 293, 294, 327, 353, 391–393, 417, 418, 439, 458, 459 acromioclavicular 34, 55, 76, 77

annular 24, 142, 147, 154 anterior cruciate 299, 300, 302, 327 anterior longitudinal 244 anterior oblique 434 anterior sacroiliac 232 anterior spinal 240 anterior talofibular 353, 386, 393 calcaneofibular 353, 386, 393, 398 capsular 55, 392, 417 carpal 35, 168, 171, 418 collateral 147, 154, 159, 167, 169, 181, 196, 299, 310, 328, 353, 391–393, 439, 462, 463, 466, 467 Cooper’s 18 coracoacromial 55, 94, 124 coracoclavicular 55, 76, 77 coracohumeral 55, 57, 83, 114, 122 coronary 296, 305 costoclavicular 55, 72 deltoid 351, 359, 392, 394, 398 distal syndesmosis 387 dorsal radiocarpal 459 fan-shaped 296 fibrous 310 iliofemoral 257 inguinal 249, 254 interclavicular 55, 71 intertarsal 444 intracapsular 170, 459 ischiofemoral 257 laciniate 407 lax 317, 321 lunotriquetral 210 orbicular 151 palmar radiocarpal 171 paraspinous 240 patellar 319 pisometacarpal 172 plantar 405, 408, 445

Index



plantar interosseous 444 popliteal 312, 396 popliteal fibular 313 posterior 399 posterior cruciate 300, 304, 305, 328 posterior talofibular 353, 393 pubofemoral 257 radioscapholunate 459 retinacular 465 sacrospinous 224, 225 sacrotuberous 224, 225 scapholunate 209 spring 344, 349, 350 Struthers’ 151, 152 suspensory 17 tibionavicular 394 transverse acetabular 255 transverse humeral 55, 57, 62 transverse metacarpal 460 transverse metatarsal 404, 405 transverse scapular 14 triangular 257, 392, 465 ulnocarpal 459 ulnolunate 459 ulnotriquetral 167 vaginal 464 volar 459 volar radioulnar 167, 169, 457 limb 4, 8, 205, 206, 249, 251–253, 270, 272, 273, 275, 286, 287, 299, 302, 304, 305, 413–470 Lippman’s test 66 Lisfranc injury 365, 413, 446, 447, 450, 452, 455, 456 Lister’s tubercle 167, 175, 188, 207 load and shift test 68 long thoracic nerve (LTN) 10, 53, 102, 105 LTN see long thoracic nerve Ludington’s test 66 lumbrical muscle 30, 33, 35, 41, 43, 199, 405–408, 465–467

magnetic resonance imaging (MRI) 80, 111, 120, 124, 128, 133, 238, 281, 282, 333, 355, 440, 442, 450 Maudsky’s test 158 MCL see medial collateral ligament MCP joint see metacarpophalangeal joint medial collateral ligament (MCL) 142, 153, 296, 299, 300, 303, 310–312, 332, 344, 351 medial epicondyle 23, 31, 35, 39, 149–154, 158, 160, 163, 296, 311 medial femoral circumflex artery (MFCA) 258, 262 medial malleolus 269, 270, 344, 345, 351, 352, 359, 362, 370, 372, 374, 390, 392–394, 398, 399 medial meniscus 294, 296, 297, 305, 319, 334 metacarpals 23, 25, 32, 34, 37–39, 42, 43, 166, 168–170, 175, 176, 182, 183, 185–187, 207, 414, 415, 417, 418, 427, 428, 434, 435, 460 metacarpophalangeal joint (MCP joint) 9, 36, 43, 44, 182–184, 186, 193, 214, 433, 437, 439– 442, 456, 462, 463, 465–470 metatarsal head 344, 346, 347, 356, 358, 361, 363, 364, 375, 377, 378, 401 MFCA see medial femoral circumflex artery MRI see magnetic resonance imaging muscle 29, 30, 33, 35, 37, 39–44, 47, 57–59, 105, 124, 125, 127, 130, 131, 153, 154, 170, 172, 173 , 249, 250, 259–262, 361, 362, 404–406, 410, 411, 462, 463, 466, 467

487

488

Index

accessory 398 biceps 48, 127, 131 bipennate 410 brachioradialis 22, 27, 153 calf 132 fan-shaped 48 flexor 35 flexor-pronator 147 gastrocnemius 298, 362 gluteal 224 hypothenar 42 iliopsoas 250 interrossei 199 parascapular 95 paravertebral 247 peroneal 382 peroneus 410 plantaris 404 popliteus 297 posterior 383 quadriceps 132, 293, 295, 301, 305, 309, 321 rhomboid 105 sartorius 249, 250, 297 scapular 67, 102, 121 semitendinosus 296, 297 supraspinatus 63 thenar 40, 172, 187, 417, 468, 469 thorax 105 trapezius 103 unipennate 409 muscle belly 35, 126, 127, 154, 361 Naffziger’s test 70 neck 6, 46, 47, 49, 53, 54, 64, 68, 69, 101, 154, 252, 256, 392, 393 anatomical 88 femoral 256, 257, 262, 281 humeral 97 intracapsular 262, 281

metatarsal 346 scapular 83 surgical 10, 15, 88 wry 47 Neer’s test 63, 118 nerve 19, 21, 22, 27, 31, 153, 154, 198, 201, 250, 260, 298, 352, 353, 404, 406 axillary 10, 12–15, 17, 50, 51, 53, 54, 56, 58, 91, 157 brevisradial 184 cluneal 250 cranial 52 digital 405 dorsal scapular 52 femoral 249, 252, 259, 301 lateral anterior thoracic 51 lateral pectoral 58 lateral plantar 403, 406–411 medial supraclavicular 72 median 22–24, 28–31, 39, 40, 42, 151, 154, 156, 168, 171, 178, 183–185, 187, 193, 199, 215 musculocutaneous 21, 50, 144, 154, 156, 157 obturator 253, 264 peroneal 361, 397, 401 posterior articular 328 posterior interosseous 28, 38 radial 17, 25–28, 34, 37, 38, 143, 156, 176, 183–185, 203, 414, 415 saphenous 301, 401 scapular 50 sciatic 249, 298, 301 sensory 441 spinal 243 superficial peroneal 361, 396, 401, 410 suprascapular 13, 14, 58, 66, 126 sural 401 thoracic 10, 53, 105 thoracodorsal 14, 15, 17, 50

Index

tibial 328, 351, 352, 361, 362, 396, 398, 403, 407, 408, 410, 411 trapezius-spinal accessory 52 ulnar 23, 27, 29–31, 39, 40, 42–44, 141, 147, 148, 151, 152, 154, 159, 162, 164, 168, 172, 175, 177, 178, 183–185, 187, 193, 200, 201 nerve root 53, 69, 244, 406–409 neuropathy 66 alcoholic 374 diabetic 365, 374, 390 peripheral 365, 374 numbness 28, 178, 189, 201–203, 215, 411

O’Brien test 64 Ochsner’s test 200 olecranon 23, 143, 147, 149, 151–154, 161, 163 olecranon bursitis 142, 149, 158 open reduction internal fixation (ORIF) 53, 435, 438, 455 ORIF see open reduction internal fixation ossification 8, 54, 233, 236, 237, 240, 244 osteoarthritis 73–75, 162, 164, 211, 212, 264, 265, 279, 287, 294, 323, 324, 413, 414, 416 osteochondritis dissecans 162, 294, 322, 323 osteophytes 75, 79, 119, 226, 237, 279, 287, 294, 369 osteotomy 103, 211, 242–244, 284, 287, 323, 378 clavicular 103 derotation 282, 283 eggshell 243 geo-metric fixation 286 pedicle subtraction 243 pelvic 283



posterior 243 supraspinatus fossa 104 tibial 316 wedge 161

palmaris longus (PL) 29, 39, 150, 153, 168, 177, 178, 187, 328, 368, 442 palpation 46, 47, 147, 149–151, 153, 155, 173, 179, 194, 206, 248, 249, 267, 294–297, 344– 347, 356, 357, 369 bimanual 282 bony 151, 173, 248 lymph node 150 soft tissue 47, 151, 152, 176, 249, 295, 347 paralysis 9, 10, 102, 104, 105, 199, 200, 353 patella 8, 132, 133, 260, 293–296, 300, 306, 308, 309, 317, 319, 321, 337 patella apprehension test 308 PCL see posterior cruciate ligament pelvis 223, 224, 226, 233, 237, 240, 247–252, 254–290, 364 peroneus longus 345, 361, 368, 396, 410 phalanges 32, 176, 179, 182, 404, 407 phalanx 213, 214, 383, 407, 439, 462, 463 Phalen’s test 178, 201, 202 physiotherapy 112, 113, 163, 182, 240, 334, 335 PIP joint see proximal interphalangeal joint pisiform 23, 34, 153, 166, 168, 173, 175, 178, 187, 207, 210, 211 pivot shift test 303, 313, 331, 332 PL see palmaris longus plantar aponeurosis 345, 356, 403–406

489

490

Index

plantarflexion 343, 345, 351, 354, 359, 361, 364, 370, 372, 377, 379, 382, 391, 394–396, 398, 399 platelet-rich plasma (PRP) 336, 341 poliomyelitis 163, 298, 351 posterior cruciate ligament (PCL) 300, 304, 305, 310, 312, 313, 328 posterior superior iliac spine (PSIS) 225, 232, 248, 250, 254 Pott’s fracture 398, 399 procedure arthrographic 112 arthroscopic 99, 336 bony 366 extra-articular 336 inferior capsular shift 97 intraarticular 336 invasive 282 laserjet 94 outpatient 123 soft tissue 321, 366 surgical 97, 102, 105 tear repair 122 process alveolar 4 endochondral 7 energy-efficient 362 history-taking 147 intra-articular 109 pathologic 85 systemic inflammatory 239 pronation 22, 25, 61, 64, 142, 145, 148, 151–153, 155, 156, 180, 182, 183, 210, 413, 414 pronator quadratus 24, 29, 30, 143, 145, 156 pronator teres 22, 24, 29, 40, 143, 145, 150, 153, 154, 156 Protzman test 68

provocative test 77, 78, 159 proximal interphalangeal joint (PIP joint) 36, 172, 176, 179, 182, 183, 213, 366, 378, 456, 463 proximal phalanx 34, 36, 38, 42–44, 182, 184, 186, 196, 197, 405, 406, 408, 409, 437, 440, 462–465, 467, 468 PRP see platelet-rich plasma pseudojoint 415, 428–430 PSIS see posterior superior iliac spine push-pull test 68 QoL see quality of life quality of life (QoL) 241, 263, 443

reconstruction 93, 95, 102, 159, 191, 217, 338, 456 anterior capsulolabral 95 capsular shift 98 reverse Phalen’s test 202, 203 reverse pivot shift test 313 rhomboid 52, 72, 89, 100, 103 ribs 4, 10, 11, 15, 18, 46, 47, 71, 72, 100, 103, 105 Rockwood test 59 Rolando’s fracture 413, 437, 438 rotator cuff 47, 57, 83, 85, 95, 99, 107, 116, 117, 120–122, 129, 131, 132 rotator cuff tendinitis 110, 118, 131, 132 scapula 10, 12, 13, 21, 22, 46–49, 52–54, 56, 58–60, 67, 70, 72, 87, 89, 92, 100–106, 126 sensation 69, 154, 157, 185, 195, 201, 203, 374, 375, 469 funny bone 153 grinding 118 gritty 209 Shepherd’s fracture 349 shoulder dislocation 48, 54, 82, 83, 114

Index

shoulder girdle 45–48, 50, 54, 74, 77, 100, 104, 110, 121 sinus tarsi 353, 361, 368 Smith-Petersen osteotomy 243 Speed’s test 61 spine 12, 46–48, 54, 59, 60, 64, 69, 100, 101, 232–234, 236, 237, 240, 275, 280 ankylosed 239 anterior inferior iliac 257 anterior superior iliac 247–249, 268 cervical 28, 48, 69, 70, 101, 235, 238 ischial 225 lumbar 226, 229, 237 posterior inferior iliac 225 posterior superior iliac 225, 248, 250, 254 scapular 79 superior iliac 231 spondylitis 228, 232, 240 sprain 76, 445, 450 Sprengel’s deformity 46, 100, 101, 104 Stener lesion 439, 440 stress 81, 92, 133, 159, 196, 209, 210, 229, 256, 310, 428, 429 anterior 92 posterior 88, 92, 93 tensile 462 subclavian artery 10, 15, 16, 19, 143 subluxation 91, 92, 151, 154, 245, 282, 303, 332, 399, 400, 434, 436, 440 dorsal 434, 446, 447, 449 inferior 92 joint 378 physiological 414 static 125 superior 126

subscapularis 13, 14, 47, 52, 56, 57, 59, 66, 94, 96, 98, 107, 114, 116, 124, 125 supination 61, 62, 64, 127, 128, 142, 145, 151, 152, 155, 156, 159, 180, 182, 183, 207 supraspinatus 13, 14, 16, 47, 56–58, 66, 95, 103, 107, 114, 116, 125, 126 surgery 80, 81, 97, 99, 101, 102, 104, 106, 134, 190, 336, 338, 340, 341, 433, 437, 438 coronary bypass 19 orthopedic 414 pelvic 267 salvage arthrodesis 456 surgical treatment 81, 82, 91, 97, 102, 282–284, 287, 319, 323 swelling 76, 77, 81, 141, 142, 147, 148, 177, 179, 189, 194, 206, 213, 214, 266, 267, 435, 440 bilateral 344 boggy 249 bony 189 bulbous 154 bursal 293 extra-articular 360 fusiform 191, 194 intra-articular 360 pea-sized 177 soft tissue 451 spindle-shaped 179 synovial membrane 5, 6, 34, 392, 417, 418 synovitis 160, 233, 284, 293, 317, 318, 323, 375, 419 chronic 284 transient 284, 317 talus 344, 345, 349, 352, 353, 356, 359, 360, 386, 387, 390–394 Tatar neck 370

491

492

Index

tear 60, 66, 76, 120, 122–124, 127, 132, 296, 299, 300, 302, 319, 332, 334 anterior cruciate 300 anterior cruciate ligament 312 articular side 117 biceps tendon 128 infraspinatus 125 intra-substance 334 ligamentous 440 meniscal 306, 328 microscopic 132 patellar tendon 133 PCL 328 posterior capsular 334 posterior cruciate 300 quadriceps tendon 133 tendinitis 49, 62, 107, 117, 119, 130–133, 135 tendoachilles 351, 354–356 teres 10–14, 16, 17, 47, 50, 51, 56–59, 65, 66, 104, 107, 116, 125 THA see total hip arthroplasty thenar muscle 32, 40, 41, 187 Thomas’ splint 318 Thomas’ test 272, 275 Thompson test 158, 385 tibia 294, 296, 298–300, 302, 304–306, 311–313, 316, 352, 353, 359, 360, 362, 390–399, 402, 407, 410 posterior 353 proximal 261, 387 tibialis 349–352, 361, 362, 364, 369, 370, 372, 373, 378, 382, 383, 390, 396–398, 402, 407, 408, 410 tibial tubercle 234, 294–296, 300 tingling 65, 160, 178, 201–203, 374 Tinnel’s sign 215 tissue 124, 186, 310, 347 fibroblastic 428

fibrous 107, 130, 162, 238, 405, 416 mesenchymal 8 restrictive capsular 129 shoulder capsular 108 TKR see total knee replacement total hip arthroplasty (THA) 255, 263, 288 total knee replacement (TKR) 242 traction 60, 70, 86, 87, 244, 282–285, 318, 428, 435, 437 transverse carpal ligament 168, 171, 172, 178, 215, 216, 460, 464 trapezium 32, 33, 166, 168, 170, 171, 173, 174, 178, 187, 188, 414–419, 422–430, 435, 458–461, 467 trapezius 48, 52, 58, 76, 77, 89, 100, 103–105, 125 trapezoid 32, 166, 170, 173, 207, 417, 459, 460 trauma 74, 75, 91, 130, 132, 153, 158, 191, 194, 207, 211, 212, 264, 322, 323, 365 Trendelenburg test 268, 275, 364 triceps 22, 27, 50, 53, 56, 58, 104, 129, 156, 157 triceps brachii 12, 27, 28, 143, 145 triquetrum 166, 167, 169–171, 173, 175, 207, 210, 457–460 tubercle 13, 42, 175, 176, 187, 250, 353, 417, 434 iliac 248, 254 infraglenoid 12 lateral 294, 345, 349, 352, 393, 406 peroneal 345, 353 pubic 248, 249 supraglenoid 56, 88 tuberculosis 71, 115, 149, 162, 164, 179, 212, 213, 241, 284, 318 pulmonary 214

Index

UCL see ulnar collateral ligament ulna 21–26, 31, 35, 38, 142, 144, 149, 151, 154, 159, 160, 165–167, 170, 210, 212, 458 ulnar collateral ligament (UCL) 142, 147, 159, 167, 169, 196, 413, 439–441, 457, 459, 462 ulnar nerve palsy 141, 162, 193, 198, 199 ulnar styloid process 151, 175, 177, 210 valgus 141, 159, 293, 365, 367, 382, 383, 385, 390 cubitus 141, 148, 162 hallux 347, 376, 390 valgus force 159, 303, 305, 310–312, 332 valgus stress test 159, 310, 311 varus 142, 161, 196, 367, 382 cubitus 141, 148, 161 metatarsus primus 347 vein 11, 19, 20, 72, 144, 298, 352 basilic 11, 22, 41, 144 cephalic 11, 22, 34, 41, 45, 94, 144 femoral 249 jugular 70

mammary 19, 20 median cubital 11, 22, 144 popliteal 298 saphenous 402 subclavian 11, 19, 41 subscapular 11 vertebrae 8, 100, 237, 240 dorsal 103 lumbar 226 thoracic 47, 105 vessel 19, 353, 404, 405 calcified 374 circumflex scapular 17, 58 digital 404 lateral plantar 406 spinal cord 244 VI see volar interossei volar interossei (VI) 465, 466, 468 volar plate 196, 462, 463, 465, 467 Wartenberg syndrome 203 wrist flexors 39, 161, 183, 197 Yeoman’s test 232 Yergason’s test 62 Yocum test 65

493