1 \200\207Many detailed treatments are described in this chapter, and it is not envisaged that the in- experienced doctor will try them out except under appropriate supervision. The importance of enlisting early expert help (either at once or, if appropriate, by calling t he patient back to the next morning \200\231s clinic) cannot be overemphasized. We thank James Hopkinson-Woolley and Winnie Chen and James Sewell our Specialist Readers fo r this chapter, and Fabio Conteduca for permission to use the image in \201 gure 1 \200 \224and Dr Tom Turmezei for his masterful commentaries on the many images he supplied. 657 Remain in light \200 \200\207It \200\231s better to ask than to remain in the dark; see p 701 for bone & joint types. ankylosis arthro- arthrodesis arthropathy arthroplasty arthrosc opy articular \200 Stiff ening of a joint with \201 brous or bony union across it Relating to a joint (pre \201 x) The surgical fusion of a joint A pathological process occurring within a joint Crea tion of an arti \201 cial joint (eg total hip replacement) Minimally invasive ( \200\230ke yhole \200\231) joint inspection/surgery Relating to a joint surface or capsule; extra-arti cular = outside the joint capsule; intra-articular = within the joint capsule Of a fracture , contained totally inside the body (not open) closed Of a fracture, having more than 2 par ts comminuted multifragmentary Of a fracture, having several discernible (and countable) a m u a r t d n a s c i d e a p o h t r O parts; may be preferred to \200\230comminuted \200\231 by some For axonotmesis, neurotmesi s and neurapraxia, see p760 Of fractures: having any communication with the outside world S urgical cutting, wedging, and then realignment of a bone The anterior aspect of the wrist a nd hand (preferred to volar) For physis, epiphysis, etc., see p683 nerve injuries open osteotomy palmar -physis pseudarthrosis A false joint across which movement can occur in a bone radicle (radiculo-) Nerve \201 bres that come together to form a spinal nerve root r eaming spondylo- spondylolisthesis Slippage (Greek olisthos = slippery) of one vertebra for - Surgical widening the medullary cavity of a bone Relating to a vertebra (pre \201 x; from Greek) ward on top of the other A defect in the pars interarticularis of a vertebra Term used for generalized degenerative disease of the spine Partial dislocation of a joint \200\224as opp osed to full dislocation Means \200\230twisted neck \200\231 (from Latin) \200\224see p660 . Deformity of part of a limb laterally from the normal axis Deformity of part of a limb me dially from the normal axis spondylolysis spondylosis subluxation torticollis valgus varus *A&E nomenclatures A&E stand s for Accident & Emergency; the word \200\230accident \200\231 is often dropped, and emerg ency medicine has emerged as a specialty in its own right \200\224which centers on the \200\230knowledge and skills required for the prevention, diagnosis, and management of the acute and urgent aspects of illness and injury aff ect- ing patients of all age grOUPs with a full spectrum of physical and behavioral disorders. It is a specialty in which time is c ritical \200\231.1 Principles of orthopedic examination Going through clinical examination with an expert is the best way to learn, but this experience can be reinforced by taking pr inciples and background reading with you into the arena. Most orthopedic examinations can b e de- veloped on the following structure, whether for hip, elbow, ankle 1 For each of: \200 Skin \200 Soft tissues \200 Bone 2 Do the following: \200 Look \200 Feel \200 Then, move the limb: 3 Then remember to test: \200 Ligaments \200 Neurovascular status \200 Any special te sts, eg: \200 knee meniscal tests \200 hip \201 xed \202 exion deformity. actively \200 passively (the Dr does the work) \200 versus resistance. \200\207Remember to examine one joint above and one joint below the joint in question, ie for the hip, examine the knee and lumbar spine. This will uncover any referring pathology. When thinking of movement limitation: active loss = neuromuscular de \201 cit; passive los s = bony or soft tissue impediment. The neck \200 If you suspect a cervical spine injury, immobilize the neck with hard collar , sandbags,1 and tape. NB: if very restless, use hard collar only, as otherwise the neck is vulnerable when the body moves on an immobilized head. Examination The posture of the neck and any bone tenderness (midline and over the spinous process- es) are noted. If safe to r emove collar, check the range of movements: \202 exion & extension (mainly at- lanto-occi pital joint); rotation (mainly atlanto-axial joint); lateral \202 exion (whole of cervica l spine). Rota- tion is the movement most commonly aff ected. Examine arms: test for root l esions (see MINIBOX); test the re \202 exes: (biceps C5; brachioradialis C6; triceps C7). Motor nerve roots and dermatomes are given on p716 and p762. If cord compression is suspect ed examine the lower limbs for signs of this (p770), eg upgoing plantars, hyperre \202 exi a. The main sites of injury are C6 & 7, followed by C2. 10% of C-spine fractures will have another spine fracture elsewhere, so always examine the whole spine. \200\207Take neurolo gical signs very seriously. Imaging In minor trauma use the NEXUS or Canadian C-spine rule to decide if an x-ray is required.2 Major trauma may need CT as \201 rst-line imaging (p7 79).3 When examining the image, follow 4 simple steps (ABCS): 1 Alignment: Check alignment of the following: \200 Anterior vertebral bodies; \200 Posterior vertebral bodies \200 Posterior spinal canal \200 Spinous processes ( \201 g 1). \200 A step >3mm is abnor mal (<25%=unifacet; >50%=bifacet dislocation). \200 Atlas \200\223dens interval (ADI) \200\224normal if <3mm (adults) or <5mm (children). \200 40% of <7-yr-olds have anterior displacement C2 on C3 (in this pseu- 658 \200 For root lesions, test: \200 C5: shoulder abduction \200 C6: elbow \202 exion \200 C7: elbow extension \200 C8: \201 nger \202 exion (grip) \200 T1: \201 nger abduc tion a m u a r t d n a s c i d e a p o h t r O do-subluxation the posterior spinal line is maintained). 2 Bone contour: Trace around each vertebra individually. Anterior/posterior height diff erence of >3mm (implies wedge fracture). In general <25% dif f erence is stable and >25% diff erence is unstable. \200 Pedicles (hangman \200\231s #, \201 g 4) & spinous processes (clayshoveller \200\231s #). \200 Avulsion fractures of t he vertebral body (teardrop #). 3 Cartilages: The disc space margins should be parallel (>11 is abnormal). 4 Soft tissues : Check the soft tissue shadows: Retropharyngeal \200\224C1 \200\223C3 <7mm; C4 \200\223C7 <22mm/1 vertebral body ( \201 g 2). \200 Spinous process separation (interspinous ligament rupture). Spiral CT can help d iagnose fractures here.4 \200\207All 7 cervical vertebrae must be seen, along with the c7 \200\223T1 junction: do n ot accept an incomplete image \200\224a \200\230swimmers \200\231 view of C7 \200\223T1 ma y be needed. \200\207A cross-table lateral in the best hands will still miss at least 15% of injuries. Other views and investigations \200 Open mouth \200\230peg \200\231 view (O MV, \201 g 3) for suspected odontoid peg fractures and C1 fractures (total lateral mass overhang of C1 on C2 should be <8mm). \200 CT is used to image areas not adequately assessed on plain \201 lms (p779). \200 MRI is vital for as sessing ligamentous disruption, disc prolapse, and the neu- ral elements (spinal cord and n erve roots), all of which can only be inferred from CT and plain radiography. Whole spine a ssessment is best. Spinal cord injury without radiological abnormality (SCIWORA) is a condi- tion in which the re is a neurological de \201 cit (ie spinal cord injury) in the ab- sence of a lesion on p lain radiographs (pathology may be visible on MRI). It most commonly occurs in pediatric ce rvical spine injuries and is treated in the same manner as a spinal fracture with appropria te immobilization and referral. Clinical evidence of the injury in children may be delayed in up to 50%, so always consider the injury if the mechanism is appropriate.5 1 If there is marked kyphosis, avoid hard collars to stabilize the spine, as the extension produced may be more than is natural for the patient: so collars may cause spinal injury.6 659 a m u a r t d n a s c i d e a p o h t r O Fig 1. The lines to check for discontinuity on a lateral c-spine radiograph: Yellow = anter ior spinal line = posterior spinal line Red Green = spinolaminar line Blue = tips of spinou s processes. Note that we can see all the way to C7 \200\223T1. Fig 2. More important areas to look at on the lateral c-spine radiograph: Yellow Red Blue A DI is the distance between the anterior as- pect of the odontoid peg and the posterior of t he anterior arch of C1. = ADI should be <3mm in adults = before C1 \200\223c3 should be <7mm = before C4 \200\223c7 should be <22m. Fig 3. Odontoid peg fractures are best seen on the omv. There are 3 types: Type I Type II = through the base Type III = into the body of C2. Remember to check for the overhang of C1 on C2 (<8mm in total). Figures 1 \200\2233 Courtesy of The Norfolk and Norwich University H ospitals (NNUH) Radiology Department. Fig 4. Lateral radiograph of the c-spine showing a fracture through the pedicles of the C2 vertebra \200\224the hangman \200\231s fracture, which is traumatic spondylolisthesis of C2 . = through the tip Courtesy of Professor Peter Scally. The pediatric cervical spine Below the age of 9yrs, the cervical spine needs to be assesse d as an en- tirely diff erent entity, as it creates very diff erent patterns of normality a nd abnormality. The most important point to make here is that is best to ask a specialist \200\231s opinion \200\224ie ask a Pediatric Radiologist. Nonetheless, remember: \200 Inju ry is commonest in the upper spine. \200 SCIWORA (see OPPOSITE). \200 Growth plates (phys es) and synchondroses can be mistaken for fractures. \200 C2 \200\2233 and C3 \200\2234 ca n demonstrate pseudosubluxation. \200 C7 \200\223T1 does not need to be visualized unless \211 8yrs old. Other neck pathologies Cervical spondylosis (See OHCM p512) Degenerative changes of the cer vical spine; eg featuring degeneration of the annulus \201 brosus and bony spurs nar- row the spinal canal and intervertebral foramina. Very common: 90% of men >60yrs and women >5 0yrs. Usually asymptomatic, but can cause neck and arm pain with paraesthesiae \200\224some times with myelopathy (spastic weakness and, later, incontinence). Images and treatment: se e OHCM. Cervical spondylolisthesis This is displacement of one vertebra upon the one below. Causes: 1 Congenital failure of fusion of the odontoid process with the axis, or fracture of the odontoid process (skull, atlas & odontoid process slip forward on axis). 2 In \202 ammation softens the transverse ligament ( \201 g 1) of the atlas (eg rheuma- toid or comp licating throat infections), so the atlas slips forward on the axis. 3 Instability after in juries. The most important consequence of spondylolisthe- sis is the possibility of spinal cord compression. Treatments used include trac- tion, immobilization in plaster jackets, an d spinal fusion. 660 \200 a m u a r t d n a Prolapsed cervical disc Central protrusions (typically of C5/6 & C6/7) may give symptoms of spinal cord compression (p770; refer to neurosurgeon). Postero- lateral protrusions may ca use a stiff neck, pain radiating to the arm, weakness of muscles aff ected by the nerve roo t, and depressed re \202 exes. Tests: MRI is the preferred image ( \201 g 2). Treatment i s with NSAIDs, and a collar. As pain subsides, physiotherapy may help to restore mobility. Surgery is occasionally indicated, in the light of CT/MRI \201 ndings. Cervical rib Conge nital development of the costal process of the C7 vertebra is often asymptomatic but may ca use thoracic outlet compression ( \201 gs 3 \200\2234). Similar symptoms with no radiologi cal abnormality is called a scalenus or 1st rib syndrome. Thoracic outlet compression invol ves the lowest trunk of the brachial plexus ( \201 g 3 & p765) the subclavian artery. P ain or numbness may be felt in hand or forearm (often on the ulnar side); there may be hand weakness and muscle wasting (thenar or hypothenar). Diagnosis: Weak radial pulse forear m cyanosis. Speci \201 c maneuvers (eg Adson \200\231s test) are not reliable. Ra- diograp hs may not reveal cervical ribs, as symptoms may be caused by \201 brous bands. Arteriogr aphy may show subclavian compression. Treatment: Physi- otherapy to strengthen the shoulder elevators may improve symptoms, but rib removal or band division may be needed. Spasmodic torticollis (cervical dystonia) The commonest adult focal dysto- nia. Episodes of a sudden stiff painful neck with torticollis are due to trapezius and sternocleidomastoid spasm. Soc ial withdrawal can be a problem. Causes: Genetic; trauma. Treatment: If not self-limiting, heat, manipulation, relaxants, and analgesia may help. If severe, wearing a collar may help initial discomfort but may prolong symptoms. Botulinum toxin (p460) is a safe and eff ecti ve op- tion.7,8 Adjuncts: Anticholinergics, benzodiazepines, baclofen.9 Infantile torticoll is This may result from birth damage to sternocleidomas- toid. Typical age: 1 \200\22336 mo nths. Signs: Tilted head (ear nearer shoulder on af- fected side). \200 : \200 \211\210 3 : 2. Retarded facial growth on the aff ected side, hence fa- cial asymmetry. Early, there is a tumor-like thickening in the muscle (may be palpable). \202\202 \202\202 : Spasmus n utans or \200\230nodding spasm \200\231 (head-nodding; torticollis; nystagmus); acquired l ate-infancy torticollis from rare CNS disorders (eg gan- gliocytoma). If there is an associ ated muscle mass, biopsy may be reassuring by showing a benign \201 brous lesion.10 Treat ment: Self-limiting in 97%. If persistent, physiotherapy helps by lengthening the muscle; d ivision at its lower end is more drastic.11 Acute whiplash Acceleration \200\223deceleratio n injury (eg from RTA/sport) with no radiographic abnormality or neurological signs. May be ne \201 t from early mobili- zation and an early return to activity.12 See also p758. s c i d e a p o h t r O 661 a m u a r t d n a s c i d e a p o h t r O Fig 1. Cut-away sagittal view of the atlas and the axis cervical vertebrae, showing the lig a- ments around the odontoid peg. Fig 2. T2-weighted sagittal MRI of the cervical spine showing intervertebral disc protrusio n at the C5/6 level. Fig 4. AP x-ray of the cervi- cal spine showing bilateral rudimentary cervical ribs in the form of prominent transverse processes (the condition is a spectrum). They are usually a un ilat- eral radiographic \201 nding, though the contralateral side may still have a liga- mentous band present. The presence of a cervical rib increases the likelihood of the brachi al plexus being pre \201 xed \200\224ie arise from C4 \200\223 c8 rather than C5 \200\223T 1. Fig 3. Cervical rib causing com- pression of the inferior trunk of the brachial plexus (p76 5). The distal part of the rib can also cause stenosis in the subcla- vian artery, with pos t-stenotic dilatation (visible on arteriog- raphy). Figures 2 & 4 courtesy of the Norfolk and Norwich University Hospitals (NNUH) radiology dep artment. The shoulder Anatomically, the glenohumeral joint is lax, depending far more on surround- i ng rotator cuff muscles than bony structures for stability \200\224ie the tendons of supras pinatus (abduction), subscapularis (internal rotation), infraspinatus (ex- ternal rotation) , and teres minor (external rotation + extension). Biceps \200\231 long head traverses the cuff , attaching to the top of the glenoid cavity ( \201 gs 1 \200\2233). History Occupati on? Any previous trauma? Where is the pain: shoulder or neck? Does shoulder movement make i t worse? If all movements worsen pain, suspect arthritis or capsulitis; if only some moveme nts, suspect impingement. General health OK: if aches and pains all over, is it \201 brom yalgia or polymyalgia? Examination Strip to waist. To assess glenohumeral movement, feel th e lower half of the scapula to estimate degrees of scapular rotation over the thorax. Half the range of normal abduction is by scapula movement. Test abduction by raising hands from the sides sideways to above the head; \202 exion by raising hands forwards and up; extens ion by backward movement of elbows; external rotation by holding elbows against sides \202 exed at 90 and moving the hands outwards (normal 80 ); and internal rotation by pla cing the back of the hand against the lumbar spine and moving the elbows forward; an easier test is to assess how far behind her back she can reach: \200\230imagine you are doing up a bra \200\231. This is the last movement to recover after shoulder soft-tissue surgery. T he muscles used for movement at the shoulder joint \200 Flexion: (forward movement) pecto ralis major, deltoid (ant. \205\223), coracobra- chialis. \200 Extension: Deltoid (poste rior \205\223); latissimus dorsi, pectoralis major, and teres major begin the extension if the shoulder starts out \202 exed. 662 a m u a r t d n a s c i d e a p o h t r O Abduction: Supraspinatus for \201 rst 15 , then deltoid. \200 Adduction: Pectoralis ma jor, latissimus dorsi, teres Rotator cuff muscles \200 Subscapularis \200 Teres minor \200 Infraspinatus \200 Su praspinatus major, subscapularis. \200 Medial rotation: Pectoralis major, deltoid (middle \205\223), latissimus dorsi, teres major, subscapularis. \200 Lateral rotation: Teres minor, infras pinatus. Scapula movement on the chest wall NB: serratus anterior prevents \200\230wing- i ng \200\231 of the scapula as pressure is placed on the outstretched hand. \200 Elevation : (shrug shoulders) Levator scapulae, trapezius \200 Depression: Serratus anterior, pecto ralis minor \200 Forward action: (=protraction, eg punch) Serratus anterior; pectoralis m ajor \200 Retraction: (brace shoulders) Trapezius, rhomboid. Recurrent shoulder dislocati on (For initial dislocation, see p740.) 2 types: Atraumatic: (5%) The patient is often a te enager with no history of trauma, but having general joint laxity. Remember AMBRI: atraumat ic (ie \200\230born loose \200\231); multidirectional; bilateral; treat by: rehabilitation ; inferior capsular shift sur- gery only if rehab fails. Traumatic: Dislocation is anterior (sometimes inferior, rarely posterior) and secondary to trauma (may be mild). Remember TUB S: traumatic; unilateral; Bankart lesion (see below); surgical treatment. Abduc- tion + lat eral rotation of the arm (eg donning a coat) may cause dislocation. The capsule is attached to the neck of scapula but detached from the glenoid labrum (Bankart lesion). There may be a posterolateral \200\230dent \200\231 in the humeral head, called a Hill \200\223Sachs l esion (seen on radiographs with arm medially ro- tated). Treatment: Open repair may yield b etter results than arthroscopic repair,13 though latest arthroscopic techniques (eg suture anchor \201 xation + capsule plication) merit further study.14 With the rarer recurrent p osterior dis- location, the capsule is torn from the back of the neck of scapula, the humer al dent is superomedial, and it is abduction & medial rotation which causes dis- location ( eg seizure). Treatment: Surgery \200\224if prompt closed reduction fails.15 Recurrent sublu xation is also recognized (disabling and diffi cult to treat). 663 a m u a r t d n a s c i d e a p o h t r O Fig 1. Shoulder anatomy (without deltoid): anterior view. Fig 2. The glenoid surface of the gleno- humeral the glenohumeral ligaments (GHLs) \200\224 superior (SGHL), medial (MGHL), and inferior (IGHL). joint, and Fig 3. Shoulder and acromioclavicular (AC) joint ligaments: anterior view. Some speci \201 c specialist shoulder examination tests There are many speci \201 c shoul der examination tests that can be performed: \200 Neer \200\231s test: Passive \202 exi on of shoulder with a pronated arm, whilst scapula is stabilized. A painful arc between 60 and 120 = impingement. Drop arm sign: Patient lowers arm slowly from 160 abduction. If patient can \200\231t control the arm, and it drops quickly to the side = rotator cuff tear. Jobe test: Patient internally rotates arm whilst in 90 abduction and 30 forward \202 e xion with an extended elbow. Attempt to further abduct against resistance which result in p ain = supraspinatus weakness or injury. Speed \200\231s test: Patient starts with arm \202 exed forward 60 , elbow extended and forearm in supination, and attempts to \202 ex shoulder forward against resistance. Pain on palpation of long head of biceps tendon during this ma- noeuvre = biceps tendonitis. Apprehension test: With elbow \202 exed at 90 , the forearm supine, abduct and externally rotate arm to 90 : apprehension=anterior joint instability. \200 Scarf te st: Forced adduction of arm across the neck: pain=AC joint disease. There are a further hos t of tests, but the above represent a useful quotient for the budding upper limb orthopod.1 6 The painful shoulder \200\230There is little evidence to support or refute the ef \201 ca cy of common interventions for shoulder pain \200 \200\231,17 so it is vital to clarify ex pectations before any course of treatment. Remember that the neck may refer pain via C5 to the deltoid region and via C6, C7, and C8 to the superior border of the scapula. Rotator cu ff tears Tears in supraspinatus tendon ( \201 g 1) \200\224or adjacent sub- scapularis and infraspinatus \200\224may be from degeneration, or less commonly, a sudden jolt or fall. P atients complain of shoulder weakness and pain. Night pain may aff ect sleep as patient is unable to keep the arm in a comfortable position (adducted without rotation). Partial tears cause a painful arc (be- low); complete tears limit shoulder abduction to the 45 \200\2236 0 given by scapular rotation. If the arm is passively abducted beyond 90 deltoid \200 \231s contribution to abduction comes into play, which is then possible from this point. Fu ll-range passive movement is present. Typical age: >40yrs.18 Imaging: US (good for ten- don imaging), MRI (better for imaging of labral tears,19 or MRI-arthrography (reveals communic ation between joint capsule and subacromial bursa). Treat- ment: Incomplete: expectant. Com plete: prompt referral for assessment for open or arthroscopic repair. Painful arc syndrome (on abducting 45 \200\223160 ) Causes of pain on abduction: 1 Supraspinatus tendinopath y or partial rupture of supraspinatus tendon gives pain reproduced by adducting pressure on the partially abducted arm. Typical age: 35 \200\22360. Only a proportion will have a pain ful arc (others have increasing pain up to full abduction), which is why the term impingeme nt syndrome (as the tendon catches under the acromion during abduction be- tween, eg 70 a nd 140 ) is preferred. NB: tendon rupture can also be asymp- tomatic.20 Treatment: Active shoulder movement with physiotherapy and pain relief; subacromial bursa injection of steroi d, eg triamcinolone aceto- nide 40mg with local anesthetic may help;21 arthroscopic acromio plasty. 2 Calcifying tendinopathy: One of the acute calci \201 c arthropathies. Typical ag e about 40yrs. There is acute in \202 ammation of supraspinatus. Pain is maximal during th e phase of resorption. Treatment: Physiotherapy; NSAIDs; steroid injection; rarely, excisio n of calcium. See \201 g 2. 664 \200 a m u a r t d n a s c i d e a p o h t r O 3 Acromioclavicular joint osteoarthritis: This is common. Try steroid injec- tions or excision of the lateral end of the clavicle. Long head of biceps tendinopathy Pain is in the anterior shoulder and char- acteristically \200\200 on forced contraction of biceps. \201\227: Pain relief; hydrocortisone injection to the tendon may help, but risks tendon rupture. Technique: p710. Rupture of long head of biceps Discomfort occurs after \200\230something has gone \200\231 when lifting or pullin g. A \200\230ball \200\231 appears in the muscle on elbow \202 exion, like a \200\230Po peye \200\231 muscle. Treatment: Repair is rarely indicated as function remains.1 Frozen sh oulder (adhesive capsulitis) may follow modest injury in older people. Pain may be severe a nd worse at night (eg unable to lie on one side). Active and passive movement range is redu ced. Abduction \200\201 (<90 ) external rotation \200\201 (<30 ). It may be associated with cervical spondylosis (more global restriction of movement). Treatment: NSAIDs, intra- articular steroid (see p710 for technique), physiotherapy, manipulation under anesthetic. L ocal nerve block may provide short-term pain relief.22 Meta-analyzes of randomized trials a re said not to support any one option, but they did not include Der Windt \200\231s trial w hich strongly favored injections. Resolution may take years. Shoulder osteoarthritis ( \201 g 3) This is not so common as hip or knee OA. Good success rates (especially for pain relief) are being achieved by joint replace- ment \200\224complications: infection, disloca tion, loosening, periprosthetic hu- meral/glenoid fractures, nerve injury, prosthetic fract ure; ectopic ossi \201 cation. Timing of surgery is important, so that the rotator cuff an d glenoid are not too worn for good stability.23 665 a m u a r t d n a s c i d e a p o h t r O Fig 1. Rotator cuff tear in the supraspi- natus tendon. See p663 for muscle names. Fig 2. AP radiograph of the left shoul- der showing calcifying tendinopathy in the left sup raspinatus. The gleno \200\223 humeral joint also appears subluxed, though this is most lik ely \200\230deltoid inhi- bition \200\231 caused by pain. Fig 3. AP radiograph of the left shoul- der showing osteoarthritis: loss of joint space, su bchondral sclerosis, osteophytes, glenoid erosion and hu- meral head deformity are all pres ent. Figs 2 & 3 Courtesy of The Norfolk And Norwich University Hospitals (NNUH) Radiolology Depa rtment. 1 Conversely, if it is the biceps insertion that is avulsed, surgical repair will be requir ed. The elbow The elbow joint is formed by an articulation of the distal humerus with the proxi mal radius and ulna ( \201 g 1). Flexion/extension occur at the ulnohumeral joint and is p ossible through a range of 0 \200\223150 . With the elbow \202 exed, supina- tion/pron ation of 90 should be possible \200\224this occurs at the radiohumeral and proximal radio ulnar articulations. Acceptable upper limb function requires a 100 arc in each plane, ie 30 \200\223130 extension/ \202 exion and 50 pronation/supina- tion.24 Pain at the el bow may radiate from the shoulder. Lateral epicondylitis (tennis elbow) There is in \202 a mmation where the com- mon extensor tendon arises from the lateral epicondyle of the humeru s rupture of aponeurosis \201 bres. Presentation: Pain is worst when the tendon is mos t stretched (wrist and \201 nger \202 exion with hand pronated). Pain is felt at the fr ont of the lateral condyle. Ask the patient to extend the wrist, and then to resist extensi on of the middle \201 nger: is pain elicited? Radiography: Nonspe- ci \201 c. Treatment: Pain often subsides in time, but some favor injection of the tendon origin (p710).25 If th is fails, physiotherapy may help, or an epicondyli- tis brace; with severe disability, exci sion of the diseased part of the common extensor origin and repair of the extensor mechanis m gives relief in 80% of recalcitrant disease, but there is a lack of RCTs for surgery.26 M eta-analyzes are equivocal on the best form of treatment. Medial epicondylitis (golfer \200 \231s elbow) This is less common than tennis elbow. Steroid injection may help, but be wary of the ulnar nerve that runs behind the epicondyle and the brachial artery that runs anter omedially.27 Olecranon bursitis (student \200\231s elbow) This is a traumatic bursitis foll owing pressure on the elbows, eg while engrossed in a long book. There is pain and swelling behind the olecranon. Other causes are septic and gouty bursitis (look for tophi). The bur sa should be aspirated \200\224send \202 uid for Gram stain and mi- croscopy for crystals . Traumatic bursitis may then be injected with hydrocor- tisone. Septic bursitis should be formally drained and will need a course of antibiotics.28 Ulnar neuritis (also \200\230cub ital tunnel syndrome \200\231) Osteoarthritic or rheumatoid narrowing of the ulnar groove a nd constriction of the ulnar nerve as it passes behind the medial epicondyle, or friction o f the ulnar nerve due to cubitus val- gus (a possible sequel to childhood supracondylar fra ctures) can cause \201 bro- sis of the ulnar nerve and ulnar neuropathy. Presentation: Se nsory symptoms usually occur \201 rst, eg \200\201 sensation over the little \201 nger and medial half of ring \201 nger. Patients may experience clumsiness of the hand and we akness of the small muscles of the hand innervated by the ulnar nerve (adductor pollicis, i nterossei, abductor digiti minimi and opponens digiti minimi). Tests: Nerve conduction stud ies may con \201 rm the site of the lesion. Treatment: Surgical de- compression transpo sition of the nerve to in front of the elbow (often only required if the nerve subluxes ove r the medial epicondyle after decompres- sion). Deformities Cubitus valgus: The normal degr ee of valgus ( \200\230carrying angle \200\231) at the elbow is 10 in \200 , and 15 in \200 . Fractures at the lower end of the humerus or interference with the lateral epiphys eal growth plate (ie causing arrest) may lead to the angle being greater. As a result, ulna r neuritis and osteoarthritis may occur. Treat if necessary. Association: Turner \200\231s syndrome. Cubitus varus: This may occur after poorly reduced supracondylar fractures. Osteo arthritis of the elbow ( \201 g 2). Osteochondritis dissecans and fractures involving the joint are risk factors. Tests: Flexion, extension and forearm ro- tation may be impaired. L oose bodies may cause restriction of movement, eg loss of full extension. Treatment: Surger y is rarely needed (procedures include: removal of loose bodies, debridement, radial head e xcision, joint replacement). Joint replacement may also be performed for rheumatoid arthrit is of the elbow. 666 a m u a r t d n a s c i d e a p o h t r O 667 a m u a r t d n a s c i d e a p o h t r O Fig 1. The ligaments around the elbow joint \200\224posterolateral view of the right elbow (1) and anteromedial view of the left elbow (2). Stability of this joint is mainly from bon y factors, though ligaments do play an important part \200\224eg the annular ligament wraps around the head of the radius (which can pop out in a \200\230pulled elbow \200\231), and also allows smooth prona- tion/supination. Remember that the joint is made up from 3 artic ulations: radio-humeral, proximal radioulnar, and humeroulnar. Fig 2. Lateral x-ray of the elbow showing degenera- tive changes of osteo-arthritis. There is loss of joint space, osteophyte formation, bony deformity, and subchondral sclerosis. Mo vement is painful and severely restricted. Norfolk and Norwich University Hospitals (NNUH) Radiology Department. The wrist and hand Dupuytren \200\231s contracture Progressive, painless \201 brot- ic th ickening of the palmar fascia with skin puckering and tethering. Ring and little \201 nge rs are chie \202 y aff ect- ed. It is often bilateral and symmetrical. As thickening occur s there may be MCP joint \202 exion. If interphalan- geal joints are aff ected the hand m ay be quite disabled. Surgery (eg fasciectomy) aims to remove aff ected pal- mar fascia and release contractures. As a guide, if he cannot place his palm \202 at on a \202 at sur face (Hueston \200\231s table-top test), refer for surgery. There is tendency for recurrenc e.29 Ganglia These smooth, multilocular swellings are cysts containing jelly-like \202 ui d in communication with joint capsules or tendon sheaths. Treatment is not needed unless th ey cause pain or pressure (eg on median or ulnar nerve at the wrist, or lateral popliteal n erve at the knee). They may disappear spontane- ously. Local pressure may disperse them (tr aditionally a blow from a Bible!) Aspiration via a wide-bore needle may work, or they may b e surgically dis- sected out, which may give less recurrence;30 problems include painful sc ars, neurovascular damage (esp. in palmar wrist ganglia), and recurrence.31 De Quervain \200\231s disease This refers to stenosing tenosynovitis (thickening and tightening) of the abductor pollicis longus and extensor pollicis brevis tendons (at the anterior border of t he anatomical snuff box) as they cross the distal radial styloid. Pain is worst when these tendons are stretched (eg lifting a teapot), and is more proximal than that from osteoarthr itis of the 1st carpo- metacarpal joint. Finkelstein \200\231s sign is pain elicited by sha rply pulling on the re- laxed thumb to cause ulnar deviation.32 Cause: Unknown but symptoms can be exacerbated by over use of the tendons (eg wringing clothes). Treatment: First try rest (thumb spica splint), ice, and NSAIDs. Hydrocortisone injection at tendon site during the 1st 6 months of symptoms is eff ective in 90% of patients. If injection (p710) and rest fail to relieve, decompression of the tendons is pro- vided by splitting the tendon sheath s. >80% do well post-op.33,34 Trigger \201 nger (tendon nodules) Probably caused by a swe lling of the \202 exor tendon or tightening of the \202 exor tendon sheath. Ring and mi ddle \201 ngers are most commonly aff ected, and the thumb especially in babies and child ren. Swelling of the tendon sheath, along with nodule formation on the tendon, proximal to the A1 pulley ( \201 g 3) prevents the smooth gliding of the tendon. As a result the tendo n \200\230catches \200\231 causing the \201 nger to lock in \202 exion. As extension o ccurs, the nodule moves with the \202 exor tendon, but then becomes jammed on the proxima l side of the pulley, and has to be \202 icked straight, so producing triggering. \201 \227: Simple immobilization is initial treatment of choice: if severe, steroid injection in to the region of the nodule may be tried (not if the patient is a child, has renal failure or diabetes). Risk of recurrence is high, so surgery may be needed.35,36 Volkmann \200\231s ischaemic contracture follows compartment syndrome or interruption of the brachial artery near the elbow (eg after supracondylar fracture of humerus, p740). Muscle necrosis (especia lly \202 exor pollicis longus and \202 exor digitorum profundus) results in contraction and \201 brosis causing a \202 exion deformity at wrist and elbow, with forearm pronat ion, wrist \202 exion, thumb \202 exion & adduction, digital metacarpophalangeal joint extension, and interphalangeal joint \202 exion. \200\207Suspect compartment syndrome if a damaged arm has no radial pulse, and passive \201 nger extension is painful (a crucial sign, p736). Treatment: Remove constricting splints, warm other limbs (promote va- sodilat ation). If pulse doesn \200\231t return within 30min, explore the artery. Treating contract ures: release of compressed nerves tendon lengthening and trans- fers to restore lost fu nction.37 668 \200 Causes/associations Often multifactorial: \200 Genetic (AD) \200 Smoking \200 Diabete s \200 Antiepileptics \200 Peyronie \200\231s disease (OHCM p722) a m u a r t d n a s c i d e a p o h t r O 669 a m u a r t d n a s c i d e a p o h t r O Fig 1. Cross-sectional view of the wrist showing the contents of the carpal tunnel and the extensor tendons of the hand. When trying to describe local anatomy of the hand, it is easi er to use the terms ulnar and radial, rather than medial and lateral, which can cause confu sion. Dorsal refers to the posterior surface, while palmar re- fers to the anterior surface .1 A1 A2 C1 Fig 2. Axial T1-weighted wrist MRI; note labels on \201 g 1. Norfolk and Norwich University Hospitals (NNUH) Radiology Dept. A3 Flexor tendons pulley mechanisms ( \201 g 3) In order to stop the long \202 exor tendons of the hand bowing when the \201 ngers are \202 exed, the \201 ngers have a number o f pulleys (that are well-placed thickenings in the \202 exor sheath) attached to the bone s and volar plates beneath. Named morphologically as either \200\230A \200\231 for annular , or \200\230C \200\231 for cruciate, there are 5 A-pulleys and 3 C-pulleys. The most impo rtant are A2 (which is at the proximal end of the proximal phalanx) and A4 (at the middle o f the middle phalanx), both of which need to be preserved during any surgery to prevent bow ing of the \202 exor tendons. Sometimes mountaineers, and others hanging on by their \201 ngertips, partially damage the A2 pulley (typically). Stop climbing! Apply ice and bud dy- taping/splinting. Then do only light exercises (rubber donut squeezes; mild stretches) until 2wks after pain and swelling subside. Visible bowing of the tendon may indicate that surgery is needed; get help MRI. 1 The International Federation for Societies for Surger y of the Hand recommends the term \200\230palmar \200\231 over \200\230volar \200\231. C2 A4 C3 A5 Fig 3 Pulley system.