L07 - The MSK system.pptx by mohamed nuur cade sheekh cabdi macalin

Masculoskeletal system

1. Mohamed Ali Hussein MBBS MMED ORTHOPEDIC AND TRAUMA The MSK system

2. Lecture Outline The history The physical examination Detailed examination of the musculoskeletal system Fractures, dislocations and trauma Investigations

3. The history Common presenting symptoms Pain In musculoskeletal pain, the acronym SOCRATES. prompts questions that reveal useful diagnostic clues Site Illustrates the anatomy of a typical joint. Determine which component is painful: the joint ( arthralgia ), muscle ( myalgia ) or other soft tissue. Pain may be localised and suggest the diagnosis, such as a red, hot, tender first metatarsophalangeal joint in gout , or swelling of several joints suggesting an inflammatory arthritis.

4. Conti… Onset Pain from traumatic injury is usually immediate and exacerbated by movement or haemarthrosis (bleeding into the joint). Inflammatory arthritis can develop over 24 hours, or more insidiously Crystal arthritis (gout and pseudogout) causes acute. Joint sepsis causes pain that develops over 1–2 days. Character Bone pain is penetrating, deep or boring, and is characteristically worse at night, Localised pain suggests tumour, osteomyelitis (infection), osteonecrosis or osteoid osteoma (a benign bone tumour). Generalised bony conditions, such as Osteomalacia, usually cause diffuse pain, Associated symptoms For example, swelling and redness of a joint indicate inflammatory arthritis.

5. Conti… Fracture pain is sharp and stabbing, aggravated by attempted movement, and relieved by rest and splintage, Muscle pain is often described as ‘stiffness’ or aching, and is aggravated by use. Shooting’ pain is often caused by impingement of a peripheral nerve or nerve root for example, buttock pain, which ‘shoots down the back of the leg, Progressive joint pain at age of 40 is caused by osteoarthritis. Radiation Pain from nerve compression radiates to the distribution of that nerve or nerve root such as lower leg.

6. Conti… Timing (frequency, duration and periodicity of symptoms) A history of several years of pain with a normal examination suggests fibromyalgia, A history of several weeks of pain, early-morning stiffness and loss of function is likely to be an inflammatory arthritis. ‘Flitting’ pain starting in one joint and moving to others over a period of days is a feature of rheumatic ‘Flitting’ pain starting in one joint and moving to others over a period of days is a feature of rheumatic, intermittent with resolution must likely rheumatism. Exacerbating/relieving factors Pain from joints damaged by intra-articular derangement or osteoarthritic degeneration worsens with exercise Pain from inflammatory arthritis worsens with rest. Pain from a septic joint is present both at rest and with movement.

7. Conti… Severity Apart from trauma, the most severe joint pain occurs in septic and crystal arthritis. Disproportionately severe pain is seen acutely in compartment syndrome (increased pressure in a fascial compartment, compromising perfusion and viability of compartmental structures) and chronically in complex regional pain syndrome. Neurological involvement in diabetes mellitus, leprosy (Hansen’s disease), syringomyelia and syphilis (tabes dorsalis) may impair joint sensation, reducing pain despite obvious pathology on examination.

8. Conti… Patterns of joint involvement Different patterns of joint involvement aid the differential diagnosis . Are the small or large joints of the arms or legs affected? How many joints are involved? Involvement of one joint is called a monoarthritis; 2–4 joints, oligoarthritis; and more than 4, polyarthritis. Predominant involvement of the small joints of the hands and feet suggests an inflammatory arthritis, such as rheumatoid arthritis or systemic lupus erythematosus. Medium- or large-joint swelling is more likely to be degenerative (osteoarthritis) or a seronegative arthritis (such as psoriatic arthritis). Nodal osteoarthritis has a predilection for the distal interphalangeal (DIP) joints of the hands and the carpometacarpal (CMC) joint of the thumb

9. Conti… Stiffness Ask what the patient means by stiffness. Is it: restricted range of movement? difficulty moving, but with a normal range? painful movement? localised to a particular joint or more generalised? There are characteristic differences between inflammatory and non-inflammatory presentations of joint stiffness. Inflammatory arthritis causes early-morning stiffness that takes at least 30 minutes to wear off with activity. Non-inflammatory, mechanical arthritis causes stiffness after rest that eases rapidly on movement

10. Conti… Swelling Ask about the site, extent and time course of the swelling. The speed of onset of swelling is a clue to the diagnosis: Rapid (<30 minute) severe swelling suggests a haemarthrosis Swelling over hours or days suggests traumatic effusion, such as with a meniscal tear or articular cartilage abrasion. Septic arthritis develops over a few hours with pain, marked swelling, tenderness, redness and extreme reluctance to move the joint actively or passively Crystal-induced arthritis (gout or pseudo gout) can mimic septic arthritis. It commonly starts overnight or early in the morning due to the rise in serum urate following the evening meal.

11. Conti… Erythema and warmth Erythema (redness) occurs in infective, traumatic and crystal-induced conditions, and mild erythema may be present in inflammatory arthritis. All affected joints will be warm Weakness Weakness suggests joint, neurological or muscle disease. The problem may be focal or generalised Joint disorders cause weakness, either through inhibition of function by pain, or by disruption of the joint or its supporting structures. Nerve entrapment may be the cause: for example, carpal tunnel syndrome at the wrist. Muscle disorders can produce widespread weakness associated with pain and fatigue, such as in myositis. Proximal muscle weakness can occur in endocrine disorders: for example, hypothyroidism or excess of glucocorticoids

12. Conti… Locking and triggering ‘Locking’ is an incomplete range of movement at a joint because of an anatomical block. It may be associated with pain. Patients use ‘locking’ to describe various problems, so clarify exactly what they mean, True locking is a block to the normal range of movement caused by mechanical obstruction Pseudolocking is a loss of the range of movement due to pain Triggering is a block to extension of a finger, which then ‘gives’ suddenly when extending from a flexed position. Triggering can be congenital, in which case it usually affects the thumb.

13. Conti… Extra-articular symptoms Patients may present with extra-articular features of disease that they may not connect with musculoskeletal problems Ask about: Rashes: occur with psoriasis, vasculitis and erythema nodosum. Weight loss, low-grade fever and malaise: associated with rheumatoid arthritis and SLE. Headache, jaw pain on chewing (claudication) and scalp tenderness: features of temporal arteritis. Raynaud’s phenomenon. Sicca symptoms (dryness of mouth and eyes) Rashes.

14. Conti… Respiratory problems, including dyspnoea from interstitial lung disease, or pleural pain or effusions associated with rheumatoid arthritis or connective tissue disease Back pain and stiffness or arthritis associated with abdominal pain, diarrhoea, bloody stool and mouth ulcers: may suggest arthritis associated with inflammatory bowel disease

15. Past medical history Note past episodes of musculoskeletal involvement, extra-articular diseases as listed in the previous section, fractures and possible complicating comorbidities such as diabetes or obesity. Drug history Many drugs have side effects that may either worsen or precipitate musculoskeletal conditions

16. Family history Inflammatory arthritis is more common if a first-degree relative is affected. Osteoarthritis, osteoporosis and gout are heritable in a variable polygenic fashion. Spondyloarthritis is more common in patients with human leucocyte antigen B27. A single-gene defect (monogenic inheritance) is found in hereditary sensorimotor neuropathy (Charcot–Marie–Tooth disease), osteogenesis imperfecta, Ehlers–Danlos syndrome, Marfan’s syndrome and the muscular dystrophies

17. Social, environmental and occupational histories Identify functional difficulties, including the ability to use pens, tools and cutlery. How does the condition affect the patient’s activities of daily living, such as washing, dressing and toileting? Can they use the stairs and do they need walking aids? Ask about functional independence, especially cooking, housework and shopping Ask about current and previous occupations. Is the patient working full- or part-time, on sick leave or receiving benefits? Has the patient had to take time off work because of the condition and is their job at risk Smoking is a risk factor for rheumatoid arthritis and possibly other inflammatory arthritides High alcohol intake contributes to gout and falls that may result in fracture

18. Conti… Sickle cell disease may present with bone and joint pain in African patients Osteomalacia is more common in Asian patients. Bone and joint tuberculosis is more common in African and Asian patients. A sexual history may be relevant, since sexually transmitted disease is associated with musculoskeletal problems, such as reactive arthritis, gonococcal arthritis, human immunodeficiency virus infection and hepatitis B. High alcohol intake contributes to gout and falls that may result in fracture. It can also cause myopathy, neuropathy and rhabdomyolysis.

19. The physical examination Practice examining as many joints as possible to become familiar with normal appearances and ranges of movement. General principles Firstly, examine the patient’s overall appearance for features such as pallor, rash, skin tightening and hair changes Look – feel – move Follow a process of observation, palpation and movement for each joint or group of joints in turn Look at the skin, subcutaneous tissues and bony outline of each area. Before palpating, ask the patient which area is painful or tender. Feel for warmth, swelling, stability and deformity.

20. Conti… Assess if deformity is reducible or fixed. Assess active before passive movement. Do not cause the patient additional pain. Compare one limb with the opposite side. e. Always expose the joint above and below the affected one. Use standard terminology to describe position and movement. Flexion : bending at a joint from the neutral position Extension : straightening a joint back to the neutral position Hyperextension : moving beyond the normal neutral position (indicating a torn ligament or underlying ligamentous laxity, such as benign joint hypermobility syndrome) Adduction : moving towards the midline of the body (finger adduction is movement towards the axis of the limb) Abduction : moving away from the midline

21. Conti… To describe altered limb position due to joint/bone deformity, use: Valgus : the distal part deviates away from the midline Varus : the distal part deviates towards the midline. In the wrist and hand, use: Radial deviation : the distal part deviates towards the radial side Ulnar deviation : the distal part deviates towards the ulnar side

22. Conti… General examination Skin, nail and soft tissues The skin and related structures are common sites of associated lesions. The skin changes of psoriasis may be hidden. The rash of SLE is found across the cheeks and bridge of nose. Nail pitting and onycholysis occur in psoriasis. Small, dark-red spots due to capillary infarcts occur in rheumatoid arthritis, SLE and systemic vasculitis, Common sites are the nail folds. Reactive arthritis is associated with conjunctivitis, urethritis, circinate balanitis (painless superficial ulcers on the prepuce and glans) and superficial mouth ulcers

23. Conti… Nodules The firm, non-tender, subcutaneous nodules of rheumatoid arthritis most commonly occur on the extensor surface of the forearm. sites of pressure or friction such as the sacrum or Achilles tendon, or in the lungs. Rheumatoid nodules are strongly associated with a positive anti-cyclic citrullinated peptide (anti-CCP) antibody or rheumatoid factor. Bony nodules in osteoarthritis affect the lateral aspects of the DIP joints (Heberden’s nodes) or the proximal interphalangeal (PIP) joints (Bouchard’s nodes, Fig. 13.8). They are smaller and harder than rheumatoid nodules Gouty tophi are firm, irregular subcutaneous crystal collections (monosodium urate monohydrate) Common sites are the olecranon bursa, helix of the ear and extensor aspects of the fingers, hands, knees and toes

24. Conti… Eyes Redness of the eyes may be due to conjunctivitis in reactive arthritis or ‘dry eyes’ in Sjögren’s syndrome, rheumatoid arthritis and other connective tissue disorders. Scleritis and episcleritis occur in rheumatoid arthritis and psoriatic arthritis. The sclerae are blue in certain types of osteogenesis imperfecta and in the scleromalacia of longstanding rheumatoid arthritis.

25. Conti… General features Weight loss, muscle loss, fever and lymphadenopathy are all features of systemic involvement in inflammatory arthritis and connective tissue disease.

26. Joints: the GALS screen GALS (gait, arms, legs, spine) is a rapid screen for musculoskeletal and neurological deficits, and for functional ability; it helps to identify joints that require more detailed examination, as described later Initial questions Do you have any pain or stiffness in your muscles, joints or back? Do you have difficulty dressing yourself? Do you have difficulty walking up and down the stairs? If all three replies are negative, the patient is unlikely to have a significant musculoskeletal problem; otherwise, perform the GALS screen

27. Conti…. Hypermobility Some patients have a greater than normal range of joint movement. If this is severe, patients may present with recurrent dislocations or sensations of instability. Milder cases may develop arthralgia or be symptom-free. Mild hypermobility is normal but Marfan’s, Ehlers–Danlos and benign joint hypermobility syndromes

28. Detailed examination of the musculoskeletal system The GALS screen provides a rapid but limited assessment. This section describes the detailed examination required for thorough evaluation Gait Gait is the cyclical pattern of musculoskeletal motion that carries the body forwards. Normal gait is smooth, symmetrical and ergonomically economical, with each leg 50% out of phase with the other. It has two phases: stance and swing The stance phase is from foot-strike to toe-off, when the foot is on the ground and load-bearing. The swing phase is from toe-off to foot-strike, when the foot clears the ground

29. Conti… Examination sequence Ask the patient to walk barefoot in a straight line. Then repeat in shoes Observe the patient from behind, in front and from the side Evaluate what happens at each level (foot, ankle, knee, hip and pelvis, trunk and spine) during both stance and swing phases Pain An antalgic gait is one altered to reduce pain. Pain in a lower limb is usually aggravated by weight bearing, so minimal time is spent in the stance phase on that side Patients with hip pain may lean towards the affected side, as this decreases the compression force on the hip joint.

30. Conti… Structural change Patients with limb-length discrepancy may limp or walk on tiptoe on the shorter side, with compensatory hip and knee flexion on the longer side. Weakness This may be due to nerve or muscle pathology or altered muscle tone. In a normal gait the hip abductors of the stance leg raise the contralateral hemipelvis In Trendelenburg gait, abductor function is poor when weight-bearing on the affected side, so the contralateral hemipelvis falls.

31. Conti… Common causes of a Trendelenburg gait are: painful hip joint problems, as in osteoarthritis weak hip abductors, as in poliomyelitis or after hip replacement structural hip joint problems, as in congenital dislocation. A high-stepping gait occurs in foot drop due to common peroneal nerve palsy. Increased tone This occurs with upper motor neurone lesions, such as cerebrovascular accident (stroke) or cerebral palsy

32. Conti… Spine The spine is divided into the cervical, thoracic, lumbar and sacral segments Most spinal diseases affect multiple segments, causing altered posture or function of the whole spine. Definitions Scoliosis is lateral curvature of the spine. Kyphosis is curvature of the spine in the sagittal (anterior– posterior) plane, with the apex posterior. The thoracic spine normally has a mild kyphosis. Lordosis is curvature of the spine in the sagittal plane, with the apex anterior. Gibbus is a spinal deformity caused by an anterior wedge deformity of a single vertebra, producing localised angular flexion

33. Conti… Cervical spine Anatomy and physiology????? The history The most common symptoms are pain and difficulty turning the head and neck. Neck pain is usually felt posteriorly but may be referred to the head, shoulder, arm or interscapular region Cervical disc lesions cause radicular pain in one arm or the other, roughly following the dermatomes of the affected nerve roots If the spinal cord is compromised (cervical myelopathy)

34. Conti… The physical examination Be particularly careful when examining patients with rheumatoid arthritis, as atlantoaxial instability can lead to spinal cord damage when the neck is flexed. In patients with neck injury, never move the neck. Splint it and check for abnormal posture. Check neurological function in the limbs and X-ray to assess bony injury

35. Conti… Examination sequence Ask the patient to remove enough clothing for you to see their neck and upper thorax, then to sit on a chair Look Face the patient. Observe the posture of their head and neck. Note any abnormality Feel Feel the midline spinous processes from the occiput to T1 (usually the most prominent). Feel the supraclavicular fossae for cervical ribs or enlarged lymph nodes Note any tenderness in the spine, trapezius, interscapular and paraspinal muscles

36. Conti… Move Assess active movements. Ask the patient to Look down to the floor so that you can assess forward flexion The normal range is 0 (neutral) to 80 degrees Look upwards at the ceiling as far back as possible, to assess extension The normal range is 0 (neutral) to 50 Put their ear on to their shoulder, so that you can assess lateral flexion. The normal range is 0 (neutral) to 45 degrees Look over their right/left shoulder. The normal range of lateral rotation is 0 (neutral) to 80 degrees If active movements are reduced, gently perform passive movements

37. Conti… Thoracic spine Anatomy and physiology??????? The history Presenting symptoms in the thoracic spine are localised spinal pain, pain radiating round the chest wall or, less frequently, signs of cord compression: upper motor neurone leg weakness (paraparesis), sensory loss, and loss of bladder or bowel control. Disc lesions are rare but may cause pain radiating around the chest that mimics cardiac or pleural disease. Osteoporotic vertebral fractures may present with acute pain, or painless loss of height with increased kyphosis. Vertebral collapse due to malignancy may cause cord compression. Infection causes acute pain, often with systemic upset or fever With poorly localised thoracic pain, consider intrathoracic causes, such as (MI, Infraction AA).

38. Conti… The physical examination Examination sequence Ask the patient to undress to expose their neck, chest and back. Look? Feel? Move?

39. Conti… Lumbar spine Anatomy and physiology??????? The history Low back pain is extremely common. Most is ‘mechanical’, and caused by degenerative changes in discs and facet joints (spondylosis). Analyse the symptoms using ‘SOCRATES’. For back pain, ask specifically about occupational or recreational activity that may strain the back. red flag features suggesting significant spinal pathology prior treatment with glucocorticoids

40. Conti… Radicular pain caused by sciatic nerve root compression radiates down the posterior aspect of the leg to the lower leg or ankle (sciatica). Groin and thigh pain in the absence of hip abnormality suggests referred pain from L1–2. Consider abdominal and retroperitoneal pathology, such as abdominal aortic aneurysm. Mechanical low back pain is common after standing for too long or sitting in a poor position. Symptoms worsen as the day progresses and improve after resting or on rising in the morning. Acute onset of low back pain in a young adult, often associated with bending or lifting, is typical of acute disc protrusion (slipped disc).

41. Conti… Coughing or straining to open the bowels exacerbates the pain. There may be symptoms of lumbar or sacral nerve root compression. The motor disturbance may be profound, as in paraplegia. Cauda equina syndrome and spinal cord compression are neurosurgical emergencies Acute back pain in the middle-aged, elderly or those with risk factors, such as glucocorticoid therapy, may be due to osteoporotic fracture Acute onset of severe progressive pain, especially when associated with malaise, weight loss or night sweats, may indicate pyogenic or tuberculous infection of the lumbar spine or sacroiliac join

42. Conti… The physical examination Examination sequence Ask the patient to stand with their back fully exposed. Look? Feel? Move? Special tests Schober’s test for forward flexion? Root compression tests? Sciatic nerve stretch test (L4–S1)? Femoral nerve stretch test (L2–4)? Flip test for functional overlay?

43. Conti… Upper limb The prime function of the upper limb is to position the hand appropriately in space. This requires shoulder, elbow and wrist movements. The hand may function in both precision and power modes Hand and wrist Motor and sensory innervation of the hand is shown in. The wrist joint has metacarpocarpal, intercarpal, ulnocarpal and radiocarpal components There is a wide range of possible movements, including flexion, extension, adduction (deviation towards the ulnar side), abduction (deviation towards the radial side) and the composite movement of circumduction (the hand moves in a conical fashion on the wrist). Always name the affected finger (index, middle, ring and little) in documentation to avoid confusion.

44. Conti… The history The patient will often localize symptoms of pain, stiffness, loss of function, contractures, disfigurement and trauma. If symptoms are vague or diffuse, consider referred pain or a compressive neuropathy, such as carpal tunnel syndrome Painful, swollen and stiff hand joints are common and important presenting symptoms

45. Conti… The physical examination Examination sequence Seat the patient facing you, with their arms and shoulders exposed. Start by examining the hand and fingers, and move proximally Look? Feel? Move?

46. Conti… Elbow Anatomy and physiology????? The physical examination Examination sequence Look? Feel? Move? Special tests Tennis elbow (lateral epicondylitis ) Golfer’s elbow (medial epicondylitis )

47. Conti… Shoulder Anatomy and physiology??? The history Pain is common and frequently referred to the upper arm. Glenohumeral pain may occur over the anterolateral aspect of the upper arm. Pain felt at the shoulder may be referred from the cervical spine or diaphragmatic and subdiaphragmatic peritoneum via the phrenic nerve Stiffness and limitation of movement around the shoulder, caused by adhesive capsulitis of the glenohumeral joint, is common after immobilisation or disuse following injury or stroke. This is a ‘frozen shoulder’. Some rotator cuff disorders, especially impingement syndromes and tears, present with a painful arc

48. Conti… The physical examination Examination sequence Ask the patient to sit or stand and expose their shoulder completely. Look? Feel? Move? Special tests for impingement Neer test? Hawkins–Kennedy test?

49. Conti… Lower limb Hip Anatomy? The history Pain is usually felt in the groin but can be referred to the anterior thigh, the kn ee or the buttock. Hip pain is usually aggravated by activity, but osteonecrosis and tumours may be painful at rest and at night. Lateral hip or thigh pain, aggravated when lying on that side, suggests trochanteric pain syndrome. Fracture of the neck of the femur is common following relatively minor trauma in postmenopausal women and those aged over 70 years. The classical appearance is a shortened, externally rotated leg

50. Conti… Distinguish pain arising from the hip from: lumbar nerve root irritation spinal or arterial claudication abdominal causes such as hernia Ask how the pain restricts activities. Record walking ability in terms of the time and distance the patient manages outside and on stairs, and note whether walking aids are used

51. Conti… The physical examination Examination sequence Patients should undress to their underwear and remove socks and shoes. You should be able to see the iliac crests. Look? Feel? Move Thomas test? Special tests Shortening? Trendelenburg’s sign?

52. Conti… Knee Anatomy????????? The history Pain Generalised knee pain is likely to be due to pathology in the tibiofemoral joint. Anterior knee pain, particularly after prolonged sitting or going downstairs, suggests patellofemoral joint pathology. Medial or lateral pain could come from the collateral ligaments or meniscal tears Pain in the knee may be referred from the hip. Take a detailed history of the mechanism of any injury. The direction of impact, load and deformation predict what structures are injured

53. Conti… Swelling The normal volume of synovial fluid is 1–2 mL and is clinically undetectable. An effusion indicates intra-articular pathology. Haemarthrosis (bleeding into the knee) is caused by injury to a vascular structure within the joint, such as a torn cruciate ligament or an intra-articular fracture Locking Two common causes in the knee are a loose body, such as from osteochondritis dissecans , osteoarthritis or synovial chondromatosis , and a meniscal tear. Bucket-handle and anterior beak meniscal tears are especially associated with locking. Posterior horn tears commonly cause pain and limit movement in the last few degrees of flexion

54. Conti… Instability (‘giving way’) Any of the four main ligaments may rupture from trauma or become incompetent with degenerative disease. The patella is prone to dislocate laterally because the normal knee has a valgus angle.

55. Conti… The physical examination Examination sequence Observe the patient walking and standing, as for gait. Note posture and deformities such as genu valgum (knock knee) or genu varum (bow legs). Look? Feel? Move Special tests Anterior drawer test Lachmann test Posterior drawer test Patellar apprehension test

56. Conti… Ankle and foot Anatomy???????????????? The history A ‘twisted’ ankle is very common, and is usually related to a sporting injury. Establish the exact mechanism of injury and the precise site of pain. Frequently there has been a forced inversion injury stressing the lateral ligament. A sprain occurs when some fibres are torn but the ligament remains structurally intact. A complete ligament tear allows excessive talar movement in the ankle mortise with instability Achilles tendon rupture is associated with sudden plantar flexion at the ankle. It is common in middle-aged patients doing unaccustomed activity such as squash, and is associated with some medications such as oral glucocorticoids and fluoroquinolone antibiotics. Forefoot pain, often localised to the second metatarsal, after excessive activity such as trekking, marching or dancing, suggests a stress fracture

57. Conti… Non-traumatic conditions Anterior metatarsalgia with forefoot pain is common, especially in middle-aged women. Acute joint pain with swelling suggests an inflammatory arthropathy such as rheumatoid arthritis or gout. In severe cases the metatarsal heads become prominent and walking feels like walking on pebbles or broken glass. Plantar surface heel pain that is worse in the foot-strike phase of walking may be caused by plantar fasciitis and tends to affect middle-aged patients and those with seronegative arthritides Spontaneous lancinating pain in the forefoot radiating to contiguous sides of adjacent toes occurs with Morton’s neuroma. A common site is the interdigital cleft between the third and fourth toes

58. Conti… The physical examination Examination sequence Ask patients to remove their socks and shoes Look? Feel? Move Special tests Achilles tendon?? Thomson’s ( Simmond’s ) test????? Mulder’s sign for Morton’s neuroma????

59. Fractures, dislocations and trauma A fracture is a breach in the structural integrity of a bone. This may arise in: normal bone from excessive force normal bone from repetitive load-bearing activity (stress fracture) bone of abnormal structure (pathological fracture,) with minimal or no trauma The epidemiology of fractures varies geographically. There is an epidemic of osteoporotic fractures because of increasing elderly populations. Although any osteoporotic bone can fracture, common sites are the distal radius, neck of femur, proximal humerus and spinal vertebrae

60. Conti… Fractures resulting from road traffic accidents and falls are decreasing because of legislative and preventive measures such as seat belts, air bags and improved roads The history Establish the mechanism of injury. For example, a patient who has fallen from a height on to their heels may have obvious fractures of the calcaneal bones in their ankles but is also at risk of fractures of the proximal femur, pelvis and vertebral column

61. Conti… The physical examination Use the ‘Look – feel – move’ approach. Observe patients closely to see if they move the affected part and are able to weight-bear Examination sequence Look See if the skin is intact. If there is a breach in the skin and the wound communicates with the fracture, the fracture is open or compound; otherwise it is closed. Look for associated bruising, deformity, swelling or wound infection

62. Conti… Feel Gently feel for local tenderness. Feel distal to the suspected fracture to establish if sensation and pulses are present. Move Establish whether the patient can move joints distal and proximal to the fracture. Do not move a fracture site to see if crepitus is present; this causes additional pain and bleeding Describe the fracture according to. For each suspected fracture, X-ray two views (at least) at perpendicular planes of the affected bone, and include the joints above and below

63. Investigations Common investigations in patients with musculoskeletal disease are summarised in box