Orthopedics - Oleksa A.P. 2006

Examination of the Orthopedic Patient
Supplementary Methods for Examining the Musculoskeletal System

Radiological examination has become a primary driver in The Development of Osteology and Arthrology. It is performed both for diagnostic purposes (Overview, targeted, contrast-enhanced, sectional, etc.) and for dynamic monitoring of Treatment efficacy.

In traumatology and orthopedics, plain radiography is used to determine the exact Location and type of bone fracture, The Nature of fragment displacement, and pathological changes in Bones and joints. Assessing the reparative process and bone healing is impossible without periodic radiological follow-up in two mutually perpendicular projections. Special projections are also employed to bring a specific bone into the desired plane on the radiograph (for example, the joint space of the shoulder joint (Fig. 28), the acromioclavicular joint, in cases of scaphoid pathology, or rupture of the distal tibiofibular syndesmosis, etc.).

To ensure a comprehensive radiological examination, the following technical conditions must be met:

1. The injured area or the region suspected of pathology must be centered on the image.

2. In cases of injuries and Diseases of the diaphysis of long bones, the radiograph must capture at least one of the adjacent JOINTS OF THE injured bone, located either proximal or distal to the injury.

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Fig. 28. Special positioning of the shoulder joint and X-ray tube for examining the joint space in shoulder HEAD instability.

3. If one of the bones of a two-bone segment (leg, forearm) is fractured and accompanied by longitudinal displacement of fragments (shortening), an image of the entire segment of the injured limb should be taken, including both joints.

4. X-rays are taken in two projections (anteroposterior and lateral). Under specific clinical indications, radiography in oblique or other projections may be required.

5. In spinal disorders, the radiograph must capture not only the affected vertebra but also the adjacent healthy vertebrae located above and below the site of injury (at least two vertebrae in each direction).

6. For certain bone and Joint Diseases (early forms of Osteoarticular Tuberculosis, Hematogenous Osteomyelitis, Initial Stages of dystrophic processes), comparative imaging of the affected and contralateral healthy bone (or joint) area is required to evaluate subtle changes. Comparative anteroposterior views are best obtained on a single film by positioning the tube midway between the healthy and affected sides. Lateral views of both sides should be performed under identical technical conditions (distance, development, etc.).

7. The image quality must be flawless.

8. Proper patient positioning is one of the fundamental conditions for obtaining a high-quality radiograph.

Fluoroscopy with an image intensifier (II) has gained widespread use, as it significantly enhances the X-ray image, thereby reducing radiation exposure for both the patient and medical staff. This method is used when prolonged fluoroscopic control is required (e.g., during osteosynthesis of a femoral neck fracture) or for assessing spinal function and pathological mobility between vertebrae (in osteochondrosis, articular process pathology, subluxation, etc.).

To pinpoint the lesion in the bone and prevent projection inaccuracies, targeted radiography is performed (focusing on a single vertebra or the metaphysis of tubular bones). When visualizing Bone tissue Structure is necessary, an X-ray apparatus that allows for magnified PROJECTION OF THE area several-fold is utilized.

Tomography—a method of sectional radiological examination—remains an indispensable tool in diagnosing deep-seated tumors, destructive bone processes, and other pathological foci. To detect even the smallest pathological changes, the tomographic slice increment should range from 3 to 5 mm. Tomography is performed in the desired projection (frontal, oblique, or lateral). Previously, simultaneous multi-slice cassettes were used to obtain a series of radiographs (5–6) in a single exposure. This method allowed for determining the size of the pathological focus, its depth, and its relationship with surrounding Tissues.

Today, advanced and technologically superior Methods of tomography are routinely employed.

Computed tomography is based on THE PRINCIPLE OF reconstructing radiographic images of Organs and tissues using a computer. In addition to providing high-quality sectional images of the studied area, computed tomography allows for the measurement (with digital values displayed on the screen) of the size and density of a pathological focus, comparing them with the parameters of adjacent healthy tissue. If necessary, a magnified view of the area of interest can be displayed on the screen. All data are recorded on video and can be printed on film or photographic paper for the physician upon request (Fig. 29).

The advantages of this type of tomography include high sensitivity, which allows tissues to be differentiated by their density with an accuracy of up to 0.6% (compared to only 10–20% on conventional tomograms); The ability to instantly determine the size and density of the pathological focus at various levels in numerical terms; and its spatial relationship with adjacent tissues.

Along with computed tomography, Magnetic Resonance imaging is now widely used, enabling the Assessment of the condition of not only bones but all soft-tissue structures at the desired level (Fig. 30).

Stereoradiography is used to determine the spatial position and mutual relationship of pathological foci, foreign bodies, bone fragments, and other structures.

Fig. 29. Computed tomogram of the fourth lumbar vertebra: a — cyst of the transverse process in the region of the vertebral pedicle; b — magnified view.

Fig. 30. Magnetic resonance imaging of the cervical spine (Spinal Cord compression by a herniated disc between C5 and C6).

To assess the functional capacity of the spine, cineradiography is employed, which uses a strip of serial radiographs taken during spinal movement. Due to equipment shortages, these techniques are not yet widely used in routine healthcare practice; however, spinal function is now evaluated fluoroscopically, and radiographs in two extreme positions are obtained when necessary (e.g., in spondylolisthesis).

Fig. 31. Contrast arthrography of the knee joint.

Contrast radiography is quite widely used for joint pathology (contrast arthrography, Fig. 31), bursae (bursography), fistulae of various origins (fistulography), etc. To detect intra-articular pathological changes in meniscal injury, loose bodies ("joint mice"), scar tissue (shvarts), and cavity obliteration (narrowing of the Joint Capsule isthmus and acetabular overgrowth in congenital hip dislocation, Cartilage defects, etc.), gases (oxygen, air, carbon dioxide) or contrast media solutions (cardiotrast, verotrast) are utilized. The contrast agent is injected via a puncture needle using a syringe under strict adherence to aseptic rules. Oxygen from an oxygen cylinder should not be used, even when passed through a gauze-cotton filter or a Bobrov bottle containing an antiseptic. The required amount of oxygen depends on the individual volume of the joint cavity, so it is injected until the patient feels a sensation of painful distension. When injecting the contrast fluid in the presence of synovial fluid, it is not strictly necessary to aspirate it from the joint; however, prior to gas injection, this step is mandatory to prevent foam formation and artifacts on the radiograph.

Considering the irritating effect of contrast media—especially iodine-containing ones—on synovial membranes, which may lead to synovitis, it is advisable to aspirate them after radiography or immediately before surgery.

Nevertheless, the diagnostic yield of contrast arthrography in meniscal pathology is relatively low, ranging from 40 to 60%. Its diagnostic value is significantly higher in cases of hip subluxations and congenital hip dislocations.

Fistulography provides fairly accurate information provided that the contrast solution is injected into the fistula under pressure (Fig. 32). To achieve this, a needle punctures a rubber cap (from an antibiotic vial), which is pressed tightly against the Skin, thereby sealing the fistula.

Fig. 32. Fistulography of a fistula in chronic femoral osteomyelitis.

Injecting a contrast agent into a perarticular bursa or cyst reveals its shape, dimensions, presence of septa fused with the joint capsule, and other features.

Discography is technically the most complex Procedure. During discography, the patient is positioned to eliminate or reduce the physiological lordosis. The corresponding interspinous space is identified by Palpation and marked. Under local anesthesia, a spinal puncture needle is advanced through the soft tissues into the spinal canal. The needle is carefully guided through both meningeal layers (dura and arachnoid) and the posterior longitudinal ligament, resting against the annulus fibrosus of the intervertebral disc. With some applied force, the annulus fibrosus is punctured, resulting in a distinct " yielding " sensation as the needle enters the nuclear region. The precise LOCATION OF THE needle tip is radiologically verified in a lateral projection (Fig. 33).

Radionuclide imaging. In the early 1940s, Marshak and Marinelli reported The Use of radioactive phosphorus in tumor Diagnostics. Radionuclide diagnostics is based on the differential Distribution of a radioactive tracer in healthy versus pathologically altered tissue. Numerous organotropic radioactive Pharmaceuticals have been developed for clinical diagnostics: sodium iodide-131 for thyroid studies, colloidal gold-198 for the Liver, neohydrin-203 for the Kidneys, and so on. Recently, tumorotropic agents that are selectively absorbed by tumors have been under development.

Fig. 33. Contrast discography of the spine.

To diagnose pathological changes (tumors) in bones, osteotropic radioactive phosphorus compounds labeled with technetium (99mTc-pyrophosphate), strontium, calcium, and other elements are used.

Radionuclide diagnostic methods fall into two main groups: 1) contact beta-radiometry and radioautography, which measure the differential uptake of a radioactive tracer in healthy and pathologically altered tissue; 2) radionuclide scanning and autofluoroscopy for visualizing the differential distribution of the isotope across organs and tissues (Fig. 34).

Fig. 34. Radionuclide scan of the spine.

Fig. 35. Sonogram of the hip joints in left-sided Perthes disease.

A scan provides information on the shape, size, functional activity, and STRUCTURE OF THE tissue area under investigation. On scans or scintigrams, a pathological focus appears as areas of increased or decreased radiopharmaceutical accumulation compared to healthy tissue or against a Background of hyperconcentration.

Ultrasonography (sonography). Ultrasound diagnostics is now widely integrated into orthopedic and traumatological practice. The operating principle of diagnostic ultrasound equipment is based on registering ultrasonic waves reflected from the boundary between two media with differing acoustic impedances. This method makes it possible to detect echo signals from Tissue and organ boundaries that exhibit only slight differences in acoustic density.

Given the simplicity of the procedure and the practical harmlessness of ultrasound compared to X-ray diagnostics, this method is used for the early detection of developmental Dysplasia of the hip, congenital hip dislocation, and other pre- and postnatal pathologies of The Musculoskeletal System (Fig. 35).

Electrophysiological Research Methods.

Determination of nerve conductivity. Clinical practice utilizes electrodiagnostics to assess the excitation and contraction of skeletal Muscles using galvanic current. These studies are conducted in cases of nerve trunk injuries. For example, the presence or absence of wrist extensor contraction helps determine the conductivity of the radial nerve. The absence of Muscle contraction indicates a severe nerve injury requiring urgent surgical exploration—revision of the nerve, freeing it from between bone fragments, restoring its structural integrity along with osteosynthesis, neurolysis, etc. If nerve conductivity is preserved, conservative management is pursued (as functional recovery is possible).

Electromyography is used to determine the functional state of muscles in various orthopedic conditions, as well as the extent of their degeneration, scarring, and other pathological changes.

During the movement of a specific muscle group or a single muscle, their electrical activity is automatically recorded on a myograph using surface electrodes (small silver plates) or needle electrodes. Accurate interpretation of the electrical activity patterns in pathological conditions is only possible by comparing the obtained myogram with standard electromyographic values of a healthy individual.

Rheovasography is one of the most informative quantitative Methods for Assessing Blood flow intensity, blood volume, and vascular elasticity in the extremities (Fig. 36).

The study is performed using a dual-channel electrocardiograph (EKPCH-3) coupled with a four-channel rheograph (RG-4-01). An Electrocardiogram in lead II is recorded simultaneously with the rheovasogram. Wave registration on grid paper is carried out at a paper speed of 50 mm/s. Typically, longitudinal rheovasography is performed by placing two electrodes on the skin of a specific limb segment, 10–15 cm apart. Following the recording, wave amplitude, calibration signal, anacrotis and catacrotis duration, and the rheographic index are calculated. The obtained data are compared against the age-specific normogram of a healthy person.

Polarography is a method used to determine oxygen saturation (pO₂) in blood, tissues, and joint cavities. It is primarily employed in vascular pathology and arthrology.

After determining the individual sensitivity of the electrode for recording the polarographic curve using a polarograph (LP-7), one (platinum) electrode is inserted into the studied area of the body, while the second (calcium chloride) electrode is placed on the skin of any body area to close the circuit. The polarogram is recorded on a moving paper strip under normal breathing conditions and oxygen loading (O₂ inhalation) to determine the rate and degree of tissue saturation, as well as using a tourniquet test to determine the rate and degree of tissue oxygen utilization.

Oxyhemometry is the simplest METHOD FOR DETERMINING blood oxygen saturation. A sensor clip connected to an oximeter with a digital display is attached to the earlobe.

Electrothermography and thermography are used to diagnose inflammatory processes, tumors, Circulatory Disorders, and other pathological changes of the musculoskeletal system.

An electrothermometer is used to measure the local skin Temperature. The advantage of this method is that the electrothermometer probe can be applied to any part of the body, immediately yielding a digital temperature reading on the display.

Thermography involves capturing thermal images of body areas with elevated or lowered temperatures on a thermal imager screen. The thermograph converts invisible infrared (thermal) radiation from the body surface into a visible image on a cathode-ray tube screen. For documentation purposes, this image can be reproduced in color on photographic paper.

Fig. 36. Normal rheovasograms depending on age: 1 and 3 are rheograms from two leads, 2 and 4 are the first derivatives.

The advantage of this method is the simultaneous visualization of a significant body surface area with varying temperature readings and local hyperthermia in the area of the pathological focus.

Thermographic color imaging can also be achieved through the topical application of Cholesterol crystals, but this method is overly cumbersome and therefore not used in clinical practice.

Arthroscopic examination is most commonly performed to diagnose pathological Changes in the knee joint, the cavity of which provides an adequate field of view. Indications for arthroscopy include cases where a Diagnosis cannot be established using other diagnostic methods, particularly contrast radiography.

The examination utilizes specialized arthroscopes (manufactured by Karl Storz, Germany; Watanabe, Japan) equipped with an optical illumination system, a device for pneumatic or hydraulic joint distension and irrigation, a photo unit for documenting the identified pathology, and a set of accessory instruments for biopsy, meniscectomy, cartilage shaving, and other Procedures. Arthroscopic diagnostics are used not only for knee joint pathologies but also for other large joints, as well as the wrist and ankle joints.

Arthroscopy is performed under general anesthesia (Fig. 37) or local anesthesia using a 1% novocaine solution under strict adherence to asepsis rules (the surgeon prepares as for open surgery). The arthroscope can be inserted into the knee joint either via the anterosuperior approach (suprapatellar pouch) or the anteroinferior approach, lateral to the Patella. Anterolateral approaches are the least traumatic, as they are free of muscle and do not cause bleeding. However, if visualization of the lateral compartment of the joint is required, the anteromedial approach is preferred.

To prevent the optics from becoming obscured by bleeding and to ensure clear visibility, the joint is continuously irrigated with normal saline via a flow-through system during arthroscopy, consuming up to 5-7 liters of fluid.

The arthroscope allows visualization of the synovial membrane of the joint pouches, articular cartilage, menisci, cruciate ligaments, and alar folds. Undoubtedly, visual diagnosis of pathological changes within the joint is the most reliable method. Furthermore, arthroscopy allows for tissue sampling for cytologic or histologic examination, removal of loose osteochondral bodies, meniscectomy, ligament repair, and other surgical interventions.

Post-arthroscopic complications may include hemarthrosis, subcutaneous emphysema, and reactive synovitis, which generally do not require specific treatment.

Laboratory tests. Most patients seeking medical care require a comprehensive evaluation, including blood and urine tests, analysis of other bodily excretions, and specific reactions and assays for certain diseases. To confirm a diagnosis of tuberculosis, von Pirquet and Mantoux tests are performed; for brucellosis, the Burnet test; and for Syphilis, the Wassermann test, among others. In Rheumatoid Polyarthritis, the non-specific Waaler-Rose serological test is used.

In cases of severe traumatic injuries and toxicosis, it is crucial to determine the extent of blood loss. This is done by measuring circulating blood volume, hematocrit, erythrocyte count, and blood Hemoglobin levels, as well as performing a coagulogram and urinalysis (routine urinalysis and biochemical tests such as residual nitrogen, protein, Myoglobin, etc.). Inflammatory processes and certain tumors manifest as abnormal blood Cell counts (leukocytes, lymphocytes, etc.) and an elevated ESR. Destructive processes are characterized by the presence of C-reactive protein. Biochemical assays determine quantitative blood parameters, including protein, glucose, residual nitrogen, electrolytes, Hormones, and Enzymes.

In suppurative-necrotic processes and osteomyelitis, Bacteriological examination OF wound discharge is mandatory to identify the microflora and its antibiotic sensitivity. Highly informative data are obtained through Cytological examination of wound imprints and punctates. The body's immunoreactivity is also evaluated in trauma and orthopedic patients.

Laboratory tests are one of the most essential supplementary methods for patient examination. They help clarify diagnoses, assess the patient's general condition, and monitor the progression of pathological processes dynamically.

Puncture and biopsy. A puncture can be either diagnostic or therapeutic. It is performed under local anesthesia using a large-gauge injection needle to aspirate exudate, blood, or other fluids from a joint cavity or tissue. The punctured material is examined visually, or macroscopically (color, turbidity, density, sediment); cytologically, or microscopically (type and count of Cells, microorganisms, etc.); biochemically (levels and quality of Proteins, glucose, enzymes, etc.); and bacteriologically (microbial flora and its antibiotic susceptibility), along with disease-specific assays.

Diagnostic puncture is sometimes referred to as needle biopsy. The term "needle biopsy" should be used when referring to the intravital acquisition of tissue material for morphological examination rather than fluid. Needle biopsy is performed to diagnose the nature of tumor, destructive, or inflammatory processes in soft tissues, bones, or joints.

Excisional biopsy involves taking one or more tissue fragments for histological examination. In some cases, an excisional biopsy can also serve as a therapeutic measure.

Total biopsy is the surgical removal of an entire pathological lesion followed by its morphological examination.

Trephine biopsy is used to diagnose the nature of Bone tumors. Using a special tubular burr, a cylindrical bone core is drilled and extracted along with the instrument. The obtained material is then subjected to histological examination.

Application of computer technology.

Today, the broad capabilities of computer technology have also found Applications in medicine. Computers are capable of not only performing computational tasks but also executing logical operations. This has led to the DEVELOPMENT OF NEW methods for Processing various types of information. Next-generation computer systems possessing artificial intelligence capabilities—meaning they can solve tasks inherent only to intelligent beings (such as natural language systems)—are being intensively developed and refined.

There are basic and individual computers featuring an algorithmically complete instruction set that are widely used in clinical practice.

The approximate scope of computer technology applications in traumatology and orthopedics is as follows:

1. Management of the trauma and orthopedic service at all levels (national, regional, district, and hospital).

2. Modeling of diagnostic and therapeutic activities within the trauma and orthopedic service.

3. Accumulation, systematization, storage, and retrieval of information (information and reference systems) in traumatology and orthopedics.

4. Development of DIAGNOSTIC AND PROGNOSTIC systems.

5. Creation of expert systems (for assessing treatment quality, medical staff performance, etc.).

6. Organization OF THE educational process—programmed learning and knowledge assessment.

7. Application in scientific research—data registration and analysis.