A mallet finger is a common sports injury. It's typically caused by an object (e.g., ball) hitting the fingertip, resulting in forced flexion.
This hyperflexion can rupture or avulse the extensor tendon insertion at the dorsal base of the distal phalanx.
A characteristic swan-neck deformity can occur, involving retraction of lateral bands and hyperextension of the proximal interphalangeal joint.
Treatment involves maintaining hyperextension of the distal interphalangeal joint for 6 weeks while allowing the proximal interphalangeal joint to flex.
This can be achieved using a mallet finger splint or non-stretched adhesive tape.
Summary
Mallet finger is a flexion deformity due to injury of the extensor mechanism of the distal phalanx.
Untreated, it can lead to a permanent flexion deformity.
Management includes full-time extension splinting for 8 weeks.
Compliance is crucial; any flexion during the splinting period restarts the 8-week duration from zero.
Surgery is considered for cases with:
Fractures involving >30% of the articular surface.
Injuries with volar subluxation of the distal phalanx.
Irreducible avulsed segments.
Failure of conservative management.
Absent full passive extension.
Referral to a hand specialist or sports medicine physician may be necessary.
Flexor Tenosynovitis
Pyogenic flexor tenosynovitis is a bacterial infection within the tendon sheath of the finger.
It is a painful condition needing urgent treatment to maintain hand function.
Cause
Often results from a minor penetrating injury (e.g., rose thorn, cat bite), which might be seemingly insignificant or even forgotten.
Symptoms and Signs
Increasing pain, usually in a single finger or thumb, with swelling, warmth, and redness of the entire finger.
The affected finger is slightly flexed, and full extension is painful or impossible.
Pain is elicited upon palpation of the palmar side of the affected finger.
Systemic symptoms (fever, feeling unwell) may develop as the condition progresses.
Scaphoid Fracture
Scaphoid fractures account for approximately 75% of all carpal fractures, but are rare in children and the elderly.
Typically caused by a fall onto an outstretched hand.
Features
Pain on the lateral aspect of the wrist.
Tenderness in the anatomical snuffbox (key sign).
Swelling in and around the snuffbox.
Pain or clicking on wrist movement.
Pain on axial compression of the thumb towards the radius.
There is a 20% false-negative rate in scaphoid radiographs; clinical confirmation is essential.
If a scaphoid fracture is highly suspected despite a normal X-ray, immobilize the wrist in a scaphoid plaster for 10 days (including the 1st MCP joint), then re-X-ray.
Isotopic bone scan may be indicated if suspicion remains high despite normal X-rays.
Undisplaced and stable fractures usually require 6-8 weeks in a below-elbow scaphoid cast.
Displaced fractures require reduction (open or closed) and, if unstable, internal fixation.
The mechanism of injury is usually a fall onto an outstretched hand with an extended and radially deviated wrist.
Scaphoid fractures have a high risk of nonunion and avascular necrosis due to limited blood supply.
Up to one-third of patients with clinical suspicion have a normal initial X-ray.
Standard management includes immobilization in a thumb abduction cast for 10 days with follow-up X-ray.
Advanced imaging (CT, bone scan, MRI) is increasingly used to avoid overtreatment in adults.
Children are usually treated with immobilization and follow-up plain X-ray imaging.
CT, bone scan, and MRI are equally sensitive, but CT is often preferred due to greater availability and lower radiation dose compared to nuclear medicine.
Elite athletes should preferably be imaged with MRI for training guidance.
In severe injuries, the scapholunate ligament can be disrupted, leading to scapholunate dissociation.
Rupture of both intrinsic and extrinsic wrist ligaments can result in carpal bone dislocation. A transscaphoid perilunate dislocation is an orthopedic emergency.
Colles Fracture
Complications
Most Common Complication: Malunion
Earliest complication: Volkmann contracture
Dinner fork deformity is characterized by impaction, posterior displacement and angulation, lateral displacement and angulation, and supination of the distal radius fracture
Treatment
Minimal displacement: below-elbow plaster for 4 weeks, then a crepe bandage.
Displaced: meticulous reduction under anesthesia, set in flexion 10^{\circ}, ulnar deviation 10^{\circ}, and pronation; below-elbow plaster for 4-6 weeks (6 weeks maximum).
Unstable fractures may initially require an above-elbow cast with the forearm in pronation.
Check X-ray at 10-14 days; position may be lost as swelling subsides.
Problems
Ruptured extensor pollicis longus tendon.
Stiffness of the elbow, MCP joints, and IP joints.
Discomfort at the inferior radio-ulnar joint due to disruption.
Regional pain syndrome.
Volkmann contracture.
Smith Fracture
Smith fracture of the lower end of the radius is often called a ‘reverse Colles’ fracture.
It results from a fall onto the back of the hand, causing the lower fragment to flex and impact on the upper fragment.
Treatment involves reduction and immobilization for 6 weeks in a cast, similar to a Colles fracture but with the wrist extended.
Unstable fractures may initially require an above-elbow cast with the forearm in supination.
Metacarpal Fractures
Metacarpal fractures can be stable or unstable, intra-articular or extra-articular, and closed or open.
‘Knuckle’ injuries from a punch can cause a fracture of the neck of the fourth and fifth metacarpal.
Management typically involves correcting marked displacements with manipulation (under anesthesia) and splinting with a below-elbow, padded posterior plaster slab up to the dorsum of the proximal phalanx.
The metacarpophalangeal joints are held in a position of function.
Metacarpal fractures tend to rotate, which must be prevented by splinting the metacarpophalangeal joints at 90^{\circ}, correcting any malrotation.
Surgical intervention is indicated for gross displacement, shortening, or rotation.
A felt pad can act as a suitable grip.
The patient should exercise the free fingers vigorously.
Remove the splint after 3 weeks and start active mobilization.
Phalangeal Fracture
Non-displaced phalanges without rotational malalignment: Strap the injured finger to the adjacent normal finger with elastic garter or adhesive tape for 2-3 weeks (buddy strapping).
Start the patient on active exercises.
If pain and swelling is a problem, splint the finger with a narrow dorsal or anterior slab (a felt-lined strip of malleable aluminum can be used).
Alternatively, bandage the hand while the patient holds a tennis ball or roll of bandage to maintain flexion of all interphalangeal joints.
Displaced phalangeal fractures (usually proximal and middle): Correct the deformity by traction and direct digital pressure under anesthesia.
Maintain correction by splintage for 2-3 weeks.
Ensure flexion at the interphalangeal joints with a dorsal padded plaster slab from above the wrist to the base of the fingernail.
Painful Shoulder
Common Shoulder Conditions
Instability:
Typical age group: 15-35
Problem Structure: Labrum/capsule
Symptoms: Dislocations
Diagnostic pointers: History of dislocation, apprehension sign
Stiffness:
Typical age group: 40-60
Problem Structure: Capsule
Symptoms: Pain, night pain, loss of movement, loss of external rotation
Diagnostic pointers: N/A
Impingement:
Typical age group: 30-60
Problem Structure: Rotator cuff (fatigue)
Symptoms: Night pain, pain with overhead activities
Diagnostic pointers: Impingement signs
Rotator cuff tear:
Typical age group: 50 +
Problem Structure: Rotator cuff, esp. supraspinatus
Symptoms: Constant severe pain, stiffness, loss of all movements
Diagnostic pointers: N/A
AC joint pain:
Typical age group: 25-45
Problem Structure: ACJ cartilage
Symptoms: Localized AC joint pain
Diagnostic pointers: Paxinos sign
Arthritis:
Typical age group: 70 +
Problem Structure: GHJ cartilage
Symptoms: Pain, loss of movement, crepitus
Diagnostic pointers: N/A
Rotator Cuff Tendinopathy
With tendon disorders (rotator cuff tendons or biceps), there is usually painful restriction of movement in one direction.
Capsulitis and subacromial bursitis usually restrict movement in most directions.
The four rotator cuff muscles allow the humerus to move freely during elevation of the arm.
Rotator cuff tendinopathy, also called ‘the subacromial impingement syndrome’, is the commonest cause of shoulder pain.
It may involve inflammation (tendinitis), a tear in a tendon (degeneration), calcification, amyloidosis, or impingement under the acromion.
It may involve one tendon, usually the supraspinatus, or multiple rotator cuff tendons.
It is frequently seen in young people engaged in sports with overhead activities and people over 50 years (rotator cuff tears are more common).
Diagnosis can usually be made on the history and physical examination.
Rotator Cuff Disease vs. Adhesive Capsulitis
Pain:
Rotator cuff disease: Often severe
Adhesive capsulitis: Often very severe
Night pain:
Rotator cuff disease: Night pain, inability to sleep on affected side
Adhesive capsulitis: Night pain, inability to sleep on affected side
Onset:
Rotator cuff disease: Gradual or sudden
Adhesive capsulitis: Usually gradual; rapid onset suggests calcific tendinitis
Movement:
Rotator cuff disease: Painful arc, aggravated by certain movements
Adhesive capsulitis: Marked by stiffness in all directions
Systematic reviews lack sufficient information for conclusive evidence-based recommendations for treatment.
For analgesia, paracetamol orally is first line; if inadequate, NSAIDs alone or in combination.
Corticosteroid injections and physiotherapy may improve range of movement.
Experienced therapists believe peritendon and subacromial corticosteroid injections are efficacious in selected patients.
Treatment includes: rest during the acute painful phase; analgesics and NSAIDs (up to 4 weeks); peritendon or subacromial injection (if no tears on ultrasound); physiotherapy (scapular stabilizing exercises, rotator cuff strengthening); surgery (after 3-6 months, usually subacromial decompression, sometimes excision of calcium).
Rotator Cuff Tears
Asymptomatic rotator cuff tears are common.
4% of people <40 years old and in more than 50% of those over 60 years.
A significant number will become symptomatic over time.
Explain to the patient that ‘the rotator cuff is worn not torn’, like a frayed heel of a sock.
Diagnostic tip: 98% specificity for all three signs:
supraspinatus weakness
weakness in external rotation
impingement (in external or internal rotation or both)
If two of these three tests are positive in a patient over 60, there is a 98% chance of a rotator cuff tear. Refer for surgical repair.
Subacromial Bursitis
In impingement syndrome, the subacromial bursa and supraspinatus tendon become compressed between the humeral head, the acromion, and the coraco-acromial ligament.
This results in pain with forward elevation of the arm and narrowing of the subacromial space.
Causes are functional, anatomical, or a combination of both.
Functional impingement occurs when there is poor control of the shoulder stabilizers, leading to cephalad slippage of the humeral head compressing the subacromial space.
It can also result from overuse or injury, altering biomechanics and poor stabilizer control.
Anatomical impingement occurs secondary to arthritis or hypertrophic changes of the acromion, narrowing the subacromial space.
Either cause may result in subacromial bursitis and/or rotator cuff lesions.
Subacromial (subdeltoid) bursitis is the more severe association of rotator cuff pathology and may require hospital admission for pain control.
It is the only inflammatory disorder around the shoulder joint where localized tenderness is a reliable sign.
Management :
Strong analgesics (e.g., paracetamol and codeine).
Large local injection of 5-8 mL of local anesthetic into and around the bursa just beneath the acromion, followed immediately by 1mL of corticosteroid (long-acting) into the focus of the lesion.
Adhesive Capsulitis
SNE can develop due to external compression of the nerve at the suprascapular notch.
Causes include:
Excessive use of a heavy backpack when hiking or commuting
A direct blow to the nerve (e.g., from a fall)
Repetitive motion at the shoulder (e.g., weight lifting, baseball).
Clinical features of SNE at the suprascapular notch include:
Shoulder pain
Weakness of shoulder abduction (supraspinatus muscle)
Weakness of external rotation (infraspinatus muscle)
Adhesive capsulitis or idiopathic frozen shoulder is an acute inflammation affecting the glenohumeral joint, which becomes fibrotic and contracted.
It can arise spontaneously or post-injury and may be partial or global (classic ‘frozen shoulder’).
Differential diagnoses include monoarticular rheumatoid arthritis, crystal arthropathy (e.g., gout), and septic arthritis.
It is worse in diabetes.
Estimated to affect 2-5% of the general population and 10-20% of those with diabetes; 12% develop bilaterally.
Generally occurs in three stages:
‘Freezing, frozen, and thawing’—an inflammatory painful phase of 2-9 months
A fibrotic contracted (frozen) phase of 4-12 months
Partial or complete resolution (thawing) of 5-26 months
Treatment:
Conservative management involving physiotherapy is best practice.
For analgesia: paracetamol, paracetamol with NSAIDs, or NSAIDs alone.
For severe pain: oral corticosteroids rapidly alleviate pain, improve function, and may provide sustained benefit.
A typical dose is prednisolone 30 mg orally daily for 3 weeks, then taper over the next 2 weeks.
Shoulder Dislocation
Usually affects people in their 40s, 50s, and 60s.
Site: around the shoulder and outer border of the arm
Radiation: to elbow
Quality: deep throbbing pain
Frequency: constant, day and night (severe cases)
Duration: constant
Onset: spontaneous, usually gradual, wakes the patient from sleep
Associated features: stiffness of arm, may be frozen
Examination (typical features): ‘frozen’ shoulder (some cases), various active and passive movements painful and restricted, especially extension and at extremes of movement, resisted movements pain-free (patient compensates with scapulo-humeral movements)
The shoulder is an inherently unstable joint due to the shallow glenoid articulating with a small part of the humeral head.
This type of dislocation represents 50 percent of all major joint dislocations being the most regularly dislocated joint in the body.
The shoulder can dislocate in an anterior (95% of shoulder dislocations), posterior, inferior direction and completely or partially.
Fibrous tissue joining the bones is often stretched or torn, complicating a dislocation.
Biceps Tendinopathy and Rupture
Bicipital tendinopathy is a lesion (fraying or tearing) of the long head of the biceps, causing pain in front of the shoulder.
Important signs:
Pain on resisted flexion of the elbow joint.
Pain on resisted supination with the elbow flexed to 90° (Speed test) and forearm pronated (Yergason test).
A painful arc may be present when the intrascapular part is affected.
Often confused with rotator cuff lesions.
Local tenderness may be elicited by palpation along the course of the tendon in the bicipital groove (best done with the arm externally rotated).
Most active shoulder movements, especially external rotation, bring on the pain.
Bicipital tendinopathy usually follows chronic repetitive strains in young to middle-aged adults (e.g., home decorating, weight training, tennis, swimming freestyle, cricket bowling, and baseball pitching).
Two complications are complete rupture and subluxation of the tendon out of its groove.
One treatment is a corticosteroid and local anesthetic injection at the site of maximal tenderness in the bicipital groove.
Sudden popping / tearing pain in cubital fossa + bruise in forearm
Urgent surgery
Rupture of the long head of biceps usually occurs in the older person.
It may be spontaneous or occur after lifting or falling on the outstretched hand.
The patient usually feels a tearing or snapping sensation in the shoulder.
The shoulder may be painful and difficult to move.
The upper arm looks bruised, and a lump due to the rolled-up belly of biceps is obvious on flexion of the elbow.
Active treatment is not usually indicated, but surgical intervention is appropriate for young, active people, especially those in power sports.
Rupture of the distal tendon (short head) attached to the radius may occur with heavy lifting or similar load. Bruising appears at the elbow.
Polymyalgia Rheumatica
It is very important not to misdiagnose polymyalgia rheumatica in older persons (over 50 years) presenting with bilateral pain and stiffness in the shoulder girdle.
It may or may not be associated with hip girdle pain.
Polymyalgia rheumatica sometimes follows an influenza-like illness.
Patients complain bitterly about their pain and seem flat and miserable.
In the presence of a normal physical examination they are sometimes misdiagnosed as ‘rheumatics’ or ‘fibrositis’.
Routine shoulder X-rays following trauma should always include the ‘axillary shoot-through’ view and then the diagnosis becomes obvious.
Early diagnosis and management can prevent a poor outcome and perhaps litigation.
Site: shoulders and upper arms
Radiation: towards lower neck
Quality: a deep, intense ache
Frequency: daily
Duration: constant but easier in afternoon and evening
Treatment: corticosteroids give dramatic relief but long-term management can be problematic.
Classification criteria for PMR
BSR and BHPR guidelines (2009)
Age >50 years, duration >2 weeks
Bilateral shoulder or pelvic girdle aching, or both
New hip involvement (pain, tenderness, limited movement)
Morning stiffness for >45 min
Evidence of an acute-phase response
New EULAR/ACR classification (2012)
Age >50 years with new bilateral shoulder pain
Morning stiffness for >45 min
Elevated C-reactive protein and/or ESR
Normal inflammatory markers if there is a classical clinical picture and response to steroids
In the absence of peripheral synovitis or of positive RA serology
Ultrasound findings of bilateral shoulder abnormalities (subacromial bursitis, bicipital tenosynovitis, glenohumeral effusion) or abnormalities in one shoulder and hip (hip effusion, trochanteric bursitis)
A diagnosis of PMR should be considered in patients aged >50 years who have sub-acute to acute onset of bilateral shoulder pain and stiffness.
Any patient with PMR should be considered at risk of GCA and referred for temporal artery biopsy if suggestive features are present.
Treatment with corticosteroids should be commenced urgently and in higher doses if GCA is suspected.
Most patients require 1-2 years of therapy, and slow tapering of the dose reduces relapses.
Prevention and treatment of corticosteroid-induced complications should be considered early in the course of the disease.
Referral to a rheumatologist should be considered if atypical features are present.
Posterior Dislocation of Shoulder
This is a rare form of shoulder instability, which is often misdiagnosed.
On first inspection there may not be an obvious abnormality of the shoulder contour.
Often sports-related, but consider this condition if there is a history of electric shock or a tonic-clonic convulsion.
Recurrent Subluxation
Recurrent anterior or inferior subluxations, or both, are probably more common than recurrent dislocations, yet frequently are not diagnosed.
Those who complain of attacks of sudden weakness and even a ‘dead arm feeling’ lasting for a few minutes with overhead activities of the arm should be investigated for this condition.
The disorder is usually apparent on careful stress testing of the shoulder.
Air-contrast CT arthrography is considered the best investigation.
Surgery is usually curative while conservative treatment often fails for younger patients.
Supracondylar Fractures
Supracondylar fractures represent about half of all elbow fractures in children and most are extension fractures following falls onto the outstretched arm.
Pressure of the displaced bony fragments causes impingement on the brachial artery, which can lead to impending forearm flexor compartment ischaemia and muscle death.
Severe forearm pain is the most significant and important sign of ischaemia.
Neuropraxia of the median, radial, or ulnar nerves is common.
These injuries almost invariably recover.
This diagnosis must always be assumed in displaced supracondylar fractures in children.
Thus, it is the GP’s responsibility to ensure treatment is expedited.
The brachial and radial pulses should be assessed carefully.
The fracture is reduced by hyperflexion of the elbow during traction (after lateral displacement has been corrected), and then immobilized in collar and cuff and stockinet vest
The fully flexed elbow with the usually intact posterior periosteal hinge provides fracture stability.
Plaster casting is unnecessary and some would suggest contraindicated because of the significant risk of ischemic contracture.
Circulatory status requires monitoring in the first 24 hours following injury.
The collar and cuff should be used for 6 weeks.
The invariably stiff elbow quickly resolves without a need for formal therapy.
Symptoms: Pain at outer elbow, referred down back of forearm, Rest pain and night pain (severe cases), Pain in the elbow during gripping hand movements (e.g. turning on taps, turning door handles, picking up objects with grasping action, carrying buckets, pouring tea, shaking hands)
Signs: No visible swelling, Localized tenderness over lateral epicondyle, anteriorly, Pain on passive stretching wrist, Pain on resisted extension wrist and third finger, Normal elbow movement
Course: 6 to 24 months (most self-limiting)
Management:
Basic: rest from offending activity; RICE* and oral NSAIDs if acute; exercises—stretching and strengthening
Additional (if refractory): corticosteroid/LA injection (max. two); manipulation; surgery
Medial Epicondylar Tendinopathy
In ‘forehand’ tennis elbow, or golfer’s elbow, the lesion is the common flexor tendon at the medial epicondyle.
The pain is felt on the inner side of the elbow and does not radiate far.
The main signs are localized tenderness to palpation and pain on resisted flexion of the wrist.
In tennis players, it is caused by stroking the ball with a bent forearm action or using a lot of top spin, rather than stroking the ball with the arm extended.
The treatment is similar to that for lateral epicondylar tendinopathy except that in a dumbbell exercise program the palm must face upwards.
After-care and prevention (lateral and medial epicondylar tendinopathies): If related to tennis, sport should be resumed gradually. Using a good quality, lighter racket and suitable grip size, start quietly with a warm-up period. Obtain advice on style, including smooth stroke play and avoiding ‘wristy’ shots. It may be worthwhile to advise the use of a non-stretch band or brace situated about 7.5 cm below the elbow.
Olecranon Bursitis
Presents as a swelling localized to the bursa (which has a synovial membrane) over tire olecranon process.
The condition may be caused by trauma, arthritic conditions (rheumatoid arthritis and gout), or infection.
Traumatic bursitis may be caused by a direct injury to the elbow or by chronic friction and pressure as occurs in miners (beat elbow), truck drivers, or carpet layers.
Acute olecranon bursitis with redness and warmth can occur in rheumatoid arthritis, gout, pseudogout, hemorrhage, and infection (sepsis).
Septic bursitis must be considered where the problem is acute or subacute in onset, and hence aspiration of tire bursa contents with appropriate laboratory examination is necessary (smear, Gram stain, culture, and crystal examination).
Treatment depends on the cause.
Chronic recurrent traumatic olecranon bursitis with a synovial effusion may require surgery, but most cases can resolve with partial aspiration of the fluid and then injection of corticosteroid through the same needle. Sepsis must be ruled out.
De Quervain Tenosynovitis
At the wrist, a not uncommon, work-induced condition is de Quervain stenosing tenosynovitis of the first dorsal extensor compartment tendons (extensor pollicis brevis and abductor pollicis longus), which pass along the radial border of the wrist to the base of the thumb.
It is usually seen when the patient is required to engage in rapid, repetitious movements of the thumb and the wrist, especially for the first time, and thus is common in assembly line workers, such as staple gun operators.
It often occurs in pregnancy, particularly postpartum.
Clinical features:
Typical age 40-50 years
Pain at and proximal to wrist on radial border
Pain during pinch grasping
Pain on thumb and wrist movement
Dull ache or severe pain (acute flare-up)
Can be disabling with inability to use hand (e.g., writing)
Triad of diagnostic signs:
Tenderness with possible crepitations on palpation over and just proximal to radial styloid
Firm tender localized swelling in the area of the radial styloid (may be mistaken for exostosis)
Positive Finkelstein sign (the pathognomonic test)
Treatment:
Conservative management is preferred. Rest and avoid the causative stresses and strains on the thumb abductors.
Refer to occupational and hand therapists for a custom-made splint that involves the thumb and immobilizes the wrist.
Consider trial of oral or topical NSAIDs four times a day for 14-21 days.
Local long-acting corticosteroid injection can relieve and may even cure the problem but care should be taken to inject the suspension within the tendon sheath rather than into the tendon.
Surgical release is required for recalcitrant cases.
Dupuytren Contracture
Also referred to as ‘Viking disease’, this contracture, which causes discomfort and dysfunction rather than pain, is fibrous hyperplasia of the palmar fascia leading to nodular formation and contracture over the fourth and fifth fingers in particular.
It occurs in about 10% of males over 65 years.
The cause is unknown, but there is an AD genetic predisposition.
It is associated with smoking, alcoholism, liver cirrhosis, COPD, diabetes, epilepsy and heavy manual labor.
If the palmar nodule is growing rapidly, injection of corticosteroids or collagenase (e.g. Xiaflex) into the cord or nodule may be beneficial, but collagenase carries a risk of tendon rupture.
Surgical intervention is indicated for a significant flexion deformity.
Dupuytren contracture is due to fibrosis, thickening and shortening of the palmar aponeurosis beneath the skin, resulting in pulling the fingers into a contracted position.
It commonly affects the ring and little finger, but may involve the middle finger as seen in this patient.
Risk factors for developing Dupuytren contracture include diabetes mellitus, chronic liver disease, chronic alcoholism, and family history.
Smoking, epilepsy, anticonvulsants and manual labor are also implicated.
There is no effective medical treatment for Dupuytren contracture.
The disease progresses slowly over years, and the majority of patients do not require any treatment.
In severe cases of Dupuytren contracture where function of the hands are affected, surgical intervention such as partial fasciectomy is an option. However, it does not prevent a recurrence of the disease.
The use of collagenase injections is showing promise in clinical trials and may prove a better solution than surgery.
Management decisions such as disease severity and the timing of surgical referrals should be made in collaboration with the patient.
Painful Knee
Ottawa knee rules for X-ray following trauma:
aged 55 years or older
isolated tenderness of the patella
tenderness at the head of the fibula
inability to flex to 90^{\circ}
immediate inability to weight-bear and in the emergency room (four steps: unable to transfer weight twice onto each lower limb). Note: Limping does not qualify.
The sudden onset of painful swelling (usually within 60 minutes) is typical of haemarthrosis.
Bleeding occurs from vascular structures such as torn ligaments, torn synovium or fractured bones, while injuries localized to avascular structures such as menisci do not usually bleed. About 75% of cases are due to ACL tears.
If a minor injury causes acute haemarthrosis suspect a bleeding diathesis or anticoagulant usage.
Anterior knee pain:
Fat pad disorder (inflammation)
Patellofemoral syndrome
Osteoarthritis of the knee
Patellar tendinopathy
Osteonecrosis
Lateral knee pain:
Osteoarthritis of lateral compartment of knee
Lesions of the lateral meniscus
Patellofemoral syndrome
Medial knee pain:
Osteoarthritis of medial compartment of knee
Lesions of the medial meniscus
Patellofemoral syndrome
Special Tests
Thessaly test. The patient stands on the affected leg, flat-footed, with the knee flexed to 20^{\circ}, with outstretched arms supported by the examiner’s hands. The patient pivots with firm twists of the body and knee three times medially and laterally on the knee. A positive test is when the patient experiences joint line discomfort, or locking or catching. This is the most sensitive and specific clinical test for meniscal injury.
Apley grind/distraction test. The patient lies prone and the knee is flexed to 90^{\circ} and then rotated under a compression force. Reproduction of painful symptoms may indicate meniscal tear. Then repeat the rotation under distraction—tests ligament damage.
Osgood-Schlatter Disorder
Osgood-Schlatter disorder (OSD) is a traction apophysitis resulting from repetitive traction stresses at the insertion of the patellar tendon into the tibial tubercle, which is vulnerable to repeated traction in early adolescence.
Clinical features:
Commonest in ages 10-14 years
Boys:girls = 3:1
Bilateral in about one-third of cases
Common in sports involving running, kicking and jumping
Localized anterior knee pain in region of tibial tubercle during and after activity—gradually increasing over time