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PART 1: Bones, Joints, Fractures and Their Types

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1. BONES

• Supportive framework for the body
• Protection of vital organs
• Reservoirs of calcium and phosphorus
• Levers on which muscles act to produce movement
• Containers for blood-producing cells (haematopoiesis)

Types of Bone Tissue

Classification of Bones by Shape

Bone Vasculature and Innervation

• A nutrient artery (usually one per bone) enters directly into the internal cavity, supplying marrow, spongy bone, and inner compact layers.
• All bones (except at articular surfaces) are covered by the periosteum - a fibrous connective tissue membrane with the unique ability to form new bone. A bone stripped of its periosteum will not survive.
• The periosteum is richly supplied with sensory nerve fibers and is very sensitive to injury. Bone itself has few sensory fibers - this is why periosteal injury (e.g. in fractures) causes intense pain.

Bone Development

• Intramembranous ossification: Mesenchymal models undergo direct ossification (e.g., flat bones of skull)
• Endochondral ossification: Cartilaginous models are replaced by bone (e.g., long bones, base of skull)

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2. JOINTS

A. Synovial Joints

1. Articular cartilage (usually hyaline) covers opposing bony surfaces - they never contact each other directly
2. Joint capsule - two layers:
   • Inner synovial membrane: highly vascular, produces synovial fluid for lubrication
   • Outer fibrous membrane: dense connective tissue; thickenings form ligaments
3. Accessory structures include bursae (reduce friction between tendons/bone) and tendon sheaths

Types of Synovial Joints

B. Solid Joints (No cavity)

• Sutures - skull only; thin sutural ligament (nearly immobile)
• Gomphoses - teeth in bony sockets (periodontal ligament)
• Syndesmoses - bones linked by an interosseous ligament (e.g., distal tibiofibular joint)

• Primary (Synchondroses) - hyaline cartilage; temporary (e.g., growth plates/epiphyseal plates)
• Secondary (Symphyses) - fibrocartilage; stronger, slight movement (e.g., pubic symphysis, intervertebral discs)

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3. FRACTURES AND THEIR TYPES

Definition

Clinical Features

• History of trauma
• Pain and tenderness over the fracture site
• Swelling and bruising
• Loss of function
• Deformity / abnormal motion
• Crepitus

Primary Classification: Open vs Closed

If doubt exists about whether a wound communicates with a fracture, it must be treated as open.

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Types by Fracture Line Direction

Types by Completeness

Special Types

Salter-Harris Classification (Epiphyseal Fractures in Children)

All growth plate fractures must be reduced urgently to prevent asymmetrical bone growth.

AO/OTA Classification (Universal System)

• Type A - Simple (single fracture line)
• Type B - Wedge fragment present
• Type C - Complex / comminuted

Fracture Healing Stages

1. Haematoma - rupture of vessels at fracture site forms clot (procallus - no structural strength)
2. Soft callus - fibroblasts and osteoblasts invade; cartilaginous bridging callus forms
3. Hard callus - calcification of callus, acts as a biological splint
4. Remodelling - over months to a year, callus fully ossifies and remodels to mature bone

On X-ray: fracture line becomes more visible at 10-14 days (due to bone resorption). Callus first appears at 2-4 weeks.

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PART 2: GENERAL EXAMINATION

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Preparation and Positioning

• Patient should be lying flat (supine), adequately exposed
• For abdominal examination: hips and knees flexed to relax abdominal muscles
• Ensure proper lighting and patient comfort
• Vital signs recorded at the start: heart rate, blood pressure, respiratory rate, temperature
• Elective setting: weight and BMI also recorded

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Components of General Examination

1. Vital Signs (BPRT)

Core temperature in comatose patients is best measured rectally - oral and axillary are unreliable.

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2. General Inspection (Look First)

• General appearance: well/unwell, distressed, comfortable
• Body habitus: obesity, cachexia (weight loss / muscle wasting - suggests malignancy, chronic disease)
• Nutritional status and hydration: skin turgor, sunken eyes, dry mucous membranes
• Colour: pallor (anaemia), jaundice (liver disease), cyanosis (respiratory/cardiac), pigmentation abnormalities
• Oedema: pedal oedema (cardiac failure, hypoproteinaemia, venous disease)
• Posture and movements: involuntary movements, asymmetry
• Clothing and environment: IV lines, drains, monitoring equipment

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3. Hands

• Pallor of palmar creases - anaemia
• Clubbing - chronic lung disease, cyanotic heart disease, cirrhosis, IBD
• Koilonychia (spoon nails) - iron deficiency anaemia
• Leukonychia - hypoalbuminaemia (liver disease)
• Dupuytren's contracture - liver disease, alcoholism
• Arthropathy in finger joints - rheumatoid, osteoarthritis
• Palmar erythema / spider naevi - chronic liver disease
• Tremor - Parkinson's, intention tremor (cerebellar), thyrotoxicosis

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4. Head, Face and Neck

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5. Skin

• Jaundice, pallor, cyanosis
• Grey Turner's sign - flank discolouration (retroperitoneal haemorrhage; severe acute pancreatitis, leaking AAA)
• Cullen's sign - periumbilical discolouration (severe acute pancreatitis, ruptured ectopic pregnancy, liver trauma; blood tracks via ligamentum teres)
• Rashes, petechiae, purpura
• Wounds, scars (previous surgery)
• Spider naevi, telangiectasias

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6. Lymph Nodes

• Generalised lymphadenopathy - lymphoma, leukaemia, viral infections
• Regional - local infection or malignancy

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7. Neurological Screen (Brief)

• Level of consciousness (GCS)
• Orientation (time, place, person)
• Gait if ambulatory
• Cranial nerves screen
• Motor function - tone, power, reflexes (upper and lower limbs)
• Sensory function - light touch, pain
• Upper motor neuron signs (spasticity, hyperreflexia, extensor plantars) - cervical cord compression, stroke

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8. Abdominal Inspection (Briefly)

• Visible masses, distension, visible peristalsis, dilated veins, abdominal wall hernias
• Check whether abdomen moves with respiration (absent movement - peritonitis)
• Note any scars

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Sequence Summary

Vital signs → General inspection → Hands → Face/head/neck → 
Skin → Lymph nodes → Cardiovascular → Respiratory → 
Abdomen → Neurological screen → Peripheral vascular

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Sources

• Gray's Anatomy for Students - Bones and Joints sections
• Rosen's Emergency Medicine - Fracture Description and Classification (Ch. 41)
• Parikh's Textbook of Medical Jurisprudence, Forensic Medicine and Toxicology - Fracture Types
• Bailey and Love's Short Practice of Surgery, 28th Ed - General Examination
• Bradley and Daroff's Neurology in Clinical Practice - General Examination (coma assessment)
• Rheumatology, 2-Volume Set (Elsevier 2022) - General Examination in rheumatological context

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General Examination of Bone, Joint, and Fracture

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FRAMEWORK

"The examination of the painful joint is performed in a systematic manner following the general principle of inspection, palpation, range of motion (ROM), neurovascular evaluation, special tests, and imaging when appropriate."

• Rosen's Emergency Medicine

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STEP 1: HISTORY (Before Examination)

• Site and onset of pain
• Mechanism of injury (nature of force - direct, indirect, rotational)
• Duration and progression
• Functional loss - can the patient weight-bear? Use the limb?
• Prior injuries or joint disease in the same area
• Systemic symptoms - fever (infection/septic arthritis), weight loss, fatigue (malignancy, RA, IBD)
• Medications - steroids, bisphosphonates, anticoagulants

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STEP 2: GENERAL INSPECTION (Before Local Examination)

• Gait and posture - observe the patient walking; this reveals much before any hands-on examination
  • Antalgic gait - shortened stance phase on the painful limb (pain avoidance)
  • Trendelenburg gait - pelvis dips to opposite side when standing on the weak limb (hip abductor weakness)
  • High-stepping gait - foot drop (peroneal nerve palsy, often from fibular fracture)
  • Leg length inequality - limping with pelvic tilt
• General appearance - distress level, sweating, pallor (shock from blood loss in major fractures)
• Position of comfort - patients splint an injured part in the position that minimises pain

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STEP 3: LOOK (Inspection)

Inspection Findings

In joint examination: check equality of landmark heights bilaterally (shoulder tips, scapulae, pelvic brim, gluteal creases) and inspect the spine for normal curvature and scoliosis.

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STEP 4: FEEL (Palpation)

What to Palpate

• Normal large joints (e.g., knee) feel cool compared to surrounding skin
• Warmth = inflammatory process or effusion
• Hot = infection (septic arthritis) until proven otherwise

• Point tenderness directly over a bone = fracture until proven otherwise
• Palpation should extend beyond the painful area - pain may be referred (e.g., hip pathology presenting as knee pain)
• Begin at a control area (e.g., occipital protuberance for neck, uninjured bone proximally for limbs) to calibrate the patient's pain response
• Over joints: palpate the joint line, ligament attachments, tendon insertions, and nearby bursae
• Distinguish articular (from joint itself) vs periarticular (surrounding structures) tenderness

• Fine crepitus - common in large joints, often insignificant
• Coarse crepitus - advanced cartilage degeneration (OA); also felt in fractures (bony crepitus - do NOT elicit deliberately as it causes pain and displaces fragments)

• Palpate systematically: e.g., for a shoulder injury - sternoclavicular joint → clavicle → acromioclavicular joint → humeral head → entire humeral shaft → scapula posteriorly

• Bulge sign (small effusions) - milk fluid from medial gutter, tap lateral side; a bulge returns medially
• Ballottement / patellar tap (larger effusions) - fluid pushed distally, patella tapped down and "bounces"

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STEP 5: MOVE (Range of Motion)

Active vs Passive ROM

Key Principles

• Always compare with contralateral (unaffected) side
• Assess movement in all planes appropriate to that joint (flexion, extension, abduction, adduction, rotation, circumduction)
• A goniometer may be used to accurately quantify range
• Pain at end of range - may indicate bursitis or early arthritis
• Pain throughout range - suggests intra-articular pathology
• For suspected fracture - do NOT put the limb through ROM; simply assess if movement causes pain and note which movements are restricted

Normal Reference Ranges (Key Joints)

Types of Abnormal Movement

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STEP 6: NEUROVASCULAR ASSESSMENT

Neurological Assessment

Document neurological deficit before any reduction manoeuvre - to prove it was not caused by treatment.

Muscle Strength Grading (MRC Scale)

Vascular Assessment

• Palpate pulses distal to the injury (radial, ulnar, dorsalis pedis, posterior tibial)
• Capillary refill - should be < 2 seconds
• Skin colour and temperature distally
• Compartment syndrome warning signs (especially tibial shaft fractures, supracondylar fractures):
  • 5 Ps: Pain (disproportionate, especially on passive stretch), Paraesthesia, Paralysis, Pallor, Pulselessness (late sign)
  • Tense, woody swelling of the compartment
  • This is a surgical emergency requiring urgent fasciotomy

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STEP 7: SPECIAL TESTS

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STEP 8: IMAGING

• Rule of twos - two views (AP + lateral), two joints (above and below), two limbs (compare with contralateral if needed), two times (initial + repeat at 10-14 days to confirm stress fractures)
• MRI - soft tissue, ligaments, cartilage, occult fractures, bone marrow oedema
• CT - complex fractures, intra-articular assessment, planning surgery
• Ultrasound - effusion, soft tissue, tendon integrity
• Bone scan - stress fractures (especially if plain X-ray normal)

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SUMMARY TABLE

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Sources

• Harrison's Principles of Internal Medicine, 22nd Ed (2025) - Musculoskeletal Examination
• Rosen's Emergency Medicine - Joint and Fracture Examination
• Tintinalli's Emergency Medicine - Physical Examination of Fractures
• Rheumatology, 2-Volume Set (Elsevier 2022) - Regional Musculoskeletal Examination, Gait, Deformity, Inflammation
• Sabiston Textbook of Surgery, 21st Ed - Musculoskeletal Examination