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History & clinical examination in Orthopedics

Oct 07, 20257 min read

History & Clinical Examination in Orthopedics

Prof. Mamoun Kremli
Dr. Tarif Al-Akhras

History Taking in Orthopedics

History taking

  • Patient’s story
  • Doctor/student reconstructs the history
    • Open ended questions
      • How do you feel now
    • Leading questions
      • What increases the pain?
      • Can you open a door key?
      • Can you comb your hair?

Orthopedics History

  • History Structure:

    • Patient Demographic
    • Chief Complaint
    • History of Presenting Complaint
    • Past medical/surgical history
    • Medication history
    • Family history
    • Personal history and background
    • Diet
    • Activity
    • Systemic review

  • Patient Demographic

    • Name
    • Age
    • Occupation
    • Hand Dominant

  • Chief Complaint:

    • Site
    • Onset
    • Progression
    • Management

  • History of Presenting Complaint

    • Pain
    • Swelling
    • Deformity
    • Limping
    • Stiffness
      • Usually related to function
    • Loss (altered) function
      • Caused by: stiffness / pain / deformity / instability / weakness
    • Altered sensation

  • Pain

    • Site
    • Onset
    • Character
    • Radiation
    • Associations
    • Time course
    • Exacerbating/relieving factors
    • Severity

SOCRATES

  • Site:

    • Referred Pain perceived at a location other than the site of the painful stimulus. this pain referred along the tissues developed from the same sclerotome -somite. e.g. Discogenic pain with no thecal or root compression radiated from L-S spine to groin, gluteal region, but not down to the knee. Hip: to the medial aspect of the thigh and knee
    • Radiating pain: pain begins in one place and travels to another location along the path of a nerve. e.g. Sciatica :root pain radiated to lower limb below the knee

  • Onset:

    • When did it start?

  • Was it

    • Gradual or sudden? (acute – related to incident/action)
    • Constant or intermittent?

  • Character:

    • What is the pain like e.g.
      • Sharp,
      • Burning
      • Tight?

  • Radiation:

    • Pain perceived at the site of stimulus and radiate to another site
    • Does it radiate/move anywhere?

  • Associations:

    • Is there anything else associated with the pain e.g.
      • Swelling
      • Sweating
      • Fever
      • Vomiting

  • Time course:

    • Does it follow any time pattern, how long did it last?

  • Exacerbating/relieving factors:

    • Does anything make it better or worse?

  • Severity:

    • How severe is the pain
    • Consider using the 1-10 scale

SOCRATES

  • Stiffness

    • Patients complain of loss of/altered function, not stiffness
      • Can not comb hair, can not bend forward, can not sit cross-legged, can not sit in prayer, …
    • Joint involved
    • Cause:
      • Real stiffness of joint / mechanical block
      • Protective mechanism:
        • Muscle spasm to avoid pain on movement of joint
    • Generalized: systemic disease
      • e.g. Rheumatoid Arthritis, Ankylosing spondylitis
    • Localized
      • To a particular joint

  • Swelling

    • Soft tissue, joint, bone
    • After trauma:
      • Injury or reactive
    • Rapid or Slow developing
      • Rapid: bleeding / Slow: effusion
    • Painful vs. Painless
    • Constant vs. comes and goes
    • Size:
      • Same, increasing, decreasing

  • Deformity

    • Progressive, or improving?
    • Impairing function?
    • Associated with
      • Pain
      • Stiffness
      • Other metabolic diseases

  • Functional affection:

    • Relate to normal function of part
      • Walking
      • Bending, Praying
      • Going to toilet
      • Sitting cross-legged
      • Eating
      • Reaching,
      • Holding,
      • Opening,
      • etc…

  • Instability

    • Joint “gives way” or “jumps out of place”

  • Weakness

    • Generalized: part of a systemic disease
    • Localized: Patients usually describe it as:
      • The limb is “dead” / “heavy”

  • Associated conditions / other diseases

  • Careful about history of mild trauma

    • History of mild trauma, especially in children, can be a normal daily occurrence

  • Past medical/surgical history

  • Medication & Allergy history

  • Family history

    • Genetic - e.g. RA, CDH
    • Communicable - e.g. TB

  • Personal history and background

    • Occupation
    • Travel
    • Recreation
    • Home condition
    • Drug or Alcohol abuse

  • Diet

    • Food / drinks (good and bad!)
    • Sun exposure

  • Activity

  • Systemic review

    • Respiratory – e.g. TB
    • UTI – source of infection
    • GIT – deficiency
    • Renal – disease

Summary - History-taking

  • Chief complaint
    • Onset, Progression, Management
      • Pain
      • Swelling
      • Deformity
      • Limping
      • Stiffness
      • Loss (altered) function
      • Altered sensation
    • Detailed mechanism of injury in trauma
      • High velocity Vs. Low velocity
      • Open Vs. Closed
  • Relate to function

Clinical Examination in Orthopedics

Clinical examination

  • The examination begins from the moment we set eyes on the patient. Observe:
    • General appearance
    • Posture
    • Gait:
      • limping, in pain, using stick, …
    • Deformities:
      • Knock-knees? Spinal curvature? short limb? paralyzed arm?
    • Pain?
    • …The clues are endless

Principles of Assessment

  • Proper interaction with patient
  • Normal side first
  • Compare to other side/joint
  • Do not cause pain
    • Watch facial expressions
  • Extra careful with children
    • Proceed slowly, do no attack!
    • Play with child!

Orthopedic Examination

  • Which system to use?
    • Look
    • Feel
    • Move
    • Special tests

LOOK

  • What do we look at ?

  • What do we look for ?

  • General on patient.

  • General local (shoulder, back, hip, thigh, …):

    • Position
    • Major deformity, swelling
    • Extra: cast, splint, traction, dressing …

  • Anatomic local:

    • Skin: swelling, scars, color, hair, dryness …
    • Subcut.: LN, veins, nerves, tendons …
    • Muscles: bulk, wasting, twitches …
    • Bones: landmarks, swelling, angulation, deformity.
    • Joints: position, swelling, redness…

  • General on patient

    • Patient in pain, sitting on a chair holding the right wrist and hand
    • Lying comfortably in bed not in pain.
    • Lying supine, in pain, holding R thigh in flexion.
    • Patients is restless in bed

  • General on patient.
  • General local (shoulder, back, hip, thigh,.. ):
    • Position of joint
    • Major deformity, swelling
    • Extra: cast, splint, traction, dressing …etc.

  • Important Considerations:
    • Amount of exposure
    • Duration of exposure
    • Persons present during exposure
    • Place of exposure
    • Attitude and behavior during exposure

Feel

  • Ask for pain or tenderness before you put your hands on the patient!
  • Inform patient (take permission) you are going to touch him/her and ask to inform you if it hurts

  • What do we feel for ?

    • Tenderness
    • Temperature
    • Anatomical

  • Tenderness:

    • Generalized - Specific

  • Temperature:

    • Compare distal / proximal, R / L

  • Anatomic:

    • Skin: dryness, hyper/hyposthesia, scars
    • Subcut.: LN, nerves, vessels, tendons, nodules
    • Muscle: tone, bulk, twitches, gaps, tenderness
    • Bone: landmarks, tenderness, mass, crepitus
    • Joint: swelling, effusion, crepitation, synovial thickening, joint line tenderness (if joint accessible)

Move

Active Vs. Passive

  • Active
    • Always to start with / not to cause pain
    • More used in upper limb
    • A must for assessment of muscle power
  • Passive
    • If need to see difference from active
      • In muscle weakness /neurological problems
    • More used in lower limbs

Range of Movement

  • Recorded in degrees!
  • Range of motion:
    • Starting from resting xx degrees to xx degrees where motion stops
  • Zero is the neutral or anatomical position of the joint
  • Do NOT use the words:
    • ‘full’, ‘good’, ‘limited’, ‘poor’

  • Examples:

    • e.g, ‘knee flexion 0–140° means
      • range of flexion from zero (the knee absolutely straight) through an arc of 140°
    • e.g, ‘knee flexion 20–90° means
      • flexion begins at 20° (i.e. the joint cannot extend fully) and continues only to 90°

  • Assess painful arc, if present

    • e.g. Shoulder painful abduction
      • At initial abduction
      • In mid-abduction
      • At extreme of abduction

  • Painful range of motion

    • e.g. Knee flexion from zero to 90°, with pain from 90° to 110° then could not flex more because of pain

Special Tests

  • Different for different joints

    • e.g. Anterior Drawer Test for ACL tear in Knee
    • e.g. Patellar Tap for knee effusion
    • e.g. Thomas Test for fixed flexion deformity of Hip

  • Weight-bearing / gait

    • Examination of all weight-bearing joints is not complete until weight-bearing is assessed!

Bony Lumps

  • Size
  • Site
  • Margin
  • Consistency
  • Tenderness
  • Multiplicity

Motor Power Grading

  • 0 = No power
  • I = fasciculation of muscle fibers - no movement
  • II = move with gravity eliminated
  • III = move against gravity
  • IV = less than full power
  • V = full power - normal

Nerve Roots LL

  • Hip
    • Flexion: L1,2,3
    • Extension: L5, S1
  • Knee
    • Extension: L3,4
    • Flexion: L5, S1
  • Ankle
    • Dorsiflexion: L4,5
    • Plantarflexion: S1,2
    • Inversion: L4,5
    • Eversion: L5,S1
  • Toe
    • Extension: L5
    • Flexion: S1
    • Abduction: S1,2

Nerve Roots UL

  • Deltoid: C5,6

  • Supra/Infraspinatus: C5,6

  • Serratus anterior: C5,6,7

  • Elbow

    • Flexion: C5,6
    • Extension: C7

  • Supination: C5,6

  • Pronation: C6

  • Wrist

    • Extension:C6
    • Flexion: C7

  • Finger

    • Extension: C7

    • Flexion: C7,8, T1

    • Abd/Adduction: C8, T1

Sensation

  • Dermatomes:

Trauma – Clinical Exam

  • General medical condition

    • Should be evaluated to exclude
      • Shock
      • Brain injury
      • Other problems

  • Vital signs

    • Should be observed and followed up
    • Head/neck, Chest

Trauma – Clinical Exam

  • Look:
    • Adequate exposure
    • General on patient
    • Local:
      • Swelling, deformity, bruises, color, …
      • Special attention is to be paid to wounds
    • Do not forget the back!

Trauma – Clinical Exam

  • Feel:

    • Tenderness, temperature and crepitus on movement
    • Sensory and motor deficits
    • Pulse distal to injury
    • Compartment syndrome

  • Move:

    • With care
      • Make sure not to cause more pain or injury
    • Crepitus & abnormal movement indicates a fracture
    • Joints distal to the affected area

Trauma – Clinical Exam

  • Examination of the viscera
    • Liver and spleen in rib fractures
    • Urinary bladder and urethra in pelvic fractures
    • Neurological examination in head and spinal injury

Summary

  • Examination:
    • Look
      • General on patient, general local, anatomical
    • Feel
      • Tenderness, temperature, anatomical
    • Move
      • Passive, active - differs from joint to another
    • Special tests
      • Differ from joint to another

Graph View

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