Orthopedics Examination

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 $\to$ on patient.

• General $\to$ 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 $\to$ 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 $\to$ on patient.
• General $\to$ 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

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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)

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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

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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!

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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