History Taking in

Orthopaedics

Orthopaedics: Ortho – straight

Paedics – children

Musculoskeletal systems

Bones, joints, muscles, tendons, ligaments, peripheral nerves, blood vessels. special tissue:– meniscus, bursa, cartilage etc.

Divisions of Orthopaedics

Trauma SurgerySpine SurgeryArthroscopy & Sports MedicineHand SurgeryPaediatric Orthopaedics Joint Replacement (Arthroplasty)Oncology

Trauma - 80 % (worldwide)

Our setup - 95%

Group of Diseases

Congenital & Developmental abnormalities Infection & inflammation

Arthritis & rheumatic disorders

Metabolic & Endocrine disorders

Tumors & Lesions that mimic them

Sensory disturbance & muscle weakness

Injury & Mechanical derangement

History Taking

Patient – story

Doctor constructs – history

history – systematic, carefully, patiently compiled & informative

Points in history taking

• General Information

Age Sex

Occupation

• Presenting Complaint

• Pain• Stiffness• Swelling• Instability• Deformity• Limp• Altered Sensation• Loss of function

Symptoms

Specifics to the HPISpecifics to the HPI

Precipitating incidentPrecipitating incident– trauma (macrotrauma) trauma (macrotrauma) – repetitive stress (microtrauma)repetitive stress (microtrauma)– is this a work related injury?is this a work related injury?– is there a lawsuit ongoing?is there a lawsuit ongoing?

Specifics to the HPISpecifics to the HPI

For MVAs For MVAs – driver/passengerdriver/passenger– belted/non-beltedbelted/non-belted– location of impact and severity of crash location of impact and severity of crash

(required jaws of life, if anyone died in the (required jaws of life, if anyone died in the crash, thrown from the car, etc)crash, thrown from the car, etc)

– speed at impactspeed at impact– position of the patient and the limb in position of the patient and the limb in

question at impactquestion at impact

Specifics of the HPISpecifics of the HPI

for pain or presenting problemfor pain or presenting problem– OnsetOnset– DurationDuration– CharacterCharacter– CourseCourse– Aggravating and relieving factorsAggravating and relieving factors– LocationLocation– RaditionRadition– Associated symptoms Associated symptoms

Associated Associated SSymptomsymptoms

In addition to pain do they have:In addition to pain do they have:– ClickingClicking– SnappingSnapping– CatchingCatching– LockingLocking– Sensation of giving way (including Sensation of giving way (including

prior falls or dislocations)prior falls or dislocations)– SwellingSwelling– WeaknessWeakness

TTemporality or emporality or TTimingiming

Is it worse when they wake up in Is it worse when they wake up in the morning?the morning?

Does it gradually get worse over Does it gradually get worse over the course of the day?the course of the day?

Does the pain ever wake them up Does the pain ever wake them up at night?at night?

Red flagsRed flags

Pain at night or restPain at night or rest Associated weight loss and loss of Associated weight loss and loss of

appetiteappetite Hx. Of cancerHx. Of cancer Steroids useSteroids use Hx. Of traumaHx. Of trauma Extreme ageExtreme age Bowel or bladder symptomsBowel or bladder symptoms

Pain

Most Common complain

Grading of pain

I No painII Mild, can be ignoredIII Moderate, requires treatmentIV Severe, intrusive despite analgesicsV Very severe, inhibits virtually all activities

• At the site of the pathology:

Location, duration, progression, nature, intensity

Specific Characters of pain

Sharp shooting pain of back - PIVD

Chronic pain, ↑ activities - Degenerative Changes

Constant boring pain - Infective, neoplastic

• Referred pain:

From To Neck Shoulder Shoulder Arm ElbowForearm, hand Lumbar Spine Groin LS Spine Gluteal Region Hip Thigh, knee, legThigh Knee

Autonomic pain:

from autonomic nerves & accompany peripheral blood vessels

e.g. after operation

Poorly understood, often doubted

Stiffness

Symptom of joint involvement

Protective mechanism, spasm around joint

Generalized: Systemic disorder like RA, AS

Localized: to particular joint

Swelling

Soft tissue, joint, bone

After trauma, injury or reactive

Rapidly or slowly

Painful or not

Constant or comes and goes

Same size or ↑

Instability

C/O Joint giving way

Muscle weakness, ligamentous deficiency & disruption

Deformity

Associated with pain & stiffness

c/o knock knees, bowlegs,

Important: Progressive or not

Impaired function or not

Limp

Abnormal pattern of ambulation

Involved joint, dysfunctional muscle,

Due to deformity

Progressive or not

Altered Sensation

C/O tingling, numbness, burning pain

Nerve involvement

Note progressive

Eg. diabetic neuropathy, radiculopathy, laceration

Loss of function

Depends on individual needs

Judged on social, professional, domestic & recreational demands

• Personal history & background work, travel, recreation, home circumstances, support from family & friend

• Family history genetic disease RA. Communicable disease TB

Past Medical History previous trauma, injury, sprain, strain

Systemic Review LBP : Acute UTI PID

Trauma Patient

General History A B C LOC

Spine, Joints, limbs

Previous history of injury