Special features to orthopaedic history and

examination

DR. MOHAMAD KHAIRUDDIN

INTRODUCTION

HISTORY TAKING (symptoms, previous illness, family, social, drugs, childhood)

EXAMINATIONS

History taking

Key words IN SYMPTOMS:InjuryPain StiffnessSwellingDeformityInstabilityAltered sensibilityLoss of function

Injury Date of injury

Nature of injury

Mechanism of injury

Pain Onset Nature Site Intensity Aggravating & relieving factors ‘referred pain’

stiffness

Refer to joints ‘morning stiffness’ (inflammatory) Post trauma Contracted capsule / ligaments ‘locking’ / block

Swelling

Arising sites (soft tissue, bone, joint) ‘tumour’ Edema (trauma) Haemathrosis / synovial effusion

Deformity Deformed limbs in position (flexion /

extension) Curvature (spine kyphosis or scoliosis) Deformed long bone (bowing tibia,

fractured) Deformed near the joints (cubitus

varus/valgus, genuvarus/genuvalgus) Shortening Affecting growth

weakness Strength of muscles Neurological cause

instability

Refer to joint (affecting the stabilization structure)

‘gives way’ ‘Jump out’

Change in sensibility

Neurological cause Tingling sensation Numbness Entrapment of nerve, neurological

claudication

Loss of function

Functional disability Unable to comb hair, unbutton cloth,

reaching high object Limit the ability to turn the door knob Can’t squad, put on the socks

Previous illness

Related to present chief complaint Not related to present problem

Social History Work relation to injury Compensation cover Adaptation to previous work in the

future Related associated risk factor

(smoking habit, alcohol consumption, etc)

Family

Genetic linkage diseases Highly association (tumour)

Examinations

General examination system

Specific examination

General examination :

LOOK

FEEL

MOVE

Physical examination: begins from the moment we set eyes on the

patient

OBSERVE - appearance

- posture

- general attitude

- gait

- affected parts or regions

Normal gait : Gait cycle (sequence of events in each

step) consists of 4 parts (phases) in

sequence : - heel strike - stance phase - toe off - swing phase

Abnormal Gait (Heel strike):

heel pain – steps on the toes rather

than the heel

“slapping movement” immediately after heel strike is characteristic of foot drop

Abnormal gait(stance phase) :

Limping results from pain, shortening, or instability

pain – ‘hurries’ off the leg on weight bearing (antalgic gait)

shortening - ipsilateral shoulder droops instability – hip swings sideways over the

weight bearing leg (Trendelenburg gait)

Abnormal gait (toe off):

fixed flexion of the hip – heel lifts off too soon

Stiff straight knee – whole body is heaved up to provide clearance

Abnormal gait (swing phase) :

Foot drop – avoid tipping, patients adopts a high-stepping gait

Stiffness (hip & knee) and spasticity

General examination of the affected parts:

- exposure of the region

- comparing the opposite limb

- examine good limb first

- follow systematic sequence :

look

feel

move

LOOK : Skin : scar, colour, and creases

Shape : swelling, lumps, wasting

Position or attitude : deformity

Deformity : applied to a person, a bone or a joint person – “short stature” bone – “bowing” joint – “unnatural position” e.g : varus – distal part to the joint towards the midline (knee joint : genuvarus) valgus – away from midline (knee joint : genuvalgus)

FEEL: Skin : warm or cold, moist or dry Soft tissues : lump? Characteritic –

site,margin, consistency,tenderness, multiplicity

Bones and joints : outlines normal? effusion? Tenderness : location?--- what structures?

MOVE : measure the range of movement of the

respective joints involved in degrees

Common planes of movement in respective joints e.g : flexion/extension,adduction/abduction, external rotation/internal rotation, pronation/supination

MOVE : Move the joint Not testing the muscle contraction Performing movement :

- Active

- Passive

MOVE (Active) :

Patient move the joint Is the movement smooth or hesitant

and painful? If limitation due to pain present,

passive movement needs caution and gentle

MOVE (passive): Examiner move the joints

Record the ROM in each physiological plane

Abnormal movement : Joint ‘stiffness’ Three types of stiffness : 1) all movements absent – ‘fixed joint’ (arthrodesis/ankylosis) 2) all movement limited – ‘irritable joint’ due to inflammation 3) some movements limited – affect one plane eg. Meniscus tear, group of muscles paralysed, bony deformity

Specific examinations

EXAMPLES: Laxity tests to the joint Trendelenburg’s hip test Thomas test for FFD of hip Limb length measurement

Other assessment :

Peripheral vascular examination Nervous system examination

Vascular assessment : Understanding the anatomy of

vascular system to the limbs

Assess for features of vascular occlusion : diminished pulse

cold extremities

pale or dusky

Neurological assessment :

What system to assess?

- central (spinal cord)

- peripheral nerve (brachial plexus

or respective peripheral nerves

e.g median,radial,& ulnar nerve,

sciatic nerve)

CLINICAL SKILLS

NEED FREQUENT PRACTISE !