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The General Practitioner’s Orthopedic Exam Debra Weisman, DVM, MS, Dipl ACVS Newtown Veterinary Specialists, Newtown, CT A complete orthopedic exam consists of observing an animal at rest, in motion and palpation of the animal at rest and in lateral recumbency. As with the physical exam, the orthopedic exam should be performed the same way every time to assure that the practitioner does not miss the actual problem, due to clinical suspicion of another disease process. Additionally, the examiner must determine if the gait abnormality is orthopedic in origin or from another cause (i.e. neurologic or oncologic). History is a vital part of establishing a differential diagnosis. In addition to signalment, the examiner should know how long the owner has had the pet, the use or function of the animal, the chief complaint, whether or not a known traumatic event has occurred, the duration of the problem, any treatments that have been tried, and their response. A complete physical exam and medical history should also be performed to rule out any systemic abnormalities. The examiner should also be prepared to perform a complete neurologic exam based on the results of the orthopedic exam. HINDLIMB ANALYSIS At rest: Animals with rear limb lameness will often shift weight forward or will shift weight to the non-painful rear limb in a effort to unload the painful limb when standing. Dogs with cranial cruciate ligament are often reluctant to sit normally. They will sit with one or both stifles extended. Animal with painful hip may set abnormally or be reluctant to sit at all and prefer to lie down. Some postures or stances are associated with a specific disease process. For example animals with Achilles tendon ruptures will have a plantigrade stance. This stance is occasionally seen in cats with diabetic neuropathy (and intact Achilles mechanisms). Dogs with severe hip dysplasia and muscle atrophy may have hyperextension of the hocks. Standing Palpation: Specific landmarks to evaluate include iliac crest, ischiatic tuberosity, greater trochanter, stifle, quadriceps, patella, patellar tendon, tibial tuberosity, hamstring muscles, femoral condyles, distal tibia, calcaneus and tarsal joint and digits. The stifle joint should be carefully palpated for effusion. The examiner should be able to define the cranial aspect of the patellar tendon easily. If the tendon is indistinct, there is joint effusion. In normal animals, the tibial tuberosity is located 90 degrees to the greater trochanter and the quadriceps mechanism will line up along the long axis of the femur. Any deviation of the tibial tuberosity should be noted. In some dogs with a grade 3-4 medial patellar luxation, the first notable finding may be the ability to palpate the femoral trochlea. The examiner should flex and extend the stifle and hip in a standing position. In some animals this may be the most sensitive position to detect patellar luxation. Lateral Recumbency: A complete orthopedic exam cannot be performed without the help of an assistant. Starting at the toe nails; examine for evidence of abnormal wear or damage, saliva staining or swelling at the nail bed. The area between the toes and pads should be closely examined for foreign bodies, draining tracts and skin lesions. Each digit should be individually flexed and extended. The tarsus inherently has a fair amount of medial and lateral laxity that varies depending on the position of the joint. Effusion of the tarsus is usually readily palpable. Collateral ligament injuries to the hock are frequently seen therefore palpation should be palpated as stress is applied medially and laterally. Palpation of the Achilles tendon is preformed and compared to the findings in the standing animal. The tibial shaft should be palpated for pain and irregularity. The muscles should be palpated for pain, swelling or atrophy. The tibial crest should be located and firmly palpated as avulsions are often difficult to identify. The patellar tendon should be identified and followed to the patella. If the patellar tendon is difficult to identify or feels surrounded by soft tissue swelling, joint effusion is likely present. The stifle should be flexed and extended. Attention should be paid to the position of the patella and evidence of crepitus as the patella tracks within the trochlear groove. With the stifle in full extension, pressure should be applied medially and laterally while the distal limb is internally and externally rotated. Assessment for cranial cruciate insufficiency is performed by either checking for cranial drawer motion or the tibial compression test (or both). Collateral ligament injury to the stifle can also occur and the clinician should routinely assess medial to lateral stability of the joint and attempt to “open” the joint from either side. The femur is then palpated along the shaft and the major muscle groups palpated individually up to the hip. Animals with degenerative joint disease of the hip generally resent extension and abduction more than flexion. Some normal animal and those with lower back pain may also object to full hip extension. Normal abduction should be at least 90 degrees. Internal and external rotation of the hip should also be assessed. Crepitus should be noted. Assessment of hip joint laxity via the Ortolani maneuver should be performed in younger dogs. Hip luxation can be detected by a combination of assessment of bony landmarks and finding on the direct palpation. Craniodorsal hip luxations can be assessed by palpating the greater trochanter in line with, not ventral to, a line from the proximal iliac crest to the ischiatic tuberosity. Abduction of the limb will be limited. Vertebral and rectal palpation should be part of every orthopedic exam. The dorsal spinous processes of each vertebra should be palpated for alignment and to detect pain. The cervical spine should be evaluated with lateral palpation. The normal dog and cat should be able to point their nose straight up in the air, completely flex ventrally and touch the lateral aspect of the thorax on either side. The tail should be extended dorsally, and flexed laterally and along the length. Rectal exams should always be performed in dogs with rear limb lameness to assess for lumbosacral pain and for caudal abdominal or pelvic canal masses. FORELIMB ANALYSIS At rest: Animals with forelimb lameness may shift weight back to the rear limbs, or may off load the painful limb. Muscle atrophy may be visible in animals with short coats, as may carpal or elbow joint effusion. Observe at the loading of the digits and whether or not there are any toenails misaligned or pads that are more or less visible. Standing: With the animal standing, the examiner should carefully palpate and examine all of the major muscle masses in the forelimbs, in addition to the bones and joints. Specific landmarks that should be evaluated include the spine and vertebral boarder of the scapula, the acromion process, the greater tubercle of the humerus, humeral epicondyles, olecranon, and accessory carpal bone. Muscle atrophy is easiest to detect when comparing the infra- and supraspinatous muscles along the scapular spine. The triceps muscles should be compared, as should the muscles of the antebrachii. Palpate for effusion over the caudal compartment of the elbow joints and the carpal joints, then compare for symmetry. Evaluation of range of motion and palpation of the long bones can be performed in the standing position in dogs that are fractious or resist lateral recumbency. Test for knuckling and hopping (in small dogs and cats) during this portion of the exam. Lateral Recumbency: With the help of an assistant, start by examining the toenails and digits. Observe for wear, damage, and saliva staining around the nail beds. The area between the toes and pads should be examined for foreign bodies, draining tracts, skin lesions and thickening. Each interphalangeal joint should be palpated individually through full flexion and extension. Each metacarpal should be palpated individually up to the carpus. For each joint, the examiner should observe and record crepitus, range of motion, presence of effusion, pain response and instability. The carpus should be flexed and extended. In most dogs and cats, the carpal pad can touch the caudal aspect of the antebrachium. The carpus can extend past 1800 . Always compare both limbs to determine what may be normal for each animal. The radius and ulna should be palpated separately. Moving from distal to proximal, the examiner should look for boney changes or pain. The elbow should be fully extended, flexed, internally and externally rotated. The joint capsule should be palpated medially and laterally for evidence of thickness or effusion. The humeral shaft should be palpated and evaluated for muscle and bone pain. The shoulder has a very wide range of motion. If is important to manipulate in flexion, extension, abduction, adduction, internal and external rotation. If shoulder instability is suspected, hold the scapula fixed and attempt to move the proximal humerus in a “drawer” type motion cranially and caudally. Palpate the biceps tendon with the shoulder in both extension and flexion with the limb pulled parallel to the trunk. Deeply palpate the axilla to check for pain and masses.