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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: Injury Pain Stiffness Swelling Deformity Instability Altered sensibility Loss 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 !
