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 FREQUEN T PRACTISE !