1. Clinical Studies I RHS 331 Dr. Ali Aldali, MS, PT Tel# 4355010 - Ext: 478 Department of Physical Therapy King Saud University 2008

2. Required Text: Outline of Orthopadics, by JOHN CRAWFORD ADAMS and DIVID L. HAMBLEN. ISBN: 0-443-07025-3 There will also be other reading and handouts assigned during the course of the semester.

3. Orthopaedic Historical The term orthopaedic is derived from Greek (straight child)or the Art of Correcting and preventing Deformities in Children.

4. Diagnosis of orthopaedic disorders As in other field of medicine and surgery, diagnosis of orthpaedic disorders depends first upon an accurate determination of all the abnormal features from; 1.The history. 2.Clinical examination. 3.Radiographic examination and other methods of imaging. 4.Special investigations.

5. History In diagnosis of orthopaedic disorders the history is often first importance. a)Personal history a)Personal history : name, age, sex, occupation, marital status, and hobbies and recreational activities.. b)Past history b)Past history : any previous injury, trauma related to present condition or non, hypertension (HTN), or DM (diabetic mellitus). The effect of any previous treatment. c)Present history c)Present history : the main chief complaint ( c/o) “as patient stats”, the cause of problem, the behavior of symptoms from their earliest beginning up to the time of consultation (increase/decrease) what activities to improve the symptoms or to make them worse (provoke), the severity of pain or other symptoms(mild0modrate/sever), and pain scale (from 0= no pain to 10= sever pain) any radiated symptoms to extremities.

6. Routine for clinical examination Exposure for examination: It is essential that the part to be examined should be adequately exposed and in a good light. Many mistakes are made simply because the student or practitioner does not insist upon the removal of enough clothes to allow proper examination. When a limb is being examined the sound limb should always be exposed for comparison. SOAP approach.

7. Routine for clinical examination By Inspection: -deformity? -Shortening? -Swelling? -Wasting? -Scars?

8. Routine for clinical examination listen to what the patient tells you. Inspection Inspection : look or observe the area (general bones alignment and position of the parts to detect any deformity, shortening, or unusual posture), (soft tissue; note any visible evidence of general or local swelling, or of muscle wasting), (colour of skin; look for redness, cyanosis, pigmentation, loss of hair, or other changes), (scars or sinuses; if a scar is present, determine from its appearance whether it was caused by operation (linear scar with suture marks), or injuries (irregular scar))

9. Routine for clinical examination PalpationPalpation: feel gently the soft tissue for swelling, spasm or easted, painful areas, temperature changes (warmth or cold) and the exact site of any local tenderness. Measure limb length and girth or circumference of a limb segment on the two sides is often necessary especially in the lower limbs(.Measure limb length and girth or circumference of a limb segment on the two sides is often necessary especially in the lower limbs(. MovementMovement: move the limb to assess the rang of motion. Active movement is observed first, then passive. The joint movements information must be obtained on the following points: 1.What is the range of active movement? 2.Is passive movement greater than active movement? 3.Is movement painful? 4.Is movement accompanied by crepitation? 5.Is there any spasticity (stiff resistance to free movement)? Stability of a joint (Stressing): strain the ligaments to look for abnormal movements by especial tests for each segment.Stability of a joint (Stressing): strain the ligaments to look for abnormal movements by especial tests for each segment. RadiographsRadiographs are useful, but do not replace any part of the clinical examination. Methods of imaging: X-ray, US, CT scanning, or MRI (magnetic resonance imaging)

10. Routine for clinical examination The area must be fully exposed and properly prepared; a shoulder cannot be examined through a shirt or a knee through trouser. be examined through a shirt or a knee through trouser. When examining a limb, always compare the two and ask yourself the following questions: following questions: 1.Is one limb straighter or shorter than the other? 2.Are the joints swollen? 3.Is there muscle wasting? 4.Are there any scars and, if so, are they surgical or traumatic?

11. Routine for clinical examination Measurement fixed variable Measurement is part of inspection. To measure the distance between bony points, choose fixed points that are easily recognizable such as the anterior superior iliac spine or medial malleolus, rather than variable points such as the umbilicus or the center of the patella. Palpation: Apprehension Palpation: firmer pressure will locate swelling and tender areas, and show whether the patient is apprehensive when the area is touched. Apprehension is significant, particularly if the joint is unstable. Movement: Movement: always compare the range of movement with the opposite limb.

12. Routine for clinical examination Check the range of movement by asking the patient to move the limb. The passive range can then be measured to see how far the joint will move, detect a lag or find which part of the range is painful. The Quality The Quality of movement is also important. Is the movement free, or stiff? Smooth or noisy? Does the joint feel loose and unstable? Is it sound? These are subjective assessments and judgment only come with experience.

13. Routine for clinical examination Ligaments.. Ligaments. Ligamentous instability, which is difficult to assess, is detected by stressing the ligaments and looking for excess movement. Muscle power. Muscle power. Muscle weakness must be looked for and recorded. The muscle power is graded according to the MRC (Medical Research Council) scale which recognizes six grades of muscle power: Grade 0 – no power Grade 1 (trace)- a flicker of movement only. Grade 2 (poor)- enough power to move a joint with gravity eliminated. Grade 3 (fair)- enough power to move a limb against gravity> Grade 4 (good)- enough power to move a limb against gravity and against moderate resistance. Grade 5 (normal)- full and normal muscle power to move a limb against gravity and against maximum resistance plus 3sec hold at the end.