Orthopedic Examination - a Step by Step Guide: Black and White Print

By Dr. Sulabh Kumar Shrestha

Orthopedic examination is a fundamental aspect of assessing musculoskeletal conditions, injuries, and disorders. This comprehensive guide aims to provide healthcare professionals, students, and practitioners with a thorough understanding of the principles, techniques, and best practices involved in conducting orthopedic examinations. By examining the mechanics behind the tests, readers will gain the knowledge and skills necessary to accurately diagnose a variety of orthopedic issues. Whether you are an orthopedic surgeon, physical therapist, or medical student, this book serves as an invaluable resource for enhancing your clinical practice and improving patient outcomes.

 

This book has four sections: Section 1 details the principles of history taking and general examination in orthopedic patients; Section 2 covers examination of the joints and the spine; Section 3 deals with examination of the peripheral nerves of the hand; Section 4 discusses making differential diagnoses.

 

The chapters are organized in a logical and easy-to-follow manner, with numerous illustrations and photographs to aid readers in understanding the material. It is indeed difficult to find a student-friendly book on the system of Orthopedic examination and often the students struggle with the sequence and techniques during patient examination. This book comprises content in bullets and mnemonics which is expected to be easier to understand, follow and recall during patient assessment.

• Language: English
• Publisher: Epomedicine
• Release date: Jun 19, 2024
• ISBN: 9798227737939

Dr. Sulabh Kumar Shrestha

I'm Dr. Sulabh Kumar Shrestha, currently undertaking residency in Orthopedics. The allure of beautiful benign darkness makes me write sometimes. I'm fascinated by the mysteries of life and death and everything in between. I like to write in rhymes and even force it at times. Writing gives me a little escape.

Book preview

CHAPTER 1

History taking in Orthopedics

Orthopedic history taking is a crucial step in the evaluation of patients with musculoskeletal disorders or injuries. A thorough and systematic approach to taking a patient's history can help identify the underlying cause of the problem, guide further evaluation, and inform treatment decisions.

General approach to history taking with patients has been discussed here: https://epomedicine.com/clinical-medicine/history-taking-sequence-and-mnemonics/

So, a general strategy in an orthopedic history taking includes eliciting the following:

Chief complaint

COMMON ORTHOPEDIC COMPLAINTS can be remembered using the mnemonic WRISD Pain –

●  Weakness: May be due to –

●  Pain inhibition

●  Muscle strain

●  Neurologic interruption

●  Restricted movement (stiffness): May be due to –

●  Pain and muscle spasm (Pseudo-locking)

●  Stretching of soft tissue contracture

●  Mechanical blockage by osteophytes, loose bodies or bucket-handle meniscal tears (Locking)

●  Redness (Erythema) or warmth: May be due to –

●  Trauma

●  Acute infection

●  Acute inflammatory process (e.g. Gout)

●  Instability (giving away or jumping out of place): May be due to –

●  Traumatic damage of muscular, capsular or ligamentous structures

●  Inherent laxity

●  More apparent when the joint is positioned such that muscles have less mechanical advantage (overhead shoulder positions) or when a quick movement demand is faster than the reaction time for corresponding muscles (cutting or rotatory knee movements)

●  Swelling: May be –

●  Traumatic and rapid appearance: Hematoma or Hemarthrosis

●  Slow appearance: Inflammation, Joint effusion, Infection, Tumor

●  Painful: Active inflammation, Infection, Tumor

●  Sensory disturbance (numbness or paresthesia): May be due to –

●  Pressure from neighboring structure into nerve (e.g. PIVD)

●  Local ischemia of nerve (nerve entrapment)

●  Peripheral neuropathy

●  Deformity: May be related to –

●  Shortening

●  Lengthening

●  Malalignment

●  Swelling (e.g. effusion or intramuscular hematoma)

●  Disability (functional loss)

●  Pain: May be –

●  Local pain (bone pain is deep pain commonly worse in evening)

●  Referred pain:

●  From scleratogenous sources (nondermatomal pattern with no hard neurologic findings): e.g. facet and disc generated pain

●  From visceral sources (will have visceral complaints) e.g. cholelithiasis, cardiac ischemia

●  Autonomic pain: vague, widespread and often associated with vasomotor and trophic changes

History of presenting illness

REMEMBER THE MNEMONIC "SOCRATES" which is classically used for pain assessment but can be trickily used for other symptoms as well.

Past History

●  Musculoskeletal:

■  Symptomatic joint/limb

■  Opposite joint/limb

■  Other joints

■  Inflammatory or other arthropathy

■  Previous injuries – fractures or otherwise

●  Medical: To identify risk factors of the anesthesia & of surgery morbidity to determine whether the conditions have been brought into the best possible control to minimize the risk.

■  DM (risk of infection)

■  Cardiovascular and respiratory problems (surgical fitness)

■  Malignancy (metastases or recurrence)

■  Infection in other parts of the body

■  Osteonecrosis in other parts of the body

■  DVT/PE (increased postoperative risk)

■  Mouth ulcers, Rashes, Eye symptoms, Urological symptoms (Rheumatoid or Seronegative arthropathies)

●  Surgical:

■  Previous surgeries on limb or joint in question

■  Other surgeries

■  Surgical or Anesthetic complications

●  Additional for pediatric patients: Ask about problems during –

■  Pregnancy (pre-natal history)

■  Delivery (birth history)

■  Time after delivery (post-natal history)

■  Growth history and Developmental milestones

Remember a few key milestones, which will be useful for most consultations.

Mnemonics: https://epomedicine.com/medical-students/developmental-milestones-mnemonic/

Drug History

REMEMBER THE MNEMONIC "DRUGS".

1.  Doctor prescribed (including anticoagulants, antiplatelet drugs and fluoroquinolones)

2.  Recreational (including anabolic steroids, illicit drugs)

3.  User (over the counter purchases, alternative/traditional medicines)

4.  Gynecological (contraceptives, HRTs)

5.  Sensitivities (exact nature of response and allergies)

Record the medication or drug history in tabulated manner as presented below:

Record any walking aids, orthotics and prosthesis used by the patient. Record any known allergies.

Some drugs and their adverse effects affecting the limbs:

Repeatedly exceeding the recommended daily dosage of vitamins A and D supplements may lead to ectopic calcification in tendon, muscle and periarticular tissue.

Family History

1.  MUSCULOSKELETAL:

i.  Familial conditions of affected limb or joints

ii.  Familial association of osteonecrosis or inflammatory arthropathy

iii.  Familial association of conditions associated with arthropathy such as gout, inflammatory bowel disease

2.  Malignancies: to assess risk of malignancy or bone metastases in patient

Can be documented using a pedigree chart.

Symbols used in constructing a pedigree chart by John Locke (2019), CC BY-NC-SA 3.0

Social History

REMEMBER THE MNEMONIC – "LOST in Alcohol and Smoking".

●  Living conditions

●  Occupation

●  Sporting hobbies

●  Travel

●  Alcohol

●  Smoking

1. Alcohol intake and Smoking: