clinical exam in an orthopaedic patient

1. CLINICAL EXAM IN AN
ORTHOPAEDIC PATIENT.
Dr. Ahmad Shakeel
Registrar skims- bemina

2. Introduction to Orthopaedics
• Discipline of surgery that is concerned with the diseases of
axial and appendicular skeleton and its related structures.
• Orthopaedic Surgeons are involved in the diagnosis,
treatment, rehabilitation and prevention of injuries or
diseases afflicting the spine, pelvis and extremities.

3. MUSCULOSKELETAL SYSTEM
• Bones, joints, ligaments, muscles, tendons and nerves
constitute the musculoskeletal system.
• Conditions that affect these structures fall into seven
easily remembered pairs:
Congenital and developmental abnormalities
 Infection and inflammation
 Arthritis and rheumatic disorders
 Metabolic and endocrine disorders
 Tumours and lesions that mimic them
 Neurological disorders and muscle weakness
 Injury and mechanical derangement

4. • Orthopaedic surgeons often work closely with other
health professionals like Plastic Surgeons, Radiologists,
General Surgeons, Anaesthetists, Physical therapists and
Orthotists in restoring the diseased patient back to
normal function.

5. • Nicolas Andre was the first to propose the
term Orthopaedia in a self-help book he wrote for parents -
Orthopaedia: Or, The art of Correcting and Preventing
Deformities in Children.
• Ortho implying straight and free from deformity
and Paedia referring to children.
• At that point of time deformities in children due to
poliomyelitis and tuberculosis was rampant and physicians
were few or too expensive to afford.
• Today orthopaedics, as it is commonly referred to, deals
with patients from all age groups.

6. • The discovery of
anaesthesia by Horace Wells ,
imp of asepsis by Joseph Lister,
bone grafting by MacEwen, and
Internal fixation by Arbuthnot Lane
development of the "magic x rays" by William Conrad Röntgen
completed the triad of developments that propelled orthopaedics at the
turn of the 19th century to establish into a speciality.

7. SUBSPECIALITIES
• Over the past few decades orthopaedics has grown into different
subspecialties –
Paediatric Orthopaedics
Spine Surgery
 Arthroscopy
Trauma
Adult Reconstruction
Hand and Microsurgery.

8. TERMINOLOGY
• Planes – sagittal, coronal, transverse.
• Anterior/posterior – ventral/dorsal
• Medial/ lateral
• Radial/ulnar
• Proximal/distal
• Axial alignment – varus/valgus
• Rotational alignment
• Flexion/extension
• Plantar-flexion/dorsiflexion
• Abduction/adduction
• Pronation/supination
• Circumduction

10. History taking
• Introduction
• Chief complaints
• History of present illness
• FUNCTIONAL IMPAIRMENT.
• History of past illness
• Drug history
• Personnel history
• Family history

11. Chief complaints
• Pain
• Disability - activity of daily living/recreation
• Deformity - cosmetic
• Stiffness
• Swelling
• Weakness
• Instability
• Sensations
• Loss of function

13. Genu valgum - RA

14. Genu varum - OA

15. Paget’s disease

16. General physical exam
• The examination actually begins from the moment we set eyes on the
patient. We observe his or her general appearance, posture and gait.
GAIT
 Knock-knees?
Spinal curvature?
A short limb?
A paralysed arm?
Does he or she appear to be in pain?
Do their movements look natural?
Do they walk with a limp, or use a stick?
A tell-tale gait may suggest a painful hip, an unstable knee or a foot
drop.

17. • When we proceed to the structured examination, the
patient must be suitably undressed.
• If one limb is affected, both must be exposed so that they
can be compared.
• We examine the good limb (for comparison), then the
bad.
• Always one joint above & one joint below.

18. Orthopaedic exam
Look/inspection – skin/soft tissue/bone
Feel/palpation – skin/soft tissue/bone
Move/manipulation – active/passive/resisted
Measurements –longitudinal/circumferential
Special tests
Exam of neighboring joints.
Exam of lymph nodes

19. LOOK
• Shape and posture
Is the patient unusually thin or obese?
Does the overall posture look normal?
Is the spine straight or unusually curved?
Are the shoulders level?
Are the limbs normally positioned?
Look for deformity in three planes,
Always compare the affected part with the normal side.
In spinal disorders the entire torso may be deformed.
look closely for swelling or wasting – one often enhances the
appearance of the other! Or is there a definite lump?

20. contd...
• Skin - colour, quality and markings of the skin.
Look for bruising, wounds and ulceration.
Scars are an informative record of the past.
Colour reflects vascular status or pigmentation – the
pallor of ischemia, blueness of cyanosis, the redness of
inflammation, or the dusky purple of an old bruise.
Abnormal creases, unless due to fibrosis, suggest
underlying deformity which is not always obvious; tight,
shiny skin with no creases is typical of oedema or trophic
change.
• Soft tissue – swelling/wasting
• Bone – deformity

22. Contd…
• General survey- Attention is initially focused on the
symptomatic or most obviously abnormal area, but we must
also look further afield. The patient complains of the joint that
is hurting now, but we may see at a glance that several other
joints are affected as well.

23. FEEL
• Know your anatomy and you will know where to feel for the
landmarks; find the landmarks and you can construct a virtual
anatomical picture in your mind’s eye.
The skin – temperature, tenderness; sensations
The soft tissues tenderness; lumps/effusion; distal circulation
The bones and joints Are the outlines normal? Is the synovium
thickened? Is there excessive joint fluid?
• Try to localize any tenderness to a particular structure; if you know
precisely where the trouble is, you are halfway to knowing what it is.

25. MOVEMENTS
Active movement,
Passive movement,
Abnormal or unstable movement, and
Provocative movement

26. • Active movement
Ask the patient to move without your assistance. This
will give you an idea of the degree of mobility and whether
it is painful or not.
Active movement is also used to assess muscle power

27. • Passive movement
Here it is the examiner who moves the joint in each
anatomical plane.
Note whether there is any difference between the range of
active and passive movement.

28. RANGE OF MOVEMENT
• Range of movement is recorded in degrees, starting from
zero which, by convention, is the neutral or anatomical
position of the joint, and finishing where movement stops,
due either to pain or to anatomical limitation.
• Goniometer- for accurately measuring ROM
• Compare the symptomatic with the asymptomatic or normal
side.

29. • Stability – dynamic(muscles) & static(ligaments &
intact joint surfaces).
• Dynamic stability – muscle, nerve supply, nerve root
value
• Static stability – stress tests.

30. Provocative movement
• One of the most telling clues to diagnosis is reproducing
the patient’s symptoms by applying a specific,
provocative movement.
• Shoulder – subacromial impingement & previous
dislocation or subluxation.
• Apprehension test.

31. MEASUREMENTS
• Hip
• Arm
• Forearm
• Chest

32. SPECIAL TESTS
• HIP – Allen’s test, Thomas test; Trendelenberg test, Pastry roll test.
• Knee – Lag test, stress test, Flexion test; Mcmurray test; Lachman
test; ADT; PDT; Pivot shift test, Patella apprehension test
• Ankle – windlass test, Simmonds test, jack test
• Spine – Holdswath test, Schober test, SLRT test, Lasegue test,
Bragards sign, femoral nerve stretch test
• Sacro-iliac joint – Genslen test, Gillie test, Pump handle, Faber
• Elbow – cozens test; mills maneuvre;
• Wrist - Finkelstein test , Tinel’s sign, Phalen’s test, Froment’s sign.
• Shoulder – epaulette sign, thumb-down test, apprehension test,

33. NEUROLOGICAL EXAM
• MOTOR
• Bulk
• Tone
• Power – MRC grading
• Reflexes – superficial/deep
• Sensations
• Discuss – UMN/LMN diseases

35. `

36. EXAM OF BONE & JOINT INJURIES.
• INSPECTION – abnormal swelling & deformity
attitude
shortening
overlying skin
• PALPATION – tenderness
bony irregularity
abnormal movements
crepitus
pain elicited by manipulation from a distance
absence of transmitted movements
swelling
wound
• MEASUREMENTS – longitudinal
circumferential
• MOVEMENTS – active/passive.
• COMPLICATIONS.

37. THANK YOU