Simple Guide Orthopadics

Section I History, Examination, Investigations, and Treatment Orthopaedic history Orthopaedic examination

History and Examination

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A Simple Guide to Orthopaedics

Chapter 1

History and Examination

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History and Examination

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Orthopaedic History An adequate history is essential before the patient is examined. This will give a clue to the diagnosis. It will also ensure that the most relevant part of the patient is examined. It may be categorised as is shown on the opposite page.

History of present illness The present history should include questions about any pain, swelling, deformity, limitation of movement and also if these restrict normal activities. The type of pain may be relevant, as well as its radiation proximally or distally, and any associated sensory or motor disturbances. It is also important to ask whether pain is increased by exercise and if it keeps the patient awake or interrupts sleep. Questions should be asked about the parts distal and proximal to the affected area. Any extension of pain, numbness, weakness, temperature change or swelling distally should be noted. Any disabilities, pain or swelling elsewhere in the body should also be noted. The patient should be asked about any treatment for a current complaint, its effectiveness, possible side effects, and an assessment made of compliance. Finally, general and specific questions about other systems likely to be affected should be asked.

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A Simple Guide to Orthopaedics

General Medical History Identifying data: name, age, address, occupation Presenting symptom(s) History of present illness Current treatment: effectiveness, side effects and compliance Past medical and surgical history Family history Social and occupational history Systems review

History and Examination

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Past history This should include questions regarding previous operations, illnesses or injuries, and also general health.

Family history Details of the immediate family's health is an important part of the history. This should include medical and surgical illnesses in the patient's parents, siblings and children.

Social and occupational history A social history should make brief reference to domestic, interpersonal, legal and financial matters. An occupational history is important since it has a bearing on the likely risk factors, approach to treatment and patient compliance. A history of alcohol and other drug consumption is an essential part of the social history. An alcoholic, overweight, heavy smoker is much more likely to develop conditions such as lung carcinoma and hepatic cirrhosis. This patient is also more likely to have postoperative complications from surgery. The way in which the patient gives a history, and even the past history, can provide a good indication as to whether the symptoms described are genuine, and the likelihood of patient response to treatment. The type of treatment given and the availability of domiciliary care may alter the necessity for hospitalisation. Obtaining a history from a young child may be difficult. Parents may provide some information, and more reliance will need to be placed on physical examination. 6

A Simple Guide to Orthopaedics

Systems Review Cardiovascular system Chest pain, dyspnoea, swollen ankles Respiratory system Cough, sputum, dyspnoea, fever Central nervous system Headaches, weakness, altered consciousness Gastrointestinal system Nausea, vomiting, abdominal pain, altered bowel habits Genitourinary system Frequency, dysuria, discharge, haematuria Musculoskeletal system Pain, restricted movement, past trauma General Weight loss, weakness, mental state History and Examination

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A patient's occupation and ability to work may be relevant. A patient complaining of back pain, for instance may relate this to lifting heavy weights at work. This may in turn be exaggerated, with a view to compensation payments or extended time off duty. The type of work carried out by the patient may also be relevant to possible treatment. For example the management of back pain in someone in a sedentary occupation, who takes little exercise, may be viewed differently from that of someone whose job involves heavy lifting.

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A Simple Guide to Orthopaedics

Aetiology of Orthopaedic Conditions Congenital 1. Genetic eg. achondroplasia 2. Infection eg. rubella 3. Drugs eg. thalidomide 4. Radiation eg. X-rays 5. Trauma

Acquired 1. Neoplasia —

benign malignant 2. Trauma — soft tissue fracture and dislocation 3. Infection — acute chronic 4. Arthritis — degenerative autoimmune metabolic 5. Paralysis — cerebral spinal peripheral 6. Miscellaneous — Pagets disease

History and Examination

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Orthopaedic Examination Look

Feel

Move

Part affected Part distal Rest of patient

Skin

Soft tissue

Bones and joints

i. vessels ii. nerves iii. muscles, tendons, ligaments, other

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A Simple Guide to Orthopaedics

Swollen shoulder Swollen elbow

Rest of patient

Swollen wrist

Rheumatoid hands

Part affected

Part distal © Huckstep 1999

History and Examination

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Examination Principles 1. Try not to hurt your patient and watch the patient’s face, not the umbilicus. 2. Always carry a tape measure and torch. 3. Examine the relevant part of the body gently, systematically and thoroughly. 4. Examine anything else which may be of direct relevance. 5. A quick, thorough check of other systems without missing anything is important, but only if this is directly relevant to diagnosis, eg. in thyroid swelling examine the eyes for exophthalmos, the pulse for tachycardia and dysrythmias and the hands for tremor.

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A Simple Guide to Orthopaedics

History and Examination

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The Part Affected Look 1. Skin 2. Soft tissues — vessels nerves other eg. muscles, tendons, ligaments, fat, fascia, lymph nodes 3. Bone and joint including synovia and ligaments

Feel Skin The skin should be felt for — tenderness temperature fluctuation sensory disturbance It is important to compare both sides of the body, and to feel the front, back, and sides of the part affected. Soft tissue Soft tissue should be carefully palpated and abnormalities noted. Soft tissue examination can be divided into three sections: Vessels Nerves Other —muscle, tendons, ligaments fat, fascia, lymph nodes Vessels Abnormal or absent pulsation should be noted. An aneurysm can usually be moved from side to side rather than longitudinally, it may pulsate, and a bruit may 14

A Simple Guide to Orthopaedics

Look © Huckstep 1999

© Huckstep 1999

Rheumatoid hands

Talipes varus deformity

Feel

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© Huckstep 1999

Axillary lymph nodes Patella and joint margins

Move

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History and Examination

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be heard on auscultation. Examination of the distal part of the limb may highlight differences in appearance and temperature. Nerves Nerves can sometimes be palpated and may be enlarged. In some cases, the nerves may be tender, for instance following trauma, or due to pressure from underlying structures. They may also be enlarged with a tumour such as a neurofibroma. As with vessels, they can be moved from side to side rather than longitudinally. Sensory loss, hyperaesthesia or paralysis may be present in the distal part of the limb in nerve injuries. Other structures Muscles and tendons should be palpated for tenderness. Tendons may be shortened or ruptured. A ganglion is an overgrowth of synovial tissue. Ganglia often transilluminate and their size often varies as joints are moved. Benign lipomas are very soft with an indefinite edge and transilluminate. Malignant soft tissue tumours include liposarcoma, rhabdomyosarcoma and fibrosarcoma. Regional lymph nodes should always be palpated for enlargement in all cases where there is a possibility of infection or neoplastic disease. Bones and joints These should be carefully palpated for: 1. Abnormal anatomy, swelling and deformity 2. Tenderness 3. Comparison with the opposite side

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A Simple Guide to Orthopaedics

The joint should be palpated in different degrees of flexion. Swellings in the joint may become more obvious with flexion or extension. Swellings may be bony, or soft tissue, or both. If the swelling is soft tissue, it should be assessed as to whether it is: 1. Synovial tissue 2. Fluid — synovial fluid blood pus 3. Both

Move As well as testing the muscles, ligaments should be assessed where possible. This is particularly important in the knee and the ankle, where ligament laxity compromises weight bearing. Detailed examination of joints is discussed in subsequent pages. In children or apprehensive adults, active movements should be carried out before passive. Passive movements (movements gently carried out by the examiner) should always be assessed in addition, to active movements, (carried out by the patient). Individual joints have different types of movement. Most joint movements, however, can be divided into 3 major components: 1. Flexion/extension 2. Abduction/adduction 3. Internal/external rotation After assessing active and passive movements, the power of relevant muscle groups should be assessed.

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The Part Distal Look The limb should be inspected for scars, deformities and also for any obvious shortening. It is important to examine the sides, back and front of the limb, and also to compare the opposite limb. Small differences in colour, swelling, wasting and deformity can only be noticed by careful comparison of the two sides.

Feel A systematic examination of the limb affected will mean that nothing important is missed. The skin is felt for warmth. Any difference in sensation is compared with the opposite side and tender areas noted. The arterial pulses are palpated and compared, when appropriate, with the opposite side.

Move The joint should be moved through its full range of movements: 1. Active movement — movement by the patient. In children, apprehensive patients, or in cases of suspected spinal injury, always carry out active movement before passive. 2. Passive movement — movement by the examiner 3. Power 4. Ligamentous stability

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A Simple Guide to Orthopaedics

Look

© Huckstep 1999

© Huckstep 1999

Rheumatoid hands

Feel

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Ulnar nerve palsy © Huckstep 1999

Move

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© Huckstep 1999

Ankle plantarflexion and dorsiflexion History and Examination

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A Simple Guide to Orthopaedics

The Rest of the Patient

Look 1. Opposite side 2. Head and neck 3. Trunk, spine and abdomen 4. Other limbs

Feel 1. Temperature 2. Tenderness 3. Abnormal masses

Move 1. Active 2. Passive 3. Ligamentous stability

History and Examination

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Overall Examination Head and neck General inspection Swellings, wasting, deformity, skin Eyes Pupils, conjuctivae, fundi Ear, nose and throat Neck JVP, carotids, thyroid , lymph nodes, trachea

Upper limb General inspection Swelling, wasting, deformity Pulse and blood pressure Neurological examination Tone, power, reflexes, sensation, coordination Bone and joint examination

Precordium General inspection Swellings, wasting, deformity Heart Size, heart sounds, murmurs Lungs Breath sounds, additional sounds

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A Simple Guide to Orthopaedics

Overall Examination Rib cage and breasts Back General inspection Swelling, wasting , deformity Lungs Spine Scoliosis, kyphosis, tenderness Movements Abdomen General

inspection

Palpation Liver, spleen, kidneys, other masses Percussion

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auscultation

Perineum Herniae, lymph nodes (inguinal and femoral), rectal and genital examination (if relevant) Lower

limb

General inspection Swelling, wasting, deformity Neurological examination Tone, power, reflexes, sensation, coordination Vascular examination Pulses, temperature, ulceration, trophic changes Bone and joint examination Shortening

and

History and Examination

gait

disturbance

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A Simple Guide to Orthopaedics