Transcript General examination

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
FREQUENT
PRACTISE !