Examination of Orthopedic patients

Examination of Orthopedic patients

1. History and Clinical History and Clinical
Examination Examination
of Orthopedic Patientsof Orthopedic Patients

2. Examination of a Patient with
an Orthopaedic Problem
1.Questioning
2.Inspection
3.Palpation
4.Auscultation and percussion
5.Assessment of the function
6.Special tests and measuring
7.Additional methods

3. Equipment Requirements
The special tools required for the clinical
examination of a patient with an orthopaedic
complaint are modest in character. Three are
desirable:
1.A tape measure (preferably of the type used by
tailors) for measuring a limb length and girth;
2.A goniometer, for measuring the range of
movements in a joint;
3. A disposable sharp point.

4. 1.Reason for consultation (complaints of the
patient)
2.Circumstances of the trauma
3.Beginning of the illness
4.Previous treatment and its result
5.Occupation, habits and home circumstances
6.Information about parents and relatives
7.Associated and concurrent illnesses
History must include
information about:

5. Sponsored
Medical Lecture Notes – All Subjects
USMLE Exam (America) – Practice

6. Typical Complaints (Symptoms)
 Pain
 Stiffness
 Swelling
 Deformity
 Weakness
 Instability
 Change in sensibility
 Loss of function

7. Questions to ask
Joint pain
Does the pain change during the course
of the day?
Has the pain been there for a short or
long time?
Where is the maximal site of pain?
Does the pain get better or worse as
you move about?

8. Inspection
Deformity and Shortening
Swelling and Wasting
Scars and wounds
Presence or absence of limbs (part
of the limb)
Skin color
Position (active, passive)
Posture and gait

9. Osteoarthritis of the Hip
Characteristic habitus and gait
Osteoporosis
Progressive thoracic kyphosis, or
dowager’s hump, with loss of height
and abdominal protrusion
Cerebral palsy
Hemiplegia on right side.
Hip and knee contractures
and talipes equinus.

10. Deformity
Deformity results either from misalignment
of the bones forming the joint or from
alteration of the relationship between the
articular surfaces.
If misalignment exists, a deviation of the
part distal to the joint away from the
midline is called a valgus deformity and a
deviation towards the midline a varus
deformity.

11. a
c
b
Upper Extremity Deformities
(a) Normal axis of upper extremity;
(b) Cubitus valgus;
(c) Cubitus varus.
b
c

12. Lower Extremity
Deformities
a
(a) Normal axis of lower extremity;
(b) Genu valgum;
(c) Genu varum.
c
b

13. The spine: (a) the successive lordosis and kyphosis of the cervical,
thoracic, lumbar and sacral regions; (b) exaggerated lordosis; (c)
rounded kyphosis; (d) a knuckle kyphosis with gibbus.
a
db
Deformities of the back
c

14. Deformities
of the back
Scoliosis can be seen with the
patient standing but is more
marked when the patient leans
forward.

15. Swelling of joints
Causes of joint swelling include effusion,
thickening of the synovial tissues and of the
bony margins of the joint.
Differentiation of these causes is achieved by
palpation..

16. Swelling and Wasting
Ruptured biceps tendon
Residual left calf atrophy

17. Swelling and Wasting
Swelling over the mid clavicle.
Non union of a fracture
Olecranon bursitis
often may be due to
occupation (miners).
Clinical forms:
acute, chronic

18. Osteoarthritis of the knee.
Bony swelling associated
with quadriceps wasting
Rheumatoid arthritis of the hands
Swelling and Wasting

19. Swelling and Wasting
Osteomyelitis of the forearm
This was an osteogenic sarcoma in
a 10 year old girl in Uganda

20. Scars
and Wounds
Wound of the forearm
Burn of the upper extremity. Oedema
Open fracture of the both leg bones

21. Chronic infection of
the olecranon.
Scars are a map of the past.
Chronic osteomyelitis with
the scars of sinuses,one of
them still draining.
Scars and Wounds

22. Reduplicated thumb
Reduplication
of great toes
Congenital Deformities
Patient with ‘lobster claw’ congenital
deformites of both hands and feet
Amnionic constriction and club feet

23. Congenital absence
of extremities
Proximal Femoral
Focal Deficiency

24. Palpation
► Local temperature
► Crepitus in the joints and soft tissues
► Swelling
► Painful areas, tenderness
► Tonus
1
2

4

25. Note any local heat any tenderness,
whether localized or diffuse
Note any joint crepitus
Palpation

26. Auscultation and Percussion
Are needed in the chest and abdomen
damages to determinate:
 the blood level in the cavities;
 presence of pneumothorax;
 changes of breathing;
 function of intestines

27. ► Determination of the range of
motion in the joints
► Movements in an abnormal range
or plane
► The cause of abnormal range of
motion (pain, contraction, deformity)
1
2
3
Movement
Movement of a joint is either active (i.e.
inducted by the patient) or passive (i.e.
inducted by the examiner).

28. Use of the goniometer to measure
the different joint motion.
Measuring of the range of motion in the joints

29. The neutral position from which
joint measurement is performed
Neutral position:
the limbs extended
with the feet dorsi-flexed
to 90
o
, the upper limbs
midway between
pronation and supination
with the arms flexed to
90
o
at the elbow.

30. Zero starting position is
the thigh in line with the
trunk. In measuring hip
extension, the
contralateral limb should
be held in flexion to
eliminate lumbar spine
motion. Hip flexion is
typically measured by
bringing both thighs into
flexion.
Hip and Knee Range of Motion

31. Knee motion is
primarily flexion and
extension. The zero
starting position is with
the knee straight.
Normal knee flexion is
135° to 145°. Extension
beyond the zero starting
position is more often
seen in young children.
Adults commonly have
a 5° knee flexion
contracture.
Hip and Knee Range of Motion

32. Flexion and
extension
Abduction
Abduction
Extension
Flexion
(elevation)
180
o-
160
o
180
o
0
o
90
o
60
o
Slight internal rotation
and abduction required
to reach maximal
elevation
Shoulder Range of Motion

33. Maximal internal
rotation is highest
midline spinous
process reached by
extended thumb
(T
7
in young adults)
Arm abducted 90°
from side
Arm held at side
External rotation
May be tested with
arm held at side or
abducted to 90°
Shoulder Range of Motion

34. Hand and Fingers.
Range of Motion

35. Normal
Gait
MidstanceFootflatHeelstrike
Opposite
heelstrike
Terminal
swing
Heelstrike
Initial swingPre-swing

In normal walking,
each leg goes
through a stance
phase and a
swing phase
alternately.
The rhythmic
repetition of such
cycles provides
grace to the gait.

36. Gait
Watch how the patient stands and
observe his gait on walking. Note
that a patient with an unstable or
painful hip prefers to use a stick in
the opposite hand, and tends to
shorten the period of weight-bearing
on the affected limb.

37. The common pathological gaits noticed in patients with
orthopedic disorders.
►Antalgic gait: occurs in painful condition of lower limb
►Trendelenburg gait: occurs in an unstable hip due to
CDH, gluteus medius weakness etc.
►Stiff hip gait: occurs in ankylosis of the hip
►Duck waddling (sailor's) gait: occurs in bilateral CDH
►Scissoring gait: occurs in CP
►High stepping gait: occurs in foot drop
►Circumduction gait: occurs in hemiplegia
►Charlie-Chaplin gait: occurs in tibial torsion

38. Trendelenburg gait Normal gait
A child with unilateral dislocation exhibits a typical
gait in which the body lurches to the affected side
as the child bears weight on it (Trendelenburg's
gait). In a child with bilateral dislocation, there is
alternate lurching on both sides (waddling gait).
High stepping gait
or Foot drop gait
Due to drop of the foot, the leg is
lifted more. The first to touch the
ground is the forefoot, and not
the heel.

39. Hand-knee gait
The person walks with hand
on the knee to prevent the
knee from buckling in a
quadriceps deficient knee
with flexion deformity.
Scissoring gait
The legs are crossed in
front of each other while
walking due to spasm of
the adductors of the hip
Short leg limb

40. Special Tests
If this maneuver reproduces the patient’s radicular symptoms shooting
down the leg, the patient may have a pathological process (most
commonly a disc protrusion) compressing and inflaming the nerve root.
Straight leg raise
Lasegue’s sign

41. Positive Thomas test indicates a hip flexion contracture,
id est, the affected hip cannot be extended to the neutral
position.
Special Tests

42. Loss of internal rotation
with hip flexed is a
sensitive and easy test
of hip arthritis.
Limitation of Movements

43. (a) Thumb to forearm. (b) Index finger metacarpophalangeal
joint hyperextension. (c) Elbow hyperextension. (d) Knee
hyperextension.
a
b
c
d
Hypermobility in the Joints

44. The patient’s knee is flexed to 90°. The doctor sits on the patient’s foot to
stabilize it. The tibia is pulled with the examiner’s hands toward the
examiner. If the tibia slides forward more than a few degrees, there may
be a tear in the ACL.
Anterior
drawer test
Abnormal Movements in the Joints

45. Posterior
drawer test
The examiner stays seated on the patient’s foot. The tibia is
pushed posteriorly. If the patient’s tibia glides posteriorly on
the femur, PCL is likely torn.
Abnormal Movements in the Joints

46. Abnormal Movements in the
Joints
The patient’s knee flexed to 30°
and fixed with one doctor’s hand
put on its lateral surface. With
other hand placed on the ankle
the doctor tries to deviate the
patient’s shank laterally. More
than 5o of deviation suggests a
rupture (partial or complete) of
the MCL. Compare with other
extremity.
Test for stability of the medial
collateral ligament (MCL)

47. “Springing” the pelvis. Pressure
on the pelvis produces pain if
there is a pelvic fracture
“Springing” the ribs.
Compression of the chest
induces pain if there is a
rib fracture
Special Tests

48. Pressure along the extremity produces
pain in the bone fracture site.
Note: no placing your hands on the painful
area.
Special Tests

49. Shortening
Types:
1.Anatomical (absolute, true, real)
2.Relative (comparative)
3.Seeming (apparent, projectional)
4.Functional (clinical)

50. Comparison of the
Opposite
Extremities
Where there is significant true
shortening the heels will not be level
(the discrepancy is a guide to the
amount of shortening) and the pelvis
will not be tilted. The site and amount
of shortening must now be further
investigated.

51. Comparison of the
opposite extremities

52. Shortening
In apparent shortening the
limb is not altered in
length,but appears short as
a result of an adduction
contracture of the hip,which
has to be compensated for
by tilting of the pelvis.

53. 1.Anatomical: distance between
the most remote bone
prominences of the extremity
(segment), which is measured;
2.Relative: distance between the
adjacent bone prominence
(proximally) and remote
prominence of the extremity
(distally);
Variants of measuring:

54. 3.Seeming: distance
between the proximal and
distal prominence of the
same extremity in case of
its angulation;
4.Functional: using the small
boards a doctor augment
the support height under
short leg until a patient
feels balance in his pelvis
Variants of measuring

55. Measuring the
distance from
bony points
a
(a) On the upper extremity;
(b) On the lower extremity.
b

56. Muscle power.
Medical Research Council (MRC) grading
Grade 0 - no movement
Grade 1 - only a flicker of movement
(change of muscle tonus)
Grade 2 – movement with gravity eliminated
Grade 3 – movement against gravity
Grade 4 – movement against resistance
Grade 5 – normal power

57. Additional
Methods.
X-Ray
Conventional radiology: X-rays that have passed through the
human body strike radiographic film creating an image.

58. X-Ray
Standard radiographic
examination: the radiographic
representation of various tissues
depends upon their relative
densities, which determines the
amount of radiation they will
absorb. Bone tissue, which has a
high density, appears white,
while soft-tissues are reproduced
in tones of gray and gas in black.

59. Computed
Tomography
(CT)
The patient is placed inside
a ring-like structure, around which
the radiogenic tube and the
radiation detectors rotate. The CT
scan creates several high-
resolution images that are a
cross-section of the scanned
portion of the body. Together
these images provide accurate
information about the patient's
anatomy and tissue density.

60. Ultrasound Examination of Joints
An ultrasound examination involves
high frequency sound waves which
are trans-mitted through the skin
and reflected by the internal organs
and structures. These "echoes "
form a picture on a screen which
can be examined for any
abnormalities.
USI gives the possibility to diagnose lesions of tendons,
ligaments, muscles and joint capsules.

61. Diseases, associated with affection of juxta-articu-
lar and cartilaginous tissues, may be quickly and
painful diagnosed by means of USI
Normal hip of a
1-year-old infant
Displasia of the hip
in a baby
Subluxation of the
hip in a baby
Congenital
dislocation of the
hip

62. Angiography (Vasography)
Angiography is the x-ray study of the blood vessels. An angiogram uses
a radiopaque substance, or dye, to make the blood vessels visible
under x- ray. Angiography is used to detect abnormalities or blockages
in the blood vessels (occlusions) throughout the circulatory system and
in some organs.
Biplanar X-Ray Angiography

63. Arthroscopy
Arthroscopy is primarily
used to help diagnose
joint problems. This proce-
dure, most commonly
associated with knee and
shoulder problems, allows
accurate examination and
diagnosis of damaged
joint ligaments, surfaces,
and other related joint
structures.

64. Magnetic Resonance Imaging
Magnetic Resonance Imaging, or MRI, is a painless and safe
diagnostic procedure that uses a powerful magnet and radio
waves to produce detailed images of the body's organs and
structures, without the use of X-rays or other radiation.

65. Magnetic Resonance Imaging
The patient is placed on a
moveable bed that is inserted into
the magnet. The magnet creates
a strong magnetic field that aligns
the protons of hydrogen atoms,
which are then exposed to a
beam of radio waves. This spins
the various protons of the body,
and they produce a faint signal
that is detected by the receiver
portion of the MRI scanner. The
receiver information is processed
by a computer, and an image is
produced.

66. “Some people feel they’ve
entered a dark, claustropho-
bic place, from which there’s
no escape. They feel like a
trapped rat. Hope you’re not
one of those”.

67. Magnetic Resonance Imaging
Different types of tissues send back different signals. For
example, tissues that contain little or no hydrogen (such as
bone) appear black. Those that contain large amounts of
hydrogen (such as the brain) produce a bright image
The magnetic field forces hydrogen
atoms in the body to line up in a certain
way (similar to how the needle on a
compass moves when you hold it near
a magnet). When radio waves are sent
toward the lined-up hydrogen atoms,
they bounce back, and a computer
records the signal.

68. It’s strange, but he’s still alive!

69. ReferencesReferences

1.V. F. Venger, V. V. Serdyuk, Rashed
Mochammad. Traumatology and ortho-
pedics. Odessa, "Druk“. – 2006 (Ukraine)
2.Ronald McRae. ClinicaL Orthopaedic
Examination. 5
th
Edition. - Churchill Livingtone.
– Edinburgh, London, New York, Philadelphia,
St.Louis, Sydney, Toronto. – 2004.
3.J.Maheshwari. Essential Orthopaedics.
3rd Edition, Mehta Publishers. 2002.(India)
4.Apley’s Concise System of Orthopaedics
and Fractures. Louis Solomon, David
Warwick, Selvadurai Nayagam. 3rd Edition,
Hodder Arnold, 2003.
5.Clinical Examination. Owen Epsten and others.
- Mosby. – London, Philadelphia, St.Louis, Sydney,
Tokyo. – 1977.