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Special features to orthopaedic history and examination DR. MOHAMAD KHAIRUDDIN.
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Transcript of Special features to orthopaedic history and examination DR. MOHAMAD KHAIRUDDIN.
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:InjuryPain StiffnessSwellingDeformityInstabilityAltered sensibilityLoss 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 !