The knowledge of a disease forms the basis for successful diagnosis and treatment. This knowledge can be gained only by careful and accurate study of the individual cases. It is thus important that a systematized method of examination be developed for a particular group of affections or a particular regional affection.

This orthopaedics clinics book in its subsequent chapters gives the format for a systematized logistical regional examination which will be particularly helpful during case presentations. During any case presentation your thoroughness in the subject, your confidene & clarity of thoughts and eye contact is of paramount importance. Always try to prepare your cases thoroughly. During the initial part of your training, read extensively about the case from whatever source you can lay your hands on viz. library reference books, discussion with seniors and websites etc. However during the later part of your training, presenting cases impromptu will give you lot of confidence. Confidence and clarity comes with knowledge but they are also the traits that can be developed with practice, you must know when to lower the speech, alter your tone and how to give the desired impact / effect.  This comes from practicing. The larger the number of cases you present, the more the deftness will increase. Maintaining an eye contact will give an impression of honesty and lastly always be compassionate towards the patient. Remember that they are not teaching equipments they are humans too and your case presentation must also prove beneficial to him and not a headache for him.

HISTORY

It is essential to elicit a complete and accurate history of the patient’s complaint, the mode of its onset, its duration, its subsequent progression and the order in which the symptoms were first observed. The chief complaint may suggest to some extent the nature of the affection and draws atttention towards a particular body region.

Onset, duration and progression - The disease may be insidious, gradual or sudden in onset. Trauma and infections usuallty appear suddenly. Most of inflammation, granuloma, tumors, degenerative changes are usually insidious in onset. The duration and progression may give a clue as to the nature of disease, its severity, prognosis and urgency of interventiion.

Typical Orthopaedic symptoms are :-

1. Pain

2. Deformity

3. Swelling

4. Loss of functiion

5. Stiffness

6. Instability

7. Limp

8. Limb length discrepancy (LLD).

PAIN

For any pain elicit following history (Mnemonic: STOPCARR)

            Site

Time (duration)

Onset

Progression

Character

Aggravating factor

Reliving Factor

Referred /Radiation

Other history  - Night cries

Claudication distance

Current status of pain leading to what disability that exists at present ?

Pain has been defined as the psychial adjunct of an imperative protective reflex and is the sensation  one feels when injured. Anatomy of pain involves:-

1. The painful stimulus

2. Peripheral receptors

3. Nerve pathways & Peripheral nerves

4. Spinal cord

5. The Brain

1)  The Painful Stimulus :-

The pain was believed to have arisen by normal stimuli exceeding the intensity threshold for sensory nerve ending. Waddel suggested that stimulation of peripheral receptors by noxious agents produce a spatio-temporal pattern of nerve impulses, which is interpreted as pain within the higher cerebral centres, i.e. the ‘pattern theory.’ such pattern of nervous activity may be produced by many physical phenomenona such as pressure, puncturing, squeezing, tension

and alteration in temperature or by chemical effects such as teh alteration of PH or the concentration of histamine like substances, serotonin, bradykinin and other polypeptide compounds.

2)  Peripheral Receptors:-

Specialized receptor organs commonly found are

Pressure              -  Lamellated corpuscles of Pacini

Cold                     -  Bulbous Corpuscles of Krause

Touch / Traction  -  Tactile corpuscles of Meissner, Ruffini end organs and

                                     free nerve endings.

Bone and periosteum respond to pressure, percussion or tension. Capsule responds to both tension & traction and is the most sensitive of all joint structures. In vertebral column, pain sensitive nerve endings have been found in fibrous capsule of apophyseal joints, in the ligamentum flavum & interspinal ligaments, in the periosteum of vertebral bony structures, in the durameter & epidural adipose tissue and in the blood vessel walls.

3)  Pathways & Peripheral nerves: The conduction velocity and frequency of pain unpulses in different nerve fibres are dependent on fibre diameters and is described in following sensory pathways.

Table 1

4)  Spinal cord :-  The afferent impulses are carried within the peripheral nerves to spinal root ganglia and then to cord where they synapse with one or two segments of the dorsal column before closing the midline to form the contralateral spinotholmictract. At the site of dorsal column synapse, the pathway of pain fibres is regulated by fibres descending in the ipsilateral cortico-spinal tract. There exists a controlling mechanism at every junction in the substantia gelatinosa at which nerve impulse are relayed from one nerve to the next on their cerebral ascent classically known as the ‘Gate control theory of Melzack & Wall’. This knowledge has substantiated the use of transcutoneous electical nerve stimulation (TENS) for many painful conditions.

5)  The Brain:-  In the cerebral cortex, pain is localised mainly in the post central gyrus of the parietal lobe. The frontal lobe is concerned with emotion, attention and appreciation of pain.

II)  Types of Pain

1.  Local: It is felt at the site of the pathological processes in the superficial structures. It is usually associated with local tenderness to palpation or percussion.

2. Diffuse: It is seen with involvement of deeply lying tissue and may have a segmental

distribution.

3. Radicular pain: Is characterized by its paoxysmal nature and radiation from the periphery to centre not necessarily in a continous fashion but along a strict anatomical distribution. It is often associated with paraesthesias, numbness along the course of a given root nerve root.

4. Neuritic: Usually occurs due to an infective agent, from a metabolic disturbance like

mercury poisoning, and is continous in nature till the time disease has gone in remission or the nerve root has been completly destroyed.

5. Referred Pain: Usually seen with injury or disease affecting either somatic or visceral structures; the pain is experienced in other areas besides that felt in the area of initial stimulation. The pain is a result of cortical mis-representation, because of the convergence of sensory pathways onto a single cell within the spinal cord or higher centres.

STIFFNESS

Stiffness may be generalized as seen with systemic affections in rheumatoid arthiitis and ankylosing spondylitis or located at a particular joint. Regular early morning stiffness of multiple joints is a cardinal feature of rheumatoid arthritis where as transient stiffness of one or two joints after periods of inactivity is seen in osteoatthritis.

Locking should be differentiated from stiffness. In locking, there is a sudden inability to

complete one particular movement. It usually suggests a mechanical block for eg. a torn

meniscus becoming trapped between two articular surfaces in the knee joint.

SWELLING

Swelling can be due to many etiology and may arise from soft tissue, joints or bones. History of mode of onset of swelling for eg: acutely following a fall / trauma  or insidiously as in tumors should be elicited as also other it is painful or painless, whether it is constant or increases/decreases in size (suggests infectiion & rules out neoplasia) and whether it is progressively increasing in size should be enquired.

DEFORMITY

Patient may describe the deformities as crookedness or use colloquial terms like round

shoulder, bowleg, pigeon toes and flat feet. Some deformities are merely exaggeration of the normal (eg: short staturedness), some deformities may get corrected with age (for eg: gener vacuum which is physiological till 18 months). That deformity which is progressive need to be evaluated for cause.

WEAKNESS

Muscular weakness confined to a single muscle group or specific muscular groups is

suggestive of neurological or muscular disorder. History should be elicited to discover the precise functional impairement which may give clue to the precise site of lesion and often the diagnosis.

INSTABILIITY

Instability may be a result of either muscular etiology, a ligamentous deficiency as in

traumatic rupture or laxity . The usual complaint is a sensation of giving away.

FUNCTIONAL DISABILITY

All orthopedic history must encompass this aspect of information and perhaps the most

important question in history taking that helps decide the management is what is it that you can’t do now that you were able to do in past. Functional disability is an indicator of the need of patient and is more than just the sum of individual symptoms. What may be merely inconvinent to an individual may be truly incapacitating to the other one.

PAST HISTORY

Following histories of the past should be elicited :-

Tuberculosis

Childhood disorder (esp. limp)

Old injuries

Gastro-intestinal diseases,

Skin and eye affection,

Previous medication (specially steroids)

Alcohol and drug abuse.