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Orthopaedic Clinic

General Examination Format

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Usually orthopedic complaints arise either from bones , joints or soft tissues.
A systematic approach towards analysing symptoms directed towards each of the above will lead to an accurate diagnosis.
 
A. Boney Examination:
A bone can be examined for following signs: Tenderness, Irregularity, Transmitted motion, Crepitus, Mobility ( abnormal), Displacement or deformity, Pain on Distant manipulation. A useful mnemonic is TITC MDD that will help remember all the components.
 
1. Tenderness: Local boney tenderness is a valuable  sign of the fracture. Inflammatory swellings are also usually tender where as tumors are typically non tender.
 
2. Boney Irregularity: Any sharp elevation, thickness or a gap should be noted. While a gap may be present in case of acute fracture or a non union; thickness and irregularity are hall mark of a healed fracture. Bone may also be felt as irregular in case of chronic osteomyelitis.
 
3. Abnormal mobility: This is a ' sine a qua non' of a fracture either acute or non union. It should be performed with utmost genteleness in case of acute trauma as it can be painful and may also potentially displace the fracture fragments.
 
4. Crepitus: It is a grating sensation that is felt or heard on moving the bone ends against each other. It should not be performed in acute cases, however while testing for  abnormal motion in cases of non union, it may provide a clue.
 
5. Absence of transmitted motion: In case of a breach in the continuity of the bone, the motion from the distal part of bone will not be transmitted to the proximal part. This is especially useful in cases of non union where the rotatory force applied to distal end of humerus, femur and fibula is not transmitted to the greater tuberosity, greater trochenter and fibula neck respectively.
 
6. Pain on distant manipulation:
In case of fractures esp. acute ones, a distant manipulation may give rise to pain on the affected area. For eg.
i) Squeezing both bones of forearm or the leg also known as springing will elicit pain.
ii) An axial pressure applied to the metatarsals or metacarpals may give rise to pain in cases of fractures.
iii) Rotation of femur or humerus may elicit pain.
 
7) Deformity: This depends on the displcement of the bone fragment . It can be in :
Sagittal plane: Pro curvatum or recurvatum.
Coronal plane: Valgus or varus.
Rotatory in nature. 
Shortening or impaction.
 
B. Joint Examination:
 
Any joint should be examined for its mobility, its stability and it strength. Although the patients complaint may not be directed towards a joint, it is always recommended to check a joint above and below the site of complaint.
 
1. Stability: Stability to a joint is provided by the surrounding soft tissues in particular the capsule and the ligaments (extra and intar articular in some cases). Various stress tests specific to different joints have been described to asess the stability.
 
2. Mobility: Movements at joint should be tested both actively and passively. Any decrease in the arc of motion, any change in the arc of motion or a non physiological increase in the range of movement should be noted.
 
3. Strength: It is important to note the movement against resistance. A decrease may suggest a neuro muscular involvement or a local atrophy around the joint subsequent to a local pathology.
 
C. Soft tissue Examination:
The examination of local swelling has been described in a seperate section. In addition to swelling an evaluation of muscle mass for hypo or hypertrophy needs to be done; this can be done by taking circumferential measurements and comparing it with the opposite extremity. The skin should also be evaluated for scars, sinuses, local signs of inflammation, and secondary changes like atrophy, loss of hair etc.
 
D. Complications:
Looking out for potential complications goes out a long way in preventing them. It is useful to always examine-
 
1.The vascular status: the dital pulsations, colour of the extremity and capillary refill.
2. Nerve injury : Muscle strength testing, reflexes, sensations.
3. Examining a joint above and below as described above.
Lymphatic system for lympahadenopathy.
4. Venous system for deep venous thrombosis, post phlebitic syndrome.
6. Any evidence of reflex sympathetic dystrophy.
7. Any evidence of myositis ossificans.
8. Any pressure or decubitus sore or ulcer.
 
E. Functional evaluation:
 
It is mandatory to evaluate the functional staus of the extremity, for upper limb: grip, grasp and hook function should be evaluated and for lower limbs: Gait, Squatting, sitting cross legged should be evaluated. An enquiry about the occupation of the patient and the handed ness in case of upper limb affection should also be made.
 
PRESENTING A CLINICAL DIAGNOSIS:
The provisional diagnosis should include the anatomical, pathological and functional dys function in the case. The probable cause of the dysfunction should be mentioned in the diagnosis, a differential diagnosis may also be given.
 
The causative etiology in orthopedics may usually be grouped under one of these headings:
i) Congenital.
ii) Traumatic.
iii) Developmental.
iv) Neoplastic.
v) Degenerative.
vi) Inflammatory or infectious.
vii) Idiopathic.
 
A breif outline of the diagnosis can be:
1. Anatomical affection.
2. Pathological affection.
3. Duration.
4. Complications if any.
5. Probable etiology.
6. Functional disability.
 
 
 
 

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