Ortho 3; Clinical Examination in OrthopedicsWe start to examination before we take history, examination begins from the moment we set eyes on the patient, we observe …

General Appearance Posture Gait:

Limping, in pain, using stick… Deformities:

Knock knees, Spinal curvature, short limb, and paralyzed arm … Pain?

The clues are endless.

Principles of Assessment:1. Proper interaction with the patient.

Look at the patient’s facial expressions while examining him. 2. Start with the normal side first.3. Compare to the other side/joint.4. Do not cause pain.

{Facial expression!} 5. Extra carful with children.

Proceed slowly, do not attack!Play with the child.

Orthopedic Examination System:1. Look2. Feel3. Move4. Special Tests

FIRST: LOOK What do you look at? What do you look for?{Deformities, swelling, colour, wounds, bleeding, shocked, gasping for air, dying, cyanotic, depressed, muscle bulk; atrophy or normal, gait …}

A. Look generally at the patient one sentence describing the patient.For example:Patient in pain, sitting on chair, holding the right wrist and hand.Patient lying comfortable in bed not in pain.Patient lying supine, in pain, holding right thigh in flexion.Patient is restless in bed.Patient cyanotic… Gasping… Shouting… Unconscious… Shocked…

B. Generally about the local site {Shoulder, back, knee, hip, thigh …}1. Position:

Normal or abnormal, describe the position.2. Major deformity, swelling3. Extra:

Cast, splint, traction, dressing …

C. Anatomical Locally:1. Skin: swelling, scars, color, hair, dryness …2. Subcutaneous: LN, veins, nerves, tendons …3. Muscles: bulk, wasting, twitches …4. Bones: landmarks, swelling, angulation, deformity.5. Joints: position, swelling, redness…

Every joint has anterior and posterior part; do not forget to look at the posterior aspect "back"Three always forgotten locations:

1- back of knee 2- back of hip 3- medial side of shoulder

First picture Patient lying uncomfortably, in pain.Position: hip is rotated laterally (Externally), knee almost 900 flexed,Deformity & swelling: There is general swelling, deformity {One leg shorter than the other}Extra: nothing extra.Skin RednessMuscle Atrophy

Second picture Patient is unconscious, lying in supine position.Right elbow is internally rotated.Varus deformity in the elbow.No swelling.

Third picture Normal ankle position, swelling, ecchymosis, no extra and no obvious deformity.

General on the patient Patient sitting on a chair, anxious, in pain.

General local Elbow 90 degree flexion and supporting the elbow and forearm with the other hand.

Patient is standing using a frame support, walking uncomfortably.

Patient is lying supine, in distress.

Fourth picture An ankle in a cast.

Important Considerations:1. Amount of exposure2. Duration of exposure3. Persons present during exposure4. Place of exposure5. Attitude and behavior during exposure

SECOND: FEEL What do we feel for?

{Mass, tenderness, swelling, temperature, muscle bulk, tendons, pulse, skin sensation…}

Ask for pain or tenderness before you put your hands on the patient! Inform patient (take permission) you are going to touch him/her and ask to

inform you if it hurts.(I want examine your shoulder if there is pain tell me now please)

1. Tenderness:Generalized – Specific (local)

2. Temperature:Compare distal / proximal, R / LBy the palm or back of the hands.

3. Anatomic:Skin: dryness, hyper/hyposthesia, scarsSubcutaneous: LN, nerves, vessels, tendons, and nodules.Muscle: tone, bulk, twitches, gaps, tendernessBone: landmarks, tenderness, mass, crepitusJoint: swelling, effusion, crepitation, synovial thickening, joint line tenderness (if joint accessible)

If joint superficial you may able to feel like knee joint, but can not feel the deep joint like hip joint.

Do not forget to look at the posterior aspect "back"!

THIRD: MOVE A. Active Always to start with / not to cause pain

If not complete movement it could be because of the pain, joint stiffness, muscle weakness, and nerve injury …

More used in upper limb A must for assessment of muscle power

B. Passive If need to see difference from active

In muscle weakness /neurological problems More used in lower limbs

Range of Motion: Recorded in degrees of angles.

You need to assess the angles.00 full extension.

00 > Hyperextension00 < FlexionFull flexion of the knees when the calf muscles of the leg hit the thigh.

E.g, ‘knee flexion 0–140o meansRange of flexion from zero (the knee absolutely straight) through an arc of 140o

E.g, ‘knee flexion 20–90o meansFlexion begins at 20o (i.e. the joint cannot extend fully) and continues only to 90o

We can use the Goniometer for specific results. Range of motion:

Starting from resting xx degrees to xx degrees where motion stops. Zero is the neutral or anatomical position of the joint Do NOT use the words:

‘Full’, ‘good’, ‘limited’, ‘poor’ Assess painful arc, if present

E.g. Shoulder painful abduction At initial abduction In mid-abduction At extreme of abduction

Painful range of motionE.g. Knee flexion from zero to 90o, with pain from 90o to 110o then could not flex more because of pain.

FOURTH: SPECIAL TESTS Different for different joints:1. E.g. Anterior Drawer Test for ACL tear in Knee2. E.g. Patellar Tap for knee effusion3. E.g. Thomas Test for fixed flexion deformity of Hip

Weight-bearing / gait:Examination of all weight-bearing joints is not complete until weight bearing is assessed!{Ankle, foot, knee, hip, back}

Bony Lumps:1. Size2. Site3. Margin4. Consistency5. Tenderness6. Multiplicity

Motor Power Grading:0 = No powerI = fasciculation of muscle fibers – no movementII = move with gravity eliminatedIII = move against gravityIV = less than full powerV = full power – normal

Nerve Root Lower Limp: Hip

Flexion: L1, 2, 3Extension: L5, S1

KneeExtension: L3, 4Flexion: L5, S1

AnkleDorsiflexion: L4, 5Plantarflexion: S1, 2Inversion: L4, 5Eversion: L5, S1

ToeExtension: L5Flexion: S1Abduction: S1, 2

Nerve Root Upper Limp: Deltoid: C5, 6 Supra/Infraspinatus: C5, 6 Serratus anterior: C5, 6, 7 Elbow

Flexion: C5, 6Extension: C7Supination: C5, 6Pronation: C6

WristExtension: C6Flexion: C7

FingerExtension: C7Flexion: C7, 8, T1Abd/Adduction: C8, T1

Trauma – Clinical Examination:

A. General medical condition Should be evaluated to exclude

Shock Brain injury Other problems

B. Vital signs Should be observed and followed up

Head/neck, Chest

C. Look: Adequate exposure General on patient (One sentence describing the patient) Local:

Swelling, deformity, bruises, color, … Special attention is to be paid to wounds

Do not forget the back!

D. Feel: Tenderness, temperature and crepitus on movement Sensory and motor deficits Pulse distal to injury Compartment syndrome

E. Move With care!

Make sure not to cause more pain or injury Crepitus & abnormal movement indicates a fracture Joints distal to the affected area

F. Examination of the viscera Liver and spleen in rib fractures Urinary bladder and urethra in pelvic fractures Neurological examination in head and spinal injury