FORMAT FOR ORTHOPEDIC CASE PRESENTATION WITH SIMPLE KNOW-HOWS AND TIPS
Case presentation starts with basic demographic details.
- Name
- Age
- Sex
- Occupation
- Address and
- Handedness (especially in a case involving the upper limb)
Chief complaints (in chronological order)
- A
- B
- C
- D
The major complaints in orthopedic patients are:
- Pain
- Swelling
- Difficulty in bearing weight/inability to move a joint
- Deformity
- Shortening or lengthening of a limb
- Instability of the joint
- Limp
- Systemic features: Fever, weight loss, etc.
- Others
HISTORY OF PRESENT ILLNESS
The fundamental idea of history of present illness (HOPI) assessment is that each chief complaint must be evaluated and described in detail regarding onset, duration, progression, aggravating and relieving factors and other specific points, if any. Once all the chief complaints are well described, the relevant positive and negative history is taken. The aim of this exercise of detailing HOPI with positive and negative history is to zero in on the possible etiology and pathology of the symptoms in question .
Important Facts about Common Complaints
1. Pain
Apart from elaborating the pain, it is important to understand the nature of pain which could be “mechanical” pain or “rest” pain, or pain of “neurological origin.”
- Usually, mechanical pain results from loading the joint (standing, walking, turning, running, jumping, etc.). It is usually due to degenerative pathologies like osteoarthritis, spondylosis, tendinopathies, fasciitis, etc.
- Usually, rest pain happens even without loading and is often associated with morning stiffness. It is usually due to inflammatory, infective, or tumorous disorders such as rheumatoid arthritis, ankylosing spondylitis, tuberculosis of the joint, malignant tumors, respectively. Any rest pain lasting for more than 3–4 weeks should be thoroughly investigated as “rest pain” could indicate underlying sinister pathology!
However, there are a few exceptions to the general rule about rest pain, e.g. shoulder and cervical spine degenerative pathologies. Most shoulder degenerative pathologies (rotator cuff tendinopathy, tear, frozen shoulder, arthritis, calcific tendinitis, etc.) are painful at night and may not hurt much during day time. Also, cervical spine intervertebral disc prolapse with root compression often hurts at night while the patient lies on the side (due to increased root compression). So, even though these conditions are painful at night, they do not indicate any sinister pathology.3
- The pain of neurological origin: It is usually shooting/dragging type, often associated with tingling and numbness along the course of the nerve. It is often due to nerve compression due to varying etiologies.
2. Swelling
The swelling could be arising from the joint (intra-articular) or elsewhere. The swelling elsewhere could be from any underlying structure and should be evaluated as per the standard assessment. However, while assessing the intra-articular swelling, one must question the timing of onset of swelling especially after trauma.
- If the intra-articular swelling has arisen immediately after or within a few hours of trauma, it indicates hemarthrosis. Hemarthrosis is a result of injury to any intra-articular structure that is rich in blood supply (e.g. peripheral meniscal tear, cruciate ligament tear, synovial or capsular tears) or intra-articular fractures.
- If the intra-articular swelling has arisen 12–24 hours after the injury, it indicates excess synovial fluid production in the joint following synovial irritation. This could be due to any injury causing synovial irritation like cartilage injury, central or inner meniscal tear, foreign body reaction, chronic synovitis, etc.
3. Inability or difficulty in bearing weight (lower limb)
Normal weight bearing is possible due to the normal linkage between normally innervated “bone–joint–ligament–muscle–tendon–capsule” complexes. Any disturbance in this linkage could lead to inability to bear or difficulty in bearing weight.
- Acute h/o inability to bear weight after acute trauma indicates a significant bone or joint injury (fracture or dislocation), a nerve palsy, complete ligament injury, complete tendon tear, or major capsular disruption.
- If the patient can bear weight after the first acute injury, it “fairly well rules out” any significant bony or soft tissue injury. Nevertheless, in impacted fractures, one can still bear weight! Further; in case of partial injury to ligaments or tendons, the patient can bear weight albeit with difficulty.
- Chronic ligament injuries are more tolerant to weight bearing, i.e. most patients can bear weight easily or can use the limb with minimal difficulty. However, with every fresh episode of injury to the limb superimposed over chronic existing ligament injury, the patient returns to weight bearing or usage of limb faster than the previous occasion.
- A chronic h/o of inability to bear weight on lower limb indicates that there is nonunion of a fracture.
4. Inability or difficulty in moving a joint
The normal sequence to move a joint is completed by a “normal neuromuscular–tendinous–ligamentous–capsular–bone and joint-soft tissue pathway.” Table 1.1 shows the normal pathway required for joint movement, and how an abnormal condition can affect its working with a few examples.4
5. Deformity
It could be structural or spasmodic. Structural deformities are not passively correctable, whereas spasmodic ones can be corrected with changed posture or they are spontaneously corrected as pain is relieved.
- Structural deformities could be arising from bone [congenital malformation (scoliosis), malunion/nonunion of fracture, growth plate disturbance, etc.,] joint (dislocated or subluxated), muscle–tendon contractures (Volkmann's ischemic contracture), fascial contractures (Dupuytren's contracture), capsular or ligament contractures, skin or scar contractures (postburn contracture, scleroderma).
- Spasmodic deformities are seen in acute painful musculoskeletal conditions due to muscle spasm, e.g. paraspinal muscle spasm after acute intervertebral disc prolapse leading to postural scoliosis.
6. Shortening or lengthening of a limb
There could be true or apparent discrepancy in the limb length.
- True discrepancy in the limb length is due to “the lengthening or shortening of the bone” due to Traumatic (fracture/dislocation) infective, or metabolic pathology truly altering the length of the bone.
- Apparent discrepancy in the limb length is due to a “deformity” but there is no true deficit in the limb length when measured. It looks short or long but not truly long or short!
7. Instability of the joint
Normally, ligaments provide stability to the joint by linking two morphologically normal bones across the joint. So when ligament tears completely, it leads to instability of the joint. Partial ligament tears may not cause instability. Also, an abnormal shape of bony articulation can contribute to instability (e.g. Trochlear dysplasia results in patellar dislocation).5
8. Locking
Normally, the joint movement is smooth and it does not get “locked” (fixed in a particular position) because nothing gets in between the two mobile articulating surfaces. So if something loose comes in between the two articulating surfaces, it gets entrapped and stops the smooth gliding of joint surfaces. This leads to joint stuck in a fixed position without patient being able to bend it or straighten it is known as locking. It is usually an intermittent phenomenon as once the loose fragment moves out, the joint gets unlocked.
Some common causes of locking are:
- Meniscal tear in knee joint: Bucket handle tears of meniscus
- Loose body in any joint.
9. Limp
It is observed in lower limb and it could be due to various causes. The main causes are:
- Limb length discrepancy
- Painful conditions of the lower limb
- Weakness of the Hip abductor mechanism.
10. Systemic features
Fever, weight loss, or loss of appetite, etc.
- Presence of systemic feature indicates that either the local condition observed at the musculoskeletal system is having a systemic influence (e.g. septic arthritis, malignant tumor, etc.) or the local pathology is a culmination of a systemic disease (rheumatoid arthritis).
The rest of the history goes as per the standard protocol. The questions asked about the rest of the history should have an aim to further investigate the cause of the disease.
- Past history
- Personal history: Smoking, h/o alcohol intake, sleep, bowel and bladder habit
- Treatment history: One can get vital clues about diagnosis with treatment history. However, one must assess it separately and avoid mixing it with HOPI. An exception is a case of trauma wherein treatment history is assessed along with HOPI
- Family history
- Menstrual history
EXAMINATION
The examination starts with general and systemic examination whether it is a short or long case. The general and systemic examination is mandatory as per the standard protocol. It would be improper to say that I have not done the general and systemic examination.
- General examination: The examination of vital parameters and pallor, icterus, clubbing, cyanosis, lymph nodes and pedal edema in standard fashion.
- Systemic examination: Central nervous system (CNS), cardiovascular system (CVS), respiratory system (RS), abdomen and pelvis.
- Local examination
The standard order of examination in orthopaedic cases is as follows:
- Gait: In case of lower limb or spine examination
- Attitude: It is described as the position assumed by each joint and bone at rest which is comfortable to the patient.
- Palpation
- Movements
- Measurement
- Neurovascular examination
- Special tests for individual pathology/region
- Joint above and below
- Lymph node examination.
Pearls and Pitfalls while Performing Local Examination
- While presenting the examination findings:
- Adjectives must be avoided unless it has been standardized as grading, e.g. “severe” tenderness. Tenderness is either present or absent but no such grading is discussed in literature. One's “severe tenderness” could be someone else's “moderate”!
- The methodology of examination should not be informed during presentation unless asked for. One must just present the finding.
- The etiology of the finding should not be discussed while presenting the finding. It must be left for the discussion.
- InspectionWhile performing inspection, there are many findings that are general in nature (swelling, scar, sinus, ulcer, etc.) and students are already aware how to describe them with their previous exposure in surgery, medicine, and other clinical postings. However, one must look for specifics in orthopaedic case like:
- Deformities
- Limb length discrepancy
- Muscle wasting
Certain common terms that are used to describe deformity in limbs are described here:
Varus:
It implies “part of the body moving closer to the midline.” Genu varum means that “genu” or “knee” is the referencing point and the “part,” i.e. the leg has moved closer to the midline (Fig. 1.1).
Valgus:
It implies “part of body moving away from the midline.” Genu valgum means that “genu” or “knee” is the referencing point and the “part,” i.e. the leg, has moved away from the midline (Fig. 1.1). Cubitus valgus means that “cubitus,” i.e. the elbow is the referencing point and forearm has moved away from the midline.
Recurvatum:
It implies hyperextension and is observed in the elbow and knee. It is known as genu recurvatum in the knee. Normally, when the patient stands erect and observed from the side, the axis of the lower limb passes through the center of hip, knee, and ankle. However, in recurvatum, it passes anterior to the knee (Fig. 1.1).
Flexion deformity:
It implies that the affected joint cannot be brought into complete extension, passively or actively.8
Ankylosis:
Pathological fusion of a joint in a fixed position (flexed or extended) with no movements possible. (Arthrodesis: Surgical fusion of joint).
- Palpation
- Before palpation, ask the patient to mention the exact site of tenderness as it helps in localizing the site and type of pathology. Also, this helps the examiner to remain cautious while palpating the tender area.
- The palpation must be done with due gentleness especially in tender areas as it can lead to increased pain. Afterward, the patient may not cooperate with the rest of the examination.
- The palpation must follow a sequence of eliciting tenderness over bony prominences, soft tissues and joint line.
- Movement
- Always check and highlight the deformities before commenting on the range of movement (ROM).
- The ROM is assessed using a goniometer (The methodology to assess the joint movement using goniometer is discussed at the end of chapter with relevant images).
- The total “ROM” must be mentioned.
- The ROM should be assessed on the following parameters
- Active and passive ROM: Active ROM should be assessed primarily as–
- Always compare with the normal side.
- If active is not possible, it may indicate nerve palsy, tendon-muscle tear or fracture dislocations, etc.
- Also, it gives a fair assessment of painless or painful range of movement.
- Passive ROM helps in assessing total movement at the joint.
- Painless/painful ROM
- Associated crepitus with ROM: Crepitus indicates rubbing of rough surfaces in arthritis of joint, loose body in the joint; an inflamed bursa or a torn, frayed tendon edge rubbing with another bone.
- Extensor lag: This is a specific term used for the knee wherein the patient can actively flex his knee but while actively extending back, it does not come back to the starting point of flexion. It means that the knee “lags in extension.” However, passively the knee can be brought to the starting point of flexion. It occurs due to the weakness in the quadriceps mechanism.
- MeasurementThe objective of limb length measurement is to analyze the discrepancy in limb length, if any, and to assess the segment of discrepancy (arm and forearm/thigh and leg).Few important points must be ensured while limbs are measured for any discrepancy.
- A preexisting deformity in the limb must be checked and corrected (Eg. squaring the pelvis). A preexisting limb length discrepancy must be asked for, if any.
- The limb measurement is performed between the two predesignated bony landmarks.
- The bony landmarks must be marked with a skin marking pencil.
- The two limbs must be kept in identical positions for measurement.
- The segmental length of the limb must be measured.
- Finally, while mentioning the limb length assessment, the student should inform the discrepancy/normalcy of limb length rather than narrating the individual measurements of bone length and not calculate the final discrepancy.
6. Neurovascular (NV) examination: As per the standard neurovascular assessment of the limb.
7. Special tests: The key to the special tests is explain–demonstrate–interpret–compare
- “Explain (to patient)–demonstrate (on index side)–interpret (finding)–compare (with normal side)”
8. Joint above and below: As per standard examination practice.
- One must always assess the joints above and below as the disease or affection of proximal or distal joint may cause radiation of pain to the neighboring joint. (E.g. Hip pathology may lead to radiation of pain in the knee due to the Hilton's law. Another example where bilateral flat foot leads to the knee pain.) However, the pain perceived area may be absolutely normal. Hence, it is vital to examine the neighboring joints.
- Further, it can be again summarized as “Joints above and below are normal.” However, if there is an abnormal finding in neighboring joint, it should be informed.
9. Lymph node examination: It should always be done especially in suspected case of infective, inflammatory and tumorous conditions.
10. Final diagnosis: The final diagnosis should have the following components:
- Duration
- Anatomical Site
- Side
- Pathology
- Etiology
- Complication, if any.
11. Plan the investigations relevant to “your case” and not a hypothetical case.
12. Final plan of the treatment
It could be conservative or operative. Tell the plan of treatment for your patient that is optimal for the diagnosis.11
A NOTE ON TECHNIQUE OF USING A GONIOMETER FOR THE ROM MEASUREMENT
Goniometer: It is an instrument which measures range of motion joint angles of the body.
Technique: The joint's ROM is measured by number of degrees from starting point of a segment to its position at the end of full ROM present at that joint.
A double armed goniometer is used for the ROM measurement wherein stationary arm of the goniometer lies parallel to the stationary segment of the limb and mobile arm of goniometer is placed parallel to the axis of the mobile segment of the limb. The center of goniometer lies over the central axis of the joint (Fig. 1.2). When all the landmarks are well defined and arms of goniometer are placed parallel to the limb, the accuracy of ROM measurement is high.
Important Tips
- The referencing segment or stationary part of the body should be stable and stationary arm of goniometer should be stable and parallel to the referencing limb. (Figs. 1.3 and 1.4)However; sometimes, there is no referencing segment for the goniometer in cases of the joints which are connected to torso directly; shoulder and hip. In such cases, the referencing segment is the midline of the body, and stationary arm of the goniometer should be placed over or parallel to the imaginary midline axis of the body (Figs. 1.5 and 1.6)
- Look at the goniometer reading and confirm it before it is removed from the body.
Fig.1.3: ROM measurement of knee flexion (left image) and wrist ulnar deviation (right image) using goniometer. The center of goniometer is over the center of joint.
Fig.1.4: ROM measurement of ankle plantar flexion using goniometer with center of goniometer over the center of ankle joint.
Fig. 1.5: Measurement of shoulder abduction ROM keeping stationary of arm of goniometer parallel to the imaginary midline axis of body (black line) and mobile arm parallel to the abducted arm. The center of goniometer is over the center of the shoulder joint.
Fig. 1.6: Measurement of hip abduction ROM keeping stationary of arm of goniometer parallel to the imaginary midline axis of body (black line) and mobile arm parallel to the abducted thigh. The center of goniometer is over the hip joint.
Notes
