FORMAT FOR ORTHOPEDIC CASE PRESENTATION WITH SIMPLE KNOW-HOW AND TIPS
The art of extracting relevant history and eliciting positive examination findings to clinch a diagnosis during orthopedic case presentations is taught with modifications from the other subjects.
The evaluation of the patient starts with basic demographic details mentioned below.
- Name
- Age
- Gender
- Occupation
- Address
- Hand dominance
The importance of various demographic factors is discussed below.
- Age: Typically, most orthopedic conditions have a predilection for a particular age group. Several examples are mentioned below:
- At birth: Developmental dysplasia of the hip (DDH)
- 6–36 months: Rickets
- 5–10 years: Perthes’ disease, Ewing's sarcoma
- 10–15 years: Slipped capital femoral epiphysis (SCFE), Osteosarcoma
- 18–40 years: Giant cell tumor, patella/shoulder dislocation, sports injuries
- 20–40 years: Inflammatory arthritis (Rheumatoid)
- >40 years: Various degenerative conditions such as osteoarthritis, tendinopathy, osteoporosis, and rotator cuff tear; malignancies such as multiple myeloma and secondaries.
- Gender: Certain conditions have gender predilection, such as:
- Females: DDH, connective tissue disorders, giant cell tumor, rheumatoid arthritis, osteoporosis
- Males: Perthes, SCFE, and Ankylosing spondylitis
- Occupation: Various occupations may pose a hazard for different orthopedic conditions. For example, painters, heavy manual workers, and those who participate in overhead sports are more prone to shoulder pathologies. Pneumatic tool drillers, chain saw workers are more prone for carpal tunnel syndrome. Further, the treatment plan can be altered or tailored to accommodate quick mobilization and early return to work, e.g., a bone–patellar tendon–bone graft is more suitable for anterior cruciate reconstruction than soft tissue ones in contact athletes, whereas soft-tissue grafts (hamstrings) grafts do well in a sedentary patient or those who do not play contact sports.
- Address: The residence may play a significant role in the development of certain diseases in a person, especially if the person has been staying in that place for long or since birth to have enough exposure to environmental factors. For example, natives of those places where fluoride content of the water is high, are more prone to early-onset secondary osteoarthritis of joints and spinal canal stenosis. Another example, children from the south-west coast of India are more prone to Perthes' disease.
- Hand dominance: Considering hand dominance is an essential aspect while treating or rehabilitating a patient. For example, a minor deformity and less than optimal function after a “left side” malunited Colles’ fracture is more acceptable in a right-hand dominant person than a left-hand dominant person.
A. Chief Complaints (In Chronological Order)
One must always present chief complaints in chronological order. For example,
- Pain in the right shoulder for six months
- Difficulty in elevating and reaching overhead objects for three months
- Swelling over the right shoulder for two weeks
- Discoloration of skin of the hand for one week
The common chief complaints in orthopedic patients are:
- Pain
- Swelling
- Inability or difficulty in bearing weight
- Limp
- Inability or difficulty in moving a joint
- Discharging sinus, nonhealing wound
- Deformity
- Shortening or lengthening of a limb
- Instability of the joint
- Locking
- Clicks, crepitus
- Altered sensations
- Skin changes
- Effect on activities of daily living and occupation: Routinely, it may not be part of chief complaints. However, it must be included at the end of the history of the present illness to understand the effect of the disease process on one's daily activities and occupation.
B. History of Present Illness (HOPI)
The fundamental idea of HOPI assessment is that each chief complaint must be evaluated and described in detail regarding onset, duration, progression, aggravating, 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 detailing HOPI with positive and negative history is zero on the possible etiology and pathology of the symptoms in question.
Pain
Pain is one of the most common complaints in orthopedic conditions. Pain should be probed on several parameters such as site, duration, onset, progression, quality, radiation, relieving-aggravating factors, severity, and timing.
- Site of the pain: Often, identifying the site of pain can localize the structures involved in the process of pain.
- Onset of pain: Sudden or insidious. What triggered the pain, must be probed.
- Progression of pain: Constant/worsened/improved/on–off
- Trauma: Initially more (at the time of the injury) followed by a decrease in severity
- Neoplasia: Constant or gradually worsening pain
- Acute inflammation: Sudden increase followed by a gradual decrease
- Chronic inflammation: Remissions and exacerbation of pain
- New origin pain in a painless condition: Malignant change or pathological fracture
- Quality of pain:
- Throbbing: Abscess
- Burning or with tingling: Neuralgic origin
- Dull aching: Mechanical pain of degenerative conditions (osteoarthritis, spondylitis, tendinopathies)
- Radiation of pain: Ask about the site of radiation of pain, if any. The radiation site may give a clue of pathology. For example, the cervical intervertebral disc prolapse (IVDP) pain radiates along the shoulder, arm, and forearm up to the lateral three fingers indicating the level of IVDP as C5, 6, and 7. In contrast, the cervical rib/thoracic outlet related compression of C8 and T1 root pain radiates toward the inner aspect of the hand, forearm, and arm.4
- Aggravating and relieving factors:
- Ask about aggravating and relieving factors with direct and indirect questions such as what happens when you move your joint, run, jump, squat, etc.
- Its relation to food, e.g., pain due to gout increases after eating red meat, organ meat, or cabbage.
- Whether pain relieves with analgesic or rest
- Severity of pain: The pain could be mild, moderate, severe or excruciating.
- Mild pain: Easily ignored
- Moderate pain: Cannot be ignored, interferes with function, and needs time-to-time intervention/medication
- Severe: Cannot be ignored, interferes with function, and demands constant attention and intervention
- Excruciating: Incapacitating
- Timing of pain: Apart from elaborating the pain on the above-mentioned factors, it is crucial to understand the timing or nature of pain, which could be “mechanical” pain, “rest” pain, or pain of “neurological origin.”
- Mechanical pain results from loading the joint (standing, walking, turning, running, jumping, etc.). Typically, mechanical pain is due to degenerative pathologies such as osteoarthritis, spondylosis, tendinopathies, and fasciitis, and characteristically resolves upon adequate rest.
- Rest pain happens during periods of rest even without loading the joint, and might be associated with morning stiffness. It is usually due to inflammatory, infective, or tumorous disorders such as rheumatoid arthritis, ankylosing spondylitis, tuberculosis (TB) of the joint, and malignant tumors. A thorough investigation of any rest pain lasting for more than 3–4 weeks is mandatory as “rest pain” could indicate underlying sinister pathology! Night cries are a special type of rest pain, which are described in tuberculosis of the joints, especially in children. These so-called night cries are due to decreased voluntary muscle tone during sleep, permitting the diseased joint surfaces to rub against each other more than when the child is awake when the muscle spasm does not allow gross movement.However, there are a few exceptions to the general rule about rest pain, e.g., shoulder and cervical spine degenerative pathologies. Most shoulder 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 IVDP with root compression often hurts at night while the patient lies on the side (due to increased root compression in lateral position as neck tilts). So, although these conditions are painful at night, they do not indicate any sinister pathology.
- The pain of neurological origin: It is usually shooting or dragging type, often associated with tingling and numbness along the course of the nerve. Typically, it is due to nerve compression caused by varying etiologies, e.g., a prolapsed intervertebral disc compressing the nerve root can cause radiating pain along the course of the nerve, or pain on radial side of hand in carpal tunnel syndrome due to median nerve compression.5
Swelling
The symptom of swelling must be thoroughly probed on the following parameters: Site, onset, duration, progression, painful/painless, and number (single/multiple). The swelling could be intra-articular (effusion/synovial swelling) or arising from extra-articular structures. The swelling from an extra-articular structures should be evaluated as per the standard assessment (Refer to Chapter 17 on Swelling). While assessing the intra-articular swelling, one must question the timing of the onset of swelling (immediate or delayed), especially after trauma, as the timing of swelling onset could give a clue to the diagnosis.
- If the intra-articular swelling appears immediately after or within a few hours of trauma, it indicates hemarthrosis. The hemarthrosis results either from intraarticular fractures or injury to any intra-articular structure which has a rich blood supply, e.g., peripheral meniscal tear, cruciate ligament tear, synovial or capsular tears.
- If the intra-articular swelling appears 12–24 hours after the injury, it indicates excess synovial fluid production in the joint following synovial irritation. Synovial irritation could result from cartilage injury, central or inner meniscal tear, or a foreign body reaction.
- A nontraumatic origin intra-articular swelling could be due to synovial hypertrophy, excess synovial fluid, a combination of synovial hypertrophy and fluid, or pus. It can occur in infections (TB), inflammation (rheumatoid), degenerative conditions (osteoarthritis, meniscal, or cartilage damage), synovial chondromatosis, etc.
Inability or Difficulty in Bearing Weight (Lower Limb)
Typically, normal weight-bearing is possible due to the normal linkage between “normally innervated painless bone–joint–ligament–muscle–tendon–capsule complexes.” Any disturbance in this linkage could lead to inability or difficulty in bearing weight. Several examples are discussed below to understand how a normal weight-bearing is affected or compensated.
- Inability to bear weight after acute trauma indicates a significant bone or joint injury (fracture or dislocation), nerve palsy, complete ligament injury, complete muscle-tendon tear, or significant capsular disruption.
- If the patient can bear weight immediately or soon after (within few hours or a day) the first acute injury, it “fairly well rules out” any significant bony or soft tissue injury. Nevertheless, in impacted fractures or cases of partial soft tissue injuries (muscle, tendon, and ligament), one can still bear weight, albeit with pain!
- Chronic ligament injuries are more tolerant to weight-bearing, i.e., most patients can easily bear weight or use the limb with minimal difficulty after the first few days of the primary injury. However, with every fresh episode of twisting or instability to the limb superimposed over chronic existing ligament injury, the patient returns to weight-bearing or limb usage earlier than the previous occasion.
- A chronic history of inability to bear weight on the lower limb with a fracture indicates a nonunion of a fracture. Many patients get gradually adjusted to chronic injuries of muscle, tendon, neglected dislocation, and nerve palsy. However, they may continue to have difficulty in weight-bearing or using a limb.6
Limp
Limp is frequently observed in affections of the lower limb. It could be painful (traumatic, inflammatory, and infective) or painless (DDH, coxa vara, and short limb). The various leading causes of limp are:
- Painful conditions of the lower limb: Inflammatory (rheumatoid), infective (tubercular)
- Weakness of the hip abductor mechanism: DDH, coxa vara
- Limb length discrepancy
Inability or Difficulty in Moving a Joint
The typical sequence to move a joint is completed by a “normal neuromuscular–tendinous–ligamentous–capsular–bone and joint-soft tissue pathway.” Figure 1.1) shows the normal pathway required for joint movement, and Table 1.1 mentions various abnormal conditions, which can affect the working of the normal pathway for joint movement. A detailed history and examination would ascertain the cause of inability or difficulty in moving a joint.
Fig. 1.1: Illustrative neuromusculoskeletal pathway required for a normal joint movement. Horizontal line in the spinal cord depicts cross-section of spinal cord. (1) Brain; (2) Spinal cord; (3) Anterior horn cell; (4) Nerve roots; (5) Peripheral nerve; (6) Neuromuscular junction; (7) Muscle; (8) Tendon; (9) Joint and bones; (10) Ligaments, capsule and other soft tissue.
One of the major causes of difficulty in moving a joint is ‘joint stiffness, which could be due to various intra- or extra-articular causes. Box 1.1 briefly discusses the differences between the two types of stiffness.
Discharging Sinus
Chronic osteomyelitis is the most common condition in a orthopedic patient causing a discharging sinus. One must probe regarding the condition, which led to the onset of sinus (postsurgical or spontaneous after a swelling suggestive of hematogenous osteomyelitis), progression, number, remissions and exacerbation, and type of discharge (serous/seropurulent/purulent). Refer to Chapter 17 for further details.
However, one must remember that the mere presence of a discharging sinus in an “orthopedic case” does not confirm underlying osteomyelitis. Any dead and infected material [natural (bone) or foreign (nonabsorbable suture material, foreign body, etc.)] could result in a discharging sinus. Unless the sinus is fixed to the underlying bone, it cannot arise from a bone infection.
Deformity
A deformity is defined as a permanent deviation from the normal shape or contour of a bone or a joint which is not correctable by any active or passive maneuver by the patient or clinician (c.f. attitude, which is either position of ease of a limb or a temporary deviation from normal and correctable). Deformity could be structural or spasmodic. Structural deformities are passively not correctable. In contrast, spasmodic (due to pain) deformity resolves after subsidence of the pain.
- Structural deformities could be arising from:
- Bone: Congenital malformation (scoliosis), malunion/nonunion of fracture, and growth plate damage (traumatic, infective, metabolic, or iatrogenic)
- Joint: Dislocated or subluxated, ankylosed
- Muscle–tendon contractures: Volkmann's ischemic contracture, poliomyelitis
- Fascial contractures: Dupuytren's contracture, poliomyelitis
- Capsular or ligament contractures
- Skin or scar contractures: Postburn contracture, scleroderma
- Spasmodic deformities are observed in acute painful musculoskeletal conditions due to muscle spasms, e.g., paraspinal muscle spasm after acute IVDP leading to postural scoliosis or list. These deformities improve as the spasm decreases.
Shortening or Lengthening of a Limb
The limb of the patient may be short or long due to a congenital, traumatic, infective, or a metabolic cause.
Instability of a Joint
Before we understand the instability of a joint, it is essential to understand what imparts stability to a joint. A stable joint is formed by two “morphologically normal” articulating surfaces that are normally linked and stabilized by various soft tissues such as ligament, capsular, and muscle-tendon complex innervated by a nerve. Any deformation or disruption in one or more structures that form and stabilize a joint could result in an unstable joint. Several examples are discussed below.
- Fractured or deformed articulating surfaces and adjoining bones: DDH causes unstable hip, and trochlear dysplasia contributes to recurrent dislocation of the patella. Deficient posterior acetabular wall (traumatic or congenital) could result in an unstable hip. Congenitally increased scapular retroversion predisposes to posterior shoulder instability. A malunited proximal tibia fracture with slope alteration might result in knee instability.
- A complete tear in a ligament, capsule and muscle–tendon complex:
- Tears in anterior or posterior cruciate ligament or medial patellofemoral ligament of the knee results in an unstable knee.
- Lateral ulnar collateral ligament injury of elbow would result in posterolateral elbow instability.
- Anterior or posterior labral tear would result in anterior or posterior shoulder instability, respectively.
- Massive tears in the rotator cuff could result in an unstable shoulder joint.
- Paralysed muscles: The prerequisite for joint stability is not just anatomical continuity of the muscle-tendon complex but also a normal neurological innervation. A significant paralysis of a nerve (peripheral or central cause) renders the joint unstable, e.g., often, in a brachial plexus palsy, the shoulder is subluxated as there is complete atony in the muscles around the shoulder joint.
Locking
Locking implies a sudden inability to complete a particular movement. Locking of a joint is an intermittent phenomenon, which may last from several minutes to hours.
Locking is of two types: True locking and pseudolocking. True locking is a structural phenomenon, whereas pseudolocking is a spasmodic phenomenon due to pain. True locking may or may not be associated with pain, whereas pseudolocking is always associated with pain.
True locking: Typically, the joint movement is smooth without getting “stuck or fixed” in a particular position because nothing gets in between the two mobile articulating surfaces. Therefore, if something loose (structural) comes between the two articulating surfaces and gets entrapped, it prevents smooth gliding of articulating surfaces, resulting in a locked joint. Once the loose fragment moves out between the articulating surfaces, the joint gets unlocked.
Some common causes of locking are:
- Meniscal tear in the knee joint: Bucket handle tears of the meniscus
- Loose body in any joint: Single (osteochondral fracture fragement, osteochondritis dessicans) or multiple (synovial chondromatosis)
Pseudolocking: Pseudolocking is a non-structural spasmodic phenomenon due to severe pain leading to spasm, which prevents further joint movement. Several reasons for pseudolocking of the knee joint are mentioned below.
- Patella maltracking
- Patellofemoral arthritis
- Ligament sprains causing pain and spasm
Clicks, Crepitus
Click is a short, often single sound, whereas crepitus is longer lasting sound, often multiple. Crepitus happens when two rough surfaces rub against each other.
Clicks often happen when a tendon/fascia slips over a bony prominence or slip in-and-out of a groove. A point to be noted that a painless click may not be of much clinical significance, while a painful click must be investigated. Crepitus is typically felt during movement of arthritic joint surfaces or one with cartilage damage (chondromalacia) or with multiple loose bodies in the joint (synovial chondromatosis).
Altered Sensation
Many patients complain of altered sensations (tingling, numbness, burning, less or no sensations over the skin) resulting from affections of the brain, spinal cord, or nerves. In such a complaint, one must probe the reason why neurological structure is compromised, which could be due to a traumatic, infective, compressive, or metabolic (diabetes) cause.
Skin Changes
The skin changes are observed in complex regional pain syndrome (mottled, bluish), nerve palsy (dry, scaly), or other skin diseases.
Constitutional Symptoms
Many symptoms such as fever, malaise, weight loss, or loss of appetite are part of the chief complaint. It is essential to ask about constitutional symptoms during history evaluation as it almost always indicates a sinister pathology such as infection, inflammation, or tumor, and it helps in ruling out differentials.
Effect on Activities of Daily Living or Activities
One of the essential parts of the complaint assessment is to evaluate the effect of the disease process on the activities of daily living and occupation such as walking, squatting, ability to clean back, tie hair, overhead activities, and sports.
The rest of the history goes archetypal. Nevertheless, one must remember that though HOPI is undoubtedly important to probe into the current complaints in ascertaining the diagnosis, the rest of the history in the form of past, personal, treatment, family, menstrual, drugs, etc. has a strong bearing in establishing the final diagnosis and prognosis. However, the rest of the history is often less explored or missed during the rush of seeing patients, especially in the out-patient department. Therefore, the clinician must give equal importance to the rest of the history too to ensure a complete evaluation of the patient. The questions asked about the rest of the history should investigate the cause of the disease and also give a perception about the prognosis.
C. Past History
One must confirm past history about:
- A similar history in the past on the same or contralateral limb
- Other orthopedic history such as underlying osteoporosis, gout, etc.
- Medical history of diabetes, hypertension, thyroid disorder or other medical illness
- Relevant surgical history such as hysterectomy, thyroidectomy, etc.
- A pathological fracture of the femur in a patient currently undergoing treatment for lung cancer can be explained by the metastasis from the lung cancer.
D. Personal History
Smoking, alcohol intake, tobacco-chewing, sleep, diet (vegetarian, mixed), bowel–bladder habit, education, and marital status. Specific examples of the importance of personal history are: Patients who are chronic smokers and tobacco-chewers are at risk of poor wound healing, delayed or nonunion, while chronic alcoholics are at higher risk of avascular necrosis of the hip. Alcohol can also increase the level of uric acid in body, while non-vegetarians are also at higher risk of gout due to hyperuricemia.
E. Treatment History
One can get vital clues about diagnosis with treatment history. For example, a patient who underwent multiple debridements for chronic osteomyelitis of the tibia can have shortening of the leg, which can be explained by bone loss during multiple debridements. However, one must assess treatment separately and avoid mixing it with HOPI. An exception where treatment history is a part of HOPI is a case of trauma wherein discussing the treatment history in a sequence (open fracture → debridement, external fixator → re-debridement → intramedullary nailing → discharging sinus) is allowed to understand the evolution of the current status of the problem.
F. Family History
It is essential to confirm the family history of disorders such as congenital disorders (congenital talipes equinus varus, developmental dysplasia of the hip, Blount's disease), hemophilia, sickle cell anemia, rheumatoid arthritis, ankylosing spondylitis, multiple exostoses, tumors, etc.
G. Menstrual History
Postmenopausal women are prone to osteoporosis and resulting complications such as chronic back pain and fragility fractures. Also, chronic menstrual disorder and pelvic inflammatory diseases (PIDs) are related to chronic low back pain, exacerbating during cyclical menstruation changes or PID exacerbation.12
H. History of Allergies and Drug Intake
Documenting the history of drug allergies is crucial as inadvertent administration could be life-threatening and have medicolegal implications.
Eliciting the history of other drug intake is essential as many of them are implicated in disease causation or fitness for the surgery. For example,
- Chronic steroid therapy may result in avascular necrosis of the hip.
- Chronic phenytoin therapy is implicated in the etiology of Dupuytren's contracture. Also, long-term treatment with phenytoin and carbamazepine (antiepileptics) inhibit resorption of calcium and vitamin D from the intestine resulting in rickets/osteomalacia.
- Long-term bisphosphonates (for osteoporosis) can result in pathological fractures in the subtrochanteric region of the femur, which are quite challenging to treat.
- Pyrazinamide, which is an ATT, is known to cause hyperuricemia and can precipitate acute gout in a patient.
- One needs to stop or alter the dose of blood thinners (platelet aggregator inhibitor, anticoagulants) before orthopedic surgery in consultation with the concerned physician.
I. Social History
Nutrition of child, work practices, travel, and constraints
J. Perinatal and Birth History
Important in congenital conditions (DDH) or the one which are peripartum related (cerebral palsy, obstetrics brachial plexus palsy).
K. Developmental Milestone History
It is essential to elicit the developmental history (gross motor, fine motor, speech and language, and social) in pediatric patients with congenital disorders.
L. Immunization history
Important in disorders such as poliomyelitis
At the end of the complete history assessment, the clinician must arrive at a possible conclusion about the etiopathology of the condition. The possible etiologies are mentioned in Box 1.2.
After thorough history evaluation, one must proceed towards examining the patient.
EXAMINATION
The examination involves general, systemic, and local examinations, which are discussed below. The crucial prerequisites for examination are mentioned in Box 1.3.
The examination always starts with a 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 examinations.”
- General examination: The general examination must start with assessment of consciousness, orientation to time, place and person, built, and nutrition of the patient. For example, Mr SW is conscious, cooperative, moderately built and nourished'. It is followed by assessment of vital parameters (blood pressure, pulse, respiratory rate, and temperature), pallor, icterus, clubbing, cyanosis, lymph nodes, and pedal edema. Note that one must report the relevant findings and avoid nonstandard abbreviations such as “PICCLE” in examination.
- Other essential parameters such as height, weight, nutrition, and body mass index (BMI) should be assessed in relevant patients.
- A general survey from head-to-toe can give a lot of clue to the underlying disease. For example,
- Low set ears and hairline are present in patients with Down and Turner syndrome, who can present with hip dysplasia.
- Black discoloration of pinna is observed in patients with ochronosis, who can have back pain due to disc calcification and osteoporosis.
- Neurocutaneous markers such as Cafe-au-lait spots and neurofibromatosis are associated with scoliosis and congenital pseudoarthrosis of tibia.
- Tanner staging in pediatric patients could be important. Tables 1.2 and 1.3 briefly mention the Tanner grading in girls and boys.14
|
|
- Systemic examination: A quick and relevant examination of the central nervous system (CNS), cardiovascular system (CVS), respiratory system (RS), abdomen, and pelvis should be done.
- Local examination: The standard order of examination in orthopedic cases is as follows:
- Gait: It must be evaluated in patients with lower limb or spine affections. However, it can be avoided, if the patient denies walking due to severe pain or an unstable spine condition that may potentially induce or exacerbate neurological deficit.
- Hand dominance (in an upper extremity case), inspection of footwear, orthosis, prosthesis, if applicable
- Attitude: It is described as the position of ease assumed by joint and bone at rest, which is comfortable to the patient.
- Inspection (look)
- Palpation (feel)
- Movements (move)
- Measurement
- Neurovascular (NV) examination: It should be done before special tests as adequate power is required for most special tests.
- Special tests for individual pathology/region
- Joint above and below
- Lymph node examination
Pearls and Pitfalls while Performing Local Examination
General rules while presenting the examination findings:
- Adjectives must be avoided unless it has been standardized in the literature, e.g., “severe” tenderness. One's “severe tenderness” could be someone else's “moderate”! Tenderness is either present or absent. Further, no such grading is discussed in the literature.
- Unless specifically asked, the methodology of examination should not be mentioned or discussed during the presentation. One must present the clinical finding and avoid its methodology during the examination.
- Avoid discussing the etiology of the finding while presenting the finding. It must be left for discussion.
Inspection (Look)
The affected part must be inspected from all the sides. The position for inspection (standing/sitting/supine/prone) depends upon the region. There are many important findings to be observed on inspection such as deformity, muscle wasting, limb length discrepancy, swelling, scar, sinus, ulcer, condition of skin, etc. Assessment of many of these findings are already well known to residents due to their previous clinical experiences and is also discussed in Chapter 17. Other important findings are discussed below.
- Deformities
- Limb length discrepancy
- Muscle wasting
- Deformities: Specific standard terms that are used to describe deformity in limbs and spine are described below.
- 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. 1.2A).16
- Valgus: It implies “part of the 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. 1.2B). Another example, cubitus valgus means that “cubitus,” i.e., the elbow is the referencing point, and the forearm has moved away from the midline.
- Recurvatum: It implies hyperextension and is observed in the elbow and knee joints. It is known as genu recurvatum in the knee. Usually, while a patient is observed from the side, the axis of the lower limb passes through the center of the hip, knee, and ankle in an erect standing patient. However, in genu recurvatum, the axis passes anterior to the knee (Figs. 1.2C to E).
- Flexion deformity: It implies that the affected joint cannot be brought into complete extension, passively or actively.
- Scoliosis, kyphosis, torticollis, and other deformities: These important deformities will be discussed in their relevant chapters.
- Limb length discrepancy: It could be shortening or lengthening. The shortening could be true or apparent.
- Muscle wasting: Any chronic disuse of the limb results in muscle wasting.
Palpation (Feel)
During palpation, one must confirm the findings observed during the inspection. Key palpatory findings include local rise in temperature, palpation of important bony-soft tissue landmarks, joint-line tenderness and other specific findings, if any, such as synovial hypertrophy, facet tenderness, paraspinal muscle spasm in spine, etc. Specific rules must be followed during palpation such as:
- The palpation must be done with utmost gentleness using thumb or finger pulp, especially in tender areas. A hasty and jerky palpation could result in increased pain followed by guarding. Afterward, the patient may not cooperate with the rest of the examination.
- Always start palpation with assessment of local rise in temperature using dorsum of the hand, and compare with a normal area or opposite side. Often clinicians miss assessing the rise in local temperature, which is quite crucial. A rise in local temperature suggests increased local vascularity due to underlying infection, inflammation, tumor, and trauma.
- Before assessing local tenderness, always ask the patient to mention the exact site of tenderness with one finger as it helps localize the site of the pathology. Further, it helps the clinician to remain cautious while palpating the tender area in order to avoid hurting the patient inadvertently. It is important to note that tenderness must be elicited with “utmost gentleness.” The tenderness could be superficial or deep. Once the superficial tenderness is ruled out, the clinician should gently increase the pressure to elicit the deep tenderness.
- In order to avoid missing crucial areas or landmarks, the palpation must follow a sequence of eliciting tenderness over important bony prominences, soft tissues, and joint lines.
Movement
There are specific and essential rules to be followed while assessing the movements at a joint. The type of movements vary across various joints in the body.
First and foremost principle of movement assessment is to ‘start movement assessment of contralateral normal side’ followed by assessment of index side.
- Always check and highlight the deformities before commenting on the range of movement (ROM). An example of how deformity is included in ROM. If a patient has 20° abduction deformity in the right hip and further abduction up to 45° is possible, then hip abduction ROM is 20–45°. Further, there are several important points to remember while discussing movement in presence of a deformity.
- The movement in direction opposite to the deformity is not possible. For example, a hip with 10° flexion deformity cannot have an extension, or a shoulder with 20° internal rotation contracture cannot have external rotation.
- In many cases, there is free movement in the direction of deformity. For example, knee flexion ROM of 15–90° implies 15° flexion deformity, and further free flexion up to 90° is possible.
- Always assess active ROM followed by passive ROM, and the rationale behind that is:
- If active movement is full, then there is no need to perform passive ROM.
- If the patient's active movement stops at a particular point due to pain, one must not force passive ROM beyond that point to avoid exacerbating the pain.
- The ROM should be measured with a goniometer (The methodology to assess the joint movement using a goniometer is discussed on Page 24).
- While recording the movement, mention the total “ROM” with starting and an endpoint, e.g., elbow flexion is 0–160°.
- The range of motion should have adjectives of painless or painful, e.g., the total knee flexion is 110°. The first 0–100° of flexion is painless, and the remaining 10° of flexion is painful. Another example, the total wrist dorsiflexion is 0–60° and is painless.
- Assess associated crepitus with passive ROM, if any: A crepitus indicates rubbing joint surfaces in arthritis of joint, loose body in the joint; an inflamed bursa, or a torn, frayed tendon-edge rubbing with another bone.It is essential to conclude that whether crepitus is fixed or mobile. Fixed crepitus is present in an arthritic joint with fixed rough areas over the cartilage, while mobile crepitus is observed in other conditions where one of the structures is mobile and not fixed.
- Associated spasm in movement: Occasionally, there can be spasm during the ROM. especially in patients with active arthritis. To elicit the spasms, a short sharp jerk is given to the joint, and the muscle may develop spasm. Note that the spasm-related limited movement can be overcome with gradual and gentle attempts to move a joint, whereas contracture-related limitation in movement cannot be overcome.However, eliciting spasm is a provocative maneuver and could result in sudden severe pain following which patient may not cooperate for the remaining examination. Hence, either it should be elicited at the end of all examinations or could be avoided for the fear of severe pain.
- Always look for extensor lag in the knee: This is a specific term used for the knee wherein the patient can actively flex his knee, but he/she cannot actively extend the knee back to the neutral or the starting point of flexion. It means that the knee “lags in extension.” However, the knee can be passively brought to the neutral or the starting point. Extensor lag occurs due to weakness in the quadriceps mechanism, which could be post-surgical (surgeries around the knee), post-traumatic (trauma around the knee), chronic infection, or inflammation of the knee.
- ROM description/recording in a hinge joint: Hinge joints such as elbow, knee, PIP, and DIP predominantly allow uniplanar bidirectional movement, i.e., flexion and extension. At times, these joints may have hyperextension. However, typically by convention, one must mention only unidirectional ROM (flexion), which occurs from the anatomical position of the body to the opposite direction. The extension is not mentioned unless ‘hyperextension’ exists. For example, in a patient with no hyperextension and 150° flexion at the elbow joint, the ROM can be mentioned as flexion 0–150°. Although the extension movement of 150–0° occurs in the opposite direction, conventionally, it is not mentioned. However, if the patient has hyperextension, it should be mentioned. For example, in a patient with 10° hyperextension and 120° flexion at the knee joint, the ROM can be mentioned as—10°–0–120°.
Important terminologies regarding joint movement pathologies are as follows:
- Stiff joint: Stiff joint implies a joint which has lost movement in one or more directions.
- Ankylosed joint: A joint with total or near-total loss of movements due to an underlying pathological process. Ankylosis could be either intra-articular (true ankylosis) or extra-articular (false ankylosis).
Fig. 1.3: X-ray showing bony ankylosis of the ankle joint with trabaculae crossing the joint. Inset picture shows normal ankle joint space.
- True ankylosis: It is also known as intrinsic cause of joint stiffness and implies involvement of intra-articular structures such as cartilage, bone, articular surface, capsule, synovium, intra-articular adhesions, intra-articular ligaments (anterior or posterior cruciate ligaments) and intra-articular hardware. True ankylosis is of two types: Bony and fibrous.
- Bony ankylosis: A condition wherein a complete loss of joint movement occurs due to bony fusion between the two joint surfaces. Clinically, there is absolutely no movement across the joint, and there is no pain if the clinician attempts to elicit the movement. Radiologically, the bony trabeculae are seen crossing the joint with obliteration of joint space (Fig. 1.3). Typically, bony ankylosis is seen after septic arthritis of an axial joint and between the vertebrae in the TB of the spine.
- Fibrous ankylosis: A condition wherein there is near-total loss of movement across the joint due to thick fibrous intra-articular adhesions. Clinically, there is a jog of movement elicited, and there is pain if clinician attempts to elicit the movement. Radiologically, the joint space is preserved. However, there may be other features such as reduced irregular joint space due to arthritis, or articular incongruity. Typically, fibrous ankylosis is seen after TB of peripheral joints, rheumatoid arthritis, and gonococcal arthritis.20
- False ankylosis: It is also known as extrinsic cause of joint stiffness, and implies involvement of extra-articular structures such as:
- Skin and subcutaneous tissue: Contracture following trauma, surgery, burns
- Muscle tendon complex: Contracture of muscle tendon complex after trauma or surgery, Volkmann ischemic contracture or adherence to the fracture site.
- Deep fascia: Dupuytren's contracture
- Extra-articular ligaments: Collateral ligaments of the knee. For example, medial collateral ligament is contracted in OA knee with severe varus deformity.
- Bony blocks: Bony block of myositis ossificans, callus, displaced fracture fragments, and exostosis.
Sound and unsound ankylosis: Sound ankylosis is a condition wherein a joint is ankylosed in a functional position, whereas a joint ankylosed in a nonfunctional position is unsound ankylosis, e.g., a knee ankylosed in extension is sound ankylosis, whereas a knee ankylosed in flexion is unsound.
- Pseudoparalysis: A condition wherein the patient cannot move a joint due to any cause (severe pain, tendon rupture) other than neurogenic. A joint which is pseudoparalysed due to pain cannot be moved actively or passively both (acute calcific tendonitis of shoulder, septic arthritis), whereas it can be passively moved to the full arc due to tendon tear (massive rotator cuff tear).
Measurement
During measurement, limb length, muscle girth, or other region specific measurements (three bony point relation, Bryant's triangle, etc.) are performed. The measurements are always compared with the normal side.
The objective of limb length measurement is to analyze the discrepancy in limb length, if any, and to identify the segment of discrepancy (arm and forearm/thigh and leg).
Certain guidelines must be followed during the measurement of the limb length.
- A pre-existing deformity in the limb must be checked and corrected, such as squaring the pelvis. A pre-existing limb length discrepancy must be asked for, if any.
- The limb measurement is performed between the two predesignated bony landmarks, 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.
- While measuring the length of the lower limbs, there is a concept of true and apparent length.
- A 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.
- An apparent discrepancy in the limb length is due to a “deformity or posture,” but there is no actual deficit in the limb length when measured. It appears short or long; however, not truly long or short!
To understand this concept, we must understand the balance between the spine, pelvis, and lower limbs required for standing and walking. Typically in a standing person 21with a normal spine, pelvis, hips, and lower limb, the pelvis is horizontal to the floor, and both lower limbs are parallel to each other with feet flat on the ground, and the limbs appear equal in length. Further, to walk with a bipedal gait, the foot must touch the ground. However, if there is a deformity in the spine (scoliosis), pelvis or hip, or truly short or long lower limb bones, the foot is off the ground, which would result in difficulty in bipedal gait. To ensure a bipedal gait, body compensates by tilting the pelvis to correct the limb length discrepancy, and brings the ‘off the ground foot’ back on the ground. As a result of the non-parallel/tilted pelvis, the lower limb ‘appears long or short.’ If the limbs appear short or long due to a deformity in the spine/pelvis/hip, there is no true shortening, whereas if they appear short/long due to altered limb length, there is true shortening/lengthening. There is only one way to differentiate between apparent and true discrepancies; either half of the pelvis should be at the same level (both anterior–superior iliac spine at the same level), known as squaring of the pelvis. The squaring of the pelvis is performed in supine. For further clinical details of pelvis squaring and assessing lower limb length, refer to Chapter 7 (Hip). One example of a tuberculosis hip is mentioned below to highlight the concept of apparent and true length.
The tuberculosis of the hip undergoes three stages: Synovitis, arthritis, and deformity. The synovitis stage is characterized by flexion, abduction, and external rotation deformity of the hip, causing downward tilting of the pelvis, making the limb appear longer (Stage of apparent lengthening). However, there is no true lengthening as there is no destruction of the femoral head or neck. With further progression of the disease process, the hip undergoes arthritic changes resulting in flexion, adduction, and internal rotation deformity of the hip causing hemipelvis to move upwards (stage of apparent shortening). However, there is no true shortening. In the late stages of the tuberculosis hip, the femoral head's destruction and subluxation or dislocation resulting in flexion, adduction, and internal rotation deformity of the hip causing hemipelvis to move upwards (stage of true shortening). There is a true shortening of the limb due to the destruction of the femoral head and subluxation. A point to note is that detecting true or apparent discrepancy in the limb was done with the patient supine and squared pelvis.
- Finally, while mentioning the limb length assessment, the student should inform the discrepancy/normalcy of limb length rather than narrating the individual bone length measurements. Box 1.4 mentions the correct way of describing the limb length discrepancy.
Neurovascular Examination
It should be performed as per the standard NV assessment of the limb:
- If the NV examination of the limb/part is normal, it should be summarized as “neurovascular examination is normal.”
- If the NV examination is abnormal, then individual pathological findings should be mentioned, e.g., if the posterior tibial pulse is feeble on the right side and neurological examination is normal, then it is appropriate to state that “neurological examination is normal. However, the posterior tibial artery is feeble on the right side.”
Special Tests
The key to the special tests is “explain–demonstrate–interpret–compare”.
“Explain (to the patient)–demonstrate (on normal side/on self)–interpret (finding)–compare (with normal side).”
A special test is performed to diagnose the condition in question. Multiple tests are often performed for a single condition as most individual tests carry low sensitivity and specificity. A combination of several tests increases the likelihood of the presence or absence of the condition. The clinician must be well versed with the correct technique and interpretation of each test.
Joint Above and Below
As per standard examination practice.
Clinical assessment of the joints above and below is essential as the disease or affection of the proximal or distal joint may affect the functioning of the index joint in various ways, e.g., radiation of pain to the knee joint in patients with hip pathology is quite frequent. Another example is bilateral flat foot could result in knee pain due to altered mechanical loading. However, the pain-perceived area may be normal on examination. Another example is double crush syndrome wherein a proximal neurological condition (cervical disc prolapse) could initiate or worsen the distal neurological condition (carpal tunnel syndrome) due to disturbed axoplasmic flow. Hence, it is vital to examine the neighboring joints.
While reporting the finding of ‘normal’ neighboring joints, it can be summarized as “joints above and below are normal.” However, if there is an abnormal finding in the neighboring joint, it should be mentioned in standard fashion.
Lymph Node Examination
It should always be done, especially in a suspected case of infective, inflammatory, and tumorous conditions.
- In upper limb: Epitrochlear, axillary and supraclavicular
Final Diagnosis
The final diagnosis should have the following components:
- Duration
- Anatomical site
- Side (right/left)
- Pathology
- Etiology
- Complication, if any
Certain guidelines are to be followed while mentioning the diagnosis which are as follows:
- The primary diagnosis should be based upon points favoring the diagnosis from history and examination. The diagnosis must not be based upon negative points (points against primary diagnosis); the negative pointers from history and examination are for differential diagnosis.
- The presence of points against the primary diagnosis must stimulate the student to think about the differential diagnosis.
- Unless there are several pointers against primary diagnosis, giving a differential diagnosis is not always essential. For example, there will not be any differential diagnosis for fracture femur nonunion. However, tuberculosis of the knee is a possible differential diagnosis in patients with monoarticular rheumatoid arthritis of the knee.
Plan the Investigations Relevant to “Your Patient” and Not a Hypothetical Case
The Final Plan of the Treatment
It could be conservative or operative. Discuss the plan of treatment, which is relevant for the patient's diagnosis and expectation.24
A NOTE ON THE TECHNIQUE OF USING A GONIOMETER FOR THE RANGE OF MOVEMENT MEASUREMENT
- Goniometer: It is an instrument that measures the range of motion joint angles of the body.
- Technique: The joint's ROM is measured by the 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. The stationary arm of the goniometer lies parallel to the stationary segment of the limb, and the mobile arm of the goniometer is placed parallel to the axis of the mobile segment of the limb. The center of the goniometer lies over the central axis of the joint (Fig. 1.4). When all the landmarks are well-defined and goniometer arms are placed parallel to the limb, the accuracy of ROM measurement is high.
Essential Tips while Using a Goniometer
- The referencing segment or stationary part of the body should be stable, and the stationary arm of the goniometer should be stable and parallel to the referencing limb (Figs. 1.5 and 1.6). However, sometimes, there is no referencing segment for the goniometer in the joints connected to the torso directly, shoulder, and hip. In such cases, the referencing segment is the midline of the body, and the stationary arm of the goniometer should be placed over or parallel to the imaginary midline axis of the body (Figs. 1.7 and 1.8).
- Look at the goniometer reading and confirm it before it is removed from the body.
Fig. 1.5: Flexion range of movement (ROM) measurement of the knee (left image) and wrist ulnar deviation (right image) using a goniometer. The center of the goniometer is over the center of the joint.
Fig. 1.6: Ankle plantar flexion range of movement (ROM) measurement using goniometer with the center of goniometer over the center of the ankle joint. The static and mobile arm of the goniometer is placed along the long axis of leg and the foot, respectively.
Fig. 1.7: Measurement of shoulder abduction range of movement (ROM) keeping stationary the arm of goniometer parallel to the imaginary midline axis of the body (black line) and mobile arm parallel to the abducted arm. The center of the goniometer is over the center of the shoulder joint.
Fig. 1.8: Measurement of hip abduction range of movement (ROM) keeping stationary the arm of goniometer parallel to the imaginary midline axis of the body (black line) and mobile arm parallel to the long axis of the abducted thigh. The center of the goniometer is over the hip joint.
Notes
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................