Section Editor: S Pandey
Introduction
Today in an era of rapid industrialization and mechanization, orthopedics occupies an important place in the field of medical sciences. The examination and management of an osteoarticular problem very much involves assessment of the patient as a whole. However, two factors quite often missed may get their place while examining an orthopedic patient.
Modern orthopedics is concerned with the study of anatomy, function and diseases of the musculoskeletal system, which consists of injuries and disorders of bones, joints, muscles, nerves and ligaments. “Prevention is better than cure.” The best example is total immunization of the entire population by polio vaccine, which has wiped out polio from the Western and developed world and now from India too. Early recognition and timely institution of treatment may prevent certain deformities. The example is developmental dysplasia of the hip. The orthopedics is a specialized branch of surgery. Today, it has grown up to such an extent that it is being branched into various sections, such as spine surgery, hand surgery, foot and ankle diseases and injury, joint replacement, arthroscopy, traumatology, pediatric orthopedics, and so on. There is a tremendous scope for research and development of the individual branches.
Documentation
The AO group, rightly, lays great stress on the necessity to carefully document and preserve the clinical and follow-up notes, for research, learning the disease, paper presentation and for planning the treatment. Today, it has become much easier with the help of computers. However, in India, the documentation and follow-up is poor. We have a large number of cases and excellent clinical material. If we meticulously document, we can do high quality clinical research and can contribute to the world of orthopedics in a better way.
Examination of the Patient
Clinical examination of an orthopedic patient is the most important part of the training program. No part of orthopedic training is more important than developing a systematized method of examination. The meticulous history taking and a thorough clinical examination of the patient will almost lead to a successful diagnosis and treatment. Even the most ultramodern investigation will not replace the clinical examination. One is more likely to make mistakes if one relies only on the investigations.
Armamentarium Necessary for Examining an Orthopedic Patient
- A measuring tape.
- Goniometer (large and small).
- A tendon reflex rubber hammer.
- A pocket torch.
- A pin with protected point.
- Skin marker pencil and wax pencil.
- A stethoscope.
- A diagnostic set (tongue depressor, auroscope, ophthalmoscope).
- A plain white paper and impression ink for taking prints.
- A right angled triangle.
- Camera (more important than even a stethoscope for a reconstructive surgeon).
- For neurological cases—cotton wool, tuning fork, test tubes.
Certain Factors Essential for Examining an Orthopedic Case
- Hear the patient with patience, even if he or she is confused, disoriented and annoying.
- Reassure the patient and ensure gentle handling of the affected part.
- Sympathetic appreciation of the patient's problems.
- An insight into the patient's future rehabilitation program.
- Need for examining the patient as a whole, and not a part, limb or system.
- The patient must be placed in comfortable position.
- The patient is to be fully exposed which guarded covering of genital and at least the corresponding part of other limb for comparison.
- Do not hurt the patient during examination.
The first impression that a keen clinician gets of his or her patient while the patient is entering the examination room, forms the basis for his or her onward assessment.
History Taking
Apley AG1 calls history—“His”-“story” (or hers). Sit back and patiently hear the development of the orthopedic problems from the very beginning. Start with the question, “When were you completely healthy? How and when the problem had started? Enumerate all the complains. Go into the details of the problem and the progress of the disease”.
Chief Orthopedic Complaints
Pain, it is the most common symptom in orthopedics. Throbbing pain indicates acute abscess and burning pain neuralgia. Precise location of pain is important. Ask the patient to point the site of pain, depth of severity (ignorable—trivial, not ignorable as it interferes in activities—moderate, constant even in rest—severe, tossing and incapacitating—very severe), mode of onset, character, diurnal variation, path and site of radiation, relation with activities and rest, relieving/aggravating factors. Reference of pain can be due to same source of sensory supply or cortical confusion between embryologically related areas.
Types of pain:
- Local: When pain is felt at the site of pathological processes in superficial structures. It is usually associated with local tenderness to palpation or percussion.
- Diffuse: Pain appears to be more characteristic of deeply lying tissue and has a more or less segmental distribution.
- Radicular: Radicular pain is due to pressure or inflammation of a nerve root. The example is a disc prolapse in the lumbar spine with radiating pain down the leg.
Referred pain is experienced in other areas, besides that felt in the area of initial stimulation. This is seen when there is injury or disease affecting either somatic or visceral structures, and results from misplaced pain projection because of cortical representation. This occurs because of the convergence of sensory pathways onto a single cell within the cord of higher centers. It is often associated with paresthesias and tenderness along the nerve root.
Specific types of pain:2
- Bone pain has a deep boring quality usually attributable to the stimulus of internal tension, as seen in osteomyelitis, expanding tumors and vascular lesions of bone such as Paget's disease.
- Diffuse generalized pain: The body ache (“my whole body pains”) is due to skeletal disease such as osteoporosis and hyperthyroidism, multiple myeloma or metastatic disease, or even in osteomyelitis.
- Muscle pain is due to lack of blood supply or due to spasms. Pain of anterior compartment syndrome of leg is an example of muscle pain due to reduced blood supply. Another example is intermittent claudication described above. According to Duthie,2 the nocturnal cramps in the lower extremities of the elderly are quite characteristic in being relieved or prevented by quinine derivatives.
- Joint pain (night cries): Patient suddenly wakes up in the night due to severe pain. This usually occurs in tuberculosis of the joint, e.g. knee, hip and spine. During sleep, the muscles become relaxed, which remain in varying spasm to support the affected painful joint and part. With the relaxation of muscles, the affected ends sag and rub against each other leading to severe pain. Even during sleep, there may be some movements occurring in the joints. When the movements occur in the diseased joint, the articular cartilage rubs against each other causing severe pain and the muscle around the joint go into sudden spasm causing further severe pain, this phenomenon is called as night cries. Joint pain in early stage, i.e. the synovitis stage is usually due to distention of the capsule which is rich in nerve supply.
Deformity: Find out if the mode of onset is progressive or static, any attempt done earlier for correction of deformity and disabilities due to deformity. Deformity may be in the bone, in the joint or in the soft tissues. Deformity is broadly due to abnormal anatomy. It may be angular or rotational. Shortening and lengthening are also included in the deformities. Shortness of stature is a kind of deformity. In the lower limbs, the mechanical axis deviation test,3 described by Paley, is important to determine whether the deformity is in the bone, in the joint or soft tissue.
Varus and valgus: Varus means the part distal to the joint is displaced towards the midline, whereas valgus means away from it. Genu varus includes bow legs. Genu valgus leads to knock knee. In a case of congenital talipes (clubfoot), the heel shows varus deformity.
Fixed deformity: It means that a part of movement cannot be completed even passively, e.g. 40° of fixed flexion deformity means patient has no movement from zero up to 40°, further flexion movement may be possible.
Causes of joint deformity:
- Destruction due to tuberculous arthritis or septic arthritis
- Joint instability due to ligaments
- Muscle imbalance, for example, in polio paralysis
- Muscle contracture, e.g. Volkmann's ischemic contracture
- Facial contracture, e.g. Dupuytren's contracture
- Skin contractures, e.g. burn contractures
- Injury of growth plate may cause secondary joint deformity later on
- Malunited fractures.
Bowing deformity: It may be due to malunited fractures, diseases like rickets, osteogenesis imperfecta, Paget's disease, fibrous dysplasia, pathological fractures, etc.
Soft tissue contractures may be due to burns, injury or infections, or even idiopathic.
Stiffness: It may be in many joints, e.g. in rheumatoid arthritis, ankylosing spondylitis or in a single joint due to tuberculosis or extra-articular fracture. Morning stiffness of small joints of the hand is one of the cardinal signs of rheumatoid arthritis.
5Swelling: It may be in the soft tissues, bone or joint. It is important to carefully localize anatomical plane of the swelling. Carefully examine the swelling for temperature, tenderness, size, shape, any extension in the anatomical compartments, surfaces, edge, consistency, fluctuations, compressibility, pulsatility, fixity of the swelling to muscle, bone or surrounding structures. Consistency can be judged: as muscle is soft like lipoma or cold abscess. Contracted muscle is firm like fibroma. Subcutaneous bone is hard. When one presses hemangioma and releases the pressure, it gradually returns to the original size. False or true aneurysm is pulsatile. It is important to find from which tissue the swelling has arisen and its anatomical plane. If the swelling is in the subcutaneous plane, the skin can be pinched out. If the swelling is subfascial and over the muscle, it becomes more prominent when muscle contracts. When the swelling is in the muscle, and the muscle is made taut by contracting, the swelling becomes comparatively less prominent and can be moved in the direction at right angle to the muscle fibers but not in the direction of fibers. If the swelling is beneath the muscle, it becomes much less prominent, when muscle is taut.
Instability: Instability of a joint is usually due to injury to ligaments, malunited intra-articular fractures and laxity of the joints.
Neurodeficit: Neurodeficit may be sensory or motor, or both. It may be due to pressure on the nerve or nerve roots due to prolapse intervertebral disc or tumor, or may be due to nerve entrapment in fibro-osseous tunnel, as in carpal tunnel syndrome.
Laxity of joint: Abnormal degrees of laxity of a joint should be tested. The causes of joint laxity are: Marfan's syndrome, Ehlers-Danlos syndrome, osteogenesis imperfecta and acromegaly. Laxity in joints is also seen after excessive corticosteroid therapy and may be familial as well.
Discharging wound: How it started, type, color and nature of discharge, intermittent or continuous, painful or painless, any history of indigenous applications or cauterization, and any history of bony spicules in the discharge. Ulcers and sinuses must be carefully examined. Colored granules (sulfur granules) indicate Madura foot. Sinogram leads to the exact site of the lesion.
Limb length discrepancy: Limb length discrepancy (LLD) may be due to multiple causes like poliomyelitis, chronic osteomyelitis, malunited fractures, congenital deformities, etc. The best way to measure LLD is to use blocks under the short limb and make anterior superior iliac spines parallel to the ground and measure the height of the block. Long cassettes, i.e. 51” × 14”, are now available to take radiographs from hip to ankle.
Constitutional features: Like fever, anorexia, constipation, bodyache, headache, urinary trouble, eye trouble, night pain and swelling.
Cramps: Cramps and cramp-like complaint in both calves are not uncommon. There can be several causes, which may be specific or nonspecific. Claudication should be differentiated from the cramps. In claudication (vascular, e.g. Buerger's phenomenon, neurogenic, e.g. spinal stenotic syndrome), the patient feels gradually ensuing catch in both calf muscles after some walking. The walking distance, before the symptoms start appearing, gradually decreases. The claudication of spinal origin usually disappears after sitting or bending forward in chair, while that of vascular origin requires rest from walking for relief.
In cramps, the patient feels a sudden painful catch in the calf muscles, which almost disappears within a few seconds—either following local massage or rest or itself—leaving behind a dull aching pain lasting for few hours to a day or two. Constipation, overexertion and walking without habit can also induce these cramps. However, symptoms like cramps can also be seen in vague ankylosing spondylitis, thyrotoxicosis, metabolic diseases, myopathies, and depressive syndromes in adults. The nocturnal cramps in the lower extremities of the elderly are quite characteristic in being relieved or prevented by the taking of quinine derivatives.1
Any other complaints even unrelated to orthopedics should be noted chronologically.
History of Present Illness
Let the patient narrate the story of his or her ailments in his or her own words from the beginning to the present condition. Pick up the salient points. Dilate on each point with relevant leading questions. Any history of injury or febrile attacks must be explored through leading questions. Treatment received for the present complaints should be noted in detail (Table 1).
In case of injury: Enquire about its mode and nature, and if associated with any abnormal sounds.
Modes of injury
- Direct hit.
- Indirect injuries.
- Rotational strains (e.g. fracture neck femur).
- Violent muscle pulls (e.g. fracture of patella).
- Compression injuries (e.g. compression fracture of vertebra).
6In case of fall: Height of fall, surface on which fallen, level of consciousness after falling, if he or she could stand up or walk or even take weight on the affected side of his/her own or not following the injury, immediate posture after injury, any manipulation at the site of injury by himself/herself or anyone else.
After the injury
- Mode of transportation to home or hospital.
- Attempts by bone setters or quacks and/or any other treatment given.
Fever: Onset, any associated, rigor, range of temperature, continuous or intermittent. If only at particular time, e.g. in the evening, sweating, response to treatment and accompanying symptoms.
Enquire about appetite, polyuria, loss of weight.
History of Past Illness
Any earlier injury, history of earlier infections, specially tuberculosis, syphilis, leprosy, pyogenic, average duration of bleeding after any cut, any particular treatment received.
Personal history: Occupation, any tobacco/drug habit, personal hygiene, hobby, sensitivity or allergy to any drug or object.
In case of females—marital status, number of children, any gynecological complaints.
Family history: Any familial incidence related to the recent complaints, tuberculous infection in family, any hereditary disorder (Figs 1 and 2).
Social history
- Economic background, status of living.
- Topographical surroundings.
- Barriers in and around home.
- Education in the family.
Examination
- General examination.
- Regional examination.
- Local examination.
General Examination
- Look, intelligence, built, any special posture, pallor, cyanosis, edema, pulse, temperature, blood pressure, jaundice, lymph glands.
- Attitude: While entering the examination room, note the first impression and posture (general, regional, local)
- Attitude of standing
- With full weight.
- With partial weight.
- With support.
If patient can stand, also perform Trendelenburg's test.
- Gait
- Limp or lurch.
- Specific gait.
- Waddling.
- High stepping.
- Hemiplegic (spastic).
- Ataxic.
- Scissors.
- Festinent/short shuffling gait (Parkinsonism).
- Lathyriatic.
- Stamping.
- Knock knee.
Systemic Examination
- Skull and face: Contour, swelling, decubitus ulcer, and any stigmata (of syphilis, rickets, etc.).
- Cardiovascular system: Pulse, blood pressure, heart.
- Respiratory system: Thoracic cage, rib contour, chest expansion, abnormal shape of chest (flat, barrel, pigeon), rib hump, rachitic rosary, (Harrison's sulcus, scorbutic rosary).
- Abdomen: Liver, spleen, kidney, any lump, iliac fossae, any abnormal finding.
- Central nervous system
- Higher mental functions.
- Cranial nerves.
- Motor system—power, bulk, tone, reflexes, coordination, involuntary movements.
- Sensory system.
- Genitourinary system.
- Endocrinal functions.
Regional Examination
The examination of the part complained of only, does not complete the examination, because sometimes the symptoms felt in one part have their origin in another. For example, pain in the leg is often caused by a lesion in the spine, pain in the knee may have its origin in the hip, a pain or tingling and numbness in hand may have its origin in the cervical spine. Hence, regional examination is necessary.
- For lower limb, examine lumbar region to tip of toes.
- For upper limb, examine cervical region to tips of fingers.
- For trunk examine as a whole (and the supply region, if cord is involved).
- Also examine the regional lymph nodes.
Local Examination
Inspection (look for)
- Posture of the patient and position of part/limb—attitude.
- Inspect from different sides.
- Normal anatomical points:
- Bony.
- Soft tissue.
- Skin:
- Color.
- Texture.
- Erythematous changes.
- Puckering.
- Café-au-lait spots.
- Tattoo marks.
- Patch/vaccination scar.
- Superficial cuts or scars (linear scar with/without suture mark—usually operative scar; irregular scar—injury; broad, adherent puckered scar—old suppuration).
- Warts or callosities.
- Muscle condition:
- Swelling.
- Wasting.
- Spasm.
- Contracture.
- Fasciculations.
- Vascular:
- Venous prominence.
- Pulsation.
- Varicosities.
- Abnormal findings, e.g. swelling, sinus.
Palpation
- Superficial (touch): Skin condition, temperature, sensation, superficial tenderness, anatomical points—bony, soft tissue; induration (edema)—regional/local, arterial pulsation, crepitus (may be due to entrapped gas, e.g. in surgical emphysema, gas gangrene (Fig. 3), fracture, tenosynovitis).
- Deep palpation (feel): It can be tested by direct pressure, indirect twist, and deep thrust.
Deep tenderness: Tenderness of a bone, joint or soft tissue can be classified in four grades according to the reaction (facial and verbal) of the patient during examination for tenderness:
- Grade I—the patient says that part is painful on pressure.
- Grade II—the patient winces.
- Grade III—the patient winces and withdraws the affected part.
- Grade IV—the patient will not allow the part to be touched.
Deep palpation of the bone: Bone should be palpated for surface, alignment, deep tenderness, abnormal prominence, disturbed relationship of the normal bony landmarks, any crepitus (fracture) or gas/air in tissues.
Deep palpation of a joint:
Palpate for:
- Synovial thickening—soft/boggy/doughy feel—any tenderness.
- Joint line—a slit all around or available side in between the articular ends—feel for any tenderness, any abnormal mass.
- Fluid in the joint—yielding/cystic/fluctuant/tense feel.
- Articular ends—for any tenderness, roughness, crepitus.
- Adjoining bones—for any thickening, expansion, crepitus irregularity, tenderness.
- Palpation of fossae (if any).
- Palpation of muscles: Girth, feel, tone and pliability of muscles.
- Examination of any swelling should be in details—skin over the swelling, size, margin, shape, vascularity, tenderness, consistency, fixity, deeper relations, mobility, fluctuation test, transillumination test (if cystic).
- Number, site, relation with deeper tissues, relation with skin, margin discharge—intermittent/continuous, color, relation with pain, possible source, any bony spicule discharge or projecting through sinus, nature of scar (if healed).
- Sinus tract—feel, traceability to parent site, fixed to bone or mobile. Probing should be avoided.
Springing: To elicit pain at the site of lesion by intermittently compressing the distant part of the parallel bones, e.g. in fracture of the neck of radius pain can be elicited by compression of the forearm bones in lower regions.
Transmitted movement: In case of fractures, feel for transmitted movements across the fracture site.
Percussion (tap): Especially over the bone in suspected crack fracture, over the spinous processes to elicit tenderness in spine.
Auscultation (hear):
- If needed, e.g. for systolic bruit (hemangioma).
- May be of value in localizing crepitations, snaps, mild frictional rubs in joints.
Measurements:
- Linear measurements.
- Circumferential measurements.
Linear measurements:
- Apparent measurement.
- True measurement.
Apparent measurement:
- Make the limbs parallel to each other and to the trunk.
- Handle the unaffected limb to make the limbs parallel.
- Measure from any fixed central point to the most distal sharp bony point of the long limb bone.
Therefore, in the lower limb, measure from:
- Manubrium sternum, xiphisternum or umbilicus to the tip of the medial malleolus.
In the upper limb from vertebra prominence (C7) to radial styloid.
True measurement:
- Reveal the concealed deformity by handling the affected limb.
- Limbs to be kept in identical position.
- Measurement is ipsilateral and then compare with the other side.
Lower limb:
- Total length—from anterosuperior iliac spine to medial malleolus.
- Segmental length:
- Anterior superior iliac spine to knee joint line (thigh length).
- Medial knee joint line to medial malleolus (leg length).
- The components of thigh length are measured as:
- Infratrochanteric—tip of greater trochanter to knee joint line.
- Supratrochanteric—indirect measurement, e.g. Bryant's triangle.
Upper limb:
- Total length—from acromial angle to radial styloid process tip.
- Segmental length:
- From acromial angle to lateral epicondylar tip (arm length).
- From lateral epicondylar tip to radial styloid process tip (forearm length).
Circumferential measurements:
- At affected point—for any swelling.
- At fixed distances, proximal and distal, from the affected part:
- for muscular wasting.
- for muscular hypertrophy.
- For disorganized joint.
Across measurements (for cross check-up of measurement): In identical position of the limbs:
- From left anterosuperior iliac spine to right medial malleolus tip.
- From right anterosuperior iliac spine to left medial malleolus tip.
Movements: (Ask to perform—active, performed by others—passive).
Always compare with the opposite joint. In general, the range of movements at any joint is more in females than males. First look for ankylosis or stiffness of the joint.
Ankylosis (no apparent movement in a joint).
Types of ankylosis:
- Bony—no movement even on using force (true ankylosis):
- No pain on using force.
- Bony trabeculation across the joint in radiograph.
- Fibrous (jog of movement):
- Pain on using force (false ankylosis).
- Slight yield on using force.
- Joint line visible in radiograph.
Stiffness in the joint (i.e. joint in which complete movements cannot be obtained—either active or passive)—Limitation of movements can be:
- In all directions due to arthritis.
- Not in all directions due to synovitis and/or spasm of muscles.
- Fixed position in one or more direction due to fixed deformity.
Limitations of movements are painful in active arthritis and painless in healed ones due to short fibers (fibrous bondage).
Types of Joint Stiffness (Table 2)
- Extra-articular
- Intra-articular:If no ankylosis, assess the movements in various planes:
- Sagittal plane—flexion/extension.
- Coronal plane—abduction/adduction.
- Rotational plane—external/internal, supination/pronation.
For Each Movement
- Fix the zero position.
- Mark lag of movement (usually extensor lag).
| ||||||||||||||||||||||
- Assess angle of fixity of any movement (e.g. fixed flexion deformity).
- Range of active movement.
- Range of passive movement.
- Range of utility or activity—free active movement.
- Range of possibility—free active movement and free passive movement.
- Any pain during the movement—if painful focus is in the vicinity of the joint (not in the joint), patient will still be reluctant to initiate active movement. Taking the patient in confidence, passive movement can be demonstrated to variable range, in such cases.
- Limitation of terminal range.
- Achievement of “critical arc”.
- Achievement of activities of daily living (ADL).
- Any abnormal movement (e.g. hypermobility in neuropathic joint, e.g. Charcot's joint).
- Any abnormal sound during the movement (heard/felt).
- Assess the power of controlling muscles.
Active movement at a joint: Movement produced by patient himself or herself without any assistance.
Passive movement: Movement produced at a joint either by patient's other limb and/or examiner.
Fixed Deformity
It is a fixed position of a joint from where the limb cannot be brought back to neutral position, but further movement in the same axis (direction) may be possible.
Normally active and passive ranges are equal.
Passive range is more than active in:
- Paralyzed joint.
- Lax/torn:
- Capsule.
- Ligament.
- Tendon.
- Muscle.
- Subchondral/condylar fracture.Test for any laxity or tear of the aforesaid components.
Critical Arc
For any joint, the minimum range of active movement, which is necessary for the important functions of the joint is its critical arc.
Activities of daily living: The bare minimum necessary for daily living, like—eating, clothing, cleaning the private parts and minimum necessary mobility.
Power of Controlling Muscles (Table 3)
The assessment should be accurate from prognostic point of view. According to Medical Research Council (MRC) scale, muscle power is grouped under five grades. We feel that each grade is further divisible into four quadrants, depending upon lag of completion of full range, the deficit can be assessed as, e.g. “2---”, “2--”, “2-”, “2”.
Special tests: Pertaining to individual joints.
Heel Walking/Toe Walking
If the patient can walk, quick inferences can be drawn by making him or her walk on heels and toes alternately.
If he or she can walk swiftly in both positions without any complaints, probably there is no serious affection in the lower limbs including its neuromuscular control.
Erect posture along with integrity of the hip, knee, ankle, and foot are essential for painless, quick, heel/toe walking.
Any limb length disparity will obviously affect these walking and any inequality will be apparent.
If patient cannot walk swiftly, there are two broad probabilities.
- If there is inability/difficulty in walking on heels, it may be due to:
- Weakness of muscles and/or abnormal joint condition/pain:
- Weakness of dorsiflexors of ankle, stiffness of the ankle joint.
- Probable weakness in quadriceps femoris and erector spinae, unstable hip.
- Pain: This may be felt due to any of the following pathologies:
- Pain in back of thigh, knee and leg—due to sciatic stretch.
- Back of the knee, e.g. in cases of trauma—posterior cruciate lesion, condylar fracture/crush of tibia (upper end).
- Pain at ankle—in any traumatic, inflammatory, degenerative or neoplastic condition.
- Pain at heel—any cause of painful heel syndrome.
- If there is inability/difficulty in walking on toes, it may be due to:
- Weakness of muscles and/or abnormal joint condition:
- Weakness of plantar flexors, stiffness of ankle (except where in equinus), genu recurvatum, unstable hip.
- Pain: Pain in the forefoot—trauma, metatarsalgia, inflammatory lesion. Usually pain in ankle is not complained of in early affections because the gravity line falls forwards:
- If pain is in knee region—in case of trauma—probably anterior cruciate involvement, involvement of anterior horn of semilunar cartilage, affection of quadriceps apparatus.
| |||||||||||||||||
Peripheral Circulation
Impaired peripheral arterial circulation may produce symptoms in a limb, especially in lower limb. So, a thorough examination should be done to assess the state of circulation, which is done by examination of the color and temperature of skin, the texture of skin and nails and by palpating for arterial pulsation, which must always be compared with opposite side.
Peripheral Nerves (e.g. Lateral Popliteal Nerve, Ulnar Nerve, etc.)
- Tenderness.
- Thickening.
- Beading.
- Irritability.
- Detailed muscular and sensory charting.
Investigations
- Usually required for orthopedic patients.
- General investigations.
- Special investigations.
- Electrical investigations.
- Radiological and allied investigations.
General Investigations
- Routine hemogram.
- Erythrocyte sedimentation rate (ESR).
- Routine urine examination.
- Stool examination.
- Grouping and cross-matching of blood (also for human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) and hepatitis B).
Special Investigations
Serum biochemistry, e.g. sugar, urea, calcium, phosphorus, alkaline and acid phosphatase, fluorine, creatinine.
- Serology—Washerman's reaction (WR), Kahn, Venereal Disease Research Laboratory (VDRL), rheumatoid factor (Rose-Waaler test).
- Aspiration of any collection and its examination—physical, chemical, cytological, serological, culture and sensitivity, inoculation test.
- Footprint/handprint.
- Arthroscopy [diagnostic/therapeutic—knee, shoulder, ankle, elbow, and even interphalangeal (IP) joints].
Arthroscopy: Nowadays, arthroscopy is being widely used to diagnose and variably deal the pathology (mainly traumatic) affecting the interior of the joints. It is particularly useful for the knee:
- Biopsy
- Fine-needle aspiration cytology (FNAC).
- Needle biopsy.
- Open biopsy.
Electrical Investigations
- Electrocardiography (ECG).
- Electroencephalography (EEG).
- Electromyography (EMG).
- Strength duration curve.
- Nerve conduction test.
Radiological and Allied Investigations
Plain radiography, xeroradiography (by photoelectric process, the conventional radiograph exposure is recorded as positive image):
- Routine projections.
- Anteroposterior view/posteroanterior view.
- Lateral view.
- Oblique view.
- Special projections:
- Axial view.
- Stress radiography.
Contrast radiography:
- Air contrast radiography.
- Radiopaque dye contrast radiography [water soluble (metrazimide), oil soluble].
- Myelography.
- Radiculography.
- Diskography.
- Arthrography.
- Sinography.
- Venography.
- Arteriography.
- Cystography.
- Lymphangiography.
Tomography: Radiograph taken after being focused at a desired depth.
Stereoscopic: Bidimensional picture studies.
Cine-radiography.
Scintigraphy (radioactive isotope studies or radionuclide studies).
Ultrasonic scanning.
Computer-assisted tomography—CT scanning, PET-CT (positron emission tomography).
Computerized tomography and intrathecal low osmolarity contrast media studies.
Nuclear magnetic resonance (NMR) imaging or magnetic resonance imaging (MRI)—in order to avoid using the word nuclear, which induces fear, the changed terminology is MRI.
Spinal cord monitoring—recording of somatosensory-evoked potentials (SEP).
Meterecom [a three-dimensional (3-D) skeletal analyzer]—A precise, computer-based, noninvasive, 3-D digitizer designed to access bony landmarks, at any point on the body for various patient's positions.
Clinical Diagnosis
Thorough clinical examination leads to more or less accurate clinical diagnosis. However, in certain situations, this may not be possible. In such conditions, provisional diagnosis with immediate differential diagnosis should be mentioned. The most probable provisional diagnosis should be reached by the process of elimination, starting from the common to rare conditions.
In expressing the diagnosis of the disease, it is essential to make it a complete expression under the following headings:
- Duration.
- Anatomical site affected.
- Causative pathology with its stage of advancement.
- Any obvious complication.
- Any particular treatment given.
- Affection of the patient's routine life, especially the ADL, e.g.:
- 5-month-old, untreated, advanced tuberculous arthritis of right hip joint with discharging sinus and patient not able to perform ADL, or
- 7-week-old conservatively managed traumatic ununited fracture of neck of left femur with 2 cm of supratrochanteric shortening and patient not able to perform ADL.
Examination of Child Patients
All too often children are examined but not looked at (Aieard, 1998) while the basic methodology of examination remains the same as in adults, one should not expect to get same degree of cooperation as even in average adults. Try to derive as much information as possible in the same short period when the child cooperates with. The child gets irritated by repeated examinations and gets frightened seeing the white coats, examining tools and heavy environments. Younger children are always comfortable in mother's lap. Some toys and toffees will help you to make familiar with child. Before touching the child, watch the general built, expression and behavior of child, any obvious abnormality(ies) and movements of the limbs, while the child is in mother's lap.
Assessment of Elderly
Besides the chronological count, the old age requires a broad assessment. Comorbidity is the hallmark of the elderlies. Multiple systems involvement at a time, symptoms varying from 6 to 12 months and diagnosis around two or three at a time usually characterize the clinical profile of elderly patients. Usually there is overlay of depression and/or anxiety and/or insecurity while examining an elderly person, besides keeping above factors in mind; one must exclude Alzheimer's disease, which results due to deposits of amyloidal substances and several other inflammatory proteins in the brain.
Clinical Audit in Orthopedics
Ernest Codman was perhaps the first true medical auditor following his work in 1912, on monitoring surgical outcomes.
Clinical audit compares the current practice to the standard practice. The clinical audit is essential to assess one's performance. The audit guides us if we are doing the things in right direction. Of course, the knowledge about the thing to do comes from research.
References
- Apley AG. Diagnosis in orthopaedics. In: Apley AG, Solomon L (Eds). Apley's System of Orthopaedics and Fracture, 7th edition. Butterworth–Heinemann; 1993.
- Duthie RB. Introduction. In: Duthie RB, Ferguson AB (Eds). Mercer's Orthopaedic Surgery, 9th edition. Arnold; London: 1996. pp. 1-41.
- Pandey S. Introduction. In: Pandey S, Pandey AK (Eds). Clinical Orthopaedic Diagnosis. MacMillan; New Delhi: 1995. pp.1-121.