Surgery

Orthopedic History and Physical Examination

Dr. Joe Bair Alonto, MD, FPOA
August 17, 2020

OUTLINE
Some age specific conditions such as congenital diseases compared
ORTHOPEDIC HISTORY AND PHYSICAL EXAMINATION ......................... 1
with genetic conditions.
Pre-test .................................................................................................................................1 Gender specific diseases particularly in multiple myeloma in males.
Orthopedic History and PE ................................................................................................1
History...................................................................................................................................1 Arthritis and osteoporosis are more of the females.
History of Present Illness ...................................................................................................1 Occupation usually gives the causation and repetitive trauma
Physical Examination ..........................................................................................................2
Diagnosis ..............................................................................................................................3 conditions.

- Other data like religion, education, and hand-dominance may help

ORTHOPEDIC HISTORY AND PHYSICAL EXAMINATION in the planning of patient-care
- Overview - Chief complaint (what brought the patient in)
- History o Duration
- Physical examination o If the patient has several chief complaints → prioritize either
- Diagnosis by order of duration or which one is more bothersome.
- History of present illness
Pre-test - Past medical history
o Drugs and allergies to food and drugs
1. What is the most formidable tool in an orthopedist arsenal?
- Personal history
2. Outline the sequence of an orthopedic physical examination.
- Social history
3. True or false. A thorough PE will verify the patient’s history.
- Family history
4. The range of motion of elbow extension is ___.
- Others
5. Grade ___ of motor strength is described as movement against
o Menstrual history in women
gravity only
o For pediatric patients, birth history & milestones (time able
to stand, able to walk, time able to talk)
Orthopedic surgery encompasses the entire process of caring for the ▪ Delays in milestones may give a clue to the condition of
surgical patient. Although the surgical procedure is the key step the patient
towards helping the patient, it is the preliminary and follow-up care
that determines whether the surgery is successful. History of Present Illness
- Chronological order
History will suggest the key features of the problem, particularly the 1) Diagnostic facts
medical problems and other possible clues to requirements and billing o Congenital (present since birth)
purposes. o Developmental
o Infectious (fever, chills)
Social history and past medical history are similarly important. The o Metabolic (nutritional status, hormonal imbalance, seasonal
physical examination must cover the essentials necessary for the variation of symptoms, inflammatory causes)
diagnosis. Confirmational diagnosis is based on physical examination o Traumatic (history of accident/fall, nature of the trauma)
but such considerations are skin conditions and blood supply must also o Mechanical/ Degenerative (is it improved by rest? Instability or
be documented despite these processes are also part of your surgical locking sensation; if constant pain, consider metaplasm)
evaluation. o Idiopathic

2) Pain
Orthopedic History and PE o OPQRST
- Unique mix of surgical and nonsurgical options ▪ Onset (sudden or gradual)
- History is the most formidable tool in orthopedics arsenal o P - Progression (constant or worsening, has it improved, on-
- Determines direction of either towards diagnosis and/or treatment and-off)
- Key features of the problem o Q - Quality (aching, stabbing, burning, throbbing pain)
- Consistency in the history vs PE finding vs Diagnostics o R - Radiation (Referred pain, e.g if the leg pain is coming from
back, could indicate sciatica or some back pain that could be
Consistencies with your history should be checked with those findings related to a kidney stone or aortic aneurysm)
in your physical exam and further verified by your diagnostics. o S - Severity (mild, moderate, or severe; use pain scale)
o T - Timing and duration (time of onset & how long)

History 3) Swelling
- Identification (age, gender, occupation, others) o Onset: Hematoma or hemarthrosis
o Slow onset: effusion, infection, tumor

4) Limp
o Painful or painless
o Inflammatory (Tb hip, polymyelitis, osteoarthritis)
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 Surgery | Orthopedic History and Physical Examination
o Traumatic Remember!
o Consider in the space of the hip, joint or bone deformity, leg
- Measure distances from landmark (olecranon, belly button, knee,
discrepancy, past surgery in the hip, knee or ankle
patella, ankle) especially for effusion and swelling

5) Deformity - Fluctuation tests

o Sudden onset: Trauma, subluxation, dislocation of joint - Transillumination tests
o Associated with some muscle spasm
o Gradual progression: Growth-related disorders Range of motion
- Active vs passive
6) Stiffness - Instrument used: Goniometer
o Drug involvement particularly in TB myositis and septic arthritis
1. Active - the patient is doing the movement by himself/herself
2. Passive - movement is done with the aid of the examiner
7) Weakness
o Sudden: Traumatic
o Progressive: Neurological or myopathic cause
o Sensory loss: could be simple myopathy or motor neuron
disease

8) Discharges, ADL, treatment received

o Persistent discharging sinus which could be found in diabetic
foot, osteomyelitis, fungal infection, or even foreign bodies
Figure 1 A picture of goniometer. An instrument with two protractors with their
that has been lodged long arms and check for the range that is available in the patient.
o Malignant cases could also present with discharges
o Activities of Daily Living (ADL) → how the signs and symptoms Range of Motion for the Upper Extremities
have affected the patient’s daily activities 1. Shoulder Joint
o Hilot and/or treatments from other doctors
▪ E.g., Prior pain medications
▪ Steroid-use

9) Review of systems
o Positive history and relevant negative history

Physical Examination
- Inspection
- Palpation 2. Elbow Joint
- Strength / power
- Range of motion
- Neurovascular examination
- Special tests (if any)

Always remember! For the elbow joint, it is important to note that some people can go into
- Give exact location some degree of hyperextension or they can extend beyond 0 degrees.
- Compare with contralateral side
3. Wrist joint
- Consistent with history
- Include joint above and below

Inspection (SEADS)
- S - Swelling
- E - Erythema
- A - Atrophy
- D - Deformities
Range of Motion for the Lower Extremities
- S - Scars, skin changes
1. Hip joint

Palpation (TESTCA)
- T - Tenderness
- E - Effusion
- S - Swelling
- T – Temperature (particular in some inflammatory cases)
- C - Crepitus
- A – Atrophy

2. Knee joint

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 Surgery | Orthopedic History and Physical Examination

3. Ankle joint

Figure 3 Malingering Test

Strength/Power
- Ideally, do resisted isometric testing
- Ask the patient to move either against your systems and give the
following grade:

Figure 4 Lachman's Test. It is used for checking the knee for ACL.

- After doing the history examination and PE, one should already have
a WORKING DIAGNOSIS

Figure 2 Assessment for strength/power

Grade 3 - it means that the patient’s able to move it against gravity only
but when you put some sort of resistance, even how small, the patient
won’t be able to do so.

Neurovascular Examination
- P2RST
o P - Pulse and Capillary Refill Time (<2 sec) Diagnosis
o P - Power (muscle strength)
Radiographs
o R - Reflexes
o S - Sensation (Dermatomes) - The bread and butter of the diagnosis in orthopedics
o T - Tone (hypertonic or hypotonic) - Check for the joint above and below
o Do not ask for one view but two views → AP and lateral view
Special Tests which gives a 3D visualization
- special test specific to the area - Contralateral if needed
- Physis (growth plate) can be mistaken as a fracture in small children
- Checking the knee → do the blackman test + check for ACL
- Special views:
- Malingering Tests
o Stress views
o in patients complaining of back pain
▪ xray is done while the joint is in stress position
o ask the patient to lift the leg or the leg that is affected
o Skyline views
o usual response if the leg is really weak, patient will try to ▪ Used basically for the knee
compensate pushing down on the other leg ▪ To check for the patellar alignment
▪ This is a good (negative) sign ▪ Could tell the relationship for a patella over a tumor
▪ Malingering patient will only fake the weakness, and will (which will show widening)
not exhibit the compensatory movement
o if interested on the details of this test, refer to the book
“Orthopedic Physical Assessment 5th Edition” By David J
Magee

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Figure 9 CT Scan can also be used for checking metallic implant in place (arrow).
MRI is not applicable for metallic implants.

Figure 5(Left) Xray. Widening between joints. This could point out to some
instability. (Right) The examiner holds the ankle into place and then pushes it
away to create stress. This could point out to some instability and ligaments in the
area.

Figure 10 (Left) Normal CT scan. Fragments are seen (pointed by arrows). (Right)
3D CT Scan. Fragments are seen in detail and its relationship to the other
structures.

Figure 6 Skyline view position

Figure 11 (Left)CT Scan of the pelvis showing posterior dislocation with

Figure 7 Radiograph of the patella with a tumor. There is widening on the left fragments. (Right) View on top. Femoral head is coming out of the socket. 3D
side (red circle) reconstruction will tell you how big the fragment is and helps on deciding fixation.

CT Scan Magnetic Resonance Imaging (MRI)

- Some occult fractures are seen - method of choice for the detection of radiographically occult,
- 3D reconstruction with CT scan clinically significant acute fractures
o When there are metallic implants used - excellent resolution of soft tissue structures (e.g. meniscus,
o Can tell how big the fragment is and later on help on what to ligaments, or tendons)
do for the fixation

Figure 12 An MRI of the femoral bone which shows fracture in the femoral neck
Figure 8 Example of CT Scan. but with only minimal displacement. (arrow).

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Figure 13 (Left, big picture) X-ray showing the bone that’s been chipped off from
the fibular head. But in the MRI (right, two mini pictures), some collateral
fragments are frayed as well. Fixation includes both the bone and collateral
fragments

Radionuclide Bone Scans

- evaluate skeletal metabolic activity

Figure 14 (A) Lighting up of the area. (arrow) (B) A cold fracture in the sacral
bone. (arrow)

Ultrasound
- an inexpensive tool used to evaluate the shoulder, knee, glenoid,
or medial lateral ligaments
- The field of musculoskeletal US is expanding now

Figure 15 Ultrasound

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