Diagnosis in Orthopaedic

David Hariadi Masjhoer SMF Orthopedi & Traumatologi RSUD A W Sjahranie

Information consists of differences that make difference

gregory bateson

data, give me data!

sherlock holmes

ad sanitatem gradus est movisse morbum (the first step toward cure is to know what the disease is)

Orthopaedic investigation
History taking (symptoms) }
subjective
past history, family history, social background

Physical examination (signs)} Radiographic examination } objective Laboratory examination }

History Taking
Talking (serves a double purposes);
Elicits informations Therapeutic Patient need to tell, and need to be heard

Most frequently complaints :

Pain Stiffness Swelling Deformity Weakness Altered sensation Loss of function

History Taking
Pain
Most common Where, when, how often What make it better or worse Change in patient life Remember :
Patient have not learn anatomy Referred pain

History Taking
Stiffness :
Distinguish from lack of movement due to pain Totally or partially

Swelling:
Soft tissue, joint or bone Patient are seldom wrong, even doesnt look swollen Patient sense : skin feels tight, ring or shoe doesnt loosely

History Taking
Deformity
Any progressive deformity need attention

Weakness
Possibly to neurological disorder

Instability
Patient term giving way Muscle weakness or dysfunction of ligament

History Taking
Altered sensation
Numbness Tingling suggest injury localized pressure, entrapment or ischemia

Loss of function
How symptoms interfere with their activity

Past history and family history

Physical examination
Begin at first moment :
Body build (habitus) Facial appearances Walking gait Sitting or lying position

Physical examination
Walking gait, consist of four part :
Heel strike Stance phase Toe off Swing phase

Limp ? simply an abnormal gait

Examination of the affected part

Patient must suitable undressed
rolling up the trouser leg is not sufficient
Both limb must be exposed Check the normal first Compared the affected limb with the normal

Systematic order
1. 2. 3. 4. Look (inspection) Feel (palpation) Move (assesment of joint) Listening (auscultation) over joint and vessels 5. Special physical test 6. Neurological examination

Look
Looking for specific features Skin : scar, color, pigmentation, abnormal creases Shape : atrophy, hypertrophy, swelling, lump, abnormally bone bent Position : joint is three dimensional Measures any limb shortening

Look
Deformity : joint held in natural position
Varus and valgus Khyposis and lordosis Scoliosis Fixed deformity

Feel
Skin : warm or cold, moist or dry, sensation Soft tissue : lump ? pulse ? swelling Bone and joint : outlines normal ? synovium thickened? excessive joint fluid Tenderness (watch the patient face) Abnormal relationship of bone and joint

Feel
Clinical features of the lump ;
Size Site Margin Consistency Tenderness Multiplicity

Pain

Move
The range of joint movement from anatomical position is recorded in degrees, starting from zero The common planes :
Flexion /extension Abduction /adduction External /internal rotation Pronation / supination (only to forearm and foot) Circumduction

Move
Active movement : limited by pain, muscle spasm, muscle weakness, ruptured tendon or muscles, joint stiffness or contracture Passive movement : decreased for any of the reason above, or increased due to a lax capsule or torn ligaments

Listen
Crepitus from fracture Joint crepitus Snapping tendon Murmur of the peripheral arteriovenous fistula

Special Physical test

Shoulder Elbow Wrist Hand Hip Knee Foot spine

Neurological examination
Muscle weakness Muscle spasticity Involuntary movement Altered skin sensation Loss of balance motor system, sensory system, reflexes