INTRODUCTION

The evaluation for treatment consultation between a physician and a patient is at the center of all orthopedic practice activities.

From the moment of the first encounter with a patient, the physician is simultaneously observing and examining the movements and mannerisms of the patient, as well as listening to what is being said. The physician is trying to piece together the nature of the patient’s orthopedic problem.

The purpose of orthopedic evaluation is twofold. First, it allows the patient to present the problem, and second, it enables the physician to triage the nature of the problem and develop a course of action. In this context, the physician must always learn what has brought the patient to the consultation. In some cases a patient visits the orthopedic specialist because of referral by or on the advice of a third party. The diagnostic process is also complex, given that the physician needs to establish the physical issues that are of greatest importance to the patient and that are most disrupting to the activities of daily living, as well as try to differentiate the anatomic and pathologic aspects of any disease that might be present.

The history provides much information about the pathologic process involved and the impact of the condition on the patient, whereas the orthopedic physical examination is essential to define the anatomic structures involved; together these processes allow differentiation of orthopedic disorders into various categories.

Health care providers assess patients every day in clinical practice. Commonly, clinical practice is impossible without structured assessments and tests. Examination procedures look straightforward; results are either positive or negative. However, all assessment and testing in clinical practice is based on the assumption of uncertainty: Does the patient have a disease? The probability of a particular disease can be established only by performing a test from a chain of tests.

The accuracy of a test for detecting a disease or a condition is determined by sensitivity and specificity. A high sensitivity (or a high specificity) does not suffice to make a test useful in clinical practice; a test should be as sensitive as possible. The sensitivity and specificity of examination procedures and tests can often be found in the literature. Sensitivity and specificity are important characteristics of evidence-based physical assessment procedures but only in the context of a specific disease or condition.

The probability of a disease or condition after having performed a test (Bayes theorem) is dependent on two factors: (1) the specificity and sensitivity of the procedure (test characteristics) and (2) the probability of the disease or condition before conducting the procedure. Interpretation of Bayes theorem is that the probability of having a disease is not only dependent on the test or examination procedure result and the characteristics of the procedure, but also dependent on how likely the existence of the disease before the procedure is actually conducted. This factor is dependent on the prevalence of the disease.

The decision of whether to perform a new test depends on the result of the previous test. Procedures with the lowest burden, risk, and costs for the patient are performed first, and those with the highest burden, risk, or costs are reserved for certain patients in which the prior probability is highest. Examination procedures in the context of a low prior probability of disease are rarely, if ever, informative, with the yield of diagnostic testing that will increase the prior probability approximating 50%. Very experienced clinicians intuitively apply these rules and arrange their diagnostic process in such a way that the highest possible yield (a highly probable diagnosis) will be obtained at the lowest possible burden, risk, and cost for the patient. Less-experienced clinicians may learn from experienced colleagues by recalling Bayes theorem and implementing its principles in everyday clinical practice.

Health care providers cannot function adequately without physical examination procedures. In the real world, examiners accomplish clinical practice appropriately without a detailed knowledge of the principles of tests. However, the benefits from physical testing can be easily increased by recognizing that these tests do nothing more than increase the probability of a certain condition or diagnosis. Test results are never infallible.

From the moment of the first encounter with a patient, the examiner is simultaneously observing and examining the movements and mannerisms of the patient, as well as listening to what is being said. The diagnostic process is complex; the examiner needs to establish the physical issues that are of greatest importance to the patient (those most disrupting to the activities of daily living) and try to differentiate the anatomic and pathologic aspects of any disease or injury that might be present.

The history provides much information about what difficulties the patient is experiencing and the impact of these on the patient. Orthopedic examination is essential to define the structures involved; together, these processes allow differentiation of orthopedic disorders into various diagnostic categories (Box 1-1).

HISTORY

A carefully elicited history is a most crucial element in orthopedic assessment. An experienced examiner can form an idea of the extent and magnitude simply from the patient’s history. In the modern era of electronic patient medical record keeping, the examiner has new tools and methods for not only capturing patient information, but also tracking clinically significant changes.

CHIEF COMPLAINT

Patients who have more than one complaint, such as those with pain of spinal origin coupled with other body region symptoms or extremity problems, must be guided in ranking the complaints in priority. Although patients occasionally seek attention for stiffness or some other joint-related complaint, most patients with musculoskeletal conditions do so for reasons related to pain, especially when it compromises the activities of daily living.

OBSERVATION AND INSPECTION

A useful approach in clinical examination of the neuromusculoskeletal system is to seek answers to the Critical 5 questions for an orthopedic specialist. Once all five questions are answered, a differential diagnosis can usually be established (Box 1-2).

The physician needs to learn what exacerbates or relieves the symptom pattern. Equally important is how long the complaints have existed (Table 1-1).

PALPATION

Palpation is the process of assessing the physical characteristics of joints and contiguous structures by touching or feeling the patient’s body. The purpose of palpation is to locate and substantiate areas of tenderness, swelling, and abnormal muscle tone. Palpation allows the examiner to identify a localized increase or decrease in surface temperature and the presence of induration and mass. Palpation is classically performed with the fingertips, or with the blunt end of a cotton-tip applicator. However, instruments can be used in percussion (gently tapping with a reflex hammer), with vibration (using a C-128 tuning fork), or with the blunt end of a cotton-tip applicator.

NEUROLOGIC EVALUATION

The neurologic evaluation involves locating the lesion; testing deep tendon, superficial, and pathologic reflexes; testing cranial nerve and brainstem function; measuring body parts (mensuration); grading muscular strength; and testing the gross sensory modalities.

PAIN AND PATTERNS OF PAIN

Pain that arises with activity and decreases with rest is likely to have mechanical causes. The pain may be position dependent; most cases of mechanical spinal pain have both a provocative and a palliative arc of motion.

LOCAL VERSUS REFERRED PAIN

Patients with referred pain often point to large generalized areas, whereas patients with localized lesions can be more specific. A patient complaining of unrelenting spinal pain, demonstrating full, pain-free range of motion, presents a problem. The patient likely has either viscerosomatic pain, which mandates further diagnostic testing, or pain resulting from a psychosocial cause. If referred pain from a diseased organ system is mimicking a local orthopedic problem, the examiner should not hesitate to order appropriate tests.

VITAL SIGNS

Vital signs include the brachial blood pressure, peripheral pulse rate, respiration rate, height, weight, and vital capacity. The instrumentation for these measurements includes stethoscopes, spirometers, scales, tape measures, and blood pressure cuffs.

RANGE OF MOTION

Of all the orthopedic tests that an examiner can perform on a patient, none is more crucial than range-of-motion (ROM) testing of the affected articulation. ROM testing often reveals the origin of the patient’s discomfort because movement may reproduce the pain. The patient is examined symmetrically for active motion of all the joints that may be involved in the dysfunction or injury. The examiner then takes the patient through passive ROM, evaluating the end-feel (i.e., springiness) of the affected joint.

STABILITY TESTING

Because clinical examination reveals the degree of ligamentous or joint sprain (Table 1-2), the examiner must be able to test accurately for joint instability. Stability testing moves joint and periarticular structures through their respective arcs and end-range motions. Stability testing involves stressing ligamentous tissues and joint capsules.

MUSCULAR ASSESSMENT

Movement restrictions in a joint’s passive ROM are not exclusively articular. Muscular hypertonicity limits passive movement and often occurs in association with articular lesions (joint dysfunction). Chronic joint problems are also commonly associated with myofascitis.

CLINICAL LABORATORY

For the examiner concerned with musculoskeletal disorders, differential diagnosis becomes a challenge. Complete blood and urine tests can help determine a diagnosis (Box 1-3). Diseases of the heart, liver, kidney, pancreas, and prostate can mimic back pain of spinal origin.

Most laboratory testing has limited utility for orthopedic diagnosis (Table 1-3). As an example, in rheumatoid arthritis, the diagnosis is often established from the history and physical examination; for systemic lupus erythematosus, from the laboratory test antinuclear antibody (ANA); for gout, from a synovial fluid examination; and for ankylosing spondylitis, from a radiograph. In common disorders such as osteoarthritis, fibromyalgia, or muscular strains and sprains, in essence, only a limited diagnostic role exists for laboratory tests, primarily to exclude other diagnostic possibilities.

TABLE 1-3 LABORATORY STUDIES USEFUL IN DIAGNOSING LOW BACK SYNDROMES

Test	Measurement	Low Back Implication
Complete Blood Count Hematocrit hemoglobin White blood count and differential

Alkaline phosphatase Enzyme associated with bone formation; therefore, elevation implies increased bone formation May be elevated in primary or secondary osseous neoplasms. Acid phosphatase An enzyme associated with tumors metastatic to bone Increased in prostatic tumors.

HLA, Human leukocyte antigen.

Adapted from Pope ML: Occupational low back pain, assessment, treatment and prevention, St Louis, 1991, Mosby.

The simplest orthopedic screen includes rheumatoid factor, ANA, and uric acid, although more elaborate screens are available, which may include erythrocyte sedimentation rate, C-reactive protein (CRP), antistreptolysin O titer, protein electrophoresis, quantitative immunoglobulins, and ANA subsets such as anti-Ro and anti-La, anti-Sm, and anticentromere antibodies.

ORTHOPEDIC TESTS

In the orthopedic physical examination, a test is positive or a sign is present when the procedure duplicates the patient’s complaint or symptom. Tests are based on joint, muscle, or nerve function. If testing causes different pain or symptoms, it may indeed be significant, but the result is not positive for the findings that the test was designed to elicit.

DIAGNOSTIC IMAGING MODALITIES IN ORTHOPEDICS

Imaging procedures are important to the diagnosis and management of an orthopedic condition. The decision to use any diagnostic imaging procedure, especially ionizing imaging procedures, should be based on a demonstrated need and should be used only after an adequate medical history is obtained and a physical examination is conducted. The decision to use any imaging procedure must also be based on the assumption that the results of the examination, even if negative, will significantly affect the treatment of the patient. The value of the information gained from the imaging examination must be worth the possible detrimental effects of the procedure. In imaging modalities that use ionizing radiation (plain-film radiography, fluoroscopy, and computed tomography [CT]), the possible effect of radiation on the patient or future offspring must be considered.

Cervical spine Thoracic spine Lumbar spine Sacrum Chest Ribs Shoulder Humerus Clavicle Anteroposterior or posteroanterior (to include both joints with and without weight bearing) Sternum, sternoclavicular joints Radioulnar joints (forearm) Wrist and hand Pelvis, acetabulum Hip, proximal part of femur Femur Distal part of femur and knee Tibia, fibula Ankle Calcaneus Foot

From Gustilo RB, Kyle RF, Templeman DC: Fractures and dislocations, vol 1, St Louis, 1993, Mosby.

Care must be taken to investigate the possibility of associated injuries in trauma victims (Table 1-6). Patients may not realize that such injuries have occurred.

TABLE 1-6 INJURIES ASSOCIATED WITH SKELETAL TRAUMA

Fracture	Associated Injury
Bone and Bone
Spine	Remote additional spinal fracture
Chest wall	Scapula fracture
Anterior pelvic arch	Sacrum fracture or dislocated sacroiliac joint
Femoral shaft	Fracture or fracture-dislocation of hip
Tibia (severe)	Dislocated hip
Calcaneus	Fractured thoracolumbar spine
Bone and Viscera
Chance fracture of spine	Ruptured mesentery or small bowel
Lower ribs	Laceration of liver, spleen, kidney, or diaphragm
Pelvis
Pelvis	Ruptured bladder or urethra
	Ruptured diaphragm
Bone and Vascular
Ribs 1, 2, or 3	Ruptured aorta
Sternum	Myocardial contusion
Pelvis	Laceration of pelvic arterial tree
Distal third femur	Laceration of femoral artery
Knee dislocation	Popliteal artery laceration

Adapted from Rogers LF, Hendrix RW: Evaluating the multiple injured patient radiographically, Orthop Clin North Am 21(3):444, 1990.

Tomography

Conventional tomography is also known as thin-section radiography, planigraphy, and linear tomography. Conventional tomography is largely replaced by CT. However, some circumstances, such as evaluating subtle alterations of bone density and ruling out fracture, necessitate conventional tomography. CT scans are used for more detailed appreciation of skeletal pathologic processes, which can help evaluate suspected intervertebral disc protrusions or herniations, facet disease, or central canal and lateral recess stenosis. If spinal disease is suspected and is not well identified on plain films and the patient is not responding to care, a CT scan is indicated. A CT scan is especially useful for the appreciation of bone and calcifications and surpasses magnetic resonance imaging (MRI) in this regard.

Discography

Although effective, discography has been a controversial imaging modality for spinal disc disease. Clinicians use discography for specific cases of spinal pain that are recalcitrant to conventional therapy.

Magnetic Resonance Imaging

MRI is a computerized, thin-section imaging procedure that uses a magnetic field and radio-frequency waves rather than ionizing radiation. MRI can produce thin-section images in the sagittal, coronal, or axial planes, as well as any other oblique plane desired. The MRI can image neurologic structures and other soft tissues and can reveal disc degeneration before any other imaging method. Indications for MRI are similar to those for CT. MRI is superior to CT for evaluating possible spinal cord tumors or damage, intracranial disease, and various types of central nervous system disease (e.g., multiple sclerosis). MRI is especially useful in identifying small differences among similar soft tissues and surpasses CT in this regard.

For patients who have sustained head trauma with skull fractures, MRI is an efficient way to identify the early signs of cerebral edema. The test procedure of choice for diagnosing metastatic disease is an MRI scan (Table 1-7).

TABLE 1-7 MAGNETIC RESONANCE IMAGING VERSUS COMPUTED TOMOGRAPHY

Anatomic Area	Indications	Recommended Procedure
Brain (including brainstem)	Initial evaluation (e.g., demyelination disease seizures) Previous normal CT Previous abnormal CT Unchanged abnormal CT with increase in symptoms Contrast allergy Acute trauma Pituitary tumors

Ear, nose, throat, and eye Musculoskeletal spine Hips Extremities Chest Abdomen and pelvis

CT, Computed tomography; MRI, magnetic resonance imaging; US, ultrasonography.

* Consult radiologist for imaging options.

From Brier SR: Primary care orthopedics, St Louis, 1999, Mosby; originally courtesy of Robert Goodman, MD, South Suffolk MRI, PC, Bayshore, New York.

Contrast Arthrography

The conventional use of arthrography in musculoskeletal disease involves the use of air to distend a synovial joint and a radiopaque contrast agent to outline anatomic structures. The injection of contrast material into the joint space results in a radiographic outline of the cartilage, menisci, ligaments, or synovium. Conventional arthrography is used in diagnosis of the scope and magnitude of orthopedic trauma to the shoulder, wrist, knee, and ankle (Table 1-8).

TABLE 1-8 JOINTS TYPICALLY STUDIED WITH COMPUTED TOMOGRAPHIC ARTHROGRAPHY AFTER TRAUMA

Joint	To Observe
Knee	Meniscus, cruciate and collateral ligaments, hyaline cartilage tears, osteochondral defects
Shoulder	Rotator cuff, glenoid labrum disruption
Hip	Hyaline cartilage integrity and tears, prosthetic joint loosening
Wrist	Triangular fibrocartilage, intercarpal ligament integrity
Elbow	Hyaline cartilage integrity, osteochondral defects
Ankle	Ligamentous tears, osteochondral defects
Temporomandibular	Disc and condylar integrity

Adapted from Gustilo RB, Kyle RF, Templeman DC: Fractures and dislocations, vol 1, St Louis, 1993, Mosby.

Radionuclide Scanning

Examinations conducted with the use of nuclear medicine techniques, including bone scans, positron emission tomography (PET) scans, and single-photon emission computed tomography (SPECT) scans, are valuable in diagnostic imaging because of their highly sensitive and noninvasive nature. Whole-body scanning for metastatic and infectious diseases, as well as inflammatory and ischemic processes, is possible with scintigraphy.

Video Fluoroscopy

Video fluoroscopy is used when a function study of the joint is warranted. Video fluoroscopy should be used when a biomechanical abnormality is present but is not adequately demonstrated by plain film stress surveys or other examination methods.

Diagnostic Ultrasound

Diagnostic ultrasound, a sound wave echo study, is particularly useful for evaluating soft tissues. The diagnostic ultrasound does not provide the same quality of image as CT or MRI.

Myelography

Traditional myelographic techniques involve the introduction of small amounts of water-soluble contrast medium into the subarachnoid space, either through a lumbar approach below the level of the conus medullaris or at the level of C1–C2 through a posterolateral approach. Standard films of the spinal canal are made to determine the presence or absence of a filling defect. In cases of acute spinal trauma, myelography may be used in conjunction with CT. Myelography remains valuable in evaluating intrinsic spinal cord lesions, nerve root lesions, and dural tears associated with severe trauma (Box 1-5).

Thermography

Using temperature differentials of the body, thermography illustrates neurovascular changes in injury or disease. Thermograms do not provide specific information regarding the cause of nerve fiber irritation (e.g., herniated disc, scar tissue, myospasm).

Electrodiagnostic Testing

Although electrodiagnostic testing provides valuable information, it does not stand alone as a diagnostic entity (Table 1-9). The data obtained must be correlated with the physical examination findings and case history.

TABLE 1-9 STRENGTHS AND LIMITATIONS OF ELECTRODIAGNOSTIC TESTING

Testing Modality	Strengths	Limitations
Nerve conduction velocity	Helpful in ruling out peripheral entrapment neuropathic conditions (e.g., prolonged latencies exhibited in carpal tunnel syndrome, tarsal tunnel syndrome) and ulnar neuropathic variations	Provides imperfect sensitivity; limited localization and determination of injury severity; timing of study an important factor
F waves	Provides screening for late motor response with distal sweeps starting at the foot	Evaluates motor reflex only; possibly evaluates abnormal findings only in the presence of multiple-level injury
H reflex	Equivalent of ankle joint reflex; evaluates monosynaptic reflex with sensory and motor S1 function	Provides assessment of S1 nerve root only
SSEPs	Helpful in documenting sensory pathway disturbances in proximal neural injury and central conduction delays, as in myopathies and multiple sclerosis	Offers imperfect localization; findings are rarely abnormal if results of other electrodiagnostic tests are within normal limits
Needle EMG	Useful in assessing conductivity of neural tissues; helpful in determining site and severity of lesion; may be helpful in early assessment of recovery, screening for fibrillation potentials, and signs of denervation from nerve root compression disorders	Unable to detect denervation potentials for 14 to 28 days after injury; provides imperfect sensitivity; study timing an important factor; proximal lesions sometimes inaccessible anatomically; effectiveness reduced after surgery

EMG, Electromyography; SSEPs, somatosensory-evoked potentials. Adapted from Brier SR: Primary care orthopedics, St Louis, 1999, Mosby.

Doppler Ultrasonic Vascular Testing

Doppler vascular testing allows the assessment of pulses in noisy environments or when pulses are weak. This test is efficient when palpation of a pulse is questionable or not possible. The Doppler instrument aids in the assessment of circulation distal to fracture sites, burns, and other injuries that potentially compromise vascular tissue, quickly determining the extent of injury.