Clinical methods of history taking and examination

Published on 11/03/2015 by admin

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1 Clinical methods of history taking and examination

As in other fields of medicine and surgery, diagnosis of orthopaedic disorders depends first upon an accurate determination of all the abnormal features from:

1 the history
2 clinical examination
3 radiographic examination and other methods of imaging
4 special investigations.

Secondly, it depends upon a correct interpretation of the findings.

HISTORY TAKING

In the diagnosis of orthopaedic conditions the history is often of first importance. In cases of torn meniscus in the knee, for instance, the clinical diagnosis sometimes depends upon the history alone. Except in the most obvious conditions, a detailed history is always required.

First the exact nature of the patient’s complaint is determined. Then the development of the symptoms is traced step by step from their earliest beginning up to the time of the consultation. The patient’s own views on the cause of the symptoms are always worth recording: often they prove to be correct. Enquiry is made into activities that have been found to improve the symptoms or to make them worse, and into the effect of any previous treatment. Facts that often have an important bearing on the condition are the age and present occupation of the patient, previous occupations, hobbies and recreational activities, and previous injuries.

When a full history of the local symptoms has been obtained, do not omit to enquire whether there have been symptoms in other parts of the body, and whether the general health is affected. Ask also about previous illnesses.

Finally, in cases that seem trivial, a tactful enquiry as to why the patient decided to seek advice, and to what extent he is worried by his disability, will often give a valuable clue to the underlying problem. It should be remembered that very often patients seek advice not because they are handicapped by a disability (which is often insignificant) but because they fear the development of some serious disease such as cancer, paralysis, or progressive crippling deformity.

CLINICAL EXAMINATION

The part complained of is examined according to a rigid routine which should become habitual. If this is done, familiarity with the routine will ensure that no step in the examination is forgotten. Accuracy of observation is essential: it can be acquired only by much practice and by diligent attention to detail.

The examination of the part complained of does not complete the clinical examination. It sometimes happens that 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, and pain in the knee may have its origin in the hip. The possibility of a distant lesion must therefore be considered and an examination made of any region under suspicion.

Finally, localised symptoms may be the first or only manifestation of a generalised or widespread disorder. A brief examination is therefore made of the rest of the body with this possibility in mind.

Thus the clinical examination may be considered under three headings:

1 examination of the part complained of
2 investigation of possible sources of referred symptoms
3 general examination of the body as a whole.

1 EXAMINATION OF THE PART COMPLAINED OF

The following description of the steps in the clinical examination is intended only as a guide. The technique of examination will naturally be varied according to individual preference. Nevertheless, it is useful to stick to a particular routine, for a familiarity with it will ensure that no step in the examination is forgotten.

Exposure for examination

It is essential that the part to be examined should be adequately exposed and in a good light. Many mistakes are made simply because the student or practitioner does not insist upon the removal of enough clothes to allow proper examination. When a limb is being examined the sound limb should always be exposed for comparison.

Inspection

Inspection should be carried out systematically, with attention to the following four points:

1 The bones Observe the general alignment and position of the parts to detect any deformity, shortening, or unusual posture.
2 The soft tissues Observe the soft-tissue contours, comparing the two sides. Note any visible evidence of general or local swelling, or of muscle wasting.
3 Colour and texture of the skin Look for redness, cyanosis, pigmentation, shininess, loss of hair, adventitious tufts of hair or other changes.
4 Scars or sinuses If a scar is present, determine from its appearance whether it was caused by operation (linear scar with suture marks), injury (irregular scar), or suppuration (broad, adherent, puckered scar).

Palpation

Again there are four points to consider:

1 Skin temperature By careful comparison of the two sides judge whether there is an area of increased warmth or of unusual coldness. An increase of local temperature denotes increased vascularity. The usual cause is an inflammatory reaction; but it should be remembered that a rapidly growing tumour may also bring about marked local hyperaemia, with increase in skin warmth.
2 The bones The general shape and outline of the bones are investigated. Feel in particular for thickening, abnormal prominence, or disturbed relationship of the normal landmarks.
3 The soft tissues Direct particular attention to the muscles (are they in spasm, or wasted?), to the joint tissues (is the synovial membrane thickened, or the joint distended with fluid?), and to the detection of any local swelling (?cyst; ?tumour) or general swelling of the part.
4 Local tenderness The exact site of any local tenderness should be mapped out and an attempt made to relate it to a particular anatomical structure.

Determining the cause of a diffuse joint swelling. The question often arises: what is the cause of a diffuse swelling of a joint? The answer can be supplied after careful palpation. For practical purposes a diffuse swelling of the joint as a whole can have only three causes:

1 thickening of the bone end
2 fluid within the joint
3 thickening of the synovial membrane.

In some cases two or all three causes may be combined, but they can always be differentiated by palpation. Bony thickening is detected by deep palpation through the soft tissues, the bone outlines being compared on the two sides. A fluid effusion generally gives a clear sense of fluctuation between the two palpating hands. Synovial thickening gives a characteristic boggy sensation – rather as if a layer of soft sponge-rubber had been placed between the skin and the bone. It is nearly always accompanied by a well’marked increase of local warmth, for the synovium is a very vascular membrane.

Measurements

Measurement of limb length is often necessary, especially in the lower limbs, where discrepancy between the two sides is important. Measurement of the circumference of a limb segment on the two sides is also important if any asymmetry is suspected. It provides an index of muscle wasting, soft-tissue swelling or bony thickening. Details will be given in the chapters on individual regions.

Estimation of fixed deformity

Fixed deformity exists when a joint cannot be placed in the neutral (anatomical) position. Its causes are described on page 56. The degree of fixed deformity at a joint is determined by bringing the joint as near as it will come to the neutral position and then measuring the angle by which it falls short.

Valgus and varus. Explanation is needed of the commonly used terms valgus and varus, which are often confusing to students. In valgus deformity the distal part of a member is deviated laterally (outwards) in relation to the proximal part. Thus, for example, in hallux valgus the toe is deviated outwards in relation to the foot; and in genu valgum the lower leg is deviated outwards in relation to the thigh. Varus deformity is the opposite: the distal part of a member is deviated medially (inwards) in relation to the proximal part (examples – cubitus varus and genu varum).

Movements

In the examination of joint movements information must be obtained on the following points:

1 What is the range of active movement?
2 Is passive movement greater than active movement?
3 Is movement painful?
4 Is movement accompanied by crepitation?
5 Is there any spasticity (stiff resistance to free movement)?

In measuring the range of movement it is important to know what is the normal. The range is recorded as an angle usually measured from the straight position of the joint as neutral. Measurement can be facilitated by the use of a jointed protractor with long arms, termed a goniometer. With some joints the normal varies considerably from patient to patient; as, for instance, at the metacarpo-phalangeal joint of the thumb: so it is wise always to use the unaffected limb for comparison. Restriction of movement in all directions suggests some form of arthritis, whereas selective limitation of movement in some directions, with free movement in others, is more suggestive of a mechanical derangement.

Except in two sets of circumstances passive movement will usually be found equal to the active range. The passive range will exceed the active only in the following circumstances:

1 when the muscles responsible for the movement are paralysed
2 when the muscles or their tendons are torn, severed, or unduly slack.

Stability

The stability of a joint depends partly upon the integrity of its articulating surfaces, partly upon intact ligaments, and to some extent upon healthy muscles. When a joint is unstable there is abnormal mobility – for instance, lateral mobility in a hinge joint. It is important, when testing for abnormal mobility, to ensure that the muscles controlling the joint are relaxed; for a muscle in strong contraction can often conceal ligamentous instability.

Power

The power of the muscles responsible for each movement of a joint is determined by instructing the patient to move the joint against the resistance of the examiner. With careful comparison of the two sides it is possible to detect gross impairment of power. By general convention, the strength of a muscle is recorded according to the Medical Research Council grading, as follows:

0 = no contraction;
1 = a flicker of contraction;
2 = slight power, sufficient to move the joint only with gravity eliminated;
3 = power sufficient to move the joint against gravity;
4 = power to move the joint against gravity plus added resistance;
5 = normal power.

Sensation

Patients often complain of ‘numbness’ or tingling, and it is important to test sensibility both to light touch and to pin prick throughout the whole of the affected area. In unilateral affections the opposite side should be similarly tested for comparison. The precise area of any blunting or loss of sensibility should be carefully mapped out, and from a knowledge of the sensory dermatomes and the cutaneous distribution of the peripheral nerves the particular nerve or nerves affected may be identified and the root value established.

Reflexes

As part of the neurological examination the appropriate deep and superficial reflexes must be tested. Details will be given in the sections on individual regions of the body.

Peripheral circulation

Symptoms in a limb may be associated with impairment of the arterial circulation. Time should therefore be spent in assessing the state of the circulation by examination of the colour and temperature of the skin, the texture of the skin and nails, and the arterial pulses; and by such special investigations as may be necessary. This examination is particularly important in the case of the lower limb. Further details are given on page 420.

Tests of function

It is necessary next to test the function of the part under examination. How much does the disorder affect the part in its fulfilment of everyday activities? Methods of determining this vary according to the part affected. To take the lower limb as an example, the best test of function is to observe the patient standing, walking, running and jumping, or climbing and descending stairs. Special tests are required to investigate certain functions – for example, the Trendelenburg test for abductor efficiency at the hip (p. 340).

2 INVESTIGATION OF POSSIBLE SOURCES OF REFERRED SYMPTOMS

When the source of the symptoms is still in doubt after careful examination of the part complained of, attention must be directed to possible extrinsic disorders with referred symptoms. This will entail examination of such other regions of the body as might be responsible. For instance, in a case of pain in the shoulder it might be necessary to examine the neck for evidence of a lesion interfering with the brachial plexus, and the thorax and abdomen for evidence of diaphragmatic irritation, because either of these conditions may be a cause of shoulder pain. Again, in a case of pain in the thigh the examination will often have to include a study of the spine, abdomen, pelvis, and genito-urinary system as well as a local examination of the hip and thigh.

3 GENERAL EXAMINATION OF THE BODY AS A WHOLE

The mistake is sometimes made of confining the attention to the patient’s immediate symptoms and failing to assess the patient as a whole. It should be made a rule in every case, however trivial it may seem, to form an opinion not only of the patient’s general physical condition but also of his psychological outlook. In simple and straightforward cases this general survey may legitimately be brief and rapid, but it should never be omitted.

DIAGNOSTIC IMAGING

Until recent years radiography was the only method by which bone and other relatively dense tissues could be shown as a visual image contrasting with adjacent less’dense tissues. This is no longer the case, for technical developments have led to alternative methods of imaging. These include:

1 ultrasound scanning
2 radioisotope scanning
3 X-ray computerised tomography (CT scanning)
4 magnetic resonance imaging (MRI).

A more detailed consideration of these methods and their applications to the diagnosis of orthopaedic disorders will be dealt with in Chapter 2.

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