CHAPTER 1 General principles in the examination of a patient with an orthopaedic problem
In practice, the primary area of interest of the orthopaedic surgeon is in the joints of the limbs and spine, and how well they function. The major part of most orthopaedic examinations is therefore centred on the joint that troubles the patient, but the examination must often be extended to include the nerves and muscles that are responsible for movements in the joint; some of the patient’s other joints may also have to be checked to see if they are affected as well.
Joints possess a remarkable degree of individuality, and it follows that the techniques for examining one joint may have to be varied when it comes to look at another. However, a common sequence is followed, and it may be helpful to keep it in mind. (It is assumed that a full, relevant history has been obtained, and any general physical examination has been carried out.) The examination of the joint itself may be broken down into six distinct steps:
It is not always necessary to keep strictly to this order, or indeed to carry out all of these procedures.
The contents of each chapter of this book are generally ordered in this sequence unless special circumstances dictate otherwise.
Step 1: Inspection
Look carefully at the joint, paying particular attention to the following points:
1. Is there swelling? If so, is the swelling diffuse or localised? If the swelling is diffuse, does it seem confined to the joint or does it extend beyond it? Swelling confined to the joint suggests distension of the joint with (a) excess synovial fluid (effusion), e.g. from trauma or a non-pyogenic inflammatory process (such as rheumatoid or osteoarthritis); (b) blood (haemarthrosis), e.g. from recent acute injury or a blood coagulation defect; or (c) pus (pyarthrosis), e.g. from an acute pyogenic infection. Swelling extending beyond the confines of the joint may occur with major infections in a limb, tumours, and problems of lymphatic and venous drainage.
If there is a localised swelling, note its position in relation to the underlying anatomical structures, as this may give a clue to its possible nature or identity.
2. Is there bruising? This might suggest trauma, with a point of impact or gravitational or other spread.
3. Is there any other discoloration or oedema? This might occur as a localised response to trauma or infection.
4. Is there muscle wasting? This usually occurs as a result of disuse, from pain or other incapacity, or from denervation of the muscles affected.
5. Is there any alteration in shape or posture, or is there evidence of shortening? There are many possible causes for each of these abnormalities (including congenital abnormalities, past trauma, disturbances of bone mineralisation and destructive joint disease); their presence should be noted, and explored in further detail during the course of the examination.
Step 2: Palpation
Some of the points you should note include the following:
1. Is the joint warm? If so, note whether the temperature increase is diffuse or localised, always bearing in mind the false impression that may be caused by the effects of local bandaging. A diffuse increase in heat occurs when a substantial tissue mass is involved, and is seen most commonly in joints involved in pyogenic and non-pyogenic inflammatory processes, and in cases where there is anastomotic dilatation proximal to an arterial block. Away from the joints themselves, infection and tumour should be borne in mind. A localised increase in temperature generally pinpoints an inflammatory process in the underlying anatomical structure. Asymmetrical coldness of a limb commonly occurs where the limb circulation is impaired, e.g. from atherosclerosis.
2. Is there tenderness? If so, note whether it is diffuse or localised. Where tenderness is diffuse, the cause is likely to be the same as for an increase in local heat. When there is localised tenderness the site of maximal tenderness should be assiduously sought, as this may clearly identify the underlying anatomical structure that is involved.
