ORTHOPAEDIC

HISTORY TAKING &

PHYSICAL EXAMINATION
“Clinical examination is an art and has to
be learnt, as it does not come naturally.
All patients must be respected, made to
feel at ease and assured of their
confidentiality and dignity. “
 History Taking of Chief Complaint
• Identity : Age, Sex, race, present occupation
, his previous occupations, hobbies and
recreational activities, and previous injuries.
• The Fundamental Four And The Sacred
Seven
– History of Present Ilness (RPS)
– History of Previous Illness (RPD)
– History of Family
– History of Social & Economic
.
 History Taking
1. Present Illness
Chief Complaint
Sacred 7 :
– Location (dimana ? menyebar atau tidak ?)
– Onset (kapan terjadinya?berapa lama?)
– Chronology
– Quality (ringan atau berat, seberapa sering terjadi
?)
– Quantity (rasa seperti apa ?)
– Aggravating Factors (Make it worse/Improve)
– Associated compliant?
 History Taking
2. Previous Illnesses
•Ditanyakan adakah penderita pernah sakit serupa sebelumnya, bila
dan kapan terjadinya dan sudah berapa kali dan telah diberi obat apa
saja, serta mencari penyakit yang relevan dengan keadaan sekarang
dan penyakit kronik (hipertensi, diabetes mellitus, dll), perawatan lama,
rawat inap, imunisasi, riwayat pengobatan dan riwayat menstruasi
(untuk wanita).
3. Family
•Anamnesis ini digunakan untuk mencari ada tidaknya penyakit
keturunan dari pihak keluarga (diabetes mellitus, hipertensi, tumor, dll)
atau riwayat penyakit yang menular.
4. Social Economic
•Hal ini untuk mengetahui status sosial pasien, yang meliputi
pendidikan, pekerjaan pernikahan, kebiasaan yang sering dilakukan
(pola tidur, minum alkohol atau merokok, obat- obatan, aktivitas
seksual, sumber keuangan, asuransi kesehatan dan kepercayaan).
 History
• Medications
– NSAIDs
– steroids
– narcotics
• Other treatments for this injury
– Injections
– Bracing
– Physiotherapy
• Allergies ?
• Dominant Hand ?
• Functional Status ?
 Social History
• Occupation
– Working / Retired
– Manual labor / Desk job
• Living situation
– Alone / Spouse / Other supports
– Two storey house / Apartment
• Ambulatory status
– How far can they walk
– Do they use a walker / cane
• Smoking/ Alcohol/ Drug Us
 Specifics to the injury
• Precipitating incident
– trauma (macrotrauma)
– repetitive stress (microtrauma)
– is this a work related injury?
 Specifics to the Injury
• For MVAs
– driver/passenger
– belted/non-belted
– location of impact and severity of crash (required jaws of
life, if anyone died in the crash, thrown from the car, etc)
– speed at impact
– position of the patient and the limb in question at impact
 Associated Symptoms
• In addition to pain do they have:
– Clicking
– Snapping
– Catching
– Locking
– Sensation of giving way (including prior falls or
dislocations)
– Swelling
– Weakness
 Temporality or Timing
• Is it worse when they wake up in the
morning?
• Does it gradually get worse over the course of
the day?
• Does the pain ever wake them up at night?
 Red flags
• Pain at night or rest
• Associated weight loss and loss of appetite
• History Of cancer
• Steroids use
• History Of trauma
• Extreme age
• Bowel or bladder symptoms
 General Considerations for Examination

• When taking a history for an acute problem

always inquire about the mechanism of injury,
loss of function, onset of swelling (< 24
hours),Last meal, and initial treatment
• When taking a history for a chronic problem
always inquire about past injuries, past
treatments, effect on function, and current
symptoms.
 GAIT PATTERNS

The gait pattern, any limb deformities and the use of walking
aids will also be noted. This is particularly relevant when
examining the lower limbs and spine.
Examples of gait patterns include:
•Antalgic gait caused by pain that could be from the sole of the
foot to the hip. The stance phase of the affected limb is
shortened.

•High stepping gait is seen in patients with hereditary

sensorimotor neuropathy or those with a foot drop (peroneal
nerve lesion)
 Gait Cycle - Components:

• Phases:
(1) Stance Phase: (2) Swing Phase:
reference limb reference limb
in contact not in contact
with the floor with the floor
 Gait Cycle - Subdivisions:

A. Stance phase:
1. Heel contact: ‘Initial contact’
2. Foot-flat: ‘Loading response’, initial contact of forefoot w. ground
3. Midstance: greater trochanter in alignment w. vertical bisector of foot
4. Heel-off: ‘Terminal stance’
5. Toe-off: ‘Pre-swing’
 Gait Cycle - Subdivisions:

B. Swing phase:
1. Acceleration: ‘Initial swing’
2. Midswing: swinging limb overtakes the limb in stance
3. Deceleration: ‘Terminal swing’
 COMMON GAIT ABNORMALITIES

A. Antalgic Gait
B. Lateral Trunk bending
C. Functional Leg-Length Discrepancy
D. Increased Walking Base
E. Inadequate Dorsiflexion Control
F. Excessive Knee Extension
 COMMON GAIT ABNORMALITIES:
A. Antalgic Gait
• Gait pattern in which stance phase on
affected side is shortened
• Corresponding increase in stance on
unaffected side
• Common causes: OA, Fx, tendinitis
 COMMON GAIT ABNORMALITIES:
B. Lateral Trunk bending
• Trendelenberg gait
• Usually unilateral
• Bilateral = waddling gait
• Common causes:
A. Painful hip
B. Hip abductor weakness
C. Leg-length discrepancy
D. Abnormal hip joint
 COMMON GAIT ABNORMALITIES:
C. Functional Leg-Length
Discrepancy
• Swing leg: longer than stance leg
• 4 common compensations:
A. Circumduction
B. Hip hiking
C. Steppage
D. Vaulting
 COMMON GAIT ABNORMALITIES:
D. Increased Walking Base
• Normal walking base: 5-10 cm
• Common causes:
– Deformities
• Abducted hip
• Valgus knee
– Instability
• Cerebellar ataxia
• Proprioception deficits
 COMMON GAIT ABNORMALITIES:
E. Inadequate Dorsiflexion Control
• In stance phase (Heel contact – Foot flat):
Foot slap
• In swing phase (mid-swing):
Toe drag
• Causes:
– Weak Tibialis Ant.
– Spastic plantarflexors
 COMMON GAIT ABNORMALITIES:
F. Excessive knee extension
• Loss of normal knee flexion during stance phase
• Knee may go into hyperextension
• Genu recurvatum: hyperextension deformity of
knee
• Common causes:
– Quadriceps weakness (mid-stance)
– Quadriceps spasticity (mid-stance)
– Knee flexor weakness (end-stance)

* * *
 General Considerations for Examination

• The patient should be gowned and exposed

as required for the examination
• Some portions of the examination may not be
appropriate depending on the clinical
situation (performing range of motion on a
fractured leg for example)
 General Considerations for Examination

• The musculoskeletal exam is all about

anatomy

• Think of the underlying anatomy as you

obtain the history and examine the patient
 General Considerations for Examination

• The cardinal signs of musculoskeletal disease

are:
– Pain
– Redness (erythema)
– Swelling
– Increased warmth
– Deformity
– Loss of function
 General Considerations for Examination
• Always begin with inspection, palpation and range of motion,
regardless of the region you are examining which advocated
by Apley as LOOK,FEEL, MOVE
• Specialized tests are often omitted unless a specific
abnormality is suspected
• A complete evaluation will include a focused neurological
exam of the effected area
• Muscle strength is an integral part of the neurological
assessment and is best carried out in a systematic manner
from proximal to distal and recorded using the MRC scale
 Look
• Look for scars, rashes, or other lesions like
abrasions/open wounds
• Look for asymmetry, deformity, or atrophy
• Always compare with the other side
• Look for swelling
• Look for erythema (redness)
• Posture/position of the joint or limb
 Feel
• Examine each major joint and muscle group in
turn
• Identify any areas of tenderness
• Joint line
• Tendinous insertions
• Palpate for any crepitus
• Identify any areas of deformity
• Always compare with the other side
 Feel
• Warm or cold including pulses
• Fluctuation/fluid collection
• Compartments – soft or firm and painful
• Sensation
 Vascular Status
• Pulses
• Upper extremity
– Check the radial pulses on both sides
– If the radial pulse is absent or weak, check the
brachial pulses
• Lower extremity
– Check the posterior tibial and dorsalis pedis
pulses on both sides - if these pulses are absent or
weak, check the popliteal and femoral pulses
 Vascular Status
• Capillary Refill
– Press down firmly on the patient's finger or toe
nail so it blanches
– Release the pressure and observe how long it
takes the nail bed to "pink" up
– Capillary refill times greater than 2 to 3 seconds
suggest peripheral vascular disease, arterial
blockage, heart failure, or shock
 Move : Range of Motion
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?
3) Is movement painful?
4) Is movement accompanied by crepitation?
 Active ROM
• Ask the patient to move each joint through a
full range of motion
• Note the degree and type of any limitations
(pain, weakness, etc.)
• Note any increased range of motion or
instability
• Always compare with the other side
• Proceed to passive range of motion if
abnormalities are found
 Passive ROM
• Ask the patient to relax and allow you to support the
extremity to be examined
• Gently move each joint through its full range of motion
• Note the degree and type (pain or mechanical) of any
limitation
• If increased range of motion is detected, perform special
tests for instability as appropriate
• Always compare with the other side

The passive range will exceed the active only in the following circumstances:
1) when the muscles responsible for the movement are paralyzed
2) when the muscles or their tendons are torn, severed or unduly slack.
Power ( Muscle Strength)
Principles of Examination
REGIONAL EXAMINATION
Neck     
Shoulder    
Elbow   
Wrist & Hand 
Back     
Hip     
Knee     
Ankle & Foot
 Examination of the Neck
3
1. Look : Observe the
patient as a whole.
2. Observe the neck
and shoulders from
in front and behind.
3. Palpate the front
and back of the
neck with the
patient seated and
the examiner
behind.
 Examination of the Neck
4. Assess neck flexion 4.
5.
by asking the
patient to touch their
chest with their chin.
5. Assess extension by
asking the patient to
look up and as far
back as possible.
 Examination of the Neck
6. Assess lateral flexion to both sides
by asking the patient to touch their
shoulder with their ear.
7. Assess rotation by asking the
patient to look over their shoulder,
to the left and right.
8. Begin the neurological assessment
of the upper limb by examining the
motor system. This involves asking
the patient to assume a certain
position and not let you overcome
it. Begin with shoulder abduction
(C5)
9. Shoulder adduction.

10. Elbow extension.

(C7)

11. Elbow flexion (C6)

12. Wrist extension (C6)
13. Wrist flexion (C7)

14. Finger extension (T1)

15. Finger flexion (C8)
16. Thumb abduction.

17. Finger abduction

18. Elicit the reflexes of the
upper limb beginning
with the biceps jerk.
19. Triceps jerk
20. Brachioradialis jerk.
21. Assess co-ordination of
the upper limb.
22. Test sensation of the
upper limb and
determine the
distribution of any loss.
 Examination of the Shoulder

1. Observe the whole

patient, front and back.
2. Observe the shoulder.
3. Observe the axilla

Erythema , Ecchymosis,
Swelling
Side to side comparison
 Examination of the Shoulder
4. Palpate for tenderness over
the sterno-clavicular joint,
clavicle, acromioclavicular
joint, acromion process,
supraspinatus tendon and the
tendon of the long head of
biceps.
5. Observe shoulder abduction
from in front and behind,
through the entire range of
movement. Note the presence
of difficulty in initiation or a
painful arc.
 Examination of the Shoulder
6. Secure the scapula to assess
gleno-humeral movement.
7. Assess flexion and extension.
( no photos)
8. Assess external rotation with
elbows in to the sides and
flexed to 90º .
9. Assess internal rotation by
asking the patient to place
both hands behind the head.
 Examination of the Shoulder

10. Assess internal rotation by asking the patient to reach

over their opposite shoulder, behind the neck and
behind the back.
 Examination of the Shoulder

11. Test biceps function by asking the patient to flex the elbow against
resistance.
12. Test serratus anterior function by asking the patient to push against
a wall, looking for winging of the scapula.
13. Test for pain with palpation of subacromial Bursa - indicates
impingement of the rotator cuff.
 Examination of the Shoulder Instability

14. The apprehension test

standing. Abduct, externally
rotate and extend the patient's
shoulder while pushing on the
head of the humerus with the
opposite hand to test for
anterior subluxation or
dislocation.
15. Apprehension test lying down.
16. Assess any marked instability
in the shoulder.
Anterior - instability (moves too
far forward);
Posterior - instability (moves
too far back). (2 photos)
 Examination of the Elbow

1. Observe the whole patient, front and back, looking especially for
deformity.
Swelling , Redness , Carrying Angle
 Examination of the Elbow

2. Feel for tenderness.

 Examination of the Elbow
3. Accentuate the pain of tennis elbow.

4. point of 5. pain on resisted 6. pain on passive

tenderness. extension. stretch.
 Examination of the Elbow
7. Examine extension. (To 00)
 Examination of the Elbow
8. Examine flexion. ( To 1350)
 Examination of the Elbow

9. Examine supination 10. Examine pronation.

( To 900) ( To 900)
 Examination of the Elbow

11. Pivot shift of elbow 12. Provocative test for Cubital Tunnel Syndrome
(instability). (puts tension on ulnar nerve at elbow).
 Examination of the Elbow

13. Palpate the ulnar nerve.

Examination of the Wrist & Hand
1. Observe the hand positioned on a
pillow or a table. Ensure you have
adequate exposure.
2. Observe the palm of the hand.
3. Observe the dorsum of the hand.
4. Review the anatomy of the hand
noting the tip of the styloid
process, the anatomical snuffbox
bordered by extensor pollicis
brevis and extensor pollicis
longus tendons, the extensor
tendons of the fingers and the
head of the ulna.

5. Feel for tenderness. (no photos) 6. Test active movements of the wrist. (no
photos)
Examination of the Wrist & Hand

7. A useful method for screening of flexion and extension of the wrists. (2

photos)
8. Test passive movements of the wrist beginning with extension. (700)
9. Flexion. ( Nearly 900)
Examination of the Wrist & Hand

10. Radial deviation. 11. Ulnar deviation.

12. Pronation. 13. Supination.
Examination of the Wrist & Hand

14. Test thumb extension. 15. Test thumb abduction.

16. Test thumb adduction. 17. Test opposition.
Examination of the Wrist & Hand

18. Observe movement of fingers from extension to flexion. (2 photos)

19. Test flexor digitorum profundus function by holding the proximal
interphalangeal joint extended and asking the patient to flex the finger.
Successful finger flexion indicates the tendon is intact.
20. Test flexor digitorum superficialis function by holding the other fingers
extended while asking the patient to flex the finger being tested. Successful
flexion indicates the tendon is intact.
Examination of the Wrist & Hand

21. Assess joint hyperextension.

22. Axial compression test.
23. Asses ulnar nerve function with Froment's test. (choice of 2 photos)
24. Asses ulnar nerve/interosseus muscle function by asking the patient to
abduct their fingers while slowly pushing the hands together until the
weaker one collapses.
Examination of the Wrist & Hand
24. Asses ulnar nerve/interosseus
muscle function by asking the
patient to abduct their fingers
while slowly pushing the hands
together until the weaker one
collapses.
25. Assess median nerve
function. (UK sign for FP Lard
FDP working)
26. Assess the function of the
hand with the fine pinch grip
(paperclip).
27. Flat pinch grip (key).
28. Tripod grip (pen).
29. Wide grip (mug).
30. Power grip.
Examination of the Wrist & Hand
• PHALEN’S TEST
– Compression of the median nerve at the wrist
– The wrist flexed maximally for 60 seconds
– Paresthesias in the median nerve distribution
suggest carpal tunnel syndrome
• CARPAL TUNNEL PERCUSSION
– Tinel sign at the wrist
Examination of the Wrist & Hand
• FINKELSTEIN’S TEST

– Painless function of the abductor P.L , Ext P.B

– Flex and ulnarly deviate the wrist, then push
the thumb into flexion
– Sharp pain on the radial border of the wrist 
de quervain’s disease
 Examination of the Back
1. Observe the patient
as a whole, front and
back.
2. Ask the patient to
walk on their toes.
3. Ask the patient to
walk on their heels.
4. Back extension.
 Examination of the Back
5. Back flexion.
6. Bony Excursion:
measure the distance
between two bony
points when standing.
7 Ask the patient to flex
forward, the bony
points should move at
least 5 cm.
8. Lateral flexion
 Examination of the Back
9. Rotation (make sure to anchor
pelvis)
10. FABER test.
Flexion Abduction External
Rotation. Press firmly on the
knee. Pain in the groin
suggests a hip problem and
pain in the back refers to the
sacroiliac joint.
11 Straight leg ranging,
dorsiflexion increases the
sciatic stretch. Watch for pain
and limitation. (2 photos)
12. Femoral stretch test: Hip
extension and passive flexion
of the knee. Watch for pain
and limitation.
 Examination of the Back

A Neurological examination
including:
13. Knee extension.
14. Knee flexion
15. Knee jerk reflex
16. Ankle jerk reflex.
 Examination of the Back

17. Sensation
18. Pain on compression of the head can often be
attributed to non-organic pathology.
 Examination of the Hip
1. Observe the whole
patient.
2. Trendelenburg test
(normal).
3. Positive Trendelenburg
Test.
4. Ask the patient to walk
and observe their gait.
(no photo)
5. Test iliopsoas function by
asking the patient to lift
their thigh off the seat
against resistance.
 Examination of the Hip

6. Ensure the Anterior Superior Iliac Spines are horizontal.

 Examination of the Hip

7. Check the position of the

medial malleoli.
8. Measure from the ASIS
to the medial malleoli. (3
photos)
9. Measure the distance
from the xiphisternum to
the medial malleoli.

10. Feel for the femoral head. It is deep to the femoral pulse. (No photo)
 Examination of the Hip

11. Thomas Test:

Flex both hips to eliminate the lumbar lordosis. Extend the hip you are examining and if it is
normal it should return to the bed. A fixed flexion deformity of the hip will not allow it to
extend to the neutral position. (2 photos)
12. Check the patient is not compensating with a lumbar lordosis.
13. Check the ASIS are horizontal again. Anchor leg over the edge of the bed and abduct the
other hip. (0 0 to 45 0)
14. Assess adduction. ( 200 to 300)
 Examination of the Hip

14. Assess adduction.

15. Internal rotation.
(00 to 450)
16. External rotation .
( 00 to 450)
 Examination of the Knee
1. Observe the patient as a
whole.
2. Observe the knee joint
front and back. Note any
genu valgum (a slight
degree of which is
normal) or genu varum.
3. Observe knee from side.
Note any genu
recurvatum
4. Ask the patient to squat
 Examination of the Knee
5. Assess patellae tracking
from extension to flexion.
Note quadriceps action.
6. Patellar apprehension
test. Apply lateral
pressure to patellar as
the patient flexes the
knee. Observe facial
expressions for fear of
impending dislocation.
7. Observe the knee with
the patient lying on the
bed.
 Examination of the Knee
8. Pick a bony landmark on the
knee and measure a fixed
distance from it to the
approximate centre of the
quadriceps.
9. Measure the circumference of
the of the knee and leg.
10. Feel the temperature of the
knee and leg.
11. Soloman's test. Lift the patella
away from the femur. In
synovial thickening it will be
hard to grasp.
 Examination of the Knee

12. Effusion: Tap Test. Push

sharply on the patella and
with an effusion it will strike
the femur and bounce back.
13. Effusion: Feel for fluid
fluctuance.
 Examination of the Knee

14. Effusion: Bulge Test.

Empty the suprapatellar pouch with pressure above the patella.
Wipe hand along the medial side to displace fluid laterally.
Compress the lateral side and watch for a bulge medially.
 Examination of the Knee

15. Feel the superficial and posterior surface of the patella by pushing it
medially.
16. To test for patello-femoral tenderness press patella against the femur and
ask the patient to tighten their thigh muscles.
17. Palpate for tenderness with the knee flexed to 90°. Feel along the joint line,
the ligaments and the tibial tubercle.
18. Assess extension of the knee.
 Examination of the Knee
19. Flexion.
20. Internal and external
rotation of the knee is
limited.
21. Test collateral ligaments
by applying medial and
lateral pressure to the
lower leg which is tucked
away under the
examiners arm.
22. Look for posterior sag of
the femur signifying
posterior cruciate
dysfunction.
 Examination of the Knee

23. Anterior drawer test. Femur should not move forward

significantly unless the anterior cruciate ligament is torn.
24. Posterior drawer test. (Posterior cruciate)
25. Lachmans test.
 Examination of the Knee
26. MC test - lift leg off the bed
and if tibia drops there is
cruciate dysfunction.
27. MacMurrays test.
Place the thumb and finger on
the joint line. Watching the
patients face for pain, flex the
leg, externally rotate the foot,
abduct and extend leg to test
for medial meniscal "clicks".
Flex the leg, internally rotate
and adduct for lateral meniscal
"clicks". (2 photos)
28. Ask the patient to lie prone
and examine the back of the
knee.
Examination of the Foot & Ankle
Observe patient as a whole
from front and back.
1. From behind check hind-
foot alignment and "too
many toes" sign (tib. post
dysfunction).
2. & 3. Check for inversion
(tibialis function) and
eversion (peroneal
function).
4. Single stance heel raise
test.
Examination of the Foot & Ankle

5. Windlass test. 6. Coin test.

7. Dorsi flexion. 8. Plantar flexion.
Examination of the Foot & Ankle

9. Mid foot abduction/adduction. 10. Extension fore foot.

11. Flexion fore foot. 12. Tib. anterior test.
Examination of the Foot & Ankle

13. Tib. posterior test.

14. Peroneal tendons test.
15. Ankle instability - inversion test.
16. Ankle instability - Anterior draw test.
Examination of the Foot & Ankle

17. Ankle instability -

Posterior draw test.
18. Simmond's test for
TA.
19. Examine the sole.
20. Check pulses,
sensation, reflexes.
THANK YOU