Orthopedic
Examination
DR. Nishandani PT
Orthopedics is the science and art of the
diagnosis and treatment of all diseases and
disorders of the human musculoskeletal system/
locomotor system.
Greek word “Ortho” straight and “pedo” meaning
child. Nicholas Andry defined it as the subject dealt
with the problem of straightening deformities in
children.
The scope of the subject gradually increased to
include all deforming conditions, not only in children
but also in adults.
Preventive orthopaedic was later born when the
specialists in orthopedic started managing fractures
and dislocations, to achieve better results and
minimize deformities.
Till the middle of the eighteenth century,
orthopaedic treatment consisted mainly of
Emblem of Orthopedics
The emblem of orthopedics depicts a
tender young plant with a
deformity in the trunk being tied to
a straight pole used as a splint, to
gradually correct the curvature in
the stem. This typifies the
conservative management of the
deformities, which succeeds well if
it is done when the patient is
young.
Most recently, surgical management
of many orthopedic deformities is
being increasingly used and
accepted. This is symbolically
represented by a modified
Orthopedic Examination
The orthopedic examination is an essential part of the
diagnosis of complaints effecting the muscles, bones, joints
and related tissues.
These tests necessarily involve movement, or the
application of a force to resist movement.
-The purpose of many of these tests is to measure muscle
strength and joint ranges of motion.
-These tests are also used to search for the site and source
of musculoskeletal pain
-If it is necessary to perform a test which could be painful, it
is best that the test be done properly and done only once to
get the necessary information.
This often requires that the patient be able to follow
It is therefore important that examiner to give clear
instructions and, if necessary, demonstrate the
desired movement or position that require for the
test.
-In order to provide an efficient assessment of the
patient, the orthopedic examination should follow a
logical sequence.
This will normally begin with a visual inspection of
the area of complaint.
- Then palpate the area before choosing which
specific tests to perform. - Of the many tests that
could be performed, the efficient clinician will choose
those which form a path to the diagnosis.
This general guideline must be tempered by a
consideration of the patient's condition. Particularly if
a patient is in pain, you may not want to have them
changing position frequently.
Therefore, examiner may perform tests out of sequence
to avoid painful movement. For example, the examiner
might do all of the tests that he think appropriate in the
sitting position and then have the patient lie down and
do tests in that position. In this way, will avoid having
the patient repeatedly sit up and lie down.
Orthopedic tests necessarily involve physical contact
between the clinician and patient.
This may be uncomfortable or embarrassing for some
patients. By words or gestures, you should always try to
explain to the patient that you are going to touch them
before actually doing so.
Depending on their culture, they may expect you to ask
permission before touching. A professional, confident
and respectful attitude will do as much as verbal
communication to win the patient's trust and
cooperation.
Common investigations in orthopedics
1. X-Rays
an electromagnetic wave of
high energy and very short
wavelength, which is able to
pass through many materials
opaque to light.
a photographic or digital image
of the internal composition of
something, especially a part of
the body, produced by X-rays
being passed through it and
being absorbed to different
degrees by different materials.
This can help them diagnose,
monitor, and treat many
medical conditions.
X-rays
X-rays are types of electromagnetic radiation probably
most well-known for their ability to see through a
person's skin and reveal images of the bones beneath
it.
Advances in technology have led to more powerful
and focused X-ray beams as well as ever greater
applications of these light waves, from imaging
teensy biological cells and structural components of
materials like cement to killing cancer cells.
Why is an X-ray performed?
The doctor may order an X-ray to:
examine an area where experiencing pain or
discomfort, monitor the progression of a diagnosed
disease, such as osteoporosis and check how well a
prescribed treatment is working
X-Ray
Almost all Orthopaedic patients with a bone, joint or
soft tissue problem should have a base line X-Ray. Two
Orthogonal (at 90 degrees) views should be taken in
most cases. Specific anatomical examples include:-
Hand – AP, lateral and 30 degree Oblique views
Thumb Base – Roberts view (True PA) and lateral
Scaphoid – 4 view scaphoid series
Wrist – Standardised PA and lateral
Elbow – AP and lateral
Shoulder – True AP, axillary lateral (or Y scapular
instead)
Hip – AP pelvis
Knee - AP and lateral (must be weight bearing views)
2. Ultrasound Scans
An ultrasound probe emits high frequency sound waves that
are passed through the body area being studied. These
waves are reflected back by the structures inside and the
echoes are used to form an image.
The harder the structure they hit, the stronger the echo.
Thus fluid gives no image, while bone gives a very strong
image.
Doppler ultrasound is similar, but also gives an idea of blood
flow in the area.
Examples of conditions where ultrasound is useful include:-
Any tendon inflammatory disorder (De-Quervains)
Any Fluid filled lump (Cysts)
Shoulder impingement
3. Computer Tomography
A CT uses X-Rays to form an image.
Instead of a single X-Ray, as used in a normal
radiograph, CT uses multiple X-Ray beams at
different angles.
The beams pass through the body area and are
picked up on the other side.
The signal is then turned into an image by the
computer. These images can be manipulated into
3-D images.
CT in Orthopaedics is best for looking at bony
anatomy.
Examples of conditions where CT is useful
include:-
Fractures, especially non-unions e.g scaphoid
4. Magnetic Resonance Imaging (MRI)
Radiowaves are sent through the body. These excite
the protons in the cells and push them into a
different position.
As these protons move back into their normal
position, they give off their own radiowaves.
These are picked up by the scanner and turned into
an image.
There are many different sequences that can be
used in MRI. The two most common are:-
T1 = This image shows fat as a bright image and
fluid as a dark image. As a rule of thumb this image
is useful in seeing anatomy.
T2 = This image shows up water (or any fluid) as
very bright. It is therefore useful in looking at
inflammation, cysts etc. As a rule of thumb this
5. Nerve conduction studies (NCS)
This is the study of peripheral nerves and the
muscles they supply.
NCS look at the two functions of peripheral nerves,
sensation and muscle stimulation.
The motor component is performed by electrical
stimulation of a peripheral nerve and reading the
effect in the muscle further down the limb supplied
by that nerve.
The time taken to travel that distance is measured,
as well asthe reaction of the muscle.
The sensory component is similarly performed, but
the measurement is taken at a purely sensory spot
(e.g the tip of the finger).
This will therefore show if there is a block or a slowing
to the impulses travelling down that nerve at a
specific spot e.g the carpal tunnel
6. Blood tests
A number of blood tests are useful
in certain orthopaedic conditions
A). Infection = FBC, ESR, CRP
B). Inflammatory Arthritis = FBC,
ESR, Rheumatoid factor, ANA (anti-
nuclear antibodies)
FBC-
ESR- erythrocyte sedimentation
CRP-creactive protein
Inflammation
Inflammation (from Latin
inflammatio) is
part of the complex biological response
of
The cardinal signs of inflammation
include: pain, heat,
redness, swelling, and loss of function.
Some of these
indicators can be seen here due to an
allergic
reaction.
Healing of Soft Tissue
The definition of healing is "to make whole or well."
healing is desire to:
restore anatomy
restore function
Factors Which Impede Healing (Systemic)
Age
Mal-nourishment
Corticosteroids/NSAIDs
Diabetes
Anti-coagulants
Factors Which Maximize Healing (Systemic)
Adequate nutrition
Calcitonin
Vitamin A
Glucosamine
Anabolic Steroids
Factors Which Impede Healing (Local)
Prolonged immobilization
Rigid fixation
Excessive soft tissue gap
Excessive motion or stress/repeat injury
Factors Which Maximize Healing (Local)
Electrical stimulation
Injectable growth factors
Surgical gap closure/surgical
Controlled motion
Terminologies in
Orthopaedics
Arthrotomy
