Mr Abtin AlvandMr Abtin AlvandSpecialist Registrar in Trauma & OrthopaedicsSpecialist Registrar in Trauma & Orthopaedics

John Radcliffe Hospital, OxfordJohn Radcliffe Hospital, Oxford

Focused History taking & Focused History taking & Examinations in Orthopaedic Examinations in Orthopaedic

SurgerySurgery

OverviewOverview

General OSCE tipsGeneral OSCE tipsOrthopaedic History TakingOrthopaedic History TakingExamination of the Hip JointExamination of the Hip JointExamination of the Knee JointExamination of the Knee JointExamination of the HandExamination of the Hand

General OSCE TipsGeneral OSCE Tips

““Act / think as if Act / think as if …”…”Wash handsWash handsIntroduction / seek permissionIntroduction / seek permissionSite of pain (if any)Site of pain (if any)Patient PositioningPatient PositioningPatient ExposurePatient ExposureFocused History (if requested)Focused History (if requested)

Orthopaedic ExaminationsOrthopaedic Examinations

LOOKLOOK(GAIT)(GAIT)(MEASURE)(MEASURE)FEELFEELMOVEMOVESPECIAL TESTSSPECIAL TESTS

Orthopaedic ExaminationsOrthopaedic Examinations

Always Always Compare with contra lateral jointCompare with contra lateral joint

Upper Limb: Upper Limb: Functional Assessment Functional Assessment Cervical SpineCervical Spine

Lower LimbLower LimbGaitGaitWalking aidsWalking aidsThoracolumbar SpineThoracolumbar Spine

To Conclude your examinationTo Conclude your examination……

Assess the neurovascular status of the limbAssess the neurovascular status of the limbExamine the joint above and joint belowExamine the joint above and joint belowView ImagingView ImagingOther investigations (ESR, Rh factor)Other investigations (ESR, Rh factor)

Orthopaedic History TakingOrthopaedic History Taking

PainPainLoss of functionLoss of functionSwellingSwellingStiffnessStiffnessDeformityDeformity

(Establish the chronicity of symptoms)

PainPain

Most common hip / knee symptomMost common hip / knee symptomSite / RadiationSite / Radiation

Remember referred painRemember referred painHip pain felt in groin / anterior thigh / kneeHip pain felt in groin / anterior thigh / kneeHip pain may originate from lumbar spine pathologyHip pain may originate from lumbar spine pathology

Severity (Night pain!) / type of analgesic Severity (Night pain!) / type of analgesic requiredrequiredFrequency & associationFrequency & association

Early morning pain (commonly inflammatory origin)Early morning pain (commonly inflammatory origin)

Loss of functionLoss of function

Impact onImpact onActivities of Daily Living (especially Hands)Activities of Daily Living (especially Hands)

Use of stairsUse of stairsMobility (walking aids)Mobility (walking aids)OccupationOccupationSocial / sporting activitiesSocial / sporting activitiesSleepSleepPsychological well beingPsychological well being

SwellingSwelling

Unilateral vs. bilateralUnilateral vs. bilateralTime of onset Time of onset

ACL vs. Meniscal injuries ( immediate vs. delayed ACL vs. Meniscal injuries ( immediate vs. delayed effusion)effusion)

Relation to activity level (worse with OA)Relation to activity level (worse with OA)

StiffnessStiffness

More marked in RA More marked in RA Early morningEarly morningTakes longer to diminishTakes longer to diminish

Hip: Ability to get in/out of bath, care for feetHip: Ability to get in/out of bath, care for feetUpper limb: Feeding / washing / groomingUpper limb: Feeding / washing / groomingKnees: ?Locking (meniscal injury)Knees: ?Locking (meniscal injury)

DeformityDeformity

ChronicityChronicityAcute: Tendon ruptures e.g. rheumatoid handsAcute: Tendon ruptures e.g. rheumatoid handsChronic: Often degenerativeChronic: Often degenerative

Causes:Causes:Ligament / tendon ruptureLigament / tendon ruptureMuscle contracture / paralysisMuscle contracture / paralysisMechanical (Torn meniscus in locked knee)Mechanical (Torn meniscus in locked knee)Pain Pain

Orthopaedic History TakingOrthopaedic History Taking

AgeAgeLocation of symptomsLocation of symptoms

Unilateral (OA) vs. Bilateral (RA)Unilateral (OA) vs. Bilateral (RA)PolyarthropathyPolyarthropathy

PMHPMHPrevious history of trauma (predisposes to OA)Previous history of trauma (predisposes to OA)ArthritidesArthritidesPrevious joint surgeryPrevious joint surgeryChildhood: Developmental Dysplasia of the HipChildhood: Developmental Dysplasia of the Hip

Orthopaedic History TakingOrthopaedic History Taking

Medication:Medication:Analgesics Analgesics NSAIDS, steroids or disease modifying drugsNSAIDS, steroids or disease modifying drugs

Social Hx: Occupation / hobbies / sportsSocial Hx: Occupation / hobbies / sportsOther:Other:

Walking aidsWalking aidsAffect of symptoms on ADL, sleep, workAffect of symptoms on ADL, sleep, work

Examination of the Examination of the Hip Joint Hip Joint

The Hip JointThe Hip Joint

Ball and Socket jointBall and Socket joint

““LookLook””While standingWhile standing

Alignment & Deformity: Increased lumbar Alignment & Deformity: Increased lumbar lordosis indicating fixed flexion deformitylordosis indicating fixed flexion deformitySurgical scars (often lateral or posterior)Surgical scars (often lateral or posterior)SinusesSinusesSkin changesSkin changesMuscle wasting (gluteal muscles)Muscle wasting (gluteal muscles)

Trendelenburg TestTrendelenburg Test

If positive implies dysfunction / weakness of hip If positive implies dysfunction / weakness of hip abductorsabductorsCauses: chronic hip pain, iatrogenic injury, childhood Causes: chronic hip pain, iatrogenic injury, childhood diseases (DDH, polio) diseases (DDH, polio)

““GaitGait””

Use of walking aids?Use of walking aids?

Trendelenberg: WaddlingTrendelenberg: Waddling

Antalgic : Painful, short stance phaseAntalgic : Painful, short stance phase

HighHigh--stepping: Foot dropstepping: Foot drop

““MeasureMeasure””

Apparent leg lengthApparent leg length Real leg lengthReal leg length

““FeelFeel””

Greater trochanters: BursitisGreater trochanters: Bursitis

““MoveMove””

Flexion (130Flexion (130°°))

““MoveMove””

Internal Rotation (45Internal Rotation (45°°))Early sign in arthritisEarly sign in arthritis

““MoveMove””

External Rotation (45External Rotation (45°°))

““MoveMove””

Abduction (45Abduction (45°°))

““MoveMove””

Adduction (30Adduction (30°°))

““MoveMove””

Extension (10Extension (10°°))

Special Tests:Special Tests:Thomas TestThomas Test

To detect fixed flexion deformity of the To detect fixed flexion deformity of the LEFTLEFThiphip

Examination of the Examination of the Knee JointKnee Joint

AnatomyAnatomy of the kneeof the knee

Largest articular joint in the body

3 bones: femur, tibia, patella

Has no intrinsic stability

It relies on ligaments for stability

Most important ligaments are: MCL, LCL, ACL, and PCL

Anatomy of the kneeAnatomy of the knee

The MCL limits abductionThe MCL limits abductionThe LCL limits adductionThe LCL limits adductionThe ACL prevents anterior The ACL prevents anterior displacement of the tibia on the displacement of the tibia on the femurfemurThe PCL prevents posterior The PCL prevents posterior displacement of the tibia on the displacement of the tibia on the femurfemurThe menisci form a cup on the flat The menisci form a cup on the flat tibia to provide supporttibia to provide support

““LookLook””

Gait Gait AntalgicAntalgic

AlignmentAlignmentScarsScars

Arthroscopy portalsArthroscopy portalsOpen meniscectomy : Crescent shapedOpen meniscectomy : Crescent shapedJoint Replacement: MidlineJoint Replacement: Midline

Skin changes e.g. PsoriasisSkin changes e.g. PsoriasisMuscle wasting : QuadricepsMuscle wasting : Quadriceps

““LookLook””Alignment Alignment

• Valgus: lateral angulation distal to the knee (Bilateral common in RA)

• Varus: medial angulation distal to the knee joint (Common in OA due to cartilage loss in medial compartment)

• Fixed flexion: ?? locked

““MeasureMeasure””

Fixed point above the tibial tubercle (15cm)Fixed point above the tibial tubercle (15cm)Measure quadriceps muscle bulkMeasure quadriceps muscle bulkCompare with opposite legCompare with opposite legMuscle wasting due to knee pain and hence Muscle wasting due to knee pain and hence disusedisuse

Images Copyright © Clinical Skills Education Centre 2008- Queens

University Belfast

““FeelFeel””

TemperatureTemperatureCompare with opposite Compare with opposite legleg

(Active RA, haemarthrosis, (Active RA, haemarthrosis, septic arthritis)septic arthritis)

Images Copyright © Clinical Skills Education Centre 2008- Queens

University Belfast

““FeelFeel””Knee EffusionKnee Effusion

Cup your left hand over the Cup your left hand over the suprapatellar pouch and milk suprapatellar pouch and milk the fluid into the joint cavitythe fluid into the joint cavityPatellar tap:Patellar tap: Using other Using other index & middle finger (Large index & middle finger (Large effusions)effusions)Bulge Test:Bulge Test: Use the other Use the other hand to stroke/empty the hand to stroke/empty the medial compartment.medial compartment.Then stroke the lateral side Then stroke the lateral side looking for a bulge on medial looking for a bulge on medial side (Moderate effusions) side (Moderate effusions)

““FeelFeel””

• Patient sitting with the knee in flexed position

•Orient yourself by placing thumbs into the soft tissue on either side of the patellar tendon

•Work your way round systematically

““FeelFeel””Palpable landmarks of the medial kneePalpable landmarks of the medial knee

““FeelFeel””Patellar TendonPatellar Tendon

Run from the patella to Run from the patella to the tibial tubercle and the tibial tubercle and pes anserinuspes anserinus

““FeelFeel””Medial Tibial Plateau & Joint spaceMedial Tibial Plateau & Joint spacePush your thumb posteriorly Push your thumb posteriorly to feel the sharp edge of the to feel the sharp edge of the medial tibial plateaumedial tibial plateauThe plateau serves as an The plateau serves as an attachment point for the attachment point for the medial meniscus and will be medial meniscus and will be tender with a medial tender with a medial meniscus tear. meniscus tear.

““FeelFeel””Medial Collateral LigamentMedial Collateral Ligament

The MCL is a broad ligament The MCL is a broad ligament that joins the medial femoral that joins the medial femoral epicondyle and the tibia. At epicondyle and the tibia. At the midpoint of the MCL, it the midpoint of the MCL, it is attached to the medial is attached to the medial meniscusmeniscus

Tearing of the MCL often Tearing of the MCL often results in a concomitant tear results in a concomitant tear of the medial meniscusof the medial meniscus

““FeelFeel””Palpable landmarks of the lateral KneePalpable landmarks of the lateral Knee

““FeelFeel””Lateral tibia plateau & Joint spaceLateral tibia plateau & Joint spacePush down with your thumb Push down with your thumb into the soft tissue until you into the soft tissue until you feel the sharp edge the lateral feel the sharp edge the lateral tibia plateautibia plateauThe lateral meniscus is The lateral meniscus is secured to the edge of the secured to the edge of the tibial plateau and when torn tibial plateau and when torn this site may be tender to this site may be tender to palpation.palpation.

““FeelFeel””Lateral Collateral LigamentLateral Collateral Ligament

The LCL joins the lateral The LCL joins the lateral femoral epicondyle and the femoral epicondyle and the fibular head. It exists fibular head. It exists independently from the joint independently from the joint capsule, tenderness at this capsule, tenderness at this site may indicate a tearsite may indicate a tearThe ligament may be torn in The ligament may be torn in some injuries, but the some injuries, but the incidence is much lower then incidence is much lower then tears in the MCLtears in the MCL

““MoveMove””

Active & Passive range of movementActive & Passive range of movement

Flexion (135Flexion (135°°))

Extension (0Extension (0°°))

Feel for crepitus & look for painFeel for crepitus & look for pain

Special Tests:Special Tests:The Cruciate ligaments The Cruciate ligaments

Flex the knees to 90Flex the knees to 90°° and look for and look for posterior sagposterior sag (PCL)(PCL)Sit against the base of the leg to Sit against the base of the leg to prevent movement & ensure the prevent movement & ensure the hamstrings are relaxed hamstrings are relaxed Place both hands on the tibia Place both hands on the tibia posteriorly, just below the knee posteriorly, just below the knee Anterior Drawer Test for ACLAnterior Drawer Test for ACL: : Pull anteriorly on the tibia Pull anteriorly on the tibia -- there there should be a sharp end point and should be a sharp end point and no excessive forward movementno excessive forward movementPosterior Drawer Test for PCLPosterior Drawer Test for PCL: : Push back on the tibiaPush back on the tibia

Special Tests:Special Tests:The Lachman TestThe Lachman Test

ACL integrityACL integrityKnee relaxed in 15Knee relaxed in 15°°flexionflexionOne hand stabilises the One hand stabilises the femur while the other femur while the other one tries to lift the tibia one tries to lift the tibia forwardforwardPositivePositive: if tibia moves : if tibia moves forward (detected with forward (detected with thumb in the joint)thumb in the joint)

Special Tests:Special Tests:Collateral LigamentsCollateral Ligaments

Place the patient's ankle between Place the patient's ankle between your elbow and side. Support the leg your elbow and side. Support the leg with an arm with an arm Using both hands attempt to abduct Using both hands attempt to abduct and adduct the tibia at the knee and adduct the tibia at the knee Valgus Stress Test (MCL)Valgus Stress Test (MCL)

Carried out in 10Carried out in 10°° flexion.flexion.Pain or movement on abduction Pain or movement on abduction suggests medial collateral damage suggests medial collateral damage

Varus Stress Test (LCL)Varus Stress Test (LCL)Carried out in full extensionCarried out in full extensionPain or movement on adduction Pain or movement on adduction suggests lateral collateral damage suggests lateral collateral damage

Special Tests:Special Tests:Menisci Menisci –– McMurrayMcMurray’’s tests test

Medial MeniscusMedial Meniscus: Flex the knee : Flex the knee and externally rotate the foot, thus and externally rotate the foot, thus loading medial compartment. loading medial compartment. Palpate the posteromedial joint line Palpate the posteromedial joint line and extend the leg. A palpable click and extend the leg. A palpable click / pain is indicative of a tear. / pain is indicative of a tear. Lateral Meniscus: Flex the knee Lateral Meniscus: Flex the knee and internally rotate the foot. and internally rotate the foot. Palpate the posterolateral joint line Palpate the posterolateral joint line and extend the leg.and extend the leg.

Cases:Cases:Meniscal TearsMeniscal Tears

Meniscus tears are the most common of knee injuries

It’s all in the history

Associated with

locked knees,

Slow occurring mild effusion

Tenderness over the joint line

The medial meniscus is injured more often because it is more firmly attached and less mobile

Cases:Cases:Arthritis of the kneeArthritis of the knee

HistoryHistoryAgeAgeOccupationOccupationPain Pain StiffnessStiffnessDeformity (Valgus in RA, Deformity (Valgus in RA, Varus in OA)Varus in OA)Previous Hx of traumaPrevious Hx of trauma

ExaminationExaminationScars, skin changes, quads Scars, skin changes, quads wastingwastingTemperature / effusionTemperature / effusionCrepitus / stiffness / Crepitus / stiffness / instability (late RA)instability (late RA)Blood testsBlood testsXX--raysrays

Cases:Cases:Cruciate Ligament RuptureCruciate Ligament Rupture

HistoryHistoryMechanism of injury Mechanism of injury (hyperextension)(hyperextension)Swelling (immediate & Swelling (immediate & large)large)InstabilityInstabilityStair climbingStair climbing

ExaminationExaminationQuads wastingQuads wastingEffusionEffusionPosterior sagPosterior sagLachmanLachman’’s / Draw Tests / Draw TestImagingImaging

Examination of the Examination of the HandHand

LookLook

ExposureExposureSkinSkin

Thin (steroid use)Thin (steroid use)Digital ulceration Digital ulceration (Vasculitides)(Vasculitides)

ScarsScarsCarpal Tunnel Carpal Tunnel DecompressionDecompressionDupuytrenDupuytren’’s surgerys surgery

SymmetrySymmetryBilateral in RABilateral in RASingle joint (previous Single joint (previous trauma/overuse) or trauma/overuse) or Polyarticular in OAPolyarticular in OAUnilateral Nerve lesionsUnilateral Nerve lesions

Muscle wastingMuscle wastingDorsal interossei in RA Dorsal interossei in RA due to painful disusedue to painful disuseThenar muscles in Carpal Thenar muscles in Carpal Tunnel SyndromeTunnel Syndrome

LookLook

HeberdonHeberdon’’s nodess nodes: : Bony lumps, flexed Bony lumps, flexed DIPJs (OA)DIPJs (OA)BouchardBouchard’’s nodess nodes: : PIPJs (OA)PIPJs (OA)

““Metacarpal bossingMetacarpal bossing”” or or ““square handssquare hands”” at the at the CMCJs (OA)CMCJs (OA)

LookLook

Ulna DeviationUlna Deviation at at MCPJs (RA) : MCPJs (RA) :

Weakening / elongation Weakening / elongation of the capsule/ligaments of the capsule/ligaments hence joint subluxationhence joint subluxation

““ZZ”” thumbthumb deformity deformity (RA):(RA):

Hyperextension at MCPJ Hyperextension at MCPJ and flexion at IPJand flexion at IPJ

LookLook

Swan neck deformity (RA): Swan neck deformity (RA): Hyperextension of PIPJ and Hyperextension of PIPJ and flexion of DIPJflexion of DIPJDue to DIP extensor tendon Due to DIP extensor tendon laxity/rupture and PIPJ volar plate laxity/rupture and PIPJ volar plate laxitylaxity

Boutonniere deformity (RA):Boutonniere deformity (RA):Hyperextension of the DIPJ Hyperextension of the DIPJ and flexion of the PIPJand flexion of the PIPJPIP synovitis & capsular elongation PIP synovitis & capsular elongation causes extensor tendon lengthening causes extensor tendon lengthening and lateral band slipand lateral band slip

FeelFeel

Systematic examination of every joint: distal to Systematic examination of every joint: distal to proximal proximal Joint SwellingJoint SwellingPalms (contracture in DupuytrenPalms (contracture in Dupuytren’’s)s)TendernessTendernessWarmth (active RA)Warmth (active RA)Elbows (Rheumatoid nodules in 20% RAs)Elbows (Rheumatoid nodules in 20% RAs)

MoveMove

Systematic examination of every joint: distal to Systematic examination of every joint: distal to proximalproximalActive / passiveActive / passiveDigitsDigits

Flexion (FDS & FDP Tendons)Flexion (FDS & FDP Tendons)ExtensionExtension

Thumb (opposition, abduction, adduction, extension, Thumb (opposition, abduction, adduction, extension, flexion)flexion)Wrist ( flexion, extension, Wrist ( flexion, extension, ulnarulnar / radial deviation)/ radial deviation)Joint stabilityJoint stability

““Special testsSpecial tests””SensationSensation

Median NerveMedian NerveSensation: Thenar eminenceSensation: Thenar eminenceMotor: Abductor Pollicis Brevis (Motor: Abductor Pollicis Brevis (““dorsum flat on table, dorsum flat on table, thumb to the ceilingthumb to the ceiling””) )

Ulnar NerveUlnar NerveSensation: Thenar eminenceSensation: Thenar eminenceMotor: Palmer interossei (finger adduction), adductor pollicis Motor: Palmer interossei (finger adduction), adductor pollicis (Froment(Froment’’s Test)s Test)

Radial NerveRadial NerveSensation: 1Sensation: 1stst dorsal web spacedorsal web spaceMotor: MCP extensionMotor: MCP extension

DermatomesDermatomes

““Special TestsSpecial Tests””

CirculationCirculationCapillary refillCapillary refillAllenAllen’’s Tests Test

FUNCTIONAL ASSESSMENT!FUNCTIONAL ASSESSMENT!

Exam preparationExam preparation

PracticePractice

PracticePractice

Practice ...Practice ...

Passed!!Passed!!

Thank youThank you