special features to orthopaedic history and examination dr. mohamad khairuddin
TRANSCRIPT
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Special features to orthopaedic history and
examination
DR. MOHAMAD KHAIRUDDIN
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INTRODUCTION
HISTORY TAKING (symptoms, previous illness, family, social, drugs, childhood)
EXAMINATIONS
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History taking
Key words IN SYMPTOMS:InjuryPain StiffnessSwellingDeformityInstabilityAltered sensibilityLoss of function
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Injury Date of injury
Nature of injury
Mechanism of injury
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Pain Onset Nature Site Intensity Aggravating & relieving factors ‘referred pain’
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stiffness
Refer to joints ‘morning stiffness’ (inflammatory) Post trauma Contracted capsule / ligaments ‘locking’ / block
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Swelling
Arising sites (soft tissue, bone, joint) ‘tumour’ Edema (trauma) Haemathrosis / synovial effusion
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Deformity Deformed limbs in position (flexion /
extension) Curvature (spine kyphosis or scoliosis) Deformed long bone (bowing tibia,
fractured) Deformed near the joints (cubitus
varus/valgus, genuvarus/genuvalgus) Shortening Affecting growth
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weakness Strength of muscles Neurological cause
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instability
Refer to joint (affecting the stabilization structure)
‘gives way’ ‘Jump out’
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Change in sensibility
Neurological cause Tingling sensation Numbness Entrapment of nerve, neurological
claudication
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Loss of function
Functional disability Unable to comb hair, unbutton cloth,
reaching high object Limit the ability to turn the door knob Can’t squad, put on the socks
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Previous illness
Related to present chief complaint Not related to present problem
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Social History Work relation to injury Compensation cover Adaptation to previous work in the
future Related associated risk factor
(smoking habit, alcohol consumption, etc)
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Family
Genetic linkage diseases Highly association (tumour)
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Examinations
General examination system
Specific examination
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General examination :
LOOK
FEEL
MOVE
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Physical examination: begins from the moment we set eyes on the
patient
OBSERVE - appearance
- posture
- general attitude
- gait
- affected parts or regions
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Normal gait : Gait cycle (sequence of events in each
step) consists of 4 parts (phases) in
sequence : - heel strike - stance phase - toe off - swing phase
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Abnormal Gait (Heel strike):
heel pain – steps on the toes rather
than the heel
“slapping movement” immediately after heel strike is characteristic of foot drop
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Abnormal gait(stance phase) :
Limping results from pain, shortening, or instability
pain – ‘hurries’ off the leg on weight bearing (antalgic gait)
shortening - ipsilateral shoulder droops instability – hip swings sideways over the
weight bearing leg (Trendelenburg gait)
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Abnormal gait (toe off):
fixed flexion of the hip – heel lifts off too soon
Stiff straight knee – whole body is heaved up to provide clearance
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Abnormal gait (swing phase) :
Foot drop – avoid tipping, patients adopts a high-stepping gait
Stiffness (hip & knee) and spasticity
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General examination of the affected parts:
- exposure of the region
- comparing the opposite limb
- examine good limb first
- follow systematic sequence :
look
feel
move
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LOOK : Skin : scar, colour, and creases
Shape : swelling, lumps, wasting
Position or attitude : deformity
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Deformity : applied to a person, a bone or a joint person – “short stature” bone – “bowing” joint – “unnatural position” e.g : varus – distal part to the joint towards the midline (knee joint : genuvarus) valgus – away from midline (knee joint : genuvalgus)
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FEEL: Skin : warm or cold, moist or dry Soft tissues : lump? Characteritic –
site,margin, consistency,tenderness, multiplicity
Bones and joints : outlines normal? effusion? Tenderness : location?--- what structures?
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MOVE : measure the range of movement of the
respective joints involved in degrees
Common planes of movement in respective joints e.g : flexion/extension,adduction/abduction, external rotation/internal rotation, pronation/supination
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MOVE : Move the joint Not testing the muscle contraction Performing movement :
- Active
- Passive
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MOVE (Active) :
Patient move the joint Is the movement smooth or hesitant
and painful? If limitation due to pain present,
passive movement needs caution and gentle
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MOVE (passive): Examiner move the joints
Record the ROM in each physiological plane
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Abnormal movement : Joint ‘stiffness’ Three types of stiffness : 1) all movements absent – ‘fixed joint’ (arthrodesis/ankylosis) 2) all movement limited – ‘irritable joint’ due to inflammation 3) some movements limited – affect one plane eg. Meniscus tear, group of muscles paralysed, bony deformity
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Specific examinations
EXAMPLES: Laxity tests to the joint Trendelenburg’s hip test Thomas test for FFD of hip Limb length measurement
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Other assessment :
Peripheral vascular examination Nervous system examination
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Vascular assessment : Understanding the anatomy of
vascular system to the limbs
Assess for features of vascular occlusion : diminished pulse
cold extremities
pale or dusky
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Neurological assessment :
What system to assess?
- central (spinal cord)
- peripheral nerve (brachial plexus
or respective peripheral nerves
e.g median,radial,& ulnar nerve,
sciatic nerve)
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CLINICAL SKILLS
NEED FREQUENT PRACTISE !
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