Diagnosis in Orthopedics

What is

Orthopedic Orthopaedic

Steps in diagnosis:

History Clinical Exam Imaging Laboratory

Orthopedic Symptoms and Sign

History Taking and Clinical Examination)

History

Is the USUAL medical History

EVENTS and Dates

Physical examination (or clinical examination)

The process by which a health care provider investigates the body of a patient for signs of disease.

Physical Examination:

General Examination Limb Examination

Musculoskeletal Vascular Nervous

Thank You

History

Chief Complaint (Presenting Complaint): (C/O or CC) History of Present Illness: (HPI) Review of Systems: (ROS)

Alimentary, Respiratory, Cardiovascular, Urogenital, Nervous, Metabolic

Past medical History: Drug History: Family History: Social History:

History

Symptoms of disease Cause of the disease Differential diagnosis Effect of the disease on other systems Effect of other system on affected system Other unrelated condition

Diagnosis:
1- common presentation of common disease 2- uncommon presentation of common disease 3- common presentation of uncommon disease 4- uncommon presentation of uncommon disease 5- multiple pathologies

Personal Data:
Name: Age : Sex : Marital Status: Occupation:

1 Age and limping

Musculoskeletal System History:

Pain
Deformity Loss of function

Musculoskeletal System History:

Pain: Site, Radiation Durations, Onset, Progression, Offset Precipitating, Relieving Factors Nature, Severity, Cause

Pain: types:

Somatic Visceral Referred

Pain: somatic :source

Bone

Localized Diffuse Articular Pararticular

Joint

Muscle and tendon

Pain site

Pain site:

Single Oligo Poly Migratory Additive

Pain: timing

Morning Night Activity Posture

Pain Radiation:

Shoulder:

Anterior Lateral posterior

Pain onset:

Very Acute Acute Subacute Chronic

Course:

Progressive: Regressive: Intermittent:

Pain severity:

Diagnosis Management

Musculoskeletal System History:

Pain
Deformity Loss of function

Musculoskeletal System History:

Deformity: Swelling Rotation Angulation

Musculoskeletal System History:

Loss of function: Stiffnes, Loss of motion Weakness Limping

Musculoskeletal System History:

History of Lump (Mass): Duration First Symptom Other Symptoms Progression Persistence Multiplicity Cause

Musculoskeletal System History:

History of Ulcer: Duration First Symptom Other Symptoms Progression Persistence Multiplicity Cause

Musculoskeletal System History:

Pain
Deformity Loss of function

Loss of function:

Sensory
Paresthesia / anesthesia

Motor
Weakness Clumziness

Motion
Loss or range Locking / Pseudolocking / Triggering

Weakness:

Painless
Nerve, NM junction, muscle Disuse

Painful

Extra-articular manifestation:
Skin: SLE, Psoriasis, Scleroderma, Sucutaneous nodule Ischemia, Ulceration, Gangrene Neurologic: Eye, psychological, neuritis, weakness

GI: oral ulcers, bleeding, obstruction

Respiratory: pneumonia, fibrosis, hemoptysis Urogenital: ulcers

Drugs and Allergies

Corticosteroids Osteoporosis, myopathy, avascular necrosis, infections Statins Myalgia, myositis, myopathy Angiotensin-converting enzyme inhibitors Myalgia, arthralgia, positive antinuclear antibody Antiepileptics Osteomalacia, arthralgia Immunosuppresant/cytotoxic Infections Quinolones Tendonopathy, tendon rupture

Past History:
Diseases: Treatment:

Operation:

Occupation:
Repetitive strain injury, Hand-vibration syndrome, Fatigue fractures.

Drugs and Allergies

Drugs and Allergies

Smoking Alcohol

ROS
Gastrointestinal system Mouth (oral ulcers, dental problems) Difficulty swallowing (dysphagia - distinguish from odynophagia) Nausea and vomiting, haematemesis) Indigestion Heartburn Abdominal pain Change in bowel habit Change in colour of stools (pale, dark, tarry black, fresh blood)

ROS
General health Well-being Energy Appetite Sleep Weight change Mood

ROS
Cardiovascular System Chest pain on exertion (angina) Breathlessness: lying flat (orthopnoea) at night (paroxysmal nocturnal dyspnoea) on minimal exertion - record how much Palpitation Pain in legs on walking (claudication) Ankle swelling

Respiratory system Shortness of breath (exercise tolerance) Cough Wheeze Sputum production (colour, amount) Blood in sputum (haemoptysis) Chest pain (due to inspiration or coughing)

ROS
Nervous system Headaches Dizziness (vertigo or light-headed) Faints Fits Altered sensation (numbness or tingling (paraesthesiae)) Weakness Visual disturbance Hearing problems (deafness, tinnitus) Memory and concentration changes Endocrine Heat or cold intolerance Change in sweating Excessive thirst (polydipsia) Other: Bleeding or bruising

ROS
Genitourinary system Pain passing urine (dysuria) Frequency passing urine (at night, nocturia) Blood in the urine (haematuria) Sexual partners - unprotected intercourse Men If appropriate: prostatic symptoms including difficulty starting hesitancy poor stream or flow terminal dribbling incontinence urethral discharge libido erectile difficulties

ROS
Women Last menstrual period (consider pregnancy) Timing and regularity of periods Length of periods Abnormal bleeding Vaginal discharge Contraception If appropriate: libido pain during intercourse (dyspareunia) incontinence (stress and urge)

Habits:

Points on the Physical Exam

Observation is the First and Most Important Step in the Examination

General exam: Ac vs chronic, Pain, nutrition, Rash posture of the patient. muscular movements present?

Tremors, twitching of facial muscles, tonic, clonic choreiform or athetoid movements of various muscles, extremity or truncal, absence of movement from one or more extremities.

Begin slowly with a nonthreatening part of the examination, (e.g. the hands and the healthy side. )

Why Physical Examination ?!!

Confirm diagnosis of disease Rule out diagnosis of the disease Severity of disease Effect of the disease on other organs/ systems Other unrelated condition Treatment ( Choice and complications)

Physical Examination of a limb:

General

Exam MusculoSkeletal Nerve Artery/ vein Local Lymphnode

Musculoskeletal Examination:
Look
Feel

Move

Listen, others

Physical Examination:

Look

Skin
Color Scar Sinus/ ulcer Tumor

Shape/ Swelling/Deformity Attitude

Musculoskeletal Examination:
Look
Feel

Move

Listen, others

Physical Examination:
Feel

( What?)
: At rest and contraction

Skin Subcutaneous Muscle Tendon

Bone
Joint

Physical Examination:
Feel

(for What):
Superficial and deep

Temperature
Tenderness:

Masses:

Superficial and deep

Examination of a lump:

Site, Shape, Size, Surface, Skin Tender, Temperature, Tethering Reducible Composition:

Consistence Fluctuation Resonance Fluid thrill Translucency Pulsation Compressibility Bruit

Local Lymphatic

Examination of Ulcer:

Base Edge

Undermined Punched-out Slope Rolled Everted

Depth Discharge Relations

Examination of Ulcer:

Edge

Examination of Ulcer:

Base Edge

Undermined Punched-out Slope Rolled Everted

Depth Discharge Relations

Musculoskeletal Examination:
Look
Feel

Move

Listen, others

Physical Examination:
Move:
Active Passive Provoked:

Abnormal Reflex: superficial, deep

Hip Examination:

Look, feel, move Stability Nelatons line Thomas Test (for fixed flexion deformity) Trendelinberg Limb length ( Real and Apparent)

Hip Examination:

Look, feel, move Stability Nelatons line Thomas Test (for fixed flexion deformity) Trendelinberg Limb length ( Real and Apparent)

Hip Examination:

Look, feel, move Nelatons line Thomas Test (for fixed flexion deformity) Trendelinberg Limb length ( Real and Apparent)

Knee Examination:

Look, feel, move

Hand Examination

Look, Feel, Move Nerve Vascular

Hand Examination - Nerve

Hand Examination - Nerve

Phalen Tinel Sign

FIGURE 4. Radiograph showing sharply "punched-out" bony defects of the distal radius and proximal phalynx of the middle finger.

FIGURE 5. Monosodium urate crystals from a tophus, observed with polarized light microscopy. FIGURE 6. Intracellular monosodium urate crystal from synovial fluid, observed with polarized light microscopy.

Negative birefringence :
yellow when is parallel to the light

blue when is

perpendicular

Reverse Lasgue Test (Femoral Nerve Lasgue )

L3 L4 root only of significance if pain radiating down the front of the symptomatic thigh

not down the thigh of the asymptomatic leg

163

heel-toe walking

walking on the heels:

tests of L5 motor function.

walking on the toes:

test of S1 motor function

164

Schober Sign

the S1 spinous process and a point 10 cm superior to it.

about 15 cm in flexion A distance of 89 cm in maximum extension

Straight Leg raise

This test is biased toward the lower part of the lumbo-sacral plexus (L4 S1) A crossed leg (opposite leg) response may indicate disk bulge medial to the opposite side root

Lasegue Sign

Variation of Straight leg raise Flex hip first with bent knee and then straighten knee or Dorsiflex ankle with straight leg elevation to elicit increased pain

Patricks Test (FAbER)

Sacroiliac Testing

Cervical Examination

The foraminal compression test or Spurling test positive if pain radiates into the limb ipsilateral to the side that the head is rotated to. Lhermitte sign is performed by flexing the neck and asking the patient about symptoms of an electric shocklike sensation radiating down the spine, and in some patients, into the extremities. found in cervical cord involvement

cervical spondylosis tumor multiple sclerosis (MS).

Thoracic and Lumbar Spine Tests

1.

2.
3.

4. 5. 6. 7.

8.
9. 10. 11.

Adams Forward Bend Test Kyphosis Test on Hands and Knees Test of Segmental Function in the Thoracic Spine in Extension Prone Knee Flexion Test Spinous Process Tap Test Psoas Sign Lasgue Straight Leg Drop Test Springing Test Hyperextension Test Supported Forward Bend Test (Belt Test) Hoover Test

Tests of the sacroiliac joint Ligament Tests

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Springing Test Patrick Test (Fabere Sign) Three-Phase Hyperextension Test Spine Test Standing Flexion Test Sacroiliac Mobilization Test Sacroiliac Joint Springing Test Derbolowsky Sign Gaenslen Sign Iliac Compression Test Mennell Sign Yeoman Test Laguerre Test Abduction Stress Test Sacroiliac Stress Test

Nerve Root Compression Syndrome

1.
2. 3. 4.

5. 6.

7.
8. 9. 10. 11. 12.

Lasgue Sign (Straight Leg Raising Test) Bonnet Sign (Piriformis Sign) Lasgue Test with the Patient Seated Contralateral Lasgue Sign (LasgueMoutaud Martin Sign) Bragard Test Lasgue Differential Test Duchenne Sign Thomsen Sign Kernig Test Tiptoe and Heel Walking Test Brudzinski Sign Reverse Lasgue Test (Femoral Nerve Lasgue 172

Chest Circumference Test

Measures the circumference of the chest at maximum inspiration and expiration. The circumference is measured immediately above the convexity of the breast in women, and immediately below the nipples in men

The difference in chest circumference between maximum inspiration and expiration normally lies between 3.5 and 6 cm

Ankylosing spondylitis

impairment of inspiration and expirationis usually painless.

Impaired or painful inspiration and expiration with limited depth of breathing is observed in

costal and vertebral dysfunctions inflammatory or tumorous pleural processes pericarditis.

Bronchial asthma and emphysema are associated with painless impaired expiration.

Schepelmann Test

For the differential diagnosis of chest pain. patient is seated and is asked to bend first to one side, then to the other.

Pain on the concave side a sign of intercostal neuralgia; pain on the convex side a sign of pleuritis. painful on any movement of the spin Rib fractures are. e

ODonoghue Test

Differentiates between ligamentous pain and muscular pain in the back of the neck

pain during this active head motion muscular dysfunction pain during passive lateral bending of the cervical spine a functional impairment ligaments or articular, possibly degenerative processes

Shoulder Press Test

Results: radicular symptoms or Circumscribed pain on the stretched side or Decreased muscular pain in not stretched side

Thank You

Steps in diagnosis:

History Clinical Exam Imaging Laboratory

Steps in diagnosis:

History Clinical Exam Imaging

X-Ray: plain, contrast, CT Ultrasound Radio isotope MRI

Laboratory

Steps in diagnosis:--- X-Ray

Source of X Ray X-Ray properties

MRI

Visualize entire bone and adjacent joint Best test for intraosseous extent and soft tissue extent Identify skip metastases Tumor proximity to neurovascular structures Occasionally helpful in diagnosis of bone or soft tissue tumors (experienced radiologist)

CT Scan

MRI

Steps in diagnosis: Laboratory

History Clinical Exam Imaging

Laboratory

Hematology: Hb, WCC, Diff, ESR Biochemistry: renal, bone, Serology: Microbiology: Hormones: Pathology

Thank You