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PLAN OF EXAMINATION OF ORTHOPEDIC AND TRAUMATOLOGICAL PATIENTS AND WRITING A MEDICAL HISTORY Personal data: last name, name, patronimic; age; address; profession and occupation; date and time of admission, referred by, the way of admission to the medical institution. Complaints: of pain, deformities and dysfunctions. 2.1. Medical history In case of traumas: date and time of the trauma. Circumstances of the trauma – type of activity, where (at work, on the way to work/from work, at home, in places of leisure, etc.) the accident had happened which resulted in trauma. If necessary – force of the traumatic agent (height of fall, speed of the moving car and its make, mass of the pressing load and time of pressure, etc.). Sensations after the accident, ability to move independently. Rendering first aid – who it is rendered by, when, how (resuscitation elements, antishock measures, temporary stoppage of external hemorrhage, application of aseptic bandages, transport immobilization, etc.). Treatment of the patient before supervision – what diagnosis was established on admission, what therapeutic and diagnostic measures were taken; their efficacy, whether there is reposition of fragments in bone fractures, whether dislocation has been removed, whether primary surgical wound d-bridement has been performed, as well as tetanus prevention, antibiotic prescription, transfusion therapy, etc. In congenital deformities. Time when deformity was revealed. Whether there was a similar pathology in other family members. Treatment and its efficacy. In inflammatory diseases. With what the patient associates the onset of the disease. When the disease began and the character of the onset (abrupt or gradual). The course of the disease. Treatment (where and how it was treated). Exacerbation frequency. Precursors. What drugs and treatment modes helped during exacerbations in the past. Whether the patient had bacterial tests, antibiotic susceptibility tests made. Test results. In dystrophic processes. When the feeling of discomfort appeared (in joints, periarthric areas). When the patient felt limitation of movements, when he noticed joint or limb deformity. Character of pain. When he feels pain (at night, after sleep, during first steps, after continuous load (walk, work)). Changes in pain intensity caused by weather changes, cold, overchilling, etc. previous treatment: drug therapy, physiotherapy, sanatorium-and-spa treatment, surgical treatment. Special attention should be paid to administration of corticosteroids (drug, dose, duration of drug administration, side effects). 2.2. Life history. Individual pecularities of development n childhood. Previous diseases, operations. Army service (as an integral estimate of state of health). gynecological history. Bad habits. Constant administration of drugs: reasons, drug, dose. Possible allergic reactions. 2.3. Patient`s objective condition. General condition: physical development, consciousness and behaviour. State of the cardiovascular system (pulse, AP, heart sounds, heart borders, acrocyanosis, dyspnea, edemas). State of the respiratory system (shape of the thorax, its participation in respiration, the role of auxillary muscles in respiration; respiration rate and frequency; chest percussion and auscultation).
3. Bending of the limb axis (or a segment) can take place in frontal or sagittal planes. capitate humeral eminence. position of the injured limb: active. in which the top of deformity is extorse. presence of edema. etc. lying on one side with one`s legs pressed against the abdomen.State of the digestive system (teeth. sitting with one`s palm pressed against some part of the thorax.). bending. size and form of the abdomen. hepatic dullness. The top of bending can be on a bone shaft as well as on the level of a joint. a half-bent right arm is put aside from the trunk. the neck is bent to the left or to the right. tunica mucosa of mouth. sitting with one`s hand pressed against the chest. Condition of distal parts of the limb fixed with a plaster bandage: color of fingers or toes. forced. forced (standing. Pecularities in urination and evacuation. Position of the examined patient: active. etc. muscular atrophy. passive. cuff traction). Limb deformity in the frontal plane.). etc. palpatory tenderness(during deep and superficial palpation). the head is turned to the left or to the right. type of their fixation in fixation devices: rings in Ilizarov`s external fixator or in fixators for external fixation on basis of nails. head of radius and head of ulna (fig. For example.3 Fig. hernias. location of pins or nails. Brachial axis goes through the humeral head. tension of the frontal abdominal wall. etc. Type and description of traction system: type of applied traction system (continuous skeletal or glue traction. is called varus . Whether there are openings in the bandage.1. symmetry of the abdomen. phlyctenae. symptoms of irritation of the abdomen). active finger movements. to what segments glue (cuff) traction is applied. Type and description of external fixators. 2 Fig. dermatosis. 1). in deformity of the limb its axis is bent. through what osseous masses the pin goes. etc. position of the limb (abduction. On examination there are visible shortening of limb (measured later).STATE OF THE MUSCULOSKELETAL SYSTEM Examination.). passive. weight of the load placed on recoils. tongue.). Type and description of the plaster bandage (what segments of the musculoskeletal system are fixed and in what position they are. slight rotation. 2. position of additional (resetting) loops. presence of postoperative scars. edema. a half-bent left leg is bent towards the trunk. etc.4 Limb axis is determined in frontal and sagittal planes. It is desirable to draw a kinematic scheme of application of continuous traction or external fixators on the observed patient. 2.1 Fig. Fig. lying. Leg axis goes through the frontal upper axis of the ilium. lying with spread half-bent legs. internal edge of the patella and hallux (рис.
3. Guter`s line and triangle are broken in forearm dislocation. edema and sclerosis of subcutaneous fat. in which the top of deformity is anterior is called antecurvation. the tip of the forefinger. are usually used as identification points (see `Measurements`). Points. 5 Fig. between which length of a segment and the whole limb is measured. in fractures of the head of the radius and in all types of fractures without displacement (fig. bone landmarks. 5. In day-to-day practice several identification points and lines are usually used. Dislocation of certain bony prominences or articular ends of bones on their intersection of the socalled identification lines can tell about presence of injuries (dislocations) in places. 7. Limb deformity in which the top of deformity is intorse. etc. shoulder epicondyles.deformity.. Palpation allows to identify: Changes in local temperature. Palpation Palpation is performed using the whole hand. 6 Limb deformity in the sagittal planeти. fingertips. The opposite deformity is called recurvation (fig. Fig. In conclusion changes on joint forms (exudate. presence of subcutaneous hematomas. disorder of sensitivity. . 8). in fractures of olecranon of ulna. in fractures with displacement of epicondyles of the humerus. Guter`s line and triangle do not change in flexion and extension supracondylar shoulder fractures with displacement of distal fragment. 2]. position of articular ends of bones and separate bony prominences. distinct vascular pattern. In elbow joint these three points lie on one line (Guter`s line). 4). Guter`s line and triangle – joint of bony prominences-epicondyles of humerus with each other and with the top of olecranon during unbending (which makes Guter`s line). edema) and diaphysial bone fragments are described: various herniations. inaccessible on examination and undefined during palpation because they are located deep and sharp pain caused by palpation [1. morbidity: superficial and deeply extended and limited. in splintered and communited fractures of the distal end of the humerus. presence of tumor masses in it. bloatings. 6). during bending they form an isosceles triangle (Guter`s triangle). mobility (dislocation) of cutaneous covering over the examined place. Joints of these points form lines and figures. is called valgus deformity (fig.
two thirds – from the drawn line to the end of the little finger (fig.Marks) – in case of unchanged interrelation in elbow joint the line. drawn through the tibial crest. divides the space from the little finger to the end of the foot into two parts: one third – from the end of the heel to the vertical line. in normal interrelation. in dislocations in hip joint the line. When the hip is bent on the mitre of 1350 the greater trochanter is situated on this line. The line does not change in dislocations in elbow joint (unlike in case of треугольника Гютера). Symphysis pubis line goes through the tops of greater trochanters of thigh bones. The line. 13). 12 Transtrochantic line is the line.7 Fig.Fig.). 14 Vertical line. 12). 9 Fig. in fractures of proximal ends of forearm bones with displacemtnt of fragments. 16). drawn horizontally through the greater trochanter on the side of injury.e. must go through the first web space. 14). 10 Supracondylar line (described by V. drawn through lateral malleolus of a normal foot. 13 Fig. 15). Shemacker`s line begins on the top of the greater trochanter and goes through the frontal upper spine of the ilium. 11. When interrelation in the hip joint is preserved Shemacker`s line should be continued above the umbilicus (fig.O. Fig. in fractures of the femoral neck this interrelation is broken (fig. joining frontal upper bones of iliac bones.11 Fig. in normal interrelation it is parallel to the line of symphysis pubis (fig. Guter`s line) is perpendicular to the long axis of the shoulder (it goes through the middle of the humerus). goes above pubis (fig. The line changes in flexion and extension supracondylar fractures of the humerus and in fractures of shoulder epicondyles (fig.8 Fig. . 10). In fractures of femoral neck. In upward dislocations of greater trochanter on one side line parallelism is preserved. In dislocations in the hip joint. Roser-Nelaton`s line joins frontal upper spine of the ilium with the ischial tuberosity. joining epicondyles of humerus (i. Fig. 9. In foot subluxations this interrelation is broken (fig.
18 Measurement Measurement of limb length allows to define lengthening or shortening of the whole limb or its separate segments. drawn through the upper ends of iliac crests. Palpation also allows to find accumulation of fluid in bursal sacs (in elbow. 16 Identification points on the backbone. 17). the superior point in the upper region of the back.) and in joints. In order to measure length of segments of the lower limb the following identification points are used: the top of greater trochanter of the hip bone. Spinous process of the 4 th lumbal vertebra lies on the level of the line. The third thoracic vertebra is situated on the level of the lower end of the scapular spine.18). where lengths of measured . In order to provoke patella ballottement symptom one hand embraces upper torsion of the knee joint (fig. 15 Fig. etc. getting into its initial position. 19. getting farther from condyles. This moment causes sensation of a push. In order to measure a limb or a segment the centimeter band is applied in certain points. The 7th thoracic vertebra is situated on the level of the lower angle of the scapula. This should not be abused because of danger of damage of vessels and nerves. Fig. the top of ankle (for measurement of shin length) (fig. top of the olecranon of the elbow bone and the styloid process of ulna (upper joint). In case of excess of fluid in the knee join knee cap uplifts. patella. Measurement results are recorded in a table. After withdrawal of the finger the patella uplifts again. Level of spine injury (trauma or disease) is defined by counting vertebrae from several landmarks. These points are the acromion process.Fig. Cervical and thoracic vertebrae are defined by counting down from the spinous process of the 7th cervical vertebra. In order to identify fluid accumulation in the knee joint patella ballottement symptom is used. There are different types of measurement. 20). fingers of the other hand press on the patella in the direction of the joint but patella and hip condyles do not meet. In absence of exudate in the knee joint patella adjoins anterior surface of hip condyles. and the 1st sacral vertebra lies on the level of posterior lower spines of of iliac bones (fig. Fig. 17 Palpation allows to define presence of crepitation: knacking of ends of bone fragments during friction. knee-joint space (for measurement of hip length) and knee-joint space. The most widespread type is measurement with the help of the centimeter band. In order to measure length of the lower limb the following identification points are used: anterior upper spine of the ilium – patella – medial or lateral malleolus.
aggravation. medial and lower one-thirds (fig.e. movements in ankle joint are counted from 90о. Limb circumference is measured in centimeters on the level of the joint in upper. Instead of a table results can be recorded as a text. 21). Establishment of range of joint movements Traditional method is as follows: branches of fleximeter (this is a school protractor with two rulers.5cm. patient simulation. adduction) limb fixation in the joint or in case of synosteosis of shaft fractures under angle.e. its end is sharpened as an arrow.e. The end of movable branch. the position of the limb in vertical position of the body. relative or dislocation limb shortening due to displacement of articular ends of bones (dislocations). i.2. Passive movements are defined by the patient. muscle atrophy.3. for shoulder joint the countdown goes from 0о. 2.distances are compared. movements performed by the patient himself. In the last line measurement difference is recorded. protractor hinge is set above the centre of joint rotation. hip and knee joints initial position is complete unbending – 180о. It is necessary in neurological disorders. Рис. Accuracy of measuring limb length with a centimeter band is +/-1-1. moving along protractor scale. 20 There are effective (anatomical) shortening when one segment is really shorter due to loss of bone stock. i. it corresponds with the aim of patient`s clinical examination. Abduction (angle is more . i. one of which is fixed along 0-180о line and the other is connected to it with the help of hinges in the middle of protractor scale along 90о. According to the sum of all results limb shortening can be integral or functional. shows the maximum possible angle for movement. For elbow. Fig. The countdown is performed from the initial position. etc. 21 Movements Examination of movements begins with establishment of range of active movements. set on 0о) are set alongside segment axis. followed by evaluation of its results (character of shortening). 19 Рис. apparent (projection) shortening appearing in case of faulty (flexion. from the position in which the foot is perpendicular to the shin.
cm). Claudication is described: partial claudication in case of presence of pain. Comparative percussion of the thorax. which serves as a model pattern. Palpation of the thorax in case of suspected rib fractures. 2. its correspondence with the assumed diagnosis. Patient`s general condition Patient`s general condition. body weight. Findings are compared with those of the other (healthy) limb. Cardiovascular system . etc. Auscultation of the lungs. Type of load. Enlargement of regional lymphatic nodes. Fig. Respiration rate and type. Ability to stand and walk without additional support: crutches. There are anclyosis. Preserved range of movements in the joint up to immobility is examined using previously described methods and conclusion about movement amplitude in the joint (in functionally efficient and unefficient volume) is made according to measurement results. Necessity to use body jackets. 22 Alongside with normal range of joint movements and excessive joint mobility (injuries of ligamentous apparatus. intraarticular fractures) limitations of these movements are possible too. complete and partial load of patient`s limb is also noted in medical history. its participation in respiration. rigidity.3. humidity. orthopedic shoes. turgor. ortheses. complete claudication in case of absence of pain. Determination of pulmonary borders. Height.3. Consciousness (estimation of impairment of consciousness according to Glasgo scale. limitation of joint movements (from 5о to the remaining 5о). complete immobility of joints. their consistency and mobility. sudden limitation of joint movements. is taken into account. 22) are also measured from 90о. Presence of punctulated petechial hematomas on the skin of the upper part of the trunk. connecting frontal upper spines of iliac bones. Visible mucous and cutaneous covering: color. Detection of subcutaneous emphysema. walking stick.than 90о) and adduction (angle is less than 90о) in the hip joint (fig. Statics and walk. Respiratory system Thoracic norm. Immovable branch of fleximeter is set under the line. contracture. visible deformities of the thorax. the movable branch is set alongside the hip axis. prostheses. special devices like a mobile device with armpit braces and with help of other people are noted. sometimes caused by swinging movements (less than 5о).
rate. changes in the system of continuous skeletal traction. new drug administrations.7. Hepatic dullness. Classification and treatment of the fractures of the given group References are recommended by teachers. Clinical course This section contains data of the daily medical examination and changes in patient`s condition. 2. tongue.5. Heart auscultation: determination of heart rate. 2.3. detailed in-patient treatment description necessary for the out-patient doctor (aftercare department). Abdominal irritation symptoms (Blumberg`s sign). Determination of limitis of relative and absolute cardiac dullness with the help of percussion. Pulse in peripheric vessels. administration of operations and medical manipulations. Size and form of the abdomen. Plan of examination and treatment of the patient It includes administration of additional laboratory and instrumental methods of examination. CBV (hematocrit) and blood gases test in patient with severe traumas. traces of bruises on the abdominal wall. administration of infusion and transfusion therapy and drugs. Presence of hernias. percussion sound dulling in sloping places. Digestive system. 3. TEST QUESTIONS AND TASKS FOR SELF-PREPARATION .4. Blood sugar test. Clinical diagnosis (Clinical diagnoses is formulated by the student according to the data obtained from objective and additional tests and examinations). repositions. Textbooks and reference books must not be main sources of information. Teeth.6. presence of cardiac murmur. Abdomen`s part in the act of respiration. Arterial pressure. its frequency. Test for level of alcohol in blood. 2.). 2.Determination of cardiac apex beat. Palpation of the liver and spleen. changes in patient`s supervision (including operations. 2. sounds. filling and tension. Additional tests Clinical blood analysis and urinalysis. 4. results of new tests. etc. Epicrisis Reflects the essence of what happened with the patient: date. indication of duration of immobilization of the injured segments with plaster bandages or compressive-distraction osteosynthesis frames. bandaging.4. Sketch of roentgenogram contours. shift of this dulling caused by changes in patient`s position.8. roentgenogram description (in 2 projections). date of re-examination and recommendations as for the load of the injured segment. 2. circumstances accompanying the trauma (disease). REFERENCES References contain bibliographical data of sources of literature used for preparation of the topic and writing a medical history of the observed patient.
Ортопедическая диагностика. line of symphysis pubis and pertrochanteric line). 1984. What are the pecularities of taking anamnesis from a patient with isolated or multiple traumas of musculoskeletal system? 2. 5.О. Олекса А. 6.What signs of inflammatory process can be revealed during patient`s clinical examination? 7.. – 463 с. и доп.К. – 328 с. – 511 с. – 511 с.: Вища школа. What signs of traumatic fracture can be revealed during patient`s clinical examination? 5. – М. Травматологія і ортопедія – К. 2. What are the pecularities of examination of a patient with polytrauma? 4. . перераб.: Медицина. с нем. Хегглин Ю. How can one measure and record measurment data of the length of extremities? 8. Roser-Nelaton`s line.: Здоров’я. Травматологія і ортопедія – К. Травматология и ортопедия.Т. Трубников В. 3.П.Ф.: Здоровье. 1978.1. – 328 с. How can one measure and record measurment data of movements in large joints of upper and lower extremities? 9. . Скляренко Е. 1986. Marks`s line. Хирургическое обследование. Find on yourself points used for establishment of the length of extremities and construction of auxiliary lines (Guter`s line and triangle. REFERENCES 1. – К: Вища школа. Пер. 1993. 1991. – 2-е изд. Заболевания и повреждения опорно-двигательного аппарата. Маркс В. What signs of dislocation can be revealed during patient`s clinical examination? 6. – Минск: Наука и техника. Shemacker`s line.Ф. 2005. 4. – 591 с. What are the pecularities of taking anamnesis from a patient with diseases of musculoskeletal system? 3. Трубников В.
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