Orthopaedic Physical

Examination

dr. Made Agus Maharjana , M.Biomed. Sp. OT

 How to diagnosis?

• Diagnosis Disease Identification

• Systemical process to collect the information
• Systemical but not mechanical  intelligent heart
(D.H Lawrence)
• Patient as a person
mind, personality, job, hobbies, family, home VS
disorders and treatment
 Orthopaedic Diagnosis
• History
• Symptoms
• Physical examination
• Radiological examination
• Laboratory examination
• Synovial fluid analysis
• Bone biopsy
• Arthroscopy
• Electrodiagnosis
 Taking History

Symptoms :
• Look wrong (deformity, swelling, lumps)
• Feel wrong (pain, tingling, numbness)
• Move wrong (limping, weakness, instability, or stiffness)
Past History
Family history
Social history
 Symptoms
• Pain
• Stiffness
• Swelling
• Deformity
• Weakness
• Instability
• Change in sensibility
• Loss of function
 History Taking of Chief
Complaint
• Identity : Age, Sex, race, present occupation ,
his previous occupations, hobbies and
recreational activities, and previous injuries.
• The Fundamental Four And The Sacred Seven
• History of Present Ilness (RPS)
• History of Previous Illness (RPD)
• History of Family
• History of Social & Economic
.
 History Taking
1. Present Illness
Chief Complaint
Sacred 7 :
• Location (dimana ? menyebar atau tidak ?)
• Onset (kapan terjadinya?berapa lama?)
• Chronology
• Quality (ringan atau berat, seberapa sering terjadi ?)
• Quantity (rasa seperti apa ?)
• Aggravating Factors (Make it worse/Improve)
• Associated compliant?
 History Taking
2. Previous Illnesses
•Ditanyakan adakah penderita pernah sakit serupa sebelumnya, bila dan kapan
terjadinya dan sudah berapa kali dan telah diberi obat apa saja, serta mencari
penyakit yang relevan dengan keadaan sekarang dan penyakit kronik
(hipertensi, diabetes mellitus, dll), perawatan lama, rawat inap, imunisasi,
riwayat pengobatan dan riwayat menstruasi (untuk wanita).
3. Family
•Anamnesis ini digunakan untuk mencari ada tidaknya penyakit keturunan dari
pihak keluarga (diabetes mellitus, hipertensi, tumor, dll) atau riwayat penyakit
yang menular.
4. Social Economic
•Hal ini untuk mengetahui status sosial pasien, yang meliputi pendidikan,
pekerjaan pernikahan, kebiasaan yang sering dilakukan (pola tidur, minum
alkohol atau merokok, obat- obatan, aktivitas seksual, sumber keuangan,
asuransi kesehatan dan kepercayaan).
 History
• Medications
• NSAIDs
• steroids
• narcotics
• Other treatments for this injury
• Injections
• Bracing
• Physiotherapy
• Allergies ?
• Dominant Hand ?
• Functional Status ?
 Social History
• Occupation
• Working / Retired
• Manual labor / Desk job
• Living situation
• Alone / Spouse / Other supports
• Two storey house / Apartment
• Ambulatory status
• How far can they walk
• Do they use a walker / cane
• Smoking/ Alcohol/ Drug Us
 Specifics to the injury

• Precipitating incident
• trauma (macrotrauma)
• repetitive stress (microtrauma)
• is this a work related injury?
 Specifics to the Injury

• For MVAs
• driver/passenger
• belted/non-belted
• location of impact and severity of crash (required
jaws of life, if anyone died in the crash, thrown
from the car, etc)
• speed at impact
• position of the patient and the limb in question at
impact
 Associated Symptoms

• In addition to pain do they have:

• Clicking
• Snapping
• Catching
• Locking
• Sensation of giving way (including prior falls or
dislocations)
• Swelling
• Weakness
 Temporality or Timing

• Is it worse when they wake up in the morning?

• Does it gradually get worse over the course of the
day?
• Does the pain ever wake them up at night?
 Red flags

• Pain at night or rest

• Associated weight loss and loss of appetite
• History Of cancer
• Steroids use
• History Of trauma
• Extreme age
• Bowel or bladder symptoms
 Examination
• Look
• Feel
• Move

• Neurological Examination
• Gait
 General Considerations for
Examination
• Always begin with inspection, palpation and range of
motion, regardless of the region you are examining which
advocated by Apley as LOOK,FEEL, MOVE
• Specialized tests are often omitted unless a specific
abnormality is suspected
• A complete evaluation will include a focused neurological
exam of the effected area
• Muscle strength is an integral part of the neurological
assessment and is best carried out in a systematic manner
from proximal to distal and recorded using the MRC scale
 Look
• Skin
a) Scar : map of the past
b) Colour, change
c) Swelling
d) Abnormal fold
• Shape
a) Swelling
b) Muscle atrophy
c) Lumps
d) Crooked bone
• Position
a) Deformity
b) Posture
 Look

• Look for scars, rashes, or other lesions like

abrasions/open wounds
• Look for asymmetry, deformity, or atrophy
• Always compare with the other side
• Look for swelling
• Look for erythema (redness)
• Posture/position of the joint or limb
 Common Deformity

• Shortening
• Angulation (Varus and Valgus)
• Rotation (Internal and External)
• Kyphosis dan Lordosis
• Scoliosis
• Postural deformity
• Structural/Fixed deformity
 Shortening

• True Length
• Appearance Length
• Anatomical Length
• Functional Length
Varus/Valgus
Leg Length Discrepancy
Internal and External Rotation
 Feel

• Skin
• Soft Tissue
• Bone
• Joint

• Tenderness
 Feel

• Examine each major joint and muscle group in

turn
• Identify any areas of tenderness
• Joint line
• Tendinous insertions
• Palpate for any crepitus
• Identify any areas of deformity
• Always compare with the other side
 Feel

• Warm or cold including pulses

• Fluctuation/fluid collection
• Compartments – soft or firm and painful
• Sensation
 Move : Range of Motion

In the examination of joint movements information

must be obtained on the following points:

1) What is the range of active movement?

2) Is passive movement greater than active?
3) Is movement painful?
4) Is movement accompanied by crepitation?
 Active ROM

• Ask the patient to move each joint through a full

range of motion
• Note the degree and type of any limitations (pain,
weakness, etc.)
• Note any increased range of motion or instability
• Always compare with the other side
• Proceed to passive range of motion if
abnormalities are found.
 Passive ROM
• Ask the patient to relax and allow you to support the
extremity to be examined
• Gently move each joint through its full range of motion
• Note the degree and type (pain or mechanical) of any
limitation
• If increased range of motion is detected, perform special
tests for instability as appropriate
• Always compare with the other side

The passive range will exceed the active only in the following circumstances:

1) when the muscles responsible for the movement are paralyzed

2) when the muscles or their tendons are torn, severed or unduly slack.
Move
 RANGE OF MOTION
Wrist
• Flexi
• Extensi
• Radial deviasi
• Ulnar deviasi
 Range of Motion
MCP-IP
MCP joint :
• Flexion -90 degree
• Extension -20 degree
PIP joint :
• Flexion -90 degree
• Extension -0 degree
DIP joint :
• Flexion -80 degree
• Extension -0 degree
 Move

• Joint Stiffness
1. All movement absent
2. All movement limited
3. Some movement limited
 Move
Joint Laxity
• Hyperextention of elbow and knee
• MCP joint extention until 900
• Thumb to forearm

• Generalized hypermobility :
connective soft tissue disorders : Marfan syndrome
Ehler-Danlos, Larsen syndrome.
 Gait Cycle - Components :

• Phases:
(1) Stance Phase: (2) Swing Phase:
reference limb reference limb
in contact not in contact
with the floor with the floor
 Gait Cycle - Subdivisions:

A. Stance phase:
1. Heel contact: ‘Initial contact’
2. Foot-flat: ‘Loading response’, initial contact of forefoot w. ground
3. Midstance: greater trochanter in alignment w. vertical bisector of foot
4. Heel-off: ‘Terminal stance’
5. Toe-off: ‘Pre-swing’
 Gait Cycle - Subdivisions:

B. Swing phase:
1. Acceleration: ‘Initial swing’
2. Midswing: swinging limb overtakes the limb in stance
3. Deceleration: ‘Terminal swing’
COMMON GAIT ABNORMALITIES

A. Antalgic Gait
B. Lateral Trunk bending
C. Functional Leg-Length Discrepancy
D. Increased Walking Base
E. Inadequate Dorsiflexion Control
F. Excessive Knee Extension
 COMMON GAIT ABNORMALITIES:
A. Antalgic Gait
• Gait pattern in which stance phase on affected side is
shortened
• Corresponding increase in stance on unaffected side
• Common causes: OA, Fx, tendinitis
 COMMON GAIT ABNORMALITIES:
B. Lateral Trunk bending
• Trendelenberg gait
• Usually unilateral
• Bilateral = waddling gait
• Common causes:
A. Painful hip
B. Hip abductor weakness
C. Leg-length discrepancy
D. Abnormal hip joint
 COMMON GAIT ABNORMALITIES:
C. Functional Leg-Length
Discrepancy
• Swing leg: longer than stance leg
• 4 common compensations:
A. Circumduction
B. Hip hiking
C. Steppage
D. Vaulting
 COMMON GAIT ABNORMALITIES:
D. Increased Walking Base
• Normal walking base: 5-10 cm
• Common causes:
• Deformities
• Abducted hip
• Valgus knee
• Instability
• Cerebellar ataxia
• Proprioception deficits
 COMMON GAIT ABNORMALITIES:
E. Inadequate Dorsiflexion Control

• In stance phase (Heel contact – Foot flat):

Foot slap
• In swing phase (mid-swing):
Toe drag
• Causes:
• Weak Tibialis Ant.
• Spastic plantarflexors
 COMMON GAIT ABNORMALITIES:
F. Excessive knee extension
• Loss of normal knee flexion during stance phase
• Knee may go into hyperextension
• Genu recurvatum: hyperextension deformity of knee
• Common causes:
• Quadriceps weakness (mid-stance)
• Quadriceps spasticity (mid-stance)
• Knee flexor weakness (end-stance)

* * *
 Neurological Examination

• Appearance (look)
• Motoric (tonus and power)
• Tendon reflexes
• Superficial reflexes
• Sensibility
 LOOK

Waiter’s tip deformity

 LOOK

Wrist drop
 LOOK

Muscle wasting
 Tone and Power

Grade 1 -5
 Muscle Power (MRC)

• 0 No contraction
• 1 Only a flicker movement
• 2 Movement with gravity eliminated
• 3 Movement againts gravity
• 4 Movement againts resistance
• 5 Normal Power
Tendon Reflexes
Upper extremity
Tendon Reflexes
Lower Extremity
 Sensibility
Dermatom sensoric
 Sensibility
Sensoric distribution
Nervus Aksilaris
 Sensibility
Sensoric distribution
Nervus Radialis
 Sensibility
Sensoric distribution
Nervus Medianus
 Sensibilitas
Sensoric distribution
Nervus Ulnaris
 Sensibility

Nervus Nervus Common peroneal Nervus

Sciatic Femoralis Nerve Tibialis
TERIMA KASIH