Physical

Examination
of Orthopedic
Patients

dr. M. Bayu, Sp. OT

Examination of a Patient
with an Orthopaedic
Problem
1. Questioning
2. Inspection
3. Palpation
4. Auscultation and percussion
5. Assessment of the function
6. Special tests and measuring
7. Additional methods
 Equipment Requirements
The special tools required for the clinical
examination of a patient with an orthopaedic
complaint are modest in character. Three are
desirable:

1. A tape measure (preferably of the type used by

tailors) for measuring a limb length and girth;
2. A goniometer, for measuring the range of
movements in a joint;
3. A disposable sharp point.
 History must include
information about:
1. Reason for consultation (complaints of the
patient)
2. Circumstances of the trauma
3. Beginning of the illness
4. Previous treatment and its result
5. Occupation, habits and home
circumstances
6. Information about parents and relatives
7. Associated and concurrent illnesses
Typical Complaints
(Symptoms)
 Pain
 Stiffness
 Swelling
 Deformity
 Weakness
 Instability
 Change in sensibility
 Loss of function
 Questions to ask
Joint pain

 Does the pain change during the course

of the day?
 Has the pain been there for a short or
long time?
 Where is the maximal site of pain?

 Does the pain get better or worse as

 Inspection

 Deformity and Shortening

 Swelling and Wasting
 S c ars and wounds

 Presence or absence of limbs

(part of the limb)
 S k i n color
 Position (active, passive)
 Posture and gait
 Osteoarthritis of the Hip
Characteristic habitus and gait
Cerebral palsy Osteoporosis
Hemiplegia on right side. Progressive thoracic kyphosis, or
Hip and knee contractures dowager’s hump, with loss of height
and talipes equinus. and abdominal protrusion
 Deformity
Deformity results either from misalignment
of the bones forming the joint or from
alteration of the relationship between the
articular surfaces.
 If misalignment exists, a deviation of the
part distal to the joint away from the
midline is called a valgus deformity and a
deviation towards the midline a varus
deformity.
Upper Extremity Deformities b

b c

(a) Normal axis of upper extremity;

(b) Cubitus valgus;
a (c) Cubitus varus. c
Lower Extremity
Deformities

(a) Normal axis of lower extremity;

(b) Genu valgum;
(c) Genu varum.
a c
Deformities of the back

b c d
a

The spine: (a) the successive lordosis and kyphosis of the cervical,
thoracic, lumbar and sacral regions; (b) exaggerated lordosis; (c)
rounded kyphosis; (d) a knuckle kyphosis with gibbus.
 Deformities
of the
back

Scoliosis can be seen with the

patient standing but is more
marked when the patient leans
forward.
 Swelling of joints
 Causes of joint swelling include effusion,
thickening of the synovial tissues and of the
bony margins of the joint.
 Differentiation of these causes is achieved by
palpation..
Swelling and Wasting

Ruptured biceps tendon

Residual left calf atrophy
 Swelling and Wasting
Swelling over the mid clavicle.
Non union of a fracture

Olecranon bursitis
often may be due to
occupation
(miners). Clinical
forms: acute,
chronic
 Swelling and Wasting

Osteoarthritis of the knee. Rheumatoid arthritis of the hands

Bony swelling associated
with quadriceps wasting
 Swelling and Wasting

This was an osteogenic sarcoma in

Osteomyelitis of the forearm a 10 year old girl in Uganda
 Scars
and
Wounds
Burn of the upper extremity. Oedema

Open fracture of the both leg bones

Wound of the forearm
Scars and Wounds

Chronic infection of
the olecranon.

Scars are a map of the past.

Chronic osteomyelitis with
the scars of sinuses,one of
them still draining.
Congenital Deformities
Reduplication
of great toes

Reduplicated thumb

Patient with ‘lobster claw’ congenital

Amnionic constriction and club feet deformites of both hands and feet
 Proximal Femoral
Congenital absence Focal Deficiency
of extremities
 Palpation

► Local temperature
► Crepitus in the joints and soft tissues
1
► Swelling

►2Painful areas, tenderness

► Tonus
 Palpation
Note any local heat any tenderness,
whether localized or diffuse

Note any joint crepitus

Auscultation and Percussion

Are needed in the chest and abdomen

damages to determinate:

 the blood level in the cavities;

 presence of pneumothorax;
 changes of breathing;
 function of intestines
 Movement

► Determination of the range of

motion in the joints
► Movements in an abnormal range
or plane
► The cause of abnormal range of
motion (pain, contraction, deformity)

Movement of a joint is either active (i.e.

inducted by the patient) or passive
(i.e. inducted by the examiner).
Measuring of the range of motion in the joints

Use of the goniometer to measure

the different joint motion.
 Neutral position:
the limbs extended
with the feet dorsi-
flexed
to 90o, the upper limbs
midway between
pronation and supination
with the arms flexed to
90o at the elbow.

The neutral position from which

joint measurement is performed
Hip and Knee Range of Motion

Zero starting position is

the thigh in line with the
trunk. In measuring hip
extension, the
contralateral limb should
be held in flexion to
eliminate lumbar spine
motion. Hip flexion is
typically measured by
bringing both thighs into
flexion.
Hip and Knee Range of Motion
Knee motion is
primarily flexion and
extension. The zero
starting position is with
the knee straight.
Normal knee flexion is
135° to 145°. Extension
beyond the zero starting
position is more often
seen in young children.
Adults commonly
have a 5° knee flexion
contracture.
Shoulder Range of Motion
Slight internal rotation
and abduction required
Flexion and 180o-160o to reach maximal 180o Abduction
elevation
extension

90o

60o

Flexion
Extension
(elevation) Abduction

0o
Shoulder Range of Motion
External rotation
May be tested with
arm held at side
or abducted to
90°

Maximal internal
rotation is highest
midline spinous
process reached by
extended thumb
Arm abducted 90° Arm held at side (T7 in young adults)
from side
Hand and Fingers.
Range of Motion
 Normal
Gait
In normal walking,
Opposite each leg goes
Heelstrike Footflat Midstance
heelstrike
through a stance
phase and a
swing phase
alternately.
The rhythmic
repetition of such
cycles provides
grace to the gait.
Terminal Heelstrike
Pre-swing Initial swing
swing
 Gait

Watch how the patient stands and

observe his gait on walking. Note
that a patient with an unstable or
painful hip prefers to use a stick in
the opposite hand, and tends to
shorten the period of weight-bearing
on the affected limb.
 The common pathological gaits noticed in patients with
orthopedic disorders.

►Antalgic gait: occurs in painful condition of lower limb

►Trendelenburg gait: occurs in an unstable hip due to

CDH, gluteus medius weakness etc.
►Stiff hip gait: occurs in ankylosis of the hip

►Duck waddling (sailor's) gait: occurs in bilateral

CDH
►Scissoring gait: occurs in CP

►High stepping gait: occurs in foot drop

►Circumduction gait: occurs in hemiplegia

 High stepping gait
or Foot drop
gait
Due toThe
lifted more. drop of to
first thetouch the
groundfoot, leg is
is the forefoot, and not
the heel.

Normal gait Trendelenburg gait

A child with unilateral dislocation exhibits a typical

gait in which the body lurches to the affected
side as the child bears weight on it
(Trendelenburg's gait). In a child with bilateral
dislocation, there is alternate lurching on both
sides (waddling gait).
 Short leg limb

Hand-knee gait
Scissoring gait The person walks with
The legs are crossed in hand on the knee to
front of each other while prevent the knee from
walking due to spasm buckling in a quadriceps
of the adductors of the deficient knee with flexion
hip deformity.
 Special Tests

Straight leg raise

Lasegue’s sign

If this maneuver reproduces the patient’s radicular symptoms shooting

down the leg, the patient may have a pathological process (most
commonly a disc protrusion) compressing and inflaming the nerve root.
Special Tests

Positive Thomas test indicates a hip flexion contracture,

id est, the affected hip cannot be extended to the neutral
position.
Limitation of Movements

Loss of internal rotation

with hip flexed is a
sensitive and easy test
of hip arthritis.
Hypermobility in the Joints

a b

(a) Thumb to forearm. (b) Index finger metacarpophalangeal

joint hyperextension. (c) Elbow hyperextension. (d) Knee
hyperextension.
Abnormal Movements in the Joints

Anterior
drawer test

The patient’s knee is flexed to 90°. The doctor sits on the patient’s foot to
stabilize it. The tibia is pulled with the examiner’s hands toward the
examiner. If the tibia slides forward more than a few degrees, there may
be a tear in the ACL.
Abnormal Movements in the Joints

Posterior
drawer test

The examiner stays seated on the patient’s foot. The tibia is

pushed posteriorly. If the patient’s tibia glides posteriorly on
the femur, PCL is likely torn.
Abnormal Movements in the
Joints
Test for stability of the medial
collateral ligament (MCL)
The patient’s knee flexed to 30°
and fixed with one doctor’s hand
put on its lateral surface. With
other hand placed on the ankle
the doctor tries to deviate the
patient’s shank laterally. More
than 5o of deviation suggests a
rupture (partial or complete) of
the MCL. Compare with other
extremity.
 Special Tests
“Springing” the pelvis. Pressure
on the pelvis produces pain if
there is a pelvic fracture

“Springing” the ribs.

Compression of the chest
induces pain if there is a
rib fracture
 Special Tests
Pressure along the extremity produces
pain in the bone fracture site.
Note: no placing your hands on the painful
area.
 Shortening

Types:
1. Anatomical (absolute, true, real)
2. Relative (comparative)
3. Seeming (apparent, projectional)
4. Functional (clinical)
Comparison of the
Opposite
Extremities
Where there is significant true
shortening the heels will not be level
(the discrepancy is a guide to the
amount of shortening) and the pelvis
will not be tilted. The site and amount
of shortening must now be further
investigated.
Comparison of the
opposite extremities
Shortening

In apparent shortening the

limb is not altered in
length,but appears short as
a result of an adduction
contracture of the hip,which
has to be compensated for
by tilting of the pelvis.
 Variants of measuring:

1. Anatomical: distance between

the most remote bone
prominences of the
extremity (segment), which is
measured;
2. Relative: distance between the
adjacent bone prominence
(proximally) and remote
prominence of the extremity
(distally);
 Variants of measuring
3. Seeming: distance
between the proximal and
distal prominence of the
same extremity in case of
its angulation;
4. Functional: using the small
boards a doctor augment
the support height under
short leg until a patient
feels balance in his pelvis
Measuring the
distance
from bony
points

a b

(a) On the upper extremity;

(b) On the lower extremity.
It’s strange, but he’s still alive!