History

A detailed clinical history and complete physical examination are mandatory in the assessment of the patient with a painful hip. Often a tentative diagnosis can be made on the history alone. The onset (acute or insidious), duration and severity of symptoms, as well as any earlier injury, are significant in any history taken. Examination and subsequent investigations allow for confirmation or modification of the presumptive diagnosis.

Presenting complaints in hip pathology may include pain, limp and stiffness. Patients may not complain of stiffness per se but of the disability produced by it (e.g. the inability to put socks on). In trying to evaluate a patient’s symptomatology it is important to know what effect, if any, the symptoms have on the patient’s ability to undertake activities of everyday living. Mechanical symptoms such as locking, clicking, catching or popping can also be presenting symptoms in their own right.

It is important to ask patients whether they have had any previous problems with their hips. Childhood conditions affecting the hip may cause symptoms in early adult life because of the development of secondary degenerative changes. In addition, a history of previous surgery is very important when contemplating further surgical procedures as consideration needs to be given to previous scars, the surgical approach, skeletal deformity and, in addition, the increased risk of infection with arthroplasty surgery.

I am pleased to be asked to write the foreword for the second edition of Examination Techniques in Orthopaedics, coedited by Mr Nick Harris and Mr Fazal Ali. The first edition of this textbook was one of the bestselling orthopaedic books in the United Kingdom for almost a decade. This second edition is likely to at least equal that success. So often in the world of orthopaedic surgery we jump to advanced imaging and forget about the importance of the examination. This is clearly a mistake and has caused many errors in clinical judgement. Therefore, careful review of orthopaedic examination as presented in this textbook is critical for all orthopaedic surgeons, young and old alike. This book provides a complete repository of all examinations, beginning with general principles and proceeding literally from head to toe, to include paediatric examination. This is truly an excellent book and likely will be the gold standard to which examination textbooks are compared. It is my pleasure to write this foreword. I think you will enjoy this textbook and it should stay on your shelf until the third edition is available. I give it my strongest endorsement and look forward to studying it myself.

Introduction

There is rarely a need to carry out a comprehensive examination of the shoulder including all of the tests described in this chapter. Described below are the elements that can be used to differentiate between possible diagnoses suggested by the clinical presentation. To be successful clinically and to demonstrate competence in professional examinations, interpretation of the available history is combined with an appropriately directed examination of the shoulder. Each test answers a specific question about the state and function of the components of the shoulder or the structures that enable it to work effectively. Pieced together, the clinical examination narrows down the differential diagnosis and may direct one to supplementary investigations that prove a diagnosis. Alternatively, the clinical examination may reassure that treatment can proceed without further expensive tests, pending review to confirm the expected progress. No description of clinical examination of the shoulder can therefore be complete without mention of the history that should be elicited, as this is primarily responsible for focusing the examination to those components that move one efficiently towards the correct diagnosis.

History

Patients often present with shoulders that are painful, unstable and/or stiff. Even basic demographic details are helpful, and it is important to document these for medicolegal reasons. Age, handedness and occupation should be noted. Although an open mind should be kept at all times, instability tends to dominate in the younger age group, impingement symptoms in middle age and rotator cuff tears and arthritis in the older group.

History

General

Details of age, sex, occupation and problems with shoewear must always be elicited from patients with foot and ankle problems. Pain, swelling, stiffness, deformity, instability and paraesthesiae are the usual complaints. Their effects on gait, leisure and employment activities must be clearly established.

Many systemic conditions affect the foot. This is usually bilateral. A high index of suspicion must be maintained by clinicians managing foot and ankle disorders. Diabetes, rheumatoid arthritis, seronegative arthropathies, endocrinopathies, gout, pseudogout and vasculitic conditions all directly affect the foot and will influence management strategies. Swelling of the foot and ankle might reflect cardiac, hepatic and renal disease.

Unilateral swelling might be the result of secondary obstruction of the lymphatics resulting from pelvic malignancy, especially in women over the age of 50. Painless unilateral swelling of the foot or ankle may be the result of a Charcot joint in a patient with diabetic peripheral neuropathy.

Lesions of the lumbosacral spine, such as a prolapsed intervertebral disc, spina bifida and spinal stenosis, may also affect the foot, and any history of spinal abnormality must be sought.

Introduction

The spectrum of conditions of the spine in children includes spinal infection, trauma, tumours, spondylolysis and spondylolisthesis, the adolescent disc syndrome, as well as spinal deformities such as scoliosis.

The clinician should be alerted to the quality and site of any painful spinal symptoms, in terms of whether or not it is activity-related and if there is any neuropathic pain. Worrying symptoms include night pain causing disturbed sleep, unremitting pain requiring regular analgesia and pain interfering with enjoyable activities. The younger the patient, the more likely it is that any spinal tumour is neoplastic, with 75% of spinal tumours in the under-6s being malignant, contrasting with less than 33% in over-6s who have spinal tumours. The benign but painful osteoblastoma and osteoid osteoma occur principally around the thoracolumbar junction and the pain is typically relieved by non-steroidal anti-inflammatory drugs. Although pain is a cardinal feature of spinal malignancy, present in 46–83% of cases, only about one in three cases will present purely with pain and two-thirds will present with neurological problems, such as radicular pain, muscle wasting and weakness and/or a limp. Most children with an underlying neurological or neuromuscular condition will already have a diagnosis, and a previously fit and healthy child who develops new weakness and/or a limp should be suspected of having a spinal tumour until proven otherwise.

The first edition of this book has become essential reading for those preparing for postgraduate examinations in orthopaedics. Medical students and junior trainees had their own books to use. This is surprising as the same process of examination is used by all groups, the only differences being that the senior trainee should look more polished and should know more special tests. It was this realization that prompted us to come together with our many years’ experience of teaching clinical examination and to rewrite every chapter in a format that was uniform in style and in a sequence that could be used in examination situations or in clinical practice by all. Quick revision will become easier as each chapter ends with a summary of the examination technique. Another unique addition is that the illustrations also follow a sequence for quick visual revision. These illustrations are supplemented by numerous new clinical photographs. It is our hope that we have made this book even more user-friendly and an essential companion through your career in clinical practice.

Examination of a patient’s hand should always follow a comprehensive history. This provides valuable information to determine a diagnosis and to assess the impact that symptoms have on the patient’s daily functions. Always remember to ask for hand dominance, occupation and recreational activities.

The following hand examination can confirm the working diagnosis or may raise possible alternative diagnoses. It may be used to assess a patient’s hand function. Observations made from the history and examination may have an impact on the treatment options available.

There are numerous pathologies in the hand, which makes a standard approach helpful. By looking, feeling and assessing movement we can be sure of picking up most of the significant clinical findings. Special tests for individual pathologies may then complete the examination.

Screening

After exposing the upper limb adequately a screening examination is performed. Screening is an extremely important part of the examination, as close inspection whilst this is carried out will reveal clues to virtually all pathologies in the hand.

Introduction

Productive examination of the peripheral nerves in the upper limb is based on a comprehensive knowledge of the anatomy of the brachial plexus and the course of the nerves as they pass distally. Examination of the terminal components of the nerves informs us of the proximal pathology. Knowledge of dermatomal and specific sensory nerve cutaneous supply is essential (Figure 6.1).

Examination is guided by a full history. Hand dominance, main occupation, hobbies and past injuries or neurological disorders should be documented, as well as the patient’s age. Age significantly affects both the quality and quantity of nerve recovery following injury. It is better in children and young adults; the rate of nerve regeneration in children is 2–3 mm per day, compared with 1–2 mm in adults.

The nature of the injury, e.g. knife or hydraulic press, should be clearly documented, as this will have a profound impact on the results of nerve surgery. In the elective situation, localization of the site of injury along the course of the nerve may be comparatively difficult. However, enquiry should be made about previous injuries or operations in the upper limb. The timing of injury or the evolution and duration of a compressive neuropathy are important. For example, if the duration of carpal tunnel compression symptoms is less than 10 months, there is a significant chance of recovery utilizing conservative measures.

Paediatric orthopaedic examination is an art, and the success of the consultation relies on the surgeon’s ability to communicate with the parents and the child. Most children who are referred do not require surgery, and time is spent on reassuring the anxious parents or guardian of the normal variations in the development of the child. Quite often, observing the child during the consultation with the parents and a thorough general examination give the clues in making a clinical diagnosis.

The paediatric consulting area should be child-friendly, with toys and ample space for the child to play and for the surgeon to observe. Gaining the confidence of the child is crucial, as well as being warm and patient with the parents who are anxious and concerned. The initial interview should include introductions, as it is important to know the accompanying adults apart from the parents. They could be carers, guardians, grandparents or physiotherapists, and valuable information could be gained. History should be gained from the parents as well as the child, for, not infrequently, it could be conflicting. Clinical history skilfully obtained is the key to diagnosis, and a methodical examination of the child depending on the symptoms and age confirms your initial impression.

History

General history

The majority of adult patients with problems of spinal origin present with complaints of pain in the back and/or legs, with a resultant loss of function.

It is, therefore, as important to understand and record the impact of the perceived pain on the daily work and recreational activities of the patient as it is to enquire about the nature of the pain itself.

One should begin with the patient’s occupation, social circumstances (e.g. young children at home, carer for elderly relative, living alone) and sporting activities. Then enquire about the limitations on all of these aspects of daily living with particular reference to days taken off work, time periods of relative immobility and problems coping with household duties. Specific disability scoring systems can be used if wished. The patient’s age should always be used to help steer thoughts toward a likely diagnosis. Never accept a diagnosis of mechanical back pain in patients outside the age range of 20–55 years without thorough investigation, particularly in the presence of non-mechanical or other atypical symptoms.

Clinical examination is an art and has to be learnt, as it does not come naturally. All patients must be respected, made to feel at ease and assured of their confidentiality and dignity.

A detailed history should always be taken followed by clinical examination.

It is often assumed that clinical examination begins on the couch. This should not be the case, as significant information can be gained by observing the patient as they enter the room and walk towards you or as you approach them.

If the patient is seated they should be asked to stand as this is usually the first part of any orthopaedic clinical examination, except when the hand is being examined. You will observe whether the patient is tall, short, fat, thin, ill, well, energetic or slow. Observe if there is pain or if there are stigmata of orthopaedic disease such as blue sclera (osteogenesis imperfecta), café-au-lait spots (neurofibromatosis), multiple exostoses (diaphyseal aclasis; Figure 1.1), etc.

As with the examination of all other joints in the body, a carefully taken and detailed clinical history will often lead the clinician to a provisional diagnosis of the cause of the patient’s elbow problem.

It is important that, as the patient describes the symptoms, the clinician interprets the information in the light of the local anatomy, most of which, because the elbow is a superficial joint, can be palpated and assessed during the examination.

History

It is always essential when taking a history to record the patient’s age, sex and hand dominance.

Age will give an immediate clue as to the likelihood of certain conditions being responsible for the patient’s complaints. For example, osteochondritis dissecans may be the underlying cause of elbow locking in a young patient, whereas the same symptom in an older patient is more likely to be caused by loose body formation associated with degenerative disease.

The elbow may be the first presenting site of rheumatoid arthritis and, since this occurs more commonly in women, the sex of the patient should alert one to the possibility of this diagnosis if the initial symptoms are pain and slight swelling.

History

Patients with wrist problems often have a paucity of clinical signs. Specific provocative tests can be both difficult to perform and equivocal in their interpretation. A thorough history is therefore essential.

The history should start by recording the age, occupation and handedness of the patient, together with any affected recreational activities, including sports and hobbies.

The basic complaint needs to be established. Is it pain, weakness, a swelling, stiffness or a combination of these? Are there other symptoms? How long has there been a problem? Was there an injury or has the onset been insidious? What was the nature of the injury; was it a single event and, if so, did it receive treatment at the time?

The site and nature of pain should be established (Figure 4.1). The patient should be asked to try to localize it as accurately as possible (for example, by pointing). What is its nature; is it constant or intermittent, sharp, dull or ‘burning’? Is it worse with use and eased by rest? Are there particular movements that aggravate the pain such as turning taps, opening jars?

History

General questions

Usually patients present with a combination of symptoms relating to pain, swelling, locking, clicking and giving way; these form the basis of the specific questions asked on taking a history. The diagnostic specificity of each of these symptoms in isolation is poor; rather they are used in combination to guide the examiner to a differential diagnosis. In addition, the presence and degree of each of these symptoms at presentation and how they have changed with the passage of time is important.

It is then important to ascertain the duration of symptoms, exact details of the mechanism of injury and then the general course of events, including response to any treatment already received. It is through this aspect of the history that one obtains a clear picture of the degree of disability suffered by the patient.

Other key questions include occupation, sport and lifestyle.

Specific questions

Pain

The site of pain within the knee is an indication as to the structure damaged but is by no means diagnostic, particularly with traumatic disorders such as meniscal tears. As an example, lateral joint pain from a patellofemoral disorder is frequently mistaken for a lateral meniscal tear. The site of pain following an episode of injury, however, such as a medial collateral ligament (MCL) strain, is a clear indication of the possible structures involved. It is useful to obtain a description of the pain at the time of injury or presentation and then how the pain has progressed. Of particular importance is whether the pain is constant and whether it occurs at night. For instance, these symptoms are an indication to recommend arthroplasty in assessing a patient with severe degenerative changes. Constant pain may indicate more sinister pathology such as tumour or infection.