Core Content - Core Orthopaedic Concepts - History Taking and Clinical Examination


Clinical Examination

This is possibly the most important part of your T&O module as you will not be taught joint examination skills elsewhere. You should regularly practice all 6 joint exams on fellow students and practice on patients when appropriate.

Guides to examining individual joints are linked below:

Spine

Shoulder

Wrist and Hands

Hip

Knee

Foot and Ankle


History Taking

 

As with many specialties, a great piece of the diagnostic puzzle can be obtained simply by effective questioning of the patient. The history of an orthopaedic presentation is often very different to, say, respiratory or cardiology and therefor the questions that you must ask will be different. It is therefor important to practice taking a musculoskeletal history so you do not miss important clues to the diagnoisis.

 

Demographics
Age, sex, occupation and handedness

 

Presenting Complaint
What is the main reason for seeking medical advice?

Common presentations to T&O are:

  • Pain
  • Swelling
  • Stiffness
  • Deformity
  • Weakness
  • Sensory disturbance
 

History of Presenting Complaint
An in depth description of the complaint and anything related to it

Use the 'SOCRATES' pnemonic for asking about pain

  • Site - Where exactly is the pain? Can you put one finger on it?
  • Onset - How long have you had the pain for? Was there anything that started or caused it? Remember to ask about trauma!
  • Character - Can you describe the pain? Is it dull/sharp, burning/cold, etc?
  • Radiation - Does the pain go anywhere else?
  • Associated - Do you get any other symptoms with the pain?
  • Timing - Is the pain constant or does it come and go?
  • Exacerbating/relieving factors - Does anything make the pain better? Is there anything that worsens or brings on the pain?
  • Severity - At its worst, how would you rate the pain out of 10, with '0' being no pain and '10' being the worst you could imagine?
 

Swelling

  • Can be related to soft tissue or the joint itself (effusion)
  • Rapid joint swelling following injury is likely a haemarthrosis, suggesting fracture or ligament tear
  • Slow swelling suggests inflammation or joint effusion
 

Stiffness

  • May be localised to a particular joint or generalised, for example in ankylosing spondylitis
  • Although a patient may say they can't move a joint, verify this on examination but be gentle!
  • Ask when the stiffness occurs and if it gets better with movement
  • If the affected joint has a sudden and complete block to a particular movement then this is called 'locking' and is often associated with meniscal tears
 

Deformity

  • Can be a variation of normal
  • Patients will often mention this as because someone else has commented on it, for example a varus knee in osteoarthritis 
 

Weakness 

  • Is it just one joint or many?
  • Does it come on after a time or is it always present
  • Are they clumsy with it?
  • How does it affect their daily activites?
 

Sensory disturbance

  • Similar to SOCRATES questioning
  • Is it tingling, numbness, burning, increased sensativity?
 

History of Trauma and Mechanism of Injury
This is hugely important for an orthopaedic history, in both acute and chronic presentations.

  • Can you describe how the injury happened?
  • High or low energy? eg. RTA vs trip over carpet
  • Where did the injury occur? eg. domestic vs industrial
  • Associated injuries and pain
  • Previous injuries to the same body part
 

Past Medical and Surgical History
Many co-morbidities can be related to the presenting complaint or could cause problems if surgery is considered
It is important to be aware of previous operations, for example menisectomy or previous trauma surgery in a patient with knee osteoarthritis

Drug History and Allergies
Drugs may contribute to the presenting complaint, for example steroids in osteoporotic fractures, and may increase risks when operating, for example warfarin.

Social History
Ask about the patient's pre-morbid mobility level. This should include how they mobilise and what they are able to do, eg climb stairs, get out to the shops. 

  • Independent
  • Walks with stick
  • Walks with zimmer
  • Wheelchair bound
  • Bedbound

Who do they live with? Do they have help at home?
Alcohol, recreational drugs and smoking history

Family History
Any relevant diseases that affect direct relatives?

Complete the History
Systemic enquiry
Ideas, concerns and expectations