LECTURE No. 1.

Methods of examination of
traumatological and orthopedic patients
The basis that allows making a preliminary diagnosis and determining the directions
of diagnostic search has remained and remains the classical method of examining a
traumatological and orthopedic patient, without knowledge of which it is impossible
to form a competent traumatologist-orthopedist.

Examination of patients with injuries and diseases of the musculoskeletal system is

the most important step in the timely recognition of the disease and the correct
diagnosis, which determines the choice of the optimal method of treatment and the
subsequent course of the disease.

The methodology for examining traumatological and orthopedic patients is

distinguished by a number of features, consisting in a strict sequence of studying the
patient using not only special manual techniques and symptoms, but also the very
methodology of examining the patient. The following provisions are of particular
importance:

1) mandatory use of the comparative method;

2) accounting for causal relationships in the manifestations of diseases, injuries or

their consequences;

3) strict anatomical conditionality of diagnostic techniques and symptoms, depending

on the localization of the focus of the disease.

Stages of carrying out the main therapeutic and diagnostic measures for injuries and
injuries of soft tissues:

1) determine the type of damage, make a preliminary diagnosis;

2) determine the urgency and scope of first medical and follow-up care;

3) perform urgent diagnostic studies;

4) provide medical care in the appropriate amount;

5) determine the features of transportation and transport immobilization.

When a patient enters a hospital, his general condition is first of all clarified. If the
victim is in shock, anti-shock measures are taken first, then, when the patient comes
out of a serious condition, they begin to question and examine.

1. General questions of survey methodology

Clinical data remain decisive in making a diagnosis and prescribing rational
treatment.

Examination of a patient by a doctor should always begin with a question (find out
complaints and collect anamnestic data), then proceed to a careful examination, and
then apply special research methods aimed at recognizing and evaluating clinical and
other signs of injury or disease. Inspection, palpation and measurement, as well as
percussion and auscultation, are objective examination methods that have the greatest
practical value and do not require the use of special instruments and are carried out in
any setting.

The examination scheme includes the following diagnostic tests:

1) clarification of the patient's complaints; questioning the patient or his relatives

about the mechanism of injury, the features of the disease;

2) inspection, palpation, auscultation and percussion;

3) measuring the length and circumference of the limbs;

4) determination of the amplitude of movements in the joints produced by the patient

himself (active) and the doctor examining him (passive);

5) determination of muscle strength;

6) x-ray examination;

7) surgical and laboratory research methods (biopsy, puncture, diagnostic opening of

the joint).

Complaints

Frequent complaints of patients with diseases and injuries of the organs of support and
movement are pain (localization, intensity, nature, connection with the time of day,
physical activity, position, effectiveness of drug relief, etc.), loss, weakening or
dysfunction, the presence of deformation and cosmetic defect.

It should be borne in mind that often the intensity of pain does not correspond to the
place of the underlying disease, but is of a reflected nature.

Anamnesis
Anamnestic data include information about age, profession, duration and development
of the disease.

In case of injuries, the circumstances and time of the injury are clarified, its
mechanism and the nature of the traumatic agent, the volume and content of first aid,
the features of transportation and transport immobilization are established in detail. If
the injury was mild or not at all, and a bone fracture occurred, one should think about
a fracture against the background of a pathological process in the bone.

When examining patients with diseases of the musculoskeletal system, it is necessary

to clarify a number of specific questions for this group of diseases.

With congenital deformities , a family history is specified. It is necessary to clarify the

presence of such diseases in relatives, the course of pregnancy and the characteristics
of childbirth in the mother, to establish the nature of the development of the
deformity.

In inflammatory diseases , it is important to find out the nature of the onset of the
process (acute, chronic). It is necessary to establish what the body temperature was,
the nature of the temperature curve, whether there were any previous infectious
diseases, ask the patient about the presence of such diseases as brucellosis,
tuberculosis, venereal diseases, rheumatism, gout, etc.

In diseases of the nervous system . In case of deformities arising from diseases of the
nervous system, it is necessary to find out from what time these changes were noticed,
what preceded the development of this disease (features of the course of childbirth in
the mother, infectious diseases, injuries, etc.), the nature of the previous treatment.

With neoplasms , it is necessary to establish the duration and nature of the course of
the disease, previous treatment (drug, radiation, surgical), data from a previous
examination.

With dystrophic processes , it is necessary to find out the good quality of their course.

2. Features of an objective examination

Inspection

Examination of the patient is crucial for the diagnosis of the disease and differential
diagnosis. It must be remembered that victims with multiple fractures usually
complain about the most painful places, diverting the attention of the doctor from the
general examination, which often leads to the fact that other injuries are not
recognized. You can not start a manual study without examining the patient. It is
definitely recommended to compare the diseased limb and the healthy one.

On examination, it is necessary to determine the anomalies in the position and

direction of individual parts of the body , due to changes in the soft tissues
surrounding the skeleton, or in the bone tissue itself, which can lead to impaired gait
and posture, to various curvatures and postures. Particular attention should be paid to
the position of the limb, forced posture and features of gait.

In some diseases and injuries, the limb may be in the position of external or internal
rotation, flexion or extension, abduction or adduction. Distinguish the position of the
limb:

1) active - a person freely uses a limb;

2) passive - the patient cannot use the limb due to paralysis or bone fracture. For
example, in a fracture of the femoral neck, the limb is in external rotation; with
paralysis of the brachial plexus, the arm is brought to the body and rotated inward,
and the hand and fingers retain normal mobility; with paralysis of the radial nerve, the
hand and fingers are in the position of palmar flexion, active extension of the II–V
fingers and abduction of the first finger are absent;

3) the forced position of the limb or the patient is observed in systemic diseases and
can be of three types:

a) caused by pain - sparing installation ( antalgic posture for lumbalgia );

b) associated with morphological changes in the tissues or disorders of the

relationship in the articular ends, such as dislocations, ankylosis, contractures (posture
of the petitioner in ankylosing spondylitis, spastic paralysis as a result of contracture
and ankylosis);

c) pathological attitudes, which are a manifestation of compensation (with shortening

of the limbs, pelvic tilt, scoliosis).

When examining the skin , a change in color, color, localization of hemorrhage, the
presence of abrasions, ulcerations, wounds, skin tension with edema, the appearance
of new folds in unusual places are determined.

When examining the limbs , an anomaly of direction (curvature) is determined, which

is characterized by a violation of the normal axis of the limb due to curvature of the
limb in the area of the joints or within the segment, or due to a violation of the
relationship of the articular ends (dislocations) and is most often associated with
changes in the bones: the curvature may be due to rickets, degeneration or dysplasia
of the bone, violation of its integrity due to trauma or neoplasm.
When examining the joints , the shape and contours of the joint are determined, the
presence of excess fluid in the joint cavity ( synovitis , hemarthrosis).

The shape and contours of the joints can be in the form of:

1) swelling (due to inflammatory edema of periarticular tissues and effusion into the
joint cavity during an acute process);

2) defiguration (as a result of exudation and proliferation in the joint and periarticular
tissues in a subacute inflammatory process);

3) deformities (violation of the correct shape of the joint that occurs in chronic
degenerative disease).

When examining the shoulder joint , you can notice muscle atrophy or restriction of
movement of the shoulder and shoulder girdle; when examining the elbow joint -
cubitus varus and cubitus valgus , subcutaneous nodes, ulnar bursitis or restriction of
movement (flexion and extension, pronation and supination), deformity of the fingers
and Heberden's nodules.

Examination of the knee joint is carried out at rest and during exercise. Deformation
of the joint, its contracture or instability are revealed. In this case, deformations of
genu are possible. varum (angle open inwards), genu valgum (angle open outward)
and hyperextension of the knee joint.

Inspection of the foot is carried out at rest and under load. The height of the
longitudinal arch of the foot and the degree of flat feet, foot deformities are
determined: hallux valgus , hammer toe, nodulation with gout, horse (hanging) foot,
varus foot or valgus foot, adducted and abducted forefoot, abnormal gait (toes apart or
inward).

Examination of the back is performed for diseases of the spine. The patient must be
undressed and undressed. Inspection is carried out from the back, front and side.
Determine the curvature of the spine (kyphosis, scoliosis), costal hump.

Palpation

After a preliminary determination of the place of manifestation of the disease, they

begin to palpate the deformed or painful area. Palpation is carried out carefully,
carefully, with warm hands, so as not to cause a protective reaction to cold and rough
manipulation. It should be remembered that palpation is a feeling, not pressure. When
performing this diagnostic manipulation, the rule is observed - to put as little pressure
on the tissues as possible, palpation is performed with both hands, and their actions
must be separate, that is, if one hand makes a push, the other perceives it, as is done
when determining fluctuation.
Palpation is performed with the whole hand, fingertips and the tip of the index finger.
To determine the pain, you can use tapping on the spine, hip joint and pressure along
the axis of the limb or load in certain positions. Local pain is determined by deep
palpation. When palpation is recommended to use a comparative assessment.

Palpation allows you to determine the following points:

1) local increase in temperature;

2) points of maximum pain;

3) the presence or absence of swelling;

4) the consistency of pathological formations;

5) normal or abnormal mobility in the joints;

6) pathological mobility throughout the tubular bone;

7) the position of the articular ends or bone fragments;

8) crepitation of bone fragments, rough crunch or clicking;

9) springy fixation in case of dislocation;

10) nodules , gouty tufuses and fibrositis;

11) atrophy or muscle tension;

12) balloting and fluctuation.

Auscultation

In case of fractures of long tubular bones, bone sound conductivity is determined in

comparison with the healthy side. Bone formations protruding under the skin are
selected and, percussing below the fracture, sound conduction is heard with a
phonendoscope above the alleged bone damage. Even a crack in the bone gives a
reduction in the pitch and clarity of the sound. With a disease of the joints at the time
of flexion, a wide variety of noises occur: crunching, crackling, crepitus.

Percussion
Percussion is used to determine the painful segment of the spine. The percussion
hammer or the ulnar side of the fist determines general or strictly localized pain. Pain
associated with hypertension paravertebral muscles, is determined by percussion of
the spinous processes with the tip of the III finger, and II and IV fingers are set
paravertebral . Tapping on the spinous processes causes a spasm of the paravertebral
muscles, felt under the II and IV fingers.

There is a special method of percussion of the spine that allows you to determine the
increased sensitivity in the area of the affected vertebra - this is a sharp lowering of
the patient from socks to heels.

Measuring the length and circumference of a limb

For a more accurate recognition of an orthopedic disease or the consequences of an

injury, it is necessary to have data on the length and circumference of the limb.

General rules . Measurement of the length of the limb is carried out with a
symmetrical installation of the diseased and healthy limbs with a centimeter tape
between symmetrical identification points (bone protrusions). Such points are the
xiphoid process, navel, spina ilica anterior superior , tip of the greater trochanter,
condyles, ankles, etc.

With a forced position of the limb (contractures, ankylosis, etc.), a comparative

measurement is carried out by setting the healthy limb in the same position as the
patient.

The preliminary stage of measurement is the study of the axis of the limb.

The axis of the upper limb is a line drawn through the center of the head of the
humerus, the center of the capitate eminence of the shoulder, the head of the radius
and ulna. Around this axis, the upper limb performs rotational movements.

The axis of the lower limb normally passes through the anterior superior axis of the
ilium, the inner edge of the patella and the first toe in a straight line connecting these
points.

Measurement of the length of the upper limb . The arms should be parallel to the
body, extended at the “seams”, the correct position of the shoulder girdle is
determined by the same level of standing of the lower corners of the shoulder blades.

The anatomical (true) length of the shoulder is measured from the large tubercle of
the humerus to the olecranon, the forearm - from the olecranon to the styloid process
of the radius.
The relative length of the upper limb is measured from the acromial process of the
scapula to the tip of the third finger in a straight line.

If it is necessary to measure the length of the shoulder and forearm, intermediate

points are found: the tip of the olecranon or the head of the radius.

Measurement of the length of the lower limb . The patient is laid on his back, the
limbs are given a symmetrical position parallel to the long axis of the body, the
anterior superior iliac spines should be on the same line perpendicular to the long axis
of the body.

When determining the anatomical (true) length of the femur , the distance from the
top of the greater trochanter to the joint space of the knee joint is measured, while
determining the length of the lower leg, from the joint space of the knee joint to the
outer ankle. The sum of the measured length and lower leg data is the anatomical
length of the lower limb.

The relative length of the lower limb is determined by measuring in a straight line
from the anterior superior iliac spine to the foot, while the patient is given the correct
position: the pelvis is located along a line perpendicular to the body axis, and the
limbs are in a strictly symmetrical position.

The foot is measured both with and without load. The foot is placed on a blank sheet
of paper, its contours are outlined with a pencil.

On the resulting contour, the length is measured - the distance from the fingertips to
the end of the heel, the "large" width - at the level of the I-V metatarsophalangeal
joints, the "small" one - at the level of the rear edge of the ankles.

There are the following types of shortening (lengthening) of the limbs.

1. Anatomical (true) shortening (lengthening): segmental measurement establishes

that one of the bones is shortened (lengthened) compared to a healthy limb and is
determined by the total data (thigh and lower leg separately). Anatomical shortening
of the limb segment is observed in fractures of long bones with displacement of
fragments, with growth retardation after injury or inflammation of the epiphyseal
cartilage.

2. Relative shortening (lengthening) occurs with changes in the location of the

articulating segments (pelvis and thigh, thigh and lower leg), for example , with
dislocations, when the articular ends are displaced relative to each other, changes in
the neck-diaphyseal angle, contractures and ankylosis. In this case, it often happens
that the relative length of the diseased limb is less, and the anatomical length is the
same.

3. Total shortening (lengthening) - all of the listed types of length measurement must
be taken into account when loading the lower limb in the vertical position of the
patient. To determine the total shortening of the lower limb, special boards of a
certain thickness are used, which are placed under the affected leg until the pelvis is in
a horizontal position.

The height of the boards corresponds to the total shortening of the lower limb.

4. Projection (apparent) shortening is due to the vicious position of the limb due to
ankylosis or contracture in the joint.

5. Functional shortening is observed with bone curvature, flexion contractures,

dislocations, ankylosis in vicious positions, etc.

The circumference of a segment of a limb or joint is measured with a centimeter tape

at symmetrical levels of both limbs. A decrease (for example, due to muscle atrophy)
or an increase in the circumference of the joint (hemarthrosis) or limb segment
(inflammation) is determined.

Thigh circumference is measured in the upper, middle and lower thirds. On the
shoulder, forearm and lower leg, their most voluminous part is measured.

It is especially important to measure the circumference of the limb at the level of the
joints in their pathology - an increase in the circumference of the joint indicates the
presence of synovitis or hemarthrosis.

Determination of the function of the musculoskeletal system

The functionality of the musculoskeletal system is determined by:

1) range of motion in the joints;

2) compensatory capabilities of neighboring departments;

3) muscle strength.

The amplitude of mobility in the joints is determined during active and passive
movements. Passive movements in the joints are more active and are indicators of the
true range of motion. Restriction of mobility in the joints is caused by intra-articular
or extra-articular causes.

Mobility begins to be investigated from the amplitude of active movements in the

joint, then it is necessary to proceed to establish the boundaries of passive mobility
and establish the nature of the obstacle that inhibits further movement in the joint. The
limit of the possibility of passive movement should be considered the appearance of
pain.
When measuring, the initial position should be considered the position in which the
joint is established with a free vertical position of the limbs and torso.

The range of motion is measured with a goniometer. The initial position is the vertical
position of the trunk and limbs, which corresponds to 180°.

Pathological mobility throughout the diaphysis . The study presents difficulties in

those cases when the fracture has grown together with a fibrous scar or soft callus,
allowing insignificant rocking movements. For research, it is necessary to fix the
proximal part of the diaphysis so that the thumb lies on the fracture line, and with the
other hand to make jerky small movements of the peripheral part.

Easy mobility is caught by a finger.

Various types of limitation of mobility in the joint can be observed.

Ankylosis (fibrous, bone) - complete immobility.

Contracture is a limitation of passive mobility in the joint, however, no matter how

great it is, some minimum range of motion in the joint is preserved.

Contractures are divided into:

1) by the nature of the changes underlying the process: dermatogenic , desmogenic ,

neurogenic, myogenic, arthrogenic , and more often combined;

2) according to the preserved mobility: flexion , extensor, adductor, abductor, mixed;

3) by severity: expressed, unexpressed, persistent, unstable.

compensatory changes . In pathological static-dynamic conditions, compensatory

changes in the overlying sections are determined.

For example, with a decrease in the cervical-diaphyseal angle of the femur, a

compensatory descent of the half of the pelvis from the diseased side and
compensatory scoliotic deformity of the spine occurs.

Determination of muscle strength is carried out with a Colin dynamometer or, in its
absence, by counteracting the active movements of the patient with the hand and
always in a comparative aspect.

The score is set according to a five-point system: with normal strength - 5; when
decreasing - 4; with a sharp decrease - 3; in the absence of force - 2; with paralysis - 1.

Assessment of the functional ability of the musculoskeletal system is determined by

observing how the patient performs a number of normal movements. Movement
disorders include lameness, absence, limitation or excessive movement.
Gait research . Changes in gait can be very diverse, but lameness is the most
common. There are the following types:

1) sparing lameness - occurs as a protective reaction to pain during injuries and

inflammatory processes;

2) non- sparing lameness - associated with shortening of the limb and is not
accompanied by pain.

With sparing lameness , the patient avoids fully loading the affected leg, spares it and,
when walking, leans on it more briefly, more carefully than on a healthy leg. The
torso deviates to the healthy side due to the unloading of the leg. By the "sound of
walking" you can recognize sparing lameness (change in sound rhythm).

Not sparing lameness , or "falling", is characteristic of limb shortening.

A slight shortening within 1–2 cm does not cause lameness, masking itself as a
compensatory prolapse of the pelvis. With a shortening of more than 2-3 cm, the
patient, when relying on a shortened leg, transfers the weight of the body to the side
of the affected leg.

"Duck" gait - the body alternately deviates in one direction or the other. Most often,
this type of gait is observed with bilateral hip dislocation and other deformities
leading to shortening of the pelviotrochanteric muscles.

Clubfoot . The gait of a clubfoot resembles that of a person walking through mud:
with each step, the foot rises higher than usual in order to overcome the obstacle - the
other clubfoot foot.

A bouncing gait is caused by lengthening of the leg due to deformities in the ankle or
foot joints (for example, with a horse-hollow foot).

Paralytic (paretic) gait occurs with isolated paralysis, paresis of individual muscles,
with prolapse of more or less extensive muscle groups.

For example, when the strength of the hip abductors is weakened, Trendelenburg 's
symptom occurs ; with paralysis of the quadriceps muscle of the thigh, the patient
holds the knee with his hand, which bends at the time of the load, the hand in this case
replaces the extensor of the lower leg. A "cock" gait occurs with paralysis of the
peroneal muscles - with each step, the patient raises his leg higher than usual so that
the front section of the drooping foot does not cling to the floor, while producing
excessive flexion in the hip and knee joints.

Spastic gait is observed with an increase in muscle tone during spastic paralysis (for
example, after encephalitis). The legs of the patients are stiff , the patients move in
small steps, raising their feet with difficulty, dragging their feet, shuffling their soles
on the floor; legs often show a tendency to cross.
study the function of the upper limbs by inviting the patient to first perform a number
of separate movements - abduction, adduction, flexion, extension, external and
internal rotation, and then perform more complex movements, for example , lay a
hand behind the back (definition of complete internal rotation), comb, grab the ear of
the corresponding or opposite side, etc.

X-ray examination

X-ray examination, being an integral part of the general clinical examination, is of

decisive importance for the recognition of injuries and diseases of the musculoskeletal
system.

Several methods of X-ray examination are used: survey radiography, X-ray

pneumography , tomography. Radiography is carried out in two projections (face,
profile).

In some cases, for comparison, it becomes necessary to produce radiography and the
healthy side.

X-ray data allow:

1) confirm the clinical diagnosis of the fracture;

2) to recognize the location of the fracture and its variety;

3) specify the number of fragments and the type of their displacement;

4) establish the presence of dislocation or subluxation;

5) monitor the process of fracture consolidation;

6) find out the nature and prevalence of the pathological process.

The standing of the fragments after the application of skeletal traction is controlled by
radiography after 24-48 hours, and after the operation - on the operating table.

X-ray control is performed during treatment and before discharge for outpatient
follow-up care.

Surgical and laboratory research methods

Surgical methods for examining patients with diseases of the musculoskeletal system
include: biopsy, puncture, diagnostic arthrotomy.
Biopsy . To clarify the nature of tumors or chronic inflammation of the joints and
other tissues, they resort to a histological examination of the material taken from the
lesion by surgery.

Puncture of joints, subdural space, soft tissue and bone tumors, cysts is performed
with special needles for diagnostic and therapeutic purposes. The punctate is sent for
microscopic or histological examination.

The release of the joint from excess fluid brings significant relief to the patient. At the
same time, after the fluid has been evacuated, if necessary, anti-inflammatory drugs
are injected into the joint cavity through the same needle.

A lumbar puncture is performed in traumatic brain injury to recognize subarachnoid

hemorrhage and determine hyper- or hypotension.

Diagnostic arthrotomy can be performed in difficult diagnostic and therapeutic

situations.

Laboratory research methods often provide significant differential diagnostic

assistance. A change in the clinical and biochemical composition of the blood after an
injury or in orthopedic diseases is an indicator of the severity of their course and the
choice of treatment method. Biochemical, immunological and serological reactions
(C-reactive protein, anti- streptococcal antibodies, specific reactions, etc.) help
confirm the clinical diagnosis.