Orthopaedic Diseases I —

Approach to Orthopaedic Problems

Dr Tse Sut Yee

BDS (HK), MBBS (HK), Dip Med (CUHK), DCH (Sydney),
FHKCFP, FRACGP, FHKAM (Family Medicine)

Consultant
Department of Family Medicine
CUHK Medical Centre

School of Chinese Medicine, CUHK

 What is an orthopaedic problem?

• all localized problems in the 4 limbs, spine

and pelvis including bones, joints and soft
tissues (skin, fascia, muscle, ligament,
tendon, nerves, vessels)
 Exception
region problem managed by

limbs large vessel vascular surgeon of general

surgery
spine intradural pathology neurosurgery
pelvis pelvic organs O&G, surgery, urology
generalized generalized bone, joint, nerve medical
and muscle problem
skin complicated skin problem dermatology

special bone and joint skull bone, sternum, ribs neurosurgery,

cardiothoracic surgery
maxilla, mandible, TM joint maxillofacial surgeon,
dental surgeon
 Scope of orthopaedics

❖Orthopaedic diagnosis
❖Orthopaedic management
❖Orthopaedic rehabilitation
 Orthopaedic diagnosis

oHistory
oExamination
oInvestigation
 History
•Key words/symptoms to pick up or specifically asked for:
injury, pain, stiffness, swelling, deformity, instability, weakness, altered
sensation, loss of function
• When any key word/symptom is present, needs to ask for
more details:
o when it began, sudden or gradual onset
o spontaneous or after some event
o progression (static, getting worse or getting better)
o any aggravating and relieving factors
 Important symptom: pain

SOCRATES
Site Where exactly is the pain?

Onset What were they doing when the pain started?

Character What does the pain feel like?

Radiates Does the pain go anywhere else?

Associated symptoms e.g. nausea/ vomiting

Time/ duration How long have they had the pain?

Exacerbating/ Relieving Does anything make the pain better or worse?

factors
 Important symptom: pain
轉移痛

Referred pain

● to knee → hip disease

● to buttock/ back of thigh or calf → back

problem

● to shoulder → neck problem

 Important symptom: stiffness
character interpretation
localized local joint problem
強直性脊椎炎
generalized ankylosing spondylitis
rheumatological diseases

timing early morning

after a period of inability, improved after
movement
游離體
locking loose body, torn meniscus, some ACL rupture
 Important symptom: swelling

character interpretation

spontaneous, rapid onset or bleeding

after injury
積水
slow onset soft tissue inflammation, effusion, tumour

painful infection, inflammation

painless consider tumour

囊腫
fluctuating size cystic mass (some cystic mass has constant size)

progressively enlarge tumour

 Important symptom: deformity
character interpretation
symmetrical systemic disease
asymmetrical localized disease

膝关节外翻 x形腿 佝僂病

knocked knee may be physiological, also seen in ricket, rheumatoid arthritis
膝關節內翻，o形腿
bow leg physiological in toddler, osteoarthritis in elderly

flat feet congenital for early onset flat feet

拇指外翻
big toe deformity hallux valgus

finger deformity osteoathritis, rheumatoid arthritis, nerve palsy, injury, etc

 Important symptom: weakness
character interpretation
generalized chronic disease, neurological disorder
proximal > distal myopathy
distal > proximal neuropathy
weakness of a particular peripheral nerve lesion (e.g. wrist drop in radial nerve palsy,
nerve foot drop in peroneal nerve palsy)
 Important symptom: instability
instability symptom interpretation
patella going outward patellar dislocation

撐不住，軟腳
knee giving way ACL injury

shoulder moving out recurrent shoulder dislocation

partial dislocation,bones still in touch
abnormal movement of thumb subluxation of 1st carpometacarpal joint
 Important symptom: altered sensation
character interpretation
numbness nerve entrapment (e.g. carpal tunnel syndrome)

neuropathy (e.g. DM)

ischaemia (e.g. peripheral vascular disease)
截肢
hypersensitivity neuroma, amputation stump

dermatome distribution nerve root lesion (e.g. prolapsed intervertebral disc)

肘管綜合症
peripheral nerve distribution peripheral nerve lesion (e.g. cubital tunnel syndrome)
 Important symptom: loss of
function
function lost
cannot sit for long time
cannot walk for long distance
worse when walking upstairs
worse when walking downstairs
cannot put on socks
cannot use chopsticks
interpretation
prolapsed intervertebral disc
claudication 跛行
vascular claudication
spinal claudication
hip or knee stiffness
cervical myelopathy
頸椎退化性脊髓病變
 Past history
• Previous illness, accident, surgery
• Important medical disease e.g. diabetes may be
the cause of numbness or ulcer
• Important medications: e.g. steroid may be related
骨骼缺血性壞死
to hip pain due to avascular necrosis
• Smoking and alcohol: Buerger’s disease (smoking)
and avascular necrosis (alcohol)
• Allergic history
 Family history
• Some diseases may run in family, e.g.:
❖scoliosis
❖ankylosing spondylitis
❖rheumatological disease
❖some bone tumour (e.g. osteochondroma)
❖developmental dysplasia of hip (DDH, previously
called congenital dislocation of hip),
❖flat feet
❖club foot 馬蹄足內翻
 Social history
• occupation
• education
• travel history
• marital status
• family support, living in hostel or not
• recreation, sports, hobbies
• smoking and alcohol
 Physical examination
Proper and adequate exposure
Compare both sides

• Look
• Feel
• Move
 Physical examination: look
• general appearance (e.g. depressed mood)
• posture (e.g. kyphotic, scoliotic, cannot sit – acute
sciatica)
• gait
• in pain?
• skin color (pale, blue, red, dark)
• scar 皮膚皺紋

• abnormal skin crease

• lump
• wasting
• deformity
 Physical examination: feel
• skin temperature, moisture/dryness
• peripheral pulse, capillary return
• lump size, consistency, tenderness,
pulsatile?
• joint effusion/ swelling
 Physical examination: move
• Active movement: assess the functional range of movement, whether
painful or not, also used to assess power

• Passive movement: assess the maximal range of movement, compare with

active movement; also feel for any crepitus 皮下氣腫
外翻 內翻
• Abnormal movement: e.g. valgus/ varus stress of knee and elbow;
hyperextension of wrist and fingers; anterior draw test of knee for ACL
injury

• Provocative movement: e.g. shoulder impingement sign, shoulder or

patella apprehension test, Ortolani test for baby’s hip; straight leg raising
test, Lasegue’s test for prolapsed disc; Tinel sign for carpal tunnel
syndrome

• Neurological examination if required: tone, motor power, sensation, jerks,

specific tests (e.g. myelopathic signs)
 Investigations: radiology
• Plain X-ray (2 views, 2 sides, 2 joints, +/- 2 dates), read the soft tissue and
bone

• Contrast radiography: e.g. arthrogram, myelogram rarely done nowadays

(replaced by MRI)

• Ultrasound: convenient to assess soft tissue lesion, cystic mass and vascular
lesions

• Computed tomography (CT scan) +/- contrast: for visualizing the bone or
abscess

• Magnetic resonance imaging (MRI): for visualizing soft tissue, may add
contrast (gadolinium) in assessing vascular tumor, abscess or recurrence of
spinal problem after surgery

• Positron emission tomography (PET scan): for searching occult tumor or

metastasis
 Investigation: blood test
• CBP, LFT, RFT, Ca, PO4, urate, ESR, CRP
• ANA, RF, anti-dsDNA
• tumor marker when suspect malignancy
• protein electrophoresis for diagnosing multiple
myeloma
• HLAB27 when suspect ankylosing spondylitis
 Other investigations
• Synovial fluid analysis when suspect septic arthritis
– synovial fluid for urgent Gram stain, culture and AFB,
– synovium for section

• Biopsy for suspicious lesion (FNAC, incision biopsy, excision biopsy)

• Diagnostic arthroscopy: when suspect meniscal or ACL lesion, can

also be diagnostic + therapeutic at the same time e.g. meniscectomy

• Electrodiagnostic tests:
– nerve conduction test (NCT)
– electromyography (EMG)
 Take home message
• History taking is very important

• Better to formulate a list of differential diagnoses from the history before the physical
examination

• Orthopaedic examination mainly consists of “Look”, “Feel”, “Move” +/- “Special

test(s)”

• Investigation is just to confirm the diagnosis or to assess the severity

• Different investigation has its own merit, know why and how an investigation can
help before you order it

• When your history, examination, investigation cannot fit into a diagnosis, it is either a
disease that you don’t know or a psychological disorder

• Know where to refer your patient to when you decide to refer

Thank you