Orthopedic History Taking

History taking skills

History taking is the most important step in making a
diagnosis.
A clinician is:
 60% closer to a diagnosis with a thorough history.
 40% by (examination & investigations).
History taking can either:
 Traumatic,
 Non-traumatic injury.
Objective
By end of this session, you should be
able & know how to take a MSK
relevant history of the
major musculoskeletal conditions
Structure Of History
• Demographic features • Drug Hx.
• Chief complaint • Smoking
• History of presenting • Occupational Hx.
illness • Allergy
• Functional level • Family Hx.
• MSK systemic review • Social Hx.
• Systemic enquiry
• PMH
• PSH
MSK systemic review
1. Pain
2. Stiffness.
3. Swelling
4. Instability
5. Deformity
6. Limp
7. Loss of function
8. Altered Sensation.
9. Weakness.
1) Pain
• Location
 Point with a finger to where it is
• Radiation
 Does the pain go anywhere else
• Type
• How long have you had the pain
• How did it start
 Injury:
o Mechanism of injury

o How was it treated ?

 Insidious
1) Pain
• Progression
 Is it better, worse or the same
• When
 Mechanical / Walking
 Rest
 Night
 Constant
• Aggravating & Relieving Factors
 Stairs
 Start up, mechanical
 Pain with twisting & turning
 Up & down hills
 Kneeling
 Squatting
2) Swelling
Onset
Duration
Painful or not
Local vs. generalized
Constant vs. comes and goes
Size progression: same or ↑
Rapidly or slowly
Aggravated & relived factors
Associated with injury or reactive
From: soft tissue, joint, or bone
3) Instability
• Onset
• How dose it start?
• Any Hx. of trauma?
• Frequency
• Trigger/aggravated factors
• Giving way
• Locking
• I can not trust my leg!
• Associated symptoms
 Swelling
 Pain
Mechanical symptoms

Locking / clicking Giving way

Due: Due:
 Loose body,  ACL
 Meniscal tear  Patella
Locking vs. pseudo-
locking
4) Deformity
When did you notice it?
Progressive or not?
Associated with symptoms  pain, stiffness, …
Impaired function or not?
Past Hx of trauma or surgery
PMHx (neuromuscular, polio)
5) Limping
Onset (acute or chronic)
Traumatic or non-traumatic ?
Painful vs. painless
Progressive or not ?
Use walking aid ?
Functional disability ?
Associated  swelling, deformity, or fever.
6) Loss of function
How has this affected the patient’s life
Home (daily living activities DLA)
 Prayer
 Squat or kneel for gardening
 Using toilet
 Getting out of chairs / bed
 Socks
 Stairs
 Walking distance
 Go in & out of car
Work
Sport
 Type & intensity
 Run, jump
Keep In Mind
Red flags
Weight loss
Fever
Loss of sensation
Loss of motor function
Sudden difficulties with urination or defecation
Risk factors Occupation and Sport
Age (the extremes) Family History (as: SCA)
Gender Infections
Obesity Medication (as: steroid)
Lack of physical activity Alcohol
Inadequate dietary PHx MSK injury/condition
calcium and vitamin D PHx Cancer
Smoking
Current and Previous History of Treatment
• Non-operative:
 Medications:
o Analgesia
o Antibiotic
o Patient's own
 Physiotherapy
 Orthotics:
o Walking aid
o Splints

• Operative:
 What, where, and when ?
 Peri-operative complications
Special MSK
Pediatric
Product of  F.T or premature
Pregnancy  normal or not
Delivery  SVD (cephalic vs. breach), C/S (elective vs. E.R)
Family  parents relatives, patient sequence, F/H of same D.
Any  NICU, jaundice, blood transfusion
Vaccination
Milestones  neck, flip, sit, stand, walk
Who noticed the C/O
Spine
• Pain radiation  as L4, exact dermatome or myotome
• Coughing, straining
• Sphincter control (urine & stool)
• Shopping trolleys (forward flexion)
• Neuropathic:
 Increase  back extension & walking downhill
 Improves  walking uphill & sitting
• Vascular:
 Increase  walking uphill (generates more work)
 Improves  stop walking (stand) is better than sitting due
to pressure gradient
 Spine
• Cervical myelopathy:
 Hand assessment
 Coughing, straining

• Red Flags
 Constitutional symptoms  fevers, sweat, weight loss
 Pain  night or rest
 Immunosuppression
 Shoulder
• Age of the patient
 Younger patients more:
o shoulder instability,
o acromioclavicular joint injuries

 Older patients more:

o rotator cuff injuries,
o degenerative joint problems
• Mechanism of injury
 Abduction & external rotation  dislocation of the shoulder
 Chronic pain upon overhead activity or at night time  rotator
cuff problem.
Shoulder
Pain where:
 Rotator Cuff  anterolateral & superior
 Bicipital tendonitis  referred to elbow
Stiffness, Instability, Clicking, Catching, Grinding:
 Initial trauma
 What position
 How often
Weakness  if large tear in the R.C, not as neuro
Shoulder
Loss of function:
 Home:
o Dressing  coat, bra
o Grooming  toilet, brushing hair
o Lift objects
o Arm above shoulder  top shelves, hanging
 Work
 Sport
Referred pain  mediastinal disorders, cardiac
ischaemia
Knee
Injury  as: ACL
 Mechanism  position of leg at time of injury
 Direct / indirect
 Audible POP
 Did it swell up:
 Immediately (haemathrosis)

 Delayed (traumatic synovitis)

 What first aid was done / treated

 Could continue football match or had to leave
Knee
Insidious  as O.A
 Walking distance
 Walking aid
 How pray  regular or chair
 Cross legs on ground
 Squat (traditional toilet)
 Swelling on & off
 Old injury intra-articular
Remember
Now
You are able & know how to
take a relevant history of
the major MSK conditions
Orthopedic History Taking
Importance
Structure
Orthopedic C/O…
History of treatment
Special H/O:
 Pediatric
 Spine
 Shoulder
 Knee
A. IDENTIFICATION
1. Age:
Developmental Dysplasia of Hip (DDH),
<1 yr
Cerebral palsy
Nutritional rickets, Poliomyelitis, Ewing’s
1-2 yrs
sarcoma
5-10 yrs TB of hip, Perthe’s disease
Acute osteomyelitis, Juvenile Idiopathic
< 15
Arthritis

15-20 yrs Slipped Capital Femoral Epiphysis (SCFE)

10-20 yrs Bone malignancies, Osteochondroma

30-40 yrs Rheumatoid Arthritis

Degenerative disorders, Avascular necrosis,

>40 yrs Prolapsed Intervertebral Disc, Multiple
myeloma, Metastasis, Gout
 2. Gender

Males: Perthe’s disease, SCFE, Traumatic disorders, Multiple

myeloma
Females: Rheumatoid arthritis, DDH, Osteoporosis, Ankylosing
spondylitis, Osteomalacia
3. Occupation

 Gives clue to causation and physical requirement

4. Others

 Name, Address, Religion, Education, Hobbies, Hand-dominance

(Dominant hand commonly affected)
B. CHIEF COMPLAINTS

What brings patient to the hospital X Duration of

complaints (If multiple, must be in the descending
order of duration of complaints)

e.g. Pain, Difficulty using limb, Inability to walk,

Deformity of limb, Swelling, Stiffness, Weakness,
Discharging sinus, Altered sensation
C. HISTORY OF PRESENTING ILLNESS
a. Diagnostic facts:
 Present since birth: Congenital
 During development process: Developmental
 Fever, chills, rigors, night cries: Infective
 Nutrition, socio-economic: Metabolic
 Other evidence of hormonal imbalance: Endocrinal
 Seasonal variation, inflammatory signs, morning stiffness (>30
min), pain improved with use of affected part: Inflammatory
 History of Road traffic accident, fall, trauma: Traumatic
 Advancing age, pain improved by rest and worse with use of
affected part/end of the day, locking, instability:
Mechanical/Degenerative
Constant pain, Night cries, fever, night sweats,
anorexia, fatigue, weakness, weight loss, history of Ca.
prostate/thyroid/breast/lung/kidney: Neoplastic
No obvious complaints: Idiopathic

Note:
1. Locking: Sudden inability to complete a particular
movement
• Loose bodies
• Torn meniscus

2. Unlocking: Offending body slips out of way

b. Pain: Describe in OPQRST

Onset: Sudden/Insidious, What triggered? What was

patient doing?
Progression: Constant? Worsened? Improved? On and off?
 Neoplasia: Constant pain
 Trauma: Increases upto 4-6 hours and then decreases
 Acute Inflammation: Sudden increase and then subsides
 Chronic inflammation: Remissions and exacerbation of disease
 New origin pain in painless disease: Malignant change, Pathologic
fracture
Quality:
 Aching: Chronic arthritis
 Stabbing: Ruptured tendon
 Burning: Neuralgia
 Throbbing: Abscess
Radiation/Referred:
 Shoulder pain from heart or diaphragm
 Arm pain from neck
 Leg pain from back (sciatica)
 Back pain from kidney, aortic aneurysm, duodenal ulcer
 Pain may radiate to adjacent sites
Relieving and aggravating factors:
 Direct questions
 Indirect questions: what happens on joint movements, walking,
standing, body posture and exercises
 Related to any food intake: gout
 Relief with analgesics, fomentation or other means?
Site
Severity:
 Mild: easily ignored
 Moderate: can’t be ignored, interferes with function and needs
attention from time to time
 Severe: present most time, demanding constant attention or
treatment
 Excruciating: totally incapacitating
Timing and Duration
c. Swelling:
Onset/first noticed:
 rapid: hematoma, hemarthrosis.
 slow: inflammation, effusion, infection, tumor
Pain:
 painful: acute inflammation, infection, malignancy
 painless: benign growth, low grade malignancy
Progression:
 constant or increasing size: neoplastic.
 remission: inflammatory
 hardens in months: Myositis ossificans.
Swelling at other sites: Neurofibromatosis, Hereditary
multiple exostoses , Multiple enchondromas (Ollier’s
disease, Maffuci syndrome), Multifocal TB,
Polyarthritis
Following fracture: Callus formation, Displacement
Site:
 Hand/wrist: Ganglia
 Foot: Synovial sarcoma
 Knee: Osteochondroma.
 Greater toe: Gout
d. Limp:

Painful Painless
Traumatic Poliomyelitis
Inflammatory e.g. TB hip Coxa vara deformity of hip
Osteoarthritis hip Developmental dysplasia of hip
Deformity of joint or bone
Fused hip, knee or ankle
Coxa-vara (Decreased femoral neck-shaft angle): <120 degrees (Normally
160 degrees at birth and 135 degrees in adult)
1. Congenital: Growth anomaly at upper femoral epiphysis
2. Acquired: SCFE, Perthe’s disease, AVN femoral head, Femoral neck
fracture, Intertrochanteric fracture, Rickets
e. Deformity:
Trauma: Subluxation/dislocation of joint, Malunion,
Volkmann Ischemic Contracture
Acute painful: Muscle spasm initiated by pain
Gradual progression: Chronic infections, Growth-
related disorders
f. Stiffness (Joint involvement):
Early stages: Muscle spasm
Late stages: Adhesions
Advanced stages: Ankylosis
Intra-articular Extra-articular

TB Myositis

Septic arthritis Arthrogyposis Multiplex Congenita

Viral arthritis Burn contracture

Scleroderma and other such diseases

g. Weakness: loss of muscle power
Disuse atrophy of muscle
Neurological weakness:
Brain: Stroke
Spinal cord: Poliomyelitis
Nerve: Neuropathy
Neuromuscular junction: Myasthenia gravis
Muscle: Myopathy
Suggestive history:
No sensory loss: Myopathy, Motor neuropathy, Polio,
Motor neuron disease
Sudden: Injury
Progressive: Neuropathy, Myopathy
Insidious: Myopathy, Leprosy
h. Discharging sinus: Causes of persistent
discharging sinus –
Diabetes mellitus
Chronic osteomyelitis
Fungal infection
Foreign body
Epithelialisation of sinus tract
Scar tissue around sinus
Malignant change
i. Other things to be asked in HOPI:
Activities of daily living (ADL): getting up, sitting
down, using bathroom, combing hair
Change in sensibility: Intervertebral disc prolapse,
local ischemia, peripheral neuropathy
Treatment received for the complaint
For a case of trauma: Mechanism of injury, Events
surrounding the trauma
Any need to use ‘aids’?

j. Review of systems: Include only

positive history and RELEVANT negative history
D. PAST HISTORY

1. Similar problem on the contralateral side or similar

episode previously
2. Orthopedic history: Injuries, non-surgical treatment,
surgery
3. Medical history:
A. Twisted ankle: Osteoarthritis
B. Gastrointestinal disease: Ankylosing spondylitis or Osteoporosis
C. Conjunctivits, Iritis, Psoriasis, Urogenital disease: Reactive
arthritis
D. Malignancies: Metastatic bone disease
E. Others: TB, DM, Hypertension, etc.
4. Surgical history
E. PERSONAL HISTORY

Smoking
Alcohol intake
Drug abuse
F. FAMILY HISTORY

1. Orthopaedic : Dupuytren’s contracture

Rheumatoid arthritis, gout, bone dysplasias may
run in families.
2. Medical : TB, DM, HTN
G. DRUG AND ALLERGY

1. Current and post medications

 steroids: a vascular necrosis, problems in
wound healing.
 Phenytoin: Dupuytren’s contracture
H. SOCIAL HISTORY

Level of care and nutrition in children

Dietary constraints which may cause specific
deficiencies
Work practices, travel and recreation
 I. MENSTRUAL HISTORY (In
females):
Menarche: Scoliosis
Menopause: Osteoporosis
J. BIRTH HISTORY

Absence/weakness of fetal movements by 4-5

gestational months: Neuromuscular disease
Maternal Diabetes Mellitus, toxemia, drug
ingestion, fetal distress or prematurity
Type of delivery: Breech (DDH)
Physical and mental development of child:
Age (months) Milestones

1-2 Holds up chin

6-8 Sits alone

8-10 Stands with support

10-12 Walks with support

14 Walks without support

24 Ascends stairs one foot at a time