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🦴 Complete Orthopedics Posting Guide

History Taking + Clinical Examination (Easy Language)

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🔑 Golden Rule of Ortho Posting

1. History - what the patient tells you
2. Examination - what you find with your hands and eyes
3. Investigations - X-ray, MRI, blood tests

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PART 1: HISTORY TAKING

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1. Personal Details (Always Ask First!)

🔥 Age is a SUPERPOWER in Ortho - Memorize This!

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2. Chief Complaint (CC)

P - Pain
S - Swelling
D - Deformity
S - Stiffness
W - Weakness / Wasting
I - Instability ("my joint gives way")
N - Numbness / Tingling
L - Limp / Loss of function

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3. History of Presenting Illness (HPI) - The MOST IMPORTANT PART

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🎯 Special Pain Analysis for Ortho (VERY IMPORTANT)

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🎯 For Swelling - Ask:

• Sudden onset after trauma? = Haemarthrosis (blood in joint) = ligament tear, fracture
• Gradual swelling? = Synovitis, OA effusion
• Painful or painless? Painless rapidly growing swelling = tumour until proven otherwise

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🎯 For Deformity - Ask:

• Was it there since birth? = Congenital
• Developed after injury? = Fracture/dislocation
• Gradual progressive deformity? = Arthritis, rickets

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🎯 For Stiffness - Ask:

• Which joint? Morning or evening?
• Are there any clicking sounds?

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🎯 For Instability - Ask:

• Does the joint "give way"? When? On which movement?
• E.g., knee giving way going down stairs = ACL tear

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4. Past Medical History (PMH)

• Previous fractures or surgeries (especially ortho-related)
• TB (very relevant in India - can affect spine, hip, knee)
• Diabetes - poor wound healing, neuropathy, foot ulcers
• Hypertension, heart disease - affects anaesthesia risk
• Steroid use - causes AVN (avascular necrosis) of femoral head
• Cancer history - metastasis to bone causes pathological fractures
• Any previous joint problems

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5. Drug History

• Steroids (long-term use causes osteoporosis + AVN)
• Methotrexate, immunosuppressants (for RA)
• NSAIDs - are they taking them already?
• Anticoagulants (warfarin, aspirin) - affects surgery
• Antibiotics - suggests ongoing infection

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6. Family History

• RA, Ankylosing spondylitis - run in families
• Sickle cell disease - causes AVN and bone crises
• Gout - can be familial
• Achondroplasia, dwarfism - genetic

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7. Social History

• Smoking - impairs bone healing, increases fracture risk
• Alcohol - AVN of femoral head, neuropathy, falls
• Occupation - heavy labour, computer work, sports
• Activities of daily living - can the patient manage at home? Can they climb stairs?
• Walking aids - do they use a stick, crutches, wheelchair?
• Support at home - who helps them?

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PART 2: CLINICAL EXAMINATION

The Ortho Examination Framework: "LOOK - FEEL - MOVE"

LOOK (Inspection)
FEEL (Palpation)
MOVE (ROM - Range of Motion)
NEURO (Neurological exam)
VASCULAR (Circulation)
SPECIAL TESTS (for each joint)

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GENERAL EXAMINATION (Before touching the joint)

• Build and nutrition
• Pallor, cyanosis, jaundice
• Any obvious deformity
• Attitude of the limb (how they're holding it)
• Gait - watch how they walk!

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🚶 GAIT ANALYSIS (Very Important - Examiners Love This!)

Common Abnormal Gaits in Ortho:

Tip: Trendelenburg test = Ask patient to stand on one leg. If the opposite hip drops = positive = weak abductors on the standing side.

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LOOK (Inspection) - 3 Things to Inspect

A) Skin

B) Shape of Limb / Swelling

• Localised swelling = specific structure (bursa, cyst, tumour)
• Diffuse swelling = joint effusion, gross injury
• Wasting/atrophy of muscles = disuse or nerve damage

C) Deformity

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FEEL (Palpation) - Systematic

Start with: Temperature

• Use the back of your hand
• Compare both sides
• Warm = inflammation/infection
• Cold = ischaemia

Then Palpate:

• Point tenderness = fracture (press with one finger - if exact spot hurts = likely fracture)
• Diffuse tenderness = joint inflammation

• Patellar tap test - fluid > 15-20 ml (press on patella - it bounces back)
• Bulge sign / Stroke test - small effusions < 15 ml (wipe fluid from medial side, tap lateral side - see medial bulge)

• Compare both sides
• Wasting suggests disuse atrophy or nerve palsy

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MOVE (Range of Motion)

Two types of movement:

Normal ROM Values (Know These!)

Describe Movements as:

• Full and painless (normal)
• Limited but painless (stiffness without inflammation)
• Full but painful (mild inflammation)
• Limited AND painful (arthritis, infection, serious pathology)

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NEUROVASCULAR EXAMINATION (Always Do This After Move)

Vascular Check:

• Peripheral pulses (radial, ulnar, popliteal, dorsalis pedis, posterior tibial)
• Capillary refill time - press nail for 2 seconds, should pink up < 2 seconds
• Skin temperature and colour
• Compartment syndrome warning: 5 Ps = Pain out of proportion, Pallor, Pulselessness, Paraesthesia, Paralysis

Neurological Check:

• Motor - test key muscle groups (MRC grading 0-5)
• Sensory - test dermatomes with light touch/pin prick
• Reflexes - DTRs (knee jerk = L3/4, ankle jerk = S1, biceps = C5/6, triceps = C7)

MRC Muscle Power Grading:

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MEASUREMENTS - LEG LENGTH DISCREPANCY

Two types:

• Measure from Anterior Superior Iliac Spine (ASIS) to medial malleolus
• Short = fracture, DDH, AVN, post-surgery

• Measure from umbilicus / xiphisternum to medial malleolus
• True length will be equal but apparent length differs

Rule: If apparent ≠ true = there is a pelvic/spinal tilt or a deformity at the hip

Causes of True Shortening:

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GALS SCREENING EXAMINATION (Quick 2-minute Ortho Screen)

1. "Do you have any pain or stiffness in your muscles, joints, or back?"
2. "Can you dress yourself without any difficulty?"
3. "Can you walk up and down stairs without any difficulty?"

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SPECIAL TESTS BY REGION (Quick Reference)

🦴 SPINE

🦵 HIP

🦵 KNEE

💪 SHOULDER

🖐 HAND/WRIST

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INVESTIGATIONS TO KNOW

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🔴 RED FLAGS IN ORTHO - NEVER MISS THESE!

• Unremitting night pain (malignancy)
• Fever + bone/joint pain (osteomyelitis, septic arthritis)
• Constitutional symptoms (weight loss, night sweats, anorexia) with bone pain = tumour or TB
• Rapidly growing painless swelling = sarcoma until proven otherwise
• Cauda equina symptoms (saddle anaesthesia + bladder/bowel dysfunction) = SURGICAL EMERGENCY
• Bilateral neurological symptoms with spine pathology = cord compression
• Pulseless cold limb after trauma = vascular emergency

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🩺 QUICK REVISION SUMMARY - ORTHO CLERKING FORMAT

1. Greet and introduce yourself
2. PC: "What brought you here today?" (pain, swelling, deformity, stiffness)
3. HPI: SOCRATES for pain + specific ortho questions
4. Age-related differential diagnosis in mind
5. PMH: TB, DM, steroids, cancer, previous fractures
6. Drug Hx: steroids, NSAIDs, anticoagulants
7. Family Hx: RA, gout, sickle cell
8. Social Hx: occupation, smoking, alcohol, mobility
9. EXAMINATION:
   - General: build, pallor, gait (Trendelenburg? Antalgic?)
   - Local LOOK: skin changes, deformity, swelling, wasting
   - Local FEEL: temperature, tenderness (point vs diffuse), swelling type
   - Local MOVE: Active then Passive ROM in degrees
   - Measurements: leg length if lower limb
   - Neurovascular: pulses, capillary refill, sensation, power, reflexes
   - Special tests: relevant to the joint
10. Summarise findings and suggest investigations

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🧠 MNEMONICS TO REMEMBER

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