Orthopedic history taking mbbs level

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orthopedic history taking MBBS clinical examination mnemonics

Here is a complete, structured guide to Orthopedic History Taking at MBBS Level:

Orthopedic History Taking - MBBS Level

General Structure of Any History

Every history follows the standard framework: PC → HPC → PMH → DH → FH → SH → Systems Review → Summary

1. Presenting Complaint (PC)

Ask: "What brings you here today?"

In orthopedics, the most common presenting complaints are:

Pain
Swelling
Deformity
Restricted movement / stiffness
Instability / giving way
Locking (of a joint)
Weakness / wasting
Numbness / tingling (neurovascular symptoms)
Limping / difficulty walking
Trauma / fall

2. History of Presenting Complaint (HPC)

Use the mnemonic SOCRATES for any pain complaint:

Letter	Meaning	Orthopedic examples
S	Site	"Where exactly is the pain?" (pinpoint, diffuse, joint line)
O	Onset	Sudden (trauma/fracture) vs gradual (OA, tumour)
C	Character	Aching (OA), burning (nerve), sharp/stabbing, throbbing
R	Radiation	Radiculopathy (lumbar -> leg), referred pain (hip -> knee)
A	Associated symptoms	Swelling, redness, fever, weakness, numbness
T	Timing	Constant vs intermittent, morning stiffness (RA), night pain (infection/tumour)
E	Exacerbating / relieving	Movement, rest, weight-bearing, NSAIDs, elevation
S	Severity	0-10 pain scale; how does it affect daily life?

3. Key Orthopedic-Specific Questions

A. For PAIN

Morning stiffness lasting >1 hour = Inflammatory (RA, AS)
Morning stiffness lasting <30 min = Degenerative (OA)
Night pain at rest = Infection, malignancy, inflammatory arthritis (serious red flag)
Pain on weight-bearing only = Mechanical (OA, fracture)
Pain at rest AND activity = Inflammatory / infection

B. For SWELLING

Speed of onset: acute (haemarthrosis - fracture/ACL) vs gradual (effusion)
Warm, red, tender = septic arthritis (emergency) or gout
Fluctuant = fluid; Hard = bony or calcification
Single joint (monoarthritis) vs multiple joints (polyarthritis)

C. For DEFORMITY

Was it sudden (fracture/dislocation) or gradual (OA, rickets, Paget's)?
Progressive or static?
Functional impact?

D. For RESTRICTED MOVEMENT

Which movements are limited?
Active vs passive limitation (both limited = joint pathology; active only = muscle/tendon)
Painful arc (rotator cuff / subacromial impingement)?

E. For TRAUMA (very important in orthopaedics)

Ask the AMPLE trauma history:

Letter	Meaning
A	Allergies
M	Medications
P	Past medical history
L	Last meal (important pre-anaesthesia)
E	Events leading to the injury / mechanism

Mechanism of injury is crucial:
- High energy (road traffic accident, fall from height) vs low energy (simple trip)
- Direct vs indirect force
- Twisting injury (meniscus/ligament tear)
- Dashboard injury (posterior dislocation hip/PCL)
- Fall on outstretched hand (FOOSH) = Colles' fracture, scaphoid, DRUJ injury
- Axial loading (burst fracture of spine)

F. For INSTABILITY / GIVING WAY

Which direction? (anterior = ACL; posterior = PCL; lateral = peroneal nerve / LCL)
During which activity?
History of previous dislocation?

G. For LOCKING

True locking = joint locked in flexion, cannot fully extend (bucket-handle meniscal tear)
Pseudo-locking = pain inhibits movement
Unlocking mechanism?

4. Past Medical History (PMH)

Previous fractures / surgeries / joint replacements
Previous joint problems (arthritis, gout, pseudogout)
Osteoporosis (particularly in elderly women)
Diabetes mellitus (poor healing, Charcot's joint, infection risk)
Rheumatoid arthritis / ankylosing spondylitis
Malignancy (bone metastases - always ask in adults >50 with bone pain)
Bleeding disorders (haemophilic arthropathy)
Sickle cell disease (avascular necrosis, bone crises)
Steroid use (avascular necrosis, osteoporosis)
Renal disease (renal osteodystrophy)
Psoriasis (psoriatic arthritis)

5. Drug History (DH)

NSAIDs (already taking for pain?)
Steroids (long-term = osteoporosis, AVN)
Bisphosphonates (osteoporosis treatment; atypical femoral fracture risk)
Anticoagulants (warfarin, NOACs - relevant for surgery)
DMARDs / biologics (immunosuppression = infection risk)
Diuretics (gout - raised uric acid)
Calcium + Vitamin D supplements
Allergies (especially penicillin, latex, NSAIDs)

6. Family History (FH)

Rheumatoid arthritis
Ankylosing spondylitis (HLA-B27 linked)
Gout / pseudogout
Osteoarthritis
Scoliosis (10% familial)
Bone tumours / osteogenesis imperfecta
Haemophilia
Muscular dystrophy

7. Social History (SH)

This is particularly important in orthopaedics:

Occupation: Heavy manual labour (back pain, OA), desk job, overhead work (rotator cuff)
Handedness (dominant hand affected?)
Living situation: Stairs at home? Lives alone? Relevant for post-operative planning
Mobility aids: Walking stick, frame, wheelchair
Activities / sport: Which sport, level (competitive/recreational), mechanism of injury
Smoking: Impairs bone healing, increases fracture non-union risk
Alcohol: Osteoporosis, avascular necrosis (femoral head), poor compliance
Diet: Calcium intake, Vitamin D (especially in elderly, housebound, veiled women)
BMI / obesity: Exacerbates OA, complicates surgery
Functional status: What can the patient not do now that they could before?

8. Systems Review

Always screen for red flag symptoms:

Red Flags in Orthopaedics ("TUNA FISH")

Flag	Significance
Trauma (significant)	Fracture
Unexplained weight loss	Malignancy
Night pain (constant)	Tumour / infection
Age >50 or <20 with bone pain	Malignancy
Fever / rigors	Septic arthritis / osteomyelitis
Immunusuppression or IV drug use	Infection
Steroid use (prolonged)	AVN, pathological fracture
History of malignancy	Bone metastasis

9. Regional / Site-Specific Additional Questions

Spine

Bilateral leg symptoms (cauda equina syndrome - emergency): saddle anaesthesia, bowel/bladder dysfunction
Radiculopathy vs myelopathy pattern?
Upper vs lower limb involvement?

Hip

Groin pain (hip pathology), lateral thigh (ITB/trochanteric bursitis), buttock (referred from spine)
True hip pain often referred to the knee

Knee

Acute swelling after injury: haemarthrosis within 2 hours = ACL or osteochondral fracture
Mechanical symptoms: locking (meniscus), giving way (ligament)
Pain location: medial (medial compartment OA, MCL), lateral (lateral compartment, IT band), anterior (patellofemoral), posterior (Baker's cyst, PCL)

Shoulder

Painful arc 60-120 degrees = subacromial impingement
Night pain: rotator cuff tear
Can't reach behind back: OA, frozen shoulder, rotator cuff

Hand / Wrist

Dominant hand affected?
Occupation and fine motor requirements
Symptoms worse at night (carpal tunnel syndrome)

10. Putting It Together - Clinical Summary

Always end your history with a brief summary:

"This is a [age/sex] who presents with a [duration] history of [presenting complaint], affecting [location], which is [character], [onset], associated with [associated symptoms], aggravated by [exacerbating factors]. There is a background history of [relevant PMH]. This presentation is consistent with [working diagnosis], with red flags [present/absent]."

Quick Mnemonic Summary

Mnemonic	Used for
SOCRATES	Any pain assessment
AMPLE	Trauma history
OLD CARTS	Symptom characterization (Onset, Location, Duration, Character, Aggravating, Relieving, Timing, Severity)
TUNA FISH	Orthopedic red flags

Key Exam Tips for MBBS Orthopaedics:

Always ask about mechanism of injury in trauma - it predicts the fracture pattern
Night pain at rest is always a red flag until proven otherwise
Ask specifically about bladder/bowel symptoms in any spinal complaint (cauda equina)
Functional impact is always important - "How does this affect your daily life?"
In elderly patients with hip pain after a fall, assume fracture of the neck of femur until X-ray proves otherwise
True hip pathology often presents as knee pain (referred via obturator nerve) - so always examine the joint above

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