Orthopedic history taking and examination at undergraduate level.

Reading File

Finding Sources

I've reached the database query limit. The library doesn't have a dedicated undergraduate orthopaedics clinical skills textbook, but I have solid knowledge to give a thorough answer. Let me now deliver a comprehensive response from my training knowledge.

Orthopaedic History Taking and Examination - Undergraduate Level

PART 1: HISTORY TAKING

General Approach

A structured orthopaedic history follows the standard medical history format but is adapted to focus on the locomotor system. Always introduce yourself, gain consent, and ensure the patient is comfortable.

1. Presenting Complaint (PC)

Ask the patient to describe their main problem in their own words. Common orthopaedic presenting complaints include:

Pain
Swelling
Deformity
Stiffness
Weakness / loss of function
Instability / giving way
Locking / clicking
Altered sensation / paraesthesia

2. History of Presenting Complaint (HPC)

For each complaint, use a systematic framework. For pain, the mnemonic SOCRATES is standard:

Letter	Meaning	Example questions
S	Site	"Where exactly is the pain?"
O	Onset	"When did it start? Sudden or gradual?"
C	Character	"Describe the pain - sharp, dull, burning, aching?"
R	Radiation	"Does it spread anywhere?"
A	Associated features	"Any swelling, weakness, stiffness?"
T	Timing	"Constant or intermittent? Morning or evening?"
E	Exacerbating/Relieving	"What makes it better or worse?"
S	Severity	"Score 0-10. How does it affect daily life?"

Additional orthopaedic-specific questions for pain:

Mechanical vs. inflammatory pattern:
- Mechanical: worse with activity, better with rest, no morning stiffness (or < 30 min)
- Inflammatory: morning stiffness > 1 hour, worse at rest, improves with movement
Night pain (suggests serious pathology: infection, tumour, inflammatory disease)
Radicular pattern (dermatomal radiation suggests nerve root involvement)

For swelling:

Onset (acute = haemarthrosis/fracture; chronic = effusion/synovitis)
Fluctuant, hard, or soft?
Warm or cold?

For deformity:

Congenital vs. acquired
Progressive or static?

For instability:

Direction (anterior, posterior, multidirectional)
Triggering activity
Frequency of episodes

For locking:

True locking (joint stuck in flexion, cannot fully extend) vs. pseudolocking (pain-inhibited)

3. Functional Enquiry

Always assess the impact on function - this is central to orthopaedics:

Activities of daily living (ADLs): dressing, washing, cooking
Mobility: walking distance, need for walking aids
Work: occupation (manual vs. sedentary) and effect on ability to work
Sport and recreation
Sleep disturbance

4. Past Medical History (PMH)

Previous musculoskeletal problems or surgery to the same or related region
Previous trauma or fractures
Relevant systemic diseases:
- Rheumatoid arthritis, osteoarthritis, gout, pseudogout
- Osteoporosis (fragility fractures)
- Diabetes (peripheral neuropathy, poor wound healing)
- Malignancy (metastatic bone disease)
- Inflammatory bowel disease (associated arthropathy)
- Psoriasis (psoriatic arthritis)
- Neurological disease (e.g. cerebral palsy, spina bifida - affects joint biomechanics)

5. Drug History

NSAIDs, analgesics (current pain management)
Corticosteroids (long-term use - osteoporosis, avascular necrosis)
Bisphosphonates, denosumab (bone health)
DMARDs / biologics (rheumatological disease)
Anticoagulants (relevant to surgery planning)
Allergies (especially antibiotics relevant to surgery)

6. Family History

Rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis
Osteoporosis
Bone tumours (familial predisposition)
Congenital conditions (e.g. DDH - developmental dysplasia of hip)

7. Social History

Occupation (type of work, manual labour, repetitive movements)
Handedness (for upper limb problems)
Smoking (impairs bone healing, increases surgical risk)
Alcohol (falls risk, osteoporosis, avascular necrosis)
Living situation: house/flat, stairs, support at home
Mobility aids currently used

8. Systems Review

A brief systems review helps identify red flags and systemic causes:

Red flags in orthopaedics (require urgent investigation):
- Unexplained weight loss
- Night sweats / fever
- Night pain not relieved by any position
- History of malignancy
- Age > 50 with new back pain
- Bladder/bowel disturbance with back pain (cauda equina)
- Saddle anaesthesia
- Bilateral leg weakness

PART 2: PHYSICAL EXAMINATION

The orthopaedic examination follows the universal framework:

"Look, Feel, Move, then Special Tests"

Always compare both sides. Expose adequately. Begin away from the site of pain.

General Inspection

Before examining a specific joint, observe the patient:

Gait (antalgic, Trendelenburg, steppage, spastic)
Use of walking aids
Body habitus, posture
Obvious deformities
Muscle wasting

The "LOOK, FEEL, MOVE" Framework

LOOK (Inspection)

Inspect from front, side, and back.

Skin: scars (previous surgery), sinuses (infection), erythema, bruising, skin changes (psoriasis)
Shape: deformity (valgus/varus, flexion deformity), swelling (localised vs. diffuse), muscle wasting
Position: resting posture of the limb, alignment

Common deformity terms:

Valgus - distal part deviated away from midline (e.g. hallux valgus, genu valgum)
Varus - distal part deviated toward midline (e.g. genu varum)
Flexion deformity - cannot achieve full extension
Fixed deformity - cannot be corrected passively

FEEL (Palpation)

Temperature: use dorsum of hand; warmth suggests inflammation or infection
Tenderness: localise precisely (joint line, specific bony landmarks, soft tissues). Ask patient to indicate when it hurts. Map the tender area
Swelling: differentiate:
- Bony swelling - hard, non-fluctuant
- Effusion - fluctuant, ballottement (knee), bulge sign (knee)
- Soft tissue swelling - boggy (synovial thickening) vs. cystic
Crepitus: felt during movement
Neurovascular assessment: distal pulses, capillary refill, sensation

Key bony landmarks to palpate by joint:

Shoulder: acromion, AC joint, coracoid, bicipital groove, rotator cuff insertion
Elbow: medial/lateral epicondyles, olecranon
Wrist/hand: anatomical snuffbox (scaphoid), individual carpal bones, MCP/IP joints
Hip: greater trochanter, ischial tuberosity, ASIS
Knee: joint line (medial/lateral), tibial tuberosity, patella, collateral ligaments, popliteal fossa
Ankle/foot: malleoli, Achilles tendon, calcaneum, base of 5th metatarsal

MOVE (Range of Motion)

Always assess:

Active movement first (patient moves themselves - tests neuromuscular function)
Passive movement (examiner moves the joint - tests joint integrity and end-feel)
Note: pain, limitation, and crepitus during movement

End-feel assessment (passive movement):

Normal bony end-feel (elbow extension)
Normal soft tissue end-feel (knee flexion)
Abnormal: springy (meniscal block), empty (guarding due to pain)

Normal range of motion (approximate) for key joints:

Joint	Movement	Normal ROM
Shoulder	Flexion / Extension	0-180° / 0-60°
	Abduction	0-180°
	Internal / External rotation	0-90° each
Elbow	Flexion / Extension	0-145° / 0°
	Pronation / Supination	0-80° each
Wrist	Flexion / Extension	0-80° / 0-70°
Hip	Flexion / Extension	0-120° / 0-30°
	Abduction / Adduction	0-45° / 0-30°
	Int / Ext rotation	0-45° / 0-45°
Knee	Flexion / Extension	0-140° / 0°
Ankle	Dorsiflexion / Plantarflexion	0-20° / 0-50°

Special Tests by Region

Shoulder

Test	What it assesses	Positive finding
Neer's impingement	Subacromial impingement	Pain on passive forward flexion with internal rotation
Hawkins-Kennedy	Subacromial impingement	Pain on passive internal rotation at 90° flexion
Painful arc	Subacromial impingement / AC joint	Pain between 60°-120° of abduction
Empty can (Jobe's)	Supraspinatus tear	Weakness/pain in thumb-down position
Gerber's lift-off	Subscapularis	Cannot lift hand off back
Sulcus sign	Inferior instability	Sulcus below acromion on traction
Apprehension test	Anterior instability	Patient feels shoulder will dislocate
Speed's test	Bicipital tendonitis / SLAP	Pain in bicipital groove on resisted forward flexion

Elbow

Test	What it assesses
Cozen's test	Lateral epicondylitis (tennis elbow)
Medial epicondyle tenderness	Medial epicondylitis (golfer's elbow)
Tinel's at cubital tunnel	Ulnar nerve entrapment

Wrist and Hand

Test	What it assesses
Finkelstein's	De Quervain's tenosynovitis
Phalen's / Tinel's at wrist	Carpal tunnel syndrome (median nerve)
Anatomical snuffbox tenderness	Scaphoid fracture
Allen's test	Radial/ulnar artery patency

Spine

Cervical spine:

Flexion, extension, lateral flexion, rotation
Spurling's test (axial compression with rotation): radiculopathy
Upper limb neurology: power (C5-T1), reflexes (biceps C5/6, brachioradialis C6, triceps C7), sensation

Lumbar spine:

Inspection: scoliosis, kyphosis, lordosis
Schober's test: lumbar flexion (mark 10 cm above and 5 cm below lumbosacral junction; should increase by > 5 cm on full flexion in adults)
Straight leg raise (SLR / Lasegue's): L4/L5/S1 nerve root irritation. Positive if pain radiates below knee at < 60°
Crossed SLR: contralateral leg raise causes ipsilateral radicular pain - highly specific for disc prolapse
Femoral nerve stretch test (prone knee bend): L2/3/4 root
Lower limb neurology: power (L3-S2), reflexes (knee L3/4, ankle S1), sensation

Hip

Test	What it assesses
Trendelenburg test	Gluteus medius weakness / hip pathology
Thomas test	Fixed flexion deformity of hip
FABER (Patrick's) test	Hip joint pathology, sacroiliac joint disease
FADIR test	Femoroacetabular impingement
Leg length measurement	True vs. apparent leg length discrepancy

Leg length:

True leg length: ASIS to medial malleolus (structural shortening)
Apparent leg length: umbilicus to medial malleolus (pelvic tilt contributing)

Knee

Test	What it assesses
Anterior/posterior drawer	ACL/PCL integrity
Lachman's test	ACL (more sensitive than drawer)
Pivot shift	ACL rotatory instability
Valgus stress	MCL integrity
Varus stress	LCL integrity
McMurray's test	Meniscal tear (medial/lateral)
Thessaly test	Meniscal tear
Patella apprehension	Patellar instability
Effusion tests:
- Bulge sign	Small effusion
- Ballottement / patellar tap	Large effusion

Ankle and Foot

Test	What it assesses
Anterior drawer	ATFL (lateral ankle ligament)
Talar tilt	CFL integrity
Thompson's (squeeze) test	Achilles tendon rupture
Simmond's test	Achilles tendon rupture
Mulder's click	Morton's neuroma

Neurovascular Assessment

Never forget to complete:

Distal pulses (dorsalis pedis, posterior tibial in lower limb; radial, ulnar in upper limb)
Capillary refill (< 2 seconds normal)
Sensation in relevant dermatomes
Motor power (MRC grading 0-5):

Grade	Description
0	No contraction
1	Flicker of contraction
2	Movement with gravity eliminated
3	Movement against gravity
4	Movement against resistance (reduced)
5	Normal power

Reflexes: graded 0 (absent), + (reduced), ++ (normal), +++ (brisk), ++++ (clonus)

PART 3: PRESENTING YOUR FINDINGS

At the end of the examination, present findings in a structured way:

"On inspection, there was [X]. On palpation, there was [Y] tenderness at [location] with [Z] swelling. Range of motion was limited to [X degrees] with [pain/crepitus]. Special tests showed [positive Lachman's], suggesting [ACL tear]. Neurovascular status was intact distally."

Summary: Key Mnemonics

Mnemonic	Use
SOCRATES	Characterising pain
Look, Feel, Move	Physical examination structure
ALOHA	Anatomy, Ligaments, Old injuries, History, Activity level
SPINE red flags	Surgery/Steroids, Pain at night, Infection/Inflammatory, Neurological deficit, Extra-spinal/systemic symptoms

This framework covers the standard expected at undergraduate OSCE and clinical exams. Each joint examination should take approximately 5-7 minutes in a structured OSCE setting.

This is a shared conversation. Sign in to Orris to start your own chat.