Chief complaint in orthopaedics
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Here is a thorough breakdown of chief complaints in orthopaedics - the presenting symptoms that bring patients to an orthopaedic surgeon or clinic.
Chief Complaints in Orthopaedics
A chief complaint in orthopaedics is the primary symptom or problem that brings the patient for evaluation. Orthopaedic chief complaints can be grouped into 8 core categories:
1. Pain
Pain is the most common chief complaint in orthopaedics.
When evaluating orthopaedic pain, always characterize it using SOCRATES or equivalent:
| Parameter | What to ask |
|---|---|
| Site | Exact location - joint, bone, muscle, spine |
| Onset | Sudden (trauma, fracture) vs. gradual (arthritis, tumor) |
| Character | Aching, burning, shooting, stabbing |
| Radiation | Does it radiate? (e.g., sciatica, cervical radiculopathy) |
| Associated symptoms | Swelling, numbness, weakness |
| Timing | Morning stiffness (inflammatory), rest pain (tumor/infection), activity-related (mechanical) |
| Exacerbating/relieving factors | Movement, rest, NSAIDs |
| Severity | VAS/NRS scale 0-10 |
Key orthopaedic pain patterns:
- Mechanical pain - worse with activity, relieved by rest (OA, ligament injury)
- Inflammatory pain - worse at rest/morning, improves with use (RA, spondyloarthritis)
- Rest/night pain - raises concern for tumor or infection
- Radicular pain - shooting/burning along a nerve distribution (disc prolapse, stenosis)
- Referred pain - hip pathology referring to knee; shoulder pathology referring to arm
2. Swelling
The second most common chief complaint. Assess:
- Duration - acute (<48 hrs) vs. chronic
- Onset - traumatic (hemarthrosis) vs. gradual (synovitis, effusion)
- Location - intra-articular vs. extra-articular vs. bony
- Associated features - warmth, redness (septic arthritis, gout, cellulitis)
Key causes:
- Hemarthrosis (immediate post-trauma) - suspect ACL tear, fracture
- Effusion (6-24 hrs) - meniscal tear, soft tissue injury
- Synovitis - inflammatory arthritis
- Bony swelling - osteosarcoma, osteochondroma, Paget's disease
- Soft tissue swelling - bursitis, ganglion cyst
3. Deformity
Includes:
- Angular deformities: genu varum (bow leg), genu valgum (knock knee), hallux valgus, cubitus varus/valgus
- Rotational deformities: femoral anteversion, tibial torsion
- Shortening: limb length discrepancy (LLD)
- Kyphosis/scoliosis/lordosis: spinal deformities
- Post-traumatic deformity: malunited fractures
- Joint deformity: boutonniere, swan-neck (RA), Charcot joint
Always note: onset (congenital vs. acquired), progression, and functional impact.
4. Loss of Movement / Stiffness
- Reduced range of motion (ROM) - active and passive
- Morning stiffness >1 hour - inflammatory arthritis
- Locking: inability to fully extend a joint (mechanical block - torn meniscus, loose body)
- Pseudolocking: pain-inhibited movement
- Stiffness after inactivity ("gelling") - osteoarthritis
- Frozen shoulder - global restriction in all planes
5. Weakness / Inability to Use a Limb
- Muscle weakness: nerve injury, myopathy, disuse atrophy, compartment syndrome
- Drop foot: common peroneal nerve injury
- Wrist drop: radial nerve palsy
- Claw hand: ulnar nerve palsy
- Inability to weight-bear: fracture, infection, AVN
- In children: refusal to use a limb (Pseudoparalysis of Parrot in syphilis, pulled elbow, septic arthritis)
6. Instability / Giving Way
- Joint instability after ligament injury (ACL, collateral ligaments)
- Shoulder subluxation/dislocation
- Ankle instability (chronic lateral ligament laxity)
- Patellar instability
- Spinal instability (spondylolisthesis)
Distinguish:
- True instability: ligamentous laxity with joint translation
- Giving way due to pain inhibition: quadriceps weakness, patellofemoral pain
7. Numbness / Tingling / Neurological Symptoms
- Paresthesia: nerve compression (carpal tunnel, cubital tunnel, cervical/lumbar disc)
- Dermatome distribution: helps localize level of nerve root compression
- Saddle anesthesia + bladder/bowel dysfunction = cauda equina syndrome (emergency)
- Peripheral neuropathy (diabetic, etc.)
- Complex Regional Pain Syndrome (CRPS)
8. Trauma / Injury
- Mechanism of injury: fall, road traffic accident, sports, direct blow
- Time since injury
- Previous treatment received
- Functional status before injury
- Tetanus immunization status (open injuries)
Summary Table: Common Orthopaedic Chief Complaints
| Chief Complaint | Common Causes |
|---|---|
| Pain | OA, RA, fracture, infection, tumor, nerve compression |
| Swelling | Effusion, hemarthrosis, synovitis, tumor, bursitis |
| Deformity | Fracture, congenital, developmental, arthritic |
| Stiffness/loss of ROM | OA, inflammatory arthritis, adhesive capsulitis |
| Weakness | Nerve palsy, muscle injury, disuse |
| Instability | Ligament tear, joint laxity |
| Numbness/tingling | Nerve compression, radiculopathy |
| Trauma | Fracture, dislocation, ligament/muscle tear |
Mnemonic: "PSDWINT"
Pain - Swelling - Deformity - Weakness - Instability - Numbness - Trauma
Important Red Flag Symptoms in Orthopaedics
Always screen for:
- Night pain / rest pain - malignancy or infection
- Constitutional symptoms (fever, weight loss, night sweats) - infection or malignancy
- Bilateral symptoms - systemic disease
- Saddle anesthesia + sphincter dysfunction - cauda equina (surgical emergency)
- Rapidly worsening neurological deficit
- History of malignancy - metastatic bone disease
Sources: Campbell's Operative Orthopaedics 15th Ed 2026; Miller's Review of Orthopaedics 9th Ed; Rheumatology 2-Volume Set (2022, Elsevier)
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