diagnosis in orthopaedic
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Diagnosis in Orthopaedic
David Hariadi Masjhoer
SMF Orthopedi & Traumatologi
RSUD A W Sjahranie
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Information consists of differences that
make difference
gregory bateson
data, give me data!
sherlock holmes
ad sanitatem gradus est movisse morbum
(the first step toward cure is to know what
the disease is)
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Orthopaedic investigation
History taking (symptoms) }subjective
past history,
family history,
social background
Physical examination (signs)}
Radiographic examination }objective
Laboratory examination }
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History Taking
Talking (serves a double purposes); Elicits informations
Therapeutic
Patient need to tell, and need to be heard
Most frequently complaints : Pain
Stiffness
Swelling Deformity
Weakness
Altered sensation
Loss of function
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History Taking
Pain
Most common
Where, when, how often
What make it better or worse
Change in patient life
Remember :
Patient have not learn anatomy
Referred pain
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History Taking
Stiffness : Distinguish from lack of movement due to pain
Totally or partially
Swelling:
Soft tissue, joint or bone
Patient are seldom wrong, even doesnt lookswollen
Patient sense : skin feels tight, ring or shoe
doesnt loosely
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History Taking
Deformity
Any progressive deformity need attention
Weakness
Possibly to neurological disorder
Instability
Patient term giving way
Muscle weakness or dysfunction of ligament
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History Taking
Altered sensation Numbness
Tingling
suggest injury localized pressure,entrapment or ischemia
Loss of function How symptoms interfere with their activity
Past history and family history
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Physical examination
Begin at first moment :
Body build (habitus)
Facial appearances
Walking gait
Sitting or lying position
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Physical examination
Walking gait, consist of four part :
Heel strike
Stance phase
Toe off
Swing phase
Limp ?
simply an abnormal gait
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Examination of the affected part
Patient must suitable undressed
rolling up the trouser leg is not sufficient
Both limb must be exposed Check the normal first
Compared the affected limb with the normal
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Systematic order
1. Look (inspection)
2. Feel (palpation)
3. Move (assesment of joint)4. Listening (auscultation) over joint and
vessels
5. Special physical test6. Neurological examination
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Look
Looking for specific features
Skin : scar, color, pigmentation, abnormal
creases
Shape : atrophy, hypertrophy, swelling,
lump, abnormally bone bent
Position : joint is three dimensional Measures any limb shortening
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Look
Deformity : joint held in natural position
Varus and valgus
Khyposis and lordosis
Scoliosis
Fixed deformity
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Feel
Skin : warm or cold, moist or dry, sensation
Soft tissue : lump ? pulse ? swelling
Bone and joint : outlines normal ? synovium
thickened? excessive joint fluid
Tenderness (watch the patient face)
Abnormal relationship of bone and joint
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Feel
Clinical features of the lump ;
Size
Site
Margin
Consistency
Tenderness
Multiplicity
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Pain
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Move
The range of joint movement from anatomicalposition is recorded in degrees, starting fromzero
The common planes : Flexion /extension Abduction /adduction
External /internal rotation
Pronation / supination (only to forearm and foot) Circumduction
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Move
Active movement: limited by pain, muscle
spasm, muscle weakness, ruptured
tendon or muscles, joint stiffness or
contracture
Passive movement: decreased for any of
the reason above, or increased due to a
lax capsule or torn ligaments
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Listen
Crepitus from fracture
Joint crepitus
Snapping tendon Murmur of the peripheral arteriovenous
fistula
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Special Physical test
Shoulder
Elbow
Wrist Hand
Hip
Knee Foot
spine
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Neurological examination
Muscle weakness
Muscle spasticity
Involuntary movement Altered skin sensation
Loss of balance
motor system, sensory system,reflexes