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ORTHOPAEDIC SURGERY History and Examinations By Dr Reyan Saghir MBBS BSc (Hons) Pinderfields Hospital, Wakefield, West Yorkshire @BRITISHINDIANMEDICASSOCIATION @BINDIANMEDICS BRITISH INDIAN MEDICAL @BIMA ASSOCIATION BIMA Clinical Series Dr Reyan Saghir MBBS BSc (Hons) Studied MBBS Medicine at GKT School of Medicine, King’s College London – 2014 Intercalation in Anatomy, Developmental and Human Biology BSc – First Class Hons – 2018 Graduated MBBS April 2020 Foundation Training – Yorkshire and Humber Deanery Orthopaedic Themed - Core Surgical Training Dr Reyan Saghir Programme – Aug 2022 (Pinderfields Hospital, West Yorkshire) MBBS BSc (Hons) BIMA Clinical Crash Course ORTHOPAEDIC HISTORY TAKING BIMA Clinical Crash CourseStart with your BASIC HISTORY Taking: PC HPC (MSK Systems Review) PMH DH Allergies FH SH – Occupation, Smoking, Alcohol, Travel BIMA Clinical Crash CourseCase 1: 50M Rt Knee Pain What MSK Systemic Review Questions would you ask? • Exact Mechanism of Injury • Pain • Stiffness • Swelling • Unstable • Deformity, Lost Function • Limp • Altered Sensation, Weakness BIMA Clinical Crash CourseClarify with trauma exactly the Mechanism of Injury How the event happened? Speed of the vehicle? Where the impact was? Ejected from the car? What body part was impacted first? Have a clear understanding of the exact event videos even better, BIMA Clinical Crash Course PAIN Site – Point to where it is Onset -How long have you had the pain Character - Type – Burning, sharp, dull Radiation – Does the pain go anywhere else Associated Sx Timing - How did it start – Injury & Progression, Time of Day Affect? How was it treated? – Insidious What aggrevates or relieves? Severity – out of 10 Ultimately SOCRATES BIMA Clinical Crash CourseSWELLING DEFORMITY Local or Generalised, Progressive Progression, FHx Rapid or Slow Prev Surgeries Painful or Not INSTABILITY LIMPING Mechanism of Injury Walking aids, Buckling / Giving Way Functional disability ?Trauma BIMA Clinical Crash CourseLOSS of FUNCTION Affect on daily life – praying, toilet, getting out of bed, clothes, walking, Work Sports RED FLAGS Weight Loss Fever Loss of Sensation/ Motor Function Sudden Incontinence BIMA Clinical Crash CourseBIMA Clinical Crash Course MSK EXAMINATIONS BIMA Clinical Crash Course MSK EXAMINATIONS LOOK – FEEL – MOVE – Special Tests BIMA Clinical Crash CourseSPINE EXAM BIMA Clinical Crash CourseSPINE EXAM: LOOK: General Inspection – Body Habitus, Scars, Muscle Wasting Objects – Walking Aids, Wheelchairs, CLOSE INSPECTION: Anterior: Scars (e.g. neck discectomy), Posture, Asymmetry, Pelvic Tilt Lateral: Cervical Lordosis, Thoracic Kyphosis, Lumbar Lordosis Posterior: Spinal alignment, Iliac crests, muscle wasting, abnormal hair growth (spina bifida) BIMA Clinical Crash CourseSPINE EXAM: GAIT - LOOK OUT FOR THE FOLLOWING: Gait Cycle ROM Limping Leg Length Turning Trendelenburgs Gait Waddling Gait ?Footwear BIMA Clinical Crash CoursePALPATE THE SPINE: Spinal Processes Sarcoiliac Joints Paraspinal Muscles BIMA Clinical Crash Course OVE: -Spine: Flexion, Extension, Lat Flex & Rot -Spine: Rotation – sitting at edge hands across chest and urn -Spine: Flex to Toes, Extend, Lat Flexion BIMA Clinical Crash Course OVE: -Spine: Flexion, Extension, Lat Flex & Rot -Spine: Rotation – sitting at edge hands across chest and urn -Spine: Flex to Toes, Extend, Lat Flexion BIMA Clinical Crash Coursepecial Tests: SCHOBERS Test for Ankylosing Spondylitis Identify the PSIS and put a cross in the midline, then 10cm aboe and 5cm below. Then lumbar flexion this distance should increase to 20cm – if not Ank Spond.: Sciatic Nerve Stretch Test: Supine with Hip Flexed – then Dorsiflex the foot. If this causes a sharp pain to buttock sciatic impingement. To complete my exam: NV exam of the Upper and Lower Limbs Examine Hip and Shouler (Joint above and below) Further imaging if indicated. BIMA Clinical Crash Course HIP EXAM BIMA Clinical Crash CourseHIP EXAM: LOOK: General Inspection – Body Habitus, Scars, Muscle Wasting Objects – Walking Aids, Wheelchairs, CLOSE INSPECTION: Anterior: Scars, Bruising, Swelling, Quad Waste, Leg Length Discrepancy, Pelvic Tilt Lateral: Flexion Abnormalities Posterior: Scars and Muscle Wasting of the Gluteals BIMA Clinical Crash CourseHIP EXAM: GAIT - LOOK OUT FOR THE FOLLOWING: Gait Cycle ROM Limping Leg Length Turning Trendelenburgs Gait Waddling Gait ?Footwear BIMA Clinical Crash Course PALPATE THE HIPS with Pt Supine: • Temp & Tenderness • Feel GT for Troch Bursitis • Measure True Leg Length (ASIS to Medial Malleolus) and Apparent from Umbilicus to Medial Malleolus - ?Discrepancy (?Pelvic Tilt) BIMA Clinical Crash Course MOVE: Always Active then Passive TANDING – Hip Flex & Extend upine ip Flex, Int Rot, Ext Rot, bduct and Adduct rone ip Extension BIMA Clinical Crash Coursepecial Tests: Thomas Test for Fixed Flexion Deformity: Hand below Lumbar Lordosis – passively flex the hip and if the opposite thigh begins to raise off bed = FFD. Trendeleburg Test: Hip Abductor Weakness Have patient face you – hands on your shoulders for stability, then your fingers on their ASIS. Ask to stand on one leg if pelvic tilt = weak abductors Trendelenburg’s To complete my exam: NV exam of the Lower Limbs Examine Lumbar Spine and Knee (Joint above and below) Further imaging if indicated. BIMA Clinical Crash CourseKNEE EXAM BIMA Clinical Crash CourseKNEE EXAM: LOOK: General Inspection – Body Habitus, Scars, Muscle Wasting Objects – Walking Aids, Wheelchairs, CLOSE INSPECTION: Anterior: Scars, Bruising, Swelling, Patellar position, Psoriatic plaques, Valgus and Varus knees, Quad wasting Lateral: Flexion+ Extension Abnormalities Posterior: Scars and Muscle Wasting, Popliteal Swellings BIMA Clinical Crash CourseKNEE EXAM: GAIT - LOOK OUT FOR THE FOLLOWING: Gait Cycle ROM Limping Leg Length Turning Trendelenburgs Gait Waddling Gait ?Footwear BIMA Clinical Crash CoursePALPATE : • Temp • Quad Wasting (Measure) • Extend Knee – Patella, Medial and Lateral Joint Lines, • Patellar Tap • Sweep Test • Flex Knee – Patella, Medial and Lateral Joint Lines, Tib Tub and Head of Fib + Pop Fossa BIMA Clinical Crash Course MOVE: Always Active then Passive CTIVE – Flex & Extend ASSIVE – Flex & Extend BIMA Clinical Crash Coursepecial Tests: Anterior Drawers & Lachman (ACL) Posterior Drawers (PCL) Lateral Collateral – Varus Stress Medial Collateral – Valgus Stress (6 Letters) McMurrays Test for Medial (Ext Rot) and Lateral Meniscus (Int Rot) To complete my exam: NV exam of the Lower Limbs Further imaging if indicated.above and below) BIMA Clinical Crash CourseFoot & Ankle EXAM BIMA Clinical Crash CourseFoot & Ankle EXAM: LOOK: General Inspection – Body Habitus, Scars, Muscle Wasting Objects – Walking Aids, Wheelchairs, CLOSE INSPECTION: Anterior: Scars, Bruising, Swelling, Psoriatic plaques, FFD toes (hammer or mallet), Bunions, Calluses Lateral: Foot Arch Posterior: Scars, Wasting, Heel Misalign, Achiles BIMA Clinical Crash CourseFoot and Ankle EXAM: GAIT - LOOK OUT FOR THE FOLLOWING: Gait Cycle ROM Limping Leg Length Turning Trendelenburgs Gait Waddling Gait ?Footwear BIMA Clinical Crash CoursePALPATE : • Temp • Pulse – PT (post Med Mall) and DP (Lat EHL 2-3 Cuneiform) • MTPJ Squeeze - Mudlers Click • Palpate each bone • MT, Ankle joint, Calc, Fib and Tib • Achiles tendon • Gastroc BIMA Clinical Crash Course MOVE: Always Active then Passive oot Plantarflex oot Dorsiflex oe Flex oe Ext nkle Inversion nkle Eversion BIMA Clinical Crash Course Special Tests: immonds Test: queeze the calf should move achilles if not ruptured. To complete my exam: NV exam of the Lower Limbs Further imaging if indicated.Joint above and below) BIMA Clinical Crash CourseHand & Wrist Exam BIMA Clinical Crash CourseHand and Wrist EXAM: LOOK: General = Scars, Wasting, Aids CLOSE INSPECTION: DORSAL Surface: Posture of hand, scars, swelling, colour, Heberden & Bouchard – OA, Swan Neck, Z Thumb, Boutonniere – RA Psoriasis, Splinter Haemorrhage Nail Pitting + Oncholysis, Muscle Wasting BIMA Clinical Crash CourseHand & Wrist EXAM: LOOK: PALMAR Surface: Hand posture, Scars, Swelling, Dupuytrens Contracture, Thenar or Hypothenar Wasting, Elbow for Plaques Janeway Lesions (palm) & Oslers Nodes (digits) BIMA Clinical Crash CoursePALPATE : Temp Radial + Ulnar Pulse Thenar + Hypothenar Bulk Palmar Thickening Median, Ulnar + Radial Sensation MCPJ Squeeze Bimanual Joint Palpation: MCPJ, PIPJ, DIPJ, CMCJ D1 Snuffbox Wrist + Elbow – Joint Lines BIMA Clinical Crash Course MOVE: Active then PASSIVE Finger Flex and Extend Wrist Flex and Extend Radial n– Thumbs Up & Finger Ext Median – OK Ulnar – Scissor or Lottery Power Grip Pincer Grip BIMA Clinical Crash Course Special Tests: inels – Tap the Median Nerve halens – forced flexion hands backward To complete my exam: NV exam of the Upper Limbs Examine Lumbar Elbow and Shoulder (Joint above and below) Further imaging if indicated. BIMA Clinical Crash CourseShoulder Exam BIMA Clinical Crash CourseHand and Wrist EXAM: LOOK: General = Scars, Wasting, Aids CLOSE INSPECTION: Anterior – Scars, bruising, Asymetry of shoulder girdle, deltoid wasting abnormal bony prominence, Lateral – Scars, deltoid wasting Posterior – scars, trapezius muscle asymmetry, supraspinatus + infraspinatus asymmetry, scoliosis, winged scapula BIMA Clinical Crash CoursePALPATE : Temp SCJ, ACJ, Clavicle, Acromion, Coracoid, Head of Humerus, GT, Spine of Scapula BIMA Clinical Crash Course MOVE: Active then PASSIVE Shoulder flexion, extension Shoulder Abduction and ADDuction Shoulder Internal and Ext Rotation BIMA Clinical Crash Course Special Tests: upraspinatus – Empty Can/ Jobes – Abduct 90, Flex 30, nt Rot and push downward. BIMA Clinical Crash Course Special Tests: upraspinatus – Painful Arc ax Abduct and slowly lower – any impingement 60-120 BIMA Clinical Crash Course Special Tests: Infraspinatus & T.Minor: Ext Rot against Resistance. Subscap – Gerbers Lift Off BIMA Clinical Crash CourseTHANK YOU FOR LISTENING ANY QUESTIONS INSERT QR CODE FOR FEEDBACK FORM BIMA Clinical Series