The manual orthopaedic examination is used to obtain important findings. The orthopaedist checks the following points:
Skin and subcutaneous tissue:
Temperature and difference in consistency, e.g.
- Panniculoses,
- scars,
- typical skin changes in connection with trophic ulcerations etc.
Joints:
- Localization of pressure pain,
- Triggering of certain pain phenomena during movement,
- Differentiation of shape abnormalities, e.g.
- joint effusion,
- Capsular swelling,
- Positional relationship of swelling to the joint (e.g. prepatellar bursitis (bursitis), Baker's cyst, tumor in the metaphyseal area, etc.),
- Joint friction (crepitation),
- snapping phenomena
Muscles:
- Pain triggered by isometric or isotonic tension,
- pressure pain,
- Contour defects,
- reduction in strength,
- oversupply and undersupply of nutrients
Tendons and tendon insertions:
- Changes in shape, e.g.
- Pain sensation on pressure and/or movement,
- Snapping and rubbing phenomena
Vessels:
Nerves:
Triggering of pain via typical pressure points (trigger points)
- near the spine and the nerve exit points (Valleix pressure points) or
- in the course of the nerves.
The orthopaedic examination includes various tests and movement analyses © RioPatuca Images | Fotolia
Each joint has a special movement characteristic. The active and passive range of motion is tested and recorded in degrees of angle.
Recording the active range of motion is particularly important in cases of pain and paralysis. Documentation is carried out using the neutral-zero method, whereby the 0 position is the middle or starting position of the respective direction of movement.
Example: Knee joint 5-0-130: 5 corresponds to 5° hyperextension, 0 corresponds to full extension, 130 corresponds to 130° flexion.
The joints are tested in the three spatial planes frontal, sagittal and transverse. Not all joints are designed for these movements. For anatomical reasons, this practically only applies to the ball and socket joints of the hip and shoulder. Other joints, such as the elbow, knee or finger joints, physiologically only allow hinge movements in one plane.
During recording, it is noted whether an obstruction due to
- adhesions,
- pinching,
- deformation of the joint bodies (articular causes) or
- extra-articular causes (outside the joints)
is caused. In addition, the orthopaedist checks for
- Noises or "crunching" or abnormal tactile findings during movement,
- whether the movement is fluid, sluggish or irregular,
- Swelling, color and temperature of the skin (inflammation!) and
- pain on pressure and movement.
In the case of joint swelling, a distinction must be made between
- Accumulation of fluid in the lumen (effusion),
- swelling of the fibrous or synovial joint capsule and
- thickening of the cartilaginous or bony parts of the joint.
must be distinguished.
Further aspects of the differentiated joint examination are
- the localization of pressure pain,
- Triggering of certain pain phenomena during movement,
- the extent of shape abnormalities (diffuse, localized),
- Positional relationship of a swelling to the joint (e.g. prepatellar bursitis, Baker's cyst, tumor in the metaphyseal area, etc.),
- palpable joint friction (crepitation) and
- snapping phenomena.
A muscle is harder and thicker when contracted (tense) and flaccid when atonic (relaxed). Malnourished muscles can appear both flaccid and tense.
The palpation findings also provide information about
- localized hardening (myogelosis) and
- extensive tension (usually reflex contractures, hard tension).
Loss of muscle substance can be determined using a tape measure. Tight tendons indicate a shortening. It must be determined whether a tense muscle can be actively relaxed and has a normal contraction capacity. To do this, the orthopaedist checks the muscle strength and ergometry.
The active muscle performance is usually indicated in stages from 0 to 5:
0 = no muscle activity
1 = visible contraction without movement effect
2 = Possibility of movement with elimination of gravity
3 = movement against the force of gravity
4 = movement against moderate resistance
5 = normal force
The circumference measurements are taken on both extremities for comparison purposes. The doctor uses an inelastic measuring tape, which he applies to the corresponding muscle areas. Easily palpable structures on the arm and leg serve as reference points.
When examining the tendons, the doctor is interested in
- Their point of attachment to the bone,
- their course and
- their transition to the muscle.
In these sections, independently of each other
- spontaneous pain sensation,
- pressure pain or
- pain on movement
can occur independently of each other.
Pain during movement can manifest itself in different categories of sensitivity:
- triggered by passive joint action without muscle tension,
- with contracting muscle and
- muscle tension without joint movement (muscle tension against resistance).
Pain caused by tendon disorders must be distinguished from pain that
- from the periosteum (periosteum) in the vicinity of tendon insertions or
- over diaphyses (anterior edge of the tibia) or
- are caused by bursitis under or over tendon insertions or bone prominences.
Swelling in the course of the tendon can be caused by the tendon itself or its gliding tissue. These include tendon sheath inflammation or tendovaginitis, paratenonitis. They can also be accompanied by bones rubbing against each other during movement.
Visible and palpable irregularities in the tendon contour indicate local trophic disorders or interruptions in continuity.
Absent or powerless joint movement with actively forced muscle tension may indicate a tendon rupture. Such muscle tension would be, for example, an attempt to stand on one leg on the toes.
Testing the nerves includes testing
- Sensitivity,
- reflex behavior,
- the motor function of the associated muscles,
- trophism and
- blood vessel mobility.
In the case of paralysis, a distinction must be made between spastic and flaccid paralysis. This is usually consistent with the localization of their cause. Damage in the area of the spinal column can be
- limited to one nerve root: radicular deficits in the affected dermatome (nerve supply area) and/or motor disorders in the associated core muscle
- affect all or part of the nerve plexus , which is associated with loss of several roots.
A peripheral nerve injury (lesion) leads to sensory and/or motor deficits in the corresponding supply area. Paralysis of the bladder and/or bowel indicates that the 1st neuron is affected (paraplegic lesion, Cauda syndrome).
The functional diagnosis of flaccid paralysis and myopathies is carried out by voluntary and electrical muscle testing.
Electrical excitability is primarily tested using electromyography (EMG). EMG is also helpful for diagnosing the localization of nerve root damage. For this purpose, impulse conduction from the associated core muscles, which are only or predominantly innervated by a spinal root, is utilized.
Measuring the nerve conduction velocity provides information about interruptions in nerve conduction. Complete or partial interruptions of impulse transmission often occur after injuries.
The vessels are first examined by inspection and palpation, taking into account the
- Skin coloration (paleness, redness, cyanosis) at rest and during movement or exercise
- Pigmentation, skin spots (cutis marmorata)
- Visible varices(varicose veins)
- Local skin temperature (compared to the neighboring or opposite side)
- Palpation of the arterial pulses in lateral comparison
- Position tests and functional stress tests
- Ergometry
- Thermal provocation of functional circulatory disorders
Instrumental procedures are
