Orthopedic Examination: Information & Specialists

A manual orthopedic examination is used to gather important findings. The orthopedist checks the following:

Skin and subcutaneous tissue:

Differences in temperature and consistency, e.g.,

• panniculosis,
• scars,
• typical skin changes associated with trophic ulcers, etc.

Joints:

• Location of tenderness,
• Triggering of specific pain phenomena during movement,
• Differentiation of deformities, e.g.,
  • joint effusion,
  • capsular swelling,
  • Relative position of swelling in relation to the joint (e.g., prepatellar bursitis, Baker’s cyst, tumor in the metaphysis, etc.),
• joint crepitus (crepitation),
• snapping sensations

Muscles:

• Pain triggered by isometric or isotonic contraction,
• tenderness on pressure,
• Contour defects,
• Decreased strength,
• Excess or deficiency of nutrients

Tendons and tendon insertions:

• Changes in shape, e.g.,
  • thickening along the tendon or at the bony insertion,
  • indentations, e.g., in the case of an Achilles tendon rupture,
• Pain upon pressure and/or movement,
• Snapping and friction sensations

Vessels:

• Pulse checks,
• tenderness and increased tone along the course of the vessel, e.g., in thrombophlebitis and thrombosis

Nerves:

Pain triggered by typical pressure points (trigger points)

• near the spine and nerve exit points (Valleix pressure points) or
• along the nerve pathway.

The orthopedic examination includes various tests and movement analyses © RioPatuca Images | Fotolia

Each joint has its own specific range of motion. Mobility is assessed in terms of its active and passive ranges and recorded in degrees.

Measuring the active range of motion is particularly important in cases of pain and paralysis. Documentation is performed using the neutral-zero method, where the 0 position corresponds to the midpoint or starting position of the respective direction of movement.

Example: Knee joint 5-0-130: 5 corresponds to 5° of hyperextension, 0 corresponds to full extension, and 130 corresponds to 130° of flexion.

Joints are assessed in the three spatial planes: frontal, sagittal, and transverse. Not all joints are capable of these movements. For anatomical reasons, this applies in practice only to the ball-and-socket joints of the hip and shoulder. Other joints, such as the elbow, knee, or finger joints, physiologically allow only hinge movements in a single plane.

The record notes whether there is any restriction due to

• adhesions,
• entrapment,
• deformation of the joint surfaces (articular causes), or
• extra-articular causes (outside the joints)

. In addition, the orthopedic surgeon checks for

• noises or “cracking” sounds, or abnormal palpation findings during movement,
• whether movement is fluid or jerky or irregular,
• swelling, skin color, and temperature (signs of inflammation!), as well as
• pain triggered by pressure and movement.

In cases of joint swelling, a distinction must be made between

• fluid accumulation within the joint cavity (effusion),
• swelling of the fibrous or synovial joint capsule, and
• thickening of the cartilaginous or bony components

.

Other aspects of a comprehensive joint examination include

• the localization of tenderness,
• the provocation of specific pain phenomena during movement,
• the severity of deformities (diffuse, localized),
• the relationship of swelling to the joint (e.g., prepatellar bursitis, Baker’s cyst, tumor in the metaphyseal region, etc.),
• palpable joint friction (crepitation), and
• snapping sensations.

A muscle is firmer and thicker when contracted (tensed) and flaccid when atonic (relaxed). Malnourished muscles may appear either flaccid or tense.

Palpation also provides information about

• localized hardening (myogelosis) and
• diffuse tension (mostly reflex contractures, hard tension).

Loss of muscle mass can be determined using a measuring tape. Tendons that are taut like a cord indicate shortening. It must be determined whether a tense muscle can be actively relaxed and possesses normal contractile capacity. To do this, the orthopedist assesses muscle strength and ergometry.

Active muscle performance is usually rated on a scale from 0 to 5:

0 = no muscle activity
1 = visible contraction without movement
2 = ability to move when gravity
is eliminated 3 = ability to move against gravity
4 = ability to move against moderate resistance
5 = normal strength

Circumference measurements are taken on both extremities for comparison purposes. The physician uses a non-elastic measuring tape, which is placed around the corresponding muscle areas. Easily palpable structures on the arm and leg serve as reference points.

When examining the tendons, the following are of interest:

• their attachment point to the bone,
• their course, and
• their transition to the muscle.

In these sections,

• spontaneous pain,
• tenderness, or
• pain on movement

may occur.

Pain during movement can manifest in various degrees of sensitivity:

• triggered even by passive joint movement without muscle tension,
• when the muscle is contracting, and
• during muscle contraction without joint movement (muscle contraction against resistance).

Pain caused by tendon disorders must be distinguished from pain

• originates from the periosteum in the vicinity of tendon insertions or
• along the diaphysis (anterior edge of the tibia), or
• are caused by bursitis below or above tendon insertions or bony prominences.

Swelling along the course of a tendon can be caused by the tendon itself or its surrounding tissue. These include, for example, tenosynovitis or tendovaginitis, and paratenonitis. They may also be associated with bones rubbing against each other during movement.

Visible and palpable irregularities in the tendon’s contour indicate local trophic disturbances or breaks in continuity.

Absent or weak joint movement during active, forced muscle contraction may indicate a tendon rupture. An example of such muscle contraction would be attempting to stand on one leg on tiptoes.

Nerve examination includes testing

• sensation,
• reflexes,
• motor function of the associated muscles,
• trophic function, and
• vascular mobility.

In cases of paralysis, a distinction must be made between spastic and flaccid paralysis. This usually corresponds to the location of the underlying cause. Damage in the area of the spine may be

• be limited to a single nerve root: radicular deficits in the affected dermatome (the nerve’s distribution area) and/or motor disturbances in the associated core muscles
• affect the entire nerve plexus or parts of it, which is associated with deficits in multiple nerve roots.

A peripheral nerve injury (lesion) leads to sensory and/or motor deficits in the corresponding distribution area. Bladder and/or bowel paralysis suggests involvement of the first-order neuron (spinal cord injury, cauda equina syndrome).

Functional testing for flaccid paralysis and myopathies is performed through voluntary and electrical muscle testing.

Electrical excitability is primarily assessed using electromyography (EMG). EMG is also helpful for determining the level of nerve root damage. This is done by recording nerve impulses from the corresponding core muscles, which are innervated exclusively or predominantly by a single spinal root.

Measuring nerve conduction velocity provides information about interruptions in nerve conduction. Complete or partial interruptions in impulse transmission frequently occur following injuries.

The examination of blood vessels begins with visual inspection and palpation, taking into account

• skin color (pallor, redness, cyanosis) at rest and during movement or exertion
• pigmentation, skin mottling (cutis marmorata)
• Visible varicose veins
• Local skin temperature (compared to the surrounding area or the opposite side)
• Palpation of arterial pulses in a side-by-side comparison
• Postural tests and functional stress tests
• Ergometry
• Thermal provocation of functional circulatory disorders

Instrumental methods include:

• Venous stasis plethysmography
• Oscillometry
• Doppler ultrasound
• Isotope outflow test
• Angiography