Theme lecture evaluation of an orthopaedic patient
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This is a presentation, used in the Orthopedic Week of Block 4.4 CTC in College of Medicine @ KFU
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Theme lecture evaluation of an orthopaedic patient
- 1. THEME LECTURE : EVALUATION OF AN ORTHOPAEDIC PATIENT DR. UTKARSH SHAHI ASSISTANT PROFESSOR DEPARTMENT OF ORTHOPAEDICS
- 2. ORTHOPAEDIC CONDITIONS Injury and mechanical derangement. Congenital and developmental abnormalities. Infection and inflammation. Arthritis and rheumatic disorders. Metabolic and endocrine disorders. Tumours and lesions that mimic them. Neurological disorders and muscle weakness.
- 3. ORTHOPAEDIC COMPLAINTS PAIN STIFFNESS SWELLING DEFORMITY WEAKNESS INSTABILITY PARASTHESIA LOSS OF FUNCTION
- 4. PAIN Site Time and mode of onset Severity or Intensity Character or Nature Progression Referred pain Aggravating factors Relieving factors Any diurnal variation Any seasonal variation
- 5. INTENSITY OF PAIN A totally subjective phenomenon, varies from person to person Measured on a “visual analogue scale”, ranging from 0-10 Alternatively following grading system: Grade 1 (Mild): Pain that can easily be ignored Grade 2 (Moderate): Pain that cannot be ignored, interferes with function and needs attention or treatment from time to time. Grade 3 (Severe): Pain that is present most of the time, demanding constant attention or treatment. Grade 4 (Excruciating): Totally incapacitating pain.
- 6. CHARACTERS OF PAIN Aching Stabbing Burning Throbbing Constricting Gripping
- 7. REFERRED PAIN FROM SHOULDER FROM HIP FROM NECK FROM LUMBAR SPINE FROM LUMBAR SPINE
- 8. STIFFNESS Generalised •Rheumatoid Arthritis •Morning Stiffness > 1 Hour •Ankylosing Spondylitis •Stiffness relieved by exercise Localised •Osteoarthritis •Morning Stiffness < 1 Hour •Post traumatic arthritis •Peri-arthritis shoulder
- 9. STIFFNESS Locking •Sudden inability to complete a particular movement •Usually due to a mechanical block •Ligament/meniscal injury of knee •Shoulder impingement Ankylosis •Partial or complete fusion of joint •Bony Ankylosis •Usually painless •Fibrous Ankylosis •Usually painful
- 10. SWELLING Site Shape Size First notice Associated Symptoms •Pain •Pressure •Neurological •Vascular •Articular Progression Any other swelling Reducibility Any discharge •If present •Duration •Regular or intermittent •Character of discharge
- 11. DEFORMITY Site Associated Symptoms • Neurological • Vascular • Articular Amount of disability Time of Onset • Congenital • Developmental • Acquired Correctability • Completely correctable • Partially correctable • Incorrectable
- 13. INSTABILITY Time of Onset •Congenital •Developmental •Acquired Frequency •Single episode •Recurrent Aggravating factors Associated symptoms •Pain •Disability •Neurovascular Reducibility •Reducible •Irreducible Associated Illness
- 14. PARASTHESIA Aetiology Mode of onset Duration Site and Pattern Progression Aggravating and Relieving Factors
- 15. PARASTHESIA: AETIOLOGY Mechanical Pressure • Prolapsed Intervertebral disc • Compartment Syndrome Local Ischemia • Nerve entrapment in fibro- osseous tunnel • Carpal tunnel syndrome Peripheral Neuropathy • Diabetic Neuropathy • Alcoholic Neuropathy Other non orthopaedic causes • Previous surgery/trauma • Substance abuse etc.
- 16. LOSS OF FUNCTION Mode of onset • Sudden • Gradual Duration • Congenital • Chronic • Acute Involved region and function(s) Progression Associated features
- 17. DIFFERENTIAL DIAGNOSIS 1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- 19. GENERAL EXAMINATION Vitals •Pulse •Blood Pressure •Respiratory Rate •Temperature Consciousness Orientation Comfort level Position of Patient Height and Weight General Appearance Pallor Icterus Clubbing Cyanosis Pupillary Reaction Lymphadenopathy Dexterity Anything specific
- 21. REGIONAL EXAMINATION LOOK • Shape and Posture • Swelling • Deformity • Skin condition. FEEL • Localized tenderness • Temperature • Lump • Bony outlines • Vascular assessment • Neurological assessment . MOVE • Active Movement • Passive Movement • Abnormal Movement MEASURE • Shortening or Lengthening • Range of Motion • Regional measurements SPECIAL TESTS • Depends upon specific region in consideration
- 22. PROVISIONAL DIAGNOSIS 1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- 26. Haematology •Haemoglobin •TLC •DLC •ESR •Glucose Serology •Electrolytes •Proteins Immunology •RA Factor •Anti CCP •HLA B27 •CRP Enzymes •LDH •CPK LABORATORY TESTS
- 27. SYNOVIAL FLUID ANALYSIS Suspected Condition Appearance Viscosity White Cells Crystal Biochemistry Bacteriology Normal Clear Yellow High Few - As for Plasma - Septic Arthritis Purulent Low + - Low Glucose ++ Tuberculous Arthritis Turbid Low + - Low Glucose + Rheumatoid Arthritis Cloudy Low ++ - - - Gout Cloudy Normal ++ + (Urate) - - Pseudogout Cloudy Normal + + (Pyrophosphate) - - Osteoarthritis Clear Yellow High Few + (Often) - -
- 29. DEFINITIVE DIAGNOSIS 1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- 30. EVALUATION OF A FRACTURE PATIENT
- 31. SYSTEMATIC APPROACH TO A TRAUMA PATIENT Preparation Triage Primary Survey (ABCDEs) Resuscitation Adjuncts to primary survey & resuscitation Secondary Survey (head to toe evaluation & history) Adjuncts to secondary survey Continued post- resuscitation monitoring & re-evaluation Definite care.
- 32. ADVANCED TRAUMA LIFE SUPPORT (ATLS) APPROACH PRIMARY SURVEY A : Airway B : Breathing C : Circulation D : Disability E : Exposure RE-EVALUATION SECONDARY SURVEY HISTORY EXAMINATION IMAGING NORMAL X-RAY SPECIAL IMAGING ADJUNCTS
- 33. SECONDARY SURVEY: HISTORY Age, profession , handedness. Mechanism of injury Time of injury Complaint : pain , swelling , deformity, abnormal mobility, loss of function. Other injuries ; chest abdomen head … Previous injuries , Previous status of the injured limb. General medical history
- 34. EXAMINATION General Examination Systemic Examination Regional Examination Special clinical tests
- 35. EXAMINATION LOOK Swelling Deformity Skin condition. FEEL Localized tenderness Vascular Neurological assessment . MOVE Can move part distal to injury Don’t inflict pain or induce displacement
- 36. SECONDARY SURVEY Head injuries Thoracic injuries Abdominal Injuries Pelvis injuries Spinal cord Pectoral girdle Excessive bleeding Injuries in children
- 37. IMAGING X- ray : rule of two Two views Two joints: to avoid missing other associated injuries and to judge regarding displacement Two limbs : for comparison Two occasions: repeat the x-ray if not sure Two physicians: incase of suspicion
- 39. SPECIAL IMAGING CT Scan : Elective Sometimes mandatory, as in articular fractures MRI : may be the only way to determine Compression of spinal cord Line of femur neck # . Bone scan : Stress Non-displaced fractures . CT Scan For Calcaneal Fracture
- 40. SPECIAL IMAGING Bone Scan MRI
- 41. ADJUNCTS Lab tests Ultrasound Doppler studies Compartment Pressure Monitoring