Rheumatological/Orthopaedic Assessment

 

Emergency

 

Hx

Ex

Ix

Mx

 

Index

 

 

 

Rheum/Ortho History

 

HPI

PMH

Social

Family

 

 

  

Rheum/Ortho History of Presenting Illness (HPI)

 

-  

 

 

  

Rheum/Ortho Past Medical History (PMH)

 

-  

 

 

  

Rheum/Ortho Social History

 

 

-  

 

 

  

Rheum/Ortho Family History

 

 

-  

 

 

 

Rheum/Ortho Examination

 

General

Head

Arm

Back

Leg

 

 

  

General Rheum/Ortho Examination

 

 

- Look, feel, move, measure, compare

- Dolichostenomelia (disproportionately long limbs): Marfans syndrome

- Gait 

 

 

  

Rheum/Ortho Head & Neck Exam

 

 

 

 

 

  

Rheum/Ortho Upper Limb Exam

 

 

Elbow

Hand & Wrist

Shoulder

 

 

 

 

Hand & Wrist Exam

 

Wrist

 

Special Tests

 

Patient

-  Seated, wrists exposed

 

Look

-  Heberedens (DIP) or Bouchards nodes (PIP): OA

-  Boutonairre or swan neck deformities, ulnar deviation: RA 

-  Scars, wasting, nails

-  Arachnodactyly: Marfans

-  Position

-  Swan neck deformity: mallet finger, RA

-  Isolated flexion of DIP joint: mallet finger

-  Claw hand: Ulnar Nerve Neuropathy &/or Median nerve neuropathy

-  Benedict/Bishop Hand: Ulnar Nerve Neuropathy

-  Walker Sign

-  Marfans syndrome

Walker

- Steinburg sign

- Deformity of distal radius & ulnar

-  Colles # (extension #): dinner fork

-  Smiths #, (flexion #)

 

Smiths & Colles

 

Feel

-  Wrist pain

-  Thumb pain

-  Snuff box tenderness: scaphoid fracture, Dequervains tenosynovitis

-  Metacarpal: BennettŐs Fracture

-  Osteophytes in joint line: OA

-  Bogginess in joints (synovitis): RA

-  DIPs, PIPs, MCPs, carpals

 

Scaphoid

 

-  Ulnar styloid: RA

-  Radial styloid: tenosynovitis

-  Wrist pain: HPOA

-  Crepitus: fracture, Intersection syndrome

 

Move

-  Upper Limb Neuro Ex

-  Finger

-  Abd/adduction

-  Flexion PIP/DIP

-  Extension

-  Grip paper

-  Thumb

-  Movements at right angles to fingers

-  Extension (lateral)

-  Abduction (anterior)

-  Adduction (thumb to finger)

-  Oppostition (thumb to little finger)

-  Wrist

-  Flex/extention

-  Ulnar/radial deviation

 

Special Tests <Up>

 

-  Ulnar nerve examination

 

Phalens Test

-  Bilateral wrist flexion compressing carpal tunnel

-  Positive if symptoms reproduced

-  Indicates Carpal Tunnel Syndrome

 

Tinnels Test

-  Tapping along distribution of median nerve

-  Positive if paresthesia in median nerve distribution (thumb to middle finger)

-  Indicates Carpal Tunnel Syndrome

-  Can also be used to Dx Ulnar Nerve Neuropathy

 

Finklesteins Test

-  Pt clasps thumb in fingers and ulnar deviates wrist

-  Positive if pain over radial aspect

-  Indicates DeQuervains stenosing tenosynovitis

-  Helps DDx Intersection syndrome

 

Steinburb Sign

-  

 

Compare

 

 

 

Elbow Exam

<Upper Limb Exam>

 

 

Look

-  Scars, wasting

-  Effusion: olecranon bursitis

-  Subcutaneous nodules: RA

-  Tophi: Gout

-  Positioning

-  Paeds: non-use + pain: pulled elbow

 

Feel

-  Tender epicondyles

 

Move

-  Flexion/extension (passive)

 

Compare

 

 

  

Rheum/Ortho Back Exam

 

Look

-  Scars, wasting, kyphosis/scoliosis (with trunk flexion)

- Dowagers hump: osteoporosis

  

Feel

-  Bony tenderness, muscle spasm

 

Move (active)

-  Flexion (touch toes)/extension

-  Lateral flexion (slide hand to knee)

-  Rotation (seated)

-  SLR

 

Measure

-  Schobers test

-  ROM

 

Straight Leg Raise (SLR)

 

SLR

 

Compare

 

 

 

  

Lower Limb Examination

 

Gait

Hip

Knee

 

Ankle

Foot

 

 

 

Rheum/Ortho Hip Exam

 

Patient

-  Standing --> supine

-  Preferably in underwear

 

Look

-  Standing --> scars, wasting, gait

-  Trendelenburg test

-  ASIS/PSIS equal height

-  Supine --> posture

-  Shortened & externally rotated: Fractured NOF

 

Measure

-  True leg length: ASIS --> med. malleolus

-  Apparent leg length: umbilicus --> med. Malleolus

-  Shortened: Fractured NOF

 

Look

-  Prone --> gluteal wasting

 

Feel

-  Trochanteric pain

-  Trochanteric Bursitis

-  Fractured NOF

-  OA

-  Prone --> SIJ tenderness

 

Thomas Test

 

Trendelenburg Sign

-  Stand on single leg

-  Positive if pelvic tilt w unsupported side descends

-  Indicates hip pathology on supported side

-  Inidcations

-  Weakness of gluteus medius &/or gluteus minimus

-  Hip pathology: SCFE, Perthes, DDH..

 

 

FABER Test

-  Felxion of hip & knee

-  ABduction & External Rotation of hip

-  Ankle on to contralateral knee = figure of 4

-  Downward force onto bent knee which stresses SIJ (extension)

-  Positive if hip pain

-  Indications

-  Sacroiliac Joint (SIJ) pathology

 

 

Gait Assessment

 

Compare

 

Lower Limb Neuro Exam

 

 

 

Referenes

 

Pic (FABER, Trendelenburg): Upto Date – Approach to the Child with a Limp – 2010

 

 

 

Rheum/Ortho Ankle Exam

 

Patient

-  Standing --> supine, bare foot

 

Look

-  Dislocation

-  Swelling: sprain, systemic cause

-  Scars, wasting

 

Feel

-  Swelling

 

Move (passive)

-  Dorsi/plantarflexion

-  Inv/eversion

 

Compare

 

 

 

  

 Rheum/Ortho Foot Exam

 

Foot

 

Features

-  Usually examined at same time as ankle

 

Patient

-  Standing --> supine, bare foot

 

Look

-  Scars, wasting

-  Tinea unguium

-  Tophi: Gout

-  Fallen arch, hindfoot valgus + forefoot abduction: Pes planus

-  Hallux valgus: bunion, over-riding 2nd toe

 

Hallux Valgus

 

-  Mortons foot: Mortons neuroma

 

Mortons Foot

 

Feel

-  Swelling, DIPs, PIPs, Achilles tendon nodules: RA

-  Heel spurs

-  Painful heel: calcaneal fracture

 

Move (passive)

-  Dorsi/plantarflexion: plantar fasciitis

-  Inv/eversion

-  Squeeze MTPs

 

Compare

 

 

 

Gait & Balance

 

Inspection

-  Walk

-  Stance: wide

-  No arm swing: PD

-  Step length

-  Turn > 3 steps

-  Heel toe walking

-  Walk on toes/heels

-  Squat: muscle strength & balance

-  Rombergs, Marching test/Unterbergers

-  Propulsion/retro

-  Foot slap

-  Antalgia: Limp

-  Circumduction: ankle or foot pathology

-  Trendelenburg gait: hip pathology

 

Children

-  Developmental Milestones: Gross motor

-  Walk w assistance by 1yr

-  Walk wo assistance by 15months

-  Run at 18months

 

Normal Gait

-  2 phases

-  Stance

-  Contact: Heel-strike to foot-flat

-  Mid-stance: Foot-flat to heel-off

-  Propulsion: Heel-lift to toe-off

-  Ipsilateral short stance phase: antalgia

-  Swing

-  Toe-off to heel-strike

 

 

Rhombergs Test

-  Patient stand with feet together & eyes closed

-  Positive if patient falls or takes steps

-  Indicates:

-  Propioceptive or cerebellar dysfunction if equal sway w eyes open vs closed

-  Vestibular dysfunction if increased sway w closed eyes

 

Marching Test/Untenbergs Test

-  Patient marches on spot with eyes closed & shoulders flexed

-  Positive if patient roates to one direction

-  Indicates an ipsilatearal vestibular lesion

 

Propulsion/Retropulsion

 

Pillow Test

-  Patient stand on pillow with eyes closed, to effectively reduce prorioceptive input

-  Positive if patient is unable to keep balance

-  Indicates vestibular dysfunction           

 

 

 

Referenes

 

Pic (FABER, Trendelenburg): Upto Date – Approach to the Child with a Limp – 2010

 

 

 

 

 

Rheumatological/Orthopaedic Investigations

 

Path

Imaging

Proc

Micro

 

 

 

 

Rheumatology/Orthopaedic Management

 

General

Meds

Surgery

Proc

 

Wheeless Textbook of Orthopaedics: www.wheelessonline.com