Orthopaedics is concerned with bones, joints, muscles, tendons and nerves– the skeletal system

and all that makes it move. Conditions that affect these structures fall into seven easily
remembered pairs:

1. Congenital and developmental abnormalities.

2. Infection and inflammation.
3. Arthritis and rheumatic disorders.
4. Metabolic and endocrine disorders.
5. Tumours and lesions that mimic them.
6. Neurological disorders and muscle weakness.
7. Injury and mechanical derangement.

Diagnosis in orthopaedics, as in all of medicine, is the identification of disease. It begins from

the very first encounter with the patient and is gradually modified and fine-tuned until we have
a picture, not only of a pathological process but also of the functional loss and the disability
that goes with it. Understanding evolves from the systematic gathering of information from the
history, the physical examination, tissue and organ imaging and special investigations.
Systematic, but never mechanical; behind the enquiring mind there should also be what D. H.
Lawrence has called ‘the intelligent heart’. It must never be forgotten that the patient has a
unique personality, a job and hobbies, a family and a home; all have a bearing upon, and are in
turn affected by, the disorder and its treatment.

HISTORY
‘Taking a history’ is a misnomer. The patient tells a story; it is we the listeners who construct
a history. The story may be maddeningly disorganized; the history has to be systematic.
Carefully and patiently compiled, it can be every bit as informative as examination or
laboratory tests.
As we record it, certain key words and phrases will inevitably stand out: injury, pain, stiffness,
swelling, deformity, instability, weakness, altered sensibility and loss of function or inability
to do certain things that were easily accomplished before.
Each symptom is pursued for more detail: we need to know when it began, whether suddenly
or gradually, spontaneously or after some specific event; how it has changed or progressed;
what makes it worse; what makes it better.
While listening, we consider whether the story fits some pattern that we recognize, for we are
already thinking of a diagnosis. Every piece of information should be thought of as part of a
larger picture which gradually unfolds in our understanding. The surgeonphilosopher Wilfred
Trotter (1870–1939) put it well: ‘Disease reveals itself in casual parentheses’.

SYMPTOMS
Pain
Pain is the most common symptom in orthopaedics. It is usually described in metaphors that
range from inexpressively bland to unbelievably bizarre – descriptions that tell us more about
the patient’s state of mind than about the physical disorder. Yet there are clearly differences
between the throbbing pain of an abscess and the aching pain of chronic arthritis, between the
‘burning pain’ of neuralgia and the ‘stabbing pain’ of a ruptured tendon.
Severity is even more subjective. High and low pain thresholds undoubtedly exist, but to the
patient pain is as bad as it feels, and any system of ‘pain grading’ must take this into account.
The main value of estimating severity is in assessing the progress of the disorder or the response
to treatment. The commonest method is to invite the patient to mark the severity on an analogue
scale of 1–10, with 1 being mild and easily ignored and 10 being totally unbearable. The
problem about this type of grading is that patients who have never experienced very severe
pain simply do not know what 8 or 9 or 10 would feel like. The following is suggested as a
simpler system:

• Grade I (mild) Pain that can easily be ignored.

• Grade II (moderate) Pain that cannot be ignored, interferes with function and needs
attention or treatment from time to time.
• Grade III (severe) Pain that is present most of the time, demanding constant attention or
treatment.
• Grade IV (excruciating) Totally incapacitating pain.

Identifying the site of pain may be equally vague. Yet its precise location is important, and in
orthopaedics it is useful to ask the patient to point to– rather than to say – where it hurts. Even
then, do not assume that the site of pain is necessarily the site of pathology; ‘referred’ pain and
‘autonomic’ pain can be very deceptive.
Referred pain Pain arising in or near the skin is usually localized accurately. Pain arising in
deep structures is more diffuse and is sometimes of unexpected distribution; thus, hip disease
may manifest with pain in the knee (so might an obturator hernia). This is not because sensory
nervesconnect the two sites; it is due to inability of the cerebral cortex to differentiate clearly
between sensory messages from separate but embryologically related sites. A common
example is ‘sciatica’ – pain at various points in the buttock, thigh and leg, supposedly following
the course of the sciatic nerve. Such pain is not necessarily due to pressure on the sciatic nerve
or the lumbar nerve roots; it may be ‘referred’ from any one of a number of structures in the
lumbar spine, the pelvis and the posterior capsule of the hip joint.
Autonomic pain We are so accustomed to matching pain with some discrete anatomical
structure and its known sensory nerve supply that we are apt to dismiss any pain that does not
fit the usual pattern as ‘atypical’or ‘inappropriate’ (i.e. psychologically determined). But pain
can also affect the autonomic nerves that accompany the peripheral blood vessels and this is
much more vague, more widespread and often associated with vasomotor and trophic changes.
It is poorly understood, often doubted, but nonetheless real.

Stiffness
Stiffness may be generalized (typically in systemic disorders such as rheumatoid arthritis and
ankylosing spondylitis) or localized to a particular joint. Patients often have difficulty in
distinguishing localized stiffness from painful movement; limitation of movement should never
be assumed until verified by examination.
Ask when it occurs: regular early morning stiffness of many joints is one of the cardinal
symptoms of rheumatoid arthritis, whereas transient stiffness of one or two joints after periods
of inactivity is typical of osteoarthritis.
Locking ‘Locking’ is the term applied to the sudden inability to complete a particular
movement. It suggests a mechanical block – for example, due to a loose body or a torn meniscus
becoming trapped between the articular surfaces of the knee. Unfortunately, patients tend to
use the term for any painful limitation of movement; much more reliable is a history of
‘unlocking’, when the offending body slips out of the way.
Swelling
Swelling may be in the soft tissues, the joint or the bone; to the patient they are all the same. It
is important to establish whether it followed an injury, whether it appeared rapidly (think of a
haematoma or a haemarthrosis) or slowly (due to inflammation, a joint effusion, infection or a
tumour), whether it is painful (suggestive of acute inflammation, infection or a tumour),
whether it is constant or comes and goes, and whether it is increasing in size.

Deformity
The common deformities are described by patients in terms such as round shoulders, spinal
curvature, knock knees, bow legs, pigeon toes and flat feet. Deformity of a single bone or joint
is less easily described and the patient may simply declare that the limb is ‘crooked’. Some
‘deformities’ are merely variations of the normal (e.g. short stature or wide hips); others
disappear spontaneously with growth (e.g. flat feet or bandy legs in an infant). However, if the
deformity is progressive, or if it affects only one side of the body while the opposite joint or
limb is normal, it may be serious.

Weakness
Generalized weakness is a feature of all chronic illness, and any prolonged joint dysfunction
will inevitably lead to weakness of the associated muscles. However, pure muscular weakness
– especially if it is confined to one limb or to a single muscle group – is more specific and
suggests some neurological or muscle disorder. Patients sometimes say that the limb is ‘dead’
when it is actually weak, and this can be a source of confusion. Questions should be framed to
discover precisely which movements are affected, for this may give important clues, if not to
the exact diagnosis at least to the site of the lesion.

Instability
The patient may complain that the joint ‘gives way’ or ‘jumps out of place’. If this happens
epeatedly, it suggests abnormal joint laxity, capsular or ligamentous deficiency, or some type
of internal derangement such as a torn meniscus or a loose body in the joint. If there is a history
of injury, its precise nature is important.

Change in sensibility
Tingling or numbness signifies interference with nerve function – pressure from a neighbouring
structure (e.g. a prolapsed intervertebral disc), local ischaemia (e.g. nerve entrapment in a fibro-
osseous tunnel) or a peripheral neuropathy. It is important to establish its exact distribution;
from this we can tell whether the fault lies in a peripheral nerve or in a nerve root. We should
also ask what makes it worse or better; a change in posture might be the trigger, thus focussing
attention on a particular site.

Loss of function
Functional disability is more than the sum of individual symptoms and its expression depends
upon the needs of that particular patient. The patient may say ‘I can’t stand for long’ rather
than ‘I have backache’; or ‘I can’t put my socks on’ rather than ‘My hip is stiff ’. Moreover,
what to one patient is merely inconvenient may, to another, be incapacitating. Thus a lawyer
or a teacher may readily tolerate a stiff knee provided it is painless, but to a plumber or a parson
the same disorder might spell economic or spiritual disaster. One question should elicit the
important information: ‘What can’t you do now that you used to be able to do?’
PAST HISTORY
Patients often forget to mention previous illnesses or accidents, or they may simply not
appreciate their relevance to the present complaint. They should be asked specifically about
childhood disorders, periods of incapacity and old injuries. A ‘twisted ankle’ many years ago
may be the clue to the onset of osteoarthritis in what is otherwise an unusual site for this
condition. Gastrointestinal disease, which in the patient’s mind has nothing to do with bones,
may be important in the later development of ankylosing spondylitis or osteoporosis. Similarly,
certain rheumatic disorders may be suggested by a history of conjunctivitis, iritis, psoriasis or
urogenital disease. Metastatic bone disease may erupt many years after a mastectomy for breast
cancer. Patients should also be asked about previous medication: many drugs, and especially
cortico steroids, have long-term effects on bone. Alcohol and drug abuse are important, and we
must not be afraid to ask about them.

FAMILY HISTORY
Patients often wonder (and worry) about inheriting a disease or passing it on to their children.
To the doctor, information about musculoskeletal disorders in the patient’s family may help
with both diagnosis and counselling. When dealing with a suspected case of bone or joint
infection, ask about communicable diseases, such as tuberculosis or sexually transmitted
disease, in other members of the family.

SOCIAL BACKGROUND
No history is complete without enquiry about the patient’s background. There are the obvious
things such as the level of care and nutrition in children; dietary constraints which may cause
specific deficiencies; and, in certain cases, questions about smoking habits, alcohol
consumption and drug abuse, all of which call for a special degree of tact and non-judgemental
enquiry.
Find out details about the patient’s work practices,
travel and recreation: could the disorder be due to a
particular repetitive activity in the home, at work or
on the sportsfield? Is the patient subject to any
unusual occupational strain? Has he or she travelled to
another country where tuberculosis is common?
Finally, it is important to assess the patient’s home
circumstances and the level of support by family and
friends. This will help to answer the question: ‘What
has the patient lost and what is he or she hoping to
regain?’

EXAMINATION
In A Case of Identity Sherlock Holmes has the following
conversation with Dr Watson.
Watson: You appeared to read a good deal upon
[your client] which was quite invisible to me.
Holmes: Not invisible but unnoticed, Watson.
Some disorders can be diagnosed at a glance: who
would mistake the facial appearance of acromegaly or
the hand deformities of rheumatoid arthritis for anything
else? Nevertheless,
even in these cases systematic
examination
is rewarding:
it provides
information
about
the patient’s particular
disability,
as distinct
from
the clinicopathological diagnosis; it keeps reinforcing
good habits; and, never to be forgotten,
it lets
the
patient know that he or she has been thoroughly
attended
to.
The examination actually begins from the moment
we set eyes on the patient. We observe his or her general
appearance, posture
and gait. Can you spot any
distinctive
feature:
Knock-knees? Spinal curvature?
A
short
limb? A paralysed arm?
Does he or she appear to
be
in pain? Do their movements look natural? Do they
walk
with a limp, or use a stick? A tell-tale gait may
suggest
a painful hip, an unstable knee or a foot-drop.
The
clues are
endless and the game is played by everyone
(qualified or lay) at each new encounter throughout
life. In the clinical setting the assessment needs to
be
more
focussed.

When we proceed to the structured examination,

the patient must be suitably undressed; no mere
rolling up of a trouser leg is sufficient. If one limb is
affected, both must be exposed so that they can be
compared.
We examine the good limb (for comparison), then
the bad. There is a great temptation to rush in with
both hands – a temptation that must be resisted. Only
by proceeding in a purposeful, orderly way can we
avoid missing important signs.
Alan Apley, who developed and taught the system
used here, shied away from using long words where
short ones would do as well. (He also used to say ‘I’m neither an inspector nor a manipulator,
and I am definitely
not a palpator’.) Thus the traditional clinical
routine,
inspection, palpation, manipulation, was
replaced
by look,
feel, move.
With time his teaching has
been extended and we now add test, to include the
special manoeuvres we employ in assessing neurological
integrity and complex functional attributes.
Look
Abnormalities are not always obvious at first sight. A
systematic, step by step process helps to avoid mistakes.
Shape and posture The first things to catch one’s
attention are the shape and posture of the limb or the
body or the entire person who is being examined. Is
the patient unusually thin or obese? Does the overall
posture look normal? Is the spine straight or unusually
curved?
Are
the shoulders level? Are
the limbs
normally
positioned? It is important
to look for deformity
in three
planes, and always compare
the affected
part
with the normal
side. In many joint disorders
and
in
most nerve
lesions the limb assumes a characteristic
posture.
In spinal disorders
the entire
torso may be
deformed.
Now look more
closely for swelling or
wasting
– one often enhances the appearance of the
other!
Or is there
a definite lump?
Skin Careful attention is paid to the colour, quality
and markings of the skin. Look for bruising, wounds
and ulceration. Scars are an informative record of the
past – surgical archaeology, so to speak. Colour
reflects vascular status or pigmentation – for example
the pallor of ischaemia, the blueness of cyanosis, the
redness of inflammation, or the dusky purple of an old
bruise. Abnormal creases, unless due to fibrosis, suggest
underlying deformity
which is not always obvious;
tight, shiny skin with no creases
is typical of
oedema
or trophic
change.
General survey Attention is initially focussed on the
symptomatic or most obviously abnormal area, but we
must also look further afield. The patient complains of
the joint that is hurting now, but we may see at a
glance that several other joints are affected as well.
Feel
Feeling is exploring, not groping aimlessly. Know
your anatomy and you will know where to feel for the
landmarks; find the landmarks and you can construct
a virtual anatomical picture in your mind’s eye.
The skin Is it warm or cold; moist or dry; and is sensation
normal?

The soft tissues Can you feel a lump; if so, what are its
characteristics? Are the pulses normal?
The bones and joints Are the outlines normal? Is the
synovium thickened? Is there excessive joint fluid?
Tenderness Once you have a clear idea of the structural
features
in the affected
area,
feel gently for tenderness.
Keep your eyes on the patient’s face; a
grimace
will tell you as much as a grunt.
Try
to localize
any tenderness
to a particular
structure;
if you
know
precisely
where
the trouble is, you are halfway to
knowing what it is.
Move
‘Movement’ covers several different activities: active
movement, passive mobility, abnormal or unstable
movement, and provocative movement.
Active movement Ask the patient to move without
your assistance. This will give you an idea of the degree of mobility and whether it is painful
or
not. Active movement is also used to assess muscle
power.
Passive movement Here it is the examiner who moves
the joint in each anatomical plane. Note whether
there is any difference between the range of active and
passive movement.
Range of movement is recorded in degrees, starting
from zero which, by convention, is the neutral or
anatomical position of the joint and finishing where
movement stops, due either to pain or anatomical limitation.
Describing the range of movement is often
made
to seem difficult. Words
such as ‘full’, ‘good’,
‘limited’
and ‘poor’ are
misleading. Always cite the
range
or span, from
start
to finish, in degrees.
For
example,
‘knee flexion 0–140°’ means that the range
of
flexion is from
zero
(the knee absolutely straight)
through
an arc
of 140 degrees
(the leg making an
acute
angle with the thigh). Similarly,
‘knee flexion
20–90°’
means that flexion begins at 20 degrees
(i.e.
the
joint cannot extend fully) and continues only to
90
degrees.
For accuracy you can measure the range of movement
with a goniometer,
but with practice you will
learn
to estimate the angles by eye. Normal
ranges of
movement
are
shown in chapters dealing with individual
joints. What is important
is always to compare
the
symptomatic with the asymptomatic or normal
side.
While testing movement, feel for crepitus. Joint
crepitus is usually coarse and fairly diffuse; tenosynovial
crepitus
is fine and precisely
localized to the
affected
tendon sheath.
Unstable movement This is movement which is inherently
unphysiological. You
may be able to shift or
angulate
a joint out of its normal
plane of movement,
thus
demonstrating that the joint is unstable. Such
abnormal
movement may be obvious (e.g. a wobbly
knee);
often, though, you have to use special manoeuvres
to pick up minor degrees
of instability.

Provocative movement One of the most telling clues

to diagnosis is reproducing the patient’s symptoms
by applying a specific, provocative movement. Shoulder
pain due to impingement of the subacromial
structures
may be ‘provoked’
by moving the joint in
a
way that is calculated to produce
such impingement;
the patient recognizes
the similarity between
this
pain and his or her daily symptoms. Likewise, a
patient
who has had a previous
dislocation or subluxation
can be vividly reminded
of that event by stressing
the joint in such a way that it again threatens
to
dislocate;
indeed, merely
starting
the movement may
be
so distressing
that the patient goes rigid with anxiety
at the anticipated result
– this is aptly called the
apprehension
test.

Test
The apprehension test referred to in the previous paragraph
is one of several clinical tests that are
used to elicit
suspected
abnormalities:
some examples are
Thomas’
test
for
flexion deformity
of the hip, Trendelenburg’s
test
for
instability of the hip, McMurray’s test for a torn meniscus
of the knee, Lachman’s test for cruciate ligament instability
and various tests for intra-articular
fluid. These and
others
are
described in the relevant
chapters in Section 2.
Tests for muscle tone, motor power, reflexes and
various modes of sensibility are part and parcel of neurological
examination, which is dealt with on page 10.

Caveat
We recognize that the sequence set out here may
sometimes have to be modified. We may need to
‘move’ before we ‘look’: an early scoliotic deformity
of the spine often becomes apparent only when the
patient bends forwards. The sequence may also have
to be altered because a patient is in severe pain or disabled:
you would not try
to move a limb at all in
someone
with a suspected fracture
when an x-ray can
provide
the answer.
When examining a child you may
have
to take your chances with look or feel or move
whenever
you can!

TERMINOLOGY
Colloquial terms such as front, back, upper, lower,
inner aspect, outer aspect, bow legs, knock knees have
the advantage of familiarity but are not applicable to
every situation. Universally acceptable anatomical definitions
are
therefore
necessary
in describing physical
attributes.
Bodily surfaces, planes and positions are always
described in relation to the anatomical position – as
if the person were standing erect, facing the viewer,
legs together with the knees pointing directly forwards,
and arms
held by the sides with the palms facing
forwards.
The principal planes of the body are named sagittal,
coronal and transverse;
they define the direction
across
which the body (or body part)
is viewed in any
description.

Sagittal planes, parallel to each other,

pass vertically through the body from front to back;
the midsagittal or median plane divides the body
into right and left halves. Coronal planes are also orientated
vertically,
corresponding
to a frontal
view,
at
right
angles to the saggital planes; transverse
planes
pass
horizontally across
the body.
Anterior signifies the frontal aspect and posterior
the rear aspect of the body or a body part. The terms
ventral and dorsal are also used for the front and the
back respectively. Note, though, that the use of these
terms is somewhat confusing when it comes to the
foot: here the upper surface is called the dorsum and
the sole is called the plantar surface.
Medial means facing towards the median plane or midline of the body, and lateral away
from the
median plane. These terms are usually applied to a
limb, the clavicle or one half of the pelvis. Thus the
inner aspect of the thigh lies on the medial side of the
limb and the outer part of the thigh lies on the lateral
side. We could also say that the little finger lies on the
medial or ulnar side of the hand and the thumb on
the lateral or radial side of the hand.
Proximal and distal are used mainly for parts of
the limbs, meaning respectively the upper end and the
lower end as they appear in the anatomical position.
Thus the knee joint is formed by the distal end of the
femur and the proximal end of the tibia.
Axial alignment describes the longitudinal arrange
ment
of adjacent limb segments or parts
of a single bone.
The
knees and elbows, for example, are
normally
angulated
slightly outwards
(valgus)

while the opposite –

‘bow legs’ – is more correctly described as varus (see on
page 13, under Deformity). Angulation in the middle of
a long bone would always be regarded as abnormal.
Rotational alignment refers to the tortile arrangement
of segments of a long bone (or an entire
limb)
around
a single longitudinal axis. For example, in the
anatomical
position the patellae face forwards
while the
feet
are
turned
slightly outwards;
a marked difference
in
rotational
alignment of the two legs is abnormal.

Flexion and extension are joint movements in the

sagittal plane, most easily imagined in hinge joints like
the knee, elbow and the joints of the fingers and toes.
In elbows, knees, wrists and fingers flexion means
bending the joint and extension means straightening
it. In shoulders and hips flexion is movement in an
anterior direction and extension is movement posteriorwards.
In the ankle flexion is also called plantarflexion
(pointing the foot downwards) and
extension is called dorsiflexion (drawing the foot
upwards). Thumb movements are the most complicated
and are
described in Chapter 16.
Abduction and adduction are movements in the
coronal plane, away from or towards the median
plane. Not quite for the fingers and toes, though: here
abduction and adduction mean away from and
towards the longitudinal midline of the hand or foot!
Lateral rotation and medial rotation are twisting
movements, outwards and inwards, around a longitudinal
axis.
Pronation and supination are also rotatory movements,
but the terms
are
applied only to movements
of
the forearm
and the foot.
Circumduction is a composite movement made up
of a rhythmic sequence of all the other movements. It
is possible only for ball-and-socket joints such as the
hip and shoulder.
Specialized movements such as opposition of the
thumb, lateral flexion and rotation of the spine, and
inversion or eversion of the foot, will be described in
the relevant chapters.