History Taking in Orthopedics

General approach to history taking with patients have been discussed here:

So, a general strategy in an orthopedic history taking includes eliciting the following:

1. Chief complaint: Common orthopedic complaints can be remembered using the mnemonic WRISD Pain

  • Weakness: May be due to –
    • Pain inhibition
    • Muscle strain
    • Neurologic interruption
  • Restricted movement (stiffness): May be due to –
    • Pain
    • Muscle spasm
    • Stretching of soft tissue contracture
    • Mechanical blockage by osteophytes, loose bodies, fracture or effusion
  • Instability (giving away or jumping out of place): May be due to –
    • Traumatic damage of muscular, capsular or ligamentous structures
    • Inherent laxity
    • More apparent when the joint is positioned such that muscles have less mechanical advantage (overhead shoulder positions) or when a quick movement demand is faster than the reaction time for corresponding muscles (cutting or rotatory knee movements)
  • Swelling: May be –
    • Traumatic and rapid appearance: Hematoma or Hemarthrosis
    • Slow appearance: Inflammation, Joint effusion, Infection, Tumor
    • Painful: Active inflammation, Infection, Tumor
  • Sensory disturbance (numbness or paresthesia): May be due to –
    • Pressure from neighboring structure into nerve (e.g. PIVD)
    • Local ischemia of nerve (nerve entrapment)
    • Peripheral neuropathy
  • Deformity
  • Disability (functional loss)
  • Pain: May be –
    • Local pain (bone pain is deep pain commonly worse in evening)
    • Referred pain:
      • From scleratogenous sources (nondermatomal pattern with no hard neurologic findings): e.g. facet and disc generated pain
      • From visceral sources (will have visceral complaints) e.g. cholelithiasis, cardiac ischemia
    • Autonomic pain: vague, widespread and often associated with vasomotor and trophic changes

2. History of presenting illness:

a. Onset:

  • Traumatic or atraumatic?
  • Acute or insidious?
  • History of overuse?

b. Mechanism of injury (if traumatic):

  • Fall onto specific region or a structure within the region: Fracture, Dislocation or Contusion
  • Excessive varus/valgus force, rotation or flexion/extension: Ligament/capsule or Muscle/tendon pathology
  • Sudden axial traction to joint: Sprain or Subluxation
  • Axial compression to joint: Fracture or Synovitis

c. Mechanism of overuse (if present):

  • Position in which the patient works?
  • Repetitive movement at work or during sports?
  • Consider muscle strain, tendinitis, trigger points, or peripheral nerve entrapment

d. Grading of pain (if present): Mnemonic – Remember 4 “I”s

  • Grade I (mild): Ignorable
  • Grade II (moderate): Interferes with function and needs intermittent attention or treatment
  • Grade III (severe): Invariably present and needs invariable attention or treatment
  • Grade IV (excruciating): Incapacitating

e. If insidious, elicit following:

  • Any associated systemic signs of fever, malaise/fatigue, lymphadenopathy, multiple affected areas?
  • Local signs of inflammation?
  • Local deformity?
  • Associated neurological features?

f. Activities of daily living: To assess severity of symptoms

g. Red flag symptoms: Never ignore a “red flag”

  • Pain preventing sleep
  • Loss of appetite
  • Temporal headache and blurred vision
  • Loss of bowel and bladder control
  • Rapidly progressive symptoms
  • Painful swelling

3. Past history:

  • Associated spinal complaints or radiation from spine?
  • Another arthritis?
  • Systemic disorders?
  • Cancer?

4. Developmental history in children:

Remember a few key milestones, which will be useful for most consultations:
Age (months)Milestones
1-2Holds up chin
6-8Sits alone
8-10Stands with support
10-12Walks with support
14Walks without support
24Ascends stairs one foot at a time

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