History Taking in Orthopedics

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

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: