Orthopedic Examination : General Principles and Mnemonics

Remember WIPER before patient examination

The local musculoskeletal examination is carried out following the general physical examination.

The orthopedic examination proceeds in the sequence of: Look, Feel, Move, Measure, Neurovascular examination, Special tests and Neighboring joint examination.

It should flow with patient in: Walking, Standing, Sitting, Supine, Lateral, Prone.

1. Inspection (Look)

Mnemonic: SEADS GO

Look from: Anterior, Sides and Posterior

  • Skin changes including swelling
  • Edema
  • Atrophy
  • Deformity
  • Shape, Symmetry and Shortening
  • Gait
  • Orthosis, walking aid, shoes wear

2. Palpation (Feel)

Mnemonic: TEST Areas

3. Active and Passive ROM (Move)

  • Painful movements at last (to prevent overflow of painful movement to next movement)
  • Active ROM first, then passive ROM – measure angles (goniometer) or distances and determine the end feel of joint, presence of crepitus or clicks
  • Beighton’s score – for assessing generalized ligament laxity

4. Measurement

  • Limb lengths
  • Limb circumference

4. Neurovascular examination

a. Motor power and sensations around the joint

  • Resisted isometric movements: MRC grading –
    • M0 – No contraction
    • M1 – Flickering
    • M2 – Movement with gravity eliminated
    • M3 – Weak movement against gravity
    • M4 – Movement against gravity and partial resistance
    • M5 – Normal power
  • Sensation: Light touch, Pin prick, Temperature, Stereognosis, 2 point discrimination, Proprioception; MRC grading –
    • S0 – Absence of all modalities
    • S1 – Deep pain sensation
    • S2 – Protective skin sensation (skin touch, pain and temperature)
    • S3 – S2 with accurate localization
    • S3+ – Stereognosis, 2 point discrimination recovery
    • S4 – Normal sensation

b. Peripheral pulsations:

  • Dorsalis pedis artery: Just lateral to tendon of EHL (absent in 10%)
  • Posterior tibial artery: 2 cm below and posterior to medial malleolus (between FDL and FHL tendons)
  • Anterior tibial artery: midway between 2 malleoli against distal tibia, just lateral to EHL tendon
  • Popliteal artery: with knee flexed 40 degrees (to relax muscles), in lower part of popliteal fossa against the posterior aspect of tibial condyles
  • Femoral artery: just inferior to mid-inguinal point
  • Radial artery: at wrist just lateral to FCR tendon
  • Brachial artery: just medial to tendon of biceps at elbow

c. Regional lymph nodes:

  • Cervical: submental, submandibular, preauricular, tonsillar, supraclavicular, deep cervical, scalene, posterior auricular, occipital nodes
  • Axillary: anterior, central, posterior, lateral and apical groups
  • Epitrochlear: medial aspect of elbow, 4-5 cm superior to humeral epitrochlea
  • Inguinal:
    • Horizontal chain: just below inguinal ligament
    • Vertical chain: along the line of saphenous vein

5. Special tests

  • Stress/provocation testing
  • Stability testing

6. Examination of adjacent joints

Local musculoskeletal examination must be followed by a systemic examination.

Write your Viewpoint 💬

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.