Orthopedic Examination : General Principles and Mnemonics

Table of Contents

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.

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