Clinical Assessment and Examination in Orthopedics Clinical Assessment and Examination in Orthopedics SECOND EDITION C Rex MB MS Orth DNB Orth FRCS (Edin) MCh Orth (Liv) FRCS Trauma and Orth (Edin) Chief Surgeon and Head Department of Orthopedics Rex Ortho Hospital Coimbatore, Tamil Nadu, India Forewords S Rajasekaran Charles SB Galasko ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London ® Jaypee Brothers Medical Publishers (P) Ltd. Headquarter Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Offices J.P. Medical Ltd., Jaypee-Highlights Medical Publishers Inc. 83 Victoria Street, London City of Knowledge, Bld. 237, Clayton SW1H 0HW (UK) Panama City, Panama Phone: +44-2031708910 Phone: 507-301-0496 Fax: +02-03-0086180 Fax: +507-301-0499 Email: [email protected] Email: [email protected] Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2012, C Rex All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. Inquiries for bulk sales may be solicited at: [email protected] This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device. Clinical Assessment and Examination in Orthopedics First Edition: 2002 Second Edition: 2012 ISBN: 978-93-5025-642-8 Printed at Dedicated to The wisdom of my teachers, The gratitude of my patients, The love of my parents and my family who have immeasurably enriched my life Foreword to the Second Edition The basis of successful management of any orthopedic patient depends on a firm diagnosis, assessment of his disability and understanding of his needs and expectations. Although modern advances in diagnostic and imaging modalities have opened up new and exciting avenues for evaluating a disease, these can never replace good history taking and a sound clinical examination. Investigations like MRI are so sensitive that many normal changes are projected as pathology leading to over-diagnosis and many unnecessary treatment. Further, patients with similar imaging results have different disability and symptoms. It is always wise to fully understand the patient and evaluate the disease clinically before any plans for treatment is made. I am glad to note that each chapter has been written in a systematic pattern starting from good history taking and proceeding to a stepwise clinical examination following the wise principle of ‘look, feel, move and document’. Each chapter also has clinical tests specific to the region and pathology well explained and illustrated. The theoretical basis of each of these tests is also clearly explained and this will be very useful to young doctors in training. I have known the author Dr Rex personally for many years and being the good clinician that he is, it is no wonder that he has brought out this book which would not only be useful to training doctors but also be a ready-reference to all practicing orthopedic surgeons. S Rajasekaran Chairman Department of Orthopedics Ganga Hospital, Coimbatore, Tamil Nadu, India Foreword to the First Edition The basis of orthopedic surgery is the clinical examination, including history of the patient followed by the relevant investigations. Unless the clinician is able to take a proper history and conduct the clinical examination in a systematic fashion, he/she will neither be able to make the correct diagnosis nor be aware of the relevant necessary investigations required to reach the correct diagnosis and discuss the optimum management with the patient. This book is aimed at undergraduate students and orthopedic trainees and serves its purpose in detailing the techniques of examination of the different regions. The basis of the examination of each region is based on the history, followed by Alan Apley’s classical method of examination—look, feel, move. The author and the editors of the individual chapters, all of whom are experienced surgeons in their specific field, have then described specific tests and conditions. Orthopedics is a visual subject with inspection playing an important role in clinical examination. It is for this reason that the book has been well illustrated, such that the student will gain much more from the text. We live in an era of increasingly sophisticated investigations and the development of molecular biology, genetics, tissue engineering, etc. all of which will have a major impact in the delivery of orthopedic services but if the patient is to obtain the maximum benefit from these developments which are likely to revolutionize the practice of orthopedic surgery, the orthopedic surgeon must still be able to examine the patient and make a diagnosis. Unless the surgeon can reach a reliable differential diagnosis, the relevant investigations are not likely to be undertaken and the correct diagnosis is not likely to be made. Unless the correct diagnosis is made, the advances in orthopedic surgery will be meaningless. The basis of diagnosis will continue to be the clinical examination as laid down in each chapter of this book. Charles SB Galasko Professor of Orthopedic Surgery University of Manchester, UK Consultant Orthopedic Surgeon Salford Royal Hospitals NHS Trust and Central Manchester and Manchester Children’s University Hospitals NHS Trust Past President, British Orthopedic Association Past Vice President, Royal College of Surgeons of England Past Chairman, Joint Committee on Higher Surgical Training Sir Arthur Sims, Commonwealth Professor Preface to the Second Edition Overzealous response from orthopedic trainees and recent advances has made me to write this second edition. Though examination techniques are same, the recent thinking and diagnosis of various new conditions because of explosion of knowledge and array of investigation has thrown light to many new facts compelling a clinician to diagnose by simple examination. As medicine is evolving and advancing everyday our understanding on clinical assessment and examination has also improved a lot. The book is aimed at orthopedic trainee and junior consultants to sharpen their clinical skills and to follow a methodical approach in examination. I have taken every effort to update this second edition with more illustrations on demonstration techniques, clinical pictures with obvious diagnosis and additions of some of the advancement made in subspecialties like shoulder and wrist. The book must be simple and easy for understanding so that it enables a trainee to rapidly acquire knowledge in history taking and examination in a systematic way. Repeated practice will bring perfection and, when one masters the technique it takes no time to arrive at a right diagnosis. I have put together all the essential parts of clinical assessment in a nutshell to diagnose common orthopedic conditions. In history taking, importance is given for patient’s disability, patient’s perception of nature of illness and patient’s expectation in order to device a treatment plan. The sequence of examination has been described in a more practical way applying the conventional system of look, feel and move, and when patient stands, sits and lies down. The doctor can win the patient’s confidence by the way he/she communicates to the patient, handling the patient with utmost care and by a smooth clinical examination. Well dressed doctor with a compassionate approach and an authoritative talk to the patient is essential to win the patient’s confidence. A short note on clinical findings has been described on common disease conditions at the end of each chapter. Every attempt has been made to give self-explanatory illustrations on examination techniques. Each chapter has been edited by eminent experts in their respective field to keep pace with the standard and recent advances in their field, so that the reader gets the maximum benefit. I welcome suggestions to bring out an even better next edition by filling the lacunae. I hope this book will fulfill the requirement of an orthopedic trainee. C Rex Preface to the First Edition As medicine is evolving and advancing everyday, our understanding on clinical assessment and examination has also improved a lot. This book is aimed at orthopedic trainee and junior consultants to sharpen their clinical skills and to follow a methodical approach in examination. I have taken every effort to make this book simple and easy for understanding so that it enables a trainee to rapidly acquire knowledge in history taking and examination in a systematic way. Repeated practice will bring perfection and, when one masters the technique it takes no time to arrive at a right diagnosis. I have put together all the essential parts of clinical assessment in a nutshell to diagnose common orthopedic conditions. In history taking, importance is given for patient’s disability, patient’s perception of nature of illness and patient’s expectation in order to device a treatment plan. The sequence of examination has been described in a more practical way applying the conventional system of look, feel and move when patient stands, sits and lies down. The doctor can win the patient’s confidence by the way he/she communicates to the patient, handling the patient with utmost care and by a smooth clinical examination. A short note on clinical findings has been described on common disease conditions at the end of each chapter. Every attempt has been made to give self-explanatory illustrations on examination techniques.