The Rapid, High-Yield Ortho Exam: A Systematic Approach

October 24, 2013

Attention to detail and a systematic approach combined with the knowledge and use of specific diagnostic exam tests will help minimize missing common orthopedic soft tissue injuries. Tips here.

According to Dr Daniel Garza, missed joint injuries are a common cause of both patient morbidity and provider liability. These are often soft tissue injuries of ligaments, tendons, labra, or cartilage and as such are often devoid of findings on x-ray films. A good history and a targeted physical exam of the involved joint are usually what is required to make the correct diagnosis and initiate treatment.

Dr Garza covered this and related topics during his lecture at the American College of Emergency Physicians 13th annual symposium in Seattle (ACEP13) entitled “Master Clinician Series: The Rapid, High-Yield Ortho Exam in the ED.”

The 5 main parts of any joint exam involve inspection, range of motion (ROM) testing, palpation for tenderness, strength assessment, and special maneuvers or exam tests. Comparison with the normal side is often useful to make decisions about more subtle findings during any or all aspects of the exam. Inspection involves looking at the joint with the patient appropriately disrobed while searching for any swelling, change in skin color, or unusual position of comfort. ROM should be checked first actively, with the patient moving the involved extremity without assistance, then passively, with assistance provided by the examiner or with the patient using an uninjured extremity. Palpation for tenderness focuses on certain key areas around the joint. Strength assessment is most important in the shoulder and involves positioning the joint to isolate specific structures. Special maneuvers usually involve specific positions used to assess for pain triggers or instability.

Most, if not all, of the exam test/maneuvers mentioned in this article have online videos that you can search by name and watch as you make your way through this article.

Shoulder injuries and overuse syndromes are common reasons to seek medical care. The shoulder is a complex joint whose extensive ROM comes at the price of increased risk of injury and instability. Rotator cuff injuries are common and often present with posterior and/or lateral shoulder pain. The exam should include inspection from both the anterior and posterior viewpoints of a disrobed patient. Palpation should include the entire length of the clavicle from the sterno-clavicular joint to the acromio-clavicular joint, as well as for tenderness of the anterior biceps tendon. Special exam tests for the shoulder include the apprehension test for shoulder subluxation or reduced dislocation, the Hawkins’ and/or Neer’s impingement test for rotator cuff bursitis or tendonitis, the Yergason’s and Speed’s test for long head of the biceps tendonitis, and the drop arm test for a severe rotator cuff tear.

Common elbow overused syndromes include lateral and medial epicondylitis (tennis elbow and golfer’s elbow, respectively) and damage to the ulnar collateral ligament (little leaguer’s elbow) as well as joint effusions that may be traumatic, infectious, or rheumatologic. Remember that the anatomic position of the elbow is fully supinated with the palm facing forward. The lateral epicondyle where the wrist and finger extensors originate. In lateral epicondylitis, there will be tenderness at this location along with pain provoked by resisted wrist and/or middle finger extension. The medial epicondyle is where the wrist and finger flexors originated. Assess for medial epicondylitis by palpating just distal to the epicondylar protuberance, and for pain with resisted wrist and/or finger flexion. Normally, a patient should be able to extend the elbow to 90 degrees and supinate the palm so that it faces directly upward. Inability to do either of these things suggests a joint effusion or prior injury. In the setting of acute trauma, a joint effusion usually means an occult intra-articular fracture. Otherwise, infectious or inflammatory conditions should be considered.

The hip is a deep joint that is not easy to inspect or palpate. However, the position of comfort and decrease in the range of motion, especially when compared with the contralateral side, can help you assess for pathology. One of the most sensitive exam findings for an intra-articular hip condition is loss of internal rotation and/or abduction. This may equate to a preferred position of comfort that is the opposite (externally rotated and adducted).

The FABER test (Flexion Abduction, External Rotation) is useful to elucidate sacroiliac pain syndromes. It is also known as the figure-4 test to describe the position of the patient’s legs during the test.

Knee examination involves inspection for an effusion and abnormal lie of the patella, palpation for tenderness at the joint line and over the collateral ligaments, and stressing the 4 ligaments of the joint (including the Lachman and anterior and posterior drawer tests for cruciate ligament injury). A joint effusion, if present, usually causes decreased ROM in flexion accompanied by a significant bulge, which is often best palpated on the lateral side of the patellar ligament. Of course, compare with the opposite side. To evaluate for injury to the meniscus, various exam tests include the McMurray test (done supine), the Thessaly test (done standing), and the Apley compression test (done with the patient prone). The inability to perform a straight leg test usually signifies injury to the patella, the patellar ligament, or the quadriceps tendon. Chondromalacia patellae or pain due to irritation of the underside of the patella is very common and usually is characterized by intolerance to prolonged knee flexion (the theater sign) and sometimes pain with resisted knee extension-especially when combined with downward pressure on the patella.

Ankle examination includes inspection for swelling and dependent ecchymosis as well as palpations, especially over both malleoli and the 5th metacarpal base. The presence of dependent ecchymosis may be delayed, but usually signifies a fracture or significant ligamentous injury. Exam testing includes the anterior drawer test with the examiners hand on the sole pulling from behind the heel and the Thompson test for an Achilles tendon injury. Most ankle injuries are sprains and only about 10% of ankle x-ray films show a fracture. The Ottawa ankle rules have been validated as an effective tool to determine who does not need ankle x-ray films. The criteria for avoiding x-ray films include ability to walk 4 steps and the lack of focal tenderness at the posterior part of both malleoli, the navicular, and the 5th metatarsal base.

Attention to detail and a systematic approach combined with the knowledge and use of specific diagnostic exam tests will help minimize missing common orthopedic soft tissue injuries. Remember to always compare the injured or painful joint with the uninjured side and don’t forget to go online to review any exam tests that you are not already familiar with.