2.

PLAN OF EXAMINATION OF ORTHOPEDIC AND TRAUMATOLOGICAL PATIENTS AND WRITING A MEDICAL HISTORY Personal data: last name, name, patronimic; age; address; profession and occupation; date and time of admission, referred by, the way of admission to the medical institution. Complaints: of pain, deformities and dysfunctions. 2.1. Medical history In case of traumas: date and time of the trauma. Circumstances of the trauma type of activity, where (at work, on the way to work/from work, at home, in places of leisure, etc.) the accident had happened which resulted in trauma. If necessary force of the traumatic agent (height of fall, speed of the moving car and its make, mass of the pressing load and time of pressure, etc.). Sensations after the accident, ability to move independently. Rendering first aid who it is rendered by, when, how (resuscitation elements, antishock measures, temporary stoppage of external hemorrhage, application of aseptic bandages, transport immobilization, etc.). Treatment of the patient before supervision what diagnosis was established on admission, what therapeutic and diagnostic measures were taken; their efficacy, whether there is reposition of fragments in bone fractures, whether dislocation has been removed, whether primary surgical wound d-bridement has been performed, as well as tetanus prevention, antibiotic prescription, transfusion therapy, etc. In congenital deformities. Time when deformity was revealed. Whether there was a similar pathology in other family members. Treatment and its efficacy. In inflammatory diseases. With what the patient associates the onset of the disease. When the disease began and the character of the onset (abrupt or gradual). The course of the disease. Treatment (where and how it was treated). Exacerbation frequency. Precursors. What drugs and treatment modes helped during exacerbations in the past. Whether the patient had bacterial tests, antibiotic susceptibility tests made. Test results. In dystrophic processes. When the feeling of discomfort appeared (in joints, periarthric areas). When the patient felt limitation of movements, when he noticed joint or limb deformity. Character of pain. When he feels pain (at night, after sleep, during first steps, after continuous load (walk, work)). Changes in pain intensity caused by weather changes, cold, overchilling, etc. previous treatment: drug therapy, physiotherapy, sanatorium-and-spa treatment, surgical treatment. Special attention should be paid to administration of corticosteroids (drug, dose, duration of drug administration, side effects). 2.2. Life history. Individual pecularities of development n childhood. Previous diseases, operations. Army service (as an integral estimate of state of health). gynecological history. Bad habits. Constant administration of drugs: reasons, drug, dose. Possible allergic reactions. 2.3. Patient`s objective condition. General condition: physical development, consciousness and behaviour. State of the cardiovascular system (pulse, AP, heart sounds, heart borders, acrocyanosis, dyspnea, edemas). State of the respiratory system (shape of the thorax, its participation in respiration, the role of auxillary muscles in respiration; respiration rate and frequency; chest percussion and auscultation).

State of the digestive system (teeth, tongue, tunica mucosa of mouth; presence of postoperative scars, hernias, size and form of the abdomen, symmetry of the abdomen; hepatic dullness; tension of the frontal abdominal wall; palpatory tenderness(during deep and superficial palpation); symptoms of irritation of the abdomen). Pecularities in urination and evacuation. 2.3.1.STATE OF THE MUSCULOSKELETAL SYSTEM Examination. Position of the examined patient: active, passive, forced (standing; lying, lying with spread half-bent legs, lying on one side with one`s legs pressed against the abdomen; sitting with one`s hand pressed against the chest; sitting with one`s palm pressed against some part of the thorax, etc.). position of the injured limb: active, passive, forced. For example, a half-bent right arm is put aside from the trunk; a half-bent left leg is bent towards the trunk; the neck is bent to the left or to the right, the head is turned to the left or to the right. Type and description of the plaster bandage (what segments of the musculoskeletal system are fixed and in what position they are. Whether there are openings in the bandage, etc.). Condition of distal parts of the limb fixed with a plaster bandage: color of fingers or toes, presence of edema, active finger movements. Type and description of traction system: type of applied traction system (continuous skeletal or glue traction, cuff traction); position of the limb (abduction, bending, slight rotation, etc.); through what osseous masses the pin goes; to what segments glue (cuff) traction is applied; position of additional (resetting) loops; weight of the load placed on recoils, etc. Type and description of external fixators, location of pins or nails, type of their fixation in fixation devices: rings in Ilizarov`s external fixator or in fixators for external fixation on basis of nails, etc. It is desirable to draw a kinematic scheme of application of continuous traction or external fixators on the observed patient. On examination there are visible shortening of limb (measured later), muscular atrophy, edema, phlyctenae, dermatosis, etc.

Fig.1

Fig. 2

Fig.3

Fig.4

Limb axis is determined in frontal and sagittal planes. Brachial axis goes through the humeral head, capitate humeral eminence, head of radius and head of ulna (fig. 1). Leg axis goes through the frontal upper axis of the ilium, internal edge of the patella and hallux (. 2.). in deformity of the limb its axis is bent. Bending of the limb axis (or a segment) can take place in frontal or sagittal planes. The top of bending can be on a bone shaft as well as on the level of a joint. Limb deformity in the frontal plane, in which the top of deformity is extorse, is called varus

deformity. Limb deformity in which the top of deformity is intorse, is called valgus deformity (fig. 3, 4).

Fig. 5

Fig. 6

Limb deformity in the sagittal plane, in which the top of deformity is anterior is called antecurvation. The opposite deformity is called recurvation (fig. 5, 6). In conclusion changes on joint forms (exudate, edema) and diaphysial bone fragments are described: various herniations, bloatings, distinct vascular pattern. Palpation Palpation is performed using the whole hand, fingertips, the tip of the forefinger. Palpation allows to identify: Changes in local temperature, disorder of sensitivity; mobility (dislocation) of cutaneous covering over the examined place, presence of subcutaneous hematomas, edema and sclerosis of subcutaneous fat, presence of tumor masses in it, etc.; morbidity: superficial and deeply extended and limited; position of articular ends of bones and separate bony prominences, bone landmarks. Dislocation of certain bony prominences or articular ends of bones on their intersection of the socalled identification lines can tell about presence of injuries (dislocations) in places, inaccessible on examination and undefined during palpation because they are located deep and sharp pain caused by palpation [1, 2]. In day-to-day practice several identification points and lines are usually used. Points, between which length of a segment and the whole limb is measured, are usually used as identification points (see `Measurements`). Joints of these points form lines and figures. Guter`s line and triangle joint of bony prominences-epicondyles of humerus with each other and with the top of olecranon during unbending (which makes Guter`s line). In elbow joint these three points lie on one line (Guter`s line), during bending they form an isosceles triangle (Guter`s triangle). Guter`s line and triangle are broken in forearm dislocation, in fractures with displacement of epicondyles of the humerus, shoulder epicondyles, in splintered and communited fractures of the distal end of the humerus, in fractures of olecranon of ulna. Guter`s line and triangle do not change in flexion and extension supracondylar shoulder fractures with displacement of distal fragment, in fractures of the head of the radius and in all types of fractures without displacement (fig. 7, 8).

Fig.7

Fig.8

Fig. 9

Fig. 10

Supracondylar line (described by V.O.Marks) in case of unchanged interrelation in elbow joint the line, joining epicondyles of humerus (i.e. Guter`s line) is perpendicular to the long axis of the shoulder (it goes through the middle of the humerus). The line does not change in dislocations in elbow joint (unlike in case of ), in fractures of proximal ends of forearm bones with displacemtnt of fragments. The line changes in flexion and extension supracondylar fractures of the humerus and in fractures of shoulder epicondyles (fig. 9, 10). Symphysis pubis line goes through the tops of greater trochanters of thigh bones, in normal interrelation. In fractures of femoral neck, in dislocations in hip joint the line, drawn horizontally through the greater trochanter on the side of injury, goes above pubis (fig. 11.).

Fig.11

Fig. 12

Transtrochantic line is the line, joining frontal upper bones of iliac bones, in normal interrelation it is parallel to the line of symphysis pubis (fig. 12). In upward dislocations of greater trochanter on one side line parallelism is preserved. Roser-Nelaton`s line joins frontal upper spine of the ilium with the ischial tuberosity. When the hip is bent on the mitre of 1350 the greater trochanter is situated on this line. In dislocations in the hip joint, in fractures of the femoral neck this interrelation is broken (fig. 13). Shemacker`s line begins on the top of the greater trochanter and goes through the frontal upper spine of the ilium. When interrelation in the hip joint is preserved Shemacker`s line should be continued above the umbilicus (fig. 14).

Fig. 13

Fig. 14

Vertical line, drawn through lateral malleolus of a normal foot, divides the space from the little finger to the end of the foot into two parts: one third from the end of the heel to the vertical line, two thirds from the drawn line to the end of the little finger (fig. 15). The line, drawn through the tibial crest, must go through the first web space. In foot subluxations this interrelation is broken (fig. 16).

Fig. 15

Fig. 16

Identification points on the backbone. Level of spine injury (trauma or disease) is defined by counting vertebrae from several landmarks. Cervical and thoracic vertebrae are defined by counting down from the spinous process of the 7th cervical vertebra, the superior point in the upper region of the back. The third thoracic vertebra is situated on the level of the lower end of the scapular spine. The 7th thoracic vertebra is situated on the level of the lower angle of the scapula. Spinous process of the 4 th lumbal vertebra lies on the level of the line, drawn through the upper ends of iliac crests, and the 1st sacral vertebra lies on the level of posterior lower spines of of iliac bones (fig. 17).

Fig. 17 Palpation allows to define presence of crepitation: knacking of ends of bone fragments during friction. This should not be abused because of danger of damage of vessels and nerves. Palpation also allows to find accumulation of fluid in bursal sacs (in elbow, patella, etc.) and in joints. In order to identify fluid accumulation in the knee joint patella ballottement symptom is used. In absence of exudate in the knee joint patella adjoins anterior surface of hip condyles. In case of excess of fluid in the knee join knee cap uplifts, getting farther from condyles. In order to provoke patella ballottement symptom one hand embraces upper torsion of the knee joint (fig.18), fingers of the other hand press on the patella in the direction of the joint but patella and hip condyles do not meet. This moment causes sensation of a push. After withdrawal of the finger the patella uplifts again, getting into its initial position.

Fig. 18 Measurement Measurement of limb length allows to define lengthening or shortening of the whole limb or its separate segments. There are different types of measurement. The most widespread type is measurement with the help of the centimeter band. In order to measure a limb or a segment the centimeter band is applied in certain points. These points are the acromion process, top of the olecranon of the elbow bone and the styloid process of ulna (upper joint). In order to measure length of the lower limb the following identification points are used: anterior upper spine of the ilium patella medial or lateral malleolus. In order to measure length of segments of the lower limb the following identification points are used: the top of greater trochanter of the hip bone, knee-joint space (for measurement of hip length) and knee-joint space, the top of ankle (for measurement of shin length) (fig. 19, 20). Measurement results are recorded in a table, where lengths of measured

distances are compared. In the last line measurement difference is recorded. Instead of a table results can be recorded as a text, followed by evaluation of its results (character of shortening).

. 19

. 20

There are effective (anatomical) shortening when one segment is really shorter due to loss of bone stock; apparent (projection) shortening appearing in case of faulty (flexion, adduction) limb fixation in the joint or in case of synosteosis of shaft fractures under angle, relative or dislocation limb shortening due to displacement of articular ends of bones (dislocations). According to the sum of all results limb shortening can be integral or functional. Accuracy of measuring limb length with a centimeter band is +/-1-1.5cm. it corresponds with the aim of patient`s clinical examination. Limb circumference is measured in centimeters on the level of the joint in upper, medial and lower one-thirds (fig. 21).

Fig. 21 Movements Examination of movements begins with establishment of range of active movements, i.e. movements performed by the patient himself. Passive movements are defined by the patient. It is necessary in neurological disorders, muscle atrophy, aggravation, patient simulation, etc.

2.3.2. Establishment of range of joint movements Traditional method is as follows: branches of fleximeter (this is a school protractor with two rulers, one of which is fixed along 0-180 line and the other is connected to it with the help of hinges in the middle of protractor scale along 90, its end is sharpened as an arrow, set on 0) are set alongside segment axis, protractor hinge is set above the centre of joint rotation. The end of movable branch, moving along protractor scale, shows the maximum possible angle for movement. The countdown is performed from the initial position, i.e. the position of the limb in vertical position of the body. For elbow, hip and knee joints initial position is complete unbending 180; for shoulder joint the countdown goes from 0; movements in ankle joint are counted from 90, i.e. from the position in which the foot is perpendicular to the shin. Abduction (angle is more

than 90) and adduction (angle is less than 90) in the hip joint (fig. 22) are also measured from 90. Immovable branch of fleximeter is set under the line, connecting frontal upper spines of iliac bones, the movable branch is set alongside the hip axis. Findings are compared with those of the other (healthy) limb, which serves as a model pattern.

Fig. 22 Alongside with normal range of joint movements and excessive joint mobility (injuries of ligamentous apparatus, intraarticular fractures) limitations of these movements are possible too. There are anclyosis, complete immobility of joints; rigidity, sudden limitation of joint movements, sometimes caused by swinging movements (less than 5); contracture, limitation of joint movements (from 5 to the remaining 5). Preserved range of movements in the joint up to immobility is examined using previously described methods and conclusion about movement amplitude in the joint (in functionally efficient and unefficient volume) is made according to measurement results. Statics and walk. Ability to stand and walk without additional support: crutches, walking stick, special devices like a mobile device with armpit braces and with help of other people are noted. Necessity to use body jackets, ortheses, prostheses, orthopedic shoes, etc. is taken into account. Claudication is described: partial claudication in case of presence of pain, complete claudication in case of absence of pain. Type of load, complete and partial load of patient`s limb is also noted in medical history. 2.3.3. Patient`s general condition Patient`s general condition, its correspondence with the assumed diagnosis. Consciousness (estimation of impairment of consciousness according to Glasgo scale, cm). Height, body weight. Visible mucous and cutaneous covering: color, humidity, turgor. Enlargement of regional lymphatic nodes, their consistency and mobility. Respiratory system Thoracic norm, visible deformities of the thorax, its participation in respiration. Respiration rate and type. Presence of punctulated petechial hematomas on the skin of the upper part of the trunk. Comparative percussion of the thorax. Detection of subcutaneous emphysema. Palpation of the thorax in case of suspected rib fractures. Determination of pulmonary borders. Auscultation of the lungs. Cardiovascular system

Determination of cardiac apex beat. Determination of limitis of relative and absolute cardiac dullness with the help of percussion. Heart auscultation: determination of heart rate, sounds, presence of cardiac murmur. Pulse in peripheric vessels, its frequency, rate, filling and tension. Arterial pressure. Digestive system. Teeth, tongue. Size and form of the abdomen, traces of bruises on the abdominal wall. Abdomen`s part in the act of respiration. Hepatic dullness; percussion sound dulling in sloping places, shift of this dulling caused by changes in patient`s position. Abdominal irritation symptoms (Blumberg`s sign). Palpation of the liver and spleen. Presence of hernias. 2.3.4. Additional tests Clinical blood analysis and urinalysis. CBV (hematocrit) and blood gases test in patient with severe traumas. Blood sugar test. Test for level of alcohol in blood. Sketch of roentgenogram contours, roentgenogram description (in 2 projections). 2.4. Clinical diagnosis (Clinical diagnoses is formulated by the student according to the data obtained from objective and additional tests and examinations). 2.5. Plan of examination and treatment of the patient It includes administration of additional laboratory and instrumental methods of examination; administration of operations and medical manipulations; administration of infusion and transfusion therapy and drugs. 2.6. Clinical course This section contains data of the daily medical examination and changes in patient`s condition; results of new tests; changes in patient`s supervision (including operations, bandaging, repositions, changes in the system of continuous skeletal traction, etc.), new drug administrations. 2.7. Classification and treatment of the fractures of the given group References are recommended by teachers. Textbooks and reference books must not be main sources of information. 2.8. Epicrisis Reflects the essence of what happened with the patient: date, circumstances accompanying the trauma (disease), detailed in-patient treatment description necessary for the out-patient doctor (aftercare department), indication of duration of immobilization of the injured segments with plaster bandages or compressive-distraction osteosynthesis frames, date of re-examination and recommendations as for the load of the injured segment. 3. REFERENCES References contain bibliographical data of sources of literature used for preparation of the topic and writing a medical history of the observed patient. 4. TEST QUESTIONS AND TASKS FOR SELF-PREPARATION

1. What are the pecularities of taking anamnesis from a patient with isolated or multiple traumas of musculoskeletal system? 2. What are the pecularities of taking anamnesis from a patient with diseases of musculoskeletal system? 3. What are the pecularities of examination of a patient with polytrauma? 4. What signs of traumatic fracture can be revealed during patient`s clinical examination? 5. What signs of dislocation can be revealed during patient`s clinical examination? 6.What signs of inflammatory process can be revealed during patient`s clinical examination? 7. How can one measure and record measurment data of the length of extremities? 8. How can one measure and record measurment data of movements in large joints of upper and lower extremities? 9. Find on yourself points used for establishment of the length of extremities and construction of auxiliary lines (Guter`s line and triangle, Marks`s line, Roser-Nelaton`s line, Shemacker`s line, line of symphysis pubis and pertrochanteric line). REFERENCES 1. .. . : , 1978. 511 . 2. . ; . . 2- ., . . .: , 1991. 463 . 3. .. .: , 1993. 511 . 4. .. .: , 2005. 328 . 5. .. - . - .: , 1984. 328 . 6. .. . : , 1986. 591 .