Orthopedics - Oleksa A.P. 2006

Examination of the Orthopedic Patient
Overview

Depending on the patient's general condition, the examination may be superficial or thorough. A superficial examination involves assessing the patient's general condition, gait, posture of the trunk and limbs, marked deformities, etc.

The examination should always be comparative, attentive, and performed under good lighting.

A thorough examination of the patient is conducted only when they are completely undressed. One should never limit the examination solely to the area of the body where the patient reports pain or deformity. This is because, for instance, an anatomical shortening of the lower leg leads to a functional shortening of the entire limb, pelvic tilt, and compensatory spinal curvature. Only in cases of clearly defined Pathology of the shoulder girdle or upper limb is it permissible to expose only the upper half of the trunk.

A thorough comparative examination makes it possible to detect even minor deviations from the norm. First and foremost, attention is paid to the patient's general appearance and posture: their face, Skin condition, position of the trunk and limbs, presence of gross deformities, etc.

Patients with osteogenic Sarcoma appear suffering due to pain — pale, thin, and emaciated. A network of dilated Veins can be observed over the tumor. Acute inflammatory processes may present with skin hyperemia, whereas chronic ones present with pallor. A similar appearance is seen in patients with chronic Inflammatory Diseases of The Musculoskeletal System, etc.

It is also important to pay attention to the patient's posture and THE POSITION OF their limbs.

Posture refers to an individual's body build and the habitual position of the spine and limbs while standing, walking, and sitting. The core component of posture is the shape of the spine and its curves. The shape of the spine is determined by the habitual, relaxed body position that arises from the complex conditioned-reflex activity of the human Brain. The formation of posture begins in infancy and continues throughout the child's development.

In the fetus, the spine is evenly curved, forming a continuous kyphosis. After birth, the infant lies supine, causing the spine to straighten and kyphosis to disappear. The Muscle strength of a newborn is very weak and develops gradually. As neck muscle strength increases, the child begins to lift their HEAD, and with the strengthening of other Muscles, they begin to sit up. This leads to the appearance of a slight cervical lordosis and an increase in lumbar kyphosis, which should be considered normal. With the further strengthening of the neck, back, and lower limb muscles, the child begins to stand. At this stage, the physiological flexion contracture of the hips decreases, and lumbar lordosis gradually appears in the standing position. Lordosis in the cervical and lumbar Regions of the spine develops from the moment the child begins to walk. At this time, the abdomen protrudes forward, kyphosis gradually develops in the thoracic region, and both lumbar and cervical lordosis increase. Due to the persistence of a slight flexion contracture of the hips, the lower limbs remain slightly bent at the knees. Such a posture in a preschool child is considered normal.

During school age, contractures disappear completely and posture improves, which largely depends on the child's physical activity and muscle strengthening.

Posture disorders are particularly common during periods of rapid growth in children, when bones and muscles grow in length, and static Reflexes have not yet adapted to these changes. This is evident during Puberty, when significant changes in psyche and body Structure occur under METABOLISM/18.html">The Influence of Hormones, and posture is finally established.

The formation of posture is influenced by both endogenous and exogenous factors. These include muscular and gravitational pressure, static factors, persistent pain and chronic illness, the external environment (child-rearing conditions, lifestyle, physical activity, work and diet regimen, climatic factors, etc.). For the normal Development of the body and posture, children need A balanced diet, normal living, studying and recreational conditions, Physical Exercise and sports, and disease Prevention.

The Role of genetic factors in shaping posture and other traits inherited from parents should be noted. Conventionally, picnic, athletic, and asthenic body types are distinguished:

— the picnic type is characterized by average height, a developed and proportional trunk and limbs, a protruding abdomen, a barrel-shaped chest, and a tendency toward obesity;

— the athletic type is characterized by a normal and proportional body structure with well-developed musculature (muscular type);

— individuals of the asthenic type are typically tall, thin, with a Flat chest, sunken abdomen, and poorly developed muscles.

Each of these genetic types features its own individual age-related habitus posture (Fig. 1 and 2), with certain permissible daily fluctuations depending on mental state, fatigue, illness, etc. In addition, There is a habitual posture acquired through The Nature and conditions of work (in military personnel, loaders, carpenters, etc.).

In an adult, normal posture is characterized by the following features: the abdomen is flat and drawn in relative to the chest. According to Wiles, the pelvic inclination angle is about 31° in men and 28° in women, with permissible deviations in both directions of up to 4°. After the age of 35, posture begins to change gradually, and in old age, the physiological anteroposterior spinal curves increase, especially thoracic kyphosis. In elderly women, such kyphosis, resulting from Osteoporosis and the settling of vertebral bodies, is known as a "widow's hump".

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Fig. 1. Habitus posture in a girl and a boy at 7, 11, and 14 years of age.

There are many Methods for Assessing posture characteristics: the Harvard method (Lec and Brown), the point scoring method (Drew), and the photometric method (McEwen and Hove). These posture assessment methods are rather complex, and therefore, despite their accuracy, they are not used by practicing physicians. For routine posture assessments, Dega Wiktor applied a simple method of photographing nude children in two projections (lateral and posterior) alongside Haglund's calibrated frame method, supplementing them with clinical examinations.

Posture disorders are observed in cases of spinal curvatures involving an increase or decrease in physiological curves (lordosis, kyphosis). They manifest as round back (stooping), convex-concave back, flat back, or pre-scoliotic posture.

According to the Turner Saint Petersburg Institute of Pediatric Orthopedics, posture disorders in the sagittal plane occur in 18.2% of healthy children, and in the frontal plane, in 8.2%.

Round-back posture (stooping) is the most common and consists of an increased physiological curve in the thoracic region of the spinal Column (kyphosis). It is characterized by forward inclination of the head along with a similar inclination of the shoulder girdle and shoulders due to shortening of the pectoral muscles. The anterior chest is sunken, and the lower angles of the scapulae protrude from it, although they remain symmetrically positioned. A slightly decreased pelvic inclination with moderate abdominal protrusion is observed. X-ray Examination in the lateral PROJECTION OF THE spinal column reveals an increased backward curvature of the thoracic region and narrowed intervertebral spaces anteriorly in the area of the bend.

Convex-concave back posture is caused by an increase in the physiological curves of the spine: increased thoracic kyphosis is compensated by increased lumbar lordosis. The head is tilted forward, and the neck is short. The shoulder girdle is elevated and tilted forward. The chest appears similar to that in stooping. Due to lumbar hyperlordosis of the spinal column, the pelvis is more tilted.

Fig. 2. Senile kyphosis resulting from spinal osteoporosis.

Flat-back posture is typically observed in children with an asthenic body type, characterized by a slender, elongated torso, a long neck, and drooping shoulder girdles. The head position is normal, and the chest is flat, meaning its anteroposterior diameter is reduced. The scapulae may protrude slightly, and the back muscles are underdeveloped. The spinal axis is normal, but physiological curves are flattened while spinal mobility remains preserved.

Pre-scoliotic posture is characterized by lateral Displacement of the spinal column with normal physiological curves in the sagittal plane. This lateral curvature most commonly occurs in the upper lumbar or lower thoracic spine, accompanied by a corresponding trunk tilt. Waist Asymmetry is present; on the side of the bend, the shoulder girdle and scapula are depressed, and the spinous processes are displaced. A distinctive feature of this posture is that the deviations disappear upon forward bending—which relieves vertical static loading—whereas in Scoliosis they persist. An X-ray of the spine in a sitting child reveals a moderate lateral curvature without alterations in the physiological sagittal curves. An X-ray of the spine in a supine child shows no lateral curvature.

As toddlers begin to walk, they progressively develop motor proficiency and refine the muscle mechanisms required to maintain posture. Already by preschool age, synergistic and antagonistic muscles are well-developed, and the degree of tension they exert and the work they perform are quite substantial, enabling the child's free motor activity.

As previously mentioned, posture in children is constantly changing under the influence of various factors. This is particularly evident during early school age and the onset of puberty, when physiological curves become clearly pronounced. In a sexually mature individual, the body is fully formed and remains largely unchanged until old age, when it alters once again due to senile muscular weakness.

Therefore, proper attention must be paid to human body formation and posture development during the growth period of a child's Organism. At this stage, there is still an opportunity to correct and eliminate various deviations from the norm, as Tissues, including bones, are characterized by plasticity and malleability. Consequently, essential prerequisites for this include: identifying and eliminating the causes of musculoskeletal deviations, restoring joint biomechanics, and strengthening the muscles that correct the given deviation.

Furthermore, during the examination, attention is paid to the patient's posture and body position. There are three main positions of the patient and their limbs: active, passive, and forced.

An active position indicates the absence of gross functional impairments following trauma, or a compensatory adaptation in orthopedic patients. Such patients are active and readily perform Movements of the limbs and trunk within the normal range upon the physician's request.

A passive position of the patient indicates a severe condition (e.g., post-trauma, resulting from an inflammatory process) and the inability to perform active limb movements. For instance, in a fracture of the humerus or Femur, the limb hangs or lies passively; in radial nerve palsy, the wrist drops and active extension is impossible.

A forced position of the limbs or trunk occurs As a result of pain, which triggers a reflex antalgic (protective) contracture. The patient reflexively attempts to maintain a position of the trunk or limb that minimizes or eliminates pain. This is most frequently observed in inflammatory and degenerative-dystrophic joint processes. For example, coxitis of any Etiology leads to a flexion-adduction contracture of the hip joint, whereas gonitis results in a flexion antalgic contracture of the knee joint. Additionally, clinicians should note compensatory and adaptive forced limb positions in orthopedic patients. Forced limb positions also accompany joint dislocations and bone fractures. Once the inflammatory process resolves or the dislocation is reduced, the forced position of the limb disappears.

During physical examination, V.O. Marks suggests first identifying gross changes that disrupt limb structure, followed by inspecting local changes in adjacent areas, assessing muscle tone, The Nature of compensatory adaptations, and other relevant factors.

Gross changes include: malalignment of the limbs, displacement of their axis, and pathological deviations within the joints.

Inspection may reveal joint enlargement, deformation, as well as angular deformity of the limb at the level of joints or the diaphysis of long tubular bones resulting from past illnesses (such as Rickets or Blount's Disease) or malunited fractures.

Alteration of joint shape is a hallmark of pathology. It may be localized within the Joint Capsule (synovitis), periarticular tissues (periarthritis), the articular ends of the bones (arthrosis), or the periarticular fat pads (Studenikin M.Ya., Yakovleva A.A., 1987).

Astapenko M.G. and Pikhlak E.G. (1966) distinguish the following alterations in normal joint configuration: 1) joint Swelling caused by inflammatory tissue edema and synovitis, where the joint is uniformly enlarged in volume; 2) defiguration—where the joint shape is unevenly altered, as seen in bursitis, capsular thickening, or other local productive changes in periarticular tissue; 3) deformation—abnormal joint shape resulting from productive Changes in the articular bone ends due to bone overgrowth, articular Cartilage destruction, subluxations, dislocations, or tumors.

Joint swelling is characteristic of acute inflammatory processes, whereas defiguration and deformation are typical of chronic, long-standing conditions. However, arthrosoarthritis may present a combination of the first and third types of joint changes, and occasionally the second type (thickening and induration of the capsule). In obese children, defiguration of the knees and other joints sometimes occurs, the nature of which is easily determined by Palpation since only the subcutaneous Adipose tissue is involved.

Deformities of limb segments occur in both the frontal and sagittal planes.

In a normally straightened upper limb with full supination of the hand, the sagittal axis conventionally passes through the center of the heads of the humerus, radius, and ulna. When the forearm deviates outward, this axis is disrupted, forming an outward-facing angle at the elbow joint—a valgus deformity (cubitus valgus). When the forearm deviates inward, an inward-facing angle is formed, while the elbow is displaced outward. This deformity is termed varus (cubitus varus).

The normal lower limb axis runs from the anterior superior iliac spine through the center of the Patella to the space between the 1st and 2nd toes (Fig. 3,a). When the lower leg deviates inward, the knee is displaced outward. This axis deviation of the lower limb is termed genu varum (Fig. 3,b). When an outward-facing angle forms at the knee, Genu Valgum occurs—characterized by an inward deviation of the knee. Bilateral knee curvatures in the same direction result in genua vara or genua valga (Fig. 3,c). Valgus or varus axial deviation localized to a single limb segment is termed crus varum and femur valgum, respectively.

When limb segments are curved backward in the frontal plane, an anterior-facing angle is formed (Fig. 4). Depending on the site of curvature, this deformation is termed genu recurvatum and crus recurvatum, respectively. Forward curvature of the limb axis is termed antecurvatio, or specifically femur antecurvatum and humerus antecurvatus when referring to a particular segment.

Fig. 3. Lower limb axis: a — normal, b — varus deviation, c — valgus deviation of the lower leg at the knee.

Fig. 4. Recurvatum of the lower limb associated with equinus FOOT.

These deformities may result from inadequate Treatment of bone fractures, ligamentous injuries, growth disturbances due to epiphyseal cartilage pathology, or degenerative-dystrophic joint changes.

Examination allows the patient's gait and its specific characteristics to be assessed. Given that most musculoskeletal abnormalities manifest during walking, a thorough understanding of normal gait mechanics and potential deviations is essential.

Gait begins with a shift in body equilibrium caused by moving the center of gravity forward. A normal gait cycle consists of two phases: stance and swing. The stance phase starts when the heel strikes the support surface and ends with push-off, during the entire duration of which the foot remains in contact with the ground. The swing phase begins as the foot leaves the ground and ends when the heel touches down again, with the limb being carried forward (Fig. 5). In a normal gait, approximately 60% of the cycle is spent in the stance phase and 40% in the swing phase. Naturally, this requires coordinated movements of the pelvis, hips, knees, lower legs, and arms.

During the swing phase of a normal gait, the pelvis shifts laterally by approximately 2.5 cm and rotates forward by 40°. The hip extends during stance and flexes by an average of 40° during swing. The knee bends twice during the gait cycle, with the maximum flexion occurring in the early swing stage. The flexed position is maintained throughout the stance phase, except at the moment of heel strike. At slow walking speeds, there is a moment when both limbs are on the floor, whereas during running, a person Supports their weight on only one foot. The ability to walk is acquired by a child gradually, with the learning process being completed around the age of five. A child's gait approaches that of an adult by the seventh year of life. Murray and co-authors noted changes in the gait of older adults, manifested by shorter steps, greater foot out-toeing, reduced pelvic rotation, and decreased ankle extension, all of which are caused by muscle weakness.

Abnormal gait can develop as a result of neurological disorders, muscle weakness, stiffness in one of the lower limb joints, and, most frequently, pain in any part of the lower extremity. Patients presenting with pain exhibit an antalgic gait, which is characterized by shorter steps, a shortened stance phase, restricted mobility in the painful joint, and increased pelvic elevation on the affected side.

The MAIN TYPES OF gait abnormalities are distinguished as follows:

1. Antalgic limp (guarding limp) arises from pain. The patient favors the affected leg, bearing less weight on it and shifting more load to the healthy one; the weight-bearing time on the painful limb is shorter than on the healthy side. The smoothness and synchronicity of limb advancement are lost, leading to gait asymmetry and limping.

2. Sagging limp typically occurs with limb shortening or joint ankylosis (of the knee or hip) in a faulty position. Because the shortened limb is not painful, weight-bearing on it is full, and sometimes the duration of weight-bearing is even longer than on the healthy limb. The gait is abnormal, resulting in a limp whose severity depends on the degree of limb shortening. Minor limb shortening (up to 2 cm) is compensated for by an imperceptible pelvic tilt, making the limp barely noticeable. In cases of significant shortening, compensatory secondary deformations (such as pes equinus) may develop to functionally lengthen the limb, though these do not eliminate the limp.

3. Vaulting limp is observed when one limb is longer than the other (for example, knee ankylosis in full extension). When stepping on the longer leg, the patient is forced to vault upward or, in most cases, swing the leg outward in an arc to bring the longer leg forward.

Fig. 5. Phases of lower limb movement during gait.

4. Waddling gait (Trendelenburg gait) is caused by bilateral hip dislocation and occasionally by other conditions accompanied by a positive Trendelenburg sign. While walking, the person shifts their torso alternately from side to side (walking like a duck), meaning they tilt the upper body toward the weight-bearing limb.

5. Spastic gait can be unilateral or bilateral, caused by spastic paralysis dominated by increased muscle tone. It is most commonly seen in cerebral palsy (Little's disease). When flexion contractures are present in all joints, along with adductor contractures in the hips and shoulders, patients develop a characteristic spastic gait.

6. Paralytic gait results from flaccid paralysis or paresis of a single muscle or specific muscle groups (following poliomyelitis, trauma, etc.). The paralyzed muscle loses its function, altering the gait according to the functional purpose of the muscles that retain their innervation. There are various types of paralytic gait. For instance, in paralysis of the peroneal muscles, the foot passively drops down during the lifting and forward-swinging of the lower limb. To avoid dragging the toes on the floor, the patient attempts to lift the leg higher, resulting in a typical paralytic (steppage) gait.

7. Oscillating (swaying) gait is caused by significant varus or valgus deformity of the knees, lower legs, or thighs.

The signs of such a gait include restricted mobility in all JOINTS OF THE affected limb, reduced pelvic rotation and its exaggerated elevation, increased lateral spinal deviation, and a shortened step on the affected side. This type of gait imposes excessive stress on the spine and can lead to patient disability. Patients are generally unable to explain their limp and often do not even realize it. It appears that in such cases, the ability to integrate the complex neural and muscular activity, as well as the biomechanical factors required for normal gait in both the lower and upper extremities, is lost.

Habitual limping can be successfully corrected using the following technique: the patient is trained to walk with both knees braced and heel-first striking. This gait resembles the military "goose-step," and only when performed smoothly does it begin to resemble normal walking. There is no need to teach the patient simultaneous knee and lower leg movements. Once the patient masters the rhythmic movement of the hips and arms and achieves equal step lengths, the movements in the other joints of the lower limb associated with normal walking will appear spontaneously. Training a patient to walk without a limp takes only a few minutes of explanation and demonstration. This method has been applied with equal success in adults and children old enough to understand explanations and follow instructions.

Training is conducted with patients who continue to limp after two weeks of walking without crutches, a cane, or a rolling walker. It is advisable to conduct this in the presence of family members, especially when dealing with a child. It is necessary to ensure that the accompanying person understands the instructions and can, if necessary, correct the patient at home.

V. Zarichnyi has applied the described technique over the past 15 years in 600 patients recovering from pelvic or lower extremity fractures, hip or knee arthroplasty, knee surgeries including patellectomy, meniscectomy, synovectomy, correction or reconstruction of knee or ankle ligaments, as well as foot surgeries for heel spurs, bunions, and triple arthrodesis. In addition, the technique was used in convalescing patients after hip or knee joint infections, Slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and in patients who spent a long time in casts or using crutches.

This technique should be applied under the following conditions: after the elimination of the primary pathological cause, in the absence of noticeable weakness or muscular paralysis in the lower limbs, with a satisfactory range of motion in the lower extremity joints, and without excessive leg length discrepancy. Contraindications include advanced patient age, an uncorrected primary cause of the limp, and difficulty maintaining balance.

It has been found that after surgery, only about 20% of patients suffer from habitual limping. The rest recover in this regard without special training. Of particular note are those in whom the limp had developed over months or years prior to seeking medical attention. Following training, such patients quickly acquire the skill of walking without a limp, but have a tendency to relapse when they let their attention to their gait slip, until they finally overcome this habit altogether.

After the physician determines the Nature of the gait, the patient is asked to sit down, stand up, bend forward, backward, and to the sides, as well as sit and lie down. Careful observation of the execution of these functional tasks makes it possible to identify additional signs necessary to refine the Diagnosis of the condition.