What constitutes a comprehensive orthopedic history and physical examination?

Orthopedic History and Physical Examination Template

Chief Complaint and History of Present Illness

Document the specific musculoskeletal complaint with precise temporal and mechanical details:

• Onset characteristics: Record whether symptoms began acutely (with specific trauma mechanism) or progressively, including the exact date and circumstances 1, 2
• Trauma mechanism: For acute injuries, document the position of the limb, direction of force, and whether a pivot, twist, or direct blow occurred 1, 2
• Pain characteristics: Specify exact anatomical location (e.g., medial vs lateral joint line), quality (sharp, dull, aching), severity using 0-10 scale, and radiation pattern 3, 1
• Mechanical symptoms: Ask specifically about locking, catching, giving way, popping sensations, or instability episodes 1, 2
• Functional limitations: Quantify impact on weight-bearing, stairs, squatting, pivoting, and activities of daily living 3, 1
• Aggravating factors: Document specific movements or positions that worsen symptoms (e.g., pain with pivoting suggests meniscal pathology) 1, 2
• Alleviating factors: Record what improves symptoms including rest, ice, medications, or positional changes 3, 1
• Temporal pattern: Note if pain is constant versus intermittent, worse at specific times of day, or progressive versus stable 3

Past Medical and Surgical History

• Prior musculoskeletal injuries: Document all previous injuries to the same or contralateral extremity, including dates and treatments 4
• Previous orthopedic surgeries: Record all prior procedures with dates, surgical approach, and outcomes 4
• Medical comorbidities: Specifically ask about diabetes, peripheral vascular disease, bleeding disorders, and conditions affecting bone health 5, 4
• Medications: List all current medications including over-the-counter NSAIDs, anticoagulants, and supplements that may affect bleeding or bone healing 4

Family History

• Musculoskeletal conditions: Ask about family history of arthritis, connective tissue disorders, or hereditary bone conditions 4

Social History

• Occupation: Document job requirements including lifting, repetitive motions, prolonged standing, or sedentary work 4
• Athletic activities: Record sport participation, training intensity, recent changes in activity level 1
• Tobacco use: Quantify pack-years as this affects bone healing and surgical outcomes 4
• Alcohol intake: Document frequency and quantity 4

Physical Examination

General Inspection

• Gait assessment: Observe for antalgic gait, limping, use of assistive devices, and weight-bearing status 6
• Standing alignment: Assess for valgus/varus deformity, leg length discrepancy, and overall limb alignment 1
• Muscle atrophy: Compare muscle bulk bilaterally, particularly quadriceps and calf circumference 2

Examination of Uninjured Side First

Always examine the contralateral uninjured extremity first to establish baseline and reduce patient anxiety 2

Inspection of Affected Extremity

• Skin integrity: Look for lacerations, abrasions, ecchymosis, surgical scars, or open wounds 5, 6
• Swelling: Note location (joint effusion versus soft tissue edema) and measure circumference if applicable 2
• Deformity: Document any visible bone or joint deformity, subluxation, or dislocation 2
• Erythema and warmth: Assess for signs of infection or inflammation 5

Palpation

• Bony landmarks: Palpate systematically for point tenderness over bones, identifying fracture sites 2
• Joint line tenderness: Palpate medial and lateral joint lines (positive medial joint line tenderness suggests meniscal tear when combined with appropriate history) 1, 2
• Soft tissue structures: Palpate ligaments, tendons, and muscle bellies for tenderness, defects, or masses 2
• Temperature: Compare skin temperature bilaterally 5
• Effusion: Perform ballottement test or bulge sign for knee effusions 2

Range of Motion Testing

• Active range of motion: Have patient move joint through full arc, documenting degrees of motion and pain provocation 2
• Passive range of motion: Examiner moves joint through full arc, noting crepitus, end-feel, and limitations 2
• Comparison to contralateral side: Document any asymmetry in degrees of motion 2

Neurovascular Examination

• Peripheral pulses: Palpate dorsalis pedis, posterior tibial, popliteal, and femoral pulses bilaterally and grade intensity 5, 6
• Capillary refill: Assess in digits, normal is <2 seconds 5, 6
• Sensory testing: Test light touch and pinprick in all dermatomes distal to injury 5, 6
• Motor testing: Assess strength in all muscle groups distal to injury, grading 0-5/5 5
• Deep tendon reflexes: Test appropriate reflexes (patellar, Achilles) and compare bilaterally 5

Ligamentous Stability Testing (for knee injuries)

• Valgus stress test: Apply valgus force at 0° and 30° of flexion to assess medial collateral ligament 2
• Varus stress test: Apply varus force at 0° and 30° of flexion to assess lateral collateral ligament 2
• Lachman test: Most sensitive test for anterior cruciate ligament injury, performed at 20-30° of flexion 2
• Anterior drawer test: Assess anterior cruciate ligament with knee at 90° flexion 2
• Posterior drawer test: Assess posterior cruciate ligament with knee at 90° flexion 2
• Pivot shift test: Assess anterolateral rotatory instability from anterior cruciate ligament injury 2

Meniscal Testing (for knee injuries)

• McMurray test: Rotate tibia while extending knee from flexed position, positive if click or pain occurs 2
• Apley grind test: Apply compression and rotation with patient prone and knee flexed 90° 2
• Bounce test: Attempt to fully extend knee; springy block suggests meniscal tear 2

Special Tests (joint-specific)

Perform additional maneuvers based on the affected joint and suspected pathology, always comparing to the contralateral side 2

Documentation of Findings

• Positive findings: Record all abnormal examination findings with specific measurements and grades 2
• Pertinent negatives: Document relevant negative findings that help exclude differential diagnoses 3, 6
• Comparison to baseline: Note any changes from prior examinations if available 2