Structure governs function. In the human body, anatomy is the structure, and physiology and biomechanics are the functions. To perform a competent orthopedic examination, a basic knowledge of the specific structure and function of the body part must be matched with an understanding of how these parts work together to produce normal movement (biomechanics). When injury occurs, pathomechanics, such as limping, may result. Conversely, an abnormal movement pattern, particularly one that is repeated thousands of times, such as a shortened stride length when running, can result in injury. The examination process consists of connecting the findings of dysfunctional anatomy, physiology, or biomechanics with the unique circumstances of the individual and correlating those findings to disruption in the patient's function.
The examination process is repeated throughout all phases of recovery. The effectiveness of the treatment and rehabilitation protocol, and subsequent modification, is based on the ongoing reexamination of the patient's functional status. Regardless of whether the examination is an initial triage of the injury or a reevaluation of an existing condition, a systematic and methodical evaluation model leads to efficiency, consistency, and accuracy in the evaluation process.
Some findings obtained during an examination will trigger referral to a physician for medical diagnosis and management. The examination process should always attempt to rule in or rule out these conditions. Much of the exclusionary process is intuitive: a patient who is talking is obviously breathing. Findings such as bone angulation associated with an obvious fracture may become evident during the secondary survey. Other findings such as localized numbness may become apparent later in the clinical examination. If the patient's disposition is not clear, err on the side of caution and refer the patient for further medical examination.
The differential diagnosis includes all those possible diagnoses that have not been excluded by the examination findings. As the examination continues, many pathologies are quickly excluded. For example, the patient who is walking does not have a femur fracture (ruling out a potential diagnosis). In the case of a patient with an acute ankle injury, the initial differential diagnosis must include the possibility of a fracture that must be ruled in or out during the examination process.
Following the examination, the differential diagnosis often contains more than one possible pathology. If arriving at a definitive diagnosis is necessary for treatment, additional testing, such as diagnostic imaging and obtaining laboratory values, is used to further narrow the differential diagnosis. In some cases, identification of the specific involved structure is not necessary (or even possible) for effective intervention. Many individuals with low back pain, for example, are diagnosed with "nonspecific low back pain."
Systematic Examination Technique
This chapter describes the examination model used in this text, one of many that are used. A comprehensive examination model must incorporate (1) the ...