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Chapter 14 Generic joint examination
Checklist
WIPER
Bilateral limb exposure
Exposure of joint above and joint below
Aids, orthotics and soles of footwear
Physiological parameters
Tape (measure)
Length or diameter discrepancies between limbs (true or apparent)
Look
Skin: scars, erythema, ecchymosis, sinuses (SEES)
Soft tissues: wasting, swelling
Bone: deformity, asymmetry, amputations
Feel
Move
Active (and range of movement)
Passive
Resisted
Test
Special joint provocation tests
To complete the examination…
Say you would like to ask the patient questions about impact on lifestyle.
Examine the joint above and the joint below – with limb pain, consider examining the neck/back for referred pain.
Examination notes
A structured, consistent and universal approach is needed in the orthopaedics examination in order to avoid missing pathology irrespective of the joint examined.
The typical algorithm used in orthopaedics involves seven four-letter words:
| GAIT | LOOK | TEST |
| TAPE | FEEL | X-RAY |
| MOVE |
The look and feel parts of the examination are subdivided into three further categories: SKIN, SOFT (tissues) and BONE. These are easily remembered, as they are also four-letter words.
Intial observation and gait
The initial observation of the patient and any adjuncts such as walking aids, slings, heel or shoe raises, orthotics or prosthetics helps identify potential pathology. At this time ask the patient to walk. If there is lower limb pathology this is an ideal opportunity to assess smoothness and symmetry of gait. It is also important to assess the presence of an antalgic (painful) gait or walking pattern typical of a particular central or peripheral neurological pathology (e.g. foot drop or cerebral palsy). In the examination of the lower limb and spine, examine the soles of the feet for callosities and shoes for the pattern of wear. Gait examination provides the clinician with ‘thinking time’ to establish and identify gross pathology in order to formulate an answer. Typical gait patterns are shown in the following table.
| Gait pattern | Clinically | Cause |
|---|---|---|
| Spastic gait | Adducted internally rotated arm with flexed hip and plantarflexed foot | Hemiparesis |
| Antalgic gait | Reduced time spent on weight-bearing side (‘dot–dash’ gait) | Trauma, infection, arthritis |
| Ataxic gait | Wide-based unsteady gait | Unsteadiness from cerebellar or Friedreich’s ataxia |
| Trendelenburg gait | Weak hip abductors cause tilting of the pelvis away from the standing leg, i.e. normal side sags | Perthe’s disease, slipped capital femoral epiphysis, developmental dysplasia of the hip, hip arthritis, spina bifida, cerebral palsy and spinal cord injury, gluteal nerve injury or poor muscle balancing in hip replacements |
| Circumducting gait | Exaggerated hip abduction during leg swing | Hemiplegia, leg length discrepancy, unilateral spasticity |
| High-stepping gait | Exaggerated hip flexion to allow clearance of foot during swing phase of gait | Foot drop, spina bifida, polio, peripheral neuropathies |
| Tiptoe walking gait | Plantarflexed or equinus foot position | Common in children; differentials include diplegia cerebral palsy or lysosomal storage disorder |
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