History taking orthopaedics

A. IDENTIFICATION
1. Age:
<1 yr

Developmental Dysplasia of Hip (DDH), Cerebral palsy

1-2
yrs

Nutritional rickets, Poliomyelitis, Ewings sarcoma

5-10
yrs

TB of hip, Perthes disease

< 15

Acute osteomyelitis, Juvenile Idiopathic Arthritis

15-20
yrs

Slipped Capital Femoral Epiphysis (SCFE)

10-20
yrs

Bone malignancies, Osteochondroma

30-40
yrs

Rheumatoid Arthritis

>40
yrs

Degenerative disorders, Avascular necrosis, Prolapsed Intervertebral Disc,

Multiple myeloma, Metastasis, Gout

2. Gender:

Males: Perthes disease, SCFE, Traumatic disorders, Multiple myeloma

Females: Rheumatoid arthritis, DDH, Osteoporosis, Ankylosing spondylitis, Osteomalacia

3. Occupation: Gives clue to causation and physical requirement
4. Others: Name, Address, Religion, Education, Hobbies, Hand-dominance (Dominant hand
commonly affected)

B. CHIEF COMPLAINTS
What brings patient to the hospital X Duration of complaints (If multiple, must be in the descending
order of duration of complaints)
eg. Pain, Difficulty using limb, Inability to walk, Deformity of limb, Swelling, Stiffness, Weakness,
Discharging sinus, Altered sensation

C. HISTORY OF PRESENTING ILLNESS

a. Diagnostic facts:

Present since birth: Congenital

During development process: Developmental

Fever, chills, rigors, night cries: Infective

Nutrition, socio-economic: Metabolic

Other evidence of hormonal imbalance: Endocrinal

Seasonal variation, inflammatory signs, morning stiffness (>30 min), pain improved with

use of affected part: Inflammatory

History of Road traffic accident, fall, trauma: Traumatic
Advancing age, pain improved by rest and worse with use of affected part/end of the day,

locking, instability: Mechanical/Degenerative

Constant pain, Night cries, fever, night sweats, anorexia, fatigue, weakness, weight loss,

history of Ca. prostate/thyroid/breast/lung/kidney: Neoplastic

No obvious complaints: Idiopathic

Note:
1.
Locking: Sudden inability to complete a particular movement

Loose bodies


2.

Torn meniscus
Unlocking: Offending body slips out of way

b. Pain: Describe in OPQRST

Onset: Sudden/Insidious, What triggered? What was patient doing?

Progression: Constant? Worsened? Improved? On and off?

Neoplasia: Constant pain

Trauma: Increases upto 4-6 hours and then decreases

Acute Inflammation: Sudden increase and then subsides

Chronic inflammation: Remissions and exacerbation of disease

New origin pain in painless disease: Malignant change, Pathologic fracture

Quality:

Aching: Chronic arthritis

Stabbing: Ruptured tendon

Burning: Neuralgia

Throbbing: Abscess

Radiation/Referred:

Shoulder pain from heart or diaphragm

Arm pain from neck

Leg pain from back (sciatica)

Back pain from kidney, aortic aneurysm, duodenal ulcer

Pain may radiate to adjacent sites

Relieving and aggravating factors:

Direct questions
Indirect questions: what happens on joint movements, walking, standing, body
posture and exercises
Related to any food intake: gout
Relief with analgesics, fomentation or other means?
Site
Severity:
Mild: easily ignored
Moderate: cant be ignored, interferes with function and needs attention from time
to time
Severe: present most time, demanding constant attention or treatment
Excruciating: totally incapacitating
Timing and Duration

c. Swelling:

Onset/first noticed:

rapid: hematoma, hemarthrosis

slow: inflammation, effusion, infection, tumor

Pain:

painful: acute inflammation, infection, malignancy

painless: benign growth, low grade malignancy

Progression:

constant or increasing size: neoplastic

remission: inflammatory

hardens in months: myositis ossificans

Swelling at other sites: Neurofibromatosis, Hereditary multiple exostoses, Multiple

enchondromas (Olliers disease, Maffuci syndrome), Multifocal TB, Polyarthritis

Following fracture: Callus formation, Displacement

Site:
Hand/wrist: Ganglia
Foot: Synovial sarcoma
Knee: Osteochondroma
Greater toe: Gout

d. Limp:
Painful

Painless

Traumatic

Poliomyelitis

Inflammatory e.g. TB hip

Coxa vara deformity of hip

Osteoarthritis hip

Developmental dysplasia of hip

Deformity of joint or bone
Fused hip, knee or ankle

Coxa-vara (Decreased femoral neck-shaft angle): <120 degrees (Normally 160 degrees at birth
and 135 degrees in adult)
1.
Congenital: Growth anomaly at upper femoral epiphysis
2.
Acquired: SCFE, Perthes disease, AVN femoral head, Femoral neck fracture,
Intertrochanteric fracture, Rickets

e. Deformity:

Trauma: Subluxation/dislocation of joint, Malunion, Volkmann Ischemic Contracture

Acute painful: Muscle spasm initiated by pain

Gradual progression: Chronic infections, Growth-related disorders

f. Stiffness (Joint involvement):

Early stages: Muscle spasm

Late stages: Adhesions

Advanced stages: Ankylosis

Intra-articular

Extra-articular

TB

Myositis

Septic arthritis

Arthrogyposis Multiplex Congenita

Viral arthritis

Burn contracture
Scleroderma and other such diseases

g. Weakness: loss of muscle power

Disuse atrophy of muscle

Neurological weakness:

Brain: Stroke

Spinal cord: Poliomyelitis

Nerve: Neuropathy

Neuromuscular junction: Myasthenia gravis

Muscle: Myopathy
Suggestive history:
No sensory loss: Myopathy, Motor neuropathy, Polio, Motor neuron disease
Sudden: Injury
Progressive: Neuropathy, Myopathy
Insidious: Myopathy, Leprosy

h. Discharging sinus: Causes of persistent discharging sinus

Diabetes mellitus

Chronic osteomyelitis

Fungal infection

Foreign body

Epithelialisation of sinus tract

Scar tissue around sinus

Malignant change
i. Other things to be asked in HOPI:

Activities of daily living (ADL): getting up, sitting down, using bathroom, combing hair

Change in sensibility: Intervertebral disc prolapse, local ischemia, peripheral neuropathy

Treatment received for the complaint

For a case of trauma: Mechanism of injury, Events surrounding the trauma

Any need to use aids?

j. Review of systems: Include only positive history and RELEVANT negative history

D. PAST HISTORY
1.
Similar problem on the contralateral side or similar episode previously
2.
Orthopedic history: Injuries, non-surgical treatment, surgery
3.
Medical history:
1.
Twisted ankle: Osteoarthritis
2.
Gastrointestinal disease: Ankylosing spondylitis or Osteoporosis
3.
Conjunctivits, Iritis, Psoriasis, Urogenital disease: Reactive arthritis
4.
Malignancies: Metastatic bone disease
5.
Others: TB, DM, Hypertension, etc.
4.
Surgical history

E. PERSONAL HISTORY
1.
Smoking
2.
Alcohol intake
3.
Drug abuse
F. FAMILY HISTORY
1.
Orthopedic: Dupuytrens contracture, Rheumatoid arthritis, Gout, Bone dysplasias may run
in families
2.
Medical: TB, DM, HTN
G. DRUG AND ALLERGY
1.
Current and past medications

Steroids: Avascular necrosis, Problems in wound healing

Phenytoin: Dupuytrens contracture

H. SOCIAL HISTORY
1.
Level of care and nutrition in children
2.
Dietary constraints which may cause specific deficiencies
3.
Work practices, travel and recreation
I. MENSTRUAL HISTORY (In females):
1.
Menarche: Scoliosis
2.
Menopasue: Osteoporosis
J. BIRTH HISTORY
1.
Absence/weakness of fetal movements by 4-5 gestational months: Neuromuscular disease
2.
Maternal Diabetes Mellitus, toxemia, drug ingestion, fetal distress or prematurity
3.
Type of delivery: Breech (DDH)
4.
Physical and mental development of child:
Age (months)

Milestones

1-2

Holds up chin

6-8

Sits alone

8-10

Stands with support

10-12

Walks with support

14

Walks without support

24

Ascends stairs one foot at a time