Palpation, percussion, and auscultation in traumatology

Specifics of taking an orthopedic history

The first stage of diagnosis is identifying factors that directly affect the functions of the musculoskeletal system. The physician needs to find out about any previous microtraumas and assess the level of physical activity (both excessively increased and significantly reduced).

Special attention is paid to concomitant conditions:

• Allergological status: reactions to typical trauma medications—antibiotics, local and general analgesics—are recorded.
• Dermatological pathologies: the presence of contact dermatitis or eczema, which may affect the possibility of applying casts or performing surgeries.

In cases of congenital anomalies, a specialized history is taken. The course of the mother's pregnancy and labor, the rates of the patient's physical development in infancy and school age, and facts of follow-up with a pediatric orthopedist are taken into account.

For patients with prolonged disability, employment history is important: duration of sick leave, presence of disability, and facts of working conditions modification due to the disease. In addition, social status directly determines treatment tactics. The success of therapy depends on compliance (conscious cooperation), the patient's motivation to restore their quality of life, the availability of support from loved ones for care and home rehabilitation, as well as the financial ability to purchase necessary medications, expensive implants, or orthoses.

Assessment of the present state (status praesens)

General inspection begins with an assessment of the patient's appearance, body proportions, facial expression, and behavioral features.

Key criteria for primary assessment:

1. Severity of condition: ranges from satisfactory to extremely severe.
2. Consciousness and mental status: the physician pays attention to the adequacy of reactions. If signs of alcohol or drug intoxication are detected, a clinical and laboratory examination is prescribed with mandatory completion of an official report.
3. Physique and nutrition: classified as normosthenic, hypersthenic, or asthenic. Extreme states—obesity or cachexia—are noted separately.

Next, a sequential description of all body systems is performed (nervous, respiratory, endocrine, cardiovascular, digestive, urogenital, as well as the skin and subcutaneous tissue). If there is a history of diseases in these systems, they are described in as much detail as possible. Important rule: if a traumatic injury to any system is detected during the examination, data on it is transferred from the general examination to the injury site description section (status localis).

Dynamic examination and functional tests

The main objective of the examination is to determine the degree of compensation for the musculoskeletal system lesion, i.e., to understand how functionally adapted the patient is to their condition. To this end, all parts of the body must be examined, even if the patient has no direct complaints about them.

If the patient's condition permits, the examination is conducted dynamically. The physician observes how the patient gets up from a chair or bed, sits down, goes downstairs, and performs basic daily activities (dressing, eating, writing). During walking, posture, pelvic tilt, and waist symmetry are assessed. The patient's shoes serve as an additional diagnostic marker: uneven wear indicates hidden or overt gait asymmetry.

Classification of gait disorders

Observation of gait allows for the identification of typical pathological biomechanical patterns:

• Antalgic gait: occurs due to pain. The patient avoids full weight-bearing, and support on the affected limb is brief. To compensate, the trunk is thrown to the side with a tilt, the knee and hip joints are fixed, the leg is abducted and may be rotated.
• Non-antalgic gait: a consequence of pain-free leg shortening of 3 cm or more. The trunk drops, and body weight is shifted to the side of the shortening. With a severe length deficit, weight-bearing occurs only on the toes.
• Bouncing gait: characteristic of functional leg lengthening (e.g., in equinus foot). The patient either artificially shortens the long leg (by flexing joints) or lengthens the healthy one (by standing on tiptoe). The elongated limb describes an arc to the side.
• Knee joint ankylosis: when the knee is fixed in extension, the straight leg describes a lateral arc, and the pelvis on the affected side is forced to rise.
• "Waddling" gait: swaying movements of the trunk from side to side. Found in bilateral coxarthrosis, congenital hip dislocation, or pelvic ring disruption.
• Clubfoot gait: accompanied by the "windmill" symptom. The patient has to lift the affected foot unnaturally high to step over the other deformed leg acting as an obstacle.
• Paralytic gait: depends on the paralyzed muscle. In quadriceps paralysis (hip extensor), the patient fixes the thigh with their hand to prevent the knee from buckling. In peroneal nerve palsy, the foot drops, forming a "steppage" gait with high knee lifting.
• Spastic gait: occurs in spastic paralyses and hypertonia. The legs are stiff and cross over when walking. The patient moves in small steps, struggling to lift the feet and scuffing the soles.

A peculiar "auscultation": evaluation of step rhythm

Certain orthopedic pathologies can be diagnosed simply by listening to the sound of the patient's footsteps:

• Limb shortening (without pain): gait remains rhythmic, but the sound of the step on the side of the short leg becomes noticeably louder (accentuated).
• Antalgic gait (with unilateral pain syndrome): the step rhythm is disrupted, and the gait becomes arrhythmic. A cautious and very brief heel-strike on the healthy leg is heard by ear, whereas the painful leg bears a prolonged, accentuated sound.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Clinical and laboratory criteria for assessing the severity of the patient's condition
• Specifics of filling out the alcohol and drug intoxication report in an inpatient setting
• Methodology for measuring limb length to confirm shortening
• Rules for describing the status localis in polytrauma

Other topics in the section "General Questions of Traumatology and Orthopedics"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.