General scheme of patient examination
Any examination in traumatology and orthopedics is based on general principles of propedeutics. Moving to instrumental diagnostics without a preliminary clinical examination is considered a gross error and a "step backward".
The standard algorithm for working with a patient includes the following stages:
- Eliciting complaints.
- Taking a medical history: studying the history of the present illness (anamnesis morbi) and the patient's personal and social history (anamnesis vitae).
- Assessment of the present status: conducting a general physical examination (status praesens) and a targeted examination of the injury site (status localis).
- Non-invasive studies: radiography, ultrasound, CT, MRI, scintigraphy, angiography, as well as electrophysiological and biomechanical tests.
- Invasive studies: puncture, biopsy, arthroscopy.
- Laboratory diagnostics.
During the clinical examination, the physician invariably assesses posture and gait, anatomical contours, range of motion in joints, muscle strength, and measures the length and circumference of the limbs. Standard methods are also applied: palpation, percussion, auscultation, and checking peripheral blood supply and innervation.
Working with complaints: primary and secondary
All complaints of the injured person are conventionally divided into two categories. Key attention is paid to main complaints—those that bother the patient the most and are directly related to the current injury or exacerbation of an orthopedic condition.
The specialist's tasks when eliciting complaints:
- Isolate the main problems based on knowledge of typical symptoms.
- Clarify the nature of manifestations.
- Determine the exact moment of their onset.
- Identify the dependence of symptoms on physical exertion or specific movements.
Most often, the primary complaint is pain. To accurately detail it, the physician needs to find out four mandatory parameters: exact localization, presence of irradiation, degree of intensity, and general duration of the pain attack.
Features of pain perception in injuries
Taking a history in trauma patients is often complicated by atypical pain perception. The physician must take into account a number of specific factors that distort the clinical picture:
- Mismatched localization. The place where the patient feels pain does not always correspond to the real zone of damage. Irradiation is common: for example, in pathological processes of the hip joint, a person may complain exclusively of knee pain.
- Multiple injuries (polytrauma). The victim concentrates on the most acute pain focus, completely ignoring the rest. A classic example is catatrauma (landing on the feet), in which calcaneal fractures are combined with a spinal fracture. Due to unbearable pain in the feet, moderate lower back pain goes unnoticed by the patient.
- Stress and severe condition. Against the background of post-traumatic stress or a severe general condition, patients may voice only minor complaints, inadequately assess their condition, or make no complaints at all.
- Impact of chronic diseases. Patients with long-standing orthopedic pathology often think in terms of their old diagnoses. They may conceal important new symptoms (considering them irrelevant) and artificially highlight those that fit into their own "theory of illness".
Epidemiological context of traumatism
When taking a history and making a diagnosis, it is important to consider the conditions under which the injury was sustained, since treatment and rehabilitation require enormous personnel and material resources. Prevention is a priority of modern medicine.
Traumatism is classified into several types:
- Occupational (depends on safety control, equipment serviceability, and working conditions).
- Non-occupational (road traffic injuries lead here—a global problem where the "human factor" is to blame in 90% of cases).
- Intentional and military (caused by political conflicts and social tensions).
To assess the scale, statistical indicators are used: the general level of traumatism (number of injuries per 100 or 1000 people over a period) and the injury frequency rate at a specific enterprise.
Briefly: answers to topical questions
What specifically is ascertained from the patient when taking anamnesis morbi in acute trauma?
When taking anamnesis morbi in a patient with acute trauma, the circumstances, mechanism, and time of injury are ascertained. The following aspects must be clarified:
- Circumstances of the injury—what and where happened (to determine the direction of investigation, severity, and medico-legal significance).
- Mechanism of the injury—how the damage occurred (direct or indirect mechanism).
- Course of the injury—time elapsed since injury and dynamics of pain syndrome changes.
- Assessment of previous treatment—accuracy of diagnosis, treatment effect, presence of complications, and consequences of inadequate first aid.
What information must be collected in the anamnesis vitae of a trauma patient?
In the anamnesis vitae of a trauma patient, in addition to traditional information about birth, development, past illnesses, and allergy history, specific information must be gathered. Special attention is paid to:
- Conditions disrupting bone tissue structure—diabetes mellitus, thyrotoxicosis, collagenoses, tuberculosis, hormone therapy, menopause, pregnancy.
- Bad habits—systematic alcohol consumption, increasing the risk of osteoporosis and neurological disorders.
- Previously sustained injuries—their consequences and final functional outcomes.
- Working, living, and sports conditions—factors associated with regular microtraumas, presence of occupational hazards and diseases.
What types of bone and joint injury mechanisms exist?
Several main types of bone and joint injury mechanisms are distinguished depending on the application point of force and the nature of the impact. The following mechanisms exist:
- Direct mechanism—damage occurs directly at the site of impact of the damaging agent (the point of application of force and the site of injury coincide).
- Indirect mechanism—damage occurs away from the site of impact (this also includes avulsion fractures).
- Stress mechanism—fatigue or march fractures arising due to gradual bone remodeling under the influence of prolonged inadequate load, repeated pressures, or multiple direct traumas.
What absolute and relative signs of a fracture are detected during physical examination?
During physical examination, reliable (absolute) and indirect (relative) signs of a fracture are detected. Reliable symptoms are strictly forbidden to be elicited intentionally in order to avoid complications.
| Type of signs | Detected symptoms |
|---|---|
| Reliable | Crepitus, pathological mobility of bone fragments. |
| Indirect | Local tenderness, impaired function, altered segment contours and swelling, skin discoloration, presence of epidermal bullae, wounds and hematomas, body asymmetry, impaired bone sound conduction, axial loading sign. |
To detail the pain syndrome, remember the «LIIP» rule: Localization, Irradiation, Intensity, Duration.
Class and exam questions
What is the difference between status praesens and status localis?
Status praesens describes the general physical condition of the patient at the time of examination. Status localis is the targeted examination and description of a specific site of injury or disease.
Why might a patient not complain of back pain after a fall from a height?
This is a feature of pain perception in polytrauma. The patient focuses on the strongest source of pain (e.g., in fractured heels), ignoring less intense back pain.
Is it acceptable to skip the clinical examination if MRI results are available?
No, abandoning a clinical examination in favor of equipment is considered a step backward. Equipment does not replace a complete clinical examination of the patient.
How do chronic patients hinder proper history taking?
They are often influenced by their old diagnoses: they highlight habitual symptoms and conceal new ones, mistakenly believing they are unrelated to the current condition.
What else to study on this topic
- Age groups in the study of pediatric traumatology
- Methods for assessing anatomical contours and range of motion
- Non-invasive diagnostic methods (ultrasound, scintigraphy, angiography)
- Invasive methods: arthroscopy, biopsy, and puncture
- Specifics of examining patients with the consequences of old injuries
Master the entire topic in the "Traumatology" course
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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.