Orthopedic surgery encompasses the entire process of caring for the surgical patient, from diagnostic evaluation to the preoperative evaluation and through the postoperative and rehabilitative period. Although the surgical procedure itself is the key step toward helping the patient, the preliminary and follow-up care can determine whether the surgery is successful.
History and Physical Exam
Although it may seem obvious, the history and physical exam are still important in the evaluation of the patient. Every office visit is a history and physical exam, whether a new or a return visit. The completeness of the history and physical has assumed new importance in view of the complexities required for compliance with federal regulations. Regulations require that a chief complaint be specified, and this must be clearly defined because it determines the direction for the rest of the history and physical. The history must address the key features of the problem, both to elucidate the medical problem and to cover the subsidiary requirements for billing purposes. The social history and past medical history are similarly important because they change billing codes without necessarily affecting outcome or success of care. The physical again must cover the essentials necessary for diagnosis, and frequently the confirmation of the diagnosis is based on physical exam, but such considerations as skin condition and blood supply must be documented, despite the fact that this process is also part of the surgical evaluation. The next step is imaging and laboratory exams. The most important point here is to use the most cost-effective examination possible while keeping patient safety, satisfaction, and convenience in mind.
Roentgenography is still the most cost-effective and most important initial diagnostic test in the orthopedist’s armamentarium. Almost every patient should have a radiograph prior to getting a more sophisticated imaging study. Certain situations are obvious; for example, a 68-year-old man with knee pain should have standing, flexed-knee posteroanterior (PA), lateral, and Merchant plain film views taken. If those views show normal joint spaces, consideration of intraarticular pathology, such as a degenerative meniscus tear, can be worked up with magnetic resonance imaging (MRI). The normal views usually ordered are as follows:
No history of trauma, more than 4 weeks’ duration.
Younger than 35 years: anteroposterior (AP) lateral, odontoid.
Older than 35 years: obliques.
History of trauma: flexion/extension laterals (obtain on first visit).
2. Thoracic spine pain and tenderness
Younger than 40 years, no reason to suspect malignancy: AP and lateral (if history of trauma or possibility of osteoporosis on first visit, otherwise at 4 weeks).
Consider cervical (C)-spine as a source of referred pain to thoracic (T)-spine if no tenderness in T-spine.