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 going to 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).
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.
Lumbar (L)-Sacral (S)-Spine
Younger than 40 years, no reason to suspect malignancy after 4 weeks' duration of the pain. With significant trauma, at first visit, or possible malignancy (ie, weight loss, malaise, fatigue): AP, lateral.
Add obliques for chronic low back pain (ie, spondylolisthesis).
AP pelvis, lateral of affected hip.
Consider lumbar-sacral (L-S) series if pain is in the buttock rather than in the groin.
Older than 40 years or history of meniscectomy: Rosenberg, lateral, and sunrise films. Merchant views are similar to sunrise. The Rosenberg view is a 10-degree down shot of the PA of the knees while standing at 45 degrees of flexion.
For other knees: AP, lateral, and sunrise.
In the child, up to age 16, consider a pelvis film with the complaint of knee pain and negative physical exam referable to the knee.
Femur, Tibia, Humerus, Forearm
AP and lateral are indicated for trauma, palpable lesions, or suspected tumors.
AP, lateral, and oblique for routine evaluation.
AP, axillary, scapular Y, and outlet views.
AP and lateral (true lateral).
Wrist: PA, lateral, and oblique
For suspected instability: clenched fist PA in radial and ulnar deviation.
Follow-up radiographs are obtained when a change in the radiographic findings is expected. Remember that bone changes occur slowly, so radiographic changes take a comparable length of time. Radiographs are obtained in view of the clinical picture. For example, closed treatment of a distal radius fracture would not be expected to show changes because of healing for a minimum of 2 weeks. However, displacement of the fracture could occur sooner. Hence, radiographs to show displacement might be obtained at 1 week and 2 weeks. If no displacement is observed, the fracture position could be considered stable, and the next films might be obtained at 6 weeks—the earliest time healing might be observed. Similarly, closed treatment of an adult tibia fracture might be followed with radiographs at 2-week intervals, checking for displacement and healing, whereas a tibia fracture treated with an intramedullary rod might be followed at monthly intervals to check for healing.
Magnetic Resonance Imaging
This imaging modality is very useful, but like electron beam computed tomography (CT), MRI is sometimes too revealing. This method should be reserved for clarifying a particular problem. Frequently in orthopedics, a bony lesion can be localized with a radiograph or bone scan, which then provides a focus for the MRI. MRI is useful for some bony lesions, such as osteonecrosis, tumors, fatigue fractures, and osteomyelitis. It is also helpful in some soft-tissue problems, such as knee meniscus tears and shoulder rotator cuff tears. Distortion of the magnetic field by metallic implants may limit the usefulness of MRI studies of conditions such as total knee or hip replacement, or fracture fixation devices. MRI should not be used when the diagnosis can be made with a less expensive test. For example, the use of the MRI in knee studies in patients older than 45 years should always be preceded by plain films of the knee, as noted earlier. An MRI of an arthritic knee adds little additional information because the meniscus and anterior cruciate ligament are likely to be damaged from the arthritic process already. However, the MRI can be very helpful in determining soft-tissue extension of tumors or infection.
The advent of new portable MRI units that perform limited studies with more resolution adds a new dimension to their use. These can provide data on the progression of disorders such as rheumatoid arthritis or osteomyelitis in a timely and cost-effective way. The possibility of osteomyelitis in the bones adjacent to ulcers on the foot is easily determined with this test because it shows the changes, typically edema, in the bone with osteomyelitis. A bone scan usually does not have the resolution to distinguish the inflammatory response in the soft tissue from the bony involvement. Osteomyelitis should be treated much differently from a soft-tissue ulcer, which does not affect the bone.
The CT scan is an extremely important imaging modality for examining bony lesions such as fractures. Frequently, plain films provide some information about the fracture of interest, but the CT scan provides the three-dimensional information that can only otherwise be determined from the integration of the plain films in the surgeon's mind. The CT scan adds significantly to the management of such fractures as tibial plateaus, scapular fractures, ankle fractures, and cervical and lumbar spine fractures, as well as many others. Furthermore, nonunions of fractures, with or without fixation, can be identified and followed with CT scans. Again, if little information can be gained that cannot be already discerned from the plain films, the CT scan only adds expense and patient inconvenience. The spiral CT makes imaging with this modality less expensive and much more rapid. The CT scan is also now the method of choice for determining whether a pulmonary embolus (PE) has occurred. Again, a CT for this indication is easier on the patient, more accurate, and less invasive than angiography.
The bone scan finds many uses in orthopedic surgery. Keep in mind that the bone scan labels the osteoblast activity with the radioactive tracer, technetium-99; thus, bone formation activity is recorded, and little or no bone resorption activity is noted. Any disorder that results in increased bone formation, therefore, results in a “hot” bone scan. This means that a disorder such as multiple myeloma may not show up on a bone scan because only osteoclastic activity is involved in the majority of lesions. This test is helpful in discerning loose total hip and total knee prostheses, however, even though the findings are nonspecific. It is very helpful in examining probable benign bone lesions because a cold bone scan largely rules out an aggressive process such as a malignancy. The bone scan is also helpful in diagnosing any disorder of unknown origin when there is pain localized to a particular region. A cold bone scan implies that the problem is a soft-tissue one, whereas a hot bone scan points to a region that may benefit from MRI.
The two most important laboratory exams are for C-reactive protein and the erythrocyte sedimentation rate. These two tests indicate whether an inflammatory process, malignancy, or rheumatologic disorder is a diagnostic consideration. If these tests are negative, systemic causes of a complaint can frequently be ruled out. In that situation, a more localized disorder should be identified. The next most important test is the complete blood count, which provides the general indication of the patient's health, revealing information about anemia, infectious processes, and so on. The next most useful laboratory test for the orthopedic surgeon is the synovial fluid analysis. This test typically should include a culture and sensitivity. If there is any concern about infection, a cell count, differential, protein, and glucose measurement should be performed. Crystals should be looked for because they indicate chondrocalcinosis or gout. Elevated protein and reduced glucose levels suggest infection. The final factor that should be considered with any major surgery is the patient's nutritional status, which is evaluated with several tests, including lymphocyte count and levels of prealbumin, albumin, zinc, and serum iron transferrin. In addition, the Mini Nutritional Assessment is a nursing tool to screen elderly individuals at risk of malnutrition.
Educating and Informing Patients and Their Families
Surgical procedures in orthopedics have varying degrees of difficulty and importance, ranging from a relatively simple claw toe correction to the performance of a multilevel complex spinal fusion. After the decision to employ surgery as a therapeutic modality is made, it is important to help the patient completely understand what to expect before, during, and after surgery. This process, which the legal profession calls informed consent, has the more important purpose of ensuring the patient's cooperation and satisfaction.
To comply with the requirements of the legal profession and accrediting organizations, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the surgeon must provide an explanation of the risks, prognosis, alternatives, and complications that might be encountered. The risks should be reviewed in some detail for the general risks encountered in typical orthopedic surgical procedures. The risks and the complications that occur in surgery are intimately associated and thus must be dealt with together. The alternatives are sometimes straightforward. For example, a patient with an open fracture has a high risk of infection if not adequately treated with irrigation, debridement, and antibiotics. Thus, in such a situation, any reasonable and prudent person would consent to the procedure. The choice between alternatives can become significantly more subtle, however. For example, it is possible that a choice must be made between two different procedures or between a particular procedure and no procedure. In this situation, the surgeon must consider the psychosocial and physical attributes of the patient so as to assist him or her in making this decision. For example, consider men, both 75 years of age, with severe degenerative disease in the right knee noted on radiograph. One individual is now at the point where he cannot play golf, a situation that is reducing his physical exercise and a number of his social outlets. The other individual leads a relatively sedentary lifestyle, seldom walks more than a block, and obtains cardiorespiratory exercise by swimming, an activity in which his knee does not bother him. The surgeon should recommend knee replacement to one individual but not the other. At the same time, both men must be offered the alternatives, which include continued nonsteroidal anti-inflammatory medicine, bracing, sleeping medication, and analgesics.
Patients with an active lifestyle are becoming much more concerned about what will happen to them in the postoperative period, including how soon they can safely travel, when they can work, and when they will be fully able to take care of themselves. They are also concerned about what social services are available to help them if they cannot care for themselves fully. The surgeon must be prepared to address these questions and also advise patients with lower extremity or spinal problems about when they will be able to walk. In the same manner, after procedures on the hand or upper extremity, patients must be advised about when they will be able to use the hand. Advising the patient of these situations before surgery can prevent unexpected surprises in the postoperative period.
The patient should also be informed about the range of expectations for ambulation or use of the upper extremity because individuals vary in their response to surgery. For example, patients should be advised that after surgery on the hip or knee, they will need a walker for a few days, move to crutches, and typically be done with the crutches in the range of 2–4 weeks. They will use a cane before 6 weeks and be done with the cane before 3 months. Patients' response to surgery is somewhat unpredictable, so conservative estimates on the length of medication use, pain, restricted driving, and so on are prudent. Patients should be cautioned about travel after surgery, particularly with lower extremity injuries, because of the risk of deep venous thrombosis (DVT). In such cases, discourage (for the first 6–12 weeks) plane trips longer than an hour and extended car trips made without stopping perhaps every 45 minutes. Anti-inflammatory medication (to reduce platelet adhesion) or anticoagulants should be recommended if such travel is unavoidable.
Explaining the Procedures
An essential part of the patient's presurgical preparation and postsurgical cooperation is knowing what to expect at every step in the process. Nuances become important in the process of explaining the surgical procedures and their implications. For example, scheduling a bunion procedure 2 weeks prior to a patient's participation in her daughter's wedding could upset the patient if she fails to realize that she will be unable to wear the shoes she purchased for the event. Similarly, lifestyle considerations can affect the decision-making process in cases of medial gonarthrosis, in which the choice between a unicompartmental knee replacement and a high tibial osteotomy could be influenced by whether the patient plays tennis and holds a physically strenuous job or, alternatively, whether the patient is sedentary and works behind a desk most of the day.
Reviewing the Risks and Possible Complications
Reviewing the perioperative risks is important for all patients and optimally should be done well in advance and then repeated closer to the time of surgery. Some patients require more detailed explanations, particularly if their relatives have undergone surgery in the past and had a problem with anesthesia or a complication such as a PE or infection. Based on the patient's responses to explanations, the health care team members need to alter their approach to reach a balance between inadequately informing the patient and inducing unnecessary alarm that could make the patient refuse to undergo a procedure judged to be both beneficial and necessary.
Risk is a poorly understood concept in our culture. Some situations are considered to be higher in risk than they actually are. Some risks are understood better than others. It can help the patient to understand if these risks are put in perspective. The risks can be surprisingly high or low but still disturbing to the patient. For example, many people have moved away from California to avoid an earthquake or refuse to fly commercial aircraft because of the risk, not realizing that the risk of death is 10–100 times higher while driving a car (Table 1–1). This lack of understanding of the risk can contribute to significant differences in the perception of liability associated with these activities. For example, the death benefit from a commercial airline accident might reach several million dollars per passenger, whereas death in an automobile accident might have no death benefit at all. Thus, the perception of risk is very important and must be clarified in the patient's mind. Similarly, patients can understand and accept having a myocardial infarction after a major surgery because they can clearly see the strain on the heart from the surgery. However, they are not nearly as understanding of a lower extremity paralysis that can result from the epidural anesthetic for that surgery. The explanation of risks must be individualized for each patient. The patient with a previous myocardial infarction is clearly different from the healthy 20-year-old (see Table 1–1). Across-the-board rates of problems do not translate into direct risks for the individual patient.
Table 1–1. Rates of Death and Complications Associated with Common Activities. ||Download (.pdf)
Table 1–1. Rates of Death and Complications Associated with Common Activities.
Death or Complication
Death (from MI after previous MI)
Major bleed (7 days, warfarin, INR 2.65)
GI ulcer/bleed perforation (naproxen 6 months)
Paralysis (from epidural)
Death (frequent flying professor/year)
Earthquake in California/per year
Although all procedures carry some risks, the incidence and type of risks and complications vary with the surgical procedure as well as with the patient's age and general health. Potential problems are listed and discussed here in alphabetical order.
The potential problem of amputation is seldom of acute concern except in cases of significant trauma. The topic of amputation can frequently be discussed with the risk of infection because ischemia and infection can increase the risk of amputation.
One of the major risks in orthopedic surgery is associated with anesthesia, not because complications of anesthesia are frequent but because they can be devastating. Death occurs at a rate of approximately 1 in 200,000 patients undergoing elective anesthesia. Other complications include, but are not limited to, the following: nerve damage and paraplegia from nerve blocks, headaches from dural leaks following use of spinal anesthetics, aspiration of stomach contents, and cardiac problems, including ischemia and arrhythmias. The surgeon should discuss these problems with the patient only in general terms, allowing the anesthesiologist to provide the most detailed explanations.
Virtually any procedure that enters a joint, other than to replace it, has the potential to cause damage to that joint. In some instances, as in an intraarticular fracture, the surgery will likely lessen the risk of arthritis. Even in these instances, the patient should be told that the risk of damage is still real because the joint surface healing will not result in a normal cartilage surface.
Patients should be given a reasonably accurate estimate of blood loss as well as the opportunity to donate autologous blood prior to surgery. Designated donor blood is probably not safer but gives the patient who receives it a sense of security. The use of erythropoietin can elevate preoperative hemoglobin (Hgb) levels in selected cases and thereby reduce postoperative homologous blood transfusion needs. Other alternatives include the use of intraoperative blood salvage for reinfusion (OrthoPAT, Sure-Trans, Constavac). The use of erythropoietin is generally accepted by Jehovah's Witness patients, whereas the autologous reinfusion acceptance is variable. To help minimize blood loss during surgery, the patient's use of nonsteroidal anti-inflammatory drugs (NSAIDs) should be discontinued approximately 2 weeks before surgery. Discontinuation of NSAIDs can significantly compromise comfort and incite rheumatoid flares in many patients who rely on these drugs. To minimize the risk, newer cyclooxygenase-2 (COX-2) inhibitor NSAIDs may be used as a substitute during this period; no platelet disorder or bleeding time derangement occurs with these drugs because they do not affect platelet function or inhibit thromboxane A2.
Arterial and venous damage take on greater significance as the size of the vessel increases and the arterial supply becomes more calcified with age and vascular disease. Patients generally understand this, but it must be emphasized where appropriate. Hip and knee replacement puts unusual strains on the femoral and popliteal vessels, from positioning, and may damage calcified arteries.
Deep Venous Thrombosis/Pulmonary Embolism
Virtually all lower extremity and spine procedures in orthopedics involve some risk of DVT, which should be explained to the patient. As many as 40–60% of patients who undergo a relatively high-risk procedure such as total hip arthroplasty develop DVT if not receiving thromboprophylaxis. The risk of PE is much less, however, and is in the range of 0.3% for fatal emboli. This rate of fatal PE is approximately a 10-fold increase over the rate of fatal PE in the U.S. population in men older than 65 years. The risks associated with other procedures may be lower. In any case, the patient should be reassured that prevention procedures commensurate with risk will be undertaken.
Many procedures in orthopedic surgery carry the risk of a bone fracture. Some procedures, such as uncemented hip replacement, present a higher risk for this complication, but virtually any orthopedic procedure could result in fracture of a bone. The patient must be informed of the risk in relation to the probability of the occurrence of such a problem.
The risk of infection in orthopedic surgery ranges from near zero in procedures such as arthroscopy to several percent in open fracture surgery. The problem of infection should be emphasized in proportion to risk. For example, if a diabetic patient is to undergo knee replacement, he or she should not only be assured that all steps will be taken to prevent infection (eg, administration of prophylactic antibiotics, use of ultrafiltration of air, or ultraviolet lights in the operating room) but should also be told of the various techniques that would be considered if infection occurred. These options include debridement, prosthesis removal, gastrocnemius flap, reinsertion, arthrodesis, and amputation. The common use of external fixation devices for fracture care is accompanied by the frequent problems associated with pin care. The patient and family should be informed about the problems caused by percutaneous devices to prevent the presumption that something has gone wrong. Skin problems are frequently associated with infection but may arise from other causes, such as adjacent scars compromising the blood supply to a surgical flap. Older patients and individuals who are smokers, have diabetes and/or obesity, or have wounds on the distal lower extremity are at increased risk. In such cases, the patient may be warned that delayed healing or necrosis of the skin edges may occur.
Although fracture care continues to improve, displacement of hardware or fracture fragments may necessitate a second procedure. The explanation of this risk should be individualized, based on the type of fracture. Loss of reduction may contribute to delayed union or nonunion of fractures. These problems may occur despite optimal care by the orthopedic surgeon. Poor vascular supply or smoking can be a factor leading to nonunion. The rate of nonunion is site dependent but is only a few percent.
Certain procedures are associated with nerve damage, although the damage is usually minor. For example, medial parapatellar incisions on the knee cause some numbness from cutting the infrapatellar branch of the saphenous nerve. The patient should be informed in advance if some degree of minor nerve damage is anticipated in association with the particular surgical procedure being pursued and should also be informed of the risks of unexpected nerve damage that accompany all surgical procedures.
The patient's prognosis is intimately related to the procedure. However, certain guidelines may be given. The expected time off work or time away from activities is important to the patient and depends on the patient's occupation, age, and available sick leave. The bank president with more control over her agenda will be able to return to work activities sooner than the day laborer. Driving is an important activity for many people, and limitations placed by a procedure can determine how much postoperative assistance a patient will need.
The patient should be given reasonable expectations about range of motion, strength, possible disability, and when these should return to normal, if at all. Furthermore, walking or writing ability, ability to use a computer keyboard, and the time to expect to be able to do such activities may be appropriate for some patients. Again, these have to be individualized for each patient and determined for each home situation.
Keeping the Patient and Family Informed
Immediately before elective surgery, the surgeon can help comfort the patient and family by meeting them in the preoperative area and appearing relaxed, well rested, and positive about the outcome of the surgery. Giving the family a good estimate of the surgery time is important, but they should also be reassured that delays do not necessarily indicate the occurrence of complications that are detrimental to the patient. If the family members wish to be notified about delays, they should be encouraged to leave instructions about where they can be contacted. When surgery is completed and the patient is no longer at risk of untoward accidents such as aspiration during extubation, a member of the surgical team should apprise the family of the outcome. At this time, it is appropriate to emphasize particular concerns to the family, such as the need to continue vigilance for infection in a diabetic patient who has undergone foot surgery.
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