Hippocrates and ancient civilizations established foundational principles of orthopedics such as traction and fracture reduction. Over centuries, notable physicians like Galen and scholars contributed to orthopedic knowledge. Modern orthopedics emerged in the 20th century with advances like x-rays, antibiotics, and joint replacements. Today, orthopedics addresses musculoskeletal trauma, diseases, tumors, and congenital disorders through various subspecialties. A thorough history and clinical exam are essential for orthopedic evaluation and management.

1. Introduction to Orthopedic
I. History of Orthopedic
II. History Taking and Examination
Dr Jay Raj Sharma
MBBS, MS-Ortho

4. History Of Orthopedic
The term ORTHOPAEDICS was coined in 1741 by
NicholasAndré
The term orthopedia is a composite of 2 Greek words:
Orthos- “straight and
Paidios- “child.”
Orthopaedics literally means STRAIGHT CHILD

5. Symbol Of Orthopaedic Surgery
A crooked young tree attached to a
straight and strong stake,
The universal symbol of orthopaedic
surgery

6. HIPPOCRATES (460 BCE-370 BCE)
•The Father Of Medicine
• Described various reduction maneuvers
• Principles of traction and counter-traction,
• Correction of clubfoot deformity,
•Treatment of infected open fractures
•The Hippocratic method for shoulder reduction - is still used
for reducing anterior shoulder dislocations

9. LATER CIVILIZATIONS
• Splints were developed with
fresh rawhide that had been soaked in water.
splints made of clay,
• Furthermore, bone-setting or reductions was
practiced as a profession in many tribes.

11. GALEN (131AD - 201AD)
He served as a gladiatorial surgeon in Rome.
He is considered to be the Father of Sports Medicine
He described the Musculoskeletal And Nervous Systems.
He is also credited with coining the terms
SCOLIOSIS
KYPHOSIS
LORDOSIS

12. Until the 16th century
The majority of medical theories were heavily
influenced by the work of Hippocrates.
•The scientific study of anatomy gained
prominence especially due to the work done
by great artists, such as Leonardo DiVinci.

13. Scholar and surgeons provided a strong foundation for the
field of modern orthopedics.
• Additional discoveries by –
Joseph Lister,
Louis Pasteur,
Robert Koch etc.
Antisepsis appeared to revolutionize the surgical
management of orthopedic injuries.

14. THE MODERN ERA (20th CENTURY)
• Rapid development of Orthopedic surgery.
Better infection control
Introduction novel technology: Invention of x-ray in 1895 by
Wilhelm Conrad Röntgen
• Spinal surgery also developed rapidly with Russell Hibbs.

15. • In 1942, Austin Moore
performed the first metal hip
arthroplasty
Sir John Charnley in the 1960s introduced total hip replacement

16. HUGH OWEN THOMAS
He is considered the Father Of Orthopaedic
Surgery In Britain. -a pioneer of modern orthopedic
surgery.
• 'Thomas Splint‘ -to stabilize a fractured femur
and prevent infection
• 'Thomas's collar' -to treat tuberculosis of the
cervical spine.
• Thomas's wrench' for reducing fractures, as
well as an osteoclast to break and reset bones.

17. 'Thomas's manoeuvre‘: an orthopedic investigation for fracture
of the hip joint
Thomas test: a method of detecting hip deformity (FFD)

18. Orthopedic in Ancient South
Asia

19. SUSRUTHA SAMHITA – Chikitsa Sthana
In traditional Ayurveda practice, the fracture of bones and
their treatment was first mentioned in SUSRUTHA
SAMHITA – Chikitsa Sthana .
Management of fractures is the Kushabandha (wooden
splint)
In same way, the chakrayoga that is explained in Astanga
Hrudaya is in vogue in the form of the traction method.

21. 6 types of dislocations,
▪ Utpista – Fracture dislocation
▪ Vislista – Dislocations of joints due to ligamental tears
▪ Vivartita – Anterior-posterior dislocation of the head of the
humerus
▪ Avakshipta – Downward displacement of the head of the
humerus
▪ Atikshipta – Marked displacement of any articulation surface
▪ Tiryakshipta – Oblique dislocation in one of the articulating
bones

22. 12 types of fractures.
Karkataka – Depressed fracture.
Aswakarana – Complete oblique
fracture.
Churnitam – Comminuted fracture
Pichhitam – Fracture by compression.
Asthichallita – Sub periosteal
avulsion.
Kandabhagna– Complete spiral
fracture.
Majjanugatam– Impacted fracture.
Atipatitam – Complete compound
fracture.
Vakra – Green stick fracture.
Chinnam – Incomplete fracture.
Patitam – Comminuted fracture flat
bones.
Sputita – Fissured fracture.

23. ASTHIPOORANA (Bone Grafting)
The paste prepared from the combination of Sudhavarga dravya,
decoction of Rubia cordifolia, and latex of the banyan tree was used
as a graft material.
CHAKRAYOGA (SkeletalTraction)
In long bone fractures, the fractures of the shaft, hairline fractures,
oblique fractures, and in compound open fractures, there is the
reference of using of Chakrayoga

24. KAPTASHAYANA (Fracture Bed) VIDHI
This method of immobilization is used in the fracture or dislocation of
the thigh, hips, ankle, shoulder, spine, spinal column, bones of
thorax, and axillary regions

25. The musculoskeletal system

26. Muscles
Skeletal Muscle
Smooth Muscle /Visceral Muscle
Cardiac Muscle
Bony structures and connective tissue
1-The Skeleton
2-Supportive connective tissues
3-Articular system(Joints)
Supporting framework of body

27. Function
The function of muscles
• Movement of body parts: by isotonic & isometric
contractions
• Maintenance of posture
• Production of body heat
Function of Skeletal system:
• Movement
• Support: protects the internal body organs
• Production of blood cells: RBCs’ andWBCs’
• Storehouse for minerals like calcium

28. What is Orthopaedics ?
It is the branch of surgery concerned with conditions involving
– MusculoskeletalTrauma
– Sports Injuries,
– Spine Diseases
– Degenerative Diseases,
– Infections,
– Tumors And
– Congenital Disorders And Deformities.

29. 1. Hand and Upper Extremity (HAND SURGERY )
2. Shoulder and Elbow
3. Total Joint Reconstruction (ARTHROPLASTY)
4. Arthroscopy
5. Pediatric Orthopedics
6. Foot and ankle surgery (PODIATRIC
MEDICINE )
7. Spine surgery
8. Musculoskeletal oncology
9. Surgical Sports Medicine
10. OrthopedicTrauma
Orthopaedics:
sub-specialty

30. Common Problem Related
to Orthopedic

31. Information seen on Musculoskeletal System

32. Information seen on Musculoskeletal System contd..

33. Musculoskeletal conditions include
conditions that affect
▪ Joints:
osteoarthritis, rheumatoid arthritis, psoriatic arthritis,
gout, ankylosing spondylitis;
▪ Bones:
osteoporosis, osteopenia and associated fragility
fractures, traumatic fractures
▪ Muscles:
such as sarcopenia, Muscular dystrophy

34. Musculoskeletal conditions include
conditions that affect contd..
▪ The spine:
back and neck pain
▪ Supportive Connective tissue:
Tendinitis andTendinopathies, Ligament sprain, tear, Meniscus
tear, Rotator cuff injuries etc
▪ Multiple body areas or systems:
Inflammatory diseases such as connective tissue diseases
and vasculitis that have musculoskeletal manifestations like SLE

35. Common Problem Related to
Musculoskeletal System
▪ Pain
▪ Swelling
▪ Stiffness
▪ Wasting
▪ Deformity
▪ Loss of motion or limitation of motion
▪ Weakness
▪ Sensory deficit

36. Pain
MSK pain can affect Bones, muscles, ligaments, tendons, and nerves.
Bone Pain: deep, penetrating or dull
• Most commonly results from injury.
• Non traumatic bone pain- Bone tumors
Muscle Pain:
• Injury
• An autoimmune reaction,
• Ischemia
• Infection- Muscular abscess
• or a tumor.
• The pain can also include muscle spasms and cramps.

37. Pain
Tendon and Ligament pain:
• Mostly trauma-Strains and sprains,
• Tendinopathies-Tennis Elbow
Joint pain
• Very common- arthritis- OA, RA
• Trauma
Spine
▪ Mechanical pain, PIVDs, Injuries,Tumors
Nerves:
• Nerve Compression- Like CarpelTunnel Syndrome

39. Swelling
▪ Soft tissue Swelling: Ganglion cyst, Muscle tumors, Nerve
tumors, Hematoma- injuries, Myositis, Muscular Abscess-
Cold Abscess etc
▪ Bony swelling:Tumors, Callus, Osteomyelitis
▪ Joint swelling:Trauma- hemarthrosis, Arthritis,Tumors
▪ Spine: Gibbous-TB, Inflammation- sacroilitis,
▪ Nerves:Tumors- schwannoma,

41. Joint Stiffness
Arthritis-RA, OA
Adhesive capsulits
Malunion of fracture
Bursitis
Deformity
Gunstock deformity- CubitusVarus
deformity
GenuValgus
Club foot
Kyphosis
Scoliosis

42. Muscle Wasting
▪ Age- Degenerative diseases, Arthritis
▪ Neurological disease- Polio, Cerebral palsy,
Guillain-Barre syndrome,
▪ Malnutrition: PEM
▪ Bed Ridden Patient- Long hospital stay,
Immobilization

43. Musculoskeletal weakness
▪ Neuromuscular Disorders like Muscular dystrophies
▪ Autoimmune disease like: Myasthenia Gravies, GBS
▪ Thyroid disorders
▪ CVD
▪ PIVDs
▪ Peripheral nerve damage

44. Sensory Deficit
Cerebro-Vasucular Disease
Peripheral nerve damage in fracture and dislocation- Axillary
nerve damage in proximal humerus fracture, Shoulder
dislocation
Compression injuries- compartment syndrome, PIVDs, CTS

45. Loss of motion
▪ Any injuries involving joints
▪ Generalized weakness
▪ Swelling around joints
▪ Contractures
▪ Neurological deficit
▪ Joints infections

46. History taking

47. ▪ History taking and clinical examination in an art
▪ learn correctly to make proper diagnosis and management.
▪ learned over a period of time and by repeated practice.
▪ Looking at the patient as he/she walks into the room gives an
overall picture about the musculoskeletal condition of patient.

48. 1. Consent, Rapport and Other Important
Aspects
▪ Clinician must obtain consent : Patient has the right to
refuse examination
▪ Clean your hands before and after examining each patient
▪ Establish a good rapport: some orthopedic test are painful
too
▪ Be careful on opposite gender patient, female attainder
should be available if male clinician examines female
patient

49. ▪ The doctor must have lot of patience.
▪ Always explain to the patient what you are going to do.
▪ Patient must be examined gently without eliciting pain.
▪ Patient must be examined gently without eliciting pain.
▪ The questions should be worded in simple language and patient-
understanding of the questions.

50. HISTORY TAKING
Present Complaint / Chief Complaint
– Ask the patient what is his main problem.
– The duration of each complaint: charted in chronological
order.
History of Present Complaint / HOPI
– Record he progression of the symptoms, severity and
associated symptoms

51. Previous History / Past hx
Past, illness like diabetes, hypertension, Rheumatism, asthma, allergy,
tuberculosis, chest and heart problems, and dyspepsia or peptic ulcer
disease.
e.g.- fracture healing is retarded in diabetic patients.
Treatment History:
All the treatments the patient had
– medicines like non-steroidal anti-inflammatory drugs, steroids
– Physiotherapy
– Plasters
– Orthosis
– intra-articular steroid injections

52. Family History:
▪ family health,
▪ occurrence of any familial or hereditary diseases
Social and Occupational History:
▪ Exact nature of occupation—sedentary or heavy manual work
▪ the hobbies
▪ History of consanguineous marriage
presence of congenital anomalies in their offspring.

53. Personal History:
– Alcohol consumption,
– smoking habits,
– Dietary habits.
– Cigarette smoking- delayed wound healing, delayed fracture healing

54. H/O Pain and Swelling
Pain is what the patient feels
Tenderness is what the doctor elicits.
▪ Site of pain—localized or diffuse:
maximum point of pain and also the extent of pain
▪ Time and mode of onset:
– what triggered the pain at the time of onset.
– what patient was doing at that time.
– might have begun suddenly or insidiously.

56. Pain
Severity of pain:
– patient’s own words as mild, moderate and severe
– Does the pain wake-up or keep the patient awake at night
Nature of pain:
– aching, stabbing, burning, throbbing, constricting or gripping pain, or
pricking pain.
Progression of pain:
– Has the pain gone worse, remained same or decreased in time

57. Pain
Radiation:
– Find out the direction and exact site of radiation from the site of origin
Aggravating and relieving factors:
– what happens to the pain on joint movements, on walking, standing, body
posture and exercises.
– Is this pain related to any food intake (e.g. gout)
– The relief of pain with analgesics, fomentation and other means should be
noted

58. SWELLING
First notice:
▪ When did the patient noticed?
(it may not be the time when it first appeared).
▪ Might have noticed
– due to pain
– at the time of bath,
– or someone might have pointed it out

59. Swelling
Symptoms associated with lump:
Pain
Pressure symptoms—neurological, vascular or affecting
movements of adjacent joints.
–Progression of the lump: Getting bigger or smaller,
–or disappearing and reappearing

60. Other Complain..
▪ Stiffness
▪ Wasting
▪ Deformity
▪ Loss of motion or limitation of motion
▪ Weakness
▪ Sensory deficit

61. Examination in Musculoskeletal
System

62. EXAMINATION
Gait Analysis: See how the patient walk to you
General Examination
– Analyzes the patient as a whole.
– General build
– Mental state
– Presence of anemia, jaundice, cyanosis, clubbing, skin and nail changes
(pitting in Psoriasis), pedal edema etc
– Fever
– Multiple bone or joint deformities

63. LOCAL EXAMINATION
Examining the area of symptomatology and examination of
appropriate system.
Systematic approach:
– Inspection (Look)
– Palpation (Feel)
– Movements (Move)—Active and passive movements.
– Neurovascular status

64. LOOK ( Inspection)
Part to be inspected and the contra-lateral part should be exposed.
Swelling
Scars
Symmetry
Skin changes – rashes, discoloration, abrasion, bruises,
ecchymosis,
Shape- deformity
Shortening

65. FEEL ( Palpation)
▪ Affected part should be gently palpated
▪ Temperature (Warm joint in infection, cold skin in vascular
impairment)
▪ Swelling is palpable
▪ Tenderness

66. MOVE (MOVEMENT)
Active and passive movements.
Joint range of movements are measured with goniometer.
Stiffness – arthritis
Crepitus- arthritis
Fixed deformity- Contracture of muscle, tendon or joint
capsule

67. Joint examination
▪ Examine the affected joint,
▪ Contra lateral joint
▪ Joint below and above

68. Inspection of joint
▪ Swellings
▪ Skin changes
color - redness –
inflammation or infection
scars, previous surgery
rashes
▪ Adjacent structures
muscles - wasting of muscles above and
below a joint often accompanies joint
disease
compare to opposite side
•Deformity
misalignment of bones making up the joint
valgus - distal part displaced laterally
Varus - distal part displaced medially

69. Palpation of joint
Feel for any swelling and its nature
Hard : bone
Spongy or boggy: synovial thickening
Fluctuance : an effusion (fluid)
Position - joint or periarticular (e.g. bursa, joint line)
Tenderness
Assess joint margin, related ligaments, tendons and
adjacent bony structures

70. Palpation of joint
Temperature :
compare with opposite side if bilateral joint involvement
compare tissues above and below the joint
Joint crepitus
A palpable grating sensation appreciated by a hand
placed on the joint during movement
Tendon crepitus
A dry, friction rub palpable when tendons move

71. Joint Movement
Range of Movement
Active: By self
Passive: By examiner
If active ROM is demonstrated- no need of passive
movement.

75. • Abduction: movement of a part away from the body
• Adduction: movement of a part towards the body
• Eversion: turning the foot outward
• Inversion: turning the foot inward
• Extension: straightening a joint
• Flexion: bending a joint
• External rotation: outward rotation e.g., patella facing outward
• Internal rotation: inward rotation e.g., patella facing inward
• Pronation: twisting inward e.g., palm facing down
• Supination: twisting outward e.g., palm facing up

76. Neuro Vascular examination
Assessment of Muscle power and sensation of skin in the
extremity
Assessment of pulse (Vascularity): Peripheral Pulse and
Capillary Refilling time

77. Muscle strength: impaired by pain, denervation, wasting from disuse or systemic
diseases
Grade 0: No movement or flickering of
contraction
Grade 1: Movement with gravity eliminated
or side to side movement
Grade 2: Movement against gravity
Grade 3: Movement against resistance
Grade 4: Normal power or ROM

78. S0: Absent sensation of affected nerve
S1: Sensation on deep Cutaneous pain
S2: Sensation on superficialCutaneous pain
S3:Two point discrimination
S4: Normal sensation

79. Special test and examination

80. Special test and Diagnostic
Every joint or anatomical area has some unique clinical
tests for diagnosis of different pathologies.
Special tests may required to assess the integrity of specific
structure.
e.g. STRESS test:Valgus stress test: MCL
Varus Stress test: LCL

82. Special Test
Anterior DrawerTest: ACL
Posterior Drawer test: PCL

84. Patellar Tap test
Effusion around knee joint: Positive Patellar tap test.
The supra patellar pouch is compressed with one hand to
squeeze any fluid from the supra patellar pouch into the
joint.
With the other hand the patella is then tapped sharply
backwards onto the femoral condyles.
If the patella can be felt striking the femur and bouncing
back again, test is considered to be positive.

85. Special Sign Signs
Loss of ability to flex the distal phalanx of the index finger is distinctive.
This is demonstrated as the “Pointing Index sign”

86. Diagnostic test in Orthopedic
Laboratory Examination
– Total blood count and Differential Count
– ESR (Erythrocyte Sedimentation Rate)
– C-reactive Protein (CRP)
– Serum Calcium Level
– Serum Uric Acid level
– Rheumatoid Factor (RA factor)
– ASO titer
– HLA B27

87. Diagnostic test in Musculoskeletal
system
Radiology
–X-Ray
–CT Scan (ComputerizedTopography Scan)
–MRI (Magnetic Resonance Imaging)
–Angiogram, Arteriogram
–Isotopes scanning

88. ANATOMICAL POSITIONS AND DIRECTIONS
PLANES
• Coronal:
side-to-side, dividing into anterior and posterior
portions
• Horizontal:
transverse, dividing into superior and inferior
portions
• Sagittal: antero-posterior, dividing into left and
right portions

89. Thank you