The Orthopedic Examination
By Liliana Mutascio, DVM, Practice limited to Surgery
Pay Attention to the History
Always ask your clients about the history of their pet’s orthopedic problem; it is important to consider the duration and any improvement or progression of lameness. Remember to ask if there is a history of trauma (owners may forget to mention this) and if any treatments, such as medications or activity restriction, have been tried before and what the results were.
Perform the Exam from Multiple Vantage Points
You can gain a lot of information simply from observing your patient as you talk to your clients about the history. How is the dog (or cat) moving around the room? Does the patient have difficulty rising, is the patient off-loading a particular limb when standing, or do they have the characteristic “sloppy sit” of a cruciate injury dog? These findings can help you localize the problem right from the start.
Before you do a recumbent exam on your patient, make sure to watch them walk down the hallway and back. Look for signs like a head bob to indicate a forelimb lameness, or a hip hike to indicate a hind limb lameness. If there is a subtle lameness, or the patient is excitable, it may help to perform the gait evaluation on flooring that has grip. Next, make sure to perform a standing examination. Palpate each limb and joint for swelling, pain, joint effusion, and muscle atrophy or asymmetry between sides. Some joints, such as the elbow or tarsus, are much easier to detect effusion in when the animal is weight-bearing. I like to also check conscious proprioception and palpate the neck and spine for pain during the standing exam, to ensure there is no neurologic component to an abnormal gait.
Finally, position the patient in lateral recumbency and systematically palpate all the bones and joints of each limb. You should flex, extend, and check for medial and lateral instability in each joint. Note any crepitus, instability, pain, or swelling over all long bones (including metacarpals, metatarsals, and phalanges). Check the stifles for drawer and patellar luxation. Check the hips for Ortolani (but don’t completely rule it out without a sedated exam, as the muscle tone is often enough to overcome any hip laxity). In general, I try to leave palpation of the affected limb for last to avoid getting tunnel vision and missing another (or the real) problem. This also avoids exaggerating any patient discomfort until the very end of the exam.
Things to Remember
If your patient will not tolerate the exam without sedation, don’t hesitate to discuss sedation with the client. Always keep the safety of the pet, yourself, and your staff in mind with uncooperative pets. It is generally easier to localize pain in an un-sedated patient, but you can still localize a problem in most cases – and it may actually be easier to localize, such as with cranial drawer – under sedation.
Remember to rule out neurologic disease. Ataxia and weakness are not usually associated with orthopedic issues. However, some orthopedic problems can present very similarly to neurologic problems, such as the “down” dog that actually has bilateral cranial cruciate ligament tears and completely normal motor function.
Confirm your orthopedic exam findings with imaging to arrive at a diagnosis. Though surgical patients may need additional radiographs taken at a specialty hospital for surgical planning, it is never unwarranted to perform your own radiographs or other diagnostics. Without your diagnosis, a recommendation for treatment cannot be made.
Finally, it helps to develop a routine. Similar to your general physical exam (which you should always do as well to detect any comorbidities that may be more pressing than orthopedic disease), if you do the orthopedic exam the same way every time, it will become second nature.
Give Me a Call!
I am always happy to answer any orthopedic questions you may have about your patients and I can take a look at radiographs too if you want to send them over. Together we can make sure all patients get the most comprehensive care!