History Taking of the shoulder and elbow with case examples for the MSc Orthopaedics at University of Salford

1. Shoulder & Elbow

2. INTRODUCTION
&
BACKGROUND

3. The History is usually the
most important step to a
correct Diagnosis
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HISTORY
EXAMINATION
INVESTIGATIONS
DIAGNOSIS
60%
90%
100%

4. • Be Systematic:
– Pain
– Function
• Loss of Movement (stiffness/weakness)
• Instability
– Swelling
– Systemic History
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5. L Funk

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Traumatic / Non-traumatic

7. The importance of understanding the mechanism
of injury can not be underestimated - it gives clues to the
personality of the fracture and the treatment required:
• When and how did the incident occur?
• What exactly happened to the limb?
• How much force was applied?
• Has the joint ever been injured before?
Trauma
Mechanism of Injury

8. Non-Trauma
Onset
• When and how did the symptoms start?
• How has it changed?
• Have you had this before?

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Introductions
1. How ya doin’? - Introduction
2. What are you doing here? - Main Complaint
3. Have you been before? – Past Medical History
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4. Anything else?

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Introduction
How ya Doin’?
Patients are People Too!!
• Shake Hands
• Introduce yourself Clearly and your Position
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11. Main Complaint
Why are you here?
1. Pain
2. Function
– Loss of movement
– Instability / Locking
3. Swelling / Lump
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12. PAIN
• Site – where exactly is the pain?
• Radiation – Does it go anywhere else?
• Nature – Can you describe the pain?
• Severity – How bad is the pain?
• Duration – How long have you had the pain?
• Frequency – How often do you get the pain?
• Aggravating factors – What makes the pain worse?
• Relieving Factors – What makes the pain better?
• Related Features – do you get any other symptoms?
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13. PAIN
• Localised
• Referred
• Radicular
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14. PAIN
• Nociceptive Pain
– Local Tissue damage
– Worse with movement
– Opiates or NSAIDs
• Neurogenic Pain
– Peripheral Nerve or Nerve Root damage
– Pain >> Tissue damage
– Often Sensory changes
– Poor response to Opiates or NSAIDs
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15. Function
• Activities of Daily Living
– ADL
• Sports / Recreation
• What can’t you do that you used to be able to do?
• Why?
– Stiffness
– Weakness
– Pain
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16. Function
1. Loss of Movement
2. Instability
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17. Loss of Movement
• Time of Loss of Movement
• Was there a dislocation?
• Are Active and Passive movements the same?
• Stiff or Loose
• Symptoms of Neurological deficit?
• Symptoms of Tendon rupture?
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18. Instability
• Does the joint ‘Give Way’?
– Has it ever given way?
• Does the joint lock?
– What does the patient mean by this?
• Does the joint click or clunk?
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19. SWELLING
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• Has there been swelling?
• How much?
• How soon / how long?
• Has it changed?
• Related Features
– Pain
– Function

20. Past Medical History
Have you been before?
• Musculoskeletal
– Previous similar symptoms
– Other joints
– Arthritides
– Rheumatic Fever
– TB
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• Systemic
– Cardiac
– Respiratory
– GIT
– GUT
– Drugs
– Alcohol
– Tobacco

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Past Medical History
Have you been before?
• Social
– Work
– Sports / Hobbies
– Driving
– Live Alone
– Stairs
– Walking Aids
– Assistance
• Family History
– Musculoskeletal
• Anaesthetic
– Previous
– Problems

22. Mnemonic
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M OI/ onset
P ain
F unction
F eeling / Sensation
W eakness
S welling
S tiffness & Stability
M ust
P ass
F ***ing
F inals
W ith
S ome
S tudying

23. 20 year old male
Dislocated his left shoulder playing rugby
Ongoing Instability …

24. 20 year old male
Dislocated his left shoulder playing rugby
Ongoing Instability …
1. Onset:
1. Exact
Mechanism
of Injury
2. Able to continue
playing?
3. Management -
relocated on
pitch/hospital
4. Ease of
relocation
2. Pain:
1. when
2. where
3. Nature of pain
4. Associated
symptoms
(clicking,
locking,
instability)
3. Function:
1. Able to play?
2. Able to train
(what
training)?
3. If not, why?
(pain,
weakness or
instability)
4. ADL
4. Instability:
1. When
2. What position(s) /
Activity
3. Disloc / Sublux /
Loose
4. Clicking / Locking
5. Associated pain?
Considerations: Labral tear; capsular tear; fracture;
rotator cuff tear; laxity; other joints

25. 58 year old Female
Insidious onset shoulder pain 2 months ago
Pain extremely severe and unable to sleep

26. 58 year old Female
Insidious onset shoulder pain 2 months ago
Pain extremely severe and unable to sleep
1. Onset:
1. Gradual /
Sudden
2. Worsening /
improving
/ no
change
3. Previous
similar?
2. Pain:
1. when
2. where
3. Nature of pain
4. Associated
symptoms
(clicking,
locking,
instability)
5. Relieving
factors
3. Function:
1. ADL
2. Sleep
3. Work
4. Recreation
Considerations: Calcific tendonitis (most likely); Frozen
Shoulder; ACJ Arthritis; Degenerative cuff tear; Tumour;
Infection; Radicular origin

27. 58 year old Female
Fell 3 months ago injuring shoulder
Normal x-rays, but still painful and
struggling with gardening & housework

28. 58 year old Female
Fell 3 months ago injuring shoulder
Normal x-rays, but still painful and struggling with gardening
& housework
Considerations: Rotator cuff tear; Greater tuberosity fracture;
Post-traumatic Frozen Shoulder
NOT Labral injury!
1. Onset:
1. Exact
Mechanis
m of Injury
2. Able to
continue
with ADL?
3. Management
at the time
2. Pain:
1. when
2. where
3. Nature of pain
4. Associated
symptoms
3. Function:
1. ADL
2. Sleep
3. Recreation
4. Work

29. 72 year old Farmer
Elbow pain for 2 years
Increasing in severity

30. 72 year old Farmer
Elbow pain for 2 years
Increasing in severity
Considerations: Arthritis (most likely); Epicondylitis;
Biceps/Triceps Tendonitis
1. Onset:
1. Gradual /
Sudden
2. Worsening /
improving /
no change
3. Previous
similar?
2. Pain:
1. when
2. where
(lateral/
medial)
3. Nature of pain
4. Associated
symptoms
(clicking,
locking,
instability)
5. Relieving
factors
3. Function:
1. ADL
2. Sleep
3. Work
4. Recreation

31. Case 5
21 year old Rugby player
Fell onto outstretched hand
Felt a clunk
Very painful medial side of elbow

32. Case 5
21 year old Rugby player
Fell onto outstretched hand
Felt a clunk
Very painful medial side of elbow
1. Onset:
1. Exact
Mechanism
of Injury
2. Able to continue
playing?
3. Management - ?
dislocated /
subluxed - ?
relocated on
pitch/hospital
4. Ease of
relocation
2. Pain:
1. when
2. where
3. Nature of pain
4. Associated
symptoms
(clicking,
locking,
instability)
3. Function:
1. Able to play?
2. Able to train
(what
training)?
3. If not, why?
(pain,
weakness or
instability)
4. ADL
4. Instability:
1. When
2. What position(s) /
Activity
3. Disloc / Sublux /
Loose
4. Clicking / Locking
5. Associated pain?
Considerations:
Traumatic instability; fractures

33. Case 6
18 year old female
Right handed
Keen tennis player
Painful & clicking right scapula
No recollection of injury

34. Case 6 18 year old female
Right handed
Keen tennis player
Painful & clicking right scapula
No recollection of injury
1. Onset:
1. Gradual /
Sudden
2. Worsening /
improving /
no change
3. Previous
similar?
2. Pain:
1. when
2. where
3. Nature of pain
4. Associated
symptoms
(clicking,
locking,
instability)
5. Relieving factors
3. Function:
1. ADL
2. Sleep
3. Work
4. Recreation
4. Other:
1. Other joints
2. Family Hx
3. Spinal
Considerations: Snapping Scapula; Scapula Dyskinesis;
Secondary to GHJ Instability; Hyperlaxity; Overhead Athlete

35. Thank You
Lennard Funk, 2015