Assessment and Diagnostic Evaluation of the Orthopaedic Patient
The assessment chain
History → inspection → palpation → range of motion → strength → neurovascular status → imaging and labs. Mechanism of injury predicts fracture pattern and associated injuries. Pain that is constant, unrelieved by rest, and worsened by passive stretch points to compartment syndrome rather than an ordinary fracture.
Manual muscle testing (the classic trap)
Grades run 0–5: 0 no contraction; 1 trace flicker; 2 full range with gravity eliminated; 3 full range against gravity only; 4 full range against gravity with reduced resistance; 5 normal. A question describing a limb that moves but collapses under any resistance is a 3 or 4-minus, not a 5. Use the same scale and wording every time you document.
Imaging and labs
Plain radiograph is almost always first; CT defines bony detail and displacement; MRI defines soft tissue, cord, and marrow (screen for pacemakers, implants, and metal); bone scan can detect occult fracture, infection, or metastasis before radiographs change. For bone density, memorize the DXA T-score: ≥ −1.0 normal, −1.0 to −2.5 osteopenia, ≤ −2.5 osteoporosis.
Labs are pattern-based. ESR rises and falls slowly over weeks; CRP rises and falls within days, so CRP tracks acute infection better. Alkaline phosphatase is elevated in Paget disease and in healing fracture with normal calcium and phosphorus. Acute gout can present with a normal serum uric acid, so joint aspiration is the decisive test.
Rule of thumb
When a question asks "what first?" before a diagnosis is known, the answer is usually focused assessment or plain film - not an advanced scan or a lab panel.