Clinical Patterns of Orthopedic Disease

It is often said—only partly in jest—that orthopedic surgeons need to distinguish only two disease processes: fracture and degenerative arthritis. Although it is true that much of clinical orthopedic practice focuses more on the technical details of exactly what anatomy is directly involved in a given fracture or degenerative joint, as well as how best surgically to manage it, there is a broad complexity of other diagnoses that enter the purview of orthopedic diagnostic exercises, even if the incidence of each is rare. It is awareness of these other diagnoses, and the necessity to distinguish them from their more common counterparts, that drives the orthopedic surgeon's diagnostic efforts.

Although we here argue that orthopedic clinical practice involves the diagnosis of more than two disease processes, we can settle on essentially two symptoms behind the presentation of any patient to the attention of an orthopedic surgeon. Mesenchymal tissues, no matter how pathologically perturbed, simply cannot on their own generate nausea, vomiting, diarrhea, urinary incontinence, palpitations, rhinorrhea, cough, photophobia, alopecia, or any of the host of other symptoms considered on the typically thorough review of systems. No, musculoskeletal diseases can cause only two symptoms: pain and deformity. When broadly defined, pain and deformity encompass the entire range of chief complaints that bring patients to see or be referred to an orthopedic surgeon.

Beyond specifically deformed or painful parts, patients often present with loss of musculoskeletal function. For the purpose of discussion, lost function will be categorized here as pain when it is driven by pain preventing some function or as deformity when that lost function is loss in range of motion of a given joint or body part. As musculoskeletal anatomy is defined by the motion it permits, changes in this motion can be considered as anatomic aberrations in and of themselves. Although some myopathies and purely motor neuropathies, such as Guillain-Barré syndrome, similarly cause loss of musculoskeletal function, people with these conditions rarely, if ever, present to orthopedic surgeons for initial diagnostic evaluation.

With these few caveats, musculoskeletal disease is readily encapsulated by the symptoms of pain and deformity. The relationships of pain and deformity with the other critical variables—time and location—can define the breadth and depth of the clinical patterns of orthopedic disease.