Review: The Virtual Orthopedic Examination

The COVID-19 pandemic has forced many orthopedic surgeons to venture into virtual examinations of patients with non-urgent musculoskeletal conditions. In a review in The Journal of Bone and Joint Surgery, sports medicine orthopaedic surgeons Eric M. Berkson, MD, and Miho J. Tanaka, MD, director of the Women's Sports Medicine Program in the Department of Orthopaedics at Massachusetts General Hospital, and colleagues discuss how to make a virtual orthopedic examination efficient and successful.

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Preparation

At Mass General, schedulers obtain consent for a virtual visit, explain the visit and associated payments, and send paperwork securely for return through the electronic medical records patient portal. New patients undergo radiographic imaging based on predetermined protocols; if imaging is obtained at an outside facility, patients are asked to obtain and send copies to be reviewed at the time of the visit.

Patients receive a checklist (reproduced in the journal article) about clothing, lighting and proper positioning of their camera to ensure visibility of the affected body part. In some cases, photographs or videos demonstrating examination maneuvers are also sent to the patient before the visit.

Examination Tips

The authors give detailed guidance about how to virtually examine the knee, hip, shoulder and elbow. Some general advice is:

• Range of motion can be measured using a web-based goniometer (e.g., a browser extension called Protractor) and the angle from which the joint is viewed should be standardized for reproducibility
• Ask the patient to use one finger to point to and palpate the maximum area of pain on the joint
• To measure leg length, use a virtual ruler to make side-to-side comparisons of the distance from the anterior superior iliac spine (ASIS) to the floor; ask patients to place a finger on the ASIS to assist with finding this landmark
• Strength testing against gravity can be performed with the aid of common household items of known weights:
  • 0.5 pound: Handheld plastic stapler
  • 1 pound: 16-oz water bottle; empty wine bottle (750 mL)
  • 2 pounds: Quart of milk; 1-L soda bottle
  • 4 to 5 pounds: Half-gallon of milk; 2-L soda bottle; unopened bottle of wine (750 mL)
  • 8 pounds: Gallon of milk

After the Examination

The screen-sharing function on videoconferencing platforms allows the clinician to share imaging results with the patient and explain them. Although it may not be possible to use anatomic models, prepared pictures can be used as visual aids.

Provocative testing, discrete palpation and strength or stability testing can be limited in a virtual examination and should be supplemented with MRI or other advanced imaging if indicated.