The Orthopaedic Physical Examination, by Bruce Reider, is a
beautiful book. It is a black-and-white text on a fairly gray topic, but it is
beautiful nonetheless.
The beauty of the book stems first from its excellence. For those readers
who dare to tackle it from cover to cover—book reviewers,
obsessive-compulsive medical students, and maybe a few others—it flows
harmoniously. For more typical users who will consult it for reference, it
offers easy, random access. The writing is crisp; the photographs and line
drawings are illustrative; and the span of content—what Dr. Reider
decided to leave in and what he decided to leave out—is, in the words of
Goldilocks (no doubt citing Aristotle), "just right."
The book is divided into anatomical regions, and each chapter is artfully
subdivided. Within each chapter, there are major sections on inspection,
palpation, and manipulation, each of which is further partitioned into
discussions of surface anatomy, alignment, range of motion, and so on. Like a
Bach fugue or passacaglia, The Orthopaedic Physical Examination
creates beauty in its organization. It reads without the overwhelming
redolence of an expanded outline, but a firm structure both paces the reader
and ensures completeness.
In addition to the flow between parts, The Orthopaedic Physical
Examination shares two other important traits with the Baroque musical
form. The first is the articulation of a theme. The theme of this
book—perhaps obvious in this text, yet missing from some of its
rivals—is that physical examination is an art directed toward the
deduction of diagnosis. Physical examination, Dr. Reider implicitly states, is
not an exercise performed by an automaton. Rather, a thoughtful practitioner
uses these skills to answer the simple but crucial question: What is wrong
with this patient in front of me? This theme is brought to the fore by the use
of tables entitled "When the patient complains of..."
These tables associate subjective complaints, such as locking or catching of
the knee, to objective findings and diagnostic categories.
The Orthopaedic Physical Examination is also similar to Baroque
music in its meld of multiple voices in a linear text—so-called
"polyphonic texture." Dr. Reider is able to address at once
multiple classes of readers, sharing his lessons at multiple levels of
sophistication. The book talks simultaneously to the student, to the resident,
and to the teacher. It captures that spirit of "something for
everyone." The book offers fundamentals for the novice, but doles out
pearls for the teacher on the same page. I would argue that the intercalation
of simple and sophisticated within this book is one of its strongest suits and
makes for better reading by all readers.
The utility of this book for the purpose of teaching is probably its
greatest strength. Some books on physical examination are best considered
primers because they are addressed to students in search of practical advice.
Hoppenfeld's classic, Physical Examination of the Spine and
Extremities, epitomizes that mold. Other textbooks, such as
Musculoskeletal Medicine, offered by the American Academy of
Orthopaedic Surgeons, serve more as a repository of information regarding
individual physical examination maneuvers (relying on teachers, in that
example, to fill in detail). The Orthopaedic Physical Examination
serves best, I believe, as a book of pedagogy. This is a book that teachers of
physical examination could use to great advantage.
As a text for teachers, this book goes a long way to solving one of the
problems found in teaching musculoskeletal examination to medical students:
namely, the paucity of instructors. Although musculoskeletal conditions
represent a large part of clinical medicine, few clinicians feel competent to
cover the field in its entirety. Rheumatologists, for instance, may be
familiar with all of the joints of the body but have relatively less
experience examining the injured patient. Orthopaedic surgeons are often so
specialized that general physical examination skills are no longer our forte.
I can imagine that a spine surgeon considers the foot foremost as a home for
the lumbar and sacral dermatomes. The family doctor may not even feel expert
at all. Armed with The Orthopaedic Physical Examination, a variety of
clinicians can be empowered to teach musculoskeletal physical examination to
medical students.
All reviewers, it seems, must cavil about at least one aspect of the book
under evaluation to prove their bona fides. It is only to honor that ritual
that I offer the following small complaint: some of the figures in the text
would have been made clearer with the addition of arrows to indicate the
direction of force applied by the examiner. For example, the only difference
between Figure 3-36, demonstrating the testing of the biceps, and Figure 3-38,
demonstrating the testing of the triceps, is the finger position of the
examiner: his open hand signifies a pushing force of the subject's arm into
flexion, whereas his closed grip indicates that he is pulling the elbow into
extension. An arrow or two would have tripled the didactic value of the
picture without undue distraction.
Needless to say, such a minor flaw does not detract from the overall
excellence of the book. It is a triumph of completeness, accuracy, and
readability. Does this book replace Hoppenfeld? I don't think so; there is a
need for simpler books. Does it supplant Musculoskeletal Medicine?
No, that text offered physical examination only as part of a larger
introduction for students. But is The Orthopaedic Physical
Examination the best book for teachers of physical examination?
Unquestionably. It is a beautiful book.