Telemedicine in the Era of COVID-19: The Virtual Orthopaedic Examination

Abstract

With the onset of the COVID-19 pandemic, the shifting of clinical care to telemedicine visits has been hastened. Because of current limitations in resources, many elective surgeons have been forced to venture into utilizing telemedicine, in which the standards for orthopaedic examinations have not previously been fully developed. We report our experience with protocols and methods to standardize these visits to maximize the benefit and efficiency of the virtual orthopaedic examination. At the time of scheduling, patients are asked to prepare for their virtual visit and are given a checklist. In addition to confirming audiovisual capabilities prior to the visit, patients are given specific instructions on camera positioning, body positioning, setting, and attire to improve the efficiency of the visit. During the examination, digital tools can be utilized as needed. In the setting of outpatient injury evaluations, a systematic virtual examination can aid in triaging and managing common musculoskeletal conditions. With the rapid incorporation of telehealth visits, as well as the unknown future with regard to the pandemic, the utilization and capabilities of telemedicine will continue to expand. Future directions include the development of validated, modified examination techniques and new technology that will allow for improved interactive physical examinations, as we rapidly move forward into the realm of telemedicine due to unexpected necessity.

Fig. 1

During the virtual examination, hyperextension of the knee is assessed by having the patient stand on the affected leg while pushing the knee posteriorly. A virtual goniometer can be utilized on most web-based platforms; in this case, it indicates hyperextension of 2.2°.

Fig. 2

External rotation of the hip can be measured by having the patient sit in a chair facing the camera and rotating the hip with the knee bent at 90°.

Fig. 3

Hip extension strength can be assessed by having the patient sit back in a chair and arise without using the arms to assist.

Fig. 4

An internet-based goniometer can be used to assess forward flexion by measuring the angle between the midaxillary line and a line along the axis of the humeral shaft.

Fig. 5

Range of motion of the elbow is assessed from the front, with the arm abducted to 90°.

Fig. 6

Pronation is assessed by having the patient facing the camera, with the arms at the sides and elbows bent to 90°.

Fig. 7

The chair push-up test can be used for the evaluation of posterolateral rotatory instability. The patient is asked to turn 90° with the injured elbow closest to the camera and to then push off from a chair with the fingers pointed away from the body. Pain or apprehension during this maneuver may indicate possible posterolateral rotatory instability.