I remember my first experience reading an orthopedic progress/consult note. I was thoroughly confused. All I saw was “SILT, EHL, ORIF, IMN, AROM” and at the time, I had no idea what any of that meant. A good understanding of what these terms mean can help you get a better grasp of what is going on and can help you write the ortho note if given the chance as a 4th year student/intern. So, we are going to go over a sample note and breakdown some of the terms commonly found. We may also touch on some of the pertinent things to comment on in a note.

Example note:

Orthopaedic Consult note

CC- Right leg pain

HPI- 65 y/o F presents s/p GLF presents to ED with right leg pain. Patient was walking when he tripped and felt a snap in her right leg and fell to the ground. She felt an immediate sharp pain to her right leg. There was no LOC. Patient denies any numbness or tingling in her lower extremities.

Terms: GLF- ground level fall. s/p- status post, LOC- loss of consciousness

ROS, PSH, PMH, FH, SH, Allergies

I’m not going to go over ROS through SH, it’s pretty general/standard across medicine.

Physical Exam:

General: No acute distress, Alert and Oriented x3

Resp: Non-laboured breathing

Abdomen: soft, non-tender

Extremities:

RUE:

Inspection- No erythema, swelling, atrophy, hypertrophy, abrasions, or lacerations noted.

Palpation- No TTP

ROM- Full ROM about the shoulder, elbow, wrist.

Strength- 5/5 AIN/PIN/U

NV- SILT M/R/U, +2 Radial +2 ulnar pulse

LUE:

Inspection- No erythema, swelling, atrophy, hypertrophy, abrasions, or lacerations noted.

Palpation- No TTP

ROM- Full ROM about the shoulder, elbow, wrist.

Strength- 5/5 AIN/PIN/U

NV- SILT M/R/U, +2 Radial +2 ulnar pulse

Terms:

TTP- Tenderness to Palpation

Motor/Strength:

AIN- Anterior Interosseous Nerve (Typically tested by having the patient make an A-ok sign)
PIN- Posterior Interosseous Nerve (typically tested by having the patient do a thumbs up)
U- Ulnar nerve (typically tested by having the patient cross their fingers)

SILT- Sensation intact to light touch,

M-Median (nerve)
R-radial (nerve)
U- Ulnar (Nerve)

RLE:

Inspection- Obvious deformity about the leg, open wound noted about the right leg, 10cmx5cm with exposed bone and soft tissue. Swelling noted about the right leg. No abrasions noted about the thigh

Palpation- TTP about right leg

ROM- Decreased ROM secondary to pain

Strength- 3/5 EHL, FHL, TA, TP, Gastroc, EDL, FDL

NV- SILT dp/sp/t, +2 DP/PT

LLE:

Inspection- No deformity, abrasions, lacerations, atrophy, or hypertrophy noted.

Palpation- Non TTP

ROM- Full ROM

Strength- 5/5 EHL, FHL, TA, TP Gastroc, EDL, FDL

NV- SILT dp/sp/t, +2 DP/PT

Terms:

Strength/Motor-

EHL- Extensor Hallicus Longus (big toe extension)
FHL- Flexor hallicus longus (big toe flexion)
TA- tibialis anterior (ankle dorsiflexion)
TP/Gastroc- Tibialis Posterior ( ankle plantarflexion)
EDL- extensor digitorum longus (extension of the 2-5th toes)
FDL- flexor digitorum longus ( flexion of the 2nd-5th toes)

NV- Neurovascular status

DP- Dorsalis pedis pulse
PT- Posterior tibialis pulse

Imaging: Radio graphic findings consistent with mid shaft fracture of the tibia

Assessment: 65 y/o M s/p GLF with Right open Grade III fx of the tibia.

Plan: IMN of Right tibia

So typically you test all of these components when you examine the patient. A couple more terms and abbreviations you may see/use in an ortho note are the following:

Weight bearing abbreviations:

WBAT- Weight bearing as tolerated

PWB- Partial weight bearing

TTWB- Toe touch weight bearing

NWB- non-weight bearing

Range of motion abbreviations:

AROM- active range of motion

PROM- the thing you did your senior year of high school with that really cute…. Oh wait.. Passive range of motion

Ortho abbreviations

ORIF- Open reduction and internal fixation (the bone is put back into place and fixed using an implant- you are physically manipulating the bone)

IMN- Intramedullary nailing – ( a nail is inserted inside of the canal of the bone)

Ex-fix- External Fixator (rods and pins inserted to the bone that is outside of the skin)