Physical exam apps help students refine skills, others aid surgeons in the clinic

In this month’s column, we review apps designed to assist with patient examinations. First, we review a comprehensive physical examination tool that describes, demonstrates and provides statistics for nearly 250 orthopedic clinical tests and maneuvers. We also introduce a series of applications that use the internal accelerometer of phones for goniometric measurements. Lastly, expanding upon use of the internal accelerometer, we discuss apps that use the camera feature of phones to measure radiographic angles.

Clinical ORthopedic Exam (CORE)

This comprehensive utility describes nearly 250 orthopedic physical examination tests and maneuvers. The user starts by selecting a region in the body, and the app returns related subcategories. For example, selecting the shoulder yields categories such as acromioclavicular joint, biceps tendon, impingement, instability, labrum and muscle/tendinopathy. Advancing an additional step returns specific tests.

Each entry is complete with a brief description of the purpose of the test, as well as clear instructions of how to perform the maneuver, and what result is considered positive. In addition, most tests include a video demonstration that requires Internet access. An impressive feature of the app is the “test properties” button. When users press this button, they can review a comprehensive summary of publications that have evaluated and reported the statistical properties for any test. For example, selecting “speed test” under the shoulder and labrum/biceps subcategories, provides the user with the sensitivity, specificity and positive/negative likelihood ratio for detecting biceps tendon tears, SLAP tears, labral tears or impingement from 10 primary literature sources. Full abstract references are available as well, but require an Internet connection.

Overall, CORE is a comprehensive physical examination tool that would be most suitable for students learning the basics of an orthopedic physical exam, as well as residents and fellows looking to refine their examination skills and read the primary literature supporting each test. With a price tag of $39.99, this app will not appeal to everyone, but can be a valuable resource for those interested.

Matthew DiPaola

Orrin Franko

Goniometers

Most orthopedic surgeons keep a goniometer close at hand to aid in measuring range of motion while in the clinic. New apps have been developed that turn smartphones into goniometers. One developer has released a series of apps entitled, “Simple Goniometer,” “Knee Goniometer,” “Wrist Goniometer” and “Scoligauge.” Each performs the same basic function of measuring the phone’s angle relative to a reference position.

Simple Goniometer presents the user with a familiar image of a goniometer that rotates on the screen in synchrony with rotation of the phone. Selecting “set” marks the reference angle, and the app then returns the angle measured between the new position of the phone relative to the reference angle. Each of the specialized apps expands upon this basic concept.

Knee Goniometer has a similar interface, but allows the user to define either “left” or “right” and assigns a name to each side of the goniometer (tibia or femur). Functionally, the app does nothing different than Simple Goniometer, and users may find this more confusing.

Wrist Goniometer is specialized for measuring pronation/supination of the forearm by instructing the patient to pronate fully until a tone signifies a registered value, then supinate fully until the tone is heard again. The app then reports the value for each direction and calculates the difference between sides. It is important to note that the app cannot control for shoulder or carpal motion, so it still must be performed under close supervision by the examiner.

Lastly, Scoligauge attempts to replicate a standard scoliometer device in both function and appearance.

The available goniometer apps provide useful and objective range of motion data as part of the physical exam. In the future, we would love to see them sync with an electronic medical record.

Radiographic measurements

In addition to measuring angular measurements for particular joints, apps have been developed to measure radiographic angles. CobbMeter is an app with three modes of function: scoliosis, kyphosis and sacral slope. In the scoliosis mode, the app clearly instructs the user to align the edge of the device with the slope of the upper vertebra on a standing spine film, then with the lower vertebra and the app returns the angular difference between the two measures. Kyphosis and sacral slope modes are similar, but the app shows a lateral spine/sacral film for reference.

A different app, OrthoMeter, expands upon the same theme by adding three new functions: angle, horizontal and vertical. The first function is used to measure the difference between two angles (the example given measures the Q-angle after a total knee arthroplasty). The second two functions, horizontal and vertical, simply measure an angle relative to the horizontal or vertical axis.

Lastly, Hallux Angles uses the same concept but incorporates the camera function to align the phone to a radiographic image. Using drawings of the first three metatarsals, a thumbnail reference guide instructs the user how to align a guide with the proper bone (i.e., the axis of the first metatarsal or the angle of the metatarsalphalangeal joint). The app then returns the value on the drawing and allows a surgeon to take a snapshot.

The apps reviewed this month have the potential to assist surgeons, trainees and students with a complete physical and radiographic examination. However, practitioners should be advised that none of the apps presented here are FDA approved as medical devices. While the information provided appears to be valid and supported by literature data, and while the internal accelerometer of smartphones are generally accurate, clinical judgment should always form the basis of any treatment decisions.

Read next month’s column for a review of trauma apps for fracture classification and management.

• Matthew DiPaola, MD, is an assistant professor and shoulder and elbow specialist in the Department of Orthopedics at Wright State University in Dayton, Ohio. He is a writer for iMedical Apps and co-founder of Touch Consult, a developer of team based medical software to improve signout. He can be reached at matthew.dipaola@wrightstatephysicians.org.
• Orrin Franko, MD, is a PGY3 orthopedic resident at UC San Diego. He has an interest in promoting mobile technology within orthopedic surgery and founded the website www.TopOrthoApps.com to help surgeons and trainees find the most relevant orthopedic apps for their mobile devices. He can be reached at orrin@toporthoapps.com.
• Disclosures: DiPaola and Franko have no relevant financial disclosures.