In this months 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
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
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 phones angle relative to a reference
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
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.
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
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 months 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 firstname.lastname@example.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
- Disclosures: DiPaola and Franko have no relevant financial