Introduction to Orthopedic Diagnosis Flashcards
a working knowledge of the MS system forms the foundation of every
orthopedic exam
physical examination
evaluation
intervention (care plan)
_____ and ____ and how they relate to _____ is the key to diagnosis
biomechanics and anatomy
function
- what is normal versus abnormal for that patient
- what structures an tissues are functioning properly versus not working or only partially functioning
a fundamental skill of a chiropractor is to _____, _____ and ____ _____ related to human movemetn
identify
analyze
solve problems
when describing movements there is a need for starting position=
reference position
starting position is referred to as
anatomical reference position (anatomical position)
the anatomical position for the human body=
erect standing position feet slightly separated, arms hanging by the side, elbows straight and palms of the hand facing forward
superior or cranial
closer to the head
inferior or caudal
closer to the feet
anterior or ventral
toward the front of the body
posterior or dorsal
toward te back of the body
medial
toward the midline of the body
lateral
away from eh midline of the body
there are 3 planes of the body =
3 dimensions of space:
sagittal
frontal
transverse
sagittal plane
aka anterior-posterior or median plane
divides the body vertically into left halves of equal size
frontal plane
aka lateral or coronal plane
divides the body equally into front and back halves
transverse plane
aka horizontal plane
divides the body equally into top and bottom halves
3 reference axes are used to describe human motion
front
sagittal
longitudinal
the axis around which the movement takes places is always ______ to the plane in which it occurs
perpendicular
frontal axis of body
aka transverse axis, is perpendicular to the sagittal plane
sagittal axis of body
perpendicular to the frontal plane
longitudinal
aka vertical axis
perpendicular to the transverse plane
occur in the sagittal plane around a frontal-horizontal axis
flexion extension hyperextension dorsiflexion plantar flexion
occur int he frontal plane around a sagittal-horizontal axis
abduction
adduction
side flexion of the trunk
elevation and depression of
the shoulder girdle
radial/ulnar deviation of wrist
eversion/inversion of foot
occur in the frontal plane
around a sagittal-horizontal
axisoccur in the transverse plane around the longitudinal axis
rotation of head, neck & trunk
internal rotation or
external rotations of arm/leg
horizontal adduction/abduction
of the arm or thighinvolves an orderly sequence of circular movements that occur in the sagittal, frontal and oblique planes
so that segment as a whole incorporates a combination of flexion extension abduction adduction
circumduction
study of motion
kinematics
two major types of motion involved
osteokinematic
arthrokinematic
osteokinematic motion occurs when
any object forms the radius of an imaginary circle about a fixed point
the axis of rotation for osteokinematic motions is
oriented perpendicular to the plane in which the rotation occurs i.e.:
abduction/adduction of arm
flexion of hip/knee
side flexion of trunk
arthrokinematic movements
the motions occurring at joint surfaces
direction of movement based on the _____ of the joint surfaces
shape
generally, joint surfaces can be either _____ or ____ in shape (ovoid), or a ______
concave (female)
convex (male)
combination of both shapes (sellar)
3 types of movement occur at the articulating surfaces
roll
slide
spin
osteokinematic and arthrokinematic motions are
directly proportional to each other and one cannot occur completely without the other
if motion is reduced
one, or both of osteokinematic or arthokinematic motions is at fault
the number of independent modes of motion at a joint is called the
degrees of freedom (DOF)
a joint that can swing in one direction or can only spin =
1 DOF
ie: PIP joint
a joint that can spin and swig in one way only or it can swing in two completely distinct ways, but not spin=
2 DOF
ie: tibiofemoral joint
if the joint can spin and also swing in two distinct direction then =
3 DOF
ie: glenohumeral joint
the position of maximum congruity of the opposing joint surfaces
close-packed position of the joint (table 3-1 pg. 83)
movements toward the close-packed position of a joint involve
an element of joint compression (approximation)
position of maximum joint stability
ie: elbow= extension
close-packed position
-end of travel in a joint =
the surfaces are at maximum congruency, the ligaments are taut, and further movement in that direction of travel may result in dislocation or fracture
the position of least joint congruity
open-packed position (table 3-2 pg. 84)
open-packed position
-movements away from the close-packed position involve an element of joint distraction
separation
open packed-position
position of least joint stability i.e: elbow= 70 degrees flexion and 10 degrees supination
loose or open-packed position
the positions of travel of a joint away from eh close packed position where by the capsule and ligaments are NOT TAUT
loose or open packed pos.
-extreme movement in that direction usually results in
sprain/strain
if a joint moves less than what is considered normal, or when compared to the same joint on the opposite extremity
hypomobile
a joint that moves more than considered normal, or when compared to the same joint on the opposite extremity
hypermobile
instability of a joint involves disruption of the ____ and ____ structures of that joint, resulting in a _____ ___ ______
osseous
ligamentous structures
loss of function
factors of joint integrity (bone fits bone)
elastic energy
passive stiffness
muscle activation
elastic energy
stored energy that allows elastic tissue to return to original
passive stiffness
found at end range when lost = laxity
muscle activation
correct synergistic and antagonistic balance both in timing an strength - otherwise= buckling or shear translation
during daily activities, ____ and _____ forces are either generated or resisted by the body
external
internal
external forces
ground reaction force, friction, and gravity
internal forces
muscle contraction, joint contact and joint shear forces
tissues must demonstrate the ability to withstand _____ or ____ stresses if musculoskeletal health is to be maintained
excessive
repetitive
the capacity of tissue to withstand STRESS is dependent on a number of factors
- age
- the proteoglycan and collagen content of tissue
- the ability of the tissue to undergo adaptive change
- the speed at which the adaptive change must occur- depends on the type and severity of insult to tissue
kinetics
the study of FORCES created as motions change (kg)
mass
the QUANTITY of matter composing a body
inertia
the RESISTANCE to action or to change
center of gravity
a point around which the weight and mass are equally balanced in all directions
force
a VECTOR QUANTITY, with magnitude, direction and point of application to a body
load
the TYPE of force applied
stress
the FORCE PER UNIT area that occurs on the cross section of a structure in response to an externally applied load
strain
the deformation that occurs within a structure in response to externally applied loads
hysteresis
the difference in the behavior of a tissue when it is being loaded versus unloaded
the load- deformation curve
a stress-strain curve, of a structure depicts the relationship between the amount of force applied to ta structure and the structure’s response in terms of deformation or acceleration
collagen fibers at rest are
wavy
when a force lengthens collagen fibers
straighten, the slack is no longer there
slack
crimp
___ is different for each type of CT, and this provides each tissue with different____ ____
Crimp
viscoelastic properties
if a load is applied to CT and then removed
the material recoils to its original size
if the load remains the material continues to ___
stretch
after a sustained stretch
the material plateaus- collagen fibers realign in the direction of stress, H20 and proteoglycans are displaced from between the fibers= creep
gradually occurs and is time dependent (less than 15 minutes- not going to occur)
creep
once creep occurs
tissue has difficulty returning to its initial length
stress in CT can result in
no change
semi permanent change
permanent change
occurs when a tissue remains deformed and does not recover its prestress length
plastic deformation
once all possible realignment occurs any further loading
breaks tissue
on average collagen fibers are able to sustain ____% increase in elongation or strain before microscopic damage occurs
3
after a stretch (chemicals bonds and fibers intact)
the collagen fibers recover but at a slower rate and extent
loss of energy that occurs between the lengthening force + the recovery activity=
hysteresis
the more chemical bonds broken with applied stress
the greater the hysteresis
if stretch is enough so the tissue is unable to return to its original length, the new length then has increased strain resistance
instability
increased excursion is needed before the tissue develops
tension
destabilizing the connective tissue- if enough force is applied to the CT a
complete rupture occurs
ligamentous injury- characteristics can be=
point tenderness
joint effusion
history of trauma
usually ligaments are graded by
severity of injury (sprains)
see page 93 table 4-2
Grade 1
painful, but not unstable or swollen
O’Donoghue says “grade 1=
mild, tearing of a few fibers with minimal hemorrhage, no laxity or residual instability, full function and strength is maintained.
Return to sports =within 1-2 weeks, complete healing expected in 4-6 weeks
Grade II
moderate, sprain is incomplete tear of the ligament with mild laxity and instability, marked swelling and pain resulting in reduction of function, decrease in strength and loss of proprioception
- in a lower extremity, patients should crutch walk until comfortable to walk
- usually return to sports in 8-12 weeks
Grade III
severe, complete disruption of the ligament with gross instability and laxity, marked swelling, and much pain. Loss of full function, strength and proprioception, especially if rehab is not complete or inadequate
Grade III injuries can lead to
greater risk for chronic instability or osteochondral lesions, which may lead to future surgeries
connects bone to bone
tendons
the causes of a tendon injury center around ____ to the tendon tissue due to ____ ____ ____ from external factors (like incorrect use of equipment, improper training techniques, inappropriate shoe wear), or _____
microtrauma
repetitive mechanical loading
macrotrauma
inflammatory reaction to a tendon injury
-a microscopic tearing and inflammation of the tendon tissue, commonly resulting from tissue fatigue rather than direct trauma
tendinitis
indicate an inflammatory disorder of tissues surrounding the tendon such as the tendon sheath- usually the result of a repetitive friction of the tendon and its sheath
tensoynovitis/tenovaginitis
peritendinitis
paratenonitis
refers to a degenerative process of the tendon (rather than inflammatory disorder)
tendinosis
tendinosis is characterized by
presence of dense population of fibroblasts, vascular hyperplasia, disorganized collagen
degenerative tendonpathy occurs in approximately
1/3 of the population 35 years or older
tendinosis
-the degree of degeneration increases with ____ and may represent part of the “___” ___ ____
age
“normal” aging process
tendinosis dgeneration is
actively related
tendinosis
-resistance to the involved musculotendinous tissue is
pain
bone is ___ with __ ___
solid
elastic properties
bone is ___ and ___ than other tissues at higher strain levels
stiffer and stronger
bone is better able to withstand compressive forces than ___ or ____ forces
tensile or torsional
this law attempts to predict bone adaptation to stresses
Wolff’s Law
what happens if the adaptations of bone to stress to not occur fast enough
bone is resorption (bone lysis) faster than it is replaced (osteoid synthesis), and bone strength is compromised
causes of decreased bone adaptation include:
- an increase in the applied load
- an increase in the number of applied stresses
- a decrease in the size of the surface area over which the load is applied
as bone strength and mass decreases this can result in
stress fractures
the distribution and frequency of stress fracture is greatest in the
tibia
inflammation of the bursa from repeated micro trauma or direct injury
Bursitis
when bursa inflame especially chronically they become
tough, thick, fibrous
when bursa become tough, thick and fibrous they make
the structure fluid filled and easier to palpate- this is termed “boggy”
muscle injury can result from
excessive strain excessive tension contusions lacerations thermal stress myotoxic agents pg. 96 table 4-4
excessive strain
contribute > 90% of all muscle injuries
excessive tension
resulting in overstretch
contusions
also contribute to muscle injuries
myotoxic agents
local anesthetics, excessive use of corticosteroids, snake and bee venoms
contusion to a muscle belly
hematoma
two types of hematoma
intramuscular
intermuscular
associated with a muscle strain or bruise. The size of the hematoma is limited by the muscle fascia
intramuscular
this type of hematoma develops if the muscle fascia is ruptured and the blood spreads into the interfacial and interstitial spaces
intermuscular
muscle strains are often graded according to
severity
Involves a tear of a few muscle fibers with minor swelling and discomfort. Associated with no or minimal loss of strength and restriction of movement
Grade I muscle strain
greater damage of the muscle and clear loss of strength and some loss of function
Grade II muscle strain
Involves a tear extending across the whole muscle belly. Characterized by severe pain or loss of function.
Grade III muscle strain
continuous _____ of connective and skeletal muscle tissues can cause some undesirable consequences of the tissues of the MS system
immobilization
undesirable consequences to the tissues of the MS system
- cartilage degeneration
- a decrease in the mechanical and structural properties of ligaments
- a decrease in bone density
- weakness or atrophy of muscles
How does the inter/examiner/ or chiropractor obtain the information from the patient
the chiropractor examination or evaluation
- the patient serves as the most valuable resource to the intern/student
- each interaction with a patient is an opportunity to increase knowledge, skill, and understanding
- communication involves interacting with the patient using terms he or she can understand
the examination and evaluation
the success of any rehabilitation intervention depends on the _____ and ____ of the examination and the subsequent evaluation
quality
accuracy
gathering of data and information concerning a topic
examination
forming a value judgment based on the collected data and information
evaluation
the examination consists of three components of equal importance
the history
the systems review
the tests and measures
begins with meetings and greeting the patient- from the time the patient fills out forms to sitting, or standing in the clinic
observation
can be so specific to isolate the muscle, movements or joint involved
changes in body shape or posture
ie: postero- lateral disc patient may prefer to stand rather than sit in the waiting or adjusting room
formal observation can include
- posture analysis
- structural alignment and deformity
- presence of asymmetry
- scars
- crepitus
- color changes
- swelling
- muscle atrophy
it is estimated that 80% of the necessary information in a presenting patient problem can be provided by a thorough
history
this portion of the history taking can be the most challenging, it involves the gathering of both positive and negative findings, followed by the dissemination of the information into a working hypothesis
history of current condition
part of the examination that identifies possible health problems that require consultation with, or referral to, another health care provider
systems review
the purpose of this is to help RULE OUT the possibility of symptom referral from other areas, and to ensure ALL POSSIBLE causes of the symptoms are examined
Scanning Examination
used when there is no history to explain the signs and or symptoms, or when the signs and/or symptoms are unexplainable
examination
the TESTS part of the examination, serves as an adjunct to the history and systems review
physical examination
disturbed sensation that causes suffering or distress
pain
during physical examination the following factors must be investigated
onset intensity location perception quality behavior nature
this examination should determine the exact directions and types of motion that elicit the symptoms
ROM
who performs active ROM?
patient
who performs passive ROM?
Examiner
active range of motion testing gives the intern information about
- the quantity of available physiological motion
- the presence of muscle substitutions
- the willingness of the patient to move
- the integrity of the contractile tissues
- the quality of motion
- symptom reproduction
this testing gives the intern information about the integrity of the contractile tissues, and the END-FEEL
Passive ROM
pain that occurs at the END-RANGE of active and passive movement is suggestive of a
capsular contraction, or scar tissue that has not been adequately remodeled
why do we perform palpation
- check for any vasomotor changes i.e.: increase in skin temperature that might suggest an inflammatory process
- localized specific sites of swelling
- identify specific anatomical structures and their relationship to one another
- identify sites fo point tenderness
during palpation identify soft tissue
texture changes or myofascial restriction
during palpation locate changes in muscle
tone resulting from, trigger points, muscle spasm, hypertonicity, or hypotonicity
during palpation determine circulatory status by checking
distal pulses
during palpation detect changes in the
moisture of the skin
these tests are only performed if there is some indication that they would be helpful in arriving at a diagnosis
Special Tests
special tests are used to help
confirm or deny structures and may also provide information as to the degree of tissue damage
a diagnosis can only be made when
all potential causes for the symptoms have been ruled out
the prognosis is the predicted
level of function that the patient will attain within a certain time frame
the prognosis helps
guide the intensity, duration, and frequency of the protocols, and aids in justifying the intervention
