Ortho Intro Flashcards
PART 1: CLINICAL REASONING INTRODUCTION
PART 1: CLINICAL REASONING INTRODUCTION
Clinical reasoning is collaborative, reflective, and _________ and __________.
conscious and unconscious
The goal of clinical reasoning is to formulate a working __________ and select _________ (examination and intervention).
- diagnosis
- procedures
Clinical reasoning is based on clinical findings, _______ choices, and the clinician’s judgment based on their knowledge, experience, and evidence.
patient
What are the 3 problem solving methods?
- Pattern Recognition (System I)
- Hypothetico-Deductive (System II)
- Mixed (diagnostic reasoning)
Which problem solving method is our “forward reasoning” and is faster, more effecient, and develops “scripts”.
Pattern Recognition
Which problem solving method is our “backward reasoning” and has a heavy reliance in novice practice?
Hypothetico-Deductive
- Which problem solving methods do experts use in familiar instances?
- Which do they use in unfamiliar instances?
- Pattern Recognition (System I)
- Hypothetico-Deductive (System II)
What are 4 different types of reasoning used in the clinic?
- Probabilistic
- Causal
- Case-Based
- Narrative
Probabilistic Reasoning is assessing the likelihood of a clinical hypothesis via either ______ or __________, but the more common is ___________.
- statistic
- approximated
- approximated
Causal Reasoning is based on a _____ and _______ relationship of variables and normal/abnormal physiology.
cause and effect
Case-Based Reasoning is our knowledge stored in a symbolic “_____” that is recalled in subsequent encounters with similar circumstances.
script
Narrative Reasoning concerns the understanding of ________ stories to gain insight into their experiences of disability or pain and their subsequent _______, ________, and ______ behaviors.
- patients’
- beliefs, feelings, and health behaviors
Which reasoning is the source of many assumptions that are made in a clinic?
Causal Reasoning
What are the 2 main strategies used when faced with uncertainty and is used to reduce said uncertainty?
- Elimination Strategy
- Confirmation Strategy
The elimination strategy is seeking data to ______ suspicion of an unlikely hypothesis and uses _________ likelihood ratio.
- reduce
- negative
- What is negative likelihood ratio?
- What are the values of importance and significant importance?
- How many times more likely a negative test will be seen in those with the disorder than those without the disorder.
- Values <0.2 of importance
- Values <0.1 of significant importance
The confirmation strategy is seeking data to ______ a highly likely hypothesis and uses _________ likelihood ratio.
- support
- positive
- What is positive likelihood ratio?
- What are the values of importance and significant importance?
- How many times more likely a positive test will be seen in those with the disorder than those without the disorder.
- Values >5 of importance
- Values >10 of significant importance
We want to administer elimination strategies ______ in the exam and confirmation strategies _______ in the exam.
- early
- later
Both confirmation and elimination strategies aid in narrowing hypothesis.
-Tests with low - Likelihood Ratio (-LR) good to ______ a diagnostic hypothesis
Tests with high + Likelihood Ratio (+LR) good to ______ a diagnostic hypothesis
- refute
- confirm
What is a 3rd strategy used to reduce uncertainty and what is it?
- Discrimination Strategy
- Seeking information to discriminate between likely hypothesis
Ockham’s Razor = ?
“The simplest solution may be the best”
Hickman’s Dictum = ?
“Patients can have as many diseases as they damn well please”
What is the basic process involving the funneling in the differential process of diagnosis? (3 main things)
- ) Initial data gathered and preliminary diagnosis and hypothesis generation
- ) Hypothesis are modified/refined
- ) Hypothesis are verified
What are some elements of Initial Hypothesis Generation?
- Non-Musculoskeletal Health Conditions and Serious Musculoskeletal Conditions
- Potential radicular and referral sources (nerve root, peripheral nerve injury/entrapment, somatic referred pain)
- Screening adjacent joint regions
- Differentiating local MSK conditions
What is the test-retest model?
Involves testing after interventions to assess whether or not the intervention had immediate effects. From this we can see whether or not we should continue said interventions.
PART 2: THE ORTHOPEDIC EXAMINATION
PART 2: THE ORTHOPEDIC EXAMINATION
What is the 1st part of the orthopedic examination?
Chart Review/ Patient Interview
The _______ _______ ________ ________ is an individualized measure intended to reflect functional status.
Patient Specific Functional Scale (PSFS)
With the PSFS, the pt identifies activities which performance has been limited. What is the grading scale they use?
0-10 with 0 being inability to perform activity, and 10 being the ability to perform activity at same level as before injury or problem
- The minimal detectable change score is at least __ points change in the average score of the PSFS.
- The minimal detectable change for a single activity is at least __ point change.
- 2
- 3
What is the difference between red and yellow flags seen in the patient interview?
Red Flags
-S/Sx consistent with a non-musculoskeletal origin or serious musculoskeletal health condition that requires referral to another clinician
Yellow Flags
-Indicate need for more extensive examination or cautions/contraindications to certain tests/interventions
What are some screening questions done during the patient interview?
- Hx cancer
- Smoking Hx
- Weight loss
- Fatigue
- Bowel and bladder dysfunction
- Sexual dysfunction
- LE dysesthesia/ motor impairments (bi v. unilateral)
- Hx infection
- Fever
- Phoresis
- DM
- Immunocompromization
- Trauma Hx
- Other contextual patient-specific risk factors
How many red flag categories are there and what does each mean?
Category I
-Factors that require immediate medical attention
Category II
-Factors that require subjective questioning and precautionary examination and treatment procedures
Category III
-Factors that require further physical testing and differentiation analysis
What is the 2nd part of the orthopedic examination?
Visual Inspection/ Physical Exam
With the visual inspection/physical exam, what are we looking for?
- Status
- Affect
- Anthropometrics
- Preferred positions
- Integumentary
- Posture
When assessing posture, what 3 things are we looking at?
- Symmetry
- Bony/soft contours
- Resting posture vs ability to correct
What is the 3rd part of the orthopedic examination?
Systems Review
In the systems review, we test components that we ______ plan to assess further and ______ other procedures that we plan to test more thoroughly.
- do not
- defer
What is the goal of the systems review?
Identify impairments for continued tests and measures.
- Cardiopulmonary
- Integumentary
- Neuromuscular
- Cognition/Affect
- MSK
What is the 4th part of the orthopedic examination?
Elimination Tests
What is the difference between the systems review and elimination tests?
-Difference is intent (what is the goal with testing)
Systems Review
-Testing body systems to determine NEED FOR FURTHER examination IN “tests and measures”
Elimination Tests
-Part of “tests and measures” involving screening for health conditions commonly associated with the diagnostic hypotheses to aid in the differential process.
Elimination Tests: Quarter Screening
- Upper and lower quarter structures stressed to determine need for more specific __________ examination
- ____________ is often applied at the end of AROM (if motion is full and painless) to stress structures for clearance
- ___________ grossly assessed to identify force production capacity
- regional
- overpressure
- strength
Elimination Tests: Neurological Screening Tests
- Sensation
- _____ touch
- _____ prick
- __________
- Motor Function
- ________ vs peripheral nerve
- _____________
- Reflexes
- DTR
- __________ reflexes (present or absent)
Sensation
- light touch
- pin prick
- proprioception
Motor Function
- myotome vs peripheral nerve
- coordination
Reflexes
-pathological reflexes
What are the considerations for the Neurological Screening Tests?
-Is it symmetrical and is it normal/diminished/absent.
Elimination Tests: Special Tests
- What are the implications of performing special tests?
- Special Tests involve ________-________ application.
- Safety, Information Provided, Role in Differential
- Evidence-Based
What is the Beighton Scale used to assess?
hypermobility
What is the 5th part of the orthopedic examination?
Structural Stress Testing
Structural stress testing involves what 3 things?
- AROM
- PROM
- Resistive Testing
Structural stress testing is a process of _________ reasoning in which particular tissues are stressed during different types of testing procedures, and then the results of the tests are compared to narrow down a likely lesion/ tissue type.
inductive
The goal of structural stress testing is selective tension by performing _________ tests that provide information for the quantification of ____, _______ performance, and symptoms. It also provides information for qualification muscle performance and symptoms.
- provocation
- ROM, muscle performance
Symptoms can be either concordant or discordant, what does this mean?
Concordant- consistnet with pt’s complaints
Discordant- not consistent with pt’s complaints
- What are examples of contractile unit structures?
- Do we see more pain with contractile unit structures while performing resistive testing, active contraction, or passive stretching?
- muscle, tendon, bony insertion
- resistive testing > active contraction and passive stretch
What are examples of inert structures?
-joint capsule, ligament, bursa, fascia, dura mater, nerve, bone, disc
What is the 6th part of the orthopedic examination?
Palpation and Joint Mobility Tests
With palpation, we are looking to assess:
- Joint __________, tenderness, stability
- Superficial temperature, ___________
- Dryness or excessive moisture of skin
- Sensation
- Pulses, tremors, fasiculations, crepitus
- Tension, thickness, texture of soft tissue (spasm, turgor, flexibility, pliability, fibrosis)
- _____ in various structures
- congruence
- inflammation
- pain
Joint mobility testing is commonly performed in the _________ position of the joint. We stabilize the ________ segment.
- resting
- proximal
What are we assessing when performing joint mobility tests?
- Symptom provocation
- Quality (“Normal”, mechanical block, guarding)
- Quantity (joint integrity, hyper/hypomobile)
- Willingness
When talking about joint mobility mechanical loading we are looking at:
- Shear loading on _________ surfaces
- Tensile loading on inert joint _________ (capsule, ligament)
- Tensile loading on _________ contractile units
- Local compression at points of contact
- articular
- stabilizers
- guarding
What is the 7th part of the orthopedic examination?
Confirmation Tests
- When are confirmation tests used?
- Do they use a + or - likelihood ratio?
- Positive Test aids in ruling ___ a health condition.
- They are used once the hypothesis has been narrowed
- +LR
- ruling in
What are the 6 parts of the ICF model?
- Health Condition
- Body Functions and Structure
- Activity Limitations
- Participation Limitations
- Environmental Factors
- Personal Factors
List some common impairments.
- Pain
- Tissue Damage
- ROM
- Joint Mobility
- Posture
- Muscle Guarding
- Muscle Performance (coordination, endurance, strength)
PART 3: TISSUE LOADING AND INJURY
PART 3: TISSUE LOADING AND INJURY
What are 3 types of tissue loading? Describe each.
Tensile
-2 forces pulling opposite directions
Compression
-2 forces pushing together
Shear
-2 forces pushing “past” one another
Concentrating forces into one area creates ________ loading, leading to what?
excessive, leading to breakdown of that area
What are the 4 areas of the collagen stress strain curve?
- Toe Region
- Elastic Region
- Plastic Region
- Tissue Failure
- ___________ is low intensity of loading with high frequency and/or duration.
- What are some examples of this?
- Repetitive Stress
- Sponylolysthesis, Tennis Elbow
- ________ is high intensity of loading with low frequency.
- What is an example?
- Trauma
- Fractured vertebrae related to a fall from a ladder
What are the 3 classification of injuries and what are their time frames?
Acute
-typically 7-10 days
Subacute
-subsequent 5-10 days
Chronic
-Injury lasting longer than expected under “normal” healing conditions
What are the 3 phases of tissue healing?
- Phase I- acute inflammatory response
- Phase II- repair and regeneration
- Phase III- remodeling and maturation
The 2 healing requirements for tissue healing are:
- ) Controlled forces necessary to facilitate tissue ________
- ) __________ from excessive and harmful stresses on tissue
- synthesis
- protection
Phase I of LIGAMENT tissue healing is in the first __ days and is the acute inflammatory response and ________ formation.
- 3
- hematoma
Phase II of LIGAMENT tissue healing is from __ days post injury to __ weeks. This is where __________ produce collagen and the matrix is ____________.
- 3 days
- 6 weeks
- fibroblasts
- disorganized
Phase III of LIGAMENT tissue healing happens up until ___ months post injury. This is where the collagen fibers become more _______/__________. This results in increased tissue contraction and tensile _________.
- 12 or more
- parallel/organized
- strength
- Phase I (Inflammation) of TENDON tissue healing happens in the first __ days.
- Phase II (Reparative/Collagen Productive) of TENDON tissue healing happens within __ week and continue fibroblast activity through week __.
- Phase III (Remodeling) of TENDON tissue healing is typically complete in __ months.
- 3 days
- 1 week, week 4
- 2 months
After initial healing, we have ________ tensile healing.
controlled
- What is tendinopathy?
- What are 3 types of tendinopathy?
- Overarching term for injury of tendon.
- Tendonitis, Tenosynovitis, Tendinosis
What is the difference between tendonitis, tenosynovitis, and tendinosis?
Tendonitis
-inflammation of tendon
Tenosynovitis
-inflammation of synovial sheath surrounding tendon
Tendinosis
-degeneration of the collagen tissue in tendonds due to aging, microtrauma, or vascular compromise
Does tendinosis have an active inflammatory process?
No, failed healing response
With Articular Cartilage, a loss of ____________ and ________ injury are 2 mechanisms of injury to articular cartilage?
- proteoglycans
- mechanical
With a loss of proteoglycans, the matrix reaches a certain amount of loss that is _________.
irreversible
With articular cartilage mechanical injury such as blunt trauma, penetrating injury, frictional abrasion, or sharp concentration of joint forces the healing depends on the _______ of the injury.
extent, is it chondral or subchondral
In an articular cartilage chondral injury, do we see an inflammatory response?
No, does not extend to the blood supply.
With a articular cartilage subchondral injury, the injury extends to the blood supply and is ___ likely to heal, however, the tissue is filled with ______cartilage instead of hyaline cartilage.
- more
- fibrocartilage
Why is a subchondral injury filling with fibrocartilage problematic?
That area of cartilage will accept loads differently which can lead to further injury or dislodgement of the fibrocartilage “plug”.
Subchondral fibrin clots occur within ___ hours and will resemble “normal” cartilage within __ months. Erosive changes are observed around __ months.
- 48 hrs
- 2
- 6
Healing of articular cartilage injuries depend on the extent of the lesion (______ involved, size of _______).
- zones
- lesion
When it comes to tissue healing, we want “____ ________” tensile loading to stimulate healing but not too much.
just enough
What is the common immobilization/protection timelines for bone tissue healing with adults and children?
Adults= 6-8 weeks Children= 4-6 weeks
With bone healing, immobilization may be necessary to prevent excessive ______. Early excessive loading leads to a risk of __________. What is this?
- shear
- pseudoarthrosis, failure of fusion
With stress fractures remember _____ law.
Wolff’s law
-bone responds to forces imposed on it
Pathophysiology of Stress Fractures:
- Repetitive ____trauma
- Osteo______ activity lags in comparison to osteo________ activity
- Stress reaction may progress to _______ disruption, then complete fracture
- microtrauma
- osteoblast, osteoclasts
- cortical
Difference between fatigue fractures and insufficiency fractures.
Fatigue fractures
-Normal bone, abnormal stress
Insufficiency fractures
-Normal stress, abnormal bone
Stress Fractures Hx:
- _______ onset, progressive
- ADLs/ performance affected more so with _________
- __________ pain with later pathologic progression
- Increased training intensity (prior - weeks)
- Risk factors: female gender and amenorrhea
- insidious
- progression
- continual
- 6-8 weeks
What are the common symptoms of stress fractures?
- focal pain
- exercise-induced pain
- night pain
How will stress fractures present during a physical examination?
- local tenderness
- limited ROM (guarded vs painful endfeel)
- palpable guarding
- possible local swelling
- MRI, bone scan findings
What are 6 secondary responses to injury?
- Arthrogenic Muscle Inhibition (AMI)
- Guarding
- Ectopic calcification
- Atrophy
- Contracture
- Anxiety/fear
What is arthrogenic muscle inhibition?
- “continued reflex inhibition of musculature surrounding a joint following injury or joint effusion.”
- Compensation strategies may cause damage to joint structures by resulting in abnormal joint loading during activity performance
Guarding is an increase in the ______ activity level of a muscle related to a protective response from painful stimuli.
resting
What is ectopic calcification?
accumulation of osteoid material in soft tissue
What are the 2 types of instability?
- Neuromuscular (Functional) Instability
- Structural Instability
What is the difference between Neuromuscular and Structural Instability?
Neuromuscular
-Poor neuromuscular control, typically thought to be secondary to an injury, resulting in aberrant movement patterns and subsequent harm to involved structures (e.g. deep neck flexors & paraspinals following trauma)
Structural
-Disruption in the continuity of an anatomic structure that limits the structure’s ability to accept loading (fracture, ligament rupture or laxity, etc.)
Conclusions:
- Systematic, but individualized process
- Embrace the gray
- Examination is a process of the ongoing evolution of your hypothesis
- Determine pre-test probability of health conditions
- Refine hypothesis during patient interview and each component of physical examination
- Establish safety/ appropriateness of continuing examination and certain examination tests
- ALWAYS consider evidence for examination components when modifying hypotheses
- ALWAYS look at examination findings in the context of the patient’s presentation as a whole
- Avoid conclusions based on a single finding
- Consider normal physiologic healing principles throughout patient management planning, as well as individual factors that might affect tissue healing
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