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S3- Musculoskeletal > Ortho Intro > Flashcards

Ortho Intro Flashcards

1
Q

PART 1: CLINICAL REASONING INTRODUCTION

A

PART 1: CLINICAL REASONING INTRODUCTION

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2
Q

Clinical reasoning is collaborative, reflective, and _________ and __________.

A

conscious and unconscious

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3
Q

The goal of clinical reasoning is to formulate a working __________ and select _________ (examination and intervention).

A
  • diagnosis

- procedures

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4
Q

Clinical reasoning is based on clinical findings, _______ choices, and the clinician’s judgment based on their knowledge, experience, and evidence.

A

patient

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5
Q

What are the 3 problem solving methods?

A
  • Pattern Recognition (System I)
  • Hypothetico-Deductive (System II)
  • Mixed (diagnostic reasoning)
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6
Q

Which problem solving method is our “forward reasoning” and is faster, more effecient, and develops “scripts”.

A

Pattern Recognition

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7
Q

Which problem solving method is our “backward reasoning” and has a heavy reliance in novice practice?

A

Hypothetico-Deductive

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8
Q
  • Which problem solving methods do experts use in familiar instances?
  • Which do they use in unfamiliar instances?
A
  • Pattern Recognition (System I)

- Hypothetico-Deductive (System II)

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9
Q

What are 4 different types of reasoning used in the clinic?

A
  • Probabilistic
  • Causal
  • Case-Based
  • Narrative
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10
Q

Probabilistic Reasoning is assessing the likelihood of a clinical hypothesis via either ______ or __________, but the more common is ___________.

A
  • statistic
  • approximated
  • approximated
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11
Q

Causal Reasoning is based on a _____ and _______ relationship of variables and normal/abnormal physiology.

A

cause and effect

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12
Q

Case-Based Reasoning is our knowledge stored in a symbolic “_____” that is recalled in subsequent encounters with similar circumstances.

A

script

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13
Q

Narrative Reasoning concerns the understanding of ________ stories to gain insight into their experiences of disability or pain and their subsequent _______, ________, and ______ behaviors.

A
  • patients’

- beliefs, feelings, and health behaviors

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14
Q

Which reasoning is the source of many assumptions that are made in a clinic?

A

Causal Reasoning

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15
Q

What are the 2 main strategies used when faced with uncertainty and is used to reduce said uncertainty?

A
  • Elimination Strategy

- Confirmation Strategy

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16
Q

The elimination strategy is seeking data to ______ suspicion of an unlikely hypothesis and uses _________ likelihood ratio.

A
  • reduce

- negative

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17
Q
  • What is negative likelihood ratio?

- What are the values of importance and significant importance?

A
  • 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
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18
Q

The confirmation strategy is seeking data to ______ a highly likely hypothesis and uses _________ likelihood ratio.

A
  • support

- positive

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19
Q
  • What is positive likelihood ratio?

- What are the values of importance and significant importance?

A
  • 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
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20
Q

We want to administer elimination strategies ______ in the exam and confirmation strategies _______ in the exam.

A
  • early

- later

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21
Q

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

A
  • refute

- confirm

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22
Q

What is a 3rd strategy used to reduce uncertainty and what is it?

A
  • Discrimination Strategy

- Seeking information to discriminate between likely hypothesis

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23
Q

Ockham’s Razor = ?

A

“The simplest solution may be the best”

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24
Q

Hickman’s Dictum = ?

A

“Patients can have as many diseases as they damn well please”

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25
Q

What is the basic process involving the funneling in the differential process of diagnosis? (3 main things)

A
  1. ) Initial data gathered and preliminary diagnosis and hypothesis generation
  2. ) Hypothesis are modified/refined
  3. ) Hypothesis are verified
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26
Q

What are some elements of Initial Hypothesis Generation?

A
  • 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
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27
Q

What is the test-retest model?

A

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.

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28
Q

PART 2: THE ORTHOPEDIC EXAMINATION

A

PART 2: THE ORTHOPEDIC EXAMINATION

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29
Q

What is the 1st part of the orthopedic examination?

A

Chart Review/ Patient Interview

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30
Q

The _______ _______ ________ ________ is an individualized measure intended to reflect functional status.

A

Patient Specific Functional Scale (PSFS)

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31
Q

With the PSFS, the pt identifies activities which performance has been limited. What is the grading scale they use?

A

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

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32
Q
  • 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.
A
  • 2

- 3

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33
Q

What is the difference between red and yellow flags seen in the patient interview?

A

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

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34
Q

What are some screening questions done during the patient interview?

A
  • 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
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35
Q

How many red flag categories are there and what does each mean?

A

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

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36
Q

What is the 2nd part of the orthopedic examination?

A

Visual Inspection/ Physical Exam

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37
Q

With the visual inspection/physical exam, what are we looking for?

A
  • Status
  • Affect
  • Anthropometrics
  • Preferred positions
  • Integumentary
  • Posture
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38
Q

When assessing posture, what 3 things are we looking at?

A
  • Symmetry
  • Bony/soft contours
  • Resting posture vs ability to correct
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39
Q

What is the 3rd part of the orthopedic examination?

A

Systems Review

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40
Q

In the systems review, we test components that we ______ plan to assess further and ______ other procedures that we plan to test more thoroughly.

A
  • do not

- defer

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41
Q

What is the goal of the systems review?

A

Identify impairments for continued tests and measures.

  • Cardiopulmonary
  • Integumentary
  • Neuromuscular
  • Cognition/Affect
  • MSK
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42
Q

What is the 4th part of the orthopedic examination?

A

Elimination Tests

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43
Q

What is the difference between the systems review and elimination tests?

A

-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.

44
Q

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
A
  • regional
  • overpressure
  • strength
45
Q

Elimination Tests: Neurological Screening Tests

  • Sensation
    • _____ touch
    • _____ prick
    • __________
  • Motor Function
    • ________ vs peripheral nerve
    • _____________
  • Reflexes
    • DTR
    • __________ reflexes (present or absent)
A

Sensation

  • light touch
  • pin prick
  • proprioception

Motor Function

  • myotome vs peripheral nerve
  • coordination

Reflexes
-pathological reflexes

46
Q

What are the considerations for the Neurological Screening Tests?

A

-Is it symmetrical and is it normal/diminished/absent.

47
Q

Elimination Tests: Special Tests

  • What are the implications of performing special tests?
  • Special Tests involve ________-________ application.
A
  • Safety, Information Provided, Role in Differential

- Evidence-Based

48
Q

What is the Beighton Scale used to assess?

A

hypermobility

49
Q

What is the 5th part of the orthopedic examination?

A

Structural Stress Testing

50
Q

Structural stress testing involves what 3 things?

A
  • AROM
  • PROM
  • Resistive Testing
51
Q

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.

A

inductive

52
Q

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.

A
  • provocation

- ROM, muscle performance

53
Q

Symptoms can be either concordant or discordant, what does this mean?

A

Concordant- consistnet with pt’s complaints

Discordant- not consistent with pt’s complaints

54
Q
  • 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?
A
  • muscle, tendon, bony insertion

- resistive testing > active contraction and passive stretch

55
Q

What are examples of inert structures?

A

-joint capsule, ligament, bursa, fascia, dura mater, nerve, bone, disc

56
Q

What is the 6th part of the orthopedic examination?

A

Palpation and Joint Mobility Tests

57
Q

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
A
  • congruence
  • inflammation
  • pain
58
Q

Joint mobility testing is commonly performed in the _________ position of the joint. We stabilize the ________ segment.

A
  • resting

- proximal

59
Q

What are we assessing when performing joint mobility tests?

A
  • Symptom provocation
  • Quality (“Normal”, mechanical block, guarding)
  • Quantity (joint integrity, hyper/hypomobile)
  • Willingness
60
Q

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
A
  • articular
  • stabilizers
  • guarding
61
Q

What is the 7th part of the orthopedic examination?

A

Confirmation Tests

62
Q
  • When are confirmation tests used?
  • Do they use a + or - likelihood ratio?
  • Positive Test aids in ruling ___ a health condition.
A
  • They are used once the hypothesis has been narrowed
  • +LR
  • ruling in
63
Q

What are the 6 parts of the ICF model?

A
  • Health Condition
  • Body Functions and Structure
  • Activity Limitations
  • Participation Limitations
  • Environmental Factors
  • Personal Factors
64
Q

List some common impairments.

A
  • Pain
  • Tissue Damage
  • ROM
  • Joint Mobility
  • Posture
  • Muscle Guarding
  • Muscle Performance (coordination, endurance, strength)
65
Q

PART 3: TISSUE LOADING AND INJURY

A

PART 3: TISSUE LOADING AND INJURY

66
Q

What are 3 types of tissue loading? Describe each.

A

Tensile
-2 forces pulling opposite directions

Compression
-2 forces pushing together

Shear
-2 forces pushing “past” one another

67
Q

Concentrating forces into one area creates ________ loading, leading to what?

A

excessive, leading to breakdown of that area

68
Q

What are the 4 areas of the collagen stress strain curve?

A
  • Toe Region
  • Elastic Region
  • Plastic Region
  • Tissue Failure
69
Q
  • ___________ is low intensity of loading with high frequency and/or duration.
  • What are some examples of this?
A
  • Repetitive Stress

- Sponylolysthesis, Tennis Elbow

70
Q
  • ________ is high intensity of loading with low frequency.

- What is an example?

A
  • Trauma

- Fractured vertebrae related to a fall from a ladder

71
Q

What are the 3 classification of injuries and what are their time frames?

A

Acute
-typically 7-10 days

Subacute
-subsequent 5-10 days

Chronic
-Injury lasting longer than expected under “normal” healing conditions

72
Q

What are the 3 phases of tissue healing?

A
  • Phase I- acute inflammatory response
  • Phase II- repair and regeneration
  • Phase III- remodeling and maturation
73
Q

The 2 healing requirements for tissue healing are:

  1. ) Controlled forces necessary to facilitate tissue ________
  2. ) __________ from excessive and harmful stresses on tissue
A
  • synthesis

- protection

74
Q

Phase I of LIGAMENT tissue healing is in the first __ days and is the acute inflammatory response and ________ formation.

A
  • 3

- hematoma

75
Q

Phase II of LIGAMENT tissue healing is from __ days post injury to __ weeks. This is where __________ produce collagen and the matrix is ____________.

A
  • 3 days
  • 6 weeks
  • fibroblasts
  • disorganized
76
Q

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 _________.

A
  • 12 or more
  • parallel/organized
  • strength
77
Q
  • 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.
A
  • 3 days
  • 1 week, week 4
  • 2 months
78
Q

After initial healing, we have ________ tensile healing.

A

controlled

79
Q
  • What is tendinopathy?

- What are 3 types of tendinopathy?

A
  • Overarching term for injury of tendon.

- Tendonitis, Tenosynovitis, Tendinosis

80
Q

What is the difference between tendonitis, tenosynovitis, and tendinosis?

A

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

81
Q

Does tendinosis have an active inflammatory process?

A

No, failed healing response

82
Q

With Articular Cartilage, a loss of ____________ and ________ injury are 2 mechanisms of injury to articular cartilage?

A
  • proteoglycans

- mechanical

83
Q

With a loss of proteoglycans, the matrix reaches a certain amount of loss that is _________.

A

irreversible

84
Q

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.

A

extent, is it chondral or subchondral

85
Q

In an articular cartilage chondral injury, do we see an inflammatory response?

A

No, does not extend to the blood supply.

86
Q

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.

A
  • more

- fibrocartilage

87
Q

Why is a subchondral injury filling with fibrocartilage problematic?

A

That area of cartilage will accept loads differently which can lead to further injury or dislodgement of the fibrocartilage “plug”.

88
Q

Subchondral fibrin clots occur within ___ hours and will resemble “normal” cartilage within __ months. Erosive changes are observed around __ months.

A
  • 48 hrs
  • 2
  • 6
89
Q

Healing of articular cartilage injuries depend on the extent of the lesion (______ involved, size of _______).

A
  • zones

- lesion

90
Q

When it comes to tissue healing, we want “____ ________” tensile loading to stimulate healing but not too much.

A

just enough

91
Q

What is the common immobilization/protection timelines for bone tissue healing with adults and children?

A 
Adults= 6-8 weeks
Children= 4-6 weeks
92
Q

With bone healing, immobilization may be necessary to prevent excessive ______. Early excessive loading leads to a risk of __________. What is this?

A
  • shear

- pseudoarthrosis, failure of fusion

93
Q

With stress fractures remember _____ law.

A

Wolff’s law

-bone responds to forces imposed on it

94
Q

Pathophysiology of Stress Fractures:

  • Repetitive ____trauma
  • Osteo______ activity lags in comparison to osteo________ activity
  • Stress reaction may progress to _______ disruption, then complete fracture
A
  • microtrauma
  • osteoblast, osteoclasts
  • cortical
95
Q

Difference between fatigue fractures and insufficiency fractures.

A

Fatigue fractures
-Normal bone, abnormal stress

Insufficiency fractures
-Normal stress, abnormal bone

96
Q

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
A
  • insidious
  • progression
  • continual
  • 6-8 weeks
97
Q

What are the common symptoms of stress fractures?

A
  • focal pain
  • exercise-induced pain
  • night pain
98
Q

How will stress fractures present during a physical examination?

A
  • local tenderness
  • limited ROM (guarded vs painful endfeel)
  • palpable guarding
  • possible local swelling
  • MRI, bone scan findings
99
Q

What are 6 secondary responses to injury?

A
  • Arthrogenic Muscle Inhibition (AMI)
  • Guarding
  • Ectopic calcification
  • Atrophy
  • Contracture
  • Anxiety/fear
100
Q

What is arthrogenic muscle inhibition?

A
  • “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
101
Q

Guarding is an increase in the ______ activity level of a muscle related to a protective response from painful stimuli.

A

resting

102
Q

What is ectopic calcification?

A

accumulation of osteoid material in soft tissue

103
Q

What are the 2 types of instability?

A
  • Neuromuscular (Functional) Instability

- Structural Instability

104
Q

What is the difference between Neuromuscular and Structural Instability?

A

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.)

105
Q

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
A

1

S3- Musculoskeletal (27 decks)

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