Orthopedic Manual

439 Pages·2014·60.73 MB·English

You are what you don’t excrete
• An accurate working diagnosis (including stage of healing, severity of injury & pathoanatomy) is
required to ensure proper treatment & restore a patient to health
• -75% of diagnosis comes from history & another 15% comes form physical exam
Table of Contents
• When special tests are indicated, the significance of their results cannot be fully understood
in isolation or without knowing the likelihood of the condition, test validity & potential for false
Introduction ...............1
positives or false negatives
• Prioritize a differential diagnosis list Spinal
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Head & Neck ...........17 o s
TL--ssppiinnee && RPeiblvsi .s. . ............6899 oducti Elbow stemic
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Upper Extremity nt S
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Shoulder & Arm ......121
Elbow ......................151
Wrist & Hand ...........169
o
Lower Extremity ck nd eur
e a N
Hip & Thigh ............193 & N & H al
Knee .......................231 d t er
a s h
Leg, Ankle & Foot ...263 He Wri rip
Systemics ..................299 Pe
Peripheral Neuro .......345
Rehab protocols ........371
s
Appendix ....................397 Ribs gh ocol
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research & design were spent to develop the content & format. This text bridges T- e
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the gap between basic academic learning and practical clinical application.
Information sources include: thousands of original research articles with cutting-
edge information, pathoanatomy & kinesiology texts, cadaver dissections & decades
of evidence based best practices & multidisciplinary clinical experience. vis
Illustrations have been drawn and adapted from the greatest illustrators of all el x
time; Dr. Paul Richer ‘Artistic Anatomy’, Dr. H.V. Carter ‘Gray’s Anatomy’ - the same & P ee ndi
sources used by Frank Netter). Coil binding allows the book to lay flat; chapters are e Kn pe
n p
marked with soft tabs, icons & the start of each chapter provides a detailed table of pi A
contents for that section. S
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In order to get the most clinical utility from this text, it must be available at all
times, as such the books size allows for easy transport & storage. The paper used
is uncoated to allow you to write your own notes directly on the pages. Do not be
fooled, this text contains more useful information than most full-size textbooks and m ot
r o
is supported by numerous student, clinician & instructor Apps, quizzes, video & A F
patient handouts on our website. & &
To help ensure gender equity, ‘his’ & ‘her’ are used interchangeable throughout der kle
the text. The ☺ symbol signifies a section containing humor, laughter is optional ☺. oul An
“The doctor of the future will give no medicine, but will interest her or his patients in the Sh eg,
care of the human frame, in a proper diet & in the cause & prevention of disease.” L
Thomas A Edison
Vizniak www.prohealthsys.com Introduction | i
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Evidence Informed Practice
Evidence ‘Informed’ or ‘Based’ Medicine? Evidence Informed Practice Model
Evidence-Based Medicine (EBM) is the
conscientious use of current best evidence in Healthcare
making decisions about the assessment & care of Resources
individual patients1. All healthcare providers must
realize that EBM alone is not enough for effective
utilization of best practices & must be integrated with
the following fundamental abilities to make evidence
informed clinical decisions: Research Clinical Clinical
• A detailed understanding of pathoanatomy & Evidence Expertise Presentation
Experience
expertise in performing a history, examination &
condition management (including referrals)
• Understanding of the patient’s family, personal &
social history & the community in which they live
Patient Preferences
• Developing a relationship with the patient & Actions
formed by mutual respect & an understanding
of their desires, beliefs & values to help create a
functional context for therapeutic decision-making
An evidence-informed medicine (EIM) approach Hierarchy of Evidence
helps to promote life-long learning & liberates
clinicians from a reliance on tradition, which further
Practice
permits the critical evaluation of both traditional & Guidelines
alternative therapies on an even playing field. EIM Systemic
puts the patient at the center of care by emphasizing Reviews
outcome markers that matter directly to patients Synopsis in EBM
such as pain, activities of daily living, quality of life & journals & texts
even cost (financial & personal). Original RCTs & other studies
Why use Evidence-Informed Medicine? Expert Opinions & Consensus
It provides a solid foundation for evaluation of
new evidence from the literature, critical appraisal Personal Experience (foundation)
of existing practices, & the effective use of clinical
information gathered from patients. Gathering information?
Perhaps the most direct change due to EIM is To be useful, information must be relevant
the potential improvement in clinical efficiency, which to everyday practice, valid, easy to obtain & low
results in reduced healthcare costs by improving cost. Knowing where to look for answers to clinical
both assessment & treatment, as well as a net questions is an important skill. Most clinicians gather
increase in earning potential for its providers as they information from a wide variety of sources;
are better able to competently see more patients in a
1. Straus SE, et al. Evidence Based Medicine. 4th Edition. Churchill Livingstone:
given time period. Edinburgh, 2011.
Information source Relevance Validity Work Cost Usefulness
Evidence-based textbook/website High High Low Low High
Systematic review (evidence-based) High High Low High High
Asking colleagues High Mod Low Low High-mod
Practice guidelines (evidence-based) Mod High Low Low High-mod
Practice guidelines (consensus) Mod Mod Low Low Mod
Original journal articles Low High Very High High Low
ProHealth resources are relevant to everyday practice, valid, easy to obtain & free or low cost!
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Clinical Problem Solving
A detailed history & physical exam in combination with critical thinking, past
experience and education are your most useful diagnostic tools!
True understanding is gained through clinical experience, based on the foundations learned in class
• Epidemiology - Who gets this disease?
• Demographics (age, gender, race)
• Risk factors (other conditions, environment, genetics, past medical history)
• Exposure (drugs, exercise, travel, occupation, activities, hobby, sexual)
• Time course - What is the typical timing?
• Onset (acute, subacute, chronic)
• Pattern (constant, episodic)
• Clinical presentation - What are the classic signs & symptoms?
• Classic signs & symptoms (key differential features from other similar syndromes)
• Must have feature to be diagnosis (exclude past diagnosis unless it was unequivocally correct - avoid
confirmation bias from prior inaccurate assessment)
• Rejecting features (if present is not condition)
• Mechanism - What are the biomedical causes of this condition?
• Pathophysiology (anatomy, physiology, immunology, biochemical pathway, genetics)
• Environmental contributors (microbiology, toxin, medications, physical environment)
• Variants - master the classic rule before you learn exceptions (increase in experience will eventually give
a clear picture of condition)
Prioritized Differential Diagnosis
Clinical Likelihood Definition
Very likely (>90%) • Condition explains all of patient’s major findings
High • Patient has all major manifestations of condition
Likely (67-90%) • No rejecting features, may have defining feature
• Condition explains most of patient’s major findings
Moderate Uncertain (34-66%) • Patient has some major manifestations of condition
• No rejecting features
Unlikely (10-33%)
• Patient has single or few features of condition
Low
• Patient has rejecting feature of condition
Very unlikely (<10%)
• Special tests are usually not indicated if a condition is very likely or very unlikely, unless the condition is a
high risk treatment or diagnosis (e.g. cancers)
• Good tests move the likelihood of a condition up or down one level (e.g. from moderate to high likelihood)
- sensitivity & specificity from ~85-99% are considered good tests
• Special considerations
• if you need to rule out a disease, use a test with >99% sensitivity
• If you need to rule in a disease, find a test with >99% specificity
• Establish a DDx, Choose correct test, Perform test correctly, Interpret test correctly - give accurate
diagnosis, treatment, co-management or referral
Clinicians should cluster their special test to improve the accuracy of diagnosis - choose a
minimum 3 tests of that you can perform & interpret well for a given condition.
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Level Regions supplies Effect
Occipital, vertrbral artery blood Headache, dizziness,
C0
to brain, suboccipital muscles vertigo
Sensitivity & Specificity
Bones of cranium, middle & Headache, vertigo, muscle
C1
inner ear, sympathetic NS tension, fatigue
------------------------ Test Diagnostic Accuracy - Remember the Basics ------------------------
C2
Sensitivity: high sensitivity helps the examiner rule out a disorder. SnOut!
Specificity: high specificity helps the examiner rule in a disorder. SpIn!
C3 +LR > 1 helps rule in (bigger number is better), -LR < 1 helps rule out (smaller number is better)
C4
C5
C6
C7
T1
T2
T3
Sensitivity (SN) - ‘SnOut’ - rule out Specificity (SP) ‘SpIn’ - rule in
T4
Definition: probability of a positive test among Definition: probability of a negative test among
patients with disease patients without disease
T5 Highly Sensitive Tests are Best used to Highly Specific Tests are Best used to
Rule Out disease Rule In disease
T6 Help to identify patients WITH disease Help to identify patients WITHOUT disease
(true positives) (true negatives)
T7 In general, as a test becomes more sensitive, it becomes less specific, and vice versa
T8 • Likelihood ratios (LRs) use multipPlea t“ielenvtse lWs”I ToHf pcoonsditiitvioen (i.e. not jusPt aat iseinmtsp Wle IyTeHsO/nUoT o cro pnodsitiiotinve/
negative result) which provide much better, more useful information to you as a clinician and
Patients who test POSITIVE
help take into consideration the suTbrtuleet iPeoss oitfi vinetse r(pTrPe)ting many physicFaal lesxea Pmo spirtoivcee d(FuPre)s
T9 (Positive Predictive Value)
• +LR > 1 indicates increased probability condition is present (bigger is better, > 10 is excellent)
Patients who test NEGATIVE
False Negative (FN) True Negative (TN)
T10 (•N e-LgRat i<v e1 Pinreddicicatitvees Vaa dlueec)reased probability that disorder is present (smaller is better)
T11
Negative Predictive Value (NPV) Positive Predictive Value (PPV)
Percentage of patients who both test negative & do Percentage of patients who both test positive &
T12
not have disease (true negatives) have the disease (true positives)
Sensitivity & specificity by themselves are only useful when they are very high (~95% or higher)
Predictive values help answer the question: “Given a positive or negative test result, what is the
new probability of disease?” - realize that the predictive value varies with the pre-test probability
of disease - the same test result may give one post-test probability on the playing field, and differ-
ent one in your office, if the pre-test probabilities changes so does the predictive value.
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Select Therapeutic Interventions
Least Invasive Basic Therapeutic Options Most Invasive Osseous Electro-Bioenergetic Soft tissue InsertionIngestionInjectionMeditationTalkSurgerymanipulationtherapymanipulationmanipulation ExerciseNutritionAcupunctureStretchingMobilizationCounselingSittingHerbsIntermuscular US, TENS, Strengthening MedicationsMinor/ManipulationHelp groupsTouch therapyArt therapyBotanicalsstimulation MENS, IFCMassageProlotherapymajor(Adjustments)PrayerVisualizationGarden Homeopathics(IMS)LaserPNF, CR, IASTMMusic therapytherapyMedicationsDry NeedlingAcupressureHeat, Cold, Hydro Techniques favored by Selected Healthcare providers Psychotherapeutic approachesDietitianMassage therapyAllopathic & osteopathic Chiropractic, osteopathic, physical therapy Naturopathic Traditional Chinese Medicine HerbalistMovement therapies (yoga, exercise) Note that this is not a complete list & individual practitioners may offer a variety of therapeutic interventions depending upon the local scope of practice & practitioner educational level. US = ultrasound (therapeutic), TENS = transcutaneous electrical neuromuscular stimulation, MENS = microcurrent, IFC = interferrential current, CR = contract-relax, PNF = proprioceptive neuromuscular facilitation, IASTM = instrument assisted soft tissue manipulation
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Soft Tissue Healing
Wound & Hemostasis (bleeding)
• If superficial wound consider topical antimicrobials - Calendula, polysporin
• Avoid medications, botanicals, vitamins & minerals that affect clotting & prolong
bleeding time
1. Acute Inflammation (after injury, hematoma formation)
• Usually 1-2 days, may last up to 5 days (depends on tissue & severity of injury)
• Cardinal Signs (SHARP) - Swelling, Heat, A loss of function, Redness, & Pain
(chemical irritation & nerve pressure) - may not reach peak until 5-7 days post injury
• Consider: Vitamin A, increase protein intake, bromelain
• Vitamin C enhances neutrophil migration & lymphocyte transformation
Clinical Objectives: relieve pain; prevent further injury, initiate vasoconstriction;
increase circulation; maintain muscle tone & PFROM; reduce effects of ischemia,
address psychosocial issues
2. Post Acute Repair/ Proliferation (scar tissue formation)
• May last from 48 hours up to 6+ weeks
• Involves synthesis & deposition of collagen; macrophages/phagocytes remove cell
debris, erythrocytes, & fibrin clot
• Collagen is not oriented in direction of tensile strength & quality is inferior to original
• Nutritional support (see specific tissues)
• Increase vitamin C & Centella asiatica - promotes type 1 collagen synthesis
• Glucosamine - for GAG synthesis & hyaluronic acid production
Video
• Zinc, Mn, Mg, Ca for protein synthesis, DNA synthesis & cell division
Clinical Objectives: prevent early adhesions; orient repair tissue along line of tension;
relieve pain; maintain normal muscle tone; maintain normal ROM, reduce edema,
PFROM & exercise to return to normal activity ASAP, address psychosocial issues
to prevent transition to chronic condition
3. Remodelling (fibroblastic activity & fibrosis)
• May last from 3 weeks to 12+ months
• Collagen is remodeled to increase the functional capabilities of the tissue in the
direction of stresses imposed upon it (PFROM/stretching help re-establish strength)
• New collagen forms which increases tensile strength of wounds
• Scar tissue is ~80% as strong as original tissue & residual fibrosis is common
Clinical Objectives: maintain nutrition, ppprrrooopppeeerrr aaallliiigggnnnmmmeeennnttt ooofff rrreeepppaaaiiirrr cccooollllllaaagggeeennn;;; iiinnncccrrreeeaaassseee eeelllaaassstttiiiccciiitttyyy ooofff ssscccaaarrr
tissue; reduce fibrotic adhesions; relieve muscle spasms; increase strength; increase range of motion;
normalize joint & muscle activity, address psychosocial issues, prevent chronicity & permanent
impairment
Tissue Repair Phase & Time Scale
bleeding
1. Inflammation
2. Post acute Proliferation
3. Remodelling
Minutes Hours Days Weeks Months Years
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