Test 1

Why Do We Need a Standard Reference?

• Consistency

• Communication

• Documentation

Why do we need consistency?

Everyone describes the body from the same reference position

Why do we need communication?

Clinicians can communicate location and movement clearly.

Why do we need documentation?

Findings can be recorded precisely and interpreted by others

Anatomical terminology removes ________.

ambiguity

Anatomical Position

• Body upright (or described as if upright)

• Head and eyes facing forward

• Upper extremities at the sides

• Palms facing forward

• Lower extremities straight

• Feet/toes pointing forward

Anatomical descriptions are based on this standardized position, even…

when the patient is sitting, lying down, or moving

Superior

toward the head / above

Inferior

toward the feet / below

Anterior

toward the front

Posterior

toward the back

Medial

toward the midline

Lateral

away from the midline

PROXIMAL

closer to the trunk or point of attachment

Distal

farther from the trunk or point of attachment

Superficial

closer to the body's surface

Deep

farther from the body's surface

Directional terms describe relationships, not…

isolated structures

IPSILATERAL

on the same side of the body

CONTRALATERAL

on the opposite side of the body

The Three Anatomical Planes

• Sagittal

• Frontal/Coronal

• Transverse

Sagittal Plane

• Divides the body into right and left portions.

• Common motions: flexion & extension

Frontal/Coronal Plane

• Divides the body into anterior and posterior portions.

• Common motions: abduction & adduction

Transverse Plane

• Divides the body into superior and inferior portions.

• Common motions: rotation

Flexion

decreases joint angle

Extension

increases joint angle

ABduction

away from midline

ADduction

toward midline

Internal Rotation

rotation toward midline

External Rotation

rotation away from midline

Pronation

the rotational movement that turns your palm to face downward or backward

• Forearm

Supination

rotational movement that turns your palm to face upward or forward

• Forearm

Dorsiflexion

the upward movement of the foot at the ankle joint that brings your toes and the top of your foot closer to your shin

Plantarflexion

the movement where you point your foot and toes downward, away from your shin and body

Inverson

the movement where the sole of the foot turns inward toward the midline of the body

Eversion

the anatomical movement of the sole of the foot away from the midline of the body

Elevation

upward movement of the shoulder blades toward the ears

Depression

the downward movement of the shoulder blades (scapula) away from the ears along the rib cage

Protraction

the act of moving a body part forward or extending something in duration

• Scapula

Retraction

the posterior and medial movement of a body part back toward the midline or its original resting position

• Scapula

Lateral flexion

side-bending

Rotation

a twisting movement where a bone or body part moves around its own central longitudinal axis

VALGUS

Distal segment moves away from the body's midline.

• Example: knee valgus

VARUS

Distal segment moves toward the body's midline.

• Example: knee varus

Injury initiates a series of responses known as…

inflammation and repair

STANDARD PROCEDURE

The body follows a general process intended to return the injured area toward normal

HEALING PROCESS

The process is consistent and predictable, but it is a changing continuum of events.

PRIMARY INTENTION

• Separation of tissue is small.

• A bridge of cells binds the tissue together.

• Examples: minor wounds; surgery when the ends are sutured together

SECONDARY INTENTION

• Wound ends are farther apart.

• The body must produce tissue from the bottom and sides of the wound to fill the space.

• Example: secondary ligament sprains.

Healing Process | Three Phases

1. ACUTE INFLAMMATION

   1. Control the area of injury

2. PROLIFERATION

   1. First stage of tissue repair

3. MATURATION

   1. Clean up and increase strength

Phase 1 | Acute Inflammation

• Sum of the body's tissue reactions to cell injury and death.

• Purpose: control the area of injury.

• Five cardinal signs are present.

• If the duration is excessive, the effects are detrimental

5 CARDINAL SIGNS

• Redness

• Swelling

• Tenderness

• Increased temperature

• Loss of function

Acute Inflammation | Vascular Response

1. TRANSIENT VASOCONSTRICTION

   1. Occurs first.

2. VASODILATION

   1. Follows and increases capillary permeability.

3. EXUDATE FORMATION

   1. Escaping cells create an osmotic gradient; platelets and serum proteins enter the injured area.

4. CHEMOTAXIS / CLOTTING

   1. Released products stimulate chemical release and clotting factors

Acute Inflammation | Phagocytosis

5–6 HOURS

• Neutrophils and polymorphonuclear leukocytes (PMNs) appear and begin debris removal.

24–48 HOURS

• Monocytes and macrophages become the predominant cells.

PHAGOCYTES

• PMNs and macrophages act as phagocytes to remove debris.

Phagocytosis =

removal of debris

Acute Inflammation | Clot & Lymphatic Response

CLOT FORMATION

• Fibronectin binds with collagen and fibrin.

• The clot is temporary, shuts off blood flow to the area, and walls off the injury.

LYMPHATIC DISRUPTION

• Small lymph vessels are damaged and can become clogged by fibrin.

• This slows removal of fluid from extracellular spaces.

Why does redness occur during inflammation?

Histamine + vasodilation

why does SWELLING / EDEMA occur during inflammation?

Increased substance in the area + blockage of lymph vessels

Why does TENDERNESS / PAIN occur during inflammation?

Chemical irritation of local nerve endings + pressure from edema

Why does INCREASED TEMPERATURE happen during inflammation?

Increased local cellular and chemical activity

Why does LOSS OF FUNCTION occur during inflammation?

Pain + injured tissue

Phase 2 | Proliferation

• Removal of debris formed during the inflammatory phase continues.

• This is the first stage of tissue repair.

• The hallmark is revascularization and formation of granulation tissue.

• Scar formation requires vascular production.

• Fibroblasts are largely responsible for production of new growth.

• Increasing numbers of fibroblasts mark the proliferation phase.

• Generally lasts 2–4 weeks

Proliferation | Granulation Tissue

MATRIX

• Part of granulation tissue.

CAPILLARY BUDS

• Part of granulation tissue.

PLASMINOGEN ACTIVATOR

• Breaks down the fibrin network to restore lymph flow.

FIBROUS COMPONENTS

• Collagen

• Elastin

GROUND SUBSTANCE

• GAGs

• Proteoglycans

• Glycoproteins

• Fills gaps between fibrous elements

Proliferation | Collagen Transition

Type III collagen —> Type I collagen

Phase 3 | Maturation

• “Cleans up” the area and increases strength of repaired

  tissue.

• Fibroblasts disappear as they convert to myofibroblasts.

• Myofibroblasts shrink or contract the wound size.

• Wound contraction is beneficial unless it causes loss of

  mobility or function.

• The emphasis shifts toward strengthening and organizing the repaired tissue

Maturation | Increasing Tissue Strength

• Vascularity is reduced.

• Fibroblasts diminish.

• Fluid content decreases.

• Collagen forms more cross-links.

• Tissue tensile strength increases.

• Collagen fibers align in a more organized, parallel fashion.

• May last up to one year

ACUTE Inflammation

Normally complete in 2 weeks.

SUBACUTE Inflammation

If the reaction continues for 1 month

CHRONIC Inflammation

If the reaction continues for months or years

When Inflammation Persists

• Loss of function may be the only sign remaining.

• The body is still reacting to the presence of foreign material.

• Large quantities of collagen often envelop the affected area

Factors That Modify Inflammation & Repair

PATIENT FACTORS

• Age • Health • Nutrition

MEDICATIONS

• Corticosteroids may impair the proliferation phase.

IMMOBILIZATION

• Prolonged immobilization

TRAUMA

Physical injury or wound produced by an internal or external force

MECHANICAL INJURY

Results from force or mechanical energy that changes the state of rest or uniform motion of matter.

SIGN

• Observable

• Objectively measurable

• Examples:

  • Swelling • discoloration • deformity • crepitus • redness

SYMPTOM

• Subjective complaint

• Abnormal sensation described by the patient

• Examples:

  • Pain • nausea • altered sensation • fatigue

ACUTE Injury

• Sudden onset

• Usually from a single traumatic event

• Short in duration

CHRONIC Injury

• Gradual onset

• Exact mechanism often not known

• Patient may not identify a specific date of injury

• Prolonged duration

Contusion

• “Bruise”

• Compression of soft tissue by a direct blow or impact.

• Disrupts small capillaries within the tissue.

• Results in ecchymosis.

ecchymosis

Bruise

Sprain Injures what?

Ligament or capsular structure

• POSSIBLE RESULT: Laxity of the involved ligament or capsule

WHAT DO LIGAMENTS DO?

Ligaments connect bone to bone

Strain is a injury to what?

Muscle or tendon

How does a sprain occur?

Violent, forceful contraction

OR

overstretching of the myotendon unit

Strain V. Sprain

• Sprain = ligament/capsule

• Strain = muscle/tendon

SUBLUXATION

• Incomplete disassociation of two joint surfaces.

• More common than a dislocation.

• Can be difficult to identify because it may reduce on its own

DISLOCATION

• Complete disassociation of two joint surfaces.

• Results when forces cause the joint to exceed its normal ROM.

Clinical Evaluation & Diagnosis

• A clinical evaluation is more detailed than a basic assessment.

• The overall examination outline remains consistent.

• Specific special tests vary by body region and suspected

  injury.

• Evaluation findings help guide a clinical impression, treatment planning, and/or referral

CLINICAL REASONING

Your examination is not a collection of random tests. Each step should help you gather information about the patient's problem

CLINICAL / PHYSICAL DIAGNOSIS

• Based on the external examination and clinical findings.

• Used to identify the likely pathology or structures involved

MEDICAL DIAGNOSIS

• Reserved for physicians in the provided course reference.

• May involve additional diagnostic testing

Before You Touch the Patient | Introduce Yourself

1 - WHO YOU ARE

• State your name and role.

2 - WHY YOU'RE HERE

• Briefly explain the purpose of the evaluation.

3 - WHAT TO EXPECT

• Describe what you plan to do before you begin.

Consent Is a Process — Not a Single Question

EXPLAIN

• Tell the patient what you want to do and why.

ASK

• Obtain permission before beginning the examination or a new hands-on procedure.

CHECK IN

• Continue to monitor comfort and willingness as the examination progresses.

PATIENT CONTROL

The patient can ask questions, decline a procedure, or ask you to stop. Respect the response and adapt the examination appropriately

Patient-Centered Orthopedic Examination

LISTEN

• Start with the patient's concerns, goals, and description of the problem.

EXPLAIN

• Use clear language and tell the patient what you are doing.

RESPECT

• Protect privacy, dignity, comfort, and individual preferences.

COLLABORATE

• Include the patient in decisions about the pace and progression of the examination.

RESPOND

• Modify or stop when symptoms, concerns, or patient preferences require it.

CONFIRM

• Check understanding and invite questions throughout

SUBJECTIVE Part tells you what

What does the patient tell you?

OBJECTIVE part tells you what?

What do you observe or measure?

the ASSESSMENT tells you what?

What is your professional impression?

Documentation Matters

• Complete and accurate documentation is critical.

• Records should be clear, concise, and accurate.

• Documentation supports communication among providers.

• Good documentation contributes to quality patient care.

• The provided course reference also notes its importance for third-party billing.

DOCUMENT THE STORY

Your record should allow another provider to understand what the patient reported, what you found, your impression, and your plan

SOAP Notes | A Documentation Framework

• S • SUBJECTIVE

• O • OBJECTIVE

• A • ASSESSMENT

• P • PLAN