Core - Section 02: General Knowledge

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SECTION 2: GENERAL KNOWLEDGE

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SECTION 2: GENERAL KNOWLEDGE

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13. Medicolegal Issues

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13. Medicolegal Issues

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Termination of the physician-patient relationship by the physician without reasonable notice to the patient at a time when the patient requires medical attention and without the opportunity to make arrangements for appropriate continuation and follow-up care.

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Abandonment

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Typically, a plaintiff’s responsibility to affirmatively prove a fact or facts in dispute on an issue raised between parties in a case.

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Burden of proof

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The causal connection between the act or omission of the defendant and the injury suffered by the plaintiff. The plaintiff must show causation of an injury by the defendant to prove negligence.

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Causation

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Money receivable through judicial order by a plaintiff sustaining harm, impairment, or loss to his or her person or property as the result of the accidental, intentional, or negligent act of another. Damages can be grouped into two primary types: compensatory and punitive.

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Damages

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______ ________ are to compensate the injured party for the injury sustained and nothing more. Compensatory damages can be divided into economic, noneconomic, and special damages.

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Compensatory damages

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__________ damages include an estimate of lost wages, both past and future, of the plaintiff and affected family members, and all costs associated with residual disability of the patient.

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Economic damages

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_________damages include intangible damage resulting from the negligent act such as pain and suffering, disfigurement, and interference with the ordinary enjoyment of life.

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Noneconomic damages

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_________ damages are the actual out-of-pocket losses incurred by the plaintiff, such as medical expenses, rehabilitation expenses, and earnings lost during treatment and recovery.

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Special damages

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__________ damages are awarded to punish a defendant who has acted maliciously or in reckless disregard of the plaintiff’s rights.

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Punitive damages

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Duty is the obligation of the physician to care for the patient in a manner that is consistent with the quality of care provided by other physicians in treating a patient’s particular condition.

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Duty

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______ is the intentional deception or misrepresentation that an individual knows to be false (or does not believe to be true) and he or she makes, knowing that the deception could result in some unauthorized benefit to himself or herself or some other person.

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Fraud

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Consent is “fully informed” only when the patient knows and understands the information necessary to make an informed decision about the treatment or procedure. There is no informed consent when the treatment or procedure extends beyond the scope of consent. For example, if the risk associated with the changed treatment or procedure is substantially different from that contemplated by the patient, the courts may find the original informed consent was not sufficient. There are certain circumstances for which special informed consent rules apply. These are medical emergencies, situations involving a minor, and those rare circumstances where authorization for treatment or procedure is obtained from a court.

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Informed Consent

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In the case of a physician, failure to exercise the degree of care and skill that a physician or surgeon of the same specialty would use under similar circumstances (professional negligence).

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Malpractice

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In medical malpractice cases, a legal cause of action involving the failure of a defendant physician to exercise that degree of diligence and care that an average qualified physician practicing in the same specialty as that of the defendant physician would have exercised in a similar situation, and which has resulted in the breach of a legal duty owed by the physician to the patient which proximately caused an injury which the law recognizes as deserving of compensation (damages).

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Negligence

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(“The thing speaks for itself”): A doctrine that may be invoked in a negligence action when the plaintiff has no direct evidence of negligence, but the injury itself leads to the inference that it would not have occurred in the absence of a negligent act. It raises an inference of the defendant’s negligence, thereby altering the burden of proof so that the defendant must produce evidence that he or she did not commit a negligent act.

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Res ipsa loquitur

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14. Medical Ethics

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14. Medical Ethics

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Breaches of medical professionalism include ____________ billing, ________ to maintain adequate medical records, and ____________ disclosure.

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inappropriate; failure; incomplete

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The three elements essential to informed consent are ________, __________ and __________.

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information, comprehension, and voluntariness

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Physicians may not accept gifts from industry valued greater than ______.

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$100

Front 22

Physicians attending _____________ _______ _________ courses may not accept subsidies for travel, lodging, recreational activities, or personal expenses.

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continuing medical education

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________ regulations prohibit a physician from referring a Medicare patient for certain designated health services to an entity with which the physician or immediate family member has a direct or indirect financial relationship.

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Stark II

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Essential components to improvement of ____ _______ and the rate or reporting of medical errors include emphasis on the patient over the practitioner; systems over the individual; proaction over retrospection; and maintenance of confidentiality.

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peer review

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_______ __________ may be established through oral conversations, living wills, or the appointment of a health care proxy.

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Advance directives

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Patient ___________ may be breached justifiably when a patient is at risk, when a third party is at risk, or when there is a legal obligation to do so.

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confidentiality

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The three essential components of the ________ ________ are respect for persons, beneficence in maximizing benefit and minimizing risk, and justice of distribution of benefits of human research.

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Belmont Report

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Cultural ________ will improve accuracy of, delivery of, and access to health care, thereby improving patient outcomes and satisfaction.

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competence

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15. Occupational Health/Work-Related Injury and Illness

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15. Occupational Health/Work-Related Injury and Illness

Front 30

A workers’ compensation claim is valid when a patient’s diagnosis is related to ____ exposure.

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work

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It is crucial that the history, review of medical records, and physical examination findings support the diagnosis and its _________ analysis.

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causation

Front 32

Workplace safety programs and _______ activities have greatly reduced major industrial accidents.

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OSHA

Front 33

Cumulative trauma/musculoskeletal disorders have become more obvious with the ______ of major work injuries.

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decline

Front 34

It is important to know the precise meanings of the terms often used in _______ _________ matters, including impairment, disease, illness, and disability.

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workers’ compensation

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Key factors in a workers’ compensation case include medical decisions about causation, treatment, light work status, and ________ impairments.

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residual

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Calling someone a _________ is an accusation, not a diagnosis.

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malingerer

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___________ is far more common than malingering.

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Somatization

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__________ patients often have a heightened sense of impairment.

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Depressed

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Early _______ __ _________ is an important key to obtaining a successful outcome after a work injury.

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return to work

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16. Musculoskeletal Imaging

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16. Musculoskeletal Imaging

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All clinical MRI scans image the protons in _________ atoms.

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hydrogen

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It is extremely important to screen patients with metallic objects before entering the MRI machine. ____________ objects in or on the body can be pulled toward the magnet and cause serious injuries.

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Ferromagnetic

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Patients with advanced _______ _________ should not receive gadolinium-containing contrast agents because exposure to the agent can cause development of ___________ ____________ ___________.

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kidney failure; nephrogenic fibrosing dermopathy

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A lower frequency ultrasound beam has a ________ wavelength and _____ resolution but ________ penetration.

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longer; less; deeper

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A higher frequency ultrasound beam can give __________ resolution for superficial structures such as tendons and ligaments.

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higher

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Caution is advised when ordering nuclear medicine tests for women who are ______ - ________; some of the pharmaceuticals can pass into the mother’s milk and subsequently into the child.

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breast-feeding

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Exposure to radiation decreases as an ________ _______ of the distance from the source.

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inverse square

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CT delivers the _________ radiation dosage of all imaging modalities.

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highest

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The risk of cancer is approximately ____ per sievert (100 rem).

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4%

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It is important to ensure that the patient is not _________ when obtaining any imaging examinations other than ultrasonography. Performance of other types of imaging examinations can be discussed in consultation with the radiologist and physician.

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pregnant

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17. Perioperative Medical Management

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17. Perioperative Medical Management

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Choose preoperative tests that assess for stability of current comorbidities or diagnose unclear symptoms or signs. _____ ________ policies are not cost effective and can be misleading.

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Blanket testing

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A directed ________ history can help to identify patients for whom preoperative bleeding tests are most useful.

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bleeding

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The _______ is a simple and highly predictive way to identify patients who should be referred to cardiology or should have surgery delayed.

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RCRI

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Risk for cardiac events can be substantially lowered if _______ are used appropriately in high-risk patients, specifically those with two or more RCRI criteria.

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ß-blockers

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Pulmonary complications such as ___________ and ________ __________ are probably more common than cardiac complications.

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pneumonia & respiratory failure

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Risk for pulmonary complications can be managed through treating an exacerbation of asthma or COPD before surgery, as well as early mobilization, use of incentive spirometers, nebulizers, and noninvasive ventilation (such as _________).

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BiPAP

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In general, maintaining blood glucose levels below _____________ in postoperative patients is optimal. Achieving this goal requires use of insulin infusions (ICU patients) or sliding scales, which include both short- and long-acting insulin.

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150 mg/dL

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Postoperative delirium is common, and can be managed effectively by minimizing noxious stimuli (eg, pain, indwelling urinary catheters, restraints), and by __________ patients as often as possible.

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reorienting

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Careful consideration of continuing _________ in patients with coronary artery stents is required; these patients are at high risk for stent restenosis and death if antiplatelet agents are discontinued.

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aspirin

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Management of warfarin around the time of surgery is predicated on the underlying reason for warfarin use—in general, shorter duration of time off warfarin (or bridging therapy with _______) is required for patients at higher risk for thrombotic complications when not anticoagulated.

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heparin

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18. Coagulation and Thromboembolism

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18. Coagulation and Thromboembolism

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LMWH inhibits _______ activity.

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factor Xa

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____________ is a synthetic pentasaccharide and an indirect inhibitor of factor X activity.

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Fondaparinux

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Both LMWH and fondaparinux are metabolized in the _________; warfarin is metabolized primarily in the liver.

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kidneys

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Patients undergoing major elective orthopaedic surgery such as hip and knee arthroplasty and those who have sustained multiple trauma and ________ _______ fractures are at high risk for thromboembolic events.

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proximal femoral

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The selection of a prophylactic agent requires balancing _________ and _________.

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efficacy and safety

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The diagnosis of thromboembolic events can be difficult to make postoperatively; clinical signs and symptoms are ________ ______ ____________.

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unreliable for diagnosis

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Initial evaluation of the patient suspected of PE includes an __________, __________ and _____________ to rule out an alternative diagnosis.

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arterial blood gas (ABG) on room air, a chest radiograph, and an ECG

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Pulse oximetry is not an adequate alternative to an ABG as patient ________ can maintain adequate oxygenation.

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hyperventilation

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Treatment of thromboembolic events with ___________ or __________ followed by oral warfarin is effective at reducing morbidity and mortality.

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intravenous heparin or LMWH

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______ _______ are indicated for patients diagnosed with a pulmonary embolus in whom anticoagulation is contraindicated or a bleeding complication has occurred, or if cardiopulmonary reserve is poor.

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IVC filters

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19. Blood Management

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19. Blood Management

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Optimal blood management constitutes proactive processes, techniques, drugs, or medical devices that reduce the need for ____________ blood when employed in an efficient, effective, and timely manner.

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allogeneic

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Blood use is ___________ in many hospitals because of poor training and inadequate oversight, review, and monitoring of transfusion practices.

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suboptimal

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Although the blood supply is the safest it has ever been, transfusion of blood components remains a __________ procedure that results in some degree of harm to all patients.

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high-risk

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Storage of blood (allogeneic and autologous) results in a progressive decline in the quality of the red cells and an increase in __________ __________.

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inflammatory mediators

Front 78

Formal ___________ for preoperative testing of hemoglobin for major blood loss surgeries and coagulation status testing in certain patient populations are important for early identification and intervention.

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protocols

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A core element of perioperative blood management is the use of _______ ________ values to make evidence based transfusion decisions. Absence of timely information often leads to excessive or improper selection of blood products, unnecessarily exposing patients to harm. There should be ready availability of hemoglobin or hematocrit testing in the perioperative period. Coagulation and platelet function testing also are useful in complex patients.

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measured laboratory

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After adequate patient preparation, the next most important orthopaedic blood management strategy is __________ yet efficient surgical technique.

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meticulous

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Postoperative transfusion decisions also should be based on measured laboratory values using _________-_______ protocols.

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evidence-based

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Major orthopaedic surgery is associated with large amounts of blood loss, with a _____ reported rate of allogeneic and autologous transfusions after primary hip and knee arthroplasty.

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46%

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Many symptoms in postoperative orthopaedic patients attributed to anemia are more causally related to volume deficits from postoperative bleeding. Aggressive but well-monitored volume replacement is generally sufficient to allow rehabilitation and timely discharge in postoperative patients with hemoglobin levels in the _____ to ___ g/dL range.

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7 to 8

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20. Normal & Pathologic Gait

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20. Normal & Pathologic Gait

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A gait cycle, also known as a stride, is the complete sequence of all the functions of a single limb during walking, from initial contact to initial contact. The sections of the gait cycle are often expressed as a percentage, beginning with the ___________ with the floor (0%) and ending with the most terminal portion of swing (100%).

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initial contact of the foot

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The sections of the gait cycle—initial contact, single-limb support, etc.—describe the events that occur. The three tasks required during gait are of more conceptual importance, however. During stance, the leg must _______, _________ and during swing the limb must be ___________.

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(a) accept body weight and (b) provide single-limb support; (c) during swing, the limb must be advanced.

Front 87

The normal gait cycle has two periods (stance and swing), and eight phases - name the eight phases.

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initial contact, limb-loading response, midstance, terminal stance, preswing, initial swing, midswing, terminal swing

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The COM is located anterior to the _________ ________ _______, midway between the hip joints.

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second sacral vertebra

Front 89

Antalgic gait is a nonspecific term that describes any gait abnormality resulting from _________.

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pain

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Flexion contracture of the hip requires compensatory ______ _____ to maintain the COM over the feet for stability, resulting in the characteristic crouched posture.

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knee flexion

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A plantar flexion contracture of the ankle results in a knee ________ moment (______ _______ thrust) at initial contact of the forefoot with the floor.

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extension - knee extension thrust

Front 92

Weakness of the hip flexor limits limb advancement during swing and results in a shortened _______ _______.

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step length

Front 93

With quadriceps weakness, the patient compensates by leaning the _______ forward to keep the COM anterior to the knee joint.

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trunk

Front 94

Ankle plantar flexor weakness causes increased __________ activity, limiting step length and predisposing the patient to painful overuse syndromes of the ________ and __________.

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quadriceps; patella & quadriceps

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21. Orthoses, Amputations, and Prostheses

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21. Orthoses, Amputations, and Prostheses

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_________ AFOs allow a more natural gait pattern and allow adjustment of plantar and dorsiflexion. The joints can be designed to provide stability in terminal stance and to provide dorsiflexion assistance to clear the toes during swing.

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Articulated

Front 97

A _____ can be used in quadriceps paralysis or weakness to maintain knee stability and control flexible recurvatum, valgus, or varus.

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KAFO

Front 98

A __________ knee joint allows limited multiplanar motion during flexion and extension that decreases specific areas of joint contact forces. This is helpful for persons with osteoarthritis.

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polycentric

Front 99

Lower limb amputation is a reconstructive procedure with the goals of preserving ________ and ________ and balancing the forces of the remaining muscles to provide a stable residual limb.

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length and strength

Front 100

The ______ ankle disarticulation provides superior mechanics and is the most common level of amputation in the foot.

Back 100

Syme

Front 101

The major advances in lower limb prostheses include (a) the development of new lightweight _______ materials; (b) the incorporation of ______ response (“energy-storing”) designs; (c) the use of computer-assisted design and computer-assisted manufacturing technology in _______; and (d) __________ control of the prosthetic knee joint.

Back 101

structural; elastic; sockets; microprocessor

Front 102

Increased levels of energy (percentage over normal) are associated with amputations: below-knee, ______ to ______; bilateral below-knee, ______ to ______; above-knee, ______ to ______.

Back 102

10-20%; 20-40%; 60-70%

Front 103

Patient management for replantation includes the following: emergent medical conditions should be treated; radiographs of both the residual limb and the amputated part should be obtained; the patient should be made NPO; and _______ prophylaxis, antibiotic therapy, and intravenous fluids should be administered. The amputated part should be wrapped in wet gauze and placed in a plastic bag on ice.

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tetanus

Front 104

Goals of upper limb amputation surgery include preservation of functional length, durable skin and soft-tissue coverage, preservation of useful sensation, prevention of symptomatic ___________, prevention of adjacent joint contractures, controlled short-term morbidity, early prosthetic fitting, and early patient return to work and recreation.

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neuromas

Front 105

A voluntary ________ _________ (the terminal device is closed at rest) is commonly used for the hand.

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opening mechanism

Front 106

22. Neuro-Orthopaedics and Rehabilitation

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22. Neuro-Orthopaedics and Rehabilitation

Front 107

A diagnosis of a complete spinal cord injury cannot be made until spinal shock has resolved as evidenced by return of the ________________ reflex.

Back 107

bulbocavernosus

Front 108

Neurologic recovery after spinal cord injury is assessed by determining the change in _____ (the sum of strength grades for each of the 10 key muscles tested bilaterally that represent neurologic segments from C5 to T1 and L2 to S1) between successive neurologic examinations. (Review C4 through C7 levels of function.)

Back 108

AMS

Front 109

Management of the spinal cord–injured patient includes prevention of ______ and maintaining range of motion, maintaining skin integrity, and intermittent catheterization.

Back 109

contractures

Front 110

The incidence of HO is approximately ____ in patients with spinal cord injury. Surgical excision is indicated when the HO interferes with function.

Back 110

20%

Front 111

A crouched posture increases the physical demand on the _______ and _______ muscles, which must continually fire to hold the patient upright. Simultaneous surgical correction of the hip and knee flexion deformities is the most desirable treatment.

Back 111

quadriceps & hip extensor

Front 112

Surgical correction of claw toe deformity requires release of the ______ _____ ______ and _____ tendons at the base of each toe.

Back 112

flexor digitorum longus and brevis

Front 113

Surgical correction of an equinovarus deformity is achieved with _______ _________ to rebalance the foot, including a split ________ _______ tendon transfer.

Back 113

tendon transfers; anterior tibial

Front 114

Wrist and finger flexion deformities in a functional hand are treated with _________ _________________.

Back 114

myotendinous lengthenings

Front 115

The recommended surgical treatment for clenched-fist deformity in a nonfunctional hand is a __________ ____ _________ _________ transfer.

Back 115

superficialis-to-profundus tendon

Front 116

Factors that influence a patient’s ability to walk include limb stability, motor control, balance reactions, and adequate ____________.

Back 116

proprioception

Front 117

23. Statistics: Practical Applications for Orthopaedics

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23. Statistics: Practical Applications for Orthopaedics

Front 118

_____ in clinical research is best defined as a systematic deviation from the truth.

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Bias

Front 119

____,_________ and _______ are key methodologic principles to limit bias in clinical research.

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Randomization, concealment of allocation, and blinding

Front 120

______ error occurs when a study concludes there is no difference between treatments when in fact a difference really exists.

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Type II (β)

Front 121

The ______ of a study is its ability to find a difference between treatments when a true difference exists.

Back 121

power

Front 122

The _______ is defined as the probability, under the assumption of no difference (null hypothesis), of obtaining a result equal to or more extreme than what was actually observed.

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P value

Front 123

A 95% ________ ___________ is the interval within which the true estimate of effect lies 95% of the time.

Back 123

confidence interval

Front 124

Two means can be compared with a _________ _______.

Back 124

Student’s t-test

Front 125

Two proportions can be compared statistically with a _________ test.

Back 125

chi-square (χ2)

Front 126

The ____________ of a test is the proportion of individuals who are free of the disorder who are so identified by the test.

Back 126

specificity

Front 127

The ___________ of a test is the proportion of individuals who have a designated disorder who are so identified by the test.

Back 127

sensitivity

Front 128

24. Evidence-Based Medicine

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24. Evidence-Based Medicine

Front 129

Evidence-based medicine is the practice of integrating individual clinical expertise with the best available clinical evidence from _________ research.

Back 129

systematic

Front 130

Evidence-based ______ __________ serve to assist the practicing orthopaedic surgeon in his or her quest to improve patient care by consolidating the relevant evidence and indicating the strength of the recommendation for treatment options.

Back 130

practice guidelines

Front 131

Grades I through V of studies are matched directly to the ________ ___ _________.

Back 131

level of evidence

Front 132

_______ studies investigate the results of treatment.

Back 132

Therapeutic

Front 133

A study’s ______ is the probability that the sample mean will be sufficiently different from the mean under null hypothesis to allow one to reject the null hypothesis. Sample size plays a critical role in power analysis. When trying to detect small differences between groups, larger sample sizes are necessary.

Back 133

power

Front 134

A _____________ is the probability of determining that there is no difference between treatment groups when there actually is a difference. Type ____ errors often occur when the sample size of the treatment group is too small and leads to a false-negative result.

Back 134

Type II error; II

Front 135

A _______ error is a false-positive conclusion that occurs when one rejects a null hypothesis that is actually true.

Back 135

type I

Front 136

The ________ is the probability of obtaining the same or more extreme data, assuming the null hypothesis is of no effect (P < 0.05).

Back 136

P value

Front 137

The _____________ is a quantification of the uncertainty of measurement. Typically, a 95% CI reports the range of values within which one can be 95% certain that the true value for the whole population lies.

Back 137

confidence interval (CI)