A System of Orthopaedic Medicine, ed 2.

Ombregt L, Bisschop P, ter Veer HJ. Philadelphia, PA 19106, Churchill Livingstone Inc, 2003, hardcover (with accompanying CD-ROM*), 1,344 pp, illus, ISBN: 0-443-07370-8, $169.95.

The purpose of this book is to provide the reader with a systematic approach--based on the approach developed by Cyriax--to the clinical examination and treatment of patients with nonsurgical orthopedic conditions. The authors focus on guiding the reader through the complete examination process in order to help them to establish an accurate diagnosis. To accomplish this, the information is provided in a simplified, step-by-step sequence. Once the appropriate diagnosis is established, the authors suggest a few of what they believe to be the best treatment choices.

The book is intended for physicians and physical therapists who are involved with orthopedics and sports medicine. (I believe that this text also would be appropriate for the physical therapist assistant.) These practitioners will find this text to be a useful, practical reference for many orthopedic problems that are encountered in the clinic.

This book effectively guides the reader through the Cyriax approach to establishing a clinical diagnosis. For clinical diagnoses such as frozen shoulder, for example, there is an entire chapter that introduces the background information, covers staging of the limitation, lists 13 different disorders that can lead to shoulder stiffness, and discusses "functional" examination and treatment. More than 200 references are listed at the end of the chapter.

The information regarding the Cyriax approach in clinical examination is presented in sufficient detail and is well referenced. These references, however; are anecdotal or not directly related to the Cyriax approach.

Because of the clarity of the introductory material, even the clinician who is beginning professional practice and who has not been trained in the Cyriax approach should be able to follow the book without much difficulty.

The book has 16 sections containing 88 chapters that sufficiently cover the major body regions and associated injuries that would be typically treated in an outpatient orthopedic environment. Because each section contains ample information concerning the topics in this book, it could be used as a stand-alone text. Most of the sections that focus on a specific joint or region include chapters on the applied anatomy, clinical examination, interpretation of the clinical examination, disorders of the inert (ie, noncontractile) structures, and disorders of the contractile structures. The authors use a consistent writing style that flows smoothly from section to section for an easy transition between topic areas.

The chapters include sidebars containing important information to alert the reader about critical topics (eg, differential diagnosis and warning signs for cervical tumor). In addition, these boxes contain an outline of the important information from the chapters, such as muscle innervations, summaries, practitioner's checklists, classifications, and special tests. I found these sections to be a very helpful method of highlighting some of the important concepts in the chapters. The book concludes with a 61-page subject index, which makes finding information on a specific topic relatively easy.

The text includes many diagrams, figures, photographs, schematics, flow charts, tables, and graphs that complement the material well. In chapter 9, for example, the table titled "Root syndromes in neck and upper limb" includes columns for specific nerve roots, pain patterns, a diagram for paresthesia patterns, motor deficit, sensory deficit, and differential diagnosis. If a patient is suspected of having C6 nerve root involvement, a quick review of the chart would show that the patient may have pain down the lateral arm, paresthesia in the palmar aspect of the first and second digits, motor deficits (biceps, brachio-radialis, supinator, extensor carpi radialis muscles), a weak biceps muscle reflex, and sensory deficit in the distal portions of the first and second digits; the differential diagnosis may include pressure on the median nerve in the carpal tunnel among other competing diagnoses. This table is just one example of how the book is an excellent quick reference and how it would be a great tool for patient education because of the wonderfully illustrated diagrams and easy-to-follow text.

This edition comes with a CD-ROM that includes a series of video clips and explanatory text for joint examination and assessment techniques for the shoulder, elbow, wrist, hip, knee, and foot and ankle. The CD chapter on the knee, for example, has short video clips (with accompanying text) that demonstrate passive knee extension/flexion, passive valgus/varus movement of the knee, passive lateral/medial rotation of the knee, anterior/posterior drawer test, medial/lateral drawer test, resisted extension/flexion of the knee, patellar tap, eliciting fluctuation, and palpation for synovial thickening. It is unclear why these tests were selected to be included on the CD. Passive knee extension, for example, seems to be self-explanatory, and the addition of the information obtained from the CD adds little to understanding how to perform this test.

The authors do not provide general testing principles for the examination procedures on the CD. The CD could be an effective mechanism to reinforce the principles of the examination procedures if these types of video clips were added. On the CD, the varus/ valgus movement of the knee is performed with the knee in full extension even though in other texts it is more often described as having the knee in approximately 30 degrees of flexion. The authors mention this fact, yet they elected to demonstrate this test with the knee in full extension.

The "eliciting fluctuation tests" are included in the text and CD without discussing the validity and reliability of the measurements provided by these tests. In fact, numerous special tests and examination procedures are described without any discussion of reliability and validity. A large portion of the Cyriax examination consists of making clinical observations such as the capsular pattern of an involved joint. Because the capsular pattern is an important element of the Cyriax approach and this text, this material would have been greatly strengthened if it had included some of the research that has been published concerning the validity of the capsular patterns. In fact, the main weakness of this text is that it does not address many of the critical issues concerning the clinical examination procedures, such as sensitivity, specificity, reliability, and validity. Unfortunately, the research support--or lack of it--for the Cyriax approach is not discussed in this text.

This book is directly related to the practice of orthopedic physical therapy and is an effective reference for the Cyriax approach to orthopedic injuries. This is a very/large volume that contains a great deal of useful information for the clinician. This book would be a valuable reference to add to the professional library for both physical therapists and physical therapist assistants whose practices deal primarily with patients with orthopedic dysfunction.

[* Note: System requirements for CD-ROM: For PC: Pentium 200 or higher, Microsoft Windows '95 or later, 16 MB RAM (32 MB recommended), 4x CD-ROM drive or faster, and Quick Time. For Macintosh: G3 processor and OS 9.]

Ricardo A Fernandez, PT, OCS 

Northwestern University

The Feinberg School of Medicine 

Chicago, III

Mr. Fernandez is Assistant Professor/Clinician in the Department of Physical Therapy and Human Movement Sciences and specializes in orthopedic rehabilitation of patients with shoulder and knee dysfunctions.