Orthopaedic Case Studies.

Orthopaedic Case Studies Gann N. Gaithersburg, MD 20878, Aspen Publishers Inc, 1998, paperback, 161 pp, $29.

This text was written to help physical therapist students and clinicians develop problem-solving skills for patient care. The author divides the studies into 4 levels of difficulty. In part 1, the reader is given all the information necessary to prepare a plan of care and the rationale for it. In part 2, the studies provide less information, and the clinician is challenged to determine what critical information is needed to develop a working hypothesis and plan of care. Part 3 includes postsurgical scenarios, complex cases, and medical differential diagnosis. Part 4 consists of critiquing the evaluations, assessments, and interventions of other practitioners and includes cases that involve dealing with insurance companies. Questions are asked following each study, and answers with references are provided.

Case studies are recognized as a tool that the clinician uses to develop clinical reasoning skills and to make generalizations about patients who share similar traits. The author includes a wide variety of orthopedic problems, from the ankle to headaches, from acute trauma to chronic dysfunction, and from the teenager to the elderly person. The author also acknowledges that her solutions may not be the only ones and encourages the readers to add their own.

The main shortcoming of this book is that all of the information was given in written form. None of the case studies included a body chart showing the area of the symptoms, how the patient described them, whether they were constant or intermittent, and the relationships between more than one area. When the symptoms involve several parts of the body, a visual presentation can be very helpful in identifying a recognizable pattern and determining whether a patient has more than one problem. A second concern is the issue of cost-effectiveness. Many of the plans of care involved a prescription of "3 times a week for 2 weeks"--a prescription that is rarely possible in this era of managed care, probably not cost-effective, and often not efficacious. Third, to alert the beginning clinician, some tests that were performed in the case studies might need further discussion regarding their adequacy. For example, in the study on a patient with cervical whiplash seen 5 days after a motor vehicle accident, the cervical active range of motion was limited, and the author did a vertebral artery test; however, there was no discussion of whether the test results would be valid given the limited range of motion.

Depending on your clinical background, your examination, evaluation, and intervention for these patients might be different in form or content. However, this book can provide a format for encouraging the discussion of how patients should be examined and treated, and what other diagnoses might be present. I would recommend this book for use in a physical therapy classroom or for experienced clinicians who want to challenge their clinical reasoning skills. Keep in mind that the information provided is not necessarily complete and that the book provides a springboard for discussion, not a cookbook for answers.

Maggie Fillmore, PT Kaiser Permanente Medical Center-Oakland Oakland, Calif

Ms Fillmore is a clinical specialist in outpatient orthopaedics at Kaiser Permanente and a faculty member of the Kaiser Residency Program in Advanced Orthopaedic Manual Therapy.