How the Practical Exam Works and How to Prepare

Part IV does not ask what you know; it asks what you do with a real person in front of you and a clock on the wall. Candidates who know the material cold still lose points by skipping a consent statement, adjusting without stating a contraindication screen, or running out of time before the note is written. This chapter explains how a practical exam of this kind is built and scored, and how to prepare so that the right actions come out of you automatically on exam day and, later, in practice.

Section 1The structure of the practical exam

What a practical exam is designed to measure

Written board parts measure recall and reasoning on paper. A practical exam measures observable performance: whether a candidate can gather the right information from a patient, examine correctly, reach a defensible diagnosis, choose safe care, set up and deliver (or simulate) an adjustment, read a film, and communicate throughout. The underlying design idea is the objective structured clinical examination (OSCE): many short, standardized encounters instead of one long, unstructured one. Breaking the exam into stations does two things. It samples a wider range of skills than any single encounter could, and it lets every candidate meet the same task, the same patient script and the same scoring sheet, which makes the result fairer and more reliable.

Part IV follows this general model. Candidates rotate through a series of timed stations. Some stations involve a standardized patient (SP), a trained person who portrays a case consistently for every candidate. Some involve imaging, where a candidate views films and answers questions or writes an interpretation. Some involve chiropractic technique, where the candidate identifies a listing and demonstrates the set up. Exact station counts, timings, the number of days, and the format of written components change over time, so always confirm the current details in the official candidate materials published by the testing body before you sit the exam. This book teaches the behaviors that score well in any well designed station of each type.

The three content areas

These areas overlap. A case station may hand you a film to interpret before you decide on care. A technique station may include a patient whose history contains a reason not to adjust. The exam rewards candidates who carry safety and reasoning across every boundary instead of treating each station as a narrow skill check.

Door cards and the station cycle

Each station begins outside the room with a door card (sometimes called a station instruction sheet). A typical door card states the patient's name, age and sex, the setting, the chief complaint or the reason for the visit, sometimes vital signs, and the task: for example, "Take a focused history and perform a focused examination" or "Demonstrate the set up for the listing shown." The door card is the most important page of the station. It tells you which skills are being scored. If it says "focused history only," a perfect physical examination earns nothing and wastes time. If it says "explain your findings to the patient," the closing explanation is scored.

The station cycle is consistent: a reading period at the door, an encounter period inside, and often a post-encounter task (a patient note, written questions, or a film question) before rotation to the next station. A signal (bell, buzzer, announcement or timer) marks transitions. When the signal ends the encounter, you stop, thank the patient and leave, even mid-sentence. Unfinished items are simply unscored, so pacing matters more than perfection on any single item.

Standardized patients and examiners

A standardized patient is trained to give the same history, the same answers and the same physical responses to every candidate. If the case calls for a positive straight leg raise at 40 degrees, the SP reproduces leg pain at about that angle each time. SPs are often instructed to answer only what is asked. They will not volunteer that they take warfarin or lost 15 pounds without trying unless you ask. This is the single most important fact about SP stations: information you do not ask for does not exist. The scoring sheet expects you to elicit it.

Scoring may be done by the SP after the encounter, by an examiner watching in the room, by an examiner watching remotely, or by review of a recording. Examiners in technique stations are often licensed doctors who know what a good set up looks like and will notice an unstable stance or a contact on the wrong side. Treat the examiner as a silent observer: address the patient, not the examiner, unless the door card tells you to explain to the examiner. When you verbalize for scoring, speak clearly enough to be heard, but phrase it for the patient where you can ("I am checking for a condition that would make adjusting unsafe").

SPs also have a limited physical role. Many may not be actually adjusted, may have true physical findings that are part of their real body rather than the case (a surgical scar, a mole), and may have instructions to simulate findings. Some exams use mannequins or allow only simulated thrusts. Follow the door card and any proctor instruction on whether a thrust is delivered; when not permitted, you set up fully, take tissue pull and preload, state the line of drive and say "I would now deliver a high velocity, low amplitude thrust" without delivering it.

How timing shapes everything

Time pressure is the defining condition of the exam. Whatever the official station length, you will feel it is too short. Candidates fall into two errors: they rush and skip consent or red flags, or they go deep on one part (often the history) and never reach the examination or the plan. The solution is a rehearsed internal clock. For a history and examination station, a common practice split is roughly one third of the time on history, a little over one third on the focused examination, and the remainder on findings, diagnosis, plan, consent and questions. For a technique station, most of the time goes to the set up and verbalization; the thrust or simulated thrust is seconds long.

Section 2How stations are scored

Checklists: the scoring backbone

Most practical stations are scored with a checklist: a list of specific, observable actions, each marked done or not done (sometimes done correctly, done incorrectly, or not done). A history checklist might include "asked about onset," "asked about bowel or bladder function," "asked about prior episodes," and "asked about medications." An examination checklist might include "performed straight leg raise with correct technique" and "stated the result." A technique checklist might include "contact point on correct side," "stabilization established," and "line of drive appropriate to listing." Checklists reward explicit, complete behavior. They cannot award credit for what an examiner assumes you thought.

Many practical exams also use global ratings: a holistic score for communication, organization, professionalism or overall competence. Global ratings capture what checklists miss, such as whether the encounter flowed, whether the patient felt respected, and whether the candidate seemed safe. A candidate who completes every checklist item but is brusque, disorganized or rough may still score poorly on global ratings.

Critical actions

Some items matter more than others. A critical action is an item whose omission is considered unsafe or a serious failure of care, regardless of how well the rest of the station goes. Exams differ in how they treat them (heavier weighting, mandatory items, or automatic failure of the station), and you should not assume a particular rule, but you should behave as though each of the following can sink a station by itself.

Why verbalizing matters

Verbalizing means saying aloud what you are doing, why, and what you found. It is not chatter. It turns your reasoning into something an observer can score. Consider two candidates who both perform a Spurling test. The first presses down on the head silently, sees the patient wince and moves on. The second says, "I am going to tilt and turn your head toward the right and press gently downward; tell me if this reproduces your arm symptoms," and afterward, "That reproduced pain down your right arm, which suggests irritation of a nerve root in the neck on the right." The second candidate has demonstrated correct technique, patient communication, and interpretation. The first has demonstrated a hand movement.

Verbalizing is especially important in technique stations, where the decisive elements (segmental contact, line of drive, depth) are hard to see from across the room. A strong technique verbalization names the listing, the contact point (the part of the doctor's hand), the segmental contact (the part of the patient's vertebra), the stabilization, the line of drive in plain anatomical terms, and the screening that preceded it. Practice the phrasing until it is short and automatic.

Common reasons candidates lose points

Score reports and faculty experience with practical exams point to a short, repeated list of errors. Nearly all of them are habit failures rather than knowledge gaps.

• Skipping the opening. No hand hygiene, no introduction, no identity check, no consent. These are easy items lost in the first 20 seconds by candidates eager to start.
• Not reading the door card. Doing the wrong task, examining the wrong region, or ignoring a vital sign printed on the card (a blood pressure of 190/115 changes the whole station).
• Silent performance. Correct tests with no stated result, correct set ups with no stated line of drive.
• Incomplete red flags. Asking two red flag questions instead of a full screen, especially missing medications (anticoagulants, corticosteroids) and cancer history.
• Leading questions. "You don't have any bladder problems, do you?" invites a reflexive no. Ask open or neutral closed questions.
• Poor technique. Wrong side contact, unstable stance, no tissue pull, a line of drive that does not match the listing, or a set up that is uncomfortable or unsafe.
• Time mismanagement. An excellent history and no time left for the exam, plan or note.
• No plan or referral. Finding the problem but never stating what to do about it.
• Ignoring the patient. Not responding when the SP says "that hurts," not checking comfort, poor draping.
• Inaccurate documentation. A patient note that contradicts the encounter or omits key negatives.

Section 3Exam day logistics and conduct

Before you arrive

Practical exams are run on tight schedules with many candidates, patients and examiners moving in synchrony. Late arrival may mean you are not admitted. Read the official candidate materials well in advance for the required identification, arrival time, permitted and prohibited items, attire rules, and any rules about equipment you bring versus equipment provided. Plan travel with a margin, stay close to the site the night before if travel is long, and confirm the test site address in advance. Sleep and food are performance variables: a well rested candidate reads door cards faster and makes fewer slips.

Prohibited items commonly include phones, smart watches, notes, recording devices and bags in the testing area. Assume nothing on your person will be allowed except what the materials list. If you are permitted to bring equipment (for example, a reflex hammer, pinwheel or tuning fork), check it the night before. If equipment is provided, practice with ordinary standard tools so you are not thrown by an unfamiliar model.

Attire and presentation

Dress as a professional doctor would for a new patient. Clean clinic attire or business attire, closed toe shoes, minimal jewelry, short clean nails, hair secured away from the face and away from the patient during set ups, and no strong fragrance. Avoid anything that dangles over the patient (long necklaces, ties without a clip, lanyards) because it will touch the patient during prone and supine set ups. Some exams provide or prohibit lab coats or have rules about names and logos on clothing; follow the official instructions.

Using the door card and the reading time

The reading period is short, so use a fixed routine every time, practiced until automatic:

1. Name, age, sex. You will use the name in the introduction. Age and sex steer the differential and red flags (an older patient with back pain raises malignancy and aneurysm; a young adult with morning stiffness raises inflammatory spondyloarthropathy).
2. Chief complaint and duration. Acute versus chronic, traumatic versus insidious.
3. Vital signs, if given. Read them; abnormal values are placed on purpose.
4. The task verbs. History, examination, technique, imaging, explanation, documentation.
5. Plan your first three questions or first three steps. A quick mental outline beats walking in blank.

If scratch paper or a note board is permitted, jot a skeleton (OPQRST and red flags, or the region and the listing). If not, rely on your memorized templates. Do not try to memorize the entire door card; you may be allowed to see it again or a copy may be inside the room, depending on the exam, but plan as if you cannot.

Entering the room

Knock, wait a beat, and enter. Make eye contact with the patient, smile, and perform hand hygiene where the patient can see it (alcohol based rub or hand washing as available). Many checklists include hand hygiene as an item at the start and sometimes after the encounter. Introduce yourself with your name and role ("Hello, I am Dr. Patel, one of the chiropractors here"), confirm the patient's identity using the name on the door card, and state the purpose of the visit. Ask how the patient prefers to be addressed. Sit at eye level for history taking where possible.

Draping and positioning

Expose only what you need to examine, and only for as long as you need it. Explain before asking a patient to change position or move clothing: "I would like to look at your lower back; may I lift the back of your gown to just above the waist?" Use a drape or sheet to cover areas not being examined. For a gowned patient, tie or hold the gown so it does not fall open when the patient moves. In prone positioning, check that the face piece is comfortable and that the patient can breathe easily. In side posture, make sure the patient is secure and will not roll off the table. Ask before touching any sensitive area, and explain what you are about to do and why, in plain language.

Respecting the standardized patient

Treat the SP exactly as you would treat a real patient. The SP is scoring how it felt to be your patient. Rough handling, cold hands without warning, careless draping, talking over the patient, or making jokes at the patient's expense cost points. Never perform tests that are clearly painful or invasive and not indicated by the task. Do not perform rectal, genital or breast examinations in a station; if one would be indicated clinically, state that you would perform it (with a chaperone and consent) or that you would refer. Do not deliver a real thrust unless the station explicitly permits it.

Staying within the time

Know where the clock is, or know how time is announced. Many exams give a warning before the end of the encounter. Use the warning as a hard trigger: whatever you are doing, move to your close (findings, diagnosis, plan, consent, questions). It is better to skip the last two orthopedic tests than to leave without stating a plan. When the end signal sounds, stop, thank the patient and exit. Do not continue talking, do not return for a forgotten item, and do not argue. If a post-encounter task follows, the patient note or answers are written from what you actually did.

One bad station does not end the exam. Each station is independent. Leave each room mentally, take one slow breath at the next door card, and start fresh. Candidates who dwell on a previous station misread the next one.

Section 4A study plan for the practical

Why knowledge is not enough

Candidates who passed Parts I to III know enough to pass Part IV. What separates candidates on a practical exam is retrieval under pressure and smooth motor performance. Both are trained by repetition with feedback, not by rereading. Your study plan should therefore spend most of its hours doing stations out loud, on a partner, against a timer, with someone scoring you from a checklist. Reading is for filling the gaps those rehearsals reveal.

Build your own checklists

Start by writing your own scoring sheets. Use the official candidate materials and course syllabi for the content domains, and write, for each station type, the items an examiner would likely look for. Personal checklists teach you to think like an examiner and give your practice partners something concrete to score. Keep them short enough to use in real time.

Practicing with partners

Work in groups of three: one doctor, one patient, one examiner with the checklist and timer. Rotate roles every station. The patient should play a scripted case, answer only what is asked, and report how the encounter felt. The examiner marks only what is observed and gives feedback at the end on the three most important misses. Being the examiner is as valuable as being the doctor; it trains you to see what scorers see.

Write case scripts for each other covering common presentations and the important can't-miss conditions: mechanical low back pain, lumbar radiculopathy, cauda equina syndrome, spinal stenosis, compression fracture, metastatic disease, abdominal aortic aneurysm, cervical radiculopathy, vertebral artery dissection, whiplash, tension type headache and migraine, shoulder impingement and rotator cuff tear, adhesive capsulitis, carpal tunnel syndrome, lateral epicondylopathy, knee ligament and meniscus injuries, ankle sprain, hip osteoarthritis, and inflammatory spondyloarthropathy. A good case script has a door card, a history script with planted red flags or pertinent negatives, the expected examination findings, and the expected diagnosis and plan.

Timed mock stations

Once each skill is solid untimed, practice with a strict timer. Aim to finish your full routine with time to spare; on exam day nerves will slow you. Record yourself on video (with your partner's permission) and watch for silent periods, filler words, awkward positioning, poor draping, and set ups where your line of drive is not visible. Run at least several full mock circuits in the final weeks, with the same door card reading time, encounter time and transition time as your best understanding of the real exam. Fatigue across many stations is real; train for it.

Using film libraries

Imaging interpretation is a pattern recognition skill. Build volume: look at many normal films first so that abnormal becomes obvious, then work through high yield pathology. Use any film library available to you through your program, teaching files, and reputable educational image collections. For every film, force yourself through the same search pattern and say a one line impression and a recommendation aloud, then check. Time yourself. Keep a log of misses by category (missed finding, wrong location, wrong description, wrong recommendation) and review it weekly. Chapters 2 to 4 of this book teach the search pattern, normal anatomy and the high yield film cases.

Linking Parts I to III to performance

A sample timeline

Adapt the timeline to your schedule; the proportions matter more than the dates. In the early phase, write checklists, review core technique set ups region by region, and look at normal films daily. In the middle phase, practice stations with partners several times a week, untimed first and then timed, rotating through regions and case types, and add pathology films. In the final phase, run full mock circuits under realistic timing, focus on your logged weaknesses, and rehearse the universal opening and closing until they are effortless. In the final days, rest, review checklists lightly, prepare attire and identification, and confirm logistics.

Section 5Professionalism, communication and patient safety in every station

The communication spine of every encounter

Every station, whatever its content, sits on the same communication spine: open, explain, consent, perform, check, close. Communication items appear throughout checklists and drive global ratings, and they are the same items that protect patients and doctors in practice. Learn one version of each element and use it everywhere so that it costs no thought on exam day.

Informed consent in a station

Informed consent is a process, not a signature. The patient must understand the nature of the proposed examination or treatment, its material risks, the expected benefits, the reasonable alternatives (including no treatment), and the right to decline or stop at any time. Consent must be voluntary and given by a patient with capacity. For a minor, a parent or guardian consents and the child should assent where able.

In a station, separate consent to examine from consent to treat. Ask permission before the physical examination. Before an adjustment, give a short, accurate risk statement. For spinal manipulation, commonly discussed effects include temporary local soreness, stiffness or headache, which usually resolve within a day or two; rare but serious risks include fracture in weakened bone, worsening of a disc herniation, and, for cervical manipulation, cervical artery dissection and stroke, which are very rare and for which a causal relationship is debated. Be honest and calm, use plain language, and avoid either frightening or minimizing. Then confirm understanding and agreement. If the patient declines, accept it, document it and offer alternatives.

Consent can be withdrawn at any moment, including mid set up. If a patient says "stop" or "wait," stop immediately, release the contact and ask what is wrong.

Explaining procedures in plain language

Patients understand plain words, short sentences and one idea at a time. Replace jargon: "joint" not "zygapophyseal articulation," "nerve irritation" not "radiculopathy," "the bone in your neck" not "C5." Use the teach back method for important points: "So that I know I explained it well, can you tell me what you will do if the leg numbness gets worse?" This shows the examiner that you checked understanding rather than assumed it. Watch for nonverbal signals of anxiety (guarding, holding breath, clenched hands) and respond: "You look a little tense. Would you like me to explain what I'm about to do again?"

Modesty, boundaries and chaperones

Modesty is protected by explaining, asking, draping and limiting exposure. Professional boundaries are protected by keeping touch purposeful and announced, avoiding personal comments about the patient's body, and never touching sensitive areas without explicit explanation, consent and clinical need. A chaperone should be offered for examinations of sensitive areas and whenever the patient or doctor would be more comfortable; follow the policies stated in the candidate materials. If a patient appears uncomfortable, pause and ask. A patient's discomfort is information, not an obstacle.

Safety in every station

Safety is not a separate station. It is a thread through every encounter. Before any manual procedure, you screen. During it, you check in. After it, you reassess. And at any time, you are prepared to stop, decline to treat, and refer.

Documentation habits

Many practical exams include a written patient note or post-encounter task. Even when they do not, documenting well in practice begins with how you think in the room. A useful note follows the SOAP structure: subjective (history, including pertinent negatives such as "denies bowel or bladder changes"), objective (vital signs and examination findings with sides and values), assessment (working diagnosis and differential, with the reasoning) and plan (treatment, consent obtained, home care, referral, follow up and outcome measures). Write only what you did and found. Never document a test you did not perform. Use standard abbreviations sparingly and clearly. Record the patient's consent, any refusal, any adverse event and your response.

Words worth knowing

Reading Films Under Time: Approach and Normal Anatomy

An imaging station gives you a film, a short history and very little time, and it scores what you find, how you describe it and what you recommend. The candidates who do well are not the ones who know the rarest diagnoses; they are the ones who search every film the same way, know normal anatomy and its variants so well that abnormal stands out, and can say a clear one line impression and a safe recommendation before the signal. This chapter builds that engine; Chapters 3 and 4 load it with high yield pathology.

Section 1A fast systematic search pattern

Why a fixed pattern beats a good eye

Expert readers do not look at a film; they move through it. Eye tracking work on radiologists shows that experienced readers combine a quick global impression with a deliberate search, while novices fixate on the first abnormal or interesting spot and stop. On a timed exam the risk doubles: anxiety narrows attention, and the obvious finding becomes the only finding. A fixed search pattern costs perhaps 30 to 60 seconds per film once it is practiced, and it turns every film into the same task.

Before the search: the label check

Spend five seconds on the administrative data, and say it aloud if the station involves speaking. Confirm the patient name and age (age changes the differential more than any other single fact), the date, the view (AP, PA, lateral, oblique, open mouth, flexion, extension), the side marker, and whether the film is weight bearing. Check technical quality: is the area of interest included, is the exposure adequate, is the patient rotated? A rotated lateral cervical film doubles the posterior margins and can mimic a subluxation; an underpenetrated film hides lytic lesions. If the films provided are inadequate, recommending additional views is a legitimate answer.

ABCS

Different teachers expand the acronym (for example, ABCDS adds "D" for disc space, or ABCs plus "S" for soft tissue). The specific letters matter less than using one version every time. Begin with alignment because it is the fastest whole film overview, then go structure by structure.

Check every corner and the review areas

Lesions hide where the eye does not travel: at the edges of the film, behind dense structures, and in the parts of the film that are not the stated area of interest. A lumbar film includes the lower ribs, the kidneys, the abdominal aorta, the iliac wings, the sacroiliac joints and often the hips. A cervical film includes the skull base, the airway, the lung apices and the upper ribs. A thoracic film includes the heart, both lungs and the upper abdomen. The board often places a finding in one of these peripheral areas precisely to test whether the search was complete.

Satisfaction of search

Satisfaction of search is the tendency to stop searching after finding one abnormality. It is a classic source of missed second findings: the obvious spondylolisthesis that hides the renal stone, the obvious fracture that hides the second fracture, the degenerative changes that hide a lytic metastasis. Prevent it with three habits. First, finish the pattern even after you find something. Second, when you find one abnormality, ask what it is commonly associated with (a fracture of one forearm bone suggests looking for injury to the other bone or a dislocation at a joint; a lytic lesion in an older adult suggests looking for others). Third, look at the review areas last, deliberately, as the final step before you speak.

Global impression first, then detail

Before the formal search, take two seconds for a global look at the whole film from a distance: overall density, overall alignment, anything strikingly asymmetric. This gestalt catches large findings (a diffusely dense spine of metastatic prostate cancer or Paget disease, a scoliosis, a missing hemipelvis density) that a close up search can paradoxically miss. Then begin ABCS.

Section 2Normal cervical, thoracic and lumbar radiographs and their variants

The standard views and what each shows best

The lateral cervical film: lines and spaces

On the neutral lateral cervical film, trace four smooth, roughly parallel curves (Figure 2.2). The anterior vertebral line joins the anterior body margins. The posterior vertebral line (George's line) joins the posterior body margins and outlines the front of the spinal canal. The spinolaminar line joins the points where the laminae meet the spinous processes and outlines the back of the canal. The posterior spinous line joins the spinous tips. A step in any line suggests subluxation, dislocation or fracture; in children, C2 on C3 needs special interpretation (below).

The atlantodental interval (ADI) is measured from the posterior surface of the anterior arch of C1 to the anterior surface of the dens. It is 3 mm or less in adults and up to 5 mm in children; widening suggests transverse ligament insufficiency (trauma, rheumatoid arthritis, Down syndrome, inflammatory disease). The sagittal canal diameter, from the posterior body to the spinolaminar line, is normally more than about 12 to 13 mm in the lower cervical spine; values near 10 mm or less suggest stenosis, and the body to canal (Torg or Pavlov) ratio below about 0.8 suggests a developmentally narrow canal.

The prevertebral soft tissue (retropharyngeal space at C2, retrotracheal space at C6) is the soft tissue sign of the cervical spine. Widening suggests hematoma from a fracture, infection or a mass. Commonly taught adult upper limits are about 7 mm at C2 and about 22 mm at C6 (in children about 14 mm at C6). Crying in an infant and flexion of the neck can widen it spuriously.

The upper cervical spine and its normal mimics

On the open mouth view, the lateral masses of C1 should line up with the lateral margins of the C2 superior articular facets. Lateral overhang of the C1 masses suggests a Jefferson burst fracture; a combined overhang of more than about 7 mm suggests disruption of the transverse ligament (the rule of Spence). In children up to about 4 years old, the C1 ring grows faster than C2, so a pseudospread of the atlas is normal.

Several normal shadows mimic a dens fracture. The Mach band effect, a dark line created where the edge of the posterior arch of C1 or the incisors overlie the base of the dens, can look like a fracture; it extends beyond the bone margins and changes with a repeat view. Overlapping teeth, the tongue and the occiput can do the same. The subdental synchondrosis between the dens and the body of C2 fuses between about 3 and 6 years and is visible as a lucent line in young children; it is a growth center, not a fracture. The ossiculum terminale (a small ossicle at the tip of the dens that appears around age 3 and normally fuses by about 12) is a normal variant when it persists; os odontoideum, a larger ossicle separated from a short dens with a smooth corticated gap, is not a normal variant because it may be unstable and needs flexion and extension evaluation before any upper cervical manipulation.

A ponticulus posticus (posterior ponticle, arcuate foramen) is a bony bridge over the vertebral artery groove on the posterior arch of C1. It is common (seen in a sizable minority of adults) and benign, but many clinicians modify or avoid forceful rotatory upper cervical techniques in its presence because the artery runs through the ring. Mention it in a report.

Pediatric cervical variants

In children, ligamentous laxity and horizontal facets allow normal forward slip of C2 on C3 (and sometimes C3 on C4) of up to about 3 to 4 mm in flexion: pseudosubluxation. To tell it from true injury, draw the posterior cervical line (Swischuk line) from the anterior cortex of the C1 spinous process to the anterior cortex of the C3 spinous process. The anterior cortex of the C2 spinous process should lie within about 2 mm of this line; a greater deviation suggests a true injury such as a hangman fracture. Children may also show loss of lordosis, wedge shaped bodies that look like compression fractures (normal anterior wedging of young vertebrae) and unfused ring apophyses at the endplates that look like chip fractures.

Thoracic and lumbar variants that mimic disease

Section 3Normal pelvis, hip and extremity radiographs and variants

The AP pelvis and hip: lines that should be smooth

The AP pelvis is read with the same ABCS discipline, plus a few lines that reveal subtle hip disease (Figure 2.3). Shenton's line is a smooth arc formed by the inferior border of the superior pubic ramus continuing onto the medial (inferior) border of the femoral neck. A break suggests a femoral neck fracture, hip dislocation or developmental dysplasia. Klein's line runs along the superior border of the femoral neck on the AP view and should intersect a portion of the lateral femoral epiphysis; if it does not, think slipped capital femoral epiphysis (SCFE) in an adolescent. Kohler's line (the ilioischial line) runs from the medial border of the ilium to the medial border of the ischium; if the acetabular floor or femoral head crosses medial to it, the finding is protrusio acetabuli (seen with rheumatoid arthritis, Paget disease, osteomalacia and other conditions). The teardrop marks the acetabular floor and helps judge rotation and protrusion.

Growth plates versus fractures

Children's films are full of lucent lines that are normal. A physis (growth plate) is a lucent band with smooth, well defined, often slightly undulating and sclerotic margins, in a predictable location, symmetric with the other side. A fracture line is usually sharp, uncorticated, irregular, in an unexpected place or orientation, and associated with soft tissue swelling. When in doubt, comparison views of the opposite side resolve the question; they are a legitimate recommendation. Know the order of ossification centers at the elbow, which is commonly remembered as CRITOE: capitellum (about 1 year), radial head (about 3), internal or medial epicondyle (about 5), trochlea (about 7), olecranon (about 9) and external or lateral epicondyle (about 11). The ages vary and girls are generally earlier; the order is what matters. A trochlear center seen before a medial epicondyle center suggests the "trochlea" is actually a displaced medial epicondyle fragment trapped in the joint.

Two elbow lines catch subtle injury. The anterior humeral line, drawn along the anterior humeral cortex on a true lateral, should pass through the middle third of the capitellum; if it passes anterior to it, suspect a supracondylar fracture with posterior displacement. The radiocapitellar line, through the center of the radial neck, should pass through the capitellum on every view; if not, the radial head is dislocated. A visible posterior fat pad, or a raised anterior fat pad (the sail sign), indicates a joint effusion and, after trauma, an occult fracture.

Accessory ossicles and sesamoids

Accessory ossicles are separate bones from unfused ossification centers, and sesamoids are bones within tendons. Both are smooth, rounded, completely corticated, often bilateral, and lie in predictable places. Acute fracture fragments are sharp, uncorticated on at least one side and have a matching defect in the parent bone.

Nutrient canals, bone islands and other normal findings

Nutrient canals are thin, oblique lucent lines through the cortex of long bones carrying the nutrient artery. They are smooth, with sclerotic margins, and run obliquely. A traditional memory aid states their direction: the canals point toward the elbow and away from the knee ("to the elbow I go, from the knee I flee"). A fracture line is sharper, often crosses the whole cortex at a different angle, and has soft tissue change.

Section 4Normal chest and abdominal film anatomy for the chiropractor

Why a chiropractor reads chest and abdomen

Chiropractors order and read spinal films that always include part of the chest or abdomen, and they see patients whose back or shoulder pain comes from the viscera. A thoracic spine film is also a chest film; a lumbar film is also an abdominal film. You are responsible for recognizing a lung mass at the apex of a cervical film, an aneurysm in front of the lumbar spine or a large kidney stone on an AP lumbar view, and for referring appropriately. You need a working knowledge of normal anatomy so that abnormal stands out.

Is the chest film adequate?

Before reading anatomy, judge quality, because poor technique creates false disease. The checks can be remembered as rotation, inspiration and penetration.

Normal PA chest anatomy

Read the chest with the same ABCS idea adapted to the region, or use any fixed pattern that covers the airway, bones, cardiac silhouette, diaphragm, lung fields, hila and soft tissues (Figure 2.4). The trachea is midline (a slight rightward displacement at the aortic knob is normal). The right heart border is the right atrium, with the superior vena cava above it. The left heart border, from top to bottom, is formed by the aortic knob (arch), the main pulmonary artery, the left atrial appendage (normally flat or slightly concave) and the left ventricle. The cardiothoracic ratio (widest cardiac diameter divided by the widest internal thoracic diameter) is normally less than 0.5 on a PA film. The mediastinum on a PA film is normally less than about 8 cm wide at the level of the aortic knob.

The hila contain the pulmonary arteries and bronchi; the left hilum normally sits slightly higher than the right because the left pulmonary artery arches over the left main bronchus. The lung markings are vessels; they taper toward the periphery and are larger at the bases on an erect film because of gravity. The right hemidiaphragm is normally about 1.5 to 2 cm higher than the left because the liver lies beneath it, and the gastric air bubble lies under the left. Both costophrenic angles are sharp. Look for the horizontal fissure on the right (from the hilum laterally to about the fourth rib). Check the breast shadows, axillae and chest wall soft tissue.

On the lateral film, the retrosternal clear space sits behind the sternum and in front of the heart, and the vertebral bodies should become more lucent (darker) from top to bottom because less soft tissue overlies the lower thorax. If the lower thoracic vertebrae look whiter than the upper ones (the spine sign), suspect a lower lobe density.

The silhouette sign

Borders are seen only where tissues of different density meet. When lung next to a structure fills with fluid or tissue, the border disappears: the silhouette sign. Loss of the right heart border places the disease in the right middle lobe; loss of the left heart border places it in the lingula; loss of a hemidiaphragm places it in the lower lobe; loss of the aortic knob suggests the left upper lobe. This is how a chiropractor localizes a density on a single film and words a referral.

Normal abdominal film anatomy

The AP lumbar or KUB (kidneys, ureters, bladder) film shows the liver shadow in the right upper quadrant, the splenic tip on the left, the psoas margins as oblique lines diverging from the spine to the pelvis, and the kidneys, which lie at roughly T12 to L3, are about three to four vertebral body heights long, lie along the psoas, and usually sit with the left slightly higher than the right. The bowel gas pattern is normally a gastric bubble, gas scattered through the colon, and small amounts in nondilated small bowel. A common rule of thumb for upper limits of diameter is 3, 6 and 9 cm for the small bowel, colon and cecum. Small bowel has valvulae conniventes crossing the full width of the lumen; the colon has haustra that cross only part of it.

Section 5Describing and reporting under time

Describe before you diagnose

When you see something abnormal, resist naming it at once. A description built from standard features does three things: it shows the examiner a systematic mind, it narrows the differential logically, and it protects you when the diagnosis is uncertain, because a correct description with a safe recommendation earns credit even if the final label is not the one on the answer key. The description has a fixed order: location, morphology (size, shape, number, density), margins and zone of transition, matrix, periosteal reaction, cortex and soft tissue. Then comes the patient's age, which with location narrows most bone lesion differentials more than any other features.

Location

Name the bone, the side, the part of the bone and the position within it. In long bones the parts are the epiphysis (or apophysis), the metaphysis and the diaphysis; within the cross section a lesion is central (medullary), eccentric, cortical or juxtacortical (surface). In the spine, name the level and whether the lesion involves the body, the pedicle, the posterior elements or the disc. Location is powerful: epiphyseal lesions in a skeletally immature patient suggest chondroblastoma or infection; lesions of the posterior elements in young patients suggest osteoid osteoma, osteoblastoma or aneurysmal bone cyst; body and pedicle destruction in an older adult suggests metastasis.

Margins, zone of transition and the pattern of bone destruction

The zone of transition, the border between lesion and normal bone, is the single best indicator of biological activity. A narrow zone (sharp, geographic edge), especially with a sclerotic rim, means the bone has had time to wall off a slow lesion. A wide zone means the lesion is permeating faster than bone can respond. Moth eaten destruction is multiple small holes that coalesce; permeative destruction is innumerable tiny holes, often best seen in the cortex, typical of round cell tumors (Ewing sarcoma, lymphoma, myeloma) and of osteomyelitis. Remember that infection can look as aggressive as a malignancy.

Matrix

Matrix is the mineralized material a lesion produces. Osteoid matrix is cloud like, fluffy or ivory dense (osteosarcoma, osteoblastoma, bone island). Chondroid matrix forms rings and arcs or popcorn calcification (enchondroma, chondrosarcoma). Fibrous matrix gives a hazy ground glass appearance (fibrous dysplasia). A purely lytic lesion has no visible matrix. Naming the matrix narrows the differential to bone forming, cartilage forming or fibrous lesions.

Periosteal reaction

The periosteum responds to an underlying process by laying down new bone. A solid, thick, smooth reaction means slow, benign or chronic processes (healing fracture, osteoid osteoma, chronic infection, hypertrophic osteoarthropathy). Lamellated (onion skin) reaction means repeated episodes of periosteal lifting, classically Ewing sarcoma but also infection. Spiculated reaction, in sunburst or hair on end patterns, means a very rapid process, classically osteosarcoma. A Codman triangle is a cuff of periosteal new bone lifted at the edge of a rapidly growing lesion and broken through; it signals aggressiveness, usually malignancy, though infection and hemorrhage can produce it.

The one line impression

The impression distills everything into one sentence: the most likely diagnosis (or the leading differential), its location, and any qualifier that matters for care. Good impressions are short and specific: "Grade 1 isthmic spondylolisthesis of L5 on S1." "Aggressive lytic lesion of the L2 body and left pedicle in a 70 year old, suspicious for metastasis." "Normal lateral cervical spine for age." If you are unsure, give the leading diagnosis and one or two alternatives: "Lytic lesion of the T10 body, metastasis versus myeloma." Avoid hedging long lists; on a timed exam, three plausible items is enough.

The recommendation

The recommendation is where many points are won or lost, because it is the safety step. It answers three questions: does this need more imaging or tests, does it need referral and how urgently, and is manipulation of this region safe?

Putting it together in under a minute

A complete, timed oral report follows a template you can say almost without thinking: label, search summary, finding described by location and features, impression, recommendation. Practice the template on normal films so the structure is automatic, then the abnormal content drops into place. In a written answer, use the same order in short sentences.

Words worth knowing

High Yield Films I: Trauma

Trauma films are where an imaging station tests judgment as much as recognition. The candidate who names the fracture but then says "I would adjust above and below it" has failed the station, while the candidate who calmly states the finding, its location and view, a one line impression, and "no manipulation of this region, immobilize and refer" has earned nearly every point. This chapter covers the trauma films that recur on practical exams and in practice, and shows how to turn each one into a spoken answer that is fast, accurate and safe.

Section 1Cervical trauma films

How a trauma film station usually runs

An imaging task usually gives a door card with a brief history and one or more films, and asks what you see and what you would do. Examiners typically score the key finding, its location and best view, the impression and a safe recommendation; missing an unstable fracture, or recommending manipulation through one, can outweigh everything else. Formats and timing change, so check the current official candidate materials.

Use a fixed spoken template for every film: the view, adequacy, the key finding with level and side, secondary findings, a one line impression and the recommendation. Ending on the recommendation every time guarantees you never forget the step that carries the most weight.

The adequate lateral cervical film and the four lines

The neutral lateral is adequate only when the top of T1 is visible; missed lower cervical injuries hide at C6 to T1 behind the shoulders. The plain film fix is a swimmer's view, but a patient with real trauma risk needs CT. Trace four smooth curves: the anterior vertebral line, the posterior vertebral line (George's line, the front wall of the canal), the spinolaminar line (the back wall of the canal; in children the posterior cervical line of Swischuk separates C2 to C3 pseudosubluxation from a hangman fracture) and the spinous process line. A step or abrupt angle localizes the injured segment; fanning of spinous processes, a widened facet or focal kyphosis point to ligament disruption even without a fracture line.

Soft tissue signs

Blood and edema widen the prevertebral soft tissue. Commonly taught adult limits are about 7 mm at C2 and 22 mm at C6 ("7 at 2, 22 at 6"; about 14 mm at C6 in children). It is a supporting sign, not a rule out: many fractures do not widen it, and crying or flexion can. Displacement of the prevertebral fat stripe is a related clue.

Upper cervical injuries: C1 and C2

The atlas is a ring with two thick lateral masses. The axis carries the dens, which is held against the anterior arch of C1 by the transverse ligament. The atlantodental interval (ADI), measured on the lateral from the posterior surface of the anterior arch of C1 to the anterior surface of the dens, is normally 3 mm or less in adults and 5 mm or less in children. A larger ADI means transverse ligament failure, whether from trauma, rheumatoid arthritis, Down syndrome or infection in the pharynx (Grisel syndrome).

Odontoid fractures (Anderson and D'Alonzo): type I avulses the tip and is rare; type II crosses the poorly perfused base and is the most common and most likely to fail to unite; type III enters the C2 body and heals better. Separate a true fracture from a Mach band (a lucency from overlapping arch or teeth that runs beyond the dens margins) and, in young children, the dentocentral synchondrosis. An os odontoideum (smooth corticated ossicle, hypertrophied anterior arch of C1) is unstable and earns the same answer: no upper cervical manipulation and referral. Lateral mass offset can come from head rotation, and children up to about 4 years show a pseudo Jefferson offset; bilateral overhang in an adult after axial load is a fracture until CT says otherwise.

Lower cervical injuries: C3 to C7

Below C2, injuries are best understood by mechanism. Flexion compresses the front and distracts the back; extension does the reverse; rotation added to flexion produces unilateral facet injury.

The two teardrops share a name and nothing else. In the flexion teardrop the small fragment signals a three column injury, with the body driven back into the canal and often an anterior cord syndrome. In the extension teardrop the anterior longitudinal ligament pulls off a corner and the posterior structures are intact. In a unilateral facet dislocation the facets superimpose above the level and sit side by side (bow tie) at and below it; a slip of half the body width or more means bilateral dislocation with torn disc and posterior ligaments.

Flexion and extension films and instability

Spasm can hide ligament injury on neutral films. Flexion and extension laterals reveal abnormal motion; widely cited lower cervical limits are more than about 3.5 mm of translation or more than about 11 degrees of angulation relative to adjacent levels, and an ADI that widens in flexion means transverse ligament insufficiency. Do not take them with a known or suspected fracture, dislocation or neurologic deficit, or in an obtunded or intoxicated patient. Early films are often falsely normal, so they are commonly repeated after 7 to 14 days, with the patient moving actively within comfort.

Section 2Thoracolumbar trauma films

The three column concept

The Denis three column model remains the simplest way to reason about thoracolumbar stability on a plain film. The anterior column is the anterior longitudinal ligament, the anterior two thirds of the vertebral body and the anterior annulus. The middle column is the posterior third of the body, the posterior annulus and the posterior longitudinal ligament. The posterior column is the pedicles, facets, laminae, spinous processes and the posterior ligament complex (supraspinous, interspinous and ligamentum flavum, plus the facet capsules). Injury to one column is usually stable; injury to two or more columns, and especially any injury involving the middle column, is potentially unstable. The more columns broken, the less stable the spine.

About half of thoracolumbar fractures occur at the thoracolumbar junction (T11 to L2), where the stiff, rib supported thoracic spine meets the mobile lumbar spine. High energy fractures here travel with other injuries: a burst fracture from a fall onto the feet often accompanies calcaneal fractures, and a Chance fracture from a lap belt often accompanies abdominal visceral injury.

Compression, burst and Chance fractures

On the lateral, judge a compression fracture by comparing anterior, middle and posterior heights. A commonly used semiquantitative grading (after Genant) calls height loss of about 20 to 25% mild, 25 to 40% moderate and more than 40% severe. Signs that a fracture is acute include a step defect or buckle in the anterior cortex, a band of increased density under the endplate (the zone of impaction, where trabeculae have been crushed together), endplate disruption and paraspinal soft tissue swelling. An old healed fracture has smooth margins and no impaction zone. When age cannot be settled on the plain film, MRI (fluid sensitive sequences show marrow edema in an acute fracture) or a bone scan answers the question.

The deciding structure is the posterior body wall: straight and intact suggests a wedge fracture; bowed, broken, with a fragment behind the posterior vertebral line or with widened pedicles on the AP means a burst fracture and CT.

Osteoporotic versus pathologic compression fracture

In older adults, the commonest compression fracture is osteoporotic (insufficiency fracture of weakened bone under normal load), but a fracture through bone already destroyed by metastasis or myeloma (pathologic fracture) looks similar at first glance and carries a very different plan. The distinction relies on the pattern of the vertebra and its neighbors.

Suspected pathologic fracture: MRI, labs (CBC, ESR or CRP, calcium, alkaline phosphatase, protein electrophoresis) and referral. Osteoporotic fracture: no thrust at or near it, low force care, DXA and bone health referral.

Thoracic and lumbar trauma mimics

Mimics: Schmorl nodes (rounded corticated endplate defects), the limbus bone (a smooth corticated anterosuperior corner fragment from disc herniation under the ring apophysis), Scheuermann disease (three or more adjacent wedged thoracic bodies with irregular endplates) and mild physiologic wedging at T12 and L1.

Section 3Pars defects and spondylolisthesis

Spondylolysis and the Scotty dog

Spondylolysis is a defect in the pars interarticularis, the narrow bridge of bone between the superior and inferior articular processes. Most defects are fatigue (stress) fractures that develop in childhood or adolescence from repeated extension and rotation, which is why they are common in gymnasts, divers, football linemen, dancers and fast bowlers. About 85 to 90% occur at L5, most of the rest at L4, and roughly three quarters are bilateral. When the defects are bilateral, the vertebral body, pedicles and superior facets can slide forward while the lamina, inferior facets and spinous process stay behind: that forward slip is isthmic spondylolisthesis.

The classic plain film sign is on the oblique lumbar view, where the posterior elements form the outline of a Scotty dog. The nose is the transverse process, the eye the pedicle, the ear the superior articular process, the neck the pars interarticularis, the body the lamina and the front leg the inferior articular process. A pars defect appears as a lucent band across the neck, the collar on the dog. On the lateral view a defect is sometimes visible as a lucent oblique line behind the pedicle, and the slip itself is measured on the lateral. Many defects are invisible on plain films; CT shows the gap, and MRI or SPECT shows an early stress reaction.

Grading the slip

The Meyerding method divides the superior endplate of the vertebra below (usually S1) into four equal parts and grades the slip by how far the posteroinferior corner of the vertebra above has moved forward: grade I up to 25%, grade II 26 to 50%, grade III 51 to 75%, grade IV 76 to 100%, and grade V (spondyloptosis) beyond the front of the sacrum. Ullmann's line (Garland's line), drawn up from the anterior margin of the sacral base perpendicular to the sacral endplate, should not be crossed by the L5 body; crossing it indicates an anterior slip. In spondyloptosis the AP film shows the inverted Napoleon hat sign, the L5 body projected end on over the sacrum.

Types of spondylolisthesis

Isthmic versus degenerative: what the film and the hands show

The two common types behave in opposite ways in the canal. In isthmic spondylolisthesis, the posterior arch stays behind as the body slides forward, so the canal at that level actually widens, and symptoms are usually low back pain with or without radicular pain from the nerve root caught in the fibrocartilaginous tissue of the defect (the L5 root at an L5 slip). In degenerative spondylolisthesis, the whole vertebra slides forward, arch and all, so the canal is pinched between the posterior arch above and the body below, causing central and lateral recess stenosis and neurogenic claudication (leg pain with walking or standing that is relieved by sitting or flexing).

The palpable step follows the same logic. With an isthmic L5 slip the L5 spinous process stays back with the arch while L4 and everything above move forward with the L5 body, so the step is felt between the L4 and L5 spinous processes, at the level above the slipped vertebra. With a degenerative L4 slip the L4 spinous process travels forward with its body, so the step is felt at the slipped level itself.

What to recommend

Most adults with a stable grade I or II isthmic slip do well with conservative care, and spondylolisthesis by itself is not an absolute contraindication to chiropractic care. Sensible modifications include avoiding a forceful posterior to anterior thrust directly on the anteriorly displaced segment, favoring adjacent level adjustments, flexion distraction and core stabilization, and avoiding repetitive end range extension. Flexion and extension laterals show whether the slip moves; translation of more than about 4 mm, or a slip that changes grade between flexion and extension, suggests instability.

Section 4Pelvis, hip and extremity trauma films

General rules for extremity trauma films

Follow the rule of two: two views at right angles, the joints above and below a long bone fracture, and comparison views in children when needed. After the first fracture keep looking (satisfaction of search); a broken forearm bone usually has a partner injury. The Ottawa rules tell you when films are needed.

Pelvis and hip

Hip fractures in older adults follow low energy falls and present with a shortened, externally rotated leg and inability to bear weight. They are divided by their relation to the joint capsule. Intracapsular fractures (subcapital, transcervical and basicervical femoral neck fractures) can tear the retinacular vessels that supply the femoral head, so they carry a high risk of avascular necrosis and nonunion, especially when displaced. The Garden classification grades femoral neck fractures from I (incomplete or valgus impacted) and II (complete, undisplaced) to III (partially displaced) and IV (fully displaced); III and IV are the high AVN risk group. Extracapsular fractures (intertrochanteric and subtrochanteric) bleed more but rarely cause AVN. On the AP pelvis, look for disruption of Shenton's line (the smooth arc from the inferior femoral neck to the superior border of the obturator foramen), a change in the neck shaft angle, a sclerotic band of impaction, and a break in the cortex of the neck.

Up to about 10% of hip fractures are invisible on the initial films. A patient who cannot bear weight after a fall, with pain on axial loading or log roll, needs MRI (or CT if MRI is unavailable) the same day, not reassurance. A femoral neck stress fracture in a runner or military recruit is a separate trap: compression side fractures on the inferomedial neck are usually managed with rest, but tension side fractures on the superolateral neck can displace and need urgent orthopedic referral.

Slipped capital femoral epiphysis (SCFE) is a Salter Harris type I injury through the proximal femoral physis in an adolescent (typically 10 to 16 years, often overweight, boys more than girls), presenting with hip, thigh or knee pain and a limp. The epiphysis slips posteriorly and medially. On the AP, Klein's line along the superolateral neck fails to intersect the epiphysis, and the physis looks widened and blurred; the frog leg lateral shows the slip best. About a fifth to a quarter are bilateral. The patient must stop weight bearing and be referred the same day for surgical pinning, because further slip risks AVN. Legg Calve Perthes disease (idiopathic AVN of the femoral head, ages about 4 to 8) shows a small, dense, flattened and later fragmented epiphysis, often with a subchondral lucent crescent sign.

Also recognize adolescent apophyseal avulsions (ASIS by sartorius, AIIS by rectus femoris, ischial tuberosity by hamstrings), pelvic ring fractures (one break usually means a second), sacral insufficiency fractures in osteoporotic women, and posterior hip dislocation (dashboard injury, adducted and internally rotated limb, sciatic nerve risk), an emergency.

Wrist and hand

The scaphoid is the most commonly fractured carpal bone, usually from a fall on the outstretched hand in a young adult. About 70 to 80% occur at the waist. Tenderness in the anatomical snuffbox, pain on axial loading of the thumb and tenderness of the scaphoid tubercle are the clinical clues. The dedicated scaphoid view (PA in ulnar deviation) elongates the bone. A significant fraction of scaphoid fractures are not visible on the first films, so the standard plan for a suspected fracture with negative films is thumb spica immobilization and either repeat films in about 10 to 14 days or early MRI. Because the main blood supply enters the distal pole and flows back toward the proximal pole, waist and proximal fractures risk avascular necrosis of the proximal pole (dense, sclerotic fragment) and nonunion.

Normal volar tilt of the distal radius is about 11 degrees and radial inclination about 22 degrees; a Colles fracture reverses the tilt and shortens the radius.

Elbow and shoulder

At the elbow, a visible posterior fat pad or raised anterior fat pad (sail sign) after trauma means an occult fracture: radial head in adults, supracondylar humerus in children. The anterior humeral line should cross the middle third of the capitellum and the radiocapitellar line should hit the capitellum on every view. Pair forearm injuries: Monteggia (proximal ulna fracture, radial head dislocation) and Galeazzi (distal radius fracture, DRUJ dislocation). Know the pediatric ossification order (CRITOE) so a normal center is not called a fragment.

At the shoulder, anterior dislocation dominates (head below the coracoid), with the Hill Sachs (posterolateral head impaction) and Bankart (anteroinferior glenoid) lesions. Posterior dislocation follows seizure or electric shock and shows the lightbulb sign; the axillary or Y view proves it.

Knee, ankle and foot

On the mortise view a medial clear space over about 4 mm means deltoid disruption and an unstable ankle. In a child the fifth metatarsal apophysis runs parallel to the shaft; a fracture runs across it.

Pediatric fractures and the growth plate

Children's bones are more pliable and their physes are weaker than their ligaments, so they bend, buckle and slip at the growth plate instead of spraining. The Salter Harris classification (mnemonic SALTR) describes physeal fractures: type I straight through the physis (Slipped), type II through the physis and a corner of the metaphysis (Above, the most common), type III through the physis and the epiphysis (Lower, intra articular), type IV through metaphysis, physis and epiphysis (Through), and type V a crush of the physis (Ruined, often recognized only later by growth arrest). The higher the number, the greater the risk of growth disturbance. Also know the torus (buckle), greenstick and toddler's (spiral distal tibia) fractures. Metaphyseal corner fractures, posterior rib fractures, fractures of different ages and fractures in a nonwalking child suggest nonaccidental trauma: document objectively and make the mandated report.

Section 5Trauma decision making in a station

The decision the examiner is really scoring

A trauma film station is a safety station dressed as an imaging station. Exams of this type generally reward a candidate who recognizes when the area must not be manipulated, protects the patient now, refers at the right speed and orders the right follow up imaging, all said aloud: an examiner cannot score a silent decision.

Who needs imaging after trauma

Before you can act on a film you must know when one is needed. For the neck, two validated decision rules are widely taught. The NEXUS criteria say that an alert patient can be cleared without imaging when all five are absent: posterior midline cervical tenderness, focal neurologic deficit, altered alertness, intoxication and a painful distracting injury. The Canadian C spine rule images any high risk patient (age 65 or older, dangerous mechanism such as a fall from about 1 m or five stairs, axial load, high speed or rollover collision, or extremity paresthesias); otherwise, if a low risk factor allows assessment (simple rear end collision, ambulatory, delayed onset, no midline tenderness) and the patient can actively rotate 45 degrees each way, no imaging is needed. Real risk calls for CT.

For the lower back, image after significant trauma, minor trauma in an older or osteoporotic patient, long term steroid use, or with neurologic deficit.

When a film must not be adjusted through

These findings are absolute contraindications to manipulating the involved region:

Relative situations call for modification rather than refusal: a healed, stable old compression fracture (low force methods, adjust other regions), a stable grade I slip (no thrust into the slipped segment), or a long healed extremity fracture. In each case say why the modification is safe and what you would watch for.

Immobilization and referral

For a suspected unstable cervical injury, keep the patient still with the head in neutral, apply a rigid collar if trained, do not let them walk out or drive, and call EMS; a neurologic deficit makes this a 911 call. A stable acute fracture without deficit gets protection and same day orthopedic or emergency evaluation. For limb fractures, document pulses, capillary refill, sensation and motor function before and after splinting; a pulseless limb or open fracture is an emergency.

Follow up imaging

• Suspected ligament injury, normal neutral films: flexion and extension laterals at 7 to 14 days if no fracture or deficit; MRI with neurologic signs.
• Occult fracture (scaphoid, femoral neck, stress): immobilize; MRI or repeat films in 10 to 14 days.
• Compression fracture of uncertain age or cause: MRI and DXA.
• Burst fracture: CT for canal compromise.
• Spondylolisthesis in a growing child: periodic standing laterals.

When the patient reports a problem

If the standardized patient reports new numbness or feels faint, stop, keep them still, reassess ABCs and neurologic status, call for help and say so aloud. Continuing the scripted task costs safety credit.

Words worth knowing

High Yield Films II: Arthritides, Tumors, Infection, Metabolic Disease and Soft Tissue

Most films in a chiropractic office are not trauma films. They show degeneration, inflammation, a congenital surprise, a curve, a quiet lytic lesion, or a calcified aorta in front of the lumbar spine. In an imaging station, the candidate who can name the pattern, say why it fits, and attach the right recommendation (treat with modification, order the next test, or refer today) shows exactly the judgment the practical exam is built to score.

Section 1Arthritides on film

The ABCDS of arthritis

Every arthritis can be described with the same five headings, and saying them aloud in a station shows a method rather than a guess: Alignment (subluxation, deformity), Bone density (normal or periarticular osteopenia), Cartilage space (uniform or nonuniform narrowing, or preserved), Distribution (which joints, symmetric or not, axial or peripheral) and Soft tissue (swelling, tophi, calcification). Two further questions finish the analysis: are there erosions (marginal, central, or punched out away from the joint), and is there new bone (osteophytes, syndesmophytes, periostitis, ankylosis)?

Degenerative joint and disc disease

Degenerative joint disease (osteoarthritis) is cartilage failure with a bony repair response. The film shows nonuniform joint space narrowing where load is greatest (superolateral hip, medial knee compartment), subchondral sclerosis, osteophytes and subchondral cysts (geodes), with normal bone density. In the hands it involves the DIP joints (Heberden nodes), PIP joints (Bouchard nodes) and the first carpometacarpal joint, sparing the MCPs; erosive osteoarthritis adds central erosions that make a gull wing shape in the DIP joints.

In the spine, degenerative disc disease gives disc space narrowing, endplate sclerosis, the vacuum phenomenon (gas in a degenerated disc, which effectively excludes infection), and osteophytes that arise a few millimeters from the endplate margin, project horizontally and then curve toward the adjacent body. The posterior joints develop facet arthrosis (enlarged, sclerotic articular processes). In the cervical spine the uncovertebral joints hypertrophy and, with facet osteophytes, narrow the intervertebral foramina, best seen on the oblique views. Combined disc, facet and ligamentum flavum changes produce spinal stenosis, which plain films suggest but MRI confirms. Degenerative change is common and often painless, so the board answer links findings to symptoms rather than treating the film.

DISH

Diffuse idiopathic skeletal hyperostosis (Forestier disease) is a bone forming enthesopathy of older adults, more common in men and in people with diabetes and obesity. The diagnostic picture is flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies with preserved disc height, no significant facet ankylosis and normal sacroiliac joints (bridging of the upper, ligamentous part of the SI joint can occur). It favors the right side of the thoracic spine, because the pulsating descending aorta on the left inhibits it. A thin lucent line often separates the ossified ligament from the vertebral body. Peripheral entheses ossify too (heel and olecranon spurs, pelvic "whiskering"). DISH in the cervical spine can cause dysphagia, and it travels with ossification of the posterior longitudinal ligament (OPLL), which narrows the canal. A long ossified segment behaves like a long bone: it fractures with minor trauma and is unstable when it does.

Rheumatoid arthritis

Rheumatoid arthritis is a synovial disease, and its film signs follow: soft tissue swelling, periarticular osteopenia, uniform joint space loss, and marginal erosions at the bare areas where synovium touches bone not covered by cartilage, with little or no new bone. It is bilateral and symmetric in the MCP, PIP and wrist joints (an early erosion of the ulnar styloid is classic) and the MTP joints of the feet; late deformities include ulnar deviation, swan neck and boutonniere. In the hip it causes axial migration and protrusio acetabuli; in the knee, uniform loss across all compartments.

The cervical spine is the high stakes area. Pannus at C1 to C2 weakens the transverse ligament and erodes the dens, producing atlantoaxial instability (ADI over 3 mm in an adult), cranial settling (basilar invagination, the dens migrating up toward the foramen magnum) and subaxial stair step subluxations. Neutral and flexion lateral films (taken carefully) are standard before any treatment of the neck in a patient with RA; instability or myelopathic signs (hand clumsiness, gait change, hyperreflexia) are an absolute contraindication to cervical manipulation and a reason for referral.

Ankylosing spondylitis and the seronegatives

The seronegative spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, reactive arthritis and enteropathic arthritis with inflammatory bowel disease) share HLA B27 association, sacroiliitis, enthesitis and new bone formation. Ankylosing spondylitis begins in young adults, more often men, with inflammatory back pain (morning stiffness over 30 minutes, better with exercise). It starts in the sacroiliac joints, bilaterally and symmetrically: erosions on the iliac side make the joint look wide and irregular (pseudowidening), then sclerosis and finally fusion. In the spine, inflammation at the annulus attachment gives Romanus lesions (shiny corners), then squaring of the vertebral bodies, then thin marginal syndesmophytes that bridge the discs to create the bamboo spine. Ossified interspinous and supraspinous ligaments give the dagger sign, and with fused facets the trolley track sign. The hips are often involved, bilaterally and concentrically.

Psoriatic arthritis is asymmetric and favors the DIP joints, with erosions that create the pencil in cup deformity, fluffy periostitis, acro osteolysis and the sausage digit; its SI involvement is often asymmetric and its spinal bone is bulky, nonmarginal and asymmetric (parasyndesmophytes). Reactive arthritis looks similar but favors the feet and heels. Enteropathic arthritis mimics AS.

Gout and CPPD

Gout (monosodium urate, negatively birefringent needle shaped crystals) is a disease of middle aged men and postmenopausal women; film changes appear only after years of attacks. Look for punched out erosions with sclerotic, overhanging edges (the Martel or rat bite sign), often slightly away from the joint, preserved joint space until late, normal bone density and asymmetric tophi (soft tissue masses that may calcify). The first MTP (podagra) is classic; the elbow (olecranon bursa), hands and knees follow.

Calcium pyrophosphate deposition (positively birefringent rhomboid crystals) has two film faces. Chondrocalcinosis is calcification in cartilage: the knee menisci, the triangular fibrocartilage of the wrist and the pubic symphysis. Pyrophosphate arthropathy looks like osteoarthritis in unusual places: the radiocarpal joint, the second and third MCP joints (with hook like osteophytes), and isolated patellofemoral disease. Calcification around the dens (crowned dens) can cause acute neck pain with fever that mimics meningitis. Hemochromatosis gives an almost identical picture.

Section 2Congenital anomalies and scoliosis on film

Why anomalies matter in a station

Congenital anomalies arise from failures of segmentation (somites do not separate), formation (part of a vertebra never develops) or fusion (ossification centers do not unite). Most are incidental, but the examiner wants three things from you: do not call them fractures or disease, know which ones change mechanics or stability, and know which ones alter your technique.

Scoliosis on film

Scoliosis is a lateral curvature of the spine of 10 degrees or more measured by the Cobb method, usually with vertebral rotation. Most cases in adolescents are idiopathic, typically a right thoracic curve in a girl. Features that suggest an underlying cause and call for MRI include a left thoracic curve, a painful curve (consider osteoid osteoma, with the lesion on the concave side), rapid progression, a curve in a young child, and neurologic signs or cutaneous markers (hair patch, dimple). Functional (nonstructural) curves from leg length inequality or muscle spasm straighten on side bending or when the leg length is corrected; structural curves do not.

Measuring and managing the curve

The Risser sign grades ossification of the iliac crest apophysis, which spreads from the anterior superior iliac spine toward the posterior superior iliac spine: grade 0 none, 1 up to 25%, 2 up to 50%, 3 up to 75%, 4 complete but not fused, 5 fused to the ilium. Low Risser grades mean growth remains and the curve is more likely to progress. Commonly taught thresholds in a growing adolescent: under about 20 to 25 degrees, observe with periodic films (typically every 4 to 6 months); about 25 to 40 degrees in a skeletally immature patient (Risser 0 to 2), refer for bracing; over about 40 to 50 degrees, refer for surgical consultation. Curves over about 50 degrees may keep progressing in adulthood. Chiropractic care can be part of management, but it does not replace indicated bracing or surgical referral, and serial imaging should use PA projections and the lowest dose that answers the question.

Measurement error for the Cobb angle is about 3 to 5 degrees, so a change of 5 degrees or more between films is the usual definition of progression. Measure from the same end vertebrae on each film.

Section 3Tumors and tumor like lesions on film

Aggressive or nonaggressive: the first judgment

You do not need to name every bone tumor in a station, but you must decide whether a lesion looks aggressive or nonaggressive, because that decision sets the recommendation. Combine the patient's age (over 40, metastasis and myeloma dominate; under 30, primary tumors and benign lesions) with five film features.

Matrix narrows the differential: cloud like or ivory density suggests osteoid (osteosarcoma, osteoblastic metastasis); rings and arcs or popcorn stippling suggest cartilage (enchondroma, chondrosarcoma); hazy ground glass suggests fibrous dysplasia. Remember that plain films show a lytic lesion only after roughly 30 to 50% of the bone is gone, so a normal film does not exclude tumor in a patient with red flags; MRI is the sensitive test for marrow disease.

Metastasis and myeloma

Metastasis is the most common malignant tumor of bone and goes where red marrow is: spine, pelvis, ribs, skull and proximal long bones. Most metastases are lytic (lung, kidney, thyroid, breast, gastrointestinal); blastic lesions point to prostate cancer in men and breast cancer in women (mixed lesions are common in breast). In the spine, the plain film hallmark is the missing pedicle on the AP (the winking owl or one eyed pedicle sign), because tumor that starts in the posterior body destroys the cortical pedicle ring. A single dense vertebra, the ivory vertebra, has a short differential: blastic metastasis, Hodgkin lymphoma and Paget disease (Paget enlarges the bone; the others do not). Metastasis typically spares the disc. Recommendation: no manipulation of the involved region, MRI, laboratory tests and urgent referral; screen every patient for spinal cord compression (band like pain, leg weakness, sensory level, bladder change), which is an emergency.

Multiple myeloma is the most common primary malignant tumor of bone, in adults over about 40 to 50. Films show punched out lytic lesions without sclerotic margins (the raindrop skull), or simply diffuse osteopenia with compression fractures. The pedicles tend to be spared early, because they contain little red marrow, which helps separate myeloma from metastasis. Myeloma is often cold on bone scan (there is little osteoblastic response), so a skeletal survey, low dose CT or MRI is used. Laboratory clues follow CRAB: hyperCalcemia, Renal failure, Anemia and Bone lesions, with an M protein on serum protein electrophoresis. A single lesion is a plasmacytoma.

Benign lesions you must recognize

Primary malignancies

Osteosarcoma peaks in adolescence (with a second peak in older adults with Paget disease or prior radiation), in the metaphysis around the knee; it shows mixed destruction with cloud like osteoid, a sunburst periosteal reaction, a Codman triangle and a soft tissue mass. Ewing sarcoma affects children and young adults (about 5 to 20 years), often in the diaphysis of long bones or in flat bones (pelvis), with a permeative pattern, laminated onion skin periosteal reaction and a large soft tissue mass; fever and a raised ESR mimic infection. Chondrosarcoma affects adults (40 to 60) in the pelvis, proximal femur and shoulder girdle, with rings and arcs and deep endosteal scalloping. Chordoma arises from notochord remnants in the sacrum and clivus of older adults as a midline destructive mass. Any of these is an urgent referral to an orthopedic oncologist, with no manipulation of the region.

Section 4Infection, hematologic, metabolic and endocrine disease on film

Discitis and vertebral osteomyelitis

Spinal infection usually reaches the spine through the blood and settles first in the vascular endplate, then spreads into the disc, which in turn destroys the endplate on the other side. That sequence explains the defining film rule: infection crosses and destroys the disc; tumor usually spares it. Pyogenic discitis (most often Staphylococcus aureus; consider gram negatives in intravenous drug users and after urinary procedures) is most common in the lumbar spine of older adults, diabetics, the immunocompromised and patients after spinal procedures. The earliest film sign is disc space narrowing, followed by loss of the sharp white endplate line and erosion of both endplates, then destruction of the bodies and, with healing, sclerosis and fusion. Films lag the disease by about 2 to 3 weeks; MRI is the test of choice early, with ESR and CRP (almost always raised), CBC and blood cultures.

Tuberculous spondylitis (Pott disease) is slower, favors the thoracolumbar spine, spreads under the anterior longitudinal ligament to several contiguous levels, preserves the disc longer, produces large paraspinal and psoas abscesses (which may calcify) and ends in anterior collapse with a sharp kyphosis (gibbus), usually with little sclerosis.

In long bones of children, hematogenous osteomyelitis settles in the metaphysis; films are normal for about 10 to 14 days, then show permeative lysis and periosteal reaction, and later a sequestrum (dead bone) and involucrum (new bone shell). A Brodie abscess is a subacute lucent metaphyseal lesion with a sclerotic rim. Septic arthritis destroys cartilage on both sides of a joint within days and is an emergency.

Avascular necrosis and sickle cell disease

Avascular necrosis (osteonecrosis) most often affects the femoral head. Risk factors are commonly remembered as ASEPTIC: Alcohol and AIDS, Steroids and sickle cell, Erlenmeyer flask (Gaucher disease), Pancreatitis, Trauma, Idiopathic and infection, Caisson disease and collagen vascular disease (lupus). Films are normal early (MRI shows the double line sign), then show mottled sclerosis and lucency, a subchondral lucent crescent sign (subchondral fracture), flattening and collapse of the head, and finally secondary osteoarthritis. Unlike osteoarthritis, the joint space is preserved until collapse. Named osteonecroses include Legg Calve Perthes (child femoral head), Kienbock (lunate, linked with negative ulnar variance), Preiser (scaphoid), Freiberg (second metatarsal head), Kohler (navicular) and Panner (capitellum). Recommend MRI for early disease, protected weight bearing and orthopedic referral.

Sickle cell disease causes marrow hyperplasia and repeated infarction. Look for H shaped vertebrae (square central endplate depressions from infarction of the central growth plate), serpiginous medullary bone infarcts, AVN of the femoral and humeral heads, dactylitis in infants, and widened medullary cavities. Patients are prone to osteomyelitis, classically with Salmonella.

Metabolic and endocrine bone disease

Section 5Soft tissue findings on spine and chest films

Look outside the bones

The soft tissues are a review area that candidates skip under time pressure, and examiners know it. A lateral lumbar film shows the abdominal aorta and the kidneys; a thoracic or cervical film shows lung apices, pleura and the prevertebral space; an AP lumbar or pelvis film shows the renal outlines, the gallbladder region and the pelvic calcifications. Finish every film by sweeping these areas deliberately and saying that you did: "Soft tissues: no abnormal calcification, aorta not dilated, lung apices clear."

Abdominal aortic aneurysm

An abdominal aortic aneurysm (AAA) is a dilation of the aorta to 3 cm or more (normal is about 2 cm). Most are infrarenal and lie in front of L2 to L4, ending at the bifurcation at about L4. Risk factors are age over 65, male sex, smoking, hypertension, atherosclerosis and family history. On the lateral lumbar film, atherosclerotic calcification often outlines the walls as thin curvilinear lines in front of the vertebral bodies; measure from the outer edge of the anterior wall to the outer edge of the posterior wall. A plain film can suggest an aneurysm but cannot exclude one, because many are not calcified. Confirmation is by ultrasound (or CT).

The recommendation depends on size and symptoms. Any AAA needs confirmation by ultrasound and referral to the patient's physician or a vascular surgeon for surveillance; the commonly taught repair threshold is about 5.5 cm in men (about 5 cm in women) or growth faster than about 0.5 to 1 cm per year. A tender or painful aneurysm is an urgent referral; back, flank or abdominal pain with hypotension, syncope or a pulsatile mass suggests rupture, a 911 emergency. Avoid forceful lumbar manipulation, especially rotational side posture thrusts and deep abdominal pressure, in a patient with a known or suspected aneurysm until it has been evaluated; many clinicians use low force methods only.

Abdominal and pelvic calcifications

Chest findings on spine films

Thoracic and cervical films show part of the lungs. A solitary pulmonary nodule (under 3 cm) or mass (3 cm or more) seen on a spine film needs a dedicated chest film or CT and referral; a smoker, an irregular or spiculated edge, or growth raise concern for cancer. The classic trap is a Pancoast (superior sulcus) tumor: an apical opacity, sometimes with destruction of the first to third ribs, in a smoker with shoulder and arm pain in the C8 to T1 distribution and possibly Horner syndrome (ptosis, miosis, anhidrosis). It mimics a cervical radiculopathy, so always look at the lung apices on cervical and upper thoracic films.

A pneumothorax shows a thin white visceral pleural line with no lung markings beyond it; on a supine film, air collects anteriorly and inferiorly and deepens the costophrenic angle (deep sulcus sign). Spontaneous pneumothorax typically occurs in tall, thin young men and in smokers or people with emphysema; it can also follow rib fracture. A tension pneumothorax (mediastinal shift away from the affected side, flattened diaphragm, worsening breathlessness and falling blood pressure) is a 911 emergency. A pleural effusion blunts the costophrenic angle with a curved meniscus. Rib lesions (lytic metastasis, healing fractures) are also part of the chest sweep.

Prevertebral swelling and neck calcifications

On the lateral cervical film, widened prevertebral soft tissue (more than about 7 mm at C2 or 22 mm at C6 in an adult) has three main causes: hematoma from trauma (Chapter 3), retropharyngeal abscess (usually a child or an adult after pharyngeal infection, with fever, painful swallowing, drooling and neck stiffness; sometimes gas in the soft tissue; an emergency because of airway risk) and acute calcific tendinitis of the longus colli (amorphous calcification in front of C1 to C2 with swelling below it, acute neck pain and painful swallowing, self limiting with NSAIDs, but it must be separated from abscess). Other neck calcifications: carotid artery calcification near C3 to C4 (atherosclerosis; recommend carotid ultrasound and physician follow up, and use caution with cervical manipulation), calcified stylohyoid ligament (Eagle syndrome), nuchal ligament ossicles and calcified thyroid or tracheal cartilage (normal with age).

Words worth knowing

The History in a Standardized Patient Encounter

In a case management station the history is where most of the diagnosis is made and where most of the points are quietly lost. Candidates who know their orthopedic tests cold still fail history stations because they forget to introduce themselves, ask leading questions, skip the cauda equina screen or run out of time before the red flags. This chapter turns the history into a repeatable script you can run under a clock with a standardized patient, so that the diagnosis, the safety screen and the professional behaviors examiners score all happen every time.

Section 1Opening the encounter

What a history station is testing

Practical exams of this kind usually place you in a small room with a standardized patient (SP), an actor trained to portray a case consistently and, in many formats, to score or help score your performance. You read a door card outside the room that gives the patient's name, age, sex, the reason for the visit and sometimes vital signs, then you enter and perform a task under a time limit. Some stations ask only for a history; others combine history and examination; still others follow with written items or a patient note. Scoring generally combines checklist items (did you ask about bladder function, did you ask about night pain), communication and professionalism ratings (introduction, respect, plain language, empathy), and critical actions, the small number of behaviors whose omission can sink the station regardless of everything else, such as failing to screen for a red flag that the case was written around. The exact number of stations, their timing and the weighting of each domain change over time, so read the current official candidate materials and practice to whatever timing they describe.

Think of three overlapping scores: content (the facts that matter), process (how you collected them) and safety (catching what would hurt the patient if missed). Charm without the saddle numbness question fails; a complete checklist delivered as an interrogation loses process points.

The door card: your first 30 seconds of thinking

The door card is the only information you get before the clock is running in the room, so use it. Read it for four things: who (age and sex shift the probabilities more than anything else), what (the chief complaint), the task (history only, history and exam, or focused exam) and any data (vitals, a medication, a prior diagnosis). Then build a working list of three to five hypotheses, including at least one serious condition that must not be missed. A 68 year old man with new thoracic pain should make you think of compression fracture, metastasis, aortic aneurysm or dissection, cardiac disease and herpes zoster before you think of a rib subluxation. A 24 year old woman with neck pain after a rear end collision suggests whiplash associated disorder, facet sprain, muscle strain, and a must not miss list of fracture, ligamentous instability and cervical artery dissection.

The first minute in the room

The opening is the most predictable part of the station and the easiest place to earn reliable points. Do it the same way every time so that it costs no thought.

1. Knock and enter. Make eye contact and smile appropriately to the situation (a patient in severe pain does not want a grin).
2. Hand hygiene. Sanitize or wash your hands in view of the patient, or say that you are doing so if the setting is simulated.
3. Introduce yourself with your name and role: "Hello, I am Dr. Patel, one of the chiropractors here."
4. Identify the patient with two identifiers, usually full name and date of birth: "Can you tell me your full name and date of birth?" Asking the patient to state them, rather than reading them aloud and waiting for a nod, is the safer habit.
5. Ask how they prefer to be addressed and use that name.
6. Attend to comfort. Offer a seat or position of ease, notice obvious distress, and adjust the gown or drape if needed.
7. State the purpose and get consent to proceed: "I would like to ask you some questions about your back and then, with your permission, examine you. Is that all right?"
8. Set the agenda: "Is there anything else you were hoping we would address today?" This one question surfaces hidden concerns (a fear of cancer, a work form) that otherwise appear at the end and wreck your timing.

Consent at the start of a history

Consent in a history station is lighter than consent for an adjustment, but it still exists. You are asking permission to collect personal information and, usually, to examine afterward. A short statement of purpose with a question ("Is that all right with you?") is enough. If the SP hesitates, explore it: "You seem unsure. What worries you about that?" Never proceed over an objection. Respect for autonomy is a scored professional behavior, and an SP may be scripted to test it by declining part of the encounter. If a patient declines the examination, acknowledge it, explain what you will not be able to determine without it, offer alternatives, and document the refusal.

Rapport inside a time limit

Rapport is not small talk; there is no time for it. In a station, rapport comes from a handful of fast behaviors: using the patient's preferred name, sitting at eye level, an open posture, a brief empathy statement when the patient expresses pain or worry, and visibly listening. The most efficient empathy technique is naming and validating: "That sounds really frightening, waking up unable to move your leg" takes three seconds and earns credit on most communication scales. Avoid false reassurance ("I am sure it is nothing") before you have any data; it is both unprofessional and potentially unsafe.

Section 2The focused history under time

Start open, then funnel

The history of present illness begins with an open question and a short period of uninterrupted listening. Patients who are allowed to finish their opening statement typically take well under two minutes and volunteer much of the history; interrupting early makes the history longer, not shorter, because you then have to retrieve what they would have told you. Use facilitators ("Go on," "And then?", a nod, a brief silence) to keep the story moving. When the opening statement ends, ask "Anything else?" once, then move to focused questions to fill in what is missing, and finish with closed questions for specific yes or no facts such as red flags. This open to closed movement is the question funnel.

The chief complaint

Record the chief complaint in the patient's words and confirm its location by asking the patient to point with one finger. "My back" can mean the thoracolumbar junction, the lumbosacral junction, the sacroiliac joint or the flank; the one finger test localizes it instantly and differentiates a focal source (a finger pointing to the posterior superior iliac spine suggests the sacroiliac joint, the Fortin finger sign) from a diffuse one (a sweeping hand over the whole region). If there is more than one complaint, list them all and ask which matters most today.

OPQRST, done efficiently

Most graduates know OPQRST; the station skill is asking each element in one natural question and not missing any. Some programs teach the variant OPPQRST (with palliative and provocative separated) or add A for associated symptoms and U for "what do you think it is" (understanding). Associated symptoms should never be skipped, because they are where numbness, weakness, bladder change, fever and visceral clues appear.

Prioritizing questions that change the diagnosis

Under time, every question should earn its place by changing the probability of a hypothesis or clearing a danger. Experienced clinicians ask far fewer questions than novices but ask the discriminating ones. A useful habit is to ask yourself, before each question, "If the answer is yes, what would I do differently?" If the answer is nothing, skip it or save it for the end.

Mechanism of injury questions

When trauma is involved, mechanism predicts injury and drives the fracture screen. For a collision ask direction of impact, seat belt and headrest, head position at impact, loss of consciousness, ability to walk at the scene and when symptoms began; for a fall ask height and what landed first; for lifting ask load and posture (flexion with rotation is the classic disc mechanism). Inability to bear weight, midline tenderness, neurological symptoms or a dangerous mechanism flag possible fracture and imaging before manual care.

Avoiding leading questions

A leading question suggests the answer: "The pain is worse when you bend forward, right?" or "You have not had any bladder problems, have you?" Leading questions corrupt the data, and standardized patients are often trained to respond to them in a way that exposes the error, for example by simply agreeing. Neutral phrasing gives the patient room to answer either way: "What happens to the pain when you bend forward?" A related trap is the stacked question, several questions in one breath ("Any fever, chills, weight loss or night sweats?"). The patient answers only the last item, or says "no" to the bundle, and you have screened nothing. Ask red flag items one at a time or in small clusters with a pause for each answer.

Responding to cues

Standardized patients are often scripted with cues, small verbal or nonverbal hints that should prompt a follow up: a pause before answering, "well, my dad had something like this," a wince, a comment about stress or about losing weight "but I have been dieting." A cue you ignore is usually a checklist item you lose. Pick it up immediately: "You mentioned your dad. What happened to him?" Many cases hinge on a single cue that converts a mechanical story into a red flag.

Section 3Red flag and system questions that must not be skipped

Why the red flag screen is the core of the station

Most spinal and extremity complaints seen by chiropractors are mechanical and benign, which is exactly why the board tests the exceptions. A case management station is often written around one serious condition hidden inside an ordinary story: the "muscle strain" that is a compression fracture in a patient on long term prednisone, the "sciatica" with a new urinary hesitancy, the "upper back pain" that is an aortic dissection. The red flag screen is what proves you are safe to practice as a primary contact provider. Individually, most red flags have modest diagnostic accuracy and many patients with benign pain have one or two; their value lies in combinations, in the context of the whole story, and in the fact that missing the few true positives is catastrophic. In a station, ask the screen every time, ask it neutrally and one item at a time, and follow up any positive answer.

The red flag families

Organize the screen into families so that it is fast and complete. For a spinal complaint, every history should touch cancer, infection, fracture, cauda equina or cord compromise, vascular causes, visceral causes and medications. Extremity and headache cases have their own additions.

Cauda equina syndrome: ask it every lumbar case

Cauda equina syndrome (CES) is compression of the lumbosacral nerve roots below the conus medullaris, most often by a large central disc herniation at L4 to L5 or L5 to S1; tumor, epidural abscess, hematoma and fracture are other causes. Its early features (bilateral or alternating sciatica, altered saddle sensation, a subtle change in urinary stream or sensation) are easy to miss, and outcomes depend heavily on how quickly decompression occurs, especially before established urinary retention. That makes the CES questions a classic critical action. Ask about saddle or perineal numbness, urinary change (hesitancy, poor stream, loss of the sensation of a full bladder, retention, overflow incontinence), bowel change (loss of control or sensation), sexual dysfunction, bilateral leg symptoms and progressive weakness. Use plain anatomical words the patient understands: "the area you would sit on a bicycle seat," "when you wipe after the toilet, does it feel normal?"

If any of these are new, the station has changed from a history to an emergency: stop, explain your concern honestly and calmly, do not examine further than needed or treat, and arrange same day emergency evaluation with MRI and surgical assessment. Do not send the patient home to "see how it goes." Document the time, what was found and to whom the patient was referred.

Cervical spine and headache red flags

Neck pain and headache cases add vascular and neurological screens. Cervical artery dissection (vertebral or internal carotid) classically presents as new, severe, often unilateral neck pain or headache that the patient describes as unlike any previous pain, sometimes after minor trauma or sudden neck movement, and it may be followed by ischemic signs. The posterior circulation symptoms are often remembered as the 5 D's and 3 N's: dizziness, diplopia, dysarthria, dysphagia and drop attacks; nausea, numbness (often facial or perioral) and nystagmus, plus ataxia. Internal carotid dissection may add a partial Horner syndrome (ptosis and miosis), pulsatile tinnitus or hemispheric signs. A patient who describes these symptoms is a referral, not a treatment candidate.

For headache, the SNOOP list organizes the red flags: Systemic symptoms (fever, weight loss, cancer, immunosuppression), Neurological signs or symptoms (confusion, weakness, visual loss, papilledema), Onset sudden (thunderclap, maximal within a minute: subarachnoid hemorrhage until proven otherwise), Older age at onset (new headache after 50: consider giant cell arteritis, with jaw claudication, scalp tenderness and visual symptoms), and Pattern change (progressive, positional, worse with Valsalva, or a change in a long standing headache). Ask about pregnancy and the postpartum period, recent head trauma and anticoagulant use as well.

For neck pain after trauma, the fracture questions follow the logic of the Canadian C-spine rule: high risk factors (age 65 or more, a dangerous mechanism such as a fall from height, high speed collision, rollover or ejection, or limb paresthesias) and whether the patient could sit up, walk or rotate the neck afterward. Upper motor neuron symptoms (hand clumsiness, gait change, Lhermitte sign) raise the question of cervical myelopathy.

Thoracic and visceral screens

Thoracic pain carries the highest density of visceral mimics, so the history must ask whether pain relates to breathing (pleuritic pain from pleurisy, pulmonary embolus or pneumothorax), exertion (angina), eating (gallbladder, peptic ulcer, pancreas) and position (mechanical). Ask about cough, breathlessness, sweating, nausea, a rash (herpes zoster may begin with dermatomal pain days before the rash), and risk factors for cardiac and vascular disease. Sudden severe tearing chest or interscapular pain is aortic dissection until proven otherwise; this is an emergency services call.

Medications and anticoagulants

The medication history is both a diagnostic clue and a safety screen for manual therapy. Ask for every prescription, over the counter drug and supplement, then ask the high yield classes by name, because patients forget them. Anticoagulants do not automatically forbid all manual care, but they change force, technique and the threshold for imaging after trauma, and a patient on one with a new severe headache or neurological sign needs emergency evaluation for bleeding. Ask about allergies at the same time.

Section 4Past, family, social and occupational history in brief

Purpose, not completeness

The past, family and social history (PFSH) is where a station history differs most from a real new patient intake. In clinic you collect all of it; in a station you ask the items that change the diagnosis, the safety of care or the plan, and you ask them fast. Signpost the shift ("I would like to ask a little about your health in general"), then move briskly through each part with one or two questions. Many checklists award points for touching each domain, so a brief question in each is better than a long excursion into one.

Past medical history

Ask about prior episodes of the same problem ("Have you had this before? What helped?"), then surgeries, fractures, hospitalizations and the chronic conditions that alter diagnosis or the safety of care, summarized below. Ask about allergies with the medications.

Family history

Family history is short but occasionally decisive. Ask about inflammatory arthritis and its relatives (ankylosing spondylitis, psoriasis, inflammatory bowel disease, uveitis), since HLA-B27 associated disease clusters in families; then cancer, aneurysm, early cardiovascular disease, connective tissue disorders and a parent with hip fracture (a FRAX risk factor). One screening question covers most of it; unbundle any yes.

Social history

Tobacco in pack years (disc degeneration, delayed healing, osteoporosis, lung cancer with spinal metastasis, aneurysm), alcohol (falls, fractures, pancreatitis, avascular necrosis), drugs including injection use (spinal infection), activity and sport, sleep, and home support. Mood and beliefs are where the yellow flags appear, and a station patient may be scripted with them.

Ask about the patient's understanding and expectations: "What do you think is causing this?" and "What are you hoping we can do?" These two questions surface fear avoidance beliefs ("I think my spine is crumbling, so I have stopped moving"), catastrophizing, unrealistic expectations and hidden worries such as cancer. They also give you the language for the explanation at the end of the encounter.

If a patient discloses suicidal thoughts or abuse, the station has changed again. Respond with empathy, ask directly about intent, plan and safety, do not leave the patient alone if risk is immediate, and follow the referral pathway for urgent mental health or safety support. Examiners score this as a safety critical action just as they would a cauda equina finding.

Occupational history

Ask the job title and, more importantly, what the patient actually does physically: lifting (how much, how often, from what height), sustained sitting or standing, driving (whole body vibration), overhead work, repetitive hand use, keyboard and screen set up. Ask whether the problem began at work (a work injury has reporting and documentation implications), whether they are working now, on modified duty or off work, and what they need to be able to do to return. This shapes functional goals ("lift 40 lb from floor to waist" is a measurable goal for a warehouse worker) and identifies occupational risk factors and blue flags.

Section 5Summarizing and transitioning to the exam

Why the summary earns points

The summary is where the examiner hears your reasoning: two or three sentences of key positives and key negatives prove you collected the right data, and the patient gets a chance to correct an error before it reaches your diagnosis and note. Checklists often score "summarized" and "checked accuracy" as separate items.

Structure of a station summary

1. Signpost: "Let me make sure I have understood everything correctly."
2. Restate the story in plain language: who, what, since when, how it started, the main pattern.
3. State the important negatives aloud, especially the red flags you cleared: "You have not noticed any numbness between your legs or changes with your bladder or bowels, and you have had no fever or weight loss."
4. Include the patient's concern and goals: "And you are worried about getting back to lifting at work."
5. Check accuracy: "Did I get that right? Is there anything I have missed or anything you would like to add?"
6. Respond to any correction or new information, which may send you back to a red flag question.

Keep the summary short. A long recitation of every answer wastes the clock and sounds like reading a list. The summary should contain what you would put in the first lines of the patient note: the working impression in lay terms and the facts that support it, plus the safety negatives.

Explaining what comes next

The transition to the examination needs three things: an explanation of what the examination involves, a check on comfort and modesty, and consent. Say which areas you will examine and whether clothing needs to be adjusted, offer a gown and drape, and offer a chaperone for any sensitive examination or whenever the patient would prefer one. Explain that some tests may reproduce the pain and that the patient should tell you immediately if anything is too uncomfortable, and that they can ask you to stop at any time.

When the history changes the plan

If the history has revealed an emergency, the transition is to referral, not to an examination. Minimal assessment that does not delay care (vital signs, a quick neurological screen) is reasonable; provocative tests and treatment are not. Explain the concern plainly, arrange the right level of care, do not let a patient with possible stroke or dissection drive, and document. Chapter 7 develops these scenarios.

Words worth knowing

Performing the Examination in a Station

An examination station rewards what the examiner can see and hear: a test performed with the correct hand placement, in the correct position, explained to the patient, and finished with the finding stated aloud. Knowing that Spurling test suggests a cervical radiculopathy earns nothing if you do it with the head in flexion and then say nothing. This chapter turns the vital signs, orthopedic and neurological examinations into performance routines you can run under time, safely, with the reasoning that tells you which tests deserve the minutes you have.

Section 1Vital signs and general examination performance

Why vital signs are scored

Vital signs are the first screen for systemic illness and the first safety check before manual care. A fever turns back pain into a possible infection, a very high blood pressure turns a neck adjustment into a referral, and a fast irregular pulse may be atrial fibrillation in a patient whose "dizziness" you were about to attribute to the neck. In a station, vitals may be given on the door card or you may be asked to measure them. When you measure them, examiners score technique step by step, so the routine must be exact. When they are given, read them and act on any abnormal value.

Blood pressure technique

Correct technique matters because small errors produce large, predictable distortions. Prepare the patient: seated with the back supported, feet flat, legs uncrossed, quiet for a few minutes, no talking during the reading, ideally no caffeine, exercise or smoking in the previous 30 minutes. Bare the upper arm (a sleeve pushed up can act as a tourniquet). Support the arm so the cuff is at heart level (mid sternum).

1. Choose the cuff size. The bladder length should encircle about 80 percent of the arm and its width about 40 percent of the arm circumference. A cuff that is too small overestimates pressure; too large underestimates it.
2. Place the cuff snugly with the bladder center (often marked with an arrow) over the brachial artery on the medial arm and the lower edge about 2 to 3 cm above the antecubital crease.
3. Estimate systolic pressure by palpation. Palpate the radial (or brachial) pulse, inflate until it disappears, note that value, and deflate fully. This prevents missing an auscultatory gap, a silent interval in some hypertensive patients that can cause systolic pressure to be underestimated.
4. Auscultate. Place the stethoscope bell or diaphragm lightly over the brachial artery in the antecubital fossa, not tucked under the cuff. Inflate to 20 to 30 mmHg above the palpated systolic value.
5. Deflate at 2 to 3 mmHg per second. Faster deflation underestimates systolic and overestimates diastolic pressure.
6. Read the Korotkoff sounds. The first appearance of repetitive tapping sounds (phase I) is systolic; the disappearance of sounds (phase V) is diastolic in adults. Record to the nearest 2 mmHg.
7. Deflate fully, wait about a minute before repeating, and average two or more readings. At a first visit, measure both arms and use the higher arm thereafter; a consistent difference over about 10 to 15 mmHg suggests subclavian or aortic disease and is noteworthy in a patient with arm or neck symptoms.

Interpreting blood pressure

The adult categories most commonly taught in the United States are: normal under 120/80; elevated 120 to 129 systolic with diastolic under 80; stage 1 hypertension 130 to 139 systolic or 80 to 89 diastolic; stage 2 hypertension 140 or higher systolic or 90 or higher diastolic. A reading over 180 systolic and/or 120 diastolic is a hypertensive crisis: with signs of target organ damage (chest pain, breathlessness, neurological deficit, visual change, confusion, severe headache) it is an emergency for which you call emergency services; without symptoms it calls for prompt medical evaluation and you should not proceed with manual therapy that day. Recheck any abnormal value after rest before acting, unless the patient is symptomatic. Very low blood pressure with dizziness, fainting or postural change also needs attention; orthostatic hypotension is a fall of 20 mmHg systolic or 10 mmHg diastolic within about three minutes of standing.

Pulse, respiration and temperature

Pulse: palpate the radial artery with the pads of the index and middle fingers (never the thumb, which has its own pulse). If the rhythm is regular, count for 30 seconds and double; if irregular, count a full 60 seconds and note whether it is regularly irregular or irregularly irregular (the latter suggests atrial fibrillation, a stroke risk factor). Normal resting adult rate is 60 to 100 beats per minute; note rate, rhythm and volume. Respiration: count for 30 to 60 seconds while appearing to still take the pulse, because patients change their breathing when they know it is being watched; normal adult rate is 12 to 20 breaths per minute. Note effort, accessory muscle use and pattern. Temperature: normal oral temperature is about 97.8 to 99.1°F (36.5 to 37.3°C), and 100.4°F (38.0°C) or higher is the usual threshold for fever. Pulse oximetry, height, weight and body mass index may also be part of the vitals in some stations.

General inspection

Inspection starts when you enter the room: how the patient sits, stands, moves and speaks. Describe what you see in neutral, specific terms. Look at general appearance (distress, pallor, sweating, body habitus), posture in three views (head carriage, shoulder and iliac crest levels, scoliosis, kyphosis, lordosis, antalgic lean), gait (antalgic, Trendelenburg, steppage, ataxic, spastic, shuffling), skin (scars, bruising, rashes such as the dermatomal vesicles of herpes zoster, cafe au lait spots, hair tufts over the spine) and muscle bulk (atrophy of the thenar eminence, quadriceps or calf, fasciculations). An antalgic lean away from the painful side has traditionally been linked to a disc lesion lateral to the nerve root and a lean toward it to a medial (axillary) lesion; treat that rule as a teaching heuristic rather than a reliable localizer.

Then palpate and assess range of motion: active range first (willingness and pattern), then passive range where needed (end feel), and resisted isometric testing to separate contractile from inert tissue. Palpate for midline bony tenderness (a fracture screen after trauma), step offs, muscle spasm, trigger points, temperature and swelling.

Verbalizing findings

Examiners cannot score a finding they do not hear. As you finish each test, state the result in one sentence that names the test, the side and the finding: "Right Kemp test produces local right low back pain without leg radiation, suggesting a facet source." Normal findings are stated too: "Blood pressure 124 over 78, right arm, seated. Pulse 72 and regular. Respirations 14. No midline bony tenderness from T10 to the sacrum." In a station where the SP cannot simulate a sign (an absent reflex, a fever), the examiner may hand you a card or tell you the finding when you perform the test correctly; you then state its significance.

Section 2Spinal orthopedic test performance

The performance rules for every orthopedic test

Every test has the same five beats: explain what you will do and that it may reproduce symptoms, position the patient correctly, perform the maneuver with correct hand placement and controlled force, ask a neutral question ("What do you feel, and where?"), and state the result and its meaning. Test the uninvolved side first when practical, so the patient knows what to expect and you have a comparison. Stop immediately if the test produces severe pain, neurological symptoms, dizziness or any sign of vascular compromise. Never force a provocative cervical test in a patient whose history suggests instability, fracture or vascular disease; the safest test is the one you do not need.

Cervical tests

The Wainner clinical prediction rule for cervical radiculopathy combines four findings: a positive upper limb tension test A, a positive Spurling test, a positive distraction test, and cervical rotation under 60 degrees toward the involved side. Three positives make radiculopathy considerably more likely, and four positives make it very likely. Use the cluster as the frame for your cervical neurological examination.

Vertebral artery screening. Positional tests that hold the neck in sustained extension and rotation (often called George test, Maigne or DeKleyn variants) have poor diagnostic accuracy and do not reliably predict who will suffer an adverse event; current guidance emphasizes the history (new severe neck pain or headache, brainstem symptoms), vital signs, the cranial nerve and cerebellar screen and clinical reasoning. If your program or the station expects a positional test, perform it gently, in a position you would use for treatment, watching the eyes for nystagmus and asking about dizziness, and stop at the first symptom. Do not present a negative test as clearance for cervical manipulation.

Thoracic tests

Pulse diminution alone is common in healthy people during the thoracic outlet tests; the finding that counts is reproduction of the patient's symptoms. In the thoracic region, remember the visceral mimics from Chapter 5: if the examination does not reproduce thoracic pain mechanically, say so and consider a nonmusculoskeletal source.

Lumbar tests

Pelvic and sacroiliac tests

No single sacroiliac test is reliable, but a cluster is useful. The commonly taught Laslett cluster uses five provocation tests: distraction, thigh thrust, compression, sacral thrust and Gaenslen. Three or more positives of five (or two of the first four, with the thigh thrust included) support the sacroiliac joint as the pain source, particularly when centralization with repeated movements is absent.

The Waddell signs (nonorganic tenderness, simulation, distraction, regional disturbance, overreaction) suggest a nonorganic contribution when three or more of five categories are present. They indicate that psychosocial factors deserve attention; they do not mean there is no pathology and they are not a lie detector. Say so if you use them.

Section 3Extremity orthopedic test performance

Structure of an extremity examination

Extremity stations follow the same order every time: inspect (swelling, bruising, deformity, atrophy) with both sides exposed for comparison, palpate the specific structures implicated by the history, test active, passive and resisted range of motion, then perform the special tests chosen for your hypotheses, and finish with a neurovascular check distal to the injury (pulses, capillary refill, sensation, strength). Always clear the joint above and below and the relevant spinal region: shoulder pain may come from the cervical spine, knee pain from the hip, and a slipped capital femoral epiphysis in an adolescent classically presents as knee pain. Compare with the uninvolved side throughout.

Shoulder, elbow, wrist and hand

Hip, knee and ankle

Decision rules for imaging after extremity trauma

Two rules are high yield because they combine examination findings into an imaging decision. The Ottawa ankle rules: ankle radiographs are indicated if there is pain in the malleolar zone and either bone tenderness along the distal 6 cm of the posterior edge or tip of the lateral or medial malleolus, or inability to bear weight for four steps both immediately and at the examination. Foot radiographs are indicated if there is midfoot pain and tenderness at the base of the fifth metatarsal or the navicular, or the same inability to bear weight. The Ottawa knee rule: radiographs if age 55 or older, isolated patellar tenderness, fibular head tenderness, inability to flex to 90 degrees, or inability to bear weight for four steps. Both rules are highly sensitive, so a negative rule makes fracture unlikely (Section 5).

Section 4Neurologic examination performance

The regional neurological screen

For any limb symptom, the neurological screen tests three things for each root level: sensation (the dermatome), strength (the myotome) and the deep tendon reflex. Test both sides, compare, and state the findings by level. Use light touch and sharp versus dull (pinprick with a clean disposable pin) in the center of each dermatome (the autonomous zone, where overlap from adjacent roots is least), and add vibration with a 128 Hz tuning fork and joint position sense at the great toe or index finger when large fiber or dorsal column disease is possible.

Motor testing and grading

Test strength with the joint in a mid range position, stabilize proximally, and apply resistance gradually ("Don't let me push you down"). Compare sides. Grade on the 0 to 5 Medical Research Council scale: 0 no contraction, 1 flicker or trace contraction, 2 movement with gravity eliminated, 3 movement against gravity only, 4 movement against some resistance, 5 normal strength. Functional tests are fast and sensitive in the lower limb: heel walking (L4 and L5 dorsiflexors), toe walking or repeated single leg heel raises (S1 plantar flexors), and a squat and rise (L3 and L4 quadriceps).

Reflexes and their grading

Position the limb relaxed with the tendon on slight stretch, strike briskly with the hammer swinging freely, and compare sides. Grade on the 0 to 4 scale: 0 absent, 1+ diminished or present only with reinforcement, 2+ normal, 3+ brisker than average, possibly with spread, 4+ very brisk with sustained clonus. If a reflex seems absent, use reinforcement (the Jendrassik maneuver: patient hooks the fingers together and pulls just as you strike for lower limb reflexes; clenching the teeth or a fist for upper limb reflexes) before calling it absent. An isolated reduced reflex with dermatomal and myotomal findings at the same level indicates a lower motor neuron root lesion; generalized hyperreflexia indicates an upper motor neuron problem.

Pathological reflexes

• Babinski: stroke the lateral sole firmly with a blunt object from the heel toward the ball of the foot, curving medially. Positive (upgoing plantar response): extension of the great toe with fanning of the other toes, an upper motor neuron sign in anyone past infancy.
• Oppenheim (downward stroke along the tibial crest) and Chaddock (stroke around the lateral malleolus) elicit the same upgoing toe response.
• Hoffmann: hold the middle finger and flick its distal phalanx downward. Positive: flexion of the thumb and index finger, suggesting cervical cord compression (myelopathy) when asymmetric or with other signs.
• Ankle clonus: briskly dorsiflex the foot and hold. More than a few beats, or sustained clonus, indicates an upper motor neuron lesion.
• Superficial abdominal reflexes: stroke each quadrant toward the umbilicus; the umbilicus moves toward the stimulus. Upper quadrants test about T8 to T10, lower about T10 to T12. Loss may accompany upper motor neuron lesions.

Cranial nerve screen

A fast screen is mandatory for headache, dizziness, facial symptoms, neck trauma and any suspected vascular presentation, and useful whenever the cervical spine is examined.

Cerebellar and coordination screen

Finger to nose (alternating between your finger and the patient's nose, with your target moving): intention tremor and past pointing indicate ipsilateral cerebellar dysfunction. Heel to shin: run the heel down the opposite shin. Rapid alternating movements: pronation and supination of the hand on the thigh; slowness and irregularity is dysdiadochokinesia. Tandem gait (heel to toe) reveals truncal ataxia. The Romberg test (standing with feet together, eyes open and then closed, guarding the patient) is a test of proprioception: a patient who is steady with eyes open but sways or falls with eyes closed has a sensory (dorsal column or peripheral) ataxia, whereas cerebellar ataxia is unsteady even with eyes open. Always stand close enough to catch the patient.

Section 5Choosing which tests to perform

Hypothesis driven examination

A station rarely has time for every test in this chapter, and examiners do not reward a scattershot battery. They reward an examination that follows from the history: each test chosen to confirm or exclude a specific hypothesis, plus the safety screens that the case requires. Before you touch the patient, name your leading diagnosis, the main alternatives and the dangerous possibility. Then select a short sequence: a regional screen (inspection, palpation, range of motion), the two or three special tests that best separate the hypotheses, the neurological screen if any limb symptom or red flag exists, and any safety test the case demands (vital signs, cranial nerves, myelopathy signs, pulses).

Sensitivity, specificity and clusters

Sensitivity is the proportion of people with the condition who test positive; a highly sensitive test that is negative helps rule out (SnNout). Specificity is the proportion of people without the condition who test negative; a highly specific test that is positive helps rule in (SpPin). Likelihood ratios combine both: a positive likelihood ratio above about 5 to 10 meaningfully raises probability, and a negative likelihood ratio below about 0.1 to 0.2 meaningfully lowers it. Single orthopedic tests are often only moderately accurate, which is why validated clusters outperform them.

What examiners look for

• Relevance: tests that match the complaint and the hypotheses, including at least one test aimed at the dangerous alternative.
• Correct technique: positioning, hand placement, force and sequence as described in this chapter.
• Bilateral comparison, uninvolved side first where it makes sense.
• Communication: an explanation before each maneuver, a neutral question after it, and the finding stated aloud.
• Safety and dignity: consent, draping, chaperone offer, stopping when symptoms escalate, and no provocative testing when red flags are present.
• Efficiency: grouping tests by position (all standing tests, then seated, supine, side lying, prone) so the patient moves as few times as possible.

Safety and draping

Expose only the area being examined and keep the rest covered. Explain why clothing must be moved, offer a gown, step out or turn away while the patient changes, and use a drape to cover the pelvis and breasts during lumbar, pelvic, hip and thoracic examination. Ask before touching sensitive areas, offer a chaperone for any sensitive examination, and never examine the breast, genitalia or perineum in a station unless the task explicitly requires it; for suspected cauda equina, saddle sensation testing and rectal examination belong in the emergency setting. Throughout, set and honor a stop signal. If a test causes severe pain, new neurological symptoms, dizziness, nausea, visual change or a vasovagal reaction, stop, help the patient into a safe position, monitor vital signs, and change the plan.

Words worth knowing

Diagnosis, Orders and Management Decisions

A case management station is where the examiner finds out whether you can think like a primary contact doctor: take a set of findings, name what is wrong, decide what else could be wrong, order only the tests that change the plan, and choose between treating, co-managing and referring. Candidates who perform the history and examination well still lose the station when the impression is vague, the orders are a shotgun list, or a red flag is noticed but never acted on. This chapter turns those decisions into a repeatable routine you can run under time pressure.

Section 1Forming the diagnosis in a station

What the examiner is listening for

Case management stations on practical exams generally share a structure: a door card outside the room gives the patient's name, age, sex, chief complaint, sometimes vital signs, and the task. Inside, a standardized patient (SP) gives consistent answers and may reproduce findings such as pain on a provocative test. An examiner or the SP records performance on a checklist, and some stations add a written component. Check the current official candidate materials for the exact format, timing and scoring rules; this book does not reproduce them.

Whatever the scoring detail, checklists of this kind reward an impression that is specific ("lumbar disc herniation with left L5 radiculopathy," not "low back pain"), defensible (you can name the findings behind it) and safe (you have actively considered and excluded the dangerous causes, and you say so). Many stations also contain critical actions, items that weigh far more than ordinary points, such as recognizing a stroke sign and calling for emergency care. A polished candidate can still fail a station by missing the one critical action it was built around.

Working diagnosis versus differential diagnosis

The working diagnosis (also called the primary diagnosis or clinical impression) is the single condition that best explains the chief complaint and the findings. It drives the plan. The differential diagnosis is the short, ranked list of other conditions that could explain the same picture and that you have either ruled out, made less likely, or cannot yet exclude. A useful station differential has two to four items and always includes at least one "cannot miss" condition when the presentation allows it, even if your findings argue against it. Naming the dangerous alternative and explaining why you think it is unlikely shows the examiner that your safety screen was deliberate, not accidental.

Build the working diagnosis with four parts whenever the findings support them: tissue or structure (disc, facet joint, muscle, ligament, nerve root, peripheral nerve), region and level (C6, L4 to L5, right sacroiliac joint), side, and qualifiers such as acuity (acute, subacute, chronic), severity, neurologic involvement and mechanism. "Acute right C6 radiculopathy secondary to a probable C5 to C6 disc herniation, with intact strength" is a complete board impression. When you cannot be that specific, say what you can: "mechanical neck pain without neurologic deficit, most consistent with cervical facet syndrome at C5 to C6, right."

Linking findings to the impression

The habit that separates strong candidates is explicit linking: attach the two or three findings that carry the impression. "Your pain runs down the back of the leg to the outside of the foot, the straight leg raise reproduced it at 40 degrees, and your ankle reflex is reduced on the left. That pattern points to irritation of the S1 nerve root, most likely from a disc." This proves the exam was purposeful and teaches the patient.

Think in terms of pertinent positives (findings that support your impression) and pertinent negatives (absent findings that argue against an alternative). In a low back case, normal saddle sensation, normal bladder function and symmetric strength are pertinent negatives against cauda equina syndrome; their absence from your summary looks as if you never checked. In a neck case, the absence of dizziness, diplopia, dysarthria, dysphagia and drop attacks are pertinent negatives against vertebrobasilar ischemia. Say them.

A fast reasoning routine

While reading the door card, list three things: the most likely diagnosis for that age, sex and complaint; the cannot miss diagnoses; and the common mimics. A 68 year old man with new low back pain should trigger malignancy (prostate, myeloma), compression fracture and abdominal aortic aneurysm before you open the door; a 24 year old woman with right flank pain should trigger kidney stone, pyelonephritis and ectopic pregnancy. Use the history to rank the lists and the examination to test the top two or three.

1. Anatomic localization. Is the problem local (joint, muscle, ligament), radicular (dermatome, myotome, reflex), peripheral nerve (a single nerve territory), central (upper motor neuron signs, bilateral symptoms, gait) or referred from a viscus?
2. Mechanical versus non-mechanical. Mechanical pain changes with position, movement and load and eases with rest. Constant pain unchanged by position, night pain that wakes the patient, and pain with systemic features suggest inflammatory, infectious, neoplastic or visceral causes.
3. Acuity and trajectory. Improving, stable or worsening? A progressive neurologic deficit changes urgency immediately.
4. Red flags. Any flag changes the plan from "treat" to "investigate or refer" until it is cleared.
5. Yellow flags. Fear avoidance, catastrophizing, depression, work dissatisfaction and passive coping predict chronicity and shape the plan, not the diagnosis.

Using test accuracy without doing statistics in the room

You need not calculate likelihood ratios in a station, but know which tests rule in and which rule out. A negative result on a highly sensitive test helps rule a condition out (SnNout); a positive result on a highly specific test helps rule it in (SpPin). Clusters perform better than single tests: the commonly taught cervical radiculopathy cluster combines a positive upper limb tension test, rotation toward the symptomatic side under 60 degrees, a positive distraction test and a positive Spurling's test.

Section 2Ordering imaging and laboratory tests

The rule: order what changes management

Every order must answer "what will I do differently depending on the result?" Most acute, uncomplicated spinal pain without red flags needs no imaging at the first visit; routine imaging there does not improve outcomes, adds cost and radiation, and finds incidental degeneration that frightens patients. Examiners reward withholding unnecessary imaging and explaining why as much as ordering the right study when it is indicated.

Justify each order aloud in one sentence that contains the suspected condition and the trigger: "Because you are 72, have had steroid treatment and your pain started suddenly after a minor bump, I want lumbar radiographs today to look for a compression fracture." That sentence is the station equivalent of a clinical indication on a requisition, and it is exactly what an examiner checklist item such as "orders appropriate imaging with rationale" is looking for.

Clinical decision rules

Decision rules are validated shortcuts that tell you when imaging is unlikely to show a significant injury. Learn them in the form you can recite.

Red flags that justify imaging in spinal pain

For low back and neck pain without trauma, the indications for early imaging come from red flags. Each flag points at a specific dangerous condition, and the condition determines the modality.

Choosing the modality

Gadolinium contrast for MRI is used with caution in severe renal impairment, and iodinated contrast for CT requires attention to kidney function and allergy history.

Laboratory tests a chiropractic station expects you to know

Chiropractic scope for ordering laboratory tests varies by jurisdiction, but every candidate is expected to know which test answers which question, and to say so whether you order it yourself or recommend it in a referral. Tests are adjuncts to a clinical suspicion; never order a panel and hope.

Section 3Management decisions

Treat, co-manage or refer

After the impression, the station asks the central management question: is this patient appropriate for chiropractic care alone, appropriate for chiropractic care alongside another provider, or in need of referral before (or instead of) chiropractic care? Saying the decision out loud, with its reason, is usually a checklist item in itself.

• Treat when the presentation is a neuromusculoskeletal condition within scope, the pain behaves mechanically, the findings support the diagnosis, there are no red flags (or they have been cleared), there is no contraindication to the planned procedures, and the condition is expected to respond to conservative care.
• Co-manage when chiropractic care is appropriate but another provider must manage part of the problem: a stable radiculopathy that may need medication or an injection, a patient with diabetes or on anticoagulants whose comorbidity affects technique choice and healing, osteoporosis needing medical therapy, inflammatory arthritis under rheumatology care, chronic pain with depression or anxiety needing behavioral health support, or pregnancy under obstetric care.
• Refer when the complaint is not a neuromusculoskeletal condition (visceral, systemic or psychiatric), when a red flag needs investigation outside your scope, when there is an absolute contraindication to the care you would provide, when the condition is worsening or a neurologic deficit is progressing, or when a properly conducted trial of care has failed.

Referral is not abandonment, and you can say so: "I want your doctor to see you today about the fever and back pain together. Once infection is ruled out, I am happy to help with the back pain."

The treatment plan

A treatment plan said aloud in a station should be short but complete. Use the same order every time so you never leave out an element:

Frequency is highest in the acute phase and tapers as function improves; a common pattern for an acute uncomplicated case is two to three visits per week for two weeks, then reassessment. Chronic cases use lower frequency and more active care. A trial of care (commonly about two weeks) must produce measurable change; if a second trial with a different approach also fails (roughly four weeks overall), change the plan, investigate further or refer.

Outcome measures and meaningful change

Measurable goals require baseline numbers. Use a validated measure suited to the region, record it at the first visit and repeat it at every re-examination.

Home care and active management

Guidelines for spinal pain favor reassurance, staying active and exercise, with manual therapy as part of a multimodal plan. Home care should include an activity modification (not bed rest), a diagnosis specific exercise (repeated extension for a directional preference disc presentation, deep neck flexor training for neck pain, eccentric loading for tendinopathy) and a self care measure. Teach and check: "Show me how you will do that exercise." When yellow flags appear, explain that hurt does not equal harm, set graded activity goals, and consider behavioral health co-management for high risk patients.

Address yellow flags when they appear: explain that hurt does not equal harm, set graded activity goals, and consider screening tools such as STarT Back. Patients at high risk of chronic disability benefit from more education and psychologically informed care, and sometimes from a referral to behavioral health; this is co-management, not dismissal of the physical problem.

Section 4Contraindications and urgent referral scenarios

Contraindications to manipulation

A contraindication is a condition that makes a procedure inadvisable. An absolute contraindication means do not perform that procedure in that region at all (other care may still be possible elsewhere or with different methods). A relative contraindication means the procedure can be modified (lower force, different technique, avoid the region, avoid end range, avoid rotation) with appropriate caution and consent. Stations test whether you notice the condition and whether you choose an appropriate modification or referral.

Urgency levels and what to say

The response to a red flag must match its urgency. Use four levels and decide which one applies before you speak. In the station, stop any further examination or treatment that could worsen the condition, stay with the patient when the problem is an emergency, explain what you are doing and why, and document.

Cauda equina syndrome

Cauda equina syndrome (CES) is compression of the lumbosacral roots below the conus, usually by a large central disc herniation at L4 to L5 or L5 to S1, less often by tumor, abscess, hematoma or severe stenosis. Key features: saddle anesthesia, urinary retention (the earliest and most consistent sphincter sign, later overflow incontinence), fecal incontinence or reduced anal sensation, sexual dysfunction, bilateral or alternating sciatica, and leg weakness with reduced ankle reflexes. Outcome depends on early decompression, so the response is same day emergency evaluation for MRI and surgical consultation: no outpatient MRI and waiting, no manipulation, no driving home. Call ahead and send a brief written summary.

What to say: "The numbness between your legs and the change in your bladder tell me the nerves at the bottom of your spine may be squeezed. That is an emergency, because the sooner the pressure is relieved, the better those nerves recover. I am not going to treat your back today. I am calling the emergency department now. Is someone here who can drive you, or should I call an ambulance?"

Fracture and infection

For suspected fracture, use the Section 2 decision rules. A suspected unstable cervical fracture (midline tenderness, dangerous mechanism, neurologic signs) means immobilize the neck, do not move the patient unnecessarily, and call emergency services; a suspected stable compression fracture needs radiographs before any manipulation of the region. Suspected spinal infection (fever, IV drug use, recent bacteremia or procedure, diabetes, unrelenting pain with focal spinous tenderness) needs same day medical evaluation, because an epidural abscess can progress to paralysis within hours to days.

Vascular emergencies: dissection and stroke

Cervical artery dissection (vertebral or internal carotid) often presents first with neck pain and headache, which is why patients with an early dissection may seek chiropractic care before any neurologic signs appear. Suspect it when neck or occipital pain is sudden, severe and unusual for the patient, especially after minor trauma or sudden neck movement, and when accompanied by any posterior circulation sign: the 5 Ds and 3 Ns (dizziness, diplopia, dysarthria, dysphagia, drop attacks; nausea, numbness, nystagmus) plus ataxia. Internal carotid dissection can produce a partial Horner syndrome (ptosis and miosis), pulsatile tinnitus, and pain around the eye or temple.

Stroke signs follow BE FAST: Balance loss, Eyes (vision loss or double vision), Face drooping, Arm weakness, Speech difficulty, Time to call 911. In the station, a patient with any of these signs (during history, examination or after a procedure) needs: immediate cessation of examination and treatment, a call to 911, notation of the time last known well, monitoring of airway, breathing and level of consciousness, keeping the patient lying down or seated safely (nothing by mouth), and staying with them until care arrives. Do not drive the patient yourself and do not send them home to call their physician.

Cardiac, aortic and other visceral emergencies

If a problem appears after treatment

If a patient becomes dizzy, nauseated, confused, weak or develops a new neurologic symptom during or after care: stop, keep the patient lying or seated safely, check consciousness, airway, breathing, circulation and vital signs, perform a rapid neurologic screen (BE FAST, pupils, nystagmus), call 911 for any focal sign or failure to resolve promptly, note the time and stay with the patient. Then document exactly what happened and what you did, and tell the patient honestly. A brief vasovagal response that resolves lying down is managed by positioning and observation, but call it benign only after the neurologic screen.

Section 5Common case management station patterns

One routine for every station

Case stations look different on the door card but share one skeleton. Practice a single routine until it is automatic so your attention is free for reasoning. The official instructions for each station always take priority, so read the task line twice.

Neck pain walk through

Low back pain walk through: neurogenic versus vascular claudication

Headache walk through

Every headache station is first a red flag screen. Use SNOOP: Systemic symptoms or illness (fever, weight loss, cancer, immunosuppression), Neurologic signs (focal deficit, confusion, papilledema), Onset sudden (thunderclap), Older age at onset (new headache over 50), and Pattern change (progressive, positional, triggered by Valsalva or exertion, a change from a prior pattern). Then classify the primary headache.

Extremity walk through

Visceral mimic walk through

Visceral pain is referred to the body wall through shared spinal segments. Stations hide a visceral cause behind a musculoskeletal complaint; the clues are pain unchanged by movement or position, constant or colicky pain, systemic symptoms, links to meals, urination, menstruation or exertion, and abnormal vital signs.

Words worth knowing

Documentation, Consent, Communication and Referral

The best examination and the soundest plan are worth little if they are not written down clearly, agreed to by an informed patient, explained in words the patient understands, and passed accurately to the next clinician. Case management stations score these communication tasks as heavily as the clinical ones, and in practice they are where most complaints and legal claims begin. This chapter gives you the scripts, structures and documentation habits that let you do all of it well inside a timed station.

Section 1The patient note

Why the note matters in a station

Some case stations are followed by a written task: a patient note, a set of short answers, or both. Others score documentation indirectly by asking you to state what you would record. Either way, the note is judged on the same standard used in practice: could another clinician pick it up, understand what you found and why you decided what you did, and continue care safely? In practice the record is also a legal document, the basis for billing and the evidence that consent was obtained and red flags were considered. If it is not documented, for legal and audit purposes it was not done. Check the current official candidate materials for the format and length of any written component; the structure below works for any of them.

SOAP structure

The SOAP format divides the note into Subjective, Objective, Assessment and Plan. Its strength is that each part feeds the next: subjective and objective findings support the assessment, and the assessment justifies the plan. A reader should be able to trace every plan item back to a finding.