OR14.1-4 | Counselling and Rehabilitation Skills — Graded Quiz

Correct. SPIKES dictates that Perception (what does the patient already know/fear?) and Invitation (does the patient want this information now?) must precede Knowledge delivery. This prevents overwhelming a patient who is not yet ready and allows information to be calibrated to their understanding.

In SPIKES, 'P' (Perception) and 'I' (Invitation) precede 'K' (Knowledge delivery). Before delivering difficult news about amputation risk, the clinician must first assess what the patient already knows and believes, then ask for their invitation to receive more information.

Per SPIKES, Perception (step 2) and Invitation (step 3) must be completed before Knowledge delivery (step 4). Assess what the patient knows and invite disclosure before presenting complications like amputation risk.

Correct. The clinician must speak to the patient privately, assess her decision-making capacity, answer her own questions, and document voluntary consent. Family coercion (even well-intentioned) invalidates consent. If she lacks capacity, follow proper substitute decision-maker processes.

Valid consent requires voluntariness — freedom from coercion or undue influence. When a patient indicates they are deferring to a family member, the clinician must directly assess the patient's own understanding and wishes, ensure she has decision-making capacity, and document that consent was given freely.

Valid consent has three pillars: capacity, information, and voluntariness. The patient's statement suggests potential coercion — the clinician must assess voluntariness directly, not accept family proxy acceptance.

Correct. Kocher's criteria (fever >38.5°C, ESR >40, WBC >12,000, non-weight-bearing) with 3 or more positive predict >93% septic arthritis. This warrants immediate referral for aspiration, blood culture, and surgical drainage — delay causes permanent cartilage destruction.

Kocher's criteria for septic arthritis in children are: fever >38.5°C, ESR >40 mm/hr, WBC >12,000/µL, and non-weight-bearing. Three or more criteria predict >93% probability of septic arthritis requiring urgent surgical drainage. Cartilage destruction begins within 24–48 hours without intervention.

Three or more Kocher criteria predict >93% septic arthritis probability. Urgent referral for aspiration and surgical drainage is mandatory — conservative antibiotics alone risk permanent joint destruction.

Correct. Inflammatory back pain features — morning stiffness >1 hour, activity improvement, SI joint involvement — are warning signals for ankylosing spondylitis or spondyloarthropathy. Early diagnosis enables DMARDs/biologics that prevent bamboo spine deformity and disability.

Inflammatory back pain features (insidious onset age <45, morning stiffness >30–60 min, improves with activity, buttock pain, positive sacroiliac stress tests) in a young worker suggest ankylosing spondylitis or early spondyloarthropathy. Early diagnosis and DMARDs prevent progressive spinal fusion. This is a 'warning signal' for non-mechanical back pain requiring specialist evaluation.

Inflammatory back pain features (morning stiffness >1 hr, improves with activity, FABER positive) are warning signals mandating specialist referral to diagnose and treat spondyloarthropathy before irreversible fusion occurs.

Correct. The ideal transtibial stump has 12–15 cm tibial length, is cylindrical, has a posterior-based well-healed scar (not over the tibial crest which is a pressure point), good muscle cover via posterior myoplasty, and is pain-free without neuroma.

The ideal transtibial stump is: 12–15 cm of tibia from tibial tuberosity; cylindrical/conical shape; well-healed scar (not adherent, not at a pressure-bearing site); good muscle cover with posterior myoplasty; pain-free; no neuroma; non-oedematous. These properties ensure comfortable PTB socket fit and maximal prosthetic function.

The ideal stump requires 12–15 cm tibia, cylindrical shape, non-anterior scar (posterior or lateral placement avoids the tibial crest pressure point), good muscle cover, and absence of pain or neuroma.

Correct. Young BK amputees with good rehabilitation achieve K3–K4 ambulation — unlimited community walking, stair negotiation, uneven terrain, and return to most employment and educational activities. BK amputees have significantly better outcomes than AK amputees due to preserved knee function.

Young, fit, motivated below-knee amputees with well-fitted PTB prostheses can achieve near-normal community ambulation (K3–K4 functional classification), participate in sports, drive, and return to most occupations. Prognosis for prosthetic walking is excellent compared to above-knee amputees.

Young motivated below-knee amputees achieve excellent functional outcomes (K3–K4) with PTB prostheses. Preserved knee function gives BK amputees a significant advantage over AK amputees in rehabilitation potential.

Correct. Validate the pain, correct the misconception (it is cortical/CNS reorganisation, not peripheral nerve regrowth), explain phantom limb neuroscience in accessible language, and introduce evidence-based options: mirror therapy, gabapentinoids, and early prosthetic fitting.

Phantom limb pain counselling requires validating the pain as real, explaining the neuroplasticity mechanism (not nerve regrowth), and outlining evidence-based treatments. Misinformation ('nerve regrowth' or 'psychological') causes unnecessary distress and poor engagement with treatment.

Phantom pain is real, neurobiological, and treatable. Counselling should validate it, explain the brain plasticity mechanism, and introduce mirror therapy, gabapentinoids, and early prosthetic fitting.

Correct. Absent pulses after knee dislocation indicate popliteal artery injury until proven otherwise (30–40% incidence). The warm ischaemia limit is 4–6 hours. Immediate vascular assessment (CTA/duplex) and emergency repair are required. This is the compelling warning signal argument for same-day emergency transfer.

Popliteal artery injury (common peroneal nerve injury also common) after knee dislocation is a limb-threatening emergency. Absent pulses after dislocation = 30–40% popliteal artery injury rate. Warm ischaemia tolerance is 4–6 hours. Immediate CTA/duplex and vascular surgical repair are required — this is the key warning signal argument for same-day transfer.

Popliteal artery injury after knee dislocation is a limb-threatening emergency with a 4–6 hour window. Absent pulses = immediate transfer for vascular assessment and repair.

Correct. IIIA = adequate soft tissue coverage, good salvage prognosis. IIIC = arterial injury requiring repair (highest eventual amputation risk at 20–40%). Primary closure at the time of initial debridement for open fractures violates the open fracture principle — always delayed primary closure or definitive closure at 48–72 hours.

Grade IIIA open tibial fractures (adequate soft tissue coverage) are managed with limb salvage — debridement, external fixation, delayed primary closure. IIIB (requires flap coverage) and IIIC (arterial injury) have higher salvage difficulty. IIIC has the highest risk of eventual amputation and longest rehabilitation. Honest prognosis counselling should address functional outcomes of both salvage and amputation.

Grade IIIA has good limb salvage outcomes with debridement and fixation. IIIC (arterial injury = the Gustilo trap) has highest amputation risk. Primary closure of open fractures at initial debridement increases infection and is contraindicated.

Correct. BK amputation is preferred in PAD when tissue perfusion is adequate (TcPO2 >20 mmHg) because the preserved knee reduces energy expenditure, improves balance, and significantly enhances prosthetic rehabilitation success compared to AK amputation.

In PAD patients, amputation level selection is determined by perfusion: transcutaneous PO2 >20 mmHg or ankle-brachial index criteria guide level choice. Below-knee (transtibial) is preferred over above-knee when tissue perfusion allows, as preserved knee joint dramatically improves rehabilitation. Syme's is rarely feasible in PAD due to distal ischaemia.

BK amputation is always preferred when tissue perfusion allows because the preserved knee dramatically improves rehabilitation. Perfusion assessment (TcPO2, Doppler) — not inspection alone — determines the safe level.