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Introduction to the Orthopaedic
452 course
Dr. Waleed Awwad, MBBS. FRCSC
Assistant professor of Orthopaedic surgery
Spine and scoliosis surgeon
Goal
knowledge
skill
Attitude
Competent student
Knowledge
Clinical presentation,
investigation,
management &
complications of the
common and
community related
orthopedic conditions
Diagnose &
initially manage
of the urgent
Orthopaedic
conditions
Competency
in the
knowledge
Domain
Skill
History taking
Physical exam
Procedural skills
• Reduction
• Splinting & casting
• Knee aspiration
Competency
in skill
domain
Attitude
Communicator
Personal
behavior
professional
Competency
in Attitude
domain
Goals
By end of his course, students will have demonstrated the ability to:
• Demonstrate essential knowledge required to diagnose, initially manage
and to know when to immediately refer a patient with a condition that
requires urgent specialist management.
• Demonstrate knowledge to specify the symptoms, signs and immediate
complications; to outline the assessment and appropriate investigation and;
to outline the immediate and long term management of patients with
common and community related orthopedic conditions and
musculoskeletal trauma.
• To take a relevant and a focused MSK history in the knowledge of the
characteristics of the major conditions of: bone; joints; connective tissue;
nerve tissue and; muscle tissue.
• To perform a focused physical examination of major joints (shoulder, hip,
knee, foot and ankle, PN and spine)
• To order and to demonstrate an appropriate use and interpretation of
appropriate investigations including: radiography, CT/MRI/bone scan, MSK
U/S, serology, synovial fluid analysis, and EMG/NCS.
• The ability to perform a common non-surgical orthopaedic procedures like
joint aspirations and ability to apply and remove a cast.
Orthopaedic Core Competencies
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•
•
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EMERGENCIES / RED FLAGS
FRACTURES / TRAUMA
PEDIATRIC ORTHOPAEDIC CONDITIONS
NON-TRAUMATIC ORTHOPAEDIC
CONDITIONS
• CLINICAL ASSESSMENT & DIAGNOSIS SKILLS
EMERGENCIES / RED FLAGS
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•
•
•
•
•
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Open Fractures
Fractures with nerve or vascular compromise
Compartment Syndrome
Cauda Equina Compression
Bone, Joint and Soft Tissue Infection
Multiple Trauma (Pelvic Fracture)
Acute Joint Dislocations
Fractures & trauma
• Common Adult & pediatric Fractures
– Upper Limbs
– Lower Limbs
– Pelvic
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•
•
•
PERIPHERAL NERVE INJURIES
Acute Spine Injuries
Soft tissue injuries
Joint dislocation
Pediatric orthopaedic
• Common Hip Conditions
• Common Lower Extremities Condition
– Alignment / Rotational conditions
– Gait Problems
– Lower extremities deformities
NON-TRAUMATIC ORTHOPAEDIC
CONDITIONS
•
•
•
•
Spine
Tumors
Metabolic
Joints condition
Spine
• Degenerative/Mechanical neck/back pain
• Spinal cord or root entrapment (for example,
herniated lumbar disc)
• Vertebral fracture of osteoporotic origin
• Spinal deformity (scoliosis)
• Destructive (infectious and tumor related)
back pain (for example, tuberculosis,
metastasis, certain cancers)
Bone tumors
• Metastatic bone disease
• Primary bone lesions
– Benign bone tumors
– Malignant bone tumors
Metabolic bone disorders
• Osteoporosis
• Osteomalacia and Rickets
Joint conditions
• Degenerative OA
• Shoulder Chronic Condition
Clinical Assessment & diagnosis skills
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•
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•
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History taking
Physical Examination
Investigation interpretation
Communication and attitude skills
Procedural Skill
– Knee joint aspirations.
– Apply and remove a cast
– Joint/fracture reduction techniques
Teaching and learning methods and
places
• Lecture (Large group):
• Case-based learning –CBL- (Small groups):
– Topics will be assigned in a head of time to the students with clear objectives
• “Hands-on” small groups sessions:
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–
–
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Physical examination skills
Splinting and casting technique skills
Principles of fractures & joints dislocation reduction
Joint aspirations.
• Ambulatory care teaching
– History taking skills
– Each student will have a chance of take, present, and discuss patient history
with the attending staff tow times during the course
• Plaster room
– Each student will have chance to observe, apply and remove the cast/splint
during the course for at least two times
Learning Resources
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•
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Books
Tutorials / Lectures
CBL
Handouts
Assessment
• Continues assessment (20%)
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–
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History taking at OPD
CBL
Hands-on skills sessions
attendance
• OSCE (40%)
– History taking
– Physical examination
– Communication skills
• Written (40%)
Ambulatory care learning/Assessment
Students will learn and will be assessed for how :
• To take and present a relevant and a focused MSK
history in the knowledge of the characteristics of
the major conditions of: bone; joints; connective
tissue; nerve tissue and; muscle tissue.
• To perform a focused physical examination of
major joints (shoulder, hip, knee, foot and ankle,
PN and spine)
• To show an appropriate communication skills &
Attitude toward and patient.
Ambulatory care learning/Assessment
• Each student will have chance at least 2 times
during the 4 weeks course to do full clinical
assessment of real patient in the Orthopaedic
outpatient clinic.
• Student will be assessed for skills in obtaing
and presenting a full history and clinical
examination.
• 5% of total mark
Skills sessions
•
•
•
•
Cast application and removal
Principles of reduction and immobilization.
Knee aspiration
5% of total mark
Case-based learning
• Six different cases covered the most common
MSK problems which can be presented to the
ER or orthopaedic/primary clinic
• Cases will be assigned ahead of time to the
students with clear objectives
• 5% of total mark
Attendance
• 5% of total mark
Orthopedic Surgery = Not only
Bone Surgery
• Orthopedic specialty is the branch of medicine
which manage trauma and disease of
Musculoskeletal system
• It includes : bones, muscles, tendons, ligaments,
joints, peripheral nerves, vertebral column and
spinal cord and its nerves
Orthopedic Specialty
• Sub-Specialties in orthopedic include :
– General
– Pediatric Orthopedic
– Sport and Reconstructive Orthopedic
– Orthopedic Trauma
– Arthroplasty
– Spinal Surgery
– Foot and Ankle surgery
– Oncology
– Hand Surgery
Red Flags
• Red Flags = Warning Symptom or Sign
• Red flags should always be looked for and
remembered
• Presence of a red flag means the necessity for
urgent or different action/intervention
Examples of Red Flags
 Open Fractures : more serious and very high
possibility of infection and complications
 Complicated Fractures : fracture with injury to
major blood vessel, nerve or nearby structure
 Compartment Syndrome : increase in intracompartment pressure which endangers the blood
circulation of the limb and may affect nerve supply
 Cauda Equina Syndrome : compression of the nerve
roots of the Cauda Equina at the spinal canal which
affect motor and nerve supply to lower limbs and
bladder (also saddle or peri-anal area)
Examples of Red Flags
 Infection of Bone, Joint and Soft Tissue
Osteomyelitis : Infection of the bone
Septic Arthritis :Infection of the joint
Cellulitis :spreading Infection of the soft tissue
May cause septicemia or irreversible damage
. Multiple Trauma or Pelvic Injury: more than one fracture or injury
sustained at the same time
consider massive blood loss and associated injuries
. Acute joint Dislocations : requires urgent reduction or may cause
serious complications
Alignment terminology
Alignment Terminology: Cubitus
Varus
Alignment terminology: Cubitus
Valgus
Congenital or Acquired
• Acquired conditions include :
– Trauma
– Developmental
– Inflammation
– Infection
– Neuromuscular
– Degenerative
– Metabolic
– Tumor
Congenital Anomaly : Talipes Equino
Varus TEV
Traumatic Injuries
•
•
•
•
•
Fractures
Dislocations
Soft tissues injuries: ligaments, tendons
Nerve injuries
Epiphyseal injuries
Fractures: Break in the continuity
of bone
Dislocations
Complete
separation of the
articular surface
Distal to proximal
fragment
Anterior, Posterior, Inferior,
Superior
Fracture Dislocation
Dislocation with fracture of
the bone
Always X-Ray Joint
Above and Below
Avulsion Fracture
Force due to
Resisted Muscle
Action:-
“Avulsion”
Transverse pattern
Intra-articular Fractures
• If displaced ; should
always be treated by
ORIF=
Open Reduction and
Internal Fixation
failure to reduce and fix
such fracture results in
loss of function,
deformity and early
degenerative changes
Soft tissue injuries of the knee
Anterior Cruciate Ligament injury:
MRI
(Developmental Dislocation of Hip)
DDH
Developmental Foot deformity: Hallux
Valgus
Developmental: SCFE (Slipped Capital
Femoral Epiphysis)
Spinal Deformities: Kyphosis or
Hyperlordosis
Spinal Deformity: Scoliosis
Degenerative Disorders
• Occur at any joint
• Can be primary or secondary
• Can lead to pain and/or deformity and/or loss
of function
OA Hip
Osteoarthritis of Knee
Metabolic Disorders (Rickets): Bow
Legs
Osteoporosis: Pathological Fracture
Osteoporosis: Colles fracture
Bone Tumor
Bone tumors
Neurological Evaluation : Sensory &
Motor
Nerve Injury: Muscle wasting
Spinal Cord Injury
• Often results from fracture dislocation of spine
• When injury is at cervical spine it may result in
Tetraplegia or quad
• Injury at dorsal spine may result in Paraplegia
Neuromuscular disorder: Polio
Chronic Osteomyelitis : discharging
sinus
Chronic Osteomyelitis :
Sequestrum
Physiotherapy for Orthopedic
Patients
• Physiotherapy is an important part of
orthopedic and trauma management
• It is used for : pain relief, prevention of stiffness,
muscle strengthening, mobilisation of stiff joint
or spine, training non-weight bearing or partial
weight bearing
• Physiotherapy modalities include: heat, cold,
exercise, ultrasound, traction, electrical
stimulation
Clinical Skill: Cast application
Clinical Skills: Knee Aspiration
ORTHOEADIC HISTORY TAKING
History taking skills
• History taking is the most important step in
making a diagnosis.
• A clinician is 60% closer to making a diagnosis
with a thorough history. The remaining 40% is
a combination of examination findings
and investigations.
• History taking can either be of a traumatic or
non-traumatic injury.
Objective
• At the end of this session, students should be
able and know how to take a MSK relevant
history.
Competency expected from the
students
• Take a relevant history, with the knowledge of
the characteristics of the major
musculoskeletal conditions
STRUCTURE OF HISTORY
• Demographic features
• Chief complaint
• History of presenting
illness
– MOI
– Functional level
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MSK systemic review
Systemic enquiry
PMH
PSH
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Drug Hx
Occupational Hx
Allergy
Family Hx
Social Hx
MSK systemic review
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Pain
Stiffness
Swelling
Instability
Deformity
Limp
Altered Sensation
Loss of function
Weakness
Pain
• Location
– Point to where it is
• Radiation
– Does the pain go anywhere else
• Type
– Burning, sharp, dull
• How long have you had the pain
• How did it start
– Injury
• Mechanism of injury
• How was it treated?
– Insidious
Pain
• Progression
– Is it getting worse or is it remaining stable
– Is it better, worse or the same
• When
– Mechanical / Walking
– Rest
– Night
– Constant
• Aggravating & Relieving Factors
– Stairs
– Start up, mechanical
– Pain with twisting & turning
– Up & down hills
– Kneeling
– Squatting
Pain
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Where: location/radiation
When: onset/duration
WWQQAA
Quality: what it feels like
Quantity: intensity, degree of disability
Aggravating and Alleviating factors
Associated symptoms
Swelling
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Duration
Local vs generalized
Single or multiple
Onset
Constant or comes and goes
Progression: same size or↑
Aggravated and relived factors
Associated with injury or reactive
Soft tissue, joint, bone
Rapidly or slowly
Painful or not
Instability
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Onset
How dose it start?
Any Hx of trauma?
Frequency
Trigger/aggravated factors
True = Giving way
Buckling 2dary to pain
I can not trust my leg!
Associated symptoms
– Swelling
– Pain
Deformity
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•
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When did you notice it?
Progressive or not?
Associated with symptoms like pain & stiffness
Impaired function or not?
Past Hx of trauma or surgery
PMHx (neuromuscular,,etc)
Limping
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Painful vs painless
Onset (acute or chronic)
Progressive or not?
Use walking aid?
Functional disability?
Traumatic or non traumatic?
Associated with swelling, deformity, or fever.
Loss of function
• How has this affected your life
• Home (daily living activities DLA)
– Prayer
– Using toilet
– getting out of chairs / bed
– socks
– stairs
– squat or kneel for gardening
– walking distance
– get & out of cars
• Work
• Sport
– Type & intensity
– Run, jump
Mechanical symptoms
Locking / clicking
• Loose body, meniscal
tear
• Locking vs pseudolocking
Giving way
• Buckling 2° pain
• ACL
• Patella
Red flags
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Weight loss, loss of appetite, night sweat
Fever
Loss of sensation
Loss of motor function
Sudden difficulties with urination or
defecation
Risk factors
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Age
Gender
Obesity
Lack of physical activity
Inadequate dietary
calcium and vitamin D
• Smoking
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Occupation and Sport,
Family History (SCA)
Infections,
Medication (steroid)
Alcohol
PHx Musculoskeletal
injury/condition,
• PHx Cancer
Current and previous history of
treatment
• Nonoperative
– Medications
• Analgesia
• How much
• How long
– Physio
– Orthotics
• Walking sticks
• Splints
• Operative
– What, where and when?
– Perioperative complications
Knee
•
Pain
• Location
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•
•
•
•
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Burning, sharp, dull
How long have you had the pain
How did it start
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Injury
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•
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Mechanism of injury
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Position of leg at time of injury
Direct / indirect
Audible POP
Could you play on or did you leave the
field?
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•
Did it swell at the time
Immediately
Haemathrosis
Delayed
Traumatic synovitis
Audible POP
How was it treated?
ACL
Insidious
•
Is it getting worse or is it remaining stable
Is it better, worse or the same
When
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Type
•
•
•
point to where it is radiation
does the pain go anywhere else
Progression
Mechanical / Walking
Rest
Nocte
constant
Aggravating & Relieving Factors
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–
–
–
–
–
stairs
start up, mechanical
pain with twisting & turning
up & down hills
kneeling
squatting
Spine
•
Pain
– radiation exact location
• L4
• L5
• S1
– Aggravating, relieving
• Neuropathic
» extension & walking downhill
» walking uphill & sitting
• vascular
» walking uphill
• generates more work
» rest
• standing is better than sitting due to pressure gradient
– stairs
– shopping trolleys
– coughing, straining
– sitting
– forward flexion
Spine
• Associated symptoms
– Paresthesia
– Numbness
– Weakness
• L4
• L5
• S1
– Bowel, Bladder
– Cervical myelopathy
• Clumbsiness of hand
• Unsteadiness
• Manual dexterity
• Red Flags
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Loss of weight
Constitutional symptoms
Fevers, sweats
Night pain, rest pain
History of trauma
immunosuppresion
Shoulder
• Age of the patient
– Younger patients - shoulder instability and
acromioclavicular joint injuries are more prevalent
– Older patients - rotator cuff injuries and degenerative joint
problems are more common
• Mechanism of injury
– Abduction and external rotation - dislocation of the
shoulder
– Direct fall onto the shoulder - acromioclavicular joint
injuries
– Chronic pain upon overhead activity or at night time rotator cuff problem.
Shoulder
• Pain
– Where
• Rotator Cuff
–anterolateral &
superior
–deltoid
insertion
• Bicipital tendonitis
–Referred to
elbow
• Aggravating / Relieving
factors
– Position that ↑
symptoms
• RC: Window
cleaning position
• Instability: when
arm is overhead
– Neck pain
• Is shoulder pain
related to neck
pain
• ask about
radiculopathy
Shoulder
• Causes
– AC joint
– Cervical Spine
– Glenohumeral joint & rotator cuff
• Front & outer aspect of joint
• Radiates to middle of arm
– Rotator cuff impingement
• Positional : appears in the window cleaning position
– Instability
• Comes on suddenly when the arm is held high
overhead
– Referred pain
• Mediastinal disorders, cardiac ischaemia
Shoulder
•
Associated
– Stiffness
– Instability / Gives way
• Severe – feeling of joint
dislocating
• Usually more subtle
presenting with clicks/jerks
• What position
• Initial trauma
• How often
• Ligamentous laxity
– Clicking, Catching / grinding
• If so, what position
– Weakness
• Rotator cuff
– especially if large tear
– Pins & needles, numbness
• Loss of function
– Home
• Dressing
– Coat
– Bra
• Grooming
– Toilet
– Brushing hair
• Lift objects
• Difficulty working with
arm above shoulder
height
– Top shelves
– Hanging washing
– Work
– Sport