introduction to orthopaedics it will be your best course ever when you reach 6 th year!

Introduction to OrthopaedicsIt will be your best course ever when you reach 6th year!

Dr. Mohammad AttiahDr. Badr AlQahtaniDr. Salah Fallatah

Dr. Sohail Bajammal

What is Orthopaedics?orthopedie

• Greek Words• Orthos: correct, straight• Paideion: child

Orthopaedic Subspecialties

1. Pediatric Orthopaedics2. Orthopaedic Trauma3. Arthroplasty4. Spine Surgery5. Upper Extremity6. Sport Injuries7. Hand Surgery8. Orthopaedic Oncology9. Foot & Ankle Surgery

Each has different patient population,

expectations & life style

Interested in ortho?

• Do elective in orthopaedics• Get excellent marks in the ortho course• Spend 5 years in residency• Do 1-2 years of fellowship

Orthopaedic Surgeons are

• Among the top paid doctors in the US• Spine Surgeons: 600,000 US$ annually

Even if you don’t like Orthopaedics,

you need to pay attention• Back pain affects 80% of the population

• Young population Sport Injuries

• Obesity Osteoarthritis

• 20% of Primary Care Visits are MSK complaints– 90% can be managed non-operatively by family

physicians

Not convinced yet?

Cost of Road Traffic Accidentsin Saudi Arabia

USD $5.6 billion

(2.2% to 9% of the national income)

Ansari S, Akhdar F, Mandoorah M, Moutaery K. Causes and effects of road traffic accidents in Saudi Arabia. Public Health 2000;114:37-9

Trauma is a leading cause of death and disability in Saudi

Every hour in Saudi1 KILLED

4 INJURED

We deal with a diverse group of practitioners

• Trauma team• Family Physicians• Internists• Rheumatologists• Endocrinologists• Physiotherapists• Physiatrists (Rehabilitation

Physicians)• Occupational Therapists• Orthotists & Prosthetists

• Cast Technicians• Interventional Radiologists• Pain Specialists• Oncology team: medical

and radiation oncologists• Chiropractors• Podiatrists• Social Workers• Lawyers• Insurance Companies

We deal withspecial instruments

By the end of the course,you should

Objectives

• Orthopaedic Terminology• Orthopaedic History & Physical Exam• How to read an X-ray?• Some orthopaedic pathology

Orthopaedic Terminology

Joint Movements Terminology

• Active Movement vs Passive Movement• Flexion vs Extension• Abduction vs Adduction• Dorsiflexion vs Plantar/Palmar Flexion• Eversion vs Inversion• Internal rotation vs External rotation• Pronation vs Supination

IR/ER

Terminology of Deformities

• Static/Fixed vs Flexible• Varus vs Valgus

Parts of a long bone• Diaphysis• Metaphysis• Epiphysis• Physis (growth plate)• Apophysis

Types of Bone

• Cortical• Cancellous

Operative Procedures

• Osteotomy• Arthrodesis• Arthroplasty• Osteosynthesis

– Open reduction & internal fixation (ORIF)– Closed reduction & internal fixation (CRIF)– Intramedullary nail (IM nail)

Orthopaedic History & Physical

History

• Similar to other medical histories in that you need to identify:– Age– Chief complaint– History of presenting illness– Past medical history especially prior injuries or

operations

History• Medications

– NSAIDs– steroids– narcotics

• Other treatments for this injury– Injections– Bracing– Physiotherapy– Chiropractic care

• Allergies

Social History• Occupation

– Working / Retired– Manual labor / Desk job

• Living situation– Alone / Spouse / Other supports– Two storey house / Apartment

• Ambulatory status– How far can they walk– Do they use a walker / cane

• Smoking/ Alcohol/ Drug Use

Specifics to the HPI

• Precipitating incident– trauma (macrotrauma) – repetitive stress (microtrauma)– is this a work related injury?– is there a lawsuit ongoing?

Specifics of the HPI

• For MVCs – driver/passenger– belted/non-belted– location of impact and severity of crash (required jaws of

life, if anyone died in the crash, thrown from the car, etc)– speed at impact– position of the patient and the limb in question at impact

Specifics of the HPI

• For pain or presenting problem– Onset– Duration– Character– Course– Aggravating and relieving factors– Location– Radiation– Associated symptoms

Associated Symptoms

• In addition to pain do they have:– Clicking– Snapping– Catching– Locking– Sensation of giving way (including prior falls or

dislocations)– Swelling– Weakness

Temporality or Timing

• Is it worse when they wake up in the morning?• Does it gradually get worse over the course of

the day?• Does the pain ever wake them up at night?

Red flags

• Pain at night or rest• Associated weight loss and loss of appetite• History of cancer• Steroids use• History of trauma• Extreme age• Bowel or bladder symptoms

General Considerations for Examination

• When taking a history for an acute problem always inquire about the mechanism of injury, loss of function, onset of swelling (< 24 hours), and initial treatment

• When taking a history for a chronic problem always inquire about past injuries, past treatments, effect on function, and current symptoms.

General Considerations for Examination

• The patient should be gowned and exposed as required for the examination

• Some portions of the examination may not be appropriate depending on the clinical situation (performing range of motion on a fractured leg for example)

General Considerations for Examination

• The musculoskeletal exam is all about anatomy

• Think of the underlying anatomy as you obtain the history and examine the patient

General Considerations for Examination

• The cardinal signs of musculoskeletal disease are:– Pain– Redness (erythema)– Swelling– Increased warmth– Deformity– Loss of function

General Considerations for Examination

• Always begin with inspection, palpation and range of motion, regardless of the region you are examining (LOOK, FEEL, MOVE)

• Specialized tests are often omitted unless a specific abnormality is suspected

• A complete evaluation will include a focused neurological exam of the effected area

Inspection

• Look for scars, rashes, or other lesions like abrasions/open wounds

• Look for asymmetry, deformity, or atrophy • Always compare with the other side• Look for swelling• Look for erythema (redness)• Posture/position of the joint or limb

Percussion

• Typically, we don’t percuss things in orthopedics however the one exception is nerves

• If tapping over a nerve causes pain or electric shock sensations, this is called Tinel’s sign

• Present when nerves are compressed or irritated• Also used to monitor nerve recovery after injury (in the

form of an “advancing Tinel’s sign”)

Auscultation

• We don’t really listen to anything in orthopedics

Palpation

• Examine each major joint and muscle group in turn

• Identify any areas of tenderness• Joint line• Tendinous insertions• Palpate for any crepitus • Identify any areas of deformity• Always compare with the other side

Palpation

• Warm or cold including pulses • Fluctuation/fluid collection• Compartments – soft or firm and painful• Sensation

Range of Motion

• Active• Passive

Active ROM

• Ask the patient to move each joint through a full range of motion

• Note the degree and type of any limitations (pain, weakness, etc.)

• Note any increased range of motion or instability

• Always compare with the other side • Proceed to passive range of motion if

abnormalities are found

Passive ROM• Ask the patient to relax and allow you to support the

extremity to be examined• Gently move each joint through its full range of motion• Note the degree and type (pain or mechanical) of any

limitation• If increased range of motion is detected, perform special

tests for instability as appropriate• Always compare with the other side

Vascular Status

• Pulses• Upper extremity

– Check the radial pulses on both sides– If the radial pulse is absent or weak, check the

brachial pulses• Lower extremity

– Check the posterior tibial and dorsalis pedis pulses on both sides - if these pulses are absent or weak, check the popliteal and femoral pulses

Vascular Status

• Capillary Refill– Press down firmly on the patient's finger or toe

nail so it blanches– Release the pressure and observe how long it

takes the nail bed to "pink" up – Capillary refill times greater than 2 to 3 seconds

suggest peripheral vascular disease, arterial blockage, heart failure, or shock

Special tests

• Each joint has special tests

Reading X-rays

Ordering X-rays

• Two orthogonal views• Joint above and joint below• Two occasions:

– Before & after reduction– Now & two weeks for scaphoid and suspected

physeal injuries• If not trauma:

– Think weight-bearing: spine, knees, feet

How to read an X-ray

1. Take the history and examine the patient first2. Check the patient ID3. Skeletally immature?4. What area of the body & what views5. Identify each bone in the X-ray6. Follow the cortical outline of each bone7. Describe any:

1. Fracture2. Dislocation or Subluxation3. Lucency4. Deformity

How to describe a fracture on an X-ray?

• In relationship to the joint:– Intra-articular: epiphysis– Extra-articular: diaphysis or metaphysis

• Anatomical location:– Epiphysis, Metaphysis, Diaphysis

• Characteristics: oblique, transverse, spiral, comminuted

Describe

Describe

Describe

Describe

Diagnostic Tests• Plain x- ray: rule of 2s • CT Scan• Bone Scan• MRI• Arthrography• Arthrocenthesis• Arthroscopy

ORTHOPAEDIC DISORDERS

• Locomotive system– Bone– Joints– Tendons– Nerves– Muscles

WHAT CONDITIONS AFFECT THESE STRUCTURES

• Congenital and developmental anomalies• Infection and inflammation• Arthritis and inflammatory disorders• Metabolic dysfunction• Tumors and tumor like condition• Sensory and motor disorders• Injuries and mechanical derangement

CONGENITAL ANOMALIES

CONGENITAL ANOMALIES

CONGENITAL ANOMALIES

CONGENITAL ANOMALIES

INFECTION

PIP Swelling

Ulnar Deviation, MCP Swelling, Left Wrist Swelling

Nodules

ARTHRITIS

ARTHRITIS

ARTHRITIS

METABOLIC DYSFUNCTION

TUMOURS

TUMORS

NEUROMUSCULAR DISORDERS

NEUROMUSCULAR DISORDERS

NEUROMUSCULAR DISORDERS

TRAUMA• Leading cause of death in young

• Deaths– 1st hour

• Severe head injury• Severe bleeding

– 1-4 hour• Uncompensated blood loss

– Days to weeks• complication

EXTENT OF INJURY

• Age– Skeletally immature– Young but skeletally mature– Elderly

• Direction of force– Determine which structure injured

• Magnitude– Determine extent of injury

TRAUMA OF THE MUSCULOSKELETAL SYSTEM

• Bone• Joint• Ligament• Muscle• Nerve• Vascular

Bone

• Fracture– Definition– Complete vs incomplete– Open Vs Closed– Pattern – Cause (injury, fatigue, pathological)

TRAUMA OF THE MUSCULOSKELETAL SYSTEM

• Bone– Direct

• Simple contusion• Sever commonution

– Indirect• Bending => transverse fracture• Compression => depressed fracture• Twisting=> spiral fracture• Combination=> oblique, commonution,

– Penetrating • Stab & laceration• Missiles

– Low v: < 300 m/s» damage along the tract» commonution

– High v:» Wide soft tissue damage» Sever commonution with loss

Diaphyseal Fractures

• Type A– Simple fractures with two

fragments

• Type B– Wedge fractures– After reduced, length and

alignment restored

• Type C– Complex fractures with no

contact between main fragments

TRAUMA OF THE MUSCULOSKELETAL SYSTEM

• Joint:– Dislocation– Subluxation– Fracture-Dislocation

TRAUMA OF THE MUSCULOSKELETAL SYSTEM

• Ligament:– Sprain: some fibers torn remains stable– Partial rupture– Complete rupture

PRICE – Treatment of Ligament Injuries

• Protection• Rest• Ice• Compression• Elevation

TRAUMA OF THE MUSCULOSKELETAL SYSTEM

• Muscle– Direct

• Simple contusion• Sever crush

– Viability: remove all devitalised muscles– Indirect:

• By sharp end of fractured bone – Penetrating

• Laceration– Muscle – Musculotendinous junction– tendon

• Missiles – Low velocity– High velocity=> major damage

TRAUMA OF THE MUSCULOSKELETAL SYSTEM

• Nerves– Neuropraxia: conduction block, (no axonal loss focal

demyelination; rapid & complete return of sensation or function 3 to 6 weeks;

– Axonotemesis: axonal injury with subsequent degeneration, no disruption of the endoneurial sheath, perineurium, or epineurium,complete recovery may take as long as 12 months

– Neurotemesis: severe disruption of the connective tissue components of the nerve trunk with compromised sensory and functional recovery , poor prognosis for recovery, and sensory and functional recovery is never complete

TRAUMA OF THE MUSCULOSKELETAL SYSTEM

• Isolated or combination• Injury to vital organs• Survival of the limb

– Neurovascular– Integrity of skin– Bone– Prevention of complication– => limb salvage ( functioning limb) or amputation (

source of trouble)