orthopaedic management made easy
TRANSCRIPT
Orthopaedic Management
Made Easy
Department of Orthopaedics and Traumatology
TP Lam
Learning objectives
Brief review of history taking, P/E
Management
At-the-spot treatment
Workup
Definitive treatment
Acute treatment / short term plan
Long term plan
History: the basic skill you must master
Chief Complaint
Where is the problem ? beware of referral pain
Etiology
Physical
Social
mental
DDx 1 DDx 2 DDx 3 ...... DDx n
Onset
Site
Severity
Quality
factor
factor
Macro time
Micro time
Radiation
Associated factor
History
Complications
Physical
Pathological eg AVN, epiphyseal closure, osteoarthritis etc
Functional eg ambulatory status, activity tolerance, ADL
Complication due to treatment ie iatrogenic
Social - occupational, financial, marital, familial
mental – mood, self-esteem
Prognosticating factors and extent of disease
History
Patient’s background - Physical
MSK
Handedness
Pre-morbid ambulatory status
Daily activities requirement – job, hobbies,
sport, living environment
History
Patient’s background - Physical
MSK
Response to previous treatment
Patient’s expectation
History
Patient’s background - Physical
Medical
Past health
Medication
Previous operation
Allergy
Birth history
Developmental history
Immunization
History
Patient’s background - Physical
Medical
Menstrual
Obstetric history
Smoking, drinking,
Illegal drug
Traveling history
Familial disease
History
Patient’s background -
Psychosocial background
Marital
Family
Occupational
Living / environmental
Other social
Background(Response to previous treatment
Patient’s expectation)
etiology Main problem
Prognosticating factors
PhysicalsocialMental
PhysicalsocialMental
PhysicalsocialMental
PhysicalsocialMental
Complication(including iatrogenic)
PhysicalsocialMental
Physical examination
Introduce yourself, explanation,
hygienic measure
Mind-set for inspection, palpation, movement,
Standard Component
The examination matrix
Specific
Component
General
Component
General P/E
Posture
Gait
The examination matrix I
Skin Muscle Bone Joint Mass
Look Muscle bulk
Spasm
Mass
Mass
Length –
apparent, real
Deformity / instability
Deformity
EffusionSoft tissue swelling
Look for any mass,
swelling
site, size and shape
Feel Temperature Muscle spasm / tone
Compartment
Mass
Any mass
Contour
Tenderness
Tenderness
Effusion
Synovial thickening
Soreness
Structure
Surface
Skin, tissue plane
Move –
active
passive
ROM
Crepitation
Jerk, click
Percuss For fasciculation
For percussion tenderness
auscultate Crepitation Bruit
Color
Trophic change
Hair status
Skin texture
Ulcer
Hemangioma
Pigmentation
Scar
Sinus
Dilated vein
Swelling eg
rheumatoid nodule,
gouty tophi
bruising
The examination matrix II
Artery Vein Lymphatics Nerve
Motor
Nerve sensory
Look Color
Trophic change
Ulcer
Dilated vein
edema
Lymphedema Muscle wasting
fasciculation
Feel Temp
Pulse
Temp LN Muscle tone Test sensation
Move –
active
passive
Power
Clonus, Babinski
Percuss Reflex Tinel
auscultate bruit
Specific components
ShoulderElbowWristHand and fingerHipKneeAnkleNeckThoracic and lumbar spineSIJPeripheral nerves
Specific components
ShoulderElbowWristHand and fingerHipKneeAnkleNeckThoracic and lumbar spineSIJPeripheral nerves
Refer to “Orthopaedic
Assessment Made Easy” at
Teaching Web (Med 3)
3D-Matrix
Etiology Problem Complication BackgroundPrognosis /
extent of ds
History
P/E
Physical
Social
Mental
Tools Theme Domain
Tools
Domain
Theme
Etiology Problem Complication Background prognosis
History
P/E
Investigation
Conclusion
Treatment
3-D Mx MatrixPhysical
Social
Mental
Management
At-the-spot Mx
Short termLong term
At-the-spot - PPP
PPP:- Physical, Psychosocial, Plan
Physical:- depends on presenting symptoms and location
(AED or OPD)
6 A
Vital signs:- the “ABC”
AB:- Airway, Breathing,
Circulation:- bleeding, then stop the bleeding!
Distal circulation, compartmental syndrome
Iv fluid or blood replacement
Vital sign monitoring
Analgesic - pain reliefOral, im or iv analgesic
For fracture:- immobilization is the best pain-killer
Anti-sepsis:-Wound:- temporary cleansing and dressing
“Anchorage”:- temporary splintage
Splint, slab, Thomas splint, neck collar, bed rest
Anti-swelling:- RICE
?Anaesthesia:- may need to fast patient
At-the-spot - PPP
Psycho-social Be empathetic
Explanation to patient/relativeDDx
Further investigation
Probable plan of treatment
Plan ?admit or
referral OPD (early FU or routine FU) or
?discharge
At-the-spot - PPP
Another ways to remind yourself…
Skin: wound care and Anti-sepsis
Muscle: Acute compartmental syndrome
Bone and joint: preliminary reduction and immobilization (Anchorage)
Artery: stop bleeding and ABC
Vein and Lymphatic: Anti-swelling and RICE
Nerve: Analgesic for pain and work up for Anesthesia
Work-up
Blood
Excreta / body fluid
Imaging
Arthroscopy
Biopsy
Electrophysiology / Functional Study
Workup
Blood CBP ESR, CRP Clotting profile Blood for culture Cross-match Na, K, urea, Cr Liver enzymes, alkaline phosphatase Ca, phosphate ANF, RF, urate Others
Glucose, blood gas,
Workup
Body fluid, excreta
Synovial fluid
Cell count:- WBC
Glucose
Culture and gram stain, AFB
Microscopy for crystal
Urine, sputum ....
Workup
Imaging Plain x-ray
AP, lateral Special view:- principle is to take tangential view to the
spot of pathology
CT MRI U/S Contrast study radio-isotope study
Bone scan
Workup
Arthroscopy
biopsy
Electrophysiology study
EMG
NCT
3D-Matrix
Etiology Problem Complication Background prognosis
History
P/E
Investigation
Conclusion Σ Σ MSK analysisΣ MSK
analysisΣ Σ
Management Etiology Problem Complication Background prognosis
Physical
Social
Mental
At-the-spot Mx
Short termLong term
mentalsocialPhysical
OccupationalFinancialMaritalfamily
hobbies
Next slide for MSK problem listing
MSK Medical
Iatrogenic complication Response to past PxPatient’s expectation
WHO classification of health
Analysis of MSK problem (anatomic)
SkinUlcer
contracture
MusclePower
Contracture / Spastic
Bone
Length
Deformity :- frontal, sagittal, rotational
Texture eg osteoporosis
Stability / fracture
Joint
Stiffness
Instability / dislocation
degeneration
ArteryVascular insufficiency
Compartmental syndrome
Vein Venous insufficiency
Nerve
Sensation loss (including proprioception)
Neurogenic pain
In-coordination
Mass effect
Compression, mechanical effect eg spinal stenosis,
nerve entrapment
Analysis of MSK problem (anatomic)
Treatment...but how?
First of all, some important keywords ............
Conservative and Operative
Short Term / Long Term Plan
Acute phase / Chronic phase
Conservative Treatment
Physiotherapy
Occupational therapy
Prosthetics and orthotics
Medication
General Medical Advice
Non-operative Intervention
Conservative Treatment
Physiotherapy RICE Instrumental
TENS Interferential U/S
Passive Eg stretching
Active Muscle strengthening, proprioceptive training
Assistive Stick, cane, walking frame
Conservative Treatment
Occupational therapy
UL training
Splint
Functional assessment
Vocational training
ADL training
Home assessment / home visit
Conservative Treatment
Prosthetics and Orthotics
LL
Splint
Brace
corset
Prosthesis
(Teaching Web :- “Orthopaedic Ward -
equipments and devices”)
Conservative Treatment
Medication
Analgesic
NSAID
Narcotics (chronic use to be avoided)
Anti-depressant
Steroid
Gout medication
Disease modifying agent
Drug for osteoporosis
Conservative Treatment
General health advice
Change of daily activities
Sport
Hobbies
Domestic
Occupational
eg diet, weight reduction, posture
Avoid pain provoking activities
Conservative Treatment
Non-operative intervention
Close reduction, POP
Manipulation
Analysis of MSK problem (anatomic)
SkinUlcer
contracture
MusclePower
Contracture / Spastic
Bone
Length
Deformity :- frontal, sagittal, rotational
Texture eg osteoporosis
Stability / fracture
Joint
Stiffness
Instability / dislocation
degeneration
These are what you want to rectify
Conservative Treatment
Physiotherapy
Occupational therapy
Prosthetics and orthotics
Medication
General Medical Advice
Non-operative Intervention
These are the means
Operative intervention ......
Analysis of MSK problem (etiologic)
Operative
(bony procedure, soft tissue surgery)
Infection I & D
TumorExcision (curative or de-bulking)
followed by reconstruction
inflammatorySynovectomy / ? Local steroid
injection
InjuryRepair (eg nerve repair, fracture
fixation)
Analysis of MSK problem (per se)Operative
(bony procedure, soft tissue surgery)
Skin UlcerSkin grafting,
flap surgery
MusclePower
Contracture / Spastic
Tendon transfer
Release of contracture
Bone
Length
Deformity :- frontal, sagittal, rotational
Texture eg osteoporosis
Stability / fracture
Lengthening
Osteotomy
Internal fixation
Joint
Stiffness
Instability / dislocation
Degeneration / derangement
MUA, Soft tissue release
Stabilization procedure:- soft tissue procedure (eg patella), osteotomy (eg
DDH, shoulder), fusion (eg spine)
Arthroscopy / Joint replacement / arthrodesis(rarely)
Analysis of MSK problem (per se)Operative
(bony procedure, soft tissue surgery)
ArteryVascular insufficiency
Compartmental syndrome
Revascularization
release
Vein Venous insufficiency General surgeon
Nerve
Sensation loss (including proprioception)
Neurogenic pain
In-coordination
Mass effect / non-viable tissue
Compression, mechanical effect eg spinal stenosis,
nerve entrapment
Decompression, release
amputation
soft tissue surgery
skin
skin grafting
flap
muscle and tendon
tendon transfer
ligament, capsule and compartment
release
reconstruction, plication, reefing
nerve repair
others
Operative Treatment
Hard tissue surgery Bone surgery
fixation fusion osteotomy lengthening amputation
Joint surgery arthroscopy joint replacement arthrodesis / fusion repair of intraarticular lesions discectomy for PID synovectomy
Operative Treatment
Analysis of MSK problem (per se)Operative
(bony procedure, soft tissue surgery)
Skin UlcerSkin grafting,
flap surgery
MusclePower
Contracture / Spastic
Tendon transfer
Release of contracture
Bone
Length
Deformity :- frontal, sagittal, rotational
Texture eg osteoporosis
Stability / fracture
Lengthening
Osteotomy
Internal fixation
Joint
Stiffness
Instability / dislocation
Degeneration / derangement
MUA, Soft tissue release
Stabilization procedure:- soft tissue procedure (eg patella), osteotomy (eg
DDH, shoulder), fusion (eg spine)
Arthroscopy / Joint replacement / arthrodesis(rarely)
soft tissue surgery
Hard tissue surgery
Bone surgery
Joint surgery
Operative Treatment
These are what you want to rectify
These are the means
Before Conclusion ......
Let’s talk about
Red Flag Signs
Red Flag Signs
In general, they come naturally ...
surf along History and P/E and Ix
Red Flag signs in general
Elderly patient
Persistent and severe symptom
Night symptom
Associated with Trauma
Features of infection eg fever, chills, rigor, night sweating
Features of malignancy eg constitutional symptoms, symptoms due to potential primary tumor
Red Flag signs in general – surf along
History and P/E and Ix
Significant past health problem
History of malignancy
Significant medication history
eg use of steroid
Presence of complication
eg neurological deficit, vascular disturbance
Functional (physical), social or mental disturbance
Red Flag signs in general – surf along
History and P/E and Ix
Significant positive investigation
Blood test
ESR, CBC, Ca, ALP etc
Imaging
Plain xray
others
ConclusionHx – P/E – Ix - Px
History
Background(Response to previous treatment
Patient’s expectation)
etiology Main problem
Prognosticating factors
PhysicalsocialMental
PhysicalsocialMental
PhysicalsocialMental
PhysicalsocialMental
Complication(including iatrogenic)
PhysicalsocialMental
Physical examination
Introduce yourself, be polite and considerate,
hygienic measure
Mind-set for inspection, palpation, movement,
General
Posture
Gait
General Components
The examination matrix
Specific
Components
3D-Matrix
Etiology Problem Complication BackgroundPrognosis /
extent of ds
History
P/E
Physical
Social
Mental
Tools Theme Domain
Tools
Domain
Theme
3D-Matrix
Etiology Problem Complication Background prognosis
History
P/E
Investigation
Conclusion Σ Σ MSK analysisΣ MSK
analysisΣ Σ
Physical
Social
Mental
At-the-spot Mx
A case presented to youHx, P/E
At-the-spotManagement
Investigation
Problems listing
Conservative Vs Operative PxAcute Px Vs Long term Px
At the spot Mx
•Physical•ABC•Analgesic•Anti-sepsis•Anchorage•Anti-swelling•Anaesthesia?
•Psychosocial•Explanation•empathetic
•Plan•Discharge•Referral•admit
At-the-spotManagement
Blood
Body fluid, excreta
Imaging
Arthroscopy
biopsy
Electrophysiology study
Investigation
Blood
Body fluid, excreta
Imaging
Arthroscopy
biopsy
Electrophysiology study
Plain xray (+/- special view)U/SCTMRI
Contrast studyRadioisotope
Investigation
3D-Matrix
Etiology Problem Complication Background prognosis
History
P/E
Investigation
Conclusion Σ Σ MSK analysisΣ MSK
analysisΣ Σ
Management Etiology Problem Complication Background prognosis
Physical
Social
Mental
At-the-spot Mx
Short termLong term
3D-Matrix
Etiology Problem Complication Background prognosis
History
P/E
Investigation
Conclusion Σ Σ MSK analysisΣ MSK
analysisΣ Σ
Management Etiology Problem Complication Background prognosis
Physical
Social
Mental
At-the-spot Mx
Short termLong term
mentalsocialPhysical
OccupationalFinancialMaritalfamily
hobbies
Next slide for MSK problem listing
MSK Medical
Iatrogenic complication Response to past PxPatient’s expectation
WHO classification of health
Problems listing
Analysis of MSK problem (anatomic)
SkinUlcer
contracture
MusclePower
Contracture / Spastic
Bone
Length
Deformity :- frontal, sagittal, rotational
Texture eg osteoporosis
Stability / fracture
Joint
Stiffness
Instability / dislocation
degeneration
These are what you want to rectify
Conservative Treatment
Physiotherapy
Occupational therapy
Prosthetics and orthotics
Medication
General Medical Advice
Non-operative Intervention
These are the means
Conservative Vs Operative PxAcute Px Vs Long term Px
Analysis of MSK problem (per se)Operative
(bony procedure, soft tissue surgery)
Skin UlcerSkin grafting,
flap surgery
MusclePower
Contracture / Spastic
Tendon transfer
Release of contracture
Bone
Length
Deformity :- frontal, sagittal, rotational
Texture eg osteoporosis
Stability / fracture
Lengthening
Osteotomy
Internal fixation
Joint
Stiffness
Instability / dislocation
Degeneration / derangement
MUA, Soft tissue release
Stabilization procedure:- soft tissue procedure (eg patella), osteotomy (eg
DDH, shoulder), fusion (eg spine)
Arthroscopy / Joint replacement / arthrodesis(rarely)
soft tissue surgery
Hard tissue surgery
Bone surgery
Joint surgery
Operative Treatment
These are what you want to rectify
These are the means
Conservative Vs Operative PxAcute Px Vs Long term Px
Thank You for Attention