l03-introductiontoorthopaedics-240505013627-5a3689b8.pptx

foundation course orthopedis

1. Introduction to the Orthopaedic 452 course Dr. Waleed Awwad, MBBS. FRCSC Assistant professor of Orthopaedic surgery Spine and scoliosis surgeon

2. Goal Competent student Attitude knowledge skill

3. Knowledge Competency in the knowledge Domain Diagnose & initially manage of the urgent Orthopaedic conditions Clinical presentation, investigation, management & complications of the common and community related orthopedic conditions

4. Skill History taking Physical exam Procedural skills Reduction Splinting & casting Knee aspiration Competency in skill domain

5. Attitude Communicator Personal behavior professional Competency in Attitude domain

6. Goals By end of this , 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.

7. 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.

8. Orthopaedic Core Competencies EMERGENCIES / RED FLAGS FRACTURES / TRAUMA PEDIATRIC ORTHOPAEDIC CONDITIONS NON- TRAUMATIC ORTHOPAEDIC CONDITIONS CLINICAL ASSESSMENT & DIAGNOSIS SKILLS

9. EMERGENCIES / RED FLAGS 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

10. Fractures & trauma Common Adult & pediatric Fractures Upper Limbs Lower Limbs Pelvic Peripheral Nerve Injuries Acute Spine Injuries Soft tissue injuries Joint dislocation

11. Pediatric orthopaedic Common Hip Conditions Common Lower Extremities Condition Alignment / Rotational conditions Gait Problems Lower extremities deformities

12. NON-TRAUMATIC ORTHOPAEDIC CONDITIONS Spine Tumors Metabolic Joints condition

13. 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) SPINE

14. Bone tumors Metastatic bone disease Primary bone lesions Benign bone tumors Malignant bone tumors

15. Metabolic bone disorders Osteoporosis Osteomalacia and Rickets

16. Joint conditions Degenerative OA Shoulder Chronic Condition

17. Clinical Assessment & diagnosis skills History taking Physical Examination Investigation interpretation Communication and attitude skills Procedural Skill Knee joint aspirations. Apply and remove a cast Joint/fracture reduction techniques

18. 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: Physical examination skills Splinting and casting technique skills Principles of fractures & joints dislocation reduction Joint aspirations.

19. 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

20. Learning Resources Books Tutorials / Lectures CBL Handouts

21. Assessment Continues assessment (20%) History taking at OPD CBL Hands- on skills sessions attendance OSCE (40%) History taking Physical examination Communication skills Written (40%)

22. 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.

23. Ambulatory care learning/Assessment Each student will have chance 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.

24. Skills sessions Cast application and removal Principles of reduction and immobilization. Knee aspiration

25. Case- based learning D ifferent cases cover ing 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

26. 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

27. 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

28. 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

29. 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

30. Compartment Syndrome : increase in intra- compartment 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) .

31. 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 .

32. Alignment terminology

33. Alignment Terminology: Cubitus Varus

34. Alignment terminology: Cubitus Valgus

35. Congenital or Acquired Acquired conditions include : Trauma Developmental Inflammation Infection Neuromuscular Degenerative Metabolic Tumor

36. Congenital Anomaly : Talipes Equino Varus TEV

37. Traumatic Injuries Fractures Dislocations Soft tissues injuries: ligaments, tendons Nerve injuries Epiphyseal injuries

38. Fractures: Break in the continuity of bone

39. Dislocations Complete separation of the articular surface Distal to proximal fragment Anterior, Posterior, Inferior, Superior

40. Dislocation with fracture of the bone Always X- Ray Joint Above and Below Fracture Dislocation

41. Force due to Resisted Muscle Action:- “Avulsion” Transverse pattern Avulsion Fracture

42. 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

43. (Developmental Dislocation of Hip) DDH

44. Developmental Foot deformity: Hallux Valgus

45. Spinal Deformities: Kyphosis or Hyperlordosis

46. Spinal Deformity: Scoliosis

47. Degenerative Disorders Occur at any joint Can be primary or secondary Can lead to pain and/or deformity and/or loss of function

48. Metabolic Disorders (Rickets): Bow Legs

49. Bone Tumor

50. Bone tumors

51. 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

52. Neuromuscular disorder: Polio

53. 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

54. Clinical Skill: Cast application

55. Clinical Skills: Knee Aspiration

56. ORTHOEADIC HISTORY TAKING

57. 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.

58. Objective At the end of this session, students should be able and know how to take a MSK relevant history.

59. Competency expected from the students Take a relevant history, with the knowledge of the characteristics of the major musculoskeletal conditions

60. STRUCTURE OF HISTORY Demographic features Chief complaint History of presenting illness MOI Functional level MSK systemic review Systemic enquiry PMH PSH Drug Hx Occupational Hx Allergy Family Hx Social Hx

61. MSK systemic review Pain Stiffness Swelling Instability Deformity Limp Altered Sensation Loss of function Weakness

62. 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

63. 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

64. Pain Where: location/radiation When: onset/duration Quality: what it feels like Quantity: intensity, degree of disability Aggravating and Alleviating factors Associated symptoms WWQQAA

65. Swelling 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

66. Instability 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

67. Deformity 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)

68. Limping 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.

69. 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

70. Mechanical symptoms Locking / clicking Loose body, meniscal tear Locking vs pseudo- locking Giving way Buckling 2° pain ACL Patella

71. Red flags Weight loss, loss of appetite, night sweat Fever Loss of sensation Loss of motor function Sudden difficulties with urination or defecation

72. Risk factors Age Gender Obesity Lack of physical activity Inadequate dietary calcium and vitamin D Smoking Occupation and Sport, Family History (SCA) Infections, Medication (steroid) Alcohol PHx Musculoskeletal injury/condition, PHx Cancer

73. 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

74. Knee 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 Position of leg at time of injury Direct / indirect Audible POP Could you play on or did you leave the field? ACL Did it swell at the time Immediately Haemathrosis Delayed Traumatic synovitis Audible POP How was it treated? Insidious Progression When Is it getting worse or is it remaining stable Is it better, worse or the same Mechanical / Walking Rest Nocte constant Aggravating & Relieving Factors stairs start up, mechanical pain with twisting & turning up & down hills kneeling squatting

75. 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

76. Spine Associated symptoms Paresthesia Numbness Weakness L4 L5 S1 Bowel, Bladder Cervical myelopathy Clumbsiness of hand Unsteadiness Manual dexterity Red Flags Loss of weight Constitutional symptoms Fevers, sweats Night pain, rest pain History of trauma immunosuppresion

77. 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

78. 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.

79. 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

80. 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

81. 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