Introduction to Orthopaedics It will be your best course ever when you reach 6 th year! Dr. Mohammad Attiah Dr. Badr AlQahtani Dr. Salah Fallatah Dr. Sohail Bajammal

What is Orthopaedics? orthopedie Greek Words Orthos: correct, straight Paideion: child

Orthopaedic Subspecialties 1.Pediatric Orthopaedics 2.Orthopaedic Trauma 3.Arthroplasty 4.Spine Surgery 5.Upper Extremity 6.Sport Injuries 7.Hand Surgery 8.Orthopaedic Oncology 9.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 Accidents in 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 Saudi 1 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 with special 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 first 2.Check the patient ID 3.Skeletally immature? 4.What area of the body & what views 5.Identify each bone in the X-ray 6.Follow the cortical outline of each bone 7.Describe any: 1.Fracture 2.Dislocation or Subluxation 3.Lucency 4.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

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

INFECTION

PIP Swelling

Ulnar Deviation, MCP Swelling, Left Wrist Swelling

Nodules

ARTHRITIS

METABOLIC DYSFUNCTION

TUMOURS

TUMORS

NEUROMUSCULAR DISORDERS

TRAUMA Leading cause of death in young Deaths – 1 st 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)