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

1. Introduction to OrthopaedicsIt will be your best course ever when you reach 6th year! Dr. Mohammad Attiah Dr. BadrAlQahtani Dr. SalahFallatah Dr. SohailBajammal

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

3. Orthopaedic Subspecialties • Pediatric Orthopaedics • Orthopaedic Trauma • Arthroplasty • Spine Surgery • Upper Extremity • Sport Injuries • Hand Surgery • Orthopaedic Oncology • Foot & Ankle Surgery Each has different patient population, expectations & life style

4. 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

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

6. 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

7. Not convinced yet?

8. 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

9. Trauma is a leading cause of death and disability in Saudi

13. Every hour in Saudi1 KILLED 4 INJURED

14. 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

15. We deal withspecial instruments

16. By the end of the course,you should

17. Objectives • OrthopaedicTerminology • OrthopaedicHistory & Physical Exam • How to read an X-ray? • Some orthopaedic pathology

18. Orthopaedic Terminology

19. Joint Movements Terminology • Active Movement vs Passive Movement • Flexion vs Extension • Abduction vs Adduction • Dorsiflexionvs Plantar/Palmar Flexion • Eversionvs Inversion • Internal rotation vs External rotation • PronationvsSupination

22. IR/ER

23. Terminology of Deformities • Static/Fixed vs Flexible • VarusvsValgus

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

25. Types of Bone • Cortical • Cancellous

26. Operative Procedures • Osteotomy • Arthrodesis • Arthroplasty • Osteosynthesis • Open reduction & internal fixation (ORIF) • Closed reduction & internal fixation (CRIF) • Intramedullary nail (IM nail)

27. Orthopaedic History & Physical

28. 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

29. History • Medications • NSAIDs • steroids • narcotics • Other treatments for this injury • Injections • Bracing • Physiotherapy • Chiropractic care • Allergies

30. 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

31. Specifics to the HPI • Precipitating incident • trauma (macrotrauma) • repetitive stress (microtrauma) • is this a work related injury? • is there a lawsuit ongoing?

32. 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

33. Specifics of the HPI • For pain or presenting problem • Onset • Duration • Character • Course • Aggravating and relieving factors • Location • Radiation • Associated symptoms

34. Associated Symptoms • In addition to pain do they have: • Clicking • Snapping • Catching • Locking • Sensation of giving way (including prior falls or dislocations) • Swelling • Weakness

35. 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?

36. 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

37. 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.

38. 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)

39. 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

40. General Considerations for Examination • The cardinal signs of musculoskeletal disease are: • Pain • Redness (erythema) • Swelling • Increased warmth • Deformity • Loss of function

41. 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

42. 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

43. 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”)

44. Auscultation • We don’t really listen to anything in orthopedics

45. 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

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

47. Range of Motion • Active • Passive

48. 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

49. 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

50. 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 dorsalispedis pulses on both sides - if these pulses are absent or weak, check the popliteal and femoral pulses