PRINCIPLES OF ORTHOPEDICS by xiaohuicaicai

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									PRINCIPLES OF ORTHOPEDICS              *Terminology
    Two Lectures                           - Varus/valgus
                                           - FD/FFD/Recurvatum
                                           - Scoliosis/kyphosis/lordosis
                                           - Malrotation/Ante-version
                                           - Pes planus, pes cavus, equinous
                                           - Geno (valgus, varus)
                                           - Halux (valgus, varus)
                                           - Cubitus (valgus, varus)
                                           - Coxa (Magna, vara, valga)
                                           - CTEV
                                           - Malunion, non-union and
                                             delayed unions
                                           - Bone Resorption
                                           - Bone Destruction
                                           - Osteopenia
                                           - Osteoporosis
                                           - Lytic lesion
                                           - Sclerotic lesion
                                           - Monoplegia
                                           - Triplegia
                                           - Diplegia
                                           - Tetraplegia
                                           - Hemiplegia
                                           - Paraplegia

PRINCIPLES OF FRACTURES   (A) 45 min      * Definition
   Four Lectures                          * Types (simple & comminuted)
                                             (closed & open)
                                          * Mechanism of Injury
                                          * Presentations

                          (B) 45 min      *   Diagnosis
                                          *   Complications
                                          *   Healing of fracture
                                          *   Types of union
                                          *   Mal and non-union

                          (C) 45 min      Pathological fractures
                                           - Definition
                                           - Presentation
                                           - Investigation
                                           - Treatment

                            (D) 45 min    Fractures in children
GENERAL PRINCIPLES OF       * Open vs closed treatment
FRACTURE TREATMENT          * Conservative treatment (Tutorial)
  Two Lectures                     - Traction
                                   - Manipulation
                                   - Casting (complete, slab)
                                   - Splinting
                            * Operative treatment (Tutorial)
                                   - AO principles
                                   - Closed reduction + casting
                                   - Closed reduction + pinning
                                   - Plating
                                   - I.M. nailing
                                   - Ext. fixators

SOFT TISSUE CARE             *Ligament Injuries
 Two Lectures                     - ACL, collateral ligaments
                                   - Acute or delayed treatment
                                   - Rehabilitation
                             *Muscle & Tendon Injuries
                                   - Open & closed injuries
                                   - Acute or later reconstruction
                             *Acute Compartment Syndrome
                                   - Presentation
                                   - Diagnosis
                                   - Treatment
                                   - Complication

MECHANICAL KNEE DISORDERS     *Etiology of different knee injuries
 One Lecture                 *General features (symptoms and signs)
  (Tutorial)                 *General examination
                              *Useful investigations
                              *Imaging techniques
                              *Meniscal injuries
                                      - Presentation
                                      - Examination
                                      - Special tests (McMurray)
                                      - Types of meniscal injury
                                      - Complications
                               *ACL
                                      - Presentation
                                      - Examination
                                      - Special tests
                                        (Ant. Drawer – Lachman)
                                      - Complications
                            *Arthroscopic diagnosis & treatment
PERIPHERAL NERVE INJURIES   *Types of nerve injuries
    One Lecture                    - Neuropraxia
                                   - Axonotemesis
                                   - Neurotemesis
                            *Etiology
                                Special consideration to nerve
                                entrapment syndrome and common
                                fractures causing nerve injury
                            *Presentation and Diagnosis
                                   - Assessment
                                   - Investigations
                                   - EMG
                                   - NC studies

                            *Fate and Rehabilitation
                            *Examples (motor and sensory loss)
                                   - Brachial plexus (Erb’s palsy)
                                   - Carpal tunnel syndrome
                                     (median nerve)
                                   - Radial nerve injury at the arm
                                   - Ulnar nerve injury
                                   - Sciatic nerve injury
                                   - Lateral popliteal nerve injury

UPPER LIMB FRACTURES         *Fracture clavicle
AND DISLOCATIONS             *Shoulder dislocation
Two Lectures                 *Humerus shaft fractures
 (Tutorial)                  *Supracondylar fractures in children
                             *Montaggia fracture
                             *Galeazzi fracture
                             *Distal radial fractures
                             *Fracture scaphoid

LOWER LIMB FRACTURES         *Pelvic fractures
AND DISLOCATIONS             *Acetabular fractures
Two Lectures                 *Hip dislocations
 (Tutorial)                  *Proximal femoral fractures
                             *Femoral shaft fractures
                             *Fracture tibial plateau
                             *Tibial shaft fractures
                             *Ankle fractures
PRINCIPLES OF ORTHOPEDICS (1)   *Aetiology and D/D
  One Lecture                      - Congenital
                                   - Traumatic
                                   - Neurological e.g. C.P., polio
                                   - Metabolic
                                   - Infection
                                   - Tumours (soft tissues, bone)
                                   - Tumour like lesions
                                      (Bone cysts)

PRINCIPLES OF ORTHOPEDICS (2)   *Presentation
    Two Lectures                    - Pain
                                    - Swelling
                                    - Limp
                                    - Deformity
                                    - Loss of function ( ROM)
                                    - Instability
                                    - Locking
                                    - Clicking

PRINCIPLES OF ORTHOPEDICS (3)   *Investigations
     Two Lectures                    - Lab
                                        a. Blood
                                        b. Urine
                                        c. Joint aspiration
                                    - RADIOLOGICAL
                                        1. X-ray (Tutorial)
                                        2. Arthrograms. Sinogram
                                        3. CT
                                        4. MRI
                                        5. Bone scan
                                        6. U/S
                                    - EMG and NC
                                         Importance?
                                         How?
                                         When?
                                     - Biopsies
                                         Types
                                         Indications
                                     - Arthroscopy as diagnostic tool
                                     - Others – tuberculin test
PRINCIPLES OF ORTHOPEDICS (4)   *Treatment
     Two Lectures               +Conservative treatment
                                    - Pain control (Medication)
                                    - Orthotics (Tutorial)
                                    - Physiotherapy(Tutorial)
                                    - Cast
                                    - Traction
                                +Operative treatment
                                    - Pain control
                                            ORIF
                                            Drainage
                                            Arthrodesis
                                            Decompression etc
                                    - Bone and joint saving
                                          ( drainage, tumor excision )
                                    - Early restoration of normal
                                      function
                                    - Reconstruction
                                          ( ACL, joint replacement )
                                    - Restoration of shape and
                                       mechanical axis (osteotomies)

MECHANICAL DISORDES             *Anatomical and physiological
OF THE SPINE                     overview
 Two Lectures                    *Differential diagnosis of LBP
  (Tutorial)                     (Spondylolysis-Spondylolithesis)
                                *PID
                                    - Etiology
                                    - Pathological anatomy
                                    - Clinical picture
                                    - Investigations
                                       (imaging techniques)
                                    - Treatment
                                            =Prevention
                                            =Non operative
                                            =Surgical – Indications

SPINAL INJURIES                 *Definitions
Two Lectures                       - Stable – unstable
                                   - Neurological status
                                   - Mechanism of injuries

                                *Pathological anatomy
                                *Causes of spinal injuries
                    *Management
                       - First aid
                       - Transfer of the patient
                       - Clinical examination
                       - Neurological assessment
                       - Radiological assessment
                       - Initial treatment
                       - Definitive treatment
                       - Post treatment care
                       - Complications
                       - Outcome

PYOGENIC BONE AND   *Classification
JOINT INFECTION          - Duration
Two Lectures                Acute, subacute, chronic
 (Tutorial)              - Route of infection
                           Hematogenous or exogenous
                         - Host respsonse
                            Pyogenic or granulomatous

                    *Acute osteomyelitis
                         - Incidence & organism
                         - Source of Infection
                         - Pathogenesis
                         - Clinical picture
                         - Investigation
                         - Differential diagnosis
                         - Treatment
                         - Prognosis & complications
                    *Subacute osteomyelitis
                         - Definition and characteristics
                         - Radiological types
                         - Treatment
                     *Chronic Osteomyelitis
                         - Causes of chronicity
                         - Types
                         - Clinical picture
                         - Investigation
                         - Treatment & complications
                     *Acute septic arthritis
                         - Organism& route of infection
                         - Pathology & clinical picture
                         - Differential diagnosis
                         - Treatment
CHRONIC SPECIFIC BONE   *TB & Brucellosis
AND JOINT INFECTIONS       - Etiology
 Two Lectures               - Pathogenesis
  Tutorial                  - Clinical pictures
                            - Investigations
                            - Treatment
                            - Complications

CDH                     *Definition
 Two Lectures           *Spectrum of the disorder
                        *Etiology & risk factors
                        *Natural history
                        *Diagnosis
                        *Treatment
                             - Non-surgical & surgical
                             - According to age
                        *Prognosis & complications

CTEV                    *Definition
 Two Lectures           *Types of clubfoot (TEV)
                            - Congenital
                            - Postural
                            - Secondary
                        Congenital Clubfoot
                        *Predisposing factors
                        *Clinical pictures
                            - Description of deformity
                            - Muscle wasting
                            - Correction
                            - Secondary changes
                            - Back examination
                            - Associated anomalies
                        *Treatment
                            - Non-surgical & surgical
                            - According to age
                        *Residual deformity
                        *Recurrence
OSTEOARTHROSIS (O.A.)      *Types
 Two Lectures                  - Primary & secondary
                               - Monarticular & polyarticular
                           *Etiology & predisposing factors
                           *Pathogenesis
                           *Clinical features
                           *Investigations
                           *Differential Diagnosis
                           *Treatment
                                - Conservative
                                - Surgical

METABOLIC BONE DISORDERS   *Introduction
    Two Lectures                - Ca & phosphorus metabolism
     Tutorial                   - Nomenclatures
                           *Rickets & osteomalacia
                                - Definition
                                - Clinical picture
                                - Laboratory Findings
                                - X-ray pictures
                                - Treatment
                           *Hyperparathyroidism
                                - Definition
                                - Clinical picture
                                - Laboratory Findings
                                - X-ray pictures
                                - Treatment
                            *Osteoporosis
                                - Definition
                                - Types
                                  (Idiopathic & secondary)
                                - Clinical picture
                                - Laboratory Findings
                                - X-ray pictures
                                - Prevention
                                - Treatment
BONE TUMOR                 *General radiological features
 Two Lectures              *Classification
  Tutorial                 *Benign tumors and tumor
                             like conditions
                                - Simple bone cyst
                                - ABC
                                - Osteoid osteoma
                                - Osteochondroma
                                - Enchondroma
                                - Fibrous cortical defect
                            *Malignant Tumors
                                - Giant cell tumor
                                - Osteosarcoma
                                - Ewings sarcoma
                                - Bone metastasis
                                - Multiple myeloma

NEUROMUSCULAR CONDITIONS   *Cerebral Palsy (60 min)
   Two Lectures                - Definition
                               - Incidence
                               - Causes
                               - Risk babies
                               - Topographic Classification
                               - Physiological Classification
                               - Deformities in CP
                               - Management (aim-methods)
                               - Surgical treatment
                                  (Goal-Criteria-Options)
                            *Spina bifida (30 min)
                               - Definition
                               - Incidence
                               - Classification
                               - Deformities
                               - Treatment
                                      General principles
                                      Goal and options
                             *Poliomyelitis (20 min)
                               - Definition
                               - Brief general idea about
                                    =Pathophysiology
                                    =Power grading
                                    =Deformities
                                    =Management
EXAMINATION

The system we are going to use is:

*    Look       - Inspection
*    Feel       - Palpation
*    Move       - Movement
*    Do:
          1. Special tests: for location – when required
          2. Measurements – when required
          3. Functional tests – when required
     Always compare
     Stand beside the limb you want to examine

* Look -     Skin condition/sinuses/ulcers
       -     Position of limb
       -     Deformity
       -     Swelling
       -     Shortening
       -     Wasting

* Feel - Superficial - mainily for temperature
            * Skin
            * Soft tissue
            * Peripheral pulses
            * Bone
            * Cripitus (with movement)
            * Swelling
            * Severe tenderness

         -   Deep – tenderness please palpate, bony promenance, joint line,
             ligament, look for consistency, thickness of synovium, effusion.

* Move
     - Active movement – most upper limb examination is active.
     - Passive – most examination of lower limb is passive.
     - Abnormal - is the joint unstable?
                  - is there movement at an old fracture site?
     - Painful movement

* Range of movement need to be recorded by goniometer.
* Do
       -   Special tests – there are special tests for certain joints like the knee and
           hip you must do it to fulfill the examination according to the location.

       -   Measurement

               Shortening may be true or false
               Muscle power grading.
               Wasting

       -   Functional – walking, limping, tiptoe, walk on heel.

Special test for special disease

Only to check the disease e.g. Barlow sign for CDH.

Knee Examination

 Inspection – deformity, thigh and calf muscle wasting, swelling, shortening of
  lower limb, position of lower limb and popliteal fossa.
 Feel - knee in flexion
       - Bony land marks - P.F. joints
       - Joint line
 Movement – flexion, extension (active and passive)
 Special test
  - Stability of joint
     A.D. – Lachman test for ACL
     P.D. – for PCL
     Valgus stress – for MCL in 250 if positive repeat in extension
     Varus stresses for LCL in 250 if positive repeat in extension
  - Friction test – for retropatellar pain.
  - Apprehension test for patella dislocation or subluxation.
Meniscal Injury - McMurray – for meniscus from full flexion to full extension
 For effusion - bulge test for minimal fluid
                - Fluctuation test for huge fluid.
                - Patella tapping for moderate.

Shoulder Examination

 Inspection – from front, behind, side, superior, axilla, look for skin color,
  contour, swelling and deformity.

 Palpation from front and back – front st. clav. J., clavicle, A.C. joint, scapula
  G. tuberosity, post. joint.

 Movement – flexion, extension, abduction, adduction, rotation (external and
  internal) and circumduction.

Special test

 Apprehension test for recurrent dislocation, impingement test for rotating cuff
  tendenitis.

Hip Examination

 Inspection – skin, deformity, muscle wasting (quad. & gluteal), shortening. If
  shortening is present, true or apparent do squaring pelvis and measurement.

 Feel – hip is deep joint to palpate for tenderness, bony and soft tissue land
  marks.

 Movement – flexion, extension, abduction, adduction, rotation

 Gait – antalgic, trendelenburgh

 Special test - Thomas test for flexion deformity
               - Trendelenburgh test for abductor muscle function

 Length : do measurement – true/apparent.
Elbow Examination

 Inspection – deformity look for carrying angle, triangular relationship,
  swelling, muscle wasting.

 Feel – medial, lateral epicondyle and olecranon process
     - Ulnar nerve
     - Head of radius
     - Swelling and/or effusion

 Movement – flexion, extension, supination and pronation (elbow in flexion and
  shoulder in adduction) position.

 Special test for disease – tennis elbow, golf elbow.

Back Examination

 Standing position

   -   Inspection    From back – for scoliosis, tilting, muscle spasm
                     From side – for lordosis, kyphosis

   -   Feel – for tenderness, muscle spasm and kypous

   -   Movement – flexion, extension, lateral flexion, rotation (also rotation in
       standing)

   -   Gait

   - Walking on tiptoes, walking on heel

 On Bed – patient prone

   Feel for tenderness

   Patient supine: For neurological examination
      Do     - S.L.R./Lasaghe
             - Test for power
             - Dermatomes test for sensation
             - Knee + ankle jerks

   Know the level of the root
Ankle

 Inspection – skin, callosities, deformity, swelling

 Palpation – bony land marks, subtalar, soft tissue

 Movement – dorsoflexion, plantar flexion, eversion, inversion

 Special test – stability
  For lateral and medial ligament

 Thomson signs for torn achillis tendon.
References

   1.    Fractures and dislocations by Badr and Shaheen

   2.    Appley’s system of Orthopaedics

   3.    Orthopaedic Examination by McRae

								
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