{ORTHOPAEDICS 101

Courtesy of Centenary College & Skylands Orthopaedics

Automobile owners manual Musculoskeletal

Neurovascular

Metabolic

Most pathology is caused by acute trauma (think MVA) or chronic overuse/repetitive trauma (think mileage)

Body Shop (OR) will fix most acute trauma

Mechanics will fix most chronic pathology

The exception to keep in mind in car vs our body is, most cosmetic car damage will still allow the car to function however due to pain and inhibition our function will be dramatically altered.

Relation of Orthopaedics to Biomechanics & Function

Internal Medicine Infectious Disease Primary Care Podiatry Ob/Gyn Plastics Emergency Room Oncologist Pediatrics Etc…There is a long list, and many Doctors will

specialize even further (Pediatric Orthopaedic for example)

Compared to Other forms of Medicine

This is where the typical Orthopaedic MD spends their day

Appointments - New patients, follow-ups, reductions, certain injection procedures, wound care, evaluation/examination, diagnosis, referrals, IMEs…the list goes on…

Main objective is to develop a plan to “fix” the patient.

Rx

Sx

PT

Then follow it through.

Most patients are seen every 2-5 weeks however this varies greatly!

The Exam Room

A thorough understanding of anatomy is necessary.

Knowing what structures lie in, under and around the vicinity of symptoms is the first step to identifying the underlying cause of dis-comfort (dis-ease).

The Following is a very brief section for anatomical familiarization.

ANATOMY: The Key to Orthopaedic Medicine

Anatomical Reference Points

AnteriorPosterior

Superior Inferior

Medial Lateral

DorsalPalmer/Plantar

ProximalDistal

CranialCaudal

Coronal Plane

Sagittal Plane

Transverse Plane

Osteology

C/T/L

12 ribs5 floating

8 carpal bones –2 rows

7 Tarsal bones

LigamentsCartilageBursaeRetinaculi

Articular Surfaces

Intent of Design

Myology

MMT

Neurology

Myotomes – DTR’s

Biceps – C5Brachioradialis – C6Triceps – C7Patellar – L4Achillies – S1

MMT

Dermatomes

Angiology

Pulse strength –occlusion.

Capillary Refill

Location & Identification of vessels vital to surgery.

Blood Work can identify if a problem which presents as orthopaedic is in fact metabolic (pathway disturbances)

Exam RoomOrthopaedics in Action

A “brief” synopsis of some of the more common ailments seen at SkylandsOrthopaedics. Upper Extremity

Low Back & Hip

Lower Extremity

The Doctors work as detectives to pinpoint the cause. History

Observation

Palpation

Evaluation

Shoulder ROM – Active ROM – Passive ROM ABD – Deltoid, Supraspinatus - 150°

ADD – Lat. Dor., Pec. Maj., Teres Maj.

FLX – Biceps (LH) Ant. Delt - 180°

EXT – Post. Deltiod, Triceps – 45-60°

EXT ROT – Infraspinatus – Apley’s Scratch ≈90°

INT ROT – Subscap, Teres Maj., Deltoid, Pec. Maj. - Apley’s≈70-90°

Shoulder Luxations - AC joint is separated, GH is Dislocated Older population less likely to have a 2nd/Chronic Dislocations

of GH joint but have a higher chance of decreased ROM b/c soft tissue scars down easier

Shoulder Pathology

Shoulder - GH joint

O’Brien Test

GH joint is flexed to 90° & horizontally adducted 15° from the sagittal plane. Humerus in full internal rotation and forearm pronated.

Examiner applies downward force. Patient is to resist this force.

Pain experienced while arm is internally rotated but pain decreases with external rotation/supination.

SLAP lesion

The inability to lower the arm in a controlled manner.

Humerus fully abducted and extrotated/forearm supinated

Falls uncontrollably from approx 90°

Indicative of lesions to the rotator cuff, especially supraspinatus.

Drop Arm

SLAC wrist: (scaphoid – lunate advanced collapse) Capitate collapses through lunate/scaphoid.

FOOSH mechanism – extreme hyperextension of wrist.

Wrist & Hand

Sawed through 15% of distal phalanx of 1st digit.

Stable fracture

Sutured & Monitored for infection.

Distal Phalanx & Band Saw

May be congenital.

Middle & Ring fingers most common.

Nodule forms in tendon sheath.

Flexor Tendon.

C/O:

Finger hurts when flexing hand.

Hears popping

Operative Release common.

Trigger Finger

DeQuervain’s Syndrome

Finklestein’s Test

Tendonopathy

Extensor Pollicis Brevis

Adductor PollicisLongus

Tinnel’s sign

Median n. compressed in the carpal tunnel.

Paresthesia over sensory distribution of median n. (palmer surface of first, 2nd, 3rd & ½ of 4th)

Sx release of transverse carpal ligament.

Carpal Tunnel Syndrome

Arthritis – head of femur/acetabulum –Joint space Arthroplasty

GT Bursitis Snapping hip syndrome Test hip ROM Low back pain typically muscular Can be referred from neurological mechanical pressure – down leg or buttock

Low Back & Hip

Arthritis – head of femur/acetabulum –Joint space Arthroplasty

GT Bursitis Snapping hip syndrome Test hip ROM Low back pain typically muscular Can be referred from neurological mechanical pressure – down leg or buttock

Low Back & Hip

Spinal Stenosis

Spondylolysis – Spondylolisthesis

Disc herniation

Disc Pathology

Spinal Stenosis

The Knee

Knee in MRI – Sagittal View

Meniscus Bucket Handle Tear

Traumatic impact

Loss of cartilage over Medial Femoral condyle

Point Tenderness mimics medial meniscus tear

Arthritis develops from exposed bone.

Bony Contusion of Knee

PF Osteochondritis

Gracillus

Sartorius

Semitendinosus

Femoral n.

Obterator n.

Tibial n.

Pes Anserine Bursitis

Foot, Ankle & Lower Leg

Fractures typically take 6-8 weeks to heal.

Sx depends on severity of the fracture.

Some fractures need to be reduced and fixed.

Fractures, Casts/Splints/ORIF/EF

Injection Procedures

Supartz/Synvisc One Injection

Alleviates osteoarthritic knee pain

Sodium Hyaluronate solution (Hyaluronic Acid)

Mimics synovial fluid

Like changing oil

Lubricates & cushions the knee joint

Allows for more fluid motion and reduces bone on bone pounding/contact

Supartz: Over the course of 5 injections patients are symptom free

Synvisc one: One inj for 6 months pain relief.

Supartz/Synvisc One

2-2-2, 1-1-1

Bupivacaine – HCl 0.5% 5 mg/mL

Lidocaine – HCl – 2% 20 mg/mL

Kenalog 40 – 400 mg/mL

Acute gouty arthritis

Acute and subacute bursitis

Acute nonspecific tenosynovitis

Epicondylitis

Rheumatoid arthritis

Synovitis

Osteoarthritis

Has diagnostic ability as well Hypertrophic Synovitis vs Internal derrangement

Steriod Flare – Hurts tremendously then feels better than others who dont get the flare!

Steroid Shot

Surgical Procedures

ACL Reconstruction

ACL Reconstruction

ACL Reconstruction

Mucous Cyst/Bone Spur-”Ectomy”

SupraspinatusTear

Full thickness tear involving anterior aspect of supra c mild retraction.

Mild tendopathy in infraspinatus.

SupraspinatusTear

Pull retracted m. back to insertion if new injury (arthroscopic or small incision)

Marginal convergence for supraspinatus

Arthoplasty – reverse shoulder.

Full thickness RC tear surgery options

Total Medial Knee Repair

MCL

MPFL

Med Ret

Jt. Capsule

Partial Chondroplasty

ACL extensive debridement

Meniscus loose body removal

Manipulation under anethesia

Cartilage formed 3 weeks since injury.

Cut down to where tissue is undamaged to use as anatomical land marking

Patella did not scar down

Patellar’smedial structures repaired first:

MPFLJt. CapsuleRetinaculum

Then

MCL anchored to femur –pulled up b/c intact distally on tibia

OsteoRaptor2.9mm doubleloadedpunch/pound in anchor

Tie sutures down

Now that the medial sturctures are fixed knee is flexed & scoped

Debrided intercondylarnotch, interarticularsurfaces, ACL & PCL

THANK YOU!