Undergraduate Orthopaedics Revisited

8/6/2019 Undergraduate Orthopaedics Revisited

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UNDERGRADUATEUNDERGRADUATE

ORTHOPAEDICS REVISITEDORTHOPAEDICS REVISITED

DR WAN HAZMY CHE HONDR WAN HAZMY CHE HON MD(Ghent, Belgium), MS.Ortho(UKM), AM(Mal), MD(Ghent, Belgium), MS.Ortho(UKM), AM(Mal),

FAOI Trauma (Germany), FAOI Trauma (Germany),

FAOA Arthroscopy, Arthroplasty & Sports Surgery (Australia) FAOA Arthroscopy, Arthroplasty & Sports Surgery (Australia)

CONSULTANT ORTHOPAEDIC, TRAUMA & SPORTS SURGEON,CONSULTANT ORTHOPAEDIC, TRAUMA & SPORTS SURGEON,SEREMBAN SPECIALIST HOSPITALSEREMBAN SPECIALIST HOSPITAL



AIMS OF ORTHO EXAMAIMS OF ORTHO EXAM

Ability to identify problems/pathologyAbility to identify problems/pathology

Basic knowledge of the pathologyBasic knowledge of the pathology

Safe and practical managementSafe and practical management



IDENTIFYIDENTIFY

PROBLEMS/PATHOLOGYPROBLEMS/PATHOLOGY

Skill in history taking (salient points)Skill in history taking (salient points)

Skill in physical examinationSkill in physical examination

Interpretation of XInterpretation of X--rays/lab resultsrays/lab results

³showmanship´ ~ ³routine training/practice´³showmanship´ ~ ³routine training/practice´



BASIC KNOWLEDGE OF THEBASIC KNOWLEDGE OF THE

PATHOLOGYPATHOLOGY Mechanism of injuriesMechanism of injuries

-- direct/indirectdirect/indirect

Biomechanics of Biomechanics of

fracturesfractures

Common classificationCommon classification



SAFE&PRACTICALSAFE&PRACTICAL

MANAGEMENTMANAGEMENT

Identify orthopaedic emergenciesIdentify orthopaedic emergencies

Acute treatmentAcute treatment

Know limitation of management (when toKnow limitation of management (when to

refer)refer)



CASE 1CASE 1

8/12 child8/12 child

Mother c/o child always looking at one sideMother c/o child always looking at one side



QUESTIONSQUESTIONS

Congenital versus Secondary torticollisCongenital versus Secondary torticollis

What investigations will you request?What investigations will you request?

How do you manage torticollis?How do you manage torticollis?



CASE 2CASE 2

24/Male24/Male

MVAMVA

Pain left upper chestPain left upper chest



QUESTIONSQUESTIONS

What are the complications associated withWhat are the complications associated with

this fracture?this fracture?

How do you manage this fracture.How do you manage this fracture.



CASE 3CASE 3

19/male19/male

Rugby player Rugby player

Fell down following a tackleFell down following a tackle Pain right shoulder Pain right shoulder



QUESTIONSQUESTIONS

Type of dislocationsType of dislocations

How do you reduce the dislocationHow do you reduce the dislocation

(techniques)(techniques) Complications of shoulder dislocations (earlyComplications of shoulder dislocations (early--

late)late)

BankartBankart ± ± HillHill--Sach lesionsSach lesions



CASE 4CASE 4

45/female45/female

fell down at homefell down at home

Deformity right elbowDeformity right elbow



QUESTIONSQUESTIONS

Anterior or posterior?Anterior or posterior?

How do you manage?How do you manage?

What structure/s at risk?What structure/s at risk?



CASE 5CASE 5

55/female55/female

Fell down from bicycleFell down from bicycle

Pain left wristPain left wrist



QUESTIONSQUESTIONS

Colles #Colles # -- Smith¶s#Smith¶s# -- Barton¶s#Barton¶s#

How do you reduce & immobilise Colles #?How do you reduce & immobilise Colles #?

ComplicationsComplications XX--ray acceptable? (palmar flexionray acceptable? (palmar flexion--radialradial

heightheight--radioulna angle)radioulna angle)



CASE 6CASE 6

8/boy8/boy

Fell down at schoolFell down at school

Pain right forearmPain right forearm



QUESTIONSQUESTIONS

Why greenstick?Why greenstick?

Can you accept angulation in children?Can you accept angulation in children?

What is remodelling?What is remodelling?



CASE 7CASE 7

22/female22/female

Slipped & fell on the right hand duringSlipped & fell on the right hand during

gymnastic exercisesgymnastic exercises Pain right forearmPain right forearm



QUESTIONSQUESTIONS

Describe Galeazzi #Describe Galeazzi # -- Monteggia #Monteggia #



CASE 8CASE 8

9/boy9/boy

Fell from bicycleFell from bicycle

Pain and unable to move the left elbowPain and unable to move the left elbow Absent ipsiAbsent ipsi--lateral radial pulselateral radial pulse



QuestionsQuestions

What are the possible injuries?What are the possible injuries?

How do you confirm the injury?How do you confirm the injury?

How do you classify the injury?How do you classify the injury? What is your acute management?What is your acute management?



CASE 9CASE 9

24/male24/male

Seen at OPD with the following deformitySeen at OPD with the following deformity



QuestionsQuestions

What posture is it?What posture is it?

Which nerve lesion involved?Which nerve lesion involved?

High (FDL tim) or Low lesionHigh (FDL tim) or Low lesion--describedescribe Describe the motor & sensory distribution of Describe the motor & sensory distribution of

the nervethe nerve

Which branch arise in the arm?Which branch arise in the arm?



CASE 11CASE 11

30/female30/female

HousewifeHousewife

Numbness lateral 3 fingers especially during Numbness lateral 3 fingers especially duringcontinuous housework continuous housework

Occasional weakness of the thumbOccasional weakness of the thumb



Questions Questions

What is your diagnosis?What is your diagnosis?

What constitute the carpal tunnel?What constitute the carpal tunnel?

What is µcarpal tunnel syndrome¶?What is µcarpal tunnel syndrome¶? What are the possible causes of CTS?What are the possible causes of CTS?

What is Tinel & Phalen signs?What is Tinel & Phalen signs?

How do you manage CTS?How do you manage CTS?



CASE 12CASE 12

25/male25/male

Previously active athletePreviously active athlete

c/o inability to elevate the left wrist & fingersc/o inability to elevate the left wrist & fingers



Questions Questions

How do you describe the pathology?How do you describe the pathology?

Which nerve involved?Which nerve involved?

Describe the anatomy of the nerveDescribe the anatomy of the nerve Causes of wrist drop?Causes of wrist drop?



CASE 13CASE 13

65/female65/female

Living in a nursing homeLiving in a nursing home

Community ambulator Community ambulator Slipped in the bathroomSlipped in the bathroom

c/o right hip painc/o right hip pain



CASE 14CASE 14

75/male75/male

Pensioner Pensioner

Community ambulator Community ambulator Slipped during gardeningSlipped during gardening

Right hip painRight hip pain



CASE 15CASE 15

26/male26/male

Car driver Car driver

HeadHead--on collision with a lorryon collision with a lorry Hypovolaemic shock Hypovolaemic shock

Clinically posterior dislocation right hipClinically posterior dislocation right hip



Questions Questions

How do you treat this patient?How do you treat this patient?

Describe the pathophysiology of hypovolaemicDescribe the pathophysiology of hypovolaemic

shock shock

3 most important X3 most important X--rays and why?rays and why?

Clinical presentation of posterior hipClinical presentation of posterior hip

dislocationdislocation

Complication of hip dislocationComplication of hip dislocation



CASE 16CASE 16

1/girl1/girl

Delayed walkingDelayed walking



Questions Questions

Decribe the XDecribe the X--ray findingsray findings

Important history/predisposing factorsImportant history/predisposing factors

Clinical presentations( currentClinical presentations( current--at birth)at birth) Associated deformitiesAssociated deformities

complicationscomplications



CASE 17CASE 17

38/female38/female

Progressive pain right hipProgressive pain right hip

Trendelenburg test positiveTrendelenburg test positive



Questions Questions

Describe the XDescribe the X--rayray

Pathophysiology /predisposing factorsPathophysiology /predisposing factors

Other investigations to help youOther investigations to help you What is Trendelenburg testWhat is Trendelenburg test

Diff.diagnosis of positive testDiff.diagnosis of positive test



CASE 18CASE 18

55/female55/female

District lawnDistrict lawn--ball player ball player

Progressive pain both knees (R)>(L)Progressive pain both knees (R)>(L) Partially relieved with NSAIDPartially relieved with NSAID



Questions Questions

XX--ray features of OA kneeray features of OA knee

Pathophysiology/classification of OAPathophysiology/classification of OA

Conservative optionsConservative options Surgical optionsSurgical options

Usage of walking stick Usage of walking stick



Case 19Case 19

22/male22/male

AFL player AFL player

Injury to the left knee following a rough tackleInjury to the left knee following a rough tackle Unable to continue the gameUnable to continue the game

Now presented with knee instability Now presented with knee instability



Questions Questions

Important historyImportant history

Causes of locked kneeCauses of locked knee

Knee examinationKnee examination Knee effusionKnee effusion

Anatomy of ACL,PCLAnatomy of ACL,PCL



CASE 20CASE 20

40/male40/male

MotorcyclistMotorcyclist

Front collision with a car Front collision with a car Deformity right kneeDeformity right knee



Questions Questions

Describe the XDescribe the X--rayray

Mechanism of injuriesMechanism of injuries

Associated injuriesAssociated injuries How do you treat this patientHow do you treat this patient



CASE 21CASE 21

24/male24/male

Injury to the left ankle during skiingInjury to the left ankle during skiing



QuestionsQuestions

Describe the deformityDescribe the deformity

Associated injuriesAssociated injuries

How do you treatHow do you treat ComplicationsComplications



CASE 22CASE 22

55/female55/female

Painful right big toePainful right big toe

Difficult with shoe wear Difficult with shoe wear



Questions Questions

Describe the deformityDescribe the deformity

Predisposing factorsPredisposing factors

Treatment

Treatment



CASE 23CASE 23

19/girl19/girl

Sudden severe backacheSudden severe backache

While lifting a box full with booksWhile lifting a box full with books Associated with shooting pain to the left legAssociated with shooting pain to the left leg



CASE 24CASE 24

23/ Man23/ Man

Fell into a drainFell into a drain

Presented with large wound over the right legPresented with large wound over the right legtogether with deformity.together with deformity.



AntibioticsAntibiotics

DebridementDebridement

StabilizationStabilization Delayed closureDelayed closure

RehabilitationRehabilitation



CASE 25CASE 25

40 /male40 /male

Left foot ran over by a car Left foot ran over by a car

XX--rays: no fracturerays: no fracture Noted progressive swelling and intractable Noted progressive swelling and intractable

pain within 2 hours after the accident pain within 2 hours after the accident



Questions Questions

What is compartment syndrome?What is compartment syndrome?

Pathophysiology of compartment syndromePathophysiology of compartment syndrome

T

reatmentT

reatment Complications of fracturesComplications of fractures



CASE 26CASE 26

3 /boy3 /boy

Fan of AFLFan of AFL

Injury to the left knee during warming upInjury to the left knee during warming up



Questions Questions

Classification of epiphyseal injuriesClassification of epiphyseal injuries

ComplicationsComplications



Salter Salter--HarrisHarris

ClassificationClassification



IMPORTANT EXAMINATIONSIMPORTANT EXAMINATIONS

KNEE ( ACL, PCL, OA)KNEE ( ACL, PCL, OA)

HIP (AV N, OA)HIP (AV N, OA)

SPINE/BACK (PID)SPINE/BACK (PID)

SHOULDER (FROZEN SHOULDER)SHOULDER (FROZEN SHOULDER)

HAND (NEUROLOGY, RA, SCAPHOID )HAND (NEUROLOGY, RA, SCAPHOID )

MEASUREMENT TRUE & APPARENT LENGTHMEASUREMENT TRUE & APPARENT LENGTH



IMPORTANT ESSAYSIMPORTANT ESSAYS

Knee swelling in 10 year old childKnee swelling in 10 year old child

9/ child with a limp9/ child with a limp

23/ sportsman with knee instability23/ sportsman with knee instability

59/ woman with knee pain & swelling59/ woman with knee pain & swelling

30/ woman with acute low back pain30/ woman with acute low back pain



ADVICEADVICE



ADVICEADVICE

22

µ ..if somebody enters a garden, he will µ ..if somebody enters a garden, he will

find that his hands cannot reach all find that his hands cannot reach all

the fruit it contains, but the amount the fruit it contains, but the amount that f all within his grasp will be that f all within his grasp will be

enough for him. The garden does not enough for him. The garden does not

exist for him alone, it exists also for exist for him alone, it exists also for

those whose arms are longer than his¶ those whose arms are longer than his¶

(Bediuzzaman Said Nursi in The Supreme Sign )(Bediuzzaman Said Nursi in The Supreme Sign )

ADVICEADVICE



ADVICEADVICE

33 Have We not opened your breast for you?Have We not opened your breast for you?

And removed from you your burdenAnd removed from you your burden

Which weighed down your back Which weighed down your back

And have We not raised high your fame?And have We not raised high your fame?

Verily, along with every hardship is relief Verily, along with every hardship is relief Verily, along with every hardship is relief Verily, along with every hardship is relief

So when you have finished, devote yourself toSo when you have finished, devote yourself to

Allah¶s worshipAllah¶s worship

And to your Lord turn intentions and hopes.And to your Lord turn intentions and hopes.

(Al(Al--Quran 94:1Quran 94:1--8)8)



Thank you &Thank you &

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Undergraduate Orthopaedics Revisited

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