Introduction to the Orthopaedic 452 course Dr. Waleed Awwad. MBBS, FRCSC Assistant professor of Orthopaedic surgery Spine and scoliosis surgeon

Goal Competent student Attitude skill knowledge

Knowledge Competency in the knowledge Domain Diagnose & initially manage of the urgent Orthopaedic conditions Clinical presentation, investigation, management & complications of the common and community related orthopedic conditions

Competency in skill domain History taking Physical exam Procedural skills Reduction Splinting & casting Knee aspiration Competency in skill domain

Competency in Attitude domain Communicator Personal behavior professional Competency in Attitude domain

Goals By end of his course, students will have demonstrated the ability to:  Demonstrate essential knowledge required to diagnose, initially manage and to know when to immediately refer a patient with a condition that requires urgent specialist management. Demonstrate knowledge to specify the symptoms, signs and immediate complications; to outline the assessment and appropriate investigation and; to outline the immediate and long term management of patients with common and community related orthopedic conditions and musculoskeletal trauma. To take a relevant and a focused MSK history in the knowledge of the characteristics of the major conditions of: bone; joints; connective tissue; nerve tissue and; muscle tissue. To perform a focused physical examination of major joints (shoulder, hip, knee, foot and ankle, PN and spine) To order and to demonstrate an appropriate use and interpretation of appropriate investigations including: radiography, CT/MRI/bone scan, MSK U/S, serology, synovial fluid analysis, and EMG/NCS. The ability to perform a common non-surgical orthopaedic procedures like joint aspirations and ability to apply and remove a cast.

Orthopaedic Core Competencies EMERGENCIES / RED FLAGS FRACTURES / TRAUMA PEDIATRIC ORTHOPAEDIC CONDITIONS NON-TRAUMATIC ORTHOPAEDIC CONDITIONS CLINICAL ASSESSMENT & DIAGNOSIS SKILLS

Emergencies / Red flags Open Fractures Fractures with nerve or vascular compromise Compartment Syndrome Cauda Equina Syndrome Bone, Joint and Soft Tissue Infection Multiple Trauma (Pelvic Fracture) Acute Joint Dislocations

Fractures & trauma Common Adult & pediatric Fractures Upper Limbs Lower Limbs Pelvic     Acute Spine Injuries  Peripheral Nerve Injuries Soft tissue injuries   Joint dislocation

Pediatric orthopaedic Common Hip Conditions Common Lower Extremities Condition Alignment / Rotational conditions Gait Problems Lower extremities deformities

Non-Traumatic orthopaedic conditions Spine Tumors Metabolic Joints condition

Spine Degenerative/Mechanical neck/back pain Spinal cord or root entrapment (for example, herniated lumbar disc) Vertebral fracture of osteoporotic origin Spinal deformity (scoliosis) Destructive (infectious and tumor related) back pain (for example, tuberculosis, metastasis, certain cancers)

Bone tumors Metastatic bone disease Primary bone lesions Benign bone tumors Malignant bone tumors

Metabolic bone disorders Osteoporosis Osteomalacia and Rickets

Joint conditions Degenerative OA Shoulder Chronic Condition

Clinical Assessment & diagnosis skills History taking Physical Examination Investigation interpretation Communication and attitude skills Procedural Skill Knee joint aspirations. Apply and remove a cast Joint/fracture reduction techniques

Teaching and learning methods and places Lecture (Large group): Case-based learning –CBL- (Small groups): Topics will be assigned in a head of time to the students with clear objectives. “Hands-on” small groups sessions: Physical examination skills Splinting and casting technique skills Principles of fractures & joints dislocation reduction. Joint aspirations. Ambulatory care teaching History taking skills Each student will have a chance of take, present, and discuss patient history with the attending staff tow times during the course. Plaster room Each student will have chance to observe, apply and remove the cast/splint during the course for at least tow times.

Learning Resources Books Tutorials / Lectures CBL Handouts

Assessment Continues assessment (20%) OSCE (40%) Written (40%) History taking at OPD CBL Hands-on skills sessions attendance OSCE (40%) History taking Physical examination Communication skills Written (40%)

Ambulatory care learning/Assessment Students will learn and will be assessed for how : To take and present a relevant and a focused MSK history in the knowledge of the characteristics of the major conditions of: bone; joints; connective tissue; nerve tissue and; muscle tissue. To perform a focused physical examination of major joints (shoulder, hip, knee, foot and ankle, PN and spine) To show an appropriate communication skills & Attitude toward and patient.

Ambulatory care learning/Assessment Each student will have chance at least 2 times during the 4 weeks course to do full clinical assessment of real patient in the Orthopaedic outpatient clinic. Student will be assessed for skills in obtaing and presenting a full history and clinical examination. 5% of total mark

Skills sessions Cast application and removal Principles of reduction and immobilization. Knee aspiration 5% of total mark

Case-based learning Six different cases covered most common MSK problems which can be presented to the ER or orthopaedic/primary clinic. Cases will be assigned a head of time to the students with clear objectives. 5% of total mark

Attendance 5% of total mark

ORTHOEADIC HISTORY TAKING

History taking skills History taking is the most important step in making a diagnosis A clinician is 60% closer to making a diagnosis with a thorough history. The remaining 40% is a combination of examination findings and investigations History taking can either be of a traumatic or non-traumatic injury    

Objective At the end of this session, students should be able and know how to take a MSK relevant history

Competency expected from the students Take a relevant history, with the knowledge of the characteristics of the major musculoskeletal conditions

STRUCTURE OF HISTORY Demographic features Chief complaint History of presenting illness MOI Functional level MSK systemic review Systemic enquiry PMH PSH Drug Hx Occupational Hx Allergy Family Hx Social Hx

MSK systemic review Pain Stiffness Swelling Instability Deformity Limp Altered Sensation Loss of function Weakness

Pain Location Point to where it is Radiation Does the pain go anywhere else Type (nature) Burning, sharp, dull How long have you had the pain How did it start (on set) Injury Mechanism of injury How was it treated? Insidious

Pain Progression Is it getting worse or is it remaining stable Is it better, worse or the same When Mechanical / Walking Rest Night nocte Constant Aggravating & Relieving Factors Stairs Start up, mechanical Pain with twisting & turning Up & down hills Kneeling Squatting

Pain Where: location/radiation When: onset/duration Quality: what it feels like Quantity: intensity, degree of disability Aggravating and Alleviating factors Associated symptoms WWQQAA

Swelling Duration Local vs generalised Onset Constant or comes and goes Progression: same size or↑ Aggravated and relived factors Associated with injury or reactive Soft tissue, joint, bone Rapidly or slowly Painful or not

Instability Onset How dose it start? Any Hx of trauma? Frequency Trigger/aggravated factors True = Giving way Buckling 2dary to pain I can not trust my leg! Associated symptoms Swelling Pain

Deformity When did you notice it? Progressive or not? Associated with symptoms like pain & stiffness Impaired function or not? Past Hx of trauma or surgery PMHx (neuromuscular,,etc)

Limping Painful vs painless Onset (acute or chronic) Progressive or not? Use walking aid? Functional disability? Traumatic or non traumatic? Associated with swelling, deformity, or fever.

Loss of function How has this affected your life Home (daily living activities DLA) Prayer Using toilet getting out of chairs / bed socks stairs squat or kneel for gardening walking distance get & out of cars Work Sport Type & intensity Run, jump

Mechanical symptoms Locking / clicking Loose body, meniscal tear Locking vs pseudo-locking Giving way Buckling 2° pain ACL Patella

Red flags Weight loss, loss of appetite, night sweat Fever Loss of sensation Loss of motor function Sudden difficulties with urination or defecation

Risk factors Age Gender Obesity Lack of physical activity Inadequate dietary calcium and vitamin D Smoking Occupation and Sport, Family History (SCA) Infections, Medication (steroid) Alcohol PHx Musculoskeletal injury/condition, PHx Cancer

Current and previous history of treatment Nonoperative Medications Analgesia How much How long Physio Orthotics Walking sticks Splints Operative What, where and when? Perioperative complications

Knee Pain Location Type How long have you had the pain point to where it is radiation does the pain go anywhere else Type Burning, sharp, dull How long have you had the pain How did it start Injury Mechanism of injury Position of leg at time of injury Direct / indirect Audible POP Could you play on or did you leave the field? ACL Did it swell at the time Immediately Haemathrosis Delayed Traumatic synovitis How was it treated? Insidious Progression Is it getting worse or is it remaining stable Is it better, worse or the same When Mechanical / Walking Rest Nocte constant Aggravating & Relieving Factors stairs start up, mechanical pain with twisting & turning up & down hills kneeling squatting

Spine Pain radiation exact location L4 L5 S1 Aggravating and relieving factors Neuropathic ­ extension & walking downhill walking uphill & sitting vascular ­ walking uphill generates more work rest standing is better than sitting due to pressure gradient stairs shopping trolleys ­coughing, straining sitting forward flexion

Spine Associated symptoms Red Flags Paresthesia Numbness Weakness Bowel, Bladder Cervical myelopathy Clumbsiness of hand Unsteadiness Manual dexterity Red Flags Loss of weight Constitutional symptoms Fevers, sweats Night pain, rest pain History of trauma immunosuppresion

Shoulder Age of the patient Mechanism of injury Younger patients - shoulder instability and acromioclavicular joint injuries are more prevalent Older patients - rotator cuff injuries and degenerative joint problems are more common Mechanism of injury Abduction and external rotation - dislocation of the shoulder Direct fall onto the shoulder - acromioclavicular joint injuries Chronic pain upon overhead activity or at night time - rotator cuff problem.

Shoulder Pain anterolateral & superior deltoid insertion Where Rotator Cuff anterolateral & superior deltoid insertion Bicipital tendonitis Referred to elbow Aggravating / Relieving factors Position that ↑ symptoms RC: Window cleaning position Instability: when arm is overhead Neck pain Is shoulder pain related to neck pain ask about radiculopathy

Shoulder Causes AC joint Cervical Spine Glenohumeral joint & rotator cuff Front & outer aspect of joint Radiates to middle of arm Rotator cuff impingement Positional : appears in the window cleaning position Instability Comes on suddenly when the arm is held high overhead Referred pain Mediastinal disorders, cardiac ischaemia

Shoulder Loss of function Home Dressing Coat Bra Grooming Toilet Associated Stiffness Instability / Gives way Severe – feeling of joint dislocating Usually more subtle presenting with clicks/jerks What position Initial trauma How often Ligamentous laxity Clicking, Catching / grinding If so, what position Weakness Rotator cuff especially if large tear Pins & needles, numbness Loss of function Home Dressing Coat Bra Grooming Toilet Brushing hair Lift objects Difficulty working with arm above shoulder height Top shelves Hanging washing Work Sport