1. Introduction to Orthopedics Prof. Mamoun Kremli AlMaarefa College

2. Orthopaedics ? Derived from Greek Orthos : “correct”, “straight” Paidon: “child” Nicholas Andry in 1741 coined the word “orthopaedics” in French as “Orthopedie” He published “Orthopedie” (translated as Orthopaedia: The art of correcting and preventing deformities in children

3. Basic Anatomy of Bone Diaphysis Metaphysis Epiphysis Epiphyseal plates

4. Basic Anatomy of Bone Periosteum Endosteum Cortex Medulla Cortical bone Cancellous bone

5. Basic Anatomy of Bone Periosteum Endosteum Cortex Medulla Cortical bone Cancellous bone http://classes.midlandstech.edu/

6. Bone components A: Matrix: Organic: (40% of dry weight) Collagen fibers Cells Inorganic (Minerals): (60%) Ca hydroxyapetite, Ca phosphate Others B: Cells: Osteoblasts, osteoclasts, osteocytes, others

7. Bone cells Osteoblasts Osteoclasts Osteocytes Osteone: a unit, not a cell

8. Descriptive terms Valgus: away from midline Varus: towards midline Hallux: Big toe Genu: Knee Coxa: Hip Cubitus: Elbow Pes: Foot Cubitus varus

9. History - Orthopedics Chief complaint Onset, progression, management Pain Site, type, severity, radiation, aggravating, relieving,.. Deformity Function affection: Relate to normal function of part, reach, use, … Associated conditions / other diseases Careful about history of mild trauma

10. History - Trauma Date Mechanism of injury Loss of consciousness Pain Wound Bleeding Function Progression of injury and management

11. Clinical examination The examination begins from the moment we set eyes on the patient. Observe: General appearance Posture Gait: limping, in pain, using stick, … Deformities: Knock-knees? Spinal curvature? short limb? paralysed arm? Pain? …….The clues are endless

12. Principles of Assessment Normal side first Compare to other side/joint Do not cause pain Watch facial expressions Extra careful with children Proceed slowly, do no attack!

13. Orthopedic Examination Which system to use? Look Feel Move Special tests

14. LOOK What do we look at ? What do we look for ? Do we need a sub-system ?

15. Look General  on patient. General  local (shoulder, back, hip, thigh, ): Position Major deformity, swelling Extra: cast, splint, traction, dressing … Anatomic local: Skin: swelling, scars, color, hair, dryness … Subcut.: LN, veins, nerves, tendons … Muscles: bulk, wasting, twitches … Bones: landmarks, swelling, angulation, deformity. Joints: position, swelling, redness…

16. Look General  on patient Patient in pain, sitting on a chair holding the right wrist and hand Lying comfortably in bed not in pain. Lying supine, in pain, holding Rt thigh in flexion. Patients is restless in bed www.dreamstime.com/ www.bethanynaz.org/

17. Look General  on patient. General  local (shoulder, back, hip, thigh,. ): Position of joint Major deformity, swelling Extra: cast, splint, traction, dressing …etc. www.findherbalremedy.com/ http://openi.nlm.nih.gov/

18. Look Important Considerations: Amount of exposure Duration of exposure Persons present during exposure Place of exposure Attitude and behavior during exposure

19. Feel What do we feel for ? Do we need a sub-system ?

20. Feel Ask for pain or tenderness before you put your hand on patient! Tenderness Temperature Anatomical

21. Feel Tenderness: Generalized - Specific Temperature: Compare distal / proximal, Rt / Lt Anatomic: Skin: dryness, hyper/hypothesia, scars Subcut.: LN, nerves, vessels, tendons, nodules Muscle: tone, bulk, twitches, gaps, tenderness Bone: landmarks, tenderness, mass, crepitus Joint: swelling, effusion, crepitation, synovial thickening, joint line tenderness (if joint acessable)

22. Move Active Vs. Passive Active Always to start with / not to cause pain More used in upper limb Must for assessment of muscle power Passive If need to see difference from active More used in lower limbs

23. Range of movement Recorded in degrees Range of motion: Starting from resting xx degrees to xx degrees where motion stops Zero is the neutral or anatomical position of the joint e.g, ‘knee flexion 0–140 o means range of flexion from zero (the knee absolutely straight) through an arc of 140 o e.g, ‘knee flexion 20–90 o means flexion begins at 20 o (i.e. the joint cannot extend fully) and continues only to 90 o Do NOT use the words: ‘full’, ‘good’, ‘limited’, ‘poor’

24. Special tests Different for different joints e.g. Anterior Drawer Test for ACL tear in Knee e.g. Patellar tap for knee effusion e.g. Thomas Test for fixed flexion deformity of Hip Weight-bearing / gait Examination of all weight-bearing joints is not complete until weight-bearing is assessed!

25. Motor power grading 0 = No power I = fasciculation of muscle fibers – no movement II = move with gravity eliminated III = move against gravity VI = less than full power V = full power - normal www.orthopaedicsone.com/

26. Structures affected Bones Joints Muscles Tendons Nerves

27. Diseases

28. Congenital

29. Diseases Congenital

30. Diseases Congenital Developmental

31. Diseases Congenital Developmental Infections / Inflammations

32. Diseases Congenital Developmental Infections / Inflammations

33. Diseases Congenital Developmental Infections / Inflammations Metabolic

34. Diseases Congenital Developmental Infections / Inflammations Metabolic Tumors / tumor-like

35. Congenital Developmental Infections / Inflammations Metabolic Tumors / tumor-like Neuromuscular Diseases

36. Congenital Developmental Infections / Inflammations Metabolic Tumors / tumor-like Neuromuscular Traumatic Diseases

37. Investigations Blood Imaging Special

38. Investigations – Blood Tests CBC, differential WBC, ESR C reactive protein Biochemistry Hormones Vitamin D Special

39. Investigations - Imaging X-rays: Low of 2s Two views: AP and Lateral Two joints: Above and Below Two sides: Right and Left Two occasions Two Doctors ! Special views: Obliques, Tunnel view, skyline, functional flexion / extension Arthrography: Shows intra-articular structures Functional in hip

40. Investigations - Imaging Other imaging techniques CT scan Bone components and fragment relations MRI (with / without contrast) Soft tissue Tumors Bone scan Functional: blood supply, infection

41. Investigations - Special Culture / sensitivity Manteaux test Serology Factors Sickling Genetic Biopsy Arthrocentesis (aspiration) Arthroscopy

42. Summary Orthopedic course is interesting, logic, makes sense, mechanics History Relate to function Detailed mechanism of injury in trauma Examination: Look, Feel, Move, Special Diseases All types of disease and injury