Introduction to Orthopedics

Prof. Mamoun Kremli

AlMaarefa College

Orthopaedics ?

Derived from GreekOrthos : “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

Basic Anatomy of Bone

Diaphysis

Metaphysis

Epiphysis

Epiphyseal plates

Basic Anatomy of Bone

Periosteum

Endosteum

Cortex

Medulla

Cortical bone

Cancellous bone

Basic Anatomy of Bone

Periosteum

Endosteum

Cortex

Medulla

Cortical bone

Cancellous bone

http://classes.midlandstech.edu/

Bone components

A: Matrix:

Organic: (40% of dry weight)Collagen fibersCells

Inorganic (Minerals): (60%)Ca hydroxyapetite, Ca phosphateOthers

B: Cells:Osteoblasts, osteoclasts, osteocytes, others

Bone cells

Osteoblasts

Osteoclasts

Osteocytes

Osteone:

a unit, not a cell

Descriptive terms

Valgus: away from midline

Varus: towards midline

Hallux: Big toe

Genu: Knee

Coxa: Hip

Cubitus: Elbow

Pes: Foot

Cubitus varus

History - Orthopedics

Chief complaintOnset, progression, management

PainSite , 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

History - Trauma

Date

Mechanism of injury

Loss of consciousness

Pain

Wound

Bleeding

Function

Progression of injury and management

Clinical examination

The examination begins from the moment we set eyes on the patient. Observe:General appearancePostureGait:

limping, in pain, using stick, …Deformities:

Knock-knees? Spinal curvature? short limb? paralysed arm?

Pain?…….The clues are endless

Principles of Assessment

Normal side first

Compare to other side/joint

Do not cause painWatch facial expressions

Extra careful with childrenProceed slowly, do no attack!

Orthopedic Examination

Which system to use?

LookFeelMoveSpecial tests

LOOK

What do we look at ?

What do we look for ?

Do we need a sub-system ?

Look

General on patient.

General local (shoulder, back, hip, thigh, ):PositionMajor deformity, swellingExtra: 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…

Look

General on patientPatient in pain, sitting on a chair holding the right

wrist and handLying comfortably in bed not in pain.Lying supine, in pain, holding Rt thigh in flexion.Patients is restless in bed

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Look

General on patient.

General local (shoulder, back, hip, thigh,. ):Position of jointMajor deformity, swellingExtra: cast, splint, traction, dressing …etc.

www.findherbalremedy.com/http://openi.nlm.nih.gov/

Look

Important Considerations:Amount of exposureDuration of exposurePersons present during exposurePlace of exposureAttitude and behavior during exposure

Feel

What do we feel for ?

Do we need a sub-system ?

Feel

Ask for pain or tenderness before you put your hand on patient!

Tenderness

Temperature

Anatomical

Feel

Tenderness:Generalized - Specific

Temperature:Compare distal / proximal, Rt / Lt

Anatomic:Skin: dryness, hyper/hypothesia, scarsSubcut.: LN, nerves, vessels, tendons, nodulesMuscle: tone, bulk, twitches, gaps, tendernessBone: landmarks, tenderness, mass, crepitusJoint: swelling, effusion, crepitation, synovial thickening,

joint line tenderness (if joint acessable)

Move

Active Vs. Passive

ActiveAlways to start with / not to cause painMore used in upper limbMust for assessment of muscle power

PassiveIf need to see difference from activeMore used in lower limbs

Range of movementRecorded 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 0–140o means range of flexion from zero (the knee absolutely straight)

through an arc of 140o

e.g, ‘knee flexion 20–90o means flexion begins at 20o (i.e. the joint cannot extend fully) and

continues only to 90o

Do NOT use the words: ‘full’, ‘good’, ‘limited’, ‘poor’

Special tests

Different for different jointse.g. Anterior Drawer Test for ACL tear in Kneee.g. Patellar tap for knee effusione.g. Thomas Test for fixed flexion deformity of Hip

Weight-bearing / gaitExamination of all weight-bearing joints is not

complete until weight-bearing is assessed!

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/

Structures affected

Bones

Joints

Muscles

Tendons

Nerves

Diseases

Diseases

Congenital

Diseases

Congenital

Diseases

Congenital

Developmental

Diseases

Congenital

Developmental

Infections / Inflammations

Diseases

Congenital

Developmental

Infections / Inflammations

Diseases

Congenital

Developmental

Infections / Inflammations

Metabolic

Diseases

Congenital

Developmental

Infections / Inflammations

Metabolic

Tumors / tumor-like

Congenital

Developmental

Infections / Inflammations

Metabolic

Tumors / tumor-like

Neuromuscular

Diseases

Congenital

Developmental

Infections / Inflammations

Metabolic

Tumors / tumor-like

Neuromuscular

Traumatic

Diseases

Investigations

Blood

Imaging

Special

Investigations – Blood Tests

CBC, differential WBC, ESR

C reactive protein

Biochemistry

Hormones

Vitamin D

Special

Investigations - Imaging

X-rays:Low of 2s

Two views: AP and LateralTwo joints: Above and BelowTwo sides: Right and LeftTwo occasionsTwo Doctors !

Special views:Obliques, Tunnel view, skyline, functional flexion /

extensionArthrography:

Shows intra-articular structuresFunctional in hip

Investigations - Imaging

Other imaging techniquesCT scan

Bone components and fragment relationsMRI (with / without contrast)

Soft tissueTumors

Bone scanFunctional: blood supply, infection

Investigations - Special

Culture / sensitivity

Manteaux test

Serology

Factors

Sickling

Genetic

Biopsy

Arthrocentesis (aspiration)

Arthroscopy

Summary

Orthopedic course is interesting, logic, makes sense, mechanics

HistoryRelate to functionDetailed mechanism of injury in trauma

Examination:Look, Feel, Move, Special

DiseasesAll types of disease and injury