Orthopaedic Management

Made Easy

Department of Orthopaedics and Traumatology

TP Lam

Learning objectives

Brief review of history taking, P/E

Management

At-the-spot treatment

Workup

Definitive treatment

Acute treatment / short term plan

Long term plan

History: the basic skill you must master

Chief Complaint

Where is the problem ? beware of referral pain

Etiology

Physical

Social

mental

DDx 1 DDx 2 DDx 3 ...... DDx n

Onset

Site

Severity

Quality

factor

factor

Macro time

Micro time

Radiation

Associated factor

History

Complications

Physical

Pathological eg AVN, epiphyseal closure, osteoarthritis etc

Functional eg ambulatory status, activity tolerance, ADL

Complication due to treatment ie iatrogenic

Social - occupational, financial, marital, familial

mental – mood, self-esteem

Prognosticating factors and extent of disease

History

Patient’s background - Physical

MSK

Handedness

Pre-morbid ambulatory status

Daily activities requirement – job, hobbies,

sport, living environment

History

Patient’s background - Physical

MSK

Response to previous treatment

Patient’s expectation

History

Patient’s background - Physical

Medical

Past health

Medication

Previous operation

Allergy

Birth history

Developmental history

Immunization

History

Patient’s background - Physical

Medical

Menstrual

Obstetric history

Smoking, drinking,

Illegal drug

Traveling history

Familial disease

History

Patient’s background -

Psychosocial background

Marital

Family

Occupational

Living / environmental

Other social

Background(Response to previous treatment

Patient’s expectation)

etiology Main problem

Prognosticating factors

PhysicalsocialMental

PhysicalsocialMental

PhysicalsocialMental

PhysicalsocialMental

Complication(including iatrogenic)

PhysicalsocialMental

Physical examination

Introduce yourself, explanation,

hygienic measure

Mind-set for inspection, palpation, movement,

Standard Component

The examination matrix

Specific

Component

General

Component

General P/E

Posture

Gait

The examination matrix I

Skin Muscle Bone Joint Mass

Look Muscle bulk

Spasm

Mass

Mass

Length –

apparent, real

Deformity / instability

Deformity

EffusionSoft tissue swelling

Look for any mass,

swelling

site, size and shape

Feel Temperature Muscle spasm / tone

Compartment

Mass

Any mass

Contour

Tenderness

Tenderness

Effusion

Synovial thickening

Soreness

Structure

Surface

Skin, tissue plane

Move –

active

passive

ROM

Crepitation

Jerk, click

Percuss For fasciculation

For percussion tenderness

auscultate Crepitation Bruit

Color

Trophic change

Hair status

Skin texture

Ulcer

Hemangioma

Pigmentation

Scar

Sinus

Dilated vein

Swelling eg

rheumatoid nodule,

gouty tophi

bruising

The examination matrix II

Artery Vein Lymphatics Nerve

Motor

Nerve sensory

Look Color

Trophic change

Ulcer

Dilated vein

edema

Lymphedema Muscle wasting

fasciculation

Feel Temp

Pulse

Temp LN Muscle tone Test sensation

Move –

active

passive

Power

Clonus, Babinski

Percuss Reflex Tinel

auscultate bruit

Specific components

ShoulderElbowWristHand and fingerHipKneeAnkleNeckThoracic and lumbar spineSIJPeripheral nerves

Specific components

ShoulderElbowWristHand and fingerHipKneeAnkleNeckThoracic and lumbar spineSIJPeripheral nerves

Refer to “Orthopaedic

Assessment Made Easy” at

Teaching Web (Med 3)

3D-Matrix

Etiology Problem Complication BackgroundPrognosis /

extent of ds

History

P/E

Physical

Social

Mental

Tools Theme Domain

Tools

Domain

Theme

Etiology Problem Complication Background prognosis

History

P/E

Investigation

Conclusion

Treatment

3-D Mx MatrixPhysical

Social

Mental

Management

At-the-spot Mx

Short termLong term

At-the-spot - PPP

PPP:- Physical, Psychosocial, Plan

Physical:- depends on presenting symptoms and location

(AED or OPD)

6 A

Vital signs:- the “ABC”

AB:- Airway, Breathing,

Circulation:- bleeding, then stop the bleeding!

Distal circulation, compartmental syndrome

Iv fluid or blood replacement

Vital sign monitoring

Analgesic - pain reliefOral, im or iv analgesic

For fracture:- immobilization is the best pain-killer

Anti-sepsis:-Wound:- temporary cleansing and dressing

“Anchorage”:- temporary splintage

Splint, slab, Thomas splint, neck collar, bed rest

Anti-swelling:- RICE

?Anaesthesia:- may need to fast patient

At-the-spot - PPP

Psycho-social Be empathetic

Explanation to patient/relativeDDx

Further investigation

Probable plan of treatment

Plan ?admit or

referral OPD (early FU or routine FU) or

?discharge

At-the-spot - PPP

Another ways to remind yourself…

Skin: wound care and Anti-sepsis

Muscle: Acute compartmental syndrome

Bone and joint: preliminary reduction and immobilization (Anchorage)

Artery: stop bleeding and ABC

Vein and Lymphatic: Anti-swelling and RICE

Nerve: Analgesic for pain and work up for Anesthesia

Work-up

Blood

Excreta / body fluid

Imaging

Arthroscopy

Biopsy

Electrophysiology / Functional Study

Workup

Blood CBP ESR, CRP Clotting profile Blood for culture Cross-match Na, K, urea, Cr Liver enzymes, alkaline phosphatase Ca, phosphate ANF, RF, urate Others

Glucose, blood gas,

Workup

Body fluid, excreta

Synovial fluid

Cell count:- WBC

Glucose

Culture and gram stain, AFB

Microscopy for crystal

Urine, sputum ....

Workup

Imaging Plain x-ray

AP, lateral Special view:- principle is to take tangential view to the

spot of pathology

CT MRI U/S Contrast study radio-isotope study

Bone scan

Workup

Arthroscopy

biopsy

Electrophysiology study

EMG

NCT

3D-Matrix

Etiology Problem Complication Background prognosis

History

P/E

Investigation

Conclusion Σ Σ MSK analysisΣ MSK

analysisΣ Σ

Management Etiology Problem Complication Background prognosis

Physical

Social

Mental

At-the-spot Mx

Short termLong term

mentalsocialPhysical

OccupationalFinancialMaritalfamily

hobbies

Next slide for MSK problem listing

MSK Medical

Iatrogenic complication Response to past PxPatient’s expectation

WHO classification of health

Analysis of MSK problem (anatomic)

SkinUlcer

contracture

MusclePower

Contracture / Spastic

Bone

Length

Deformity :- frontal, sagittal, rotational

Texture eg osteoporosis

Stability / fracture

Joint

Stiffness

Instability / dislocation

degeneration

ArteryVascular insufficiency

Compartmental syndrome

Vein Venous insufficiency

Nerve

Sensation loss (including proprioception)

Neurogenic pain

In-coordination

Mass effect

Compression, mechanical effect eg spinal stenosis,

nerve entrapment

Analysis of MSK problem (anatomic)

Treatment...but how?

First of all, some important keywords ............

Conservative and Operative

Short Term / Long Term Plan

Acute phase / Chronic phase

Conservative Treatment

Physiotherapy

Occupational therapy

Prosthetics and orthotics

Medication

General Medical Advice

Non-operative Intervention

Conservative Treatment

Physiotherapy RICE Instrumental

TENS Interferential U/S

Passive Eg stretching

Active Muscle strengthening, proprioceptive training

Assistive Stick, cane, walking frame

Conservative Treatment

Occupational therapy

UL training

Splint

Functional assessment

Vocational training

ADL training

Home assessment / home visit

Conservative Treatment

Prosthetics and Orthotics

LL

Splint

Brace

corset

Prosthesis

(Teaching Web :- “Orthopaedic Ward -

equipments and devices”)

Conservative Treatment

Medication

Analgesic

NSAID

Narcotics (chronic use to be avoided)

Anti-depressant

Steroid

Gout medication

Disease modifying agent

Drug for osteoporosis

Conservative Treatment

General health advice

Change of daily activities

Sport

Hobbies

Domestic

Occupational

eg diet, weight reduction, posture

Avoid pain provoking activities

Conservative Treatment

Non-operative intervention

Close reduction, POP

Manipulation

Analysis of MSK problem (anatomic)

SkinUlcer

contracture

MusclePower

Contracture / Spastic

Bone

Length

Deformity :- frontal, sagittal, rotational

Texture eg osteoporosis

Stability / fracture

Joint

Stiffness

Instability / dislocation

degeneration

These are what you want to rectify

Conservative Treatment

Physiotherapy

Occupational therapy

Prosthetics and orthotics

Medication

General Medical Advice

Non-operative Intervention

These are the means

Operative intervention ......

Analysis of MSK problem (etiologic)

Operative

(bony procedure, soft tissue surgery)

Infection I & D

TumorExcision (curative or de-bulking)

followed by reconstruction

inflammatorySynovectomy / ? Local steroid

injection

InjuryRepair (eg nerve repair, fracture

fixation)

Analysis of MSK problem (per se)Operative

(bony procedure, soft tissue surgery)

Skin UlcerSkin grafting,

flap surgery

MusclePower

Contracture / Spastic

Tendon transfer

Release of contracture

Bone

Length

Deformity :- frontal, sagittal, rotational

Texture eg osteoporosis

Stability / fracture

Lengthening

Osteotomy

Internal fixation

Joint

Stiffness

Instability / dislocation

Degeneration / derangement

MUA, Soft tissue release

Stabilization procedure:- soft tissue procedure (eg patella), osteotomy (eg

DDH, shoulder), fusion (eg spine)

Arthroscopy / Joint replacement / arthrodesis(rarely)

Analysis of MSK problem (per se)Operative

(bony procedure, soft tissue surgery)

ArteryVascular insufficiency

Compartmental syndrome

Revascularization

release

Vein Venous insufficiency General surgeon

Nerve

Sensation loss (including proprioception)

Neurogenic pain

In-coordination

Mass effect / non-viable tissue

Compression, mechanical effect eg spinal stenosis,

nerve entrapment

Decompression, release

amputation

soft tissue surgery

skin

skin grafting

flap

muscle and tendon

tendon transfer

ligament, capsule and compartment

release

reconstruction, plication, reefing

nerve repair

others

Operative Treatment

Hard tissue surgery Bone surgery

fixation fusion osteotomy lengthening amputation

Joint surgery arthroscopy joint replacement arthrodesis / fusion repair of intraarticular lesions discectomy for PID synovectomy

Operative Treatment

Analysis of MSK problem (per se)Operative

(bony procedure, soft tissue surgery)

Skin UlcerSkin grafting,

flap surgery

MusclePower

Contracture / Spastic

Tendon transfer

Release of contracture

Bone

Length

Deformity :- frontal, sagittal, rotational

Texture eg osteoporosis

Stability / fracture

Lengthening

Osteotomy

Internal fixation

Joint

Stiffness

Instability / dislocation

Degeneration / derangement

MUA, Soft tissue release

Stabilization procedure:- soft tissue procedure (eg patella), osteotomy (eg

DDH, shoulder), fusion (eg spine)

Arthroscopy / Joint replacement / arthrodesis(rarely)

soft tissue surgery

Hard tissue surgery

Bone surgery

Joint surgery

Operative Treatment

These are what you want to rectify

These are the means

Before Conclusion ......

Let’s talk about

Red Flag Signs

Red Flag Signs

In general, they come naturally ...

surf along History and P/E and Ix

Red Flag signs in general

Elderly patient

Persistent and severe symptom

Night symptom

Associated with Trauma

Features of infection eg fever, chills, rigor, night sweating

Features of malignancy eg constitutional symptoms, symptoms due to potential primary tumor

Red Flag signs in general – surf along

History and P/E and Ix

Significant past health problem

History of malignancy

Significant medication history

eg use of steroid

Presence of complication

eg neurological deficit, vascular disturbance

Functional (physical), social or mental disturbance

Red Flag signs in general – surf along

History and P/E and Ix

Significant positive investigation

Blood test

ESR, CBC, Ca, ALP etc

Imaging

Plain xray

others

ConclusionHx – P/E – Ix - Px

History

Background(Response to previous treatment

Patient’s expectation)

etiology Main problem

Prognosticating factors

PhysicalsocialMental

PhysicalsocialMental

PhysicalsocialMental

PhysicalsocialMental

Complication(including iatrogenic)

PhysicalsocialMental

Physical examination

Introduce yourself, be polite and considerate,

hygienic measure

Mind-set for inspection, palpation, movement,

General

Posture

Gait

General Components

The examination matrix

Specific

Components

3D-Matrix

Etiology Problem Complication BackgroundPrognosis /

extent of ds

History

P/E

Physical

Social

Mental

Tools Theme Domain

Tools

Domain

Theme

3D-Matrix

Etiology Problem Complication Background prognosis

History

P/E

Investigation

Conclusion Σ Σ MSK analysisΣ MSK

analysisΣ Σ

Physical

Social

Mental

At-the-spot Mx

A case presented to youHx, P/E

At-the-spotManagement

Investigation

Problems listing

Conservative Vs Operative PxAcute Px Vs Long term Px

At the spot Mx

•Physical•ABC•Analgesic•Anti-sepsis•Anchorage•Anti-swelling•Anaesthesia?

•Psychosocial•Explanation•empathetic

•Plan•Discharge•Referral•admit

At-the-spotManagement

Blood

Body fluid, excreta

Imaging

Arthroscopy

biopsy

Electrophysiology study

Investigation

Blood

Body fluid, excreta

Imaging

Arthroscopy

biopsy

Electrophysiology study

Plain xray (+/- special view)U/SCTMRI

Contrast studyRadioisotope

Investigation

3D-Matrix

Etiology Problem Complication Background prognosis

History

P/E

Investigation

Conclusion Σ Σ MSK analysisΣ MSK

analysisΣ Σ

Management Etiology Problem Complication Background prognosis

Physical

Social

Mental

At-the-spot Mx

Short termLong term

3D-Matrix

Etiology Problem Complication Background prognosis

History

P/E

Investigation

Conclusion Σ Σ MSK analysisΣ MSK

analysisΣ Σ

Management Etiology Problem Complication Background prognosis

Physical

Social

Mental

At-the-spot Mx

Short termLong term

mentalsocialPhysical

OccupationalFinancialMaritalfamily

hobbies

Next slide for MSK problem listing

MSK Medical

Iatrogenic complication Response to past PxPatient’s expectation

WHO classification of health

Problems listing

Analysis of MSK problem (anatomic)

SkinUlcer

contracture

MusclePower

Contracture / Spastic

Bone

Length

Deformity :- frontal, sagittal, rotational

Texture eg osteoporosis

Stability / fracture

Joint

Stiffness

Instability / dislocation

degeneration

These are what you want to rectify

Conservative Treatment

Physiotherapy

Occupational therapy

Prosthetics and orthotics

Medication

General Medical Advice

Non-operative Intervention

These are the means

Conservative Vs Operative PxAcute Px Vs Long term Px

Analysis of MSK problem (per se)Operative

(bony procedure, soft tissue surgery)

Skin UlcerSkin grafting,

flap surgery

MusclePower

Contracture / Spastic

Tendon transfer

Release of contracture

Bone

Length

Deformity :- frontal, sagittal, rotational

Texture eg osteoporosis

Stability / fracture

Lengthening

Osteotomy

Internal fixation

Joint

Stiffness

Instability / dislocation

Degeneration / derangement

MUA, Soft tissue release

Stabilization procedure:- soft tissue procedure (eg patella), osteotomy (eg

DDH, shoulder), fusion (eg spine)

Arthroscopy / Joint replacement / arthrodesis(rarely)

soft tissue surgery

Hard tissue surgery

Bone surgery

Joint surgery

Operative Treatment

These are what you want to rectify

These are the means

Conservative Vs Operative PxAcute Px Vs Long term Px

Thank You for Attention