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Introduction to Orthopedics
Prof. Mamoun Kremli
AlMaarefa College
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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
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Basic Anatomy of Bone
Diaphysis
Metaphysis
Epiphysis
Epiphyseal plates
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Basic Anatomy of Bone
Periosteum
Endosteum
Cortex
Medulla
Cortical bone
Cancellous bone
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Basic Anatomy of Bone
Periosteum
Endosteum
Cortex
Medulla
Cortical bone
Cancellous bone
http://classes.midlandstech.edu/
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Bone components
A: Matrix:
Organic: (40% of dry weight)Collagen fibersCells
Inorganic (Minerals): (60%)Ca hydroxyapetite, Ca phosphateOthers
B: Cells:Osteoblasts, osteoclasts, osteocytes, others
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Bone cells
Osteoblasts
Osteoclasts
Osteocytes
Osteone:
a unit, not a cell
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Descriptive terms
Valgus: away from midline
Varus: towards midline
Hallux: Big toe
Genu: Knee
Coxa: Hip
Cubitus: Elbow
Pes: Foot
Cubitus varus
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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
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History - Trauma
Date
Mechanism of injury
Loss of consciousness
Pain
Wound
Bleeding
Function
Progression of injury and management
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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
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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!
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Orthopedic Examination
Which system to use?
LookFeelMoveSpecial tests
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LOOK
What do we look at ?
What do we look for ?
Do we need a sub-system ?
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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…
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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
www.dreamstime.com/ www.bethanynaz.org/
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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/
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Look
Important Considerations:Amount of exposureDuration of exposurePersons present during exposurePlace of exposureAttitude and behavior during exposure
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Feel
What do we feel for ?
Do we need a sub-system ?
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Feel
Ask for pain or tenderness before you put your hand on patient!
Tenderness
Temperature
Anatomical
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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)
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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
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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’
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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!
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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/
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Structures affected
Bones
Joints
Muscles
Tendons
Nerves
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Diseases
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Diseases
Congenital
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Diseases
Congenital
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Diseases
Congenital
Developmental
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Diseases
Congenital
Developmental
Infections / Inflammations
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Diseases
Congenital
Developmental
Infections / Inflammations
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Diseases
Congenital
Developmental
Infections / Inflammations
Metabolic
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Diseases
Congenital
Developmental
Infections / Inflammations
Metabolic
Tumors / tumor-like
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Congenital
Developmental
Infections / Inflammations
Metabolic
Tumors / tumor-like
Neuromuscular
Diseases
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Congenital
Developmental
Infections / Inflammations
Metabolic
Tumors / tumor-like
Neuromuscular
Traumatic
Diseases
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Investigations
Blood
Imaging
Special
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Investigations – Blood Tests
CBC, differential WBC, ESR
C reactive protein
Biochemistry
Hormones
Vitamin D
Special
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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
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Investigations - Imaging
Other imaging techniquesCT scan
Bone components and fragment relationsMRI (with / without contrast)
Soft tissueTumors
Bone scanFunctional: blood supply, infection
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Investigations - Special
Culture / sensitivity
Manteaux test
Serology
Factors
Sickling
Genetic
Biopsy
Arthrocentesis (aspiration)
Arthroscopy
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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