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