• Part 1 Approach to the Orthopaedic Patient

• Part 2 Approach to Clinical Problem Solving

• Part 3 Approach to Reading

Part 1. Approach to the Orthopaedic Patient

The transition from textbook learning to the application of information in a specific clinical situation is one of the most challenging tasks in medicine. It requires retention of information, organization of the facts, and recall of a myriad of data in precise application to the patient. The purpose of this book is to facilitate this process. The first step is gathering information, also known as establishing the database. This includes taking the history; performing the physical examination; obtaining selective imaging, such as plain x-rays; and ordering laboratory studies. Of these, the historical examination is the most important and useful. Sensitivity and respect should always be exercised during interactions with patients.

History

1. Basic information:

   1. Age and sex: It may seem obvious, but the age and sex of the orthopaedic patient is of tremendous diagnostic, therapeutic, and prognostic importance. For example, a first-time shoulder dislocation in a male less than 20 years of age is bound to recur at a rate of greater than 80%, whereas a first shoulder dislocation in a female greater than 40 years of age will only recur approximately 10% of the time.

   2. Chief complaint: What has brought the patient to your office? Urgent care clinic? Trauma bay? Has the patient suffered an acute traumatic injury, or has the patient been referred to you for chronic symptoms of several months in duration? Perhaps the most common complaint to orthopaedic physicians is pain. At a minimum, the acuity, severity, location, temporality, presence of associated symptoms, and relieving and exacerbating factors for any complaint of pain should be noted.

      • Acute trauma: In acute, high-energy traumatic situations, it is essential to carefully follow Advanced Trauma Life Support (ATLS) protocol to optimize patient survival and minimize morbidity. In many hospitals, traumatic scenarios are managed by emergency department physicians and trauma surgical teams. Orthopaedic surgeons play a vital, if supportive, role in acute life support management. After ensuring stability of the patient's airway, breathing, cardiovascular system, cerebral perfusion, and environment, the orthopaedist must work to stabilize major fractures, reduce dislocations, attenuate bleeding, provisionally irrigate contaminated lesions, and assess neurovascular deficits.

      • Mechanism of injury: In traumatic situations, whether low-energy falls from standing height or high-energy motor vehicular collisions (MVC), orthopaedic physicians must make special note of the mechanism of injury. Both the patient's positioning during injury and the direction of forces acting on the patient play a key role in the classification, treatment, and prognosis of many different types of orthopaedic injuries. In fact, several fracture classification systems are based on the very mechanism of injury, including high-energy, high-mortality pelvic fractures and comparatively lower energy “everyday” ankle fractures. For patients injured in MVCs, note whether the patient was wearing a seat belt. Likewise, was the motorcyclist wearing a helmet? Does the patient recall the accident, or did he or she lose consciousness? In the elderly especially, a hip fracture may represent more than just a broken bone. Such patients often fall as a result of syncope or presyncope, secondary to underlying cardiac and/or neurologic conditions. The fall may be the first presentation of uncontrolled atrial fibrillation or Alzheimer dementia.

      • Chronic symptomatology: In patients with chronic symptomatology, the physician must work to carefully characterize the patient's symptoms with regard to acuity, severity, location, temporality, presence of associated symptoms, and relieving and exacerbating factors. At this point, the clinician may begin to generate a list of differential diagnoses that further inquiry, examination, and testing will narrow.

      • Concomitant injuries: Does the patient have any other complaints? Does the patient complain of neck pain after crashing the car? Is the patient intoxicated? Patients under the influence of drugs or alcohol, or simply as secondary to a sympathetic response to the injury, may not immediately recognize a painful injury. This is especially true in patients with multiple distracting injuries. When evaluating the cervical spine, it is essential to rule out distracting injuries, as a painful broken femur may distract the patient from a vague neck ache, the result of an unstable ligamentous injury.

   3. Past medical history: First, any history of systemic illnesses such as diabetes, cardiovascular disease, peripheral vascular disease, and crystalloid, rheumatoid, and seronegative arthritis must be investigated. Primarily musculoskeletal conditions such as osteoporosis and osteoarthritis and histories of fracture, sprains, strains, tears, and infections should also be elicited.

   4. Past surgical history: Does the patient have a history of fracture fixation, joint replacement, spinal decompression, or other procedures, recent or distant, that may influence his or her management? A detailed knowledge of previous orthopaedic treatments is paramount for planning new interventions. For example, an acute periprosthetic femoral shaft fracture around a previous hip replacement is treated differently from hip fracture in a native (normal) joint. Although the patient without a history of joint replacement may benefit from an intramedullary rod, the canal is partially occupied by the prosthesis in the patient with the history of joint replacement, making intramedullary fixation impossible without an extensive revision of components. For any patient undergoing surgery on or around a previous orthopaedic implant, it is important to obtain documentation of the type of implant used, its size, manufacturer, and both when and by whom it was placed.

   5. Family history: Inquire about a history a familial degenerative, metabolic bone, or connective tissue disorders. In patients with arthritis, for example, be certain to ask about a familial history of rheumatoid and autoimmune diseases, as these conditions may have a familial predilection. Such information may help target your differential diagnosis.

   6. Social history: Does the patient abuse tobacco? Does the patient drink alcohol? If so, how much and for how long? Does the patient use illicit substances? Nicotine is a significant inhibitor of both wound and bone healing; in a study of open tibial shaft fractures, injuries took almost 70% longer to heal in smokers versus nonsmokers. Nicotine also has been shown to increase the rate of nonunion, or failed healing of bone. Inquire about the patient's vocation, hobbies, physical activities, and hand dominance. A high-performance college athlete, for example, may benefit more from an elective anterior cruciate ligament (ACL) repair than a 53-year-old concert pianist who spends most of her time sitting. The same concert pianist may require surgical reduction and fixation of a nondominant comminuted distal radius fracture versus the same fracture in an 86-year-old nonambulator for whom cast fixation is adequate.

   7. Allergies: Inquire about previous reactions to medications, and be certain to distinguish between true hypersensitivity and adverse responses. A distant memory of “stomach upset” from penicillin is not necessarily reason to compromise on an effective, first-line antibiotic.

   8. Medications: As usual, careful documentation of medications both past and present is important. Note dosages, durations of treatment, and indications when unclear. Pay special attention to history of steroids, bisphosphonate, anticoagulant, and antibiotic use, as these medications frequently influence perioperative management.

   9. Review of systems: A general review of symptomatology is important in assessing the orthopaedic patient. Has the patient with knee pain been experiencing fevers and chills, suggestive of a septic joint? Has the patient concerned with insidious back pain been experiencing unintended weight loss and night sweats, representative, perhaps, of a vertebral body metastasis from an unknown primary tumor? Such diagnoses may be missed if a review of systems is not performed.

Physical Exam

1. Vital signs: Note the patient's temperature, blood pressure, heart rate, respiratory rate, and peripheral oxygen saturation. Height, weight, and body mass index should also be considered.

2. General appearance: Note whether the patient is cachectic versus well-nourished, anxious versus calm, alert versus obtunded, comfortable versus distressed. Also note the patient's ambulatory status, gait, posture, and stance. Some clinicians argue that the physical exam “begins in the waiting room” as they observe patients make their way to the examination room.

3. A basic approach to the musculoskeletal examination of the extremities: Based on 5 elements: inspection, palpation, range of motion, neurovascular evaluation, and special tests.

   1. Inspection: The examination of any extremity should begin with inspection of the limb for gross deformities, open fractures, skin defects, rashes, blisters, burns, lacerations, or any other traumatic sequelae. Carefully survey the skin for tenting in the setting of displaced fractures, as protruding bone fragments can quickly erode through the skin, creating a delayed open fracture. Inspect for symmetry, atrophy, or gross defects such as dislocations, angulations, and rotational deformities. Note that a small skin “poke hole” injury from a femoral shaft fracture represents a deceptively large soft tissue injury, as the femur fragments must violate several inches of thick muscle, fascia, and skin to pierce the surface.

   2. Palpation: Palpate long bones for regions of tenderness, step-off, crepitus, and swelling. Palpate joints for tenderness, crepitus, and effusions.

   3. Range of motion: Evaluate range of motion, first passively, with the examiner moving the patient's limb through a range of motion, then actively, with the patient moving his or her own limb through a complete range of motion. Always compare the affected extremity to the contralateral side.

   4. Neurovascular evaluation: Sensation and vascularity should be assessed. Check for palpable pulses distally and for capillary refill at the finger or toe pads. Reflex testing may be performed when appropriate. When relevant, strength should be graded on a scale of 0 to 5:

      • 0. No visible or palpable contraction

      • 1. Any flicker of motion or visible and/or palpable muscle contraction

      • 2. Full range of movement out of the plane of gravity

      • 3. Full range of motion against gravity only

      • 4. Full range of motion against some resistance, but weaker than expected

      • 5. Normal strength

   5. Special testing: Special tests, or tests specific to a certain joint, bony region, or pathology, may next be performed. Details for special physical exam tests are discussed later within pertinent clinical cases.

4. A basic approach to the examination of the spine: The spine has a complex arrangement of integrated bony, muscular, ligamentous, nervous, vascular, and other structures; understanding its anatomy is paramount to performing an effective examination. Although there is considerable overlap between a basic extremity and basic spine examination, the difference in the spine exam is the neurologic focus on nerve root distributions of function. For example, a finding of thumb and index finger weakness and numbness may represent ipsilateral C6 or C7 nerve root compression to a “tunnel-visioned” examiner who is focused on the spine. To a hand surgeon, however, such a finding may be the result of an undiagnosed carpel tunnel syndrome. The key to a good examination and evaluation is being able to recognize the differential diagnosis for a particular finding and narrow its potential etiologies accordingly.

   1. Inspection: Inspect the spine for gross deformities, curvatures, skin defects, and other additional pathology. In settings of trauma, observe the skull, both anteriorly and posteriorly for evidence of blunt trauma, which may represent hyperextension and hyperflexion cervical injuries, respectively. From behind the patient, look for asymmetric scapulae, deviation from a plumb line (a median vertical line dropped from C7 by suspending a weight on a string), and observe for rib humps when the patient is in a forward-bend position. In newborns and infants, observe for defects such as dimples or tufts of hair, which are suggestive of underlying congenital abnormalities such as spinal bifida.

   2. Palpation: Similarly, palpate the spine for abnormal curvatures, areas of step-off or prominences, or regions of tenderness. In patients with complaints of pain, make sure to determine whether the tenderness is localized over bony spinous processes or over paraspinal musculature. The former is suggestive of bone pathology such as fracture or tumor. This is especially important when clearing the cervical spine (C-spine) in traumatic scenarios. Although the focus here is orthopaedic pathology, one should assess for other organic causes of back pain such as renal pathology, suggested by costovertebral tenderness. Sacroiliac tenderness, elicited with pelvic compression or a FABER maneuver (positioning the hip in flexion, abduction, external rotation and pushing on the knee may induce pain with sacroiliac pathology), is suggestive of seronegative spondylopathies, whereas rheumatoid arthritis may cause tenderness of the intervertebral joints.

   3. Range of motion: Outside of an acute trauma scenarios, the patient should be taken through an active range of motion including forward flexion, extension, lateral (sideways) bending, and rotation. Decreased range of motion with an absence of significant pain may be indicative of generalized degenerative process. A substantially decreased range of motion may be indicative of ankylosing spondylitis. Passive or physician-guided ranging of motion should be avoided in the cervical spine, as this may lead to iatrogenic injury.

   4. Neurovascular evaluation: For patients with concerns of spine pathology, a complete and thorough neurologic exam must be performed and carefully documented. Strength, graded 0 to 5, and sensation, graded 0 to 2 (0 = insensate, 1 = impaired, 2 = normal), should be evaluated in the major myo-dermatomal distributions of the bilateral upper and lower extremity. Tables I–1 and I–2 show common muscular, sensory, and reflexive distributions of the major nerve roots supplying the brachial and lumbar plexuses, respectively. For patients with acute traumatic injuries to the spine, it is essential that motor and sensory function be examined bilaterally throughout the body and carefully documented at the time of initial presentation. For patients undergoing workup for radicular pain, chronic back pain, or similar degenerative processes, physical exam findings should closely correlate with radiographic findings if one hopes to have successful surgical outcomes. Clinical correlation is paramount, as magnetic resonance imaging (MRI) of the spine has a notoriously high false-positive rate in elderly individuals.

   5. Special testing: Details for specific physical exam tests are discussed later within pertinent clinical cases.

5. Clearing the cervical spine: In the setting of high-energy trauma or in patients who have suffered blunt trauma to the head or neck, the cervical spine must be immobilized provisionally to prevent potentially catastrophic neurologic injury. Even if a patient does not initially complain of head, neck, or radicular pain, intoxication and other injuries may distract from the sometimes subtle pains of unstable cervical bony or ligamentous injury. For this reason, protocols exist to guide physicians in “clearing” the C-spine (ie, safely discontinuing provisional immobilization when there is no evidence to suggest an occult cervical spine injury). In general, the elements necessary for clearing the C-spine include an absence of posterior neck tenderness, an absence of focal neurologic deficits, a normal level of alertness, an absence of intoxication, an absence of distracting injuries, and the ability of the patient to perform an active range of painless neck motion.

Radiographic Evaluation

1. X-ray: Also known as plain films or radiographs. At a minimum, 2 images are acquired, taken in planes perpendicular to one another. These are usually anterior-posterior (AP) and lateral views. For traumatic injuries, x-rays of the joint above and below an area of interest should be obtained. Additionally, many types of specialty views are obtained, depending on the region of interest. A common example is the Mortise view of the ankle—an AP view with 15 degrees of internal rotation—which shows a smooth, uniform space between the tibia/fibula and the underlying talus. In ankle fractures, widening or disruption of this normally uniform space may clearly demonstrate injuries.

2. Computed tomography (CT): CT is essentially a series of x-rays, reassembled by a computer into 3-dimensional images or “slices.” CT plays an integral role in assessing complex anatomy such as acetabular and spine fractures and comminuted fractures and is often more sensitive than plain x-ray in diagnosis of nondisplaced or healing fractures. CT also plays a role in preoperative planning.

3. Magnetic resonance imaging: MRI is an indispensible tool for evaluating soft tissue structures such as ligaments, tendons, menisci, and nerves. When set to a T2-weighted signal, physiologic processes resulting in edema and tissue inflammation, such as infection, autoimmune processes, bone or soft tissue injury, and spinal cord or disc pathology, can be clearly visualized. MRI avoids ionizing radiation and is considered safe to use in the absence of ferromagnetic implants such as certain types orthopaedic hardware or cardiac pacemakers.

4. Ultrasound: Useful for detecting effusions, guiding needles for aspiration, evaluating for soft tissue abscesses or hematomas. Like MRI, ultrasound avoids ionizing radiation; it is frequently used in pediatric imaging.

5. Nuclear medicine scans: Bone scans, typically performed after administration of intravenous radioisotope technetium-99m, are a helpful tool for detecting bone pathology such as osteomyelitis, tumor, or healing fracture. After injection, the radioisotope localizes to regions of increased bony metabolic activity and is observable on specialized image detectors. Similarly, radioisotope-tagged white blood cells may be used in a similar fashion. Known as a tagged white blood cell scan, this modality is especially sensitive for detecting osteomyelitis.

6. Dual-emission x-ray absorptiometry (DXA) scan: DXA scanning is a radiographic method of measuring bone mineral density used in the diagnosis and management of osteoporosis.

Laboratory Tests

1. Preoperative laboratory testing: Patients suffering from high-energy traumatic injuries and patients undergoing elective orthopaedic procedures should undergo basic preoperative laboratory testing. This generally includes a complete blood count, basic metabolic panel, blood type and screening, and the basic coagulation tests, prothrombin time and partial thromboplastin time.

2. Inflammatory laboratory studies: Patients in whom infection is suspected should receive testing for an erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). These are 2 nonspecific inflammatory markers that may be used to assist with the diagnosis of, and to assess the efficacy of therapy in, chronic bone or joint infections. In patients undergoing workup for autoimmune disease, basic laboratory studies should minimally include ESR, CRP, rheumatoid factor, anticitrullinated protein, antinuclear antibody, and possibly HLA-B27 testing. Referral to a rheumatologic specialist is generally recommended.

3. Synovial fluid analyses: Frequently, orthopaedists are confronted with erythematous, swollen, and painful joints that must be aspirated to confirm a diagnosis. Synovial fluid should be sent for Gram stain, culture of aerobic and anaerobic organisms, crystal analysis, and synovial fluid cell counts, including white blood cell counts. The presence of bacteria on Gram stain is typically an indication for surgical irrigation and debridement of the joint, as bacteria in a closed joint can rapidly and irreversibly damage cartilage and other synovial structures. Crystal analysis may help with the diagnosis of gout (uric acid crystals) or pseudogout (calcium pyrophosphate crystals). Crystalloid arthropathy are typically managed nonoperatively.

4. Urine pregnancy test (a-human chorionic gonadotropin): In women of child-bearing age, it is important to eliminate the possibility of pregnancy when considering surgery or when exposing patients to ionizing radiation from x-rays, CT, or radioisotope scans.

Part 2. Approach to Clinical Problem Solving

There are typically 4 distinct steps that an orthopaedic surgeon takes to solve most clinical problems systematically:

1. Making the diagnosis

2. Assessing the severity of the disease or injury

3. Rendering a treatment based on the severity of the disease or injury

4. Following the patient's response to the treatment

Making the Diagnosis

The diagnosis is made by careful evaluation of the database, analysis of the information, assessment of the risk factors, and development of the list of possibilities (the differential diagnosis). The process includes knowing which pieces of information are meaningful and which may be thrown out. Experience and knowledge help to guide the physician to “key in” on the most important possibilities. A good clinician also knows how to ask the same question in several different ways and to use different terminology when appropriate. For example, patients at times may outright deny having any “current medical problems” but will deliver a laundry list of insulins, beta-blockers, or antidepressants when asked about their current medications. Reaching a diagnosis may be achieved by systematically reading about each possible cause and disease. The patient's presentation is then matched up against each of these possibilities, and each potential diagnosis is either placed high up on the list as a potential etiology or moved lower down because of the disease's prevalence, the patient's presentation, or other clues. A patient's risk factors may influence the probability of a diagnosis.

Although orthopaedic trauma diagnoses are seemingly straightforward fracture identifications, concomitant symptoms such as weakness or paralysis, paresthesias, or pulselessness may complicate the diagnosis of a “simple” fracture. An intimate appreciation for both anatomy and physiology is required to generate the differential diagnosis, even in the setting of acute trauma—could the patient with a proximal tibia/fibula fracture and an inability to extend his great toe be experiencing paralysis from common peroneal nerve entrapment; from decreased effort, secondary to extreme anxiety and discomfort; from neurovascular compromise, secondary to an acute compartment syndrome; or from a yet undiscovered concomitant lumbar spine injury?

For the patient in the office complaining of several days of shoulder or knee pain, a long list of possible diagnoses can be pared down to 2 to 3 most likely diagnoses based on physical exam, selective imaging, and laboratory tests. For example, a woman who complains of left knee pain and has a history of a meniscal tear may have degenerative joint disease; another patient who has left knee pain and recent fevers and chills may have a septic joint infection. Furthermore, a patient complaining of left knee pain and a history of chronic steroid use for her Crohn disease may not have true knee pathology at all, but rather referred pain from avascular necrosis of the ipsilateral hip.

Assessing the Severity of the Disease

After ascertaining the diagnosis, the next step is to characterize the severity of the disease process; in other words, describe “how bad” a disease is. Most commonly, with traumatic injuries such as fractures and dislocations, this is done using a variety of classification schemes.

To students and residents unfamiliar with fracture classification systems, it may seem overly “academic” to call the broken ankle a “Lauge-Hansen S/ER-IV” or the broken hip an “AO 31-B2.” However, classification systems play an important role in communicating the location, mechanism, and severity of an injury while simultaneously guiding its treatment. Classification schemes allow injuries to be standardized for research purposes and allow physicians to deliver more accurate prognoses to patients. The attending physician, hearing that the on-call resident has reduced and splinted an S/ER IV ankle fracture, can instantly picture this severe injury and can tell the resident to admit the patient for operative fixation the following morning.

Chronic orthopaedic conditions should be stratified in the same way. Degenerative joint disease of the hip may be mild in nature and effectively treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and activity modification; or it may be severe, with the patient all but demanding a steroid injection or even a joint replacement.

Treatment Based on Severity of the Disease or Injury

Both the treatment and prognosis for virtually any given orthopaedic diagnosis relates directly to its severity. For example, a closed tibial shaft fracture may be treated in a cast if its alignment after reduction falls within certain radiographic parameters. That same fracture, should it shift even a few millimeters, may need an intramedullary rod down its center, or a plate placed on its side, to hold the tenuous reduction. Had the skin over the fracture been damaged during the injury, it would have required urgent operative irrigation and debridement with concomitant intramedullary rodding or placement into an external fixator. Had there been a segment of bone lost during the injury, the patient may have required several staged procedures with vascularized bone grafting, soft tissue flapping, or even bone lengthening through an Ilizarov apparatus.

Orthopaedics is a broad field, with treatments ranging from quick splint application in the office to extensive and invasive procedures such as pelvic fracture reductions and internal fixation. An overview of some basic orthopaedic treatments and some of their most common indications follows. Details regarding orthopaedic treatment indications, techniques, and outcomes are discussed in the cases that follow.

Nonoperative Treatments

An orthopaedic reduction means simply to manipulate the bone or joint in such a way that anatomic positioning is restored. The principles of immobilization are simple: Hold the bones or tissues in, or as close to, their anatomic state to optimize healing and to minimize stresses on surrounding tissues. In their most simplistic form, most reduction maneuvers involve application of both axial traction and force in the direction opposite to that of the mechanism of injury. For a dorsally angulated distal radius fracture, for instance, reduction is performed by pulling axial traction and by applying volar-directed force to return the angulated carpus to its correct position. In general, immobilization should stabilize the joint above and below a fracture. One should always attempt to restore length, rotation, and angulation.

1. Casting and splinting: Defined as the application of plaster, fiberglass, or similar materials to immobilize a particular region of the body. Casts are generally applied circumferentially around an affected body part, providing more rigid and more durable immobilization. Splints may span and partially cover a region, but they allow tissues to swell and are easily removed. Several common casting techniques are detailed below; splints are applied similarly to these methods.

   1. Short arm cast: Applied from below the elbow to just proximal to the metacarpal-phalange joints at the midpalmar crease. These are generally indicated for reducible distal radius fractures. Short arm casts may be extended to a thumb spica cast wherein the thumb is immobilized up to the interphalangeal joint.

   2. Long arm cast: Similar distally to a short arm cast, but extends to the proximal third of the humerus with the elbow in approximately 90 degrees of flexion. Generally indicated in pediatric forearm fractures because, unlike short arm casts, it prevents rotation of the forearm by locking the wrist in the same plane as the arm. Long arm casts can also be extended to thumb spica casts and are thereby used to treat nondisplaced scaphoid fractures.

   3. Short leg casts: Extends from the tibial tubercle to just proximal to the metatarsal-phalange joints. Typically indicated in the treatment of stable ankle fractures. In general, it is important to dorsiflex the ankle to neutral, or 90 degrees with respect to the tibia, as prolonged plantar flexion may result in an equinus contracture of the Achilles tendon.

   4. Long leg cast: Similar to a short leg cast, but extends to the proximal thigh. Typically indicated in the treatment of nonoperative tibial shaft fractures. Like long arm casts, this cast effectively blocks rotation of the extremity. The knee should be immobilized in 5 to 20 degrees of flexion.

   5. Hand splinting: For immobilization of almost all metacarpal and phalanx fractures. The metacarpal-phalange joints should be immobilized between 70 and 90 degrees of flexion to prevent stiffening and contracture. Interphalangeal joints are immobilized in extension. Together, this is referred to as the “intrinsic plus” position because it mimics the hand position achieved with contraction of the hand intrinsic muscles.

2. Bracing:

   1. Knee immobilizer: A prefabricated brace extending from the mid-thigh to the mid-leg that holds the knee in near-complete extension. Typically used to stabilize knee dislocations, patella repairs, minimally displaced tibia plateau fractures, and postoperative arthroscopy patients.

   2. Sarmiento (functional) bracing: Typically consists of 2 pieces of half-cylindrical shells that strap together circumferentially around the site of a humeral shaft fracture. Often used as definitive treatment for humeral shaft fractures.

   3. Bledsoe bracing: Hinged braces that attach above and below a joint (typically the knee or elbow) to allow motion in a single plane. The desired degree of motion may be preset. For example, an elbow Bledsoe brace may be set from 0 to 90 degrees of flexion to protect from the extremes of flexion/extension as well as preventing varus/valgus forces in a postoperative distal humerus fracture.

3. Traction: Historically, many types of lower extremity fractures were treated with the patient in traction and on prolonged bedrest. Hip fractures and femoral shaft fractures, for example, are commonly displaced as a result of strong muscular deforming forces. Problems with hygiene, skin breakdown, and the difficulty of maintaining reductions made casting of these injuries nearly impossible. Therefore, such injuries were treated in traction, or with a constant, controlled axial force that pulls fractures into alignment. Because the skin can only tolerate limited prolonged pressure before breakdown occurs, traction pins were commonly employed. Placed through the distal femoral metaphysis or through the proximal tibia, large-diameter pins could transmit the traction forces necessary to counter deforming muscular contractions. Modern intramedullary rodding, prostheses, and generally improved surgical techniques have antiquated most indications for traction. However, traction is still used provisionally for patients awaiting definitive surgical fixation or for patients who are not medically fit to undergo major fixation procedures. Halo immobilization and Gardner-Well tong traction are another form of skeletal traction still in use today. With pins placed firmly into the skull, axial traction may be applied to the spine to assist in the reduction of injuries such as spinal facet dislocations, immobilization of unstable cervical spine injuries, and sometimes in pediatric patients to help correct scoliosis.

Operative Treatments

1. Fracture fixation:

   1. Open reduction internal fixation (ORIF): One of the mainstays of orthopaedic trauma surgery. Applies to virtually any situation in which a fracture site is directly opened and the bones reduced and fixated with a variety of implants such as screws, plates, wires, cement, and sutures.

   2. Intramedullary nailing: Similar to ORIF; however, the implant goes directly through the medullary canal, not on the surface of the bone. Furthermore, ORIF generally requires direct reduction of fracture fragments, whereas the fracture fragments in an intramedullary nailing procedure are typically indirectly reduced. Patients are sometimes surprised to hear that their scars will be nowhere near the site of their actual fracture.

   3. External fixation: External fixation is a method of temporarily stabilizing fractures and/or joints in the setting of hemodynamic instability, significant swelling, significant soft tissue injury, or other contraindications to primary fixation. Pins are typically placed in the cortices above and below a fracture site and then connected to an external frame that holds the alignment until definitive fixation may take place. These are commonly employed in multitrauma scenarios in which a patient with multiple long bone fractures and other organic injuries needs quick, temporary stabilization. Of course, if the reduction is well-aligned and the fixator remains in place long enough, external fixation may be the definitive treatment.

   4. Percutaneous pinning: A method of fixing fractures using thin wires placed through the skin under x-ray fluoroscopic guidance. Commonly used in settings such as hand fractures or supracondylar pediatric humerus fractures. Casts or splints are used in conjunction with pin placement to support the immobilized bone. After adequate callus formation, pins are typically pulled out through the skin without the need for further fixation.

2. Arthroplasty: Arthroplasty means the reconstruction of a joint. Common orthopaedic arthroplasty procedures involve the knee, hip, and shoulder, although implants are available for many other joints in the body. Arthroplasty is typically performed on an elective basis and is used as elective treatment for patients with severe degenerative joint disease and some cases of inflammatory arthritis. Elderly patients with displaced femoral neck fractures may undergo primary arthroplasty as definitive treatment for their fracture because attempted repair of the fragments has a very high incidence of failure.

3. Arthroscopy: Arthroscopy simply refers to the minimally invasive technique of using a camera to evaluate and treat intraarticular pathology. Common arthroscopic procedures include diagnostic explorations, meniscal debridements, removal of loose bodies, ligamentous repairs such as ACL reconstructions, and tendinous/joint capsule reconstructions. Thanks to the minimally invasive approach, procedures are often performed on an outpatient basis.

Following the Response to Treatment

The final step in the approach to disease is to follow the patient's response to therapy. The “measure” of response should be monitored and documented. Some responses are clinical, such as improvement, or lack thereof, in a patient's subjective joint pain, activity level, range of motion, and strength. The physician must be skilled at eliciting this subjective data in an unbiased and standardized manner. Fractures, whether treated operatively or nonoperatively, are typically followed with serial x-rays. Intervals between imaging often vary with regard to the nature of the injury: A lateral malleolar ankle fracture treated in a cast is likely to remain stable and may require only biweekly imaging until there is clear evidence of bony healing. By contrast, a comminuted distal radius fracture treated in a cast has a much greater propensity to collapse and may need close monitoring if it is to be treated nonoperatively. Patients with conditions such as chronic osteomyelitis may require 6 to 8 weeks of intravenous antibiotic treatment, during which serial ESR and CRP studies help the clinician determine the duration and efficacy of treatment.

Part 3. Approach to Reading

The clinical problem-oriented approach to reading is different from the classic “systematic” research of a disease. Outside of isolated traumatic injuries, patients rarely present with a clear diagnosis; hence the clinician-in-training must become skilled in applying textbook information to the clinical setting. Furthermore, the reader retains more information when reading with a purpose. In other words, one should read with the goal of answering specific questions. Likewise, the clinician-in-training should have a plan for the acquisition and use of the information. The process is similar to having a mental “flow chart,” with each step sifting through diagnostic possibilities, risk factors, therapies, and potential complications. There are several fundamental questions that facilitate clinical thinking:

• What is the most likely diagnosis?

• What should be the next step?

• What is the most likely mechanism for this injury or condition?

• What are the risk factors for this injury or condition?

• How is the diagnosis confirmed?

• What is the best therapy?

• What complications are associated with this injury or condition and its treatment?

What is the Most Likely Diagnosis?

The method of establishing the diagnosis has been covered in the previous section. One way of attacking this problem is to develop standard “approaches” to common clinical situations. It is helpful to recognize the most common presentation of a given disease. For example, the most common cause of knee effusion is degenerative joint disease.

The clinical scenario would be something such as:

• A 50-year-old overweight female is referred to your office with complaints of right knee pain and swelling.

With no other information to go on, the student would note that this patient has a painful knee effusion. Using “most common cause” information, the clinician would make an educated guess that the patient has degenerative joint disease.

However, what if the scenario also included the following phrase?

• The right knee is mildly erythematous and warm to the touch.

Now the most likely diagnosis is an inflammatory arthritis. Degenerative joint disease rarely presents with inflammatory signs such as localized redness or warmth.

What Should be the Next Step?

This question is difficult because the next step has many possibilities; the answer may be to obtain more diagnostic information, to stage the illness, or to introduce therapy. The next step is often a more challenging question than “What is the most likely diagnosis?” because there may be insufficient information to make a diagnosis, and thus the next step may be to pursue additional diagnostic testing. Another possibility is that there is enough information for a probable diagnosis, and thus the next step is to stage the disease or to administer treatment. Hence from clinical data, a judgment must be rendered regarding where one falls on the “make a diagnosis → stage the disease → treat based on stage → follow the response” continuum. Frequently, students and training clinicians are taught to “regurgitate” information that someone has written about a particular disease, but they are not yet skilled at determining the next step. This talent is learned optimally at the bedside, in a supportive environment, with freedom to make educated guesses, and with constructive feedback. The sample scenario that follows describes one's thought process through a case of lower back pain:

• Make the diagnosis: “Based on the information available, I believe that this 48-year-old male has a right-sided acutely herniated nucleus pulposus at L4-5. This is based on right-sided lateral leg and shin paresthesias, an isolated EHL weakness of 4/5, and a positive straight leg raise test.”

• Stage the disease: “I don't believe that this is severe disease, since he does not have progressive symptoms, bowel/bladder dysfunction, saddle anesthesia, profound or bilateral weakness, or constitutional symptoms suggestive of infection or malignancy.”

• Treat based on stage: “Therefore, my next step is to treat him with NSAIDs, acetaminophen, activity modification, and a muscle relaxant.”

• Follow the response: “I want to follow the treatment by assessing his pain and clinical exam. I will reassess him in 1 week.”

In a similar patient, when the clinical presentation is more immediately concerning— for example if the patient were experiencing urinary retention and profound weakness in his bilateral lower extremities—the next step would likely be diagnostic in nature, such as an MRI of the lumbosacral spine to evaluate for cauda equina syndrome. Finally, if given an MRI showing a large centrally-herniated lumbar disc, the next step would be emergency surgical decompression.

What is the Most Likely Mechanism for this Injury or Condition?

This question goes further than making the diagnosis, requiring the clinician to understand the underlying mechanism behind the process. For example, a clinical scenario may describe a 61-year-old female who becomes hypoxic during an intramedullary rodding procedure for a femur fracture. The surgeon must first recognize fat embolism syndrome, which may occur intraoperatively during the intramedullary reaming of long bones. Then, the surgeon must understand the process by which the reamer disseminates the intramedullary fat into the bloodstream, leading to the mechanical obstruction of pulmonary blood flow and the triggering of a secondary inflammatory response in which platelets and erythrocytes aggregate and cause a localized toxic injury to the pulmonary vascular endothelium. Students and junior clinicians are advised to learn the mechanisms by which common injuries are created. Ankle fractures, for example, are often classified by the direction of the force acting on the ankle and the position of the foot during injury. If the foot is supinated during a low-energy external rotation injury, one is more likely to injure the lateral malleolus or disrupt the lateral ankle ligaments. Conversely, if the foot is pronated during the same external rotation injury, one is more likely to suffer injury to the medial malleolus or deltoid ligaments.

What are the Risk Factors for this Injury or Condition?

Understanding the risk factors for certain conditions helps the practitioner establish a diagnosis and determine how to interpret tests. For example, understanding the risk for osteonecrosis after a 4-part fracture of the proximal humerus may direct the surgeon to perform a primary shoulder hemiarthroplasty instead of fixing the fracture with plates, sutures, and screws. In an older individual with a history of osteoporosis, multiple medical comorbidities, and tobacco use, surgeons may opt to perform a primary partial replacement instead of attempting fixation. In younger individuals with the same injury, open reduction and internal fixation may be attempted, as younger patients will typically have better bone stock and blood supply than their older counterparts. Additionally, younger individuals have higher physical demands than are typically tolerated by current shoulder prostheses.

How is the Diagnosis Confirmed?

Although confirming the diagnosis of a traumatic fracture may be as simple as acquiring an x-ray of the affected bone, many injuries and diseases relevant to orthopaedics have complicated workups and diagnoses that physicians-in-training must be familiar with. In a young patient with complaints of snuffbox tenderness after a fall onto an outstretched arm, obtaining x-rays of the wrist with scaphoid views is typically the next step in diagnosis. However, what if the x-rays are negative, despite the telltale history and physical exam findings? Occult fractures of the scaphoid are treated in spica casts with follow-up x-rays at 1 to 2 weeks from injury to identify evidence of healing fracture. If symptoms persist despite negative films, an MRI or bone scan may be performed to confirm the diagnosis of an occult fracture. Clinicians-in-training should strive to know the indications for—and limits of—diagnostic tests, not just in the setting of traumatic injuries, but for many types of common bone and joint conditions.

What is the Best Therapy?

To answer this question, the clinician needs to reach the correct diagnosis and assess the severity of the condition, and then he or she must weigh the situation to reach the appropriate intervention. For the student and even junior-most residents, knowing exact steps of a surgical procedure is not as important as understanding the operative and nonoperative treatment options, identifying the best possible treatment, and recognizing its potential complications. It is essential for the training surgeon to be able to concisely and clearly verbalize the diagnosis and communicate his or her rationale for a proposed therapy. A common error is for students and residents to “jump” to a surgical treatment, almost like a random guess, and to therefore receive only “right or wrong” feedback when all of the logical steps in the management process are not completely understood. A guess at a proposed treatment may well be correct, but for the wrong reason; conversely, the student's “shot-down” answer may actually be a very reasonable one, with only a small misstep in thinking along the way. Injuries or conditions and their proposed treatments should be presented in a stepwise, logical fashion so that feedback may be received at each decision point.

What Complications are Associated with this Injury or Condition and its Treatment?

Clinicians must be cognizant of the complications of a disease, so that they will understand how to follow and monitor the patient. Sometimes, the training physician will have to make the diagnosis from clinical clues and then apply his or her knowledge of the consequences of the pathologic process. For example, a woman who presents with a comminuted both bone forearm fracture after a fall from a balcony is at significant risk for developing a compartment syndrome in the short term, as well as developing forearm synostosis or complications from Volkmann ischemia in the long term. Furthermore, the gold standard treatment—open reduction internal fixation of the radius and ulna with plates and screws—has several associated complications of its own, including posttraumatic synostosis, infection, and neurovascular injury. Physicians must be mindful of the potential complications arising from certain conditions or injuries—for example, which types of fractures are at significant risk for developing, say, a compartment syndrome and thus need to be monitored every few hours versus those that may be admitted and addressed the following morning. A basic knowledge of complications after both operative and nonoperative therapies for a variety of orthopaedic conditions is paramount. Of course, whenever possible, potential complications should be discussed with patients before intervention.

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