Goals

Learn to evaluate and treat a wide variety of common musculoskeletal injuries and complaints.

Learn to perform common orthopedic procedures, including casting, splinting, joint injections and aspirations, simple closed fracture reductions and local nerve blocks.

Appreciate the importance of rehabilitation in recovery from musculoskeletal injuries; learn common rehabilitation techniques and exercises, as well as indications for therapy referral.

Understand the indications for orthopedic consultation; develop and maintain professional collaborative relationships important in providing care for injured patients.

Objectives: Knowledge

Radiology 1. State criteria for ordering an x-ray to diagnose a fracture or dislocation. Include literature consensus from the Ottowa ankle and knee rules.

1. Correctly interpret common orthopedic x-rays and describe the findings in a conventional manner to other providers, verbally and in written form.

2. Given negative findings on plain x-rays, list conditions where the following modalities could provide additional information for diagnosis:

a. Bone scan following skeletal injuries b. CT or MRI following skeletal injuries c. CT or MRI following extremity or spine injuries.

Pediatric Conditions 1. Describe the Salter-Harris classification system for growth plate injuries

1. Identify common growth centers that could develop apophysitis

2. Describe common presenting symptoms, physical exam findings, imaging results for the following conditions. Outline a management strategy and list indications for referral.

a. Slipped capital femoral epiphysis b. Developmental dysplasia of the hip c. Intoeing d. Scoliosis e. Osgood-Schlatter disease f. Greenstick and torus fractures of the forearm g. Epiphysial fractures

Injuries 1. Discuss conditions that place an individual at risk for overuse injuries.

1. Describe the diagnosis, management and prevention of the following overuse injuries:

a. Tennis elbow b. DeQuervain’s tenosynovitis c. Carpal tunnel syndrome d. Rotator cuff tendonitis e. Trochanteric bursitis f. Patellar femoral pain g. Plantar fasciitis

1. For the common closed fractures listed below, the resident will:

Describe common presenting signs, symptoms, physical exam findings List appropriate imaging studies and results List referral indications and review potential complications of the fracture Outline a management strategy

a. Clavicle

f. Fibula - proximal and distal

b. Medial malleolus

g. Radius - head and distal radius

c. Scaphoid

h. Metatarsal

d. Metacarpal

i. Rib

e. phalanx

1. For the following dislocations, list physical exam findings, x-ray views to request and the results, relocation maneuvers and the subsequent management:

a. Anterior shoulder b. PIP joint c. AC (separation)

1. For patients suffering from osteoarthritis of the following joints, the resident will:

Describe common presenting signs, symptoms, physical exam findings List appropriate imaging studies and results List referral indications Outline a management strategy

a. Hip

d. 1st Carpal-metacarpal joint of the thumb

b. Knee

e. IP joints of the hand

c. Lumbar spine

1. List the presenting signs and symptoms of compartment syndrome, and outline an initial approach to diagnosis and treatment.

2. Discuss the primary care approach to the diagnosis, management and rehabilitation of acute, non- traumatic low back pain and cervical strain or whiplash. Describe common red flags, list referral indications and demonstrate an efficient physical exam.

3. For the infections in the following areas, the resident will:

Describe common presenting signs, symptoms, physical exam findings List referral indications and review potential complications Outline a management strategy

a. palmar space b. suspected septic joint c. felon

1. Compare and contrast spondylolisthesis and spondylolysis, reviewing relevant anatomy, radiology findings and relevant signs and symptoms.

2. Describe the clinical appearance and most common locations of :

a. ganglion cyst b. baker’s cyst c. trigger finger

1. Discuss and demonstrate common rehab exercises for:

a. ankle sprain b. knee strain c. shoulder tendonitis d. mechanical low back pain

1. For the soft tissue injuries listed below, the resident will:

Describe common presenting signs, symptoms, physical exam findings List appropriate imaging studies and results List referral indications and review potential complications Outline a management strategy

a. gamekeeper’s thumb b. jersey finger c. mallet finger d. ankle sprains e. anterior cruciate, meniscus and collateral ligament injuries in the knee

Skills

1. Perform a thorough exam of the joints, demonstrating maneuvers to identify range of motion, joint stability, surrounding muscle strength, soft tissue damage, neurovascular integrity and signs of a fracture or dislocation.

2. Demonstrate correct technique for application of the following casts or splints, using both plaster and fiberglass material:

a. Short arm cast

e. Radial gutter / thumb spica splint

b. Thumb spica short arm

f. Posterior leg splint/stirrup splint

c. Short leg walking cast

g. Sugar tong forearm splint

d. Ulnar gutter splint

1. Demonstrate or describe the appropriate technique for reduction of the following fractures or joint dislocations:

a. Boxer’s fracture

d. Anterior shoulder dislocation

b. Colle’s / distal radius fracture

e. Radial head subluxation (nursemaid’s elbow)

c. IP finger dislocation

1. Perform the following soft tissue or joint injections, listing indications, potential complications and supplies needed:

a. Subacromial bursa

d. Hip trochanteric bursa

b. Lateral epicondyle elbow

e. 1st dorsal compartment thumb (DeQuervain’s)

c. Knee

1. Demonstrate proper technique for performing arthrocentesis of the knee, elbow and wrist.

2. Demostrate the proper technique for performing the following nerve or regional blocks:

a. digital nerve block b. distal ulna nerve block c. hematoma block

Attitudes

1. The resident will maintain collaborative relationships with other members of the musculoskeletal injury team, such as orthopedists and physical and occupational therapists.

2. The resident will evaluate musculoskeletal injuries from a family medicine perspective, keeping in mind effects of the injury on occupational needs, home ADL’s and rehab needs.

Methods

1. Madigan: In the R1 year, residents spend 1 month in the outpatient orthopedic clinic at Madigan Army Medical Center, rotating through various orthopedic specialty clinics, including general ortho, spine clinic, pediatric ortho, hand injury clinic, casting clinic and podiatry. Serving a large population of military dependent families and veterans, this rotation provides a wide variety of common acute and chronic orthopedic problems. The resident functions as the primary provider, performing the exams and any necessary outpatient procedures under the supervision of attending orthopedic staff.

2. Physical therapy: The resident spends two half days during the above month in the office of community physical therapists. Objectives and an outline of the goals for this time is listed are listed separately.

3. TFM Orthopedic Injury Clinic: During their R 2 and R 3 year, residents rotate a minimum of 6 half days through this injury clinic, seeing semi-acute and chronic musculoskeletal injuries under the supervision of both family practice and orthopedic preceptors. The resident performs an appropriate focused history and physical, any necessary procedures, such as fracture reduction, casting, splinting and injections.

4. Conferences/ Didactics: Monthly morning lectures on a variety of orthopedic and sports medicine topics are given both by resident and faculty presenters. A yearly casting and splinting workshop is held each summer to improve these important skills.

Evaluation The residents are evaluated by formal written evaluation at the end of the one month rotation at Madigan by the chief orthopedic attending. They also receive ongoing feedback during the casting and splinting workshop and 1:1 direct observation feedback at the TFM ortho injury clinic.