Orthopaedics

Diagnosis & Therapy

Dr. Su Djie To Rante, M.Biomed, Sp.OT

SCOPE OF ORTHOPAEDICS
Art and science of Prevention, Investigation,
Diagnosis, and Treatment of Disorders and
Injuries of the musculoskeletal system by
medical, surgical, and physical means ,
including physiotherapy-as well as study of
musculoskeletal physiology, pathology, and
other related basic sciences.
1. Congenital and Developmental abnormalities
2. Infection and Inflamation
3. Degeneratif Disorder
4. Metabolic Disorder
5. Neoplasms
6. Neuromuscular Disorder
7. Trauma
 Clinical Term
• Movement Of The Joints
– Active and Passive
– Adduction and Abduction
– Flexion and Extension
– Dorsoflexion and Planter (Palmar Flexion)
– Eversion and Inversion
– Internal Rotation and External Rotation
– Pronation and Supination
 Clinical Term
• Deformities in Limb
– Postural Deformity vs Static Deformity
– Dynamic vs Fixed Deformity
– Calcaneus and Equinus
– Cavus and Planus
– Internal and External Tortion
– Anteversion and retroversion
 Clinical term
• Angulation or Bowing
– Valgus
– Varus

– Clinical Measurement of Joint motiont and Def

– The Anatomical Position
Diagnosis Musculoskeletal Disorder
• The Patient’s Story (Clinical History)
– Chief Complaint
• Pain
• Decrease Function
• Physical Appearance
– Relevan Past History
– Functional Inquiry
– Social,Economic and Work History
– Familial History
Diagnosis Musculoskeletal Disorder
• Physical Examination
– Look : Skin, deformity, swelling, lump,and Measurement limb ( atrophy
and shorten)  Anatomical, Functional/true and appareance length
• “Always COMPARE”
• If able to walk  ask to walk 20 feet : Observe gait
– Feel : skin, soft tissue, bone and joint
– Moving : active and passive
– Listening : crepitus
– Special Test : Thomas test, trendelenburg test, barlow and ortolani test,
Lasegue’s test (SLR) etc
– Neurology exam ( Muscle tone, power, coordination, sensory ( touch,
pain, temperature, position, and vibration), reflexs ( tendon, abdominal,
plantar and rectal sphincter test)
 Diagnosis Imaging
• Plain Radiograph
– Rule of 2
– Quality of X-ray
– Important to look :
• General density of bone
• Local density
• Relationship between bone
• Break in bone continuity
• General contour of bone
• Local contour of bone
• Thickness of articular cartilage
• Change in soft tissue
• Scintigraphy
• CT scan
• MRI
• USG
Plain X-ray Right Ankle AP/Lat
Quality :
• Identity
•Marker
•General
Density
•SITE
•EXTENT
•CONFIGURATION
•RELATIONSHIP OF
FRACTURE
FRAGMENT
 Laboratory Investigation
• Blood
• Serum
• Urine
• CSF
• Synovial fluid
• Abnormal fluid (Exudat/transudat)
• Body tissue
 Diagnosis In Fracture and joints
Injuries
• Traumatic
• Stress
• Pathological

• History of Injury  Inability to use the injured

limb
 Diagnosis In Fracture and joints
Injuries
• Physical Factors in Production of fractures (
MOI)
– Cortical Bone
• Withsand in compression and shearing forces better than
tension failure
• ( Transverse, oblique, greenstick, spiral, avulsion fracture)
– Cancelous bone
• Sudden compression  crush fracture ( Compression
fracture)
• Impacted, Buckle/torus fracture
• Symptom associated injuries
• Previous Injuries
• General medical History

• General Signs
• Local sign
• X-ray : Rule of 2 : Views, joint, limb, injuries, occasions)
• Special Imaging
• Secondary Injuries :
– Spinal cord injury
– Pelvic and abdominal injuries
– Thorasic injuries
– Pectoral girdle injuries
 Diagnosis In Fracture and joints
Injuries
• Description of fracture
– SITE
– EXTENT
– CONFIGURATION
– RELATIONSHIP OF FRACTURE FRAGMENT
– RELATIONSHIP OF FRACTURE TO THE
EXTERNAL ENVIROMENT
– COMPLICATION
– AGE
 Aim fracture treatment
• Relieve pain
• To obtain and maintain satisfactory position
• Allow fracture union
• Restore optimum function
 General Principal
• Recognition
• Reposition
• Retention
• Rehabilitation
 Treatment
• ATLS ( Primary and Secondary survey)
• Specific of definitif tx
– Protection only
– Immobilization
– Closed reduction and immobilization
– Closed reduction and continous traction and immobilization
– Closed reduction and Fuctional Bracing
– Closed reduction and External skeletal fixation
– Closed reduction and Internal Fixation
– ORIF
– Excision of fracture fragment and replacement by
endoprostesis
 Treatment
• Diagnosis
• Age ( Child, Adult, Elderly)

• Quartet Fracture
– Hold vs Move
– Speed vs Safety
General Principles
and Spesific
Methods of
Musculoskeletal
Treatment
 General Principles of Treatment
• In the practice of medicine, general principles
are formulated from natural laws (“laws of
nature”) – laws of the behavior of body tissues
under various conditions as well as laws of
human behavior – laws that you must constantly
respect
• It is important not only to know what you are
doing or planning to do but also to know the
reason why
 General Principles of Treatment
1. First do no harm (primum non nocere)
• Although methods of treatment have a potential for great benefit,
they also have a potential for great harm
• In planning a method of treatment for your patients, its potential
benefit must be weighed against its potential harm
2. Base treatment on an accurate diagnosis and prognosis
• You will not be helping your patients as much as you should if you
treat only a secondary manifestation of their disease (a symptom or a
sign) without making an accurate diagnosis of the underlying or
primary disease
 General Principles of Treatment
3. Select treatment with specific aims
• Chief complaints of patient with musculoskeletal disorders and
injuries are :
a) Pain
b) A decrease in function
c) The physical appearance of either a deformity or an abnormal gait
• The musculoskeletal treatment will have as its specific aim one or
more of the following
a) The relief of pain
b) The improvement of function
c) The prevention or correction of deformity
d) The improvement of gait
4. Cooperate with the laws of nature
• Must appreciate the natural laws of the behavior of body tissue
under various circumstances in order to work with them through
the appropriate choice of a general type of treatment as well as
the specific method and particular technique of treatment
 General Principles of Treatment
5. Be realistic and practical in your treatment
• Certain methods of treatment that may seem
attractive in theory may be neither realistic nor
practical for your particular patient.
6. Select treatment for your patient as an individual
 General Forms of Treatment
• Treatment sometimes described as :
– Conservative (Non operative)
– Radical (Operative)
 General Forms of Treatment
1. Psychological considerations
2. Therapeutic drugs
3. Orthopaedic apparatus and appliance
4. Physical and occupational therapy
5. Surgical manipulation
6. Surgical repair and reconstruction
7. Electrical stimulation
8. Continuous passive movement
9. Radiation therapy
 1. Psychological Consideration
• Ought not treat the body without the mind (Socrates,
400BC)

• For patients with minor disorders or

musculoskeletal variations of normal, the only
type of treatment needed may be reassurance
 2. Therapeutic Drugs
• Analgesics
• Nonsteroid Anti-inflammatory Drugs (NSAID)
• Chemotherapeutic Agents
• Corticosteroids
• Vitamins
• Specific Drugs
 3. Orthopedic Apparatus and
Appliances
A.Rest
Prolonged immobilization of a limb and its synovial
joints is associated with many harmful effects :
Disuse atrophy of local muscles and resultant muscle weakness
Disuse atrophy of local bone (localized osteoporosis)
Local venous thrombosis with resultant edema
The complication of pressure sores (cast sores)
Muscle contractures
Joint capsule contractures
Intra-articular adhesions
 3. Orthopaedic Apparatus and
Appliances
 Relative rest :
1. Preventing its usual function with a sling for an upper limb
2. Crutches for the relief of weight bearing in a lower limb. A
sling for the lower limb may be used with crutches
3. Continuous traction :
a) To stretch gradually soft tissues that have become shortened
secondary to a long-standing joint deformity or dislocation (ex :
continuous traction prior to reduction of a congenital dislocation
of the hip)
b) To relieve painful muscle spasm associated with joint inflammation
or injury
c) To maintain length of the limb and alignment of fracture fragments
in unstable fractures of the shafts of long bone
 3. Orthopaedic Apparatus and
Appliances
A useful method of supporting a painful or
irritable, hip or knee that enables the patient to
move the affected joint freely  combination of slings
and springs
Fairly rigid and continuous local rest
(immobilization)  plaster of Paris casts  is used
to maintain or stabilize the position of a fracture, a
dislocation after reduction, maintain desired
position of a part following injury, surgical
manipulation, or surgical operation.
 3. Orthopaedic Apparatus and
Appliances
 Harmful effects for prolonged immobilization of a limb and
its synovial joint :
1. Disuse atrophy of local muscles and resultant muscle weakness
2. Disuse atrophy of local bone (localized osteoporosis)
3. Local venous thrombosis with resultant edema
4. The complications of pressure sores (cast sores)
5. Muscle contractures, joint capsule contractures, intra-articular
adhesion
 If the limb has been immobilized more than 1 or 2 months,
especially after intra-articular injury or operation, the joint
may never recover completely and may develop secondary
post-traumatic arthritis
 3. Orthopaedic Apparatus and
Appliances
B.Support for Muscle Weakness and Joint Instability
Extensive muscle weakness in the upper limb 
functional braces
A weak or unstable and painful spine  spinal brace
Hypermobile joints in the feet  temporary support by
arch supports and sole wedges
Mild soft tissue injuries of joints  temporary support
with adhesive tape strapping
C.Prevention and Correction of Deformity
 3. Orthopaedic Apparatus and
Appliances
C.Prevention and Correction of Deformity
When development of a joint deformity is anticipated, as
with muscle imbalance in either spastic or flaccid paralysis or
with muscle spasm in chronic arthritis  prevent deformity
by means of intermittent immobilization in a removable
splint made of plaster of Paris
Following correction of a joint deformity and the subsequent
period of immobilization  may necessary to use a
removable splint for intermittent immobilization to prevent
recurrence of the deformity
 4. Physical and Occupational
Therapy
The aims is to regain and maintain joint motion,
to increase muscle strength and to improve
musculoskeletal function.
Physical therapy  focus on gross motor
function
Occupational therapy  fine motor skills
 4. Physical and Occupational
Therapy
• Joint motion
The safest method of regaining motion in a painful
stiff joint  active movement
Intermittent passive movement in a painful stiff
joint is potentially dangerous, especially if it is
forceful
Intermittent passive movement are great in
maintaining joint motion and preventing deformity
in a joint that the patient cannot move actively
because of paralysis
 4. Physical and Occupational
Therapy
• Muscle strength
A muscle is strengthened only by active exercise
Even when a limb is immobilized (as in cast), muscle can be
strengthened by isometric exercise (muscle action without
joint motion)
Isotonic exercise (producing joint motion)  increase muscle
strength and helping regain motion
When muscle has an intact nerve, but inhibited following
injury or operation, it can be electrically stimulated to contract
by faradic current applied to its motor nerve
When muscle has lost its nerve supply gradually atrophies and
undergoes fibrosis, but there is hope of nerve recorvery, these
change can be minimized pending nerve recorvery by galvanic
current that stimulate muscle fibers diretly
 4. Physical and Occupational
Therapy
• Improvement of musculoskeletal function
Functional training involves coordination of muscles
in skillful and purposeful activity by patient.
 5. Surgical Manipulation
The aims are to correct deformity either in a
bone or in a joint, and to regain motion
The great majority of fracture and dislocation
can be treated by manipulation of the part into a
satisfactory position (closed reduction)
 6. Surgical Operations
 Surgical operations have a potential for providing
great benefit to the patient, but they also have a
potential for producing great harm to that patient
 The aims of surgical operation for musculoskeletal
condition :
1. Relief pain
2. Improvement of function and ability
3. Prevention or correction of deformity
 The general methods of operative treatment by
which these aims, are achieved involve various
combination of repair, release, resection, reconstruction,
and replacement of involved tissues
 6. Surgical Operations
• Operations on Muscles, Tendons, and Ligaments
Fasciotomy (relieved closed muscle compartment)
Tenorrhaphy (a cut tendon is repaired by suture)
Free tendon graft (replaced a segment of the tendon that irreparably
damaged by unimportant tendon such as tendon of the plantaris
muscle)
Tenolysis (to free tendon that is tethered by adhesions)
Tenotomy or Tendon lenghtening (correction of a shortened muscle)
Muscle transfer or tendon transfer (paralyzed or damaged muscle
replace by transferring the tendinous insertion (Origin) of a nearby
muscle to improve muscle balance
Tenodesis (in order to check an undisered joint motion, the tendon
of a muscle may be separated from its muscle and implanted into the
bone to serve as a ligament
Ligamentous repair
Ligamentous reconstruction (replace major ligament that are
irreparably damaged by a tendon or free graft of fascia lata)
 6. Surgical Operations
• Operations on Nerves
Nerve suture
Nerve graft
Neurolysis or decompressed
Laminectomy (removing part of the lamina on
protruded intervertebral disc / nucleus pulposus)
Transposition of a nerve (change the course of the
nerve by transposing to the flexor aspect of the joint,
example on ulnar nerve with a cubitus valgus
deformity)
 6. Surgical Operations
• Operations on Joints
Arthrotomy (open the joint)
Capsulorrhaphy (elongated fibrous capsule of the joint is tightened
and repaired, example : reccurent disloction, congenital dislocation)
Capsulotomy (divided or release the shortened fibrous capsule, in
sever joint contracture)
Capsulectomy (resect the shortened fibrous capsule)
Synovectomy (resect the diseased synovial membrane)
Arthroplasty (a reconstructive operation designed to regain or
maintain motion in a chronically painful joint, by means of altering or
replacing one or both joint surfaced)
Arthrodesis (fuse single joint by producing bony union across it)
 6. Surgical Operations
• Prosthetic Joint Replacement (Total Artificial Joint)
The pioneer of modern-day prosthetic join replacement was Sir
John Charnley of England (1962), develpoed low friction
arthroplasty of the hip joint
Prosthetic hip joint repalcement is indicated primarily for :
1. Severe arthritis in patient > 60 years old, and have an average life
expectancy of only 1 or 2 decades.
2. For younger patient with disabling arthrits and serious generalized
disease with limited life expeectancy
Contraindicated for children, healthy young and middle aged adult
 Complication of prosthetic hip joint :
• Loosening of component of the prosthesis
• Fatigue fracture
• Dislocation
• Infection
 6. Surgical Operations

• Osteocartilaginous Allografts
• Gross and Langer used small
Osteocartilaginous Allografts from fresh
cadaver since 1971 on patient with one side of
joint is arthritic
 6. Surgical Operations
• Arthroscopic Surgery
• Removal of loose body
• Partial or total meniscectomy
• Repair of peripheral tears in menisci
• Drilling defect in the articular surface
• Abrading area of chondromalacia
• Synovectomy
• Reconstruction of a torn ACL
 6. Surgical Operations
• Operations on Bones
• Bone drilling (draining pus from the metaphysis)
• Sequestrectomy
• Sauceration (removing cortex on one side)
• Bone resection (removing all part of the bone)
• Osteotomy (division of a bone with a sharp instrument)
• Surgical lengthening of a bone by the Ilizarov technique which
involve Callotasis (delayed and slow distraction of callus)
• Open reduction of a fracture and internal skeletal fixation
• Epiphyseal plate stimulation, Ephipyseal plate arrest, epiphyseodesis,
epiphyseal plate stapling (in leg length discrepancy)
• Bone grafting
• Amputation (remove part or all of the limb through bone)
• Disarticulation (remove part or all of the limb through joint)
 6. Surgical Operations
• Microsurgery
• developed since 1960
• possible to replant completely severed digits and
limbs
 Electrical Stimulation of Fracture
Healing
• Constant direct current through percutaneous
wire cathodes
• Constant direct current through implanted
electrodes and power pack
• Inductive coupling through electromagnetic coil
 Continuous Passive
Movement
• Indications for post operative CPM (in adolescent and adult
patients)
 Arthrotomy, capsulotomy, debridement, and arthrolysis of joints with
painful restriction of motion secondary to post-traumatic arthritis
 Open reduction of intra-articular fractures as well as metaphyseal and
diaphyseal fractures
 Patellectomy
 Repair of ligamentous injuries
 Synovectomy for rheumatoid arthritis and hemophilic arthropathy
 Arthrotomy and drainage (combined with appropriate antibiotics) for
acute septic arthritis
 Biological resurfacing (with periosteal graft) for a major defect in joint
surface
 Surgical repair of a complete laceration of a tendon
 Rigid internal fixation of a metaphyseal osteotomy
 Total prosthetic joint replacement
 Radiation Theraphy
• Used empirically in treatment :
• Langerhans cell histiocytosis
• Ankylosing spondylitis
• Vinonodullar synovitis
o Most serious effect on normal skeletal tissue :
• Epiphyseal plate damage
• Pathological fracture
• Malignancy
 Rehabilitation
• The broad aim of rehabilitation is to correct
physical, mental, social problem of the patient in
order that his or her life may be changed
• Require coordination of a large group, include
rehabilitation physician, the orthopaedic
surgeon, nurse, physical therapist, orthotist and
prosthesist.
Thank You