FATHER OF

ORTHOPAEDICS

HUGH OWEN THOMAS

Introduction to Orthopaedics

Orthopaedics - introduction
Branch of science that is concerned with bones,
joints, muscles, ligaments, tendons and nerves.
i.e. skeletal system and all that makes it move.
French Professor of Medicine
Nicolas Andry - book entitled
L'Orthopdie - 1741
Greek words
Orthos - straight : upright : vertical
Paidion - child

Orthopaedics - introduction
Goal
The broad goal of teaching
Orthopaedics to
undergraduate students is that
1. he / she shall acquire
understanding of related
anatomy, physiology and
pathophysiology of the
musculoskeletal system and
2. gain the ability to optimally
manage common conditions
affecting it.

Orthopaedics - introduction
Basic requirements in the understanding
Sound knowledge of Anatomy of limbs and spine
Development of bones and joints
Basic osteology, histology & physiology of bones
Muscles and nerves
Origin and Insertion
Nerves supplying the muscles
Action of the muscles
Course of the nerves
Dermatomes

Orthopaedics - introduction
Text
Essential Orthopaedics : J.Maheshwari
Book of Orthopaedics & Traumatology :
M.Natarajan & Mayilvahanan Natarajan
Apleys System of Orthopaedics and Fractures

Clinical
Manual of Clinical Surgery : S.Das
Clinical Orthopaedic Examination : Ronald McRae
Physical Examination in Orthopaedic Surgery :
Lee Joon Kiong

Orthopaedics - introduction
Reference
Apleys system of Orthopaedics & Fractures
A.Graham Apley and Louis Solomon
Clinical Oriented Anatomy
Keith L. Moore and Arthur F. Dalley

Orthopaedics - introduction
Interesting super specialty subject
Anatomy forms the basics
Rapidly developing
Scope
Orthopaedic / ians will thrive as long
as there are vehicles on roads !!!!!!!

Largely mathematical + Common sense

Orthopaedicians:
Royal carpenters / cabinet makers.
No room for error.
Cannot hide sins !!!!

Compassionate. Excellent clinician. Good

listener. Meticulous. Great sense of humor.
Open-minded. Attentive. Progressive.
This is how patients and colleagues describe
Scott Zashin, MD.
has been selected as a Super Doctor
by Texas Monthly magazine,
as one of the Best Doctors in Dallas by
D Magazine,
as one of the Best Doctors in America
by Best Doctors, Inc. every year since
1996.

Scott Zashin, M

Key to clinical success

A GOOD CLINICIAN
Disciplined approach
Hard work
Sincerity
Honesty
Constant questioning and introspection
What / When / Where / Why / How ?????
Sound theoretical knowledge: especially the
basics

Behind the enquiring head there should

intelligent mind ..
Lawrence

always be an

Orthopaedics - introduction
History Taking
- Chief complaints in chronological order of duration
- History of presenting illness
- Elaboration of chief complaints in the duration
mentioned till date of examination
- All positive and significant negative points to be
highlighted.
- Past history : All history of the past until just before the
onset of present complaints.
- Personal history : menstrual history where applicable
- Social history

Orthopaedics - introduction
History
Analysis of the history
Arriving at a logical conclusion : differential diagnosis
Parts of a complete diagnosis
Anatomy - Site and side
Aeitiology - Cause
Pathology Classification / Stage
Complications
Points in favor of every aspect of each diagnosis
Diagnosis at this stage: based on the SYMPTOMS
alone

Orthopaedics - introduction
Diagnosis at the end of the history
Post-traumatic, closed, displaced fracture of the
upper one third of the shaft of the right tibia and
fibula with no associated neuro-vascular deficit
Differential Diagnosis
Taking the diagnosis to the examination
Look for SIGNS of the diagnosis or differential
diagnosis on examination
Keep an open mind and follow protocol of
examination of the part / region

Orthopaedics - introduction
Examination
Based on the differential diagnosis
Every aspect of the examination process should try to
get points in favor of or against each of the differential
diagnosis made at the end of history taking
Keep an open mind and be alert to pick up findings
clinical signs that may be present in the patient which
may not be part of the differential diagnosis made at
the end of the history : may change the entire thought
process

Orthopaedics - introduction
Examination
Inspection
Palpation
Movements
Measurements
Special tests
Diagnosis at the end of the clinical history and
examination process : based on the history and
clinical examination findings

Orthopaedics - introduction
Investigations
To arrive at a diagnosis
Confirm the diagnosis
Investigations that may be required in the
management of the patient : eg : in preparation
for surgery
Final diagnosis
Based on clinical history, examination and
investigation

Orthopaedics - introduction
Basic need to arrive at a logical diagnosis
To identify the disease process
Decent knowledge of the subject

In Orthopaedics
Diseases leave long lasting after effects : disability
Percentage of disability

Treatment
Disease process
Functional loss
Looking into various aspects of the patient

BASIC SCIENCES
ANATOMY

Development and Structure of bone

Development and structure of the bone

Bone develops from mesenchyme
Develops in specific period of embryonic
life : susceptible to external toxic influence
Cartilage develops in the 5th embryonic life
Number of weeks after conception
Bone first appears after 7th embryonic week

Development and structure of the bone

Bone : Two types
Membranous :
Facial, Cranial
Cartilaginous : long bones

Membranous bone
Original model :
mesenchymal
Intra-membranous radial
ossification
Peripheral mesenchyme :
periosteum

Development and structure of the bone

Cartilaginous bone
Develop from cartilaginous model
Endochondral & periosteal ossification
Length and breadth of bone
Cartilage replaced by bone

Structure of the bone

Specialised connective tissue with
mineralised collagenous framework.
Function

Skeletal support of body

Muscular attachments

Shape of the body

Types of bones:

Long, flat, small

Cortical / compact
spongy / cancellous
Basic structural unit of a bone
is called as the Haversian system or
an Osteon

Parts and Structure

of the bone

Joints : Form where bones meet

Three basic types:

Synarthrosis : little movement

Amphiarthrosis : Slightly movable

Diarthrosis : free movement

Fibrous : Suture : (Synarthrosis) : Skull
Syndesmosis: (amphiarthrosis) : Distal
tibiofibular, radioulnar, Sacroiliac
Gomphosis : (synarthrosis):Tooth and socket
Cartilage: Synchondrosis : (Primary Cartilaginous,
Synchondrosis or amphiarthrosis) : Physeal
plate
Symphysis: (Secondary Cartilaginous,
Amphiarthrosis) : Pubis, Intervertebral disc

Joints
Synovial: Diarthrosis
Joint cavity, Synovial membrane and fluid, articular
surface (hyaline cartilage), ligaments, bursae
Types:
Gliding : Acromio-clavicular, Intercarpal
Hinge: Elbow, Ankle
Pivot : Atlanto - axial, Distal radio-ulnar
Condyloid: Knee
Saddle : Sterno-clavicular
Ball and socket : Hip, Shoulder

Joints
Terms used to describe movements possible:
Flexion / Extension , Hyperextension
Abduction / Adduction , Horizontal abd / add
Circumduction, Inward / Outward Rotation
Lateral flexion, Plantar / dorsal flexion
Inversion / Eversion, Pronation / Supination
Elevation / Depression, Protraction / retraction
Opposition / reposition

Muscles, Ligaments and Nerves

Muscles
Muscles of the limbs, back and abdomen
Origin and insertion
Function of individual muscle
Ligaments : important ligaments of joints
Nerves
Root value
Course
Surface anatomy
Branches of individual nerves
Flow chart of individual nerves to show level of
individual branches : Snells Anatomy

BASIC SCIENCES

PHYSIOLOGY OF BONE

Bone physiology
Bone is a living, growing
tissue.
It is a porous mineralized
structure, made up of cells,
vessels, crystals of calcium
compounds (hydroxyapatite)
proportion varies
according to bone types
and regions.

Bone physiology
Content
Organic : 25%
Bone cells: (4%) :
Mesenchymal precursor cells
Osteoblasts, osteocytes, osteoclasts
Intercellular matrix: (21%):
Collagens, protein polypeptides, proteoglycans,
lipids
Inorganic : 65 % :
Hydroxyapatite crystals, amorphous calcium
phosphate, other ions : Na, K, Mg, Fl, Citrate
Water : 10%
Cellular, extra-cellular and in crystals

Bone physiology
The human skeleton is made up of 2 types of bones:
cortical bone
trabecular bone

Cortical Bone
Represents nearly 80% of the skeletal mass.
Also called compact bone
Forms a protective outer shell around every
bone in the body

Trabecular or Cancellous Bone

Represents 20% of the skeletal mass
Less dense, more elastic and has a higher turnover
rate than cortical bone.

Bone physiology
Trabecular or Cancellous Bone
Found in epi & metaphysal
regions of long bones and
the interior of short bones.
Constitutes most of the bone
tissue of the axial skeleton:
bones of the skull, ribs and spine.
Forms interior scaffolding & helps bone maintain
shape despite compressive forces.
Appears spongy but rigid - composed of bundles
of short and parallel strands of bone fused together.
Center contains red, yellow marrow, bone cells

Bone physiology
Bone remodeling cycle
Two main types of cells are responsible :
Osteoblasts involved in bone formation
Osteoclasts involved in bone resorption.

Stages in bone remodeling

1. Activation: Preosteoclasts stimulated &
differentiated under influence of cytokine
& growth factors into active osteoclasts.
2. Resorption: Osteoclasts digest mineral
matrix, old bone.
3. Reversal: End of resorption
4. Formation: bone matrix synthesized (collagen) by
osteoblasts
5. Quiescent phase

Bone physiology
Regulation of bone remodeling
Bone formation and resorption are influenced by
many factors like:
Parathyroid hormone (PTH):
Can increase the recruitment and the cavity
of osteoblasts and osteoclasts.
If the PTH secretion is too high, there is an
acceleration of the bone turnover.
If the increase occurs along a Vitamin D
deficiency, the bone cycle is accelerated and
entails bone loss.

Regulation of bone remodeling

EFFECT OF PTH AND VIT D

Bone physiology
Regulation of bone remodeling

Vitamin D:
Plays a part in the mineralization of bone
matrix
Lack of Vitamin D results in osteomalacia
(impaired mineralization) and too much
Vitamin D entails bone loss
Other important factors
Estrogens / progesterone, calcitonin,
glucocorticoids, androgens, mechanical
constraints & genetic background

BONE PATHOLOGY

Orthopaedics - an introduction
All conditions affecting the musculo-skeletal
system can be classified into one of the following
categories:
1. Congenital
2. Developmental
3. Metabolic
4. Orthopaedic neurology
5. Trauma

6. Inflammation
7. Infection
8. Tumor / tumor like
9. Degenerative