Orthopedics
I. Rationale
Family physicians encounter a significant number of orthopedic problems in the course of practice. These
illnesses and injuries may be either acute or chronic in nature. A family physician must be prepared to
evaluate patients with orthopedic complaints, diagnose their illness, and formulate a treatment plan
acceptable to the patient. In addition, the family physician must be aware of other resources to the patient,
coordinating rehabilitation, physical and occupational therapy.
The approach to diseases and disorders in orthopedics requires specific attitudes, knowledge and skills.
Residency education is designed to provide experiences in a variety of settings that will give residents
expertise in the diagnosis, prevention, treatment and rehabilitation of orthopedic diseases. These
experiences will include patients of all ages and conditions of congenital, traumatic and degenerative
causes.
The combined burden of medical conditions affecting the musculoskeletal system and this curriculum has
two components: the focused rotation in orthopedics and the longitudinal component which takes place
over time in the Family Practice Center and on other rotations where orthopedic topics may be covered.
II. Competencies
Goals
A. Perform an appropriate musculoskeletal history and physical examination, and formulate an appropriate
diagnosis and recommend treatment, including requisite subspecialty referrals (Patient Care, Medical
Knowledge, Systems-Based Practice)
B. Communicate effectively with a wide range of individuals regarding musculoskeletal health care,
including patients, their families, coaches, school administrators and employers (Interpersonal and
Communication Skills)
III. Objectives
Medical Knowledge (See Appendix A)
A. Demonstrate ability to take a comprehensive history for musculoskeletal complaint.
B. Demonstrate a focused musculoskeletal exam.
C. Review the diagnosis and management/referral of the following fractures/dislocations:
1. cervical fracture
2. clavicular fracture
3. humeral neck fracture
4. humeral shaft fracture
5. supracondylar elbow fracture
6. radial head/neck fracture
7. radial shaft fracture
8. distal radial fracture
9. scaphoid fracture
10. metacarpal fracture
11. phalangeal fracture
12. rib fracture
Last updated March 7, 2013
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
femoral neck fracture
femoral shaft fracture
tibial plateau fracture
tib/fib fracture
distal fibular fracture
distal tibia fracture
calcaneal fracture
metatarsal fracture
toe fracture
facial fracture
skull fracture
stress fracture
finger dislocation
radial head dislocation
glenohumeral dislocation
patellar dislocation/subluxation
D. Review the diagnosis and management of the following soft tissue injuries.
1. cervical sprain/strain
2. low back strains
3. AC joint sprain
4. stemoclavicular sprain
5. medial collateral ligament sprain (elbow)
6. triangular fibrocartilage complex tear
7. muscle contusions
8. medial collateral ligament sprain (knee)
9. lateral collateral ligament sprain (knee)
10. anterior cruciate ligament sprain
11. posterior cruciate ligament sprain
12. meniscus tear
13. ankle sprain
14. calf sprain
15. rotator cuff tendonopathies
16. medial and lateral epicondylitis
17. patellofemoral syndrome
18. ITB friction syndrome
19. tendinitis/bursitis
20. plantar fasciitis
21. symptomatic plica
E. Review the diagnosis and management of infectious arthritis and osteomyelitis in both adults and
children.
F. Review the diagnosis and management of neurologic injuries:
1. Peripheral neuropathies
2. Reflex sympathetic dystrophy
3. Entrapment syndromes
4. Compartment syndromes
5. Radiculopathies
G. Learn to recognize the presentation of bony tumors.
H. Understand special considerations in pediatric orthopedics including:
Last updated March 7, 2013
1. Salter-Harris classification of fractures
2. Congenital disorders (hip dysplasia, tibial torsion and anteversion, metatarsus adductus,
club foot)
3. Slipped capital femoral epiphysis
4. Apophysitis (Osgood-Schlatter's disease, Sever's disease, Sindig-Larsen-Johansen
syndrome)
5. Osteochondritis dissecans
6. Orthopedic signs of child abuse
I. Understand special considerations in geriatric orthopedics including:
1. Degenerative joint disease
2. Hip replacement
3. Osteoporosis
4. Paget's Disease of Bone
5. Bony metastases
J. Know the indications for diagnostic imaging (plain radiographs, bone scans, CT, tomograms, MRI)
and interpretation of these tests.
K. Understand the role of the family physician in the operative care of the orthopedic patient
including1. Preoperative evaluation
2. Assisting in the operating room
3. Recognizing and managing both orthopedic and medical complications of orthopedic
surgery
L. Understand the role of rehabilitation, and physical and occupational therapy in the care of the
patient with an orthopedic illness.
M. Learn a set of procedural skills essential to the practice of family medicine and will select
advanced procedural skills appropriate to anticipated future practice needs.
1. Know how to apply splints and casts.
2. Demonstrate the techniques for aspiration/injection of the knee and shoulder.
3. Demonstrate the technique for trigger point injections.
N. List indications for referral to an orthopedic surgeon.
Learning Activities
Attending Rounds
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty
Conference
X
Morning Report
X
Didactics
Other
X
X
Evaluation Methods
X
Attending Evaluation
X
X
X
Program Director
Review
Last updated March 7, 2013
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Faculty Supervision
Procedures
X
Readings
Directly Supervised
Procedures
In-Training Exam
X
Morning Report
X
Faculty Supervision
and Feedback
X
360 ᵒ evaluation
Other
X
Videotape Review
X
Quarterly Review
Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical
principles, and sensitivity to a diverse patient population. Residents are expected to:
A. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and
society that supersedes self-interest; accountability to patients, society, and the profession; and
a commitment to excellence and on-going professional development.
B. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical
care, confidentiality of patient information, informed consent, and business practices.
C. Demonstrate sensitivity and responsiveness to patients' culture, age, gender, and disabilities.
D. Arrive at the clinic in a timely fashion.
E. Work effectively as a member of a team.
F. Respect patient privacy by guarding medical records and discussion of personal
information about patients.
G. Assist patients and their families in planning for future care needs and care decisions based on
prognosis for the disease.
H. Support the patient in their healthcare decisions.
I. Demonstrate professional, respectful demeanor when addressing team members, patients,
ancillary staff, and consultants.
J. Appear professionally dressed and well groomed.
K. Completes H&P’s, progress notes and discharge summaries in a timely fashion.
L. Attends required daily conferences and grand rounds.
M. Responds to pages and floor calls in a timely fashion.
N. Understand the need for and engage in continuing self-education about updates in diagnostic
imaging.
Learning Activities
Attending Rounds
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty
Conference
Morning Report
X
Didactics
Other
X
Evaluation Methods
X
Attending Evaluation
X
X
Program Director
Review
360 ᵒ evaluation
Other
Last updated March 7, 2013
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Faculty Supervision
Procedures
X
Readings
X
Directly Supervised
Procedures
In-Training Exam
Morning Report
X
X
Videotape Review
X
Faculty Supervision
and Feedback
Quarterly Review
Interpersonal and Communication Skills
Residents must be able to demonstrate interpersonal and communication skills that result in effective
information exchange and teaming with patients, their patients families, and professional associates.
Residents are expected to:
A. Develop patient sensitive skills for interviewing that allow accurate, and complete collection of
information regarding symptoms, the family and the community that affect the patient's health and
care.
B. Develop skills in communicating results to patients, their families, other health care providers.
C. Develop skills in educating patients and their families, in dealing with sensitive issues for patients
and families, and in negotiating a plan of investigation and treatment with the patient and family.
D. Develop professional relationships with co-workers, consultants, ancillary staff and other
professionals to enable assembling of health care teams and mobilization of community resources to
optimize care of the patient.
E. Develop an understanding of the role of the family medicine consultant, and is able to support the
patient through the process of consultation, medical evaluation, treatment, rehabilitation and longterm care.
F. Use professional language and demeanor when communicating with other residents, with Family
Medicine attending physicians, with physicians from other services, with non-physician clinical staff,
with non-physician non-clinical staff, and with patients and their families.
G. Create and sustain a therapeutic and ethically sound relationship with patients.
H. Use effective listening skills and elicit and provide information using effective nonverbal,
explanatory, questioning, and writing skills.
I. Work effectively with others as a member or leader of a health care team or other professional
group.
J. Be able to give the patient informed consent on any diagnostic or therapeutic procedures to be
performed in a manner understandable to the patient.
K. Be able to present the patient and family members with a diagnosis and treatment plan in terms
that they understand.
L. Be able to answer questions the patient and family may have concerning the diagnosis, tests and
treatment as well as address any concerns they may have about them.
M. Learn to communicate efficiently and effectively with orthopedic consultants.
Learning Activities
Attending Rounds
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty
Conference
Morning Report
X
Didactics
Other
X
Evaluation Methods
X
Attending Evaluation
X
X
X
X
Program Director
Review
360 ᵒ evaluation
Other
Last updated March 7, 2013
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
X
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Faculty Supervision
Procedures
X
Readings
Directly Supervised
Procedures
In-Training Exam
Morning Report
X
Videotape Review
X
Faculty Supervision
and Feedback
Quarterly Review
Systems-based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
health care and the ability to effectively call on system resources to provide care that is of optimal value.
Residents are expected to:
A. Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and the larger society and how these elements of the
system affect their own practice.
B. Know how types of medical practice and delivery systems differ from one another, including
methods of controlling health care costs and allocating resources.
C. Practice cost-effective health care and resource allocation that does not compromise quality of care.
D. Advocate for quality patient care and assist patients in dealing with system complexities.
E. Know how to partner with health care managers and health care providers to assess, coordinate,
and improve health care and know how these activities can affect system performance.
F. Learn the most cost-effective way of diagnosing and managing orthopedic complaints.
G. Learn to bill appropriately for procedures, including casting and splinting, cast care, and
injection/aspiration.
Learning Activities
Attending Rounds
X
Multidisciplinary Rounds
X
Grand Rounds
Sub-Specialty
Conference
Morning Report
X
Didactics
Other
X
Evaluation Methods
X
Attending Evaluation
X
X
X
Program Dir
Review
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Faculty Supervision
Procedures
X
Readings
Directly Supervised
Procedures
In-Training Exam
Morning Report
X
Faculty Supervision
and Feedback
Practice-based Learning and Improvement
Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate
scientific evidence, and improve their patient care practices. Residents are expected to:
A. Analyze practice experience and perform practice-based improvement activities using a
systematic methodology.
B. Locate, appraise, and assimilate evidence from scientific studies related to their patients' health
problems.
C. Obtain and use information about their own population of patients and the larger population
from which their patients are drawn.
D. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and
other information on diagnostic and therapeutic effectiveness.
E. Use information technology to manage information, access on-line medical information; and
support their own education.
G. Learn to incorporate health promotion and disease prevention into patient care.
Last updated March 7, 2013
H. Use evidence-based medicine, evaluation of available evidence, and use of best-available
evidence at morning report meetings and during routine clinical care.
Learning Activities
Attending Rounds
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty
Conference
X
Morning Report
X
Didactics
Other
X
Evaluation Methods
Attending Evaluation
X
X
Program Director
Review
360 ᵒ evaluation
Other
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
X
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Faculty Supervision
Procedures
X
Readings
X
Directly Supervised
Procedures
In-Training Exam
Morning Report
X
X
Videotape Review
X
Faculty Supervision
and Feedback
Quarterly Review
IV. Instructional Strategies and Assignments (see above)
A. Self Study: Orthopedics in Primary Care, Ramamurti Read: Hoppenfeld
AFP Monograph #’s 254, 272, 273, 307, & 322
B. Assessment of actual patients in preceptor's office and on orthopedic service
C. Management of actual patients in continuity clinic with case discussions
D. Ambulatory care conference
E. Casting workshop during Orientation
F. Attend weekly Family Medicine didactic conferences
G. Associated rotations: rheumatology, sports medicine, radiology, family medicine, pediatrics,
emergency medicine
V. Evaluation Strategies (see above)
The resident will be evaluated on the basis of achievement of rotation objectives by preceptors in the FPC
clinic and by the rotation coordinator. The written evaluation will be done on the FPC Rotation Evaluation
Form.
A. Observation of resident by orthopedic preceptor
B. Observation of resident by clinic preceptor
C. Procedure/ diagnosis documentation – Demonstrated knee joint aspiration and injection
competency
C. Attendance at conference series
D. End of rotation evaluation
E. Read a minimum of 4 AFP Monographs.
Last updated March 7, 2013
VI. Implementation Methods
Locations:
Brandon Mines, MD
R. Amadeus Mason, MD
Assist: Rachel Zgrabik
Rachel.zgrabik@emoryhealthcare.org
Orthopedic and Spine Center @ Executive Park
59 Executive Park South, 1st Floor, Suite 100
Atlanta, GA 30329
404-778-3350
Jeff Traub, MD
Gwinnett Bone & Joint
2400 Wisteria Drive, Suite A
Snellville, GA
770-979-2940 ofc
770-564-0001 fax
Family Practice Center: Four half days per week
Schedule:
Monday
Mines/Mason all
day @ Executive
Park office
Tuesday
Wednesday
FPC (am)
Traub (am)
Snellville Ofc.
FP didactics (am)
Mines/Mason @
Executive Park
FPC (pm)
FPC (pm)
FPC (pm)
Traub
Decatur Ofc
(pm)
Thursday
Friday
There are two orthopedists seeing patients per half day. This is not a schedule fixed in stone, but a
framework that will give you a broad exposure to different areas over the month rotation. If you and one of
the preceptors plan on you attending surgery on one of the patients, please communicate this to the person
expecting you for that day, so you do not appear to be: "missing in action."
Call/Vacation: Rotation call for the Family Practice Service. Encouraged to contact the Orthopedist on call
on those nights for additional emergency care experience. Vacation allowed.
Supervision: All orthopedists in the outpatient clinics participate in teaching and evaluation. Each is
responsible for the summary evaluation completion.
Conferences: The resident is expected to attend all family medicine didactics conferences. These will be
held Thursday at 800 am – 1200 pm.
Last updated March 7, 2013
Appendix A
Objectives
A. Demonstrate the ability to obtain a focused yet comprehensive history for musculoskeletal
complaints.
B. Demonstrate a comprehensive exam of the neck, hand, wrist, elbow, shoulder, back, hip, knee,
ankle, and foot.
C. Evaluate patients presenting with fractures, including the pertinent history, exam, diagnostic
imaging; correct identification of the fracture; and recommend a treatment plan.
D. Evaluate patients presenting with soft tissue injuries, including the pertinent history, exam,
diagnostic imaging; formulate a differential diagnosis; and recommend a treatment plan.
E. Evaluate and manage patients with infectious arthritis’s and osteomyelitis, when they present
Either in the outpatient or inpatient setting.
F. Evaluate patients presenting with neurologic injuries, including the pertinent history, exam,
diagnostic testing; formulate a differential diagnosis; and recommend a treatment plan.
G. List key features common in the presentation of bony tumors.
H. Describe special considerations in pediatric orthopedics including:
1. Listing the Salter-Harris classification of fractures.
2. Diagnosis and management of congenital problems.
3. Diagnosis and management of slipped capital femoral epiphysts.
4. Diagnosis and management of apophysitis.
5. Diagnosis and management of osteochondritis dissecans.
6. Listing fractures indicative of potential child abuse and describing the subsequent work
up.
I. Describe special considerations in geriatric orthopedics including:
1. The diagnosis, treatment, and natural course of degenerative joint disease
2. Indications for hip replacement and subsequent management of the patient with a hip
replacement
3. Prevention, diagnosis, and treatment of osteoporosis
4. Diagnosis, treatment, and prognosis of Paget's Disease of Bone
5. Common sites of bony metastases and subsequent work up of primary tumors
J. List indications for any diagnostic imaging obtained and provide correct interpretation of the test.
K. Describe:
1. The role of the family physician as part of the medical team caring for a patient with an
orthopedic problem
2. The preoperative assessment.
3. The role of the family physician as an assistant in the operating room.
4. Five common orthopedic and medical complications of orthopedic surgery and their
management.
5. Post-operative pain management techniques.
L. Describe the role of the rehabilitation team in the care of the patient with an orthopedic problem;
citing benefits of physical and occupational therapy, and write concise, informative physical and
occupational therapy referrals for patients managed.
Last updated March 7, 2013
M. Demonstrate the technique of applying the following casts and splints:
1. Short leg cast
2. Short arm cast
3. Posterior elbow splint
4. Posterior ankle splint
5. Ulnar gutter splint
6. Thumb spica splint
7. Sugar tong splint
8. Shoulder immobilizer
9. Tennis elbow splint
10. Knee immobilizer
11. Ankle air cast
12. Wrist splint
13. Finger splints
N. Demonstrate or describe proper technique in the aspiration/injection of the knee and shoulder.
O. Demonstrate or describe the proper technique for trigger point injection
P. List indications for referral to an orthopedic surgeon.
Q. Conduct informed consent on all patients undergoing diagnostic or therapeutic procedures in a
manner understandable to the patient.
R. Discuss the diagnosis and treatment plan with all patients assessed or managed in a manner
understandable to the patient.
S. Review patient questions with all patients managed and detect any concerns they may have.
T. Prepare a consultant referral form which contains a complete and succinct summary of the
patient's diagnosis, accurate description of any fracture present, the question for the consultant,
and other information pertinent to the referral.
U. Review the cost of all diagnostic imaging, testing, and treatment, including physical therapy,
performed on three patients and determine the most cost effective way of arriving at the
diagnosis and treatment.
V. Use appropriate codes for billing of services provided during the care of patients with orthopedic
problems.
W. List sources to which the resident may turn for more information or continuing education on
orthopedic illnesses.
Last updated March 7, 2013