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