Master Specialist Orthopedic Surgery (ORT5971)
for DHA Speciality

Core Concepts

Specialist Orthopedic Surgery encompasses the diagnosis, treatment, and prevention of musculoskeletal disorders involving bones, joints, ligaments, tendons, muscles, and nerves. Key principles include preserving function, alleviating pain, restoring stability, and improving quality of life. Core areas involve trauma (fracture management, dislocations), degenerative conditions (osteoarthritis, spinal stenosis), sports injuries (ligamentous tears, tendinopathies), infections (osteomyelitis, septic arthritis), tumors (primary, metastatic), and congenital/developmental conditions. Biomechanics, surgical anatomy, fracture healing biology, and rehabilitation are fundamental.

Clinical Presentation

• Pain: Most common symptom. Character (sharp, dull, aching, burning), intensity, location (localized, radiating), aggravating/alleviating factors (rest, activity, night pain), onset (acute, chronic).
• Deformity: Gross (e.g., angulation, rotation of a limb), subtle (e.g., scoliosis), or joint specific (e.g., valgus/varus).
• Swelling/Effusion: Localized tissue swelling, joint effusion (hemarthrosis, inflammatory fluid).
• Loss of Function/Reduced Range of Motion (ROM): Difficulty with weight-bearing, specific movements, grip strength, inability to perform daily activities. Passive vs. active ROM.
• Instability/Locking/Giving Way: Sensation of joint shifting, catching, or sudden weakness, common in ligamentous injuries or meniscal tears.
• Neurological Symptoms: Paresthesia, numbness, weakness, foot drop, radicular pain, myelopathic symptoms (gait disturbance, spasticity, bladder dysfunction).
• Systemic Symptoms: Fever, chills, night sweats, weight loss (suggestive of infection, malignancy).
• Crepitus: Grating sound/sensation with movement.

Diagnosis (Gold Standard)

Diagnosis begins with a thorough history and detailed physical examination. The "gold standard" often depends on the specific condition:
Clinical Examination: Cornerstone, including inspection, palpation, ROM assessment, provocative tests (e.g., Lachman for ACL, Trendelenburg for hip abductor weakness, Spurling for cervical radiculopathy).
X-ray: Initial imaging for trauma (fractures, dislocations), alignment, degenerative changes, bone lesions. AP/Lateral views are standard.
MRI: Gold standard for soft tissue injuries (ligaments, tendons, menisci, labrum), spinal cord/nerve root compression, bone marrow pathology (osteomyelitis, avascular necrosis, occult fractures), and tumor staging.
CT Scan: Gold standard for complex fractures (intra-articular, pelvis, spine), pre-operative planning, assessing cortical bone lesions, and evaluating spinal canal stenosis.
Bone Scan (Technetium-99m): Useful for stress fractures, osteomyelitis, metastatic disease, and identifying occult fractures or widespread inflammatory processes.
Arthrocentesis/Joint Aspiration: Gold standard for diagnosing septic arthritis (cell count, culture) and crystal arthropathies.
Nerve Conduction Studies/EMG: Gold standard for diagnosing and localizing peripheral neuropathies and radiculopathies.
Biopsy: Gold standard for definitive diagnosis of bone tumors and infections (histology, culture).

Management (First Line)

Management ranges from conservative to surgical, tailored to the patient, pathology, and functional goals.
Conservative:

• Rest, Ice, Compression, Elevation (RICE): Acute injuries.
• Analgesia: NSAIDs, acetaminophen, neuropathic agents.
• Physical Therapy & Rehabilitation: Crucial for restoring strength, flexibility, proprioception, and function (e.g., post-op, chronic pain, non-surgical management of tendinopathies, OA).
• Bracing/Splinting/Casting: Immobilization for fractures, ligamentous injuries, stability (e.g., osteoarthritic knee brace).
• Injections: Corticosteroids (e.g., tendinopathies, bursitis, certain arthritides), hyaluronic acid (knee OA), PRP (limited evidence for some conditions).

• Trauma: Open Reduction Internal Fixation (ORIF), intramedullary nailing, external fixation, arthroplasty (e.g., hemiarthroplasty for displaced femoral neck fracture).
• Degenerative: Total Joint Arthroplasty (THA, TKA), osteotomy (joint preservation), spinal decompression (laminectomy), fusion (arthrodesis).
• Sports Injuries: Arthroscopic repair/reconstruction (e.g., ACL reconstruction, meniscal repair, rotator cuff repair), debridement.
• Infections: Incision and drainage (I&D), debridement, antibiotic therapy (IV and oral).
• Tumors: Resection (limb salvage, amputation), reconstruction.