MB, ChB Phase III – Theory Modules
	Musculoskeletal System 52302 471 2010

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MB, ChB

Phase III – Theory Modules

2010

MUSCULOSKELETAL SYSTEM

52302 471

editor:

Dr ICM Robertson

MUSCULOSKELETAL SYSTEM

DESCRIpTION OF MODULE

theme 1: MUSCULOSKELETAL TERMINOLOGY AND DEFORMITIES. 1

THEME 2: CLINICAL EXAMINATION METHODS. 4

Session 1: Linear And Rotational Deformities Of The Limbs, Gait, Differences In Bone Length And The Examination Of A Joint 5

Session 2: Pain Staging, Muscle power, Spasticity, Myotome Innervation, Dermatome Innervation, LMN Lesion and UMN Lesion. 6

Session 3: Examination Of the Neck And Shoulder 7

Session 4: Examination Of the Back. 8

Session 5: Examination Of the Elbow, Forearm And Hand. 9

Session 6: Clinical Examination Of the Hip And The Knee joint 10

Session 7: Examination Of the Foot And Ankle. 11

THEME 3: IMAGING INVESTIGATIONS OF THE MUSCULOSKELETAL SYSTEM.. 12

Session 1: Useful Imaging Investigations. 12

Session 2: General Radiological Characteristics Of Traumatic And Non-Traumatic Bone And Joint Conditions  13

Session 3: Nuclear Medicine As Imaging Modalities In The Musculoskeletal System.. 14

THEME 4: INFECTIVE CONDITIONS OF THE MUSCULOSKELETAL SYSTEM.. 15

Session 1: General Pathological Principles. 15

Session 2: Self-Study. 16

Session 3: Microbiological Aspects Of Bone, Joints And Soft Tissue Infection. 18

Session 4: Pharmacological Aspects Of Antibiotics In Infections. 19

Session 5: Acute Septic Arthritis And Osteomyelitis. 19

Session 6: Non-Pyogenic Infections Of Bone And Joints. 20

Session 7: Clinical Problem Solving Chronic Osteomyelitis. 21

Session 8: Hand Infections. 22

theme 5: APPROACH TO POLYARTHRITIS. 24

Session 1: Rheumatoid Arthritis. 24

Session 2: Interactive Small Group Training. 25

Theme 6: APPROACH TO a PATIENT WITH GENERALISED pain. 26

Session 1: Soft Tissue/Rheumatic/Regional Pain Syndrome. 26

Session 2: Paramedical Role In Rheumatology. 27

Session 3: Self-study. 27

THEME 7: APPROACH TO THE PATIENT WITH MONO/OLIGO ARTHRITIS. 29

Session 1: The Patient With Mono-Arthritis/Oligo Arthritis. 29

Session 2: Seronegative Spondarthropathy/Infection And Arthritis. 30

Session 3: Case Study. 31

Session 4: Small Group Interaction. 31

Theme 8: approach to the patient with non-specific systemic diseases. 32

Session 1: Auto-Immune Diseases – SLE As a Prototype. 32

Session 2: Scleroderma, Dermatomyositis, Vasculitis. 33

Session 3: Self-Study. 33

Session 4: Case Study. 33

Theme 9:other topics in rheumatology. 34

Session 1: Paediatric Rheumatology. 34

Session 2: Pharmacology. 34

Session 3: Slide Show/Revision. 35

Session 4: Slide Show Portion Of Assessment 35

THEME 10: CONGENITAL AND DEVELOPMENTAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM   36

Session 1: Linear And Rotation Deformities Of The Lower Limbs, Leg Pains In Children And Osteochondroses  37

Session 2: Congenital Club Feet, Metatarsus Adductus, Cavus Feet And Flat Feet In Children. 38

Session 3: Congenital Hip dysplasia, Perthes’ Diseases Of the Hip And Sliding Proximal Femoral Epiphysis  39

Session 4: Orthopaedic Aspects Of Cerebral Palsy And Neuromuscular Diseases. 40

THEME 11: ONCOLOGICAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM.. 42

Session 1: General Pathological Principles. 42

Session 2: Primary And Secondary Bone tumours. 44

Session 3: Soft Tissue Tumours. 46

THEME 12: CONDITIONS OF THE PELVIS AND SPINAL COLUMN. 47

Session 1: Scoliosis And Kyphosis. 47

Session 2: Neck Pain And Back Pain In Adults. 48

THEME 13: CONDITIONS AND DEFORMITIES OF THE UPPER LIMB. 50

Session 1: Neurological Evaluation Of the Upper Limb. 50

Session 2: The Brachial Plexus - Self-study. 51

Session 3: Degenerative Arthritis, Rotator Cuff Lesions And Instability Of The Shoulder Girdle. 52

Session 4: Epicondylitis And Arthritis Of the Elbow joint, Swellings around The Wrist, De Quervain Synovitis, Kienbock’s Disease And Arthritis Of the Wrist joint 53

Session 5: Rheumatoid Arthritis Of the Hand. 55

Session 6: Carpal Tunnel Syndrome, Conditions And Deformities Of The Hand. 55

THEME 14: CONDITIONS AND DEFORMITIES OF THE LOWER LIMB. 57

Session 1: Osteoarthritis And Avascular Necrosis Of The Hip; Painful Hip - Problem Solving. 57

Session 2: Angular Deformities Of the Knee, Osteotomies And Knee replacements. 59

Session 3: The Sportsman With (A) a Painful Lower leg (B) The Ileotibial Band Syndrome. 60

Session 4: Chronic Instability Of the Ankle joint, Degenerative Conditions Of the Ankle, Cavus Feet And Flat feet In Adults. 61

THEME 15: GENERAL PRINCIPLES OF RESUSCITATION After TRAUMA AND EMERGENCY TREATMENT OF FRACTURES AND DISLOCATIONS. 63

THEME 16: GENERAL PRINCIPLES OF TRAUMATIC CONDITIONS. 64

Session 1: Fracture Patterns, Open Fractures, Growth Plate Injuries, The Principles Of Fracture And Dislocation, Reduction And Immobilisation. The Principles Of Open Reduction And Internal Fixation. 64

Session 2: Imminent Compartment Syndrome, Non-Accidental Injury Syndrome Reflex Sympathetic Dystrophy, Common Complications Of Fractures And Dislocations. 66

THEME 17: immobilisation techniques of the upper limb. 68

Session 1: Immobilisation Techniques Of The Upper Limb. 68

THEME 18: FRACTURES AND DISLOCATIONS OF THE SPINAL COLUMN AND PELVIS. 69

Session 1: Clinical Presentation And Incidence Of Vertebral Fractures, The Care Of Paraplegics And Tetraplegics In The Post-Injury Period, Transport Of a Tetraplegic. 69

Session 2: Pelvic Fractures. 71

THEME 19: FRACTURES AND DISLOCATIONS OF THE UPPER LIMB. 72

Session 1: Fractures And Dislocations Of The Shoulder Girdle. 72

Session 2: Fractures And Dislocations Of The Elbow And Forearm Fractures. 73

Session 3: Fractures And Dislocations Om The Wrist Joint, Hand And Fingers. 75

THEME 20: FRACTURES AND DISLOCATIONS OF THE LOWER LIMB. 77

Session 1: Hip Dislocations, Femur Neck, Intertrochanteric And Femur Shaft Fractures. 77

Session 2: Fractures Of The Distal Femur, Proximal Tibia And Patella. 78

Session 3: The Longterm Consequences Of Knee Ligament And Meniscus Injuries. 79

Session 4: Fractures Of The Tibia Shaft And Plateau. 80

Session 6: Sprains, Fractures And Dislocations Of The Ankle, Fractures And Dislocations Of The Tarsals, Metatarsal Bones And Phalanges Of The Foot 81

THEME 21: SOFT TISSUE INJURIES OF THE MUSCULOSKELETAL SISTEEM.. 83

Session 1: Lacerations And Penetrating Skin Wounds. 83

Session 2: Appropriate Wound Healing And Wound Dressing. 84

THEME 22: THE ROLE OF OCCUPATIONAL THERAPY AND PHYSIOTHERAPY IN REHABILITATION. 86

Session 1: Ot And Pt In Rehabilitation Of Orthopaedic Conditions. 86

Session 2: 87

Timetable  88

MUSCULOSKELETAL SYSTEM

introduction

Welcome to the musculoskeletal system module.

Conditions of the musculoskeletal system are particularly common, and will occupy much of your time in general practice. In the USA, it is one of the most common reasons for patients consulting their general practitioner. Approximately 75% of all people will, for example, at some time present with complaints of back pain. Trauma and violence are presently epidemic in South Africa, and with the increase in high velocity injuries and gunshot wounds, your practice with continually be overflowing with musculoskeletal injuries. Other common conditions include joint diseases, bone diseases and deformities. To better understand these, as well as the neoplastic and infective conditions of the musculoskeletal system, appropriate pathological as well as microbiological aspects will be covered. The relevance of the various imaging modalities will also be put into prospective throughout.

During this 3-week block, the presentations will, as far as possible, be multidisciplinary since treatment of these problems usually requires a multidisciplinary approach.

There will be a continual emphasis on a practical approach with regards to the most common conditions affecting the musculoskeletal system.

The most important aspects of the clinical diagnosis, radiological interpretation and treatment will be emphasized.

A number of practical self-study assignments will be expected from you; you are encouraged to complete these assignments as quick as possible and to liase with your class mates for future reference.

references AND textbooks

Please make use of the references that appear in your study guides. All references can be found in the library of the Faculty of Health sciences. You also have access to numerous videos, which are worth using to establish practical guidelines.

You are recommended to buy the following textbooks. The majority of information that you require appears within.

Concise System Of Orthopaedics And Fractures – AG Apley/L Solomons

Apleys System Of Orhtopaedics And Fractures – AG Apley/L Solomons

Clinical Orthopaedic Examination - Ronald Mcrae

Practical Fracture Treatment - Ronald Mcrae

Dorlands Medical Dictionary – Saunders

Websites

1.         Google – Orthoteers

2.         Google – Wheeless textbook of Orthopaedics

LECTURERS

These are the names and contact details of the lecturers that are involved with the module:

Contact People

Helga Oldewage, Division of Orthopaedics, Tel: (021) 938 9266, E-mail: holde@sun.ac.za

Suzette Olivier, Department of Internal Medicine, Tel: (021) 938 9376, E-mail: shv@sun.ac.za

 

ASSESSment

General

At the end of this module, there will be a theoretical and a practical (project) assessment.

Class mark

The class mark will be calculated as follows:

a)       Orthopaedic Surgery       -         80%

b)       Rheumatology                -         20%

The marks of the class test will be given within 10 working days.

Assessment

Date:           Friday – 19 February 2010

Time:           09:00 – 12:00

Location:     Examination Hall, 5th Floor, Education Block

Type:           True and false questions, short questions, paragraph questions and long questions (covering all the work)

Examination mark

Date:           Friday – 01 October 2010

Time:           09:00 – 12:00

Location:     Examination Hall, 5th Floor, Education block

Performance mark

The performance mark for this module is calculated as follows: 50% of the class mark and 50% of the examination mark. Your class mark must to be 40% and more to qualify to write your exam. Your performance mark needs to be 50% and more in order to pass the module.

EXPLANATION OF SYMBOLS

Clinical picture:

C1        -           Know about

C2        -           Tentative diagnosis

C3        -           Diagnose and refer

C4        -           Diagnose and treat

Knowledge:

T1         -           Know about

T2         -           Superficial knowledge

T3         -           Working knowledge

T4         -           Detailed knowledge

SKILLS:

S1        -           Just know about

S2        -           Must have seen this performed a few times

S3        -           Must have performed this a few times under supervision

S4        -           Must be able to perform this independently and accurately

TIMETABLE AND STUDY INFORMATION IN SAQA FORMAT

Clinical picture	Scale	Skills list	Scale
ANGULATION AND ROTATION DEFORMITIES IN CHILDHOOD Physiological Genu valgum Genu varum 'Pigeon toeing' (Femoral torsion) 'Out toeing'   Pathological Blount’s disease Rickets Osteogenesis imperfecta Neurofibromatosis Skeletal dysplasia Syphilis   NEUROMUSCULAR DISORDERS Neurological Cerebral palsy Poliomyelitis/Guillaine-Barré Syndrome Spina bifida HMSN (Charcot-Marie 'Tooth' disease) Arthrogriposis, multiplex congenital Muscular Duchenne Muscular Dystrophy Becker Muscular Dystrophy   CONGENITAL ANOMALIES Congenital torticollis Congenital scoliosis Congenital dysplasia of the hip Congenital foot deformities Syndactylia Madelung’s deformity         POSTURAL ANOMALIES Metatarsus adductus/varus Talipes calcaneo valgus Acute torticollis Postural torticollis (Griessel’s Syndrome) 'Moulded Baby' syndrome Postural scoliosis	C3 C3 C3 C3 C2 C2 C2 C1 C1 C3/ C4         C2 C3   C3 C2   C2   C3 C3     C3 C3 C2 C3 S3 S2     C3 C3 C3 C3   C3 C2	Clinical examination of the child with angular or rotation anomalies of the lower limbs                         Basic clinical neurological examination  to differentiate between upper and lower motor neuron disorders                 General and musculoskeletal clinical evaluation of a newborn, with underlying knowledge of general associated deformities. Hip examination of the newborn with suspected DDH	S2                             S2                     S2       S2
HIP ANOMALIES IN CHILDHOOD Perthes’ disease Transient synovitis of the hip SUFE (Sliding Upper Femur Epyphysis) Septic arthritis /osteomyelitis Femur neck fracture Other causes of ‘hip pain’ Intraspinal tumours / abdominal causes Apophysis injuries   FOOT ANOMALIES IN CHILDHOOD Pes planus Pes cavus / cavo varus Walking on toes   KNEE ANOMALIES IN CHILDHOOD Osgood Schlatter       BONE AND JOINT INFECTION IN CHILDHOOD Osteomyelitis Septic arthritis Pseudoparalysis in the baby Spreading staphylococcal infections TB and other infections Discitis   THE NEONATE AND YOUNG CHILD Fractures in the newborn Neonatal septic arthritis Pulled elbow   DIFFERENCES IN BONE LENGTHS Congenital Neurological Vascular Infection Tumours Trauma	C2 C2 C3   C3 C3   C2   C2     C3 C3 C3     C4 C3   C2 C4 C4 C3     C3 C3 C4     C2 C2   C2 C2 C2	Gait analysis Clinical examination of the hip Clinical examination of area Responsible for referred pain to the hip                 Examination of gait, lower limb and foot     Clinical examination of infected bones and joints for relevant signs               Clinical examination of the neonate with suspected fracture of musculoskeletal septic fokus     Measurement of apparent and actual bone lengths with a tape measure   Block methods	S2 S2 S2                     S2       S2                 S2         S2     S2
FOOT Tarsal Tunnel syndrome Bunion Claw toes Metatarsalgia Achilles tendon rupture Plantar fasciitis Interdigital neuroma Veruccas Achilles tendon pathology   CONDITIONS OF THE NECK Torticollis Griesel Syndrome Myelomeningocoele Cervical spondylosis   POSTURAL FUNCTIONAL AND STRUCTURAL ANOMALIES OF THE SPINAL CORD Postural Functional Structural (Scoliosis) Meralgia paresthetica Low mechanical back pain Discus degeneration Spondylolisthesis Discus herniation Spinal stenosis Metastases Myelomatosis   ORTHOPAEDIC INFECTIONS Acute osteomyelitis           Subacute and chronic osteomyelitis   Septic Arthritis	C2 C3 C3 C3 C3 C4 C4 C4 C3     C2 C3 C4         C4 C4 C3 C2 C4 C4 C4 C4 C4 C3       C4           C4   C4	Examination of the foot                       Examination of the back         The interpretation of Xrays of the spinal column               Clinical diagnosis/examination Drawing of blood cultures Drainage of bone abscess Prescription of antibiotics Prescription of analgesics   Clinical diagnosis and examination Applying plaster of Paris   Clinical diagnosis/examination Taking blood cultures Aspiration of a joint Prescribing appropriate antibiotics Prescribing analgesia	S4                                 S4                 S4 S4 S4 S4 S4   S4 S4   S4 S4 S4 S4 S4
BENIGN BONE TUMOURS Non - ossifying fibroma Osteochondroma Enchondroma Osteoid osteoma Aneurysmal bone cyst Giant cell tumour of bone Simple bone cyst   MALIGNANT BONE TUMOURS Myeloma Metastases Osteosarcoma Ewing sarcoma Chondrosarcoma   SOFT TISSUE TUMOURS Lipoma Fibromatosis Haemangioma Ganglion Neurofibromatosis Soft tissue sarcoma   ANOMALIES OF BONE Pagets Osteoporosis Osteomalacia   ANOMALIES OF THE HIP AREA A. DEVELOPMENTAL-ANOMALIES Dysplasia Coxa vara Femur anteflexion   B. ARTHRITIS Osteoarthritis Rheumatoid arthritis Protrusion acetabuli   C. INFECTION Pyogenic Tuberculosis	C3 C3 C3 C3 C3 C3 C2     C3 C3 C3 C3 C3     C4 C3 C3 C4 C2 C3     C3 C4 C4       C2 C2 C2     C3 C4 C1     C3/C4 C3/C4	Radiological diagnosis Surgical treatment               Radiological diagnosis Appropriate laboratory investigation Surgical treatment         Clinical diagnosis/examination Surgical treatment Laboratory investigation                       Examination of the hip Interpretation of x-rays Infiltration of larger trochanteric bursitis Aspiration hip joint Drainage of hip joint	S4 S1               S4 S4 S1         S4 S1 S4                       S2 S2 S2   S1 S1
D. ANOMALIES OF HEUP, PEES OF BURSAS Greater trochanter bursitis Ischiatic bursitis Cracking hip Groin dislocation   E. ANOMALIES OF BLOOD FLOW TO THE HIP Avascular necrosis of femoral head   F. REFERRED PAIN TO THE HIP Back Sacro-iliac joint Knee   ANOMALIES OF THE KNEE REGION Anterior knee pain Septic anomalies of the knee   a.  Infection (Septic arthritis) Pyogenic Tuberculosis b. Degenerative anomalies Osteoarthritis Rheumatoid arthritis Haemophiliac arthritis c. Meniscus anomalies Tears in the meniscus Discoid lateral meniscus d. Anomalies of the patella Recurrent dislocation 'Maltracking' Chondromalacia patellae e. Anomalies of muscles, bursa of tendon Bursitis:  Pre-patella Infra patella bursitis Pes anserinus bursitis Semimembranosus bursitis Lower patella tendonitis Cyst of the knee cavity (Baker’s cyst) Apophysis of Tibialis Tubercle (Osgood-Schlatter’s disease) Ilio-tibialis band friction syndrome	C4 C4 C1 C4       C4     C1 C1 C1       C1     C4 C4   C4 C3 C3   C3 C3   C4 C4 C4           C4 C2 C2 C2 C4 C3 C4	Examination of the knee   Aspiration of the knee Interpretation of x-rays Arthrotomy of the knee Infiltration of the knee	S2   S2 S2 S1 S2
F. MALDIRECTION OF THE KNEE Genu valgum Genu varum   RHEUMATOID ARTHRITIS (RA) Joint manifestations of RA Systemic manifestations of RA Treatment of RA Surgery for RA       SPONDYLO-ARTHROPATHY Manifestations of spinal and peripheral Joint involvement   Systemic manifestations of the spondylo-arthropathy   Treatment of spondylo-arthropathy   Surgery for spondylo-arthropathy   SOFT TISSUE INVOLVEMENT Systemic Lupus Erythematosis Scleroderma Mixed connective tissue disease Vasculitic syndrome Clinical picture of soft tissue involvement Serological evaluation in soft tissue involvement   GOUT AND THE OTHER CRYSTAL ARTHROPATHIES Gout Other crystal arthropathies Clinical picture of gout Management of gout   OSTEOARTHRITIS   FIBROMYALGIA   PULLED MUSCLE SYNDROME	C2 C4   C3/C4 C3/C4 C3 C3/C4 C3         C3     C3     C3     C3       C3 C3 C2 C2 C2 C3           C4 C2 C4 C4   C4   C4   C4	Physical examination including joint examination Aspiration of joint Examination of sinovial fluid Cortisone infiltration of joint Evaluation of xrays of Rheumatoid arthritis   Physical examination of spinal and peripheral involvement in spondylo-arthropathy   Cortisone infiltration of joints and soft tissues   Evaluation of Xrays of spondylo-arthropathy     Physical examination of patient with soft tissue involvement             Physical examination of the patient with gout     Joint aspiration Examination of sinovial fluid Physical examination of the osteo-arthritic joint Joint infiltration	S4   S4 S3 S4 S4     S3     S3                 S3               S4       S3/S4   S2   S4
CONDITIONS OF THE SHOULDER Referred pain to the shoulder Rotator cuff tendonitis Rotator cuff tear 'Frozen shoulder' Arthritis of the shoulder joint AC-joint involvement Congenital and acquired anomalies of the shoulder   CONDITIONS OF THE ELBOW Medial and lateral epicondylitis Ulnar neuritis Bursas of the elbow   CONDITIONS OF THE PERIPHERAL NERVES Brachial plexus injury in adults Brachial plexus injury in children Peripheral nerve lesion Peripheral nerve constriction syndrome: a)  Carpal tunnel b)  Tarsal tunnel c)  Cubital tunnel d)  Thoracic outlet syndrome e)  Meralgia paraesthetica f)   Plexus neuritis – brachial and      lumbosacral   CONDITIONS OF THE HAND AND WRIST Osteoarthritis of the hand and wrist:   a)  Carpo-metacarpal osteoarthritis b)  Osteoarthritis of the DIP- and      PIP joints c)  Degenerative arthritis of the      wrist   Muscle imbalance of fingers: a)  Swan neck b)  Boutonniére c)  Mallet   De Quervain Avascular necrosis of lunate Ganglion	C3 C4 C3 C3 C4 C4 C1       C4 C3 C1       C3 C3   C3   C4 C3 C3 C3 C2 C2               C4 C4         C3 C3 C3 C4   C4 C3 C4	Clinical examination of the shoulder   Sub-acromial injection             Examination of the elbow Cortisone injections in the region of the elbow       Neurological examination of the upper limb                           Examination of the hand and wrist Aspiration ganglion Cortisone injections of the hand and wrist	S3/S4   S4             S4 S2         S4                           S4 S2 S2

theme 1:
MUSCULOSKELETAL TERMINOLOGY
AND DEFORMITIES

AIM OF THE THEME

During this theme, we will build on your knowledge of terminology acquired during the Phase II module on the Musculoskeletal system. You will learn additional terminology that will describe the most common musculoskeletal anomalies, and this will enable you to communicate accurately with colleagues.

OVERVIEW OF THE THEME

Outcomes

At the end of this session, you should be able to do the following:

1.       Describe the normal posture, appearance and movements of the musculoskeletal system.

2.       Recognize and describe the common musculoskeletal anomalies.

Anything specific YOU SHOULD do?

1.       Read through the piece of work, and complete by referring to Dorland’s Medical Dictionary and the Module: The Musculoskeletal System of Phase II

RESOURCES

-        Dorland’s Medical Dictionary

Abduction:

Adduction:

Ankylosis:

Antalgia:

Arthritis:

Arthrodesis:

Arthroplasty:

Arthrosis:

Bunion:

Cavus:

Diaphysis:

Dysplasia:

Dystrophy:

Dorsiflexion:

Exocytosis:

Extension:

External rotation:

Elevation:

Epiphysis:

Eversion:

Physis:

Flexion:

Gon-arthrosis:

Hallux:

Internal rotation:

Inversion:

Involucrum:

Kyphosis:

Lysis:

Lordosis:

Metaphysis:

Metatarsalgia:

Olistesis:

Osteitis:

Osteochondritis:

Osteochondrosis: Osteolisis: Osteosclerosis:

Osteophyte:

Osteomalacia:

Osteomyelitis:

Osteoclasts:

Osteotomy:

Plantar flexion:

Planus:

Pollux:

Procurvatum:

Pronation:

Recurvatum:

Sequestrum:

Circumduction:

Sclerosis:

Scoliosis:

Spondylolysis:

Spondylolisthesis:

Spondylosis:

Supination:

Torticollis:

Valgus:

Varus:

THEME 2:
CLINICAL EXAMINATION METHODS

AIM OF THE THEME

The main aim of this theme is to prepare you for taking a useful clinical history and for peforming an appropriate clinical examination of the musculoskeletal system.

You should also be able to perform a complete, thorough and relevant clinical examination of the upper limbs, lower limbs and the spinal cord, and be able to distinguish the normal appearance, posture, movement and stability from physiological, age and pathological anomalies. You should be able to identify abnormal gaits and clinically evaluate differences in bone length. You must know the basic principles of the examination of a joint in general.

Overview of the theme

THEME 2: CLINICAL EXAMINATION METHODS

Outcomes

At the end of this session, you should be able to do the following:

1.          Name the most common linear and rotational deformities of the limbs.

2.         Name and describe the 4 most common anomalies of gait of patients, and recognize each on a video.

3.         Name the causes of an apparent difference in bone length.

4.         Be able to evaluate painful and limited active and passive movement of a joint.

5.         Evaluate a swollen joint clinically and distinguish between an effusion and a synovitis.

RESOURCES

1.          Clinical Orthopaedic Examination McCrae, Page 1

2.         Orthopaedic Assessment Video Casette, US library, WE 141 Ort

3.         Physical examination of the spine and extremities Stanley Hoppenfeld

4.         Pecutra gaits / Buckanon MFG WE103BUC US Library

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

This lecture and demonstration demonstrates the clinical methods associated with the examination of a joint, including normal movement and stability, and distinguishing this from a pathological process. The clinical evaluation of differences in bone lengths, normal gait and anomalies thereof, as well as rotational and linear deformities of the limbs will also be discussed.

Please complete the assignment that was given to you during the session.

THEME 2: CLINICAL EXAMINATION METHODS

Outcomes

At the end of this session, you should be able to do the following:

1.       Explain how the musculoskeletal system is graded.

2.       Grade muscle power according to the Oxford scale.

3.       Grade muscle spasm according to the Ashworth scale.

4.       Describe/sketch the neurological innervation of the myotomes of the limbs.

5.       Describe/sketch the sensory innervation of dermatomes.

6.       Explain how to distinguish clinically between an upper and lower motor neuron lesion.

RESOURCES

-                 Clinical Orthopaedic Examination McRae, Page 13

-                 Apleys System Of Orthopaedics And Fractures Page 194, 4

-                 Orthopaedic Physical Assessment. D Magee 3rd Edition Pages 21, 24

ANYTHING SPECIFIC YOU SHOULD DO?

Self-study

The aim of this self-study is to give you a good perception of the degree of pain that your patients experience, as well as the quantification thereof and the degree of morbidity. You must also be able to quantify power and spasm of muscles for the purpose of follow-up documentation. In addition, you should be able to localize neurological lesions anatomically by means of a good peripheral limb examination.

THEME 2: CLINICAL EXAMINATION METHODS

Outcomes

At the end of this session, you should be able to do the following:

1.          Explain how to examine normal movements of the neck.

2.         Perform an appropriate neurological and vascular examination of the upper limbs.

3.         Demonstrate how to examine normal movements of the shoulder girdle and explain how to identify limited movement.

4.         Describe the clinical tests to identify rotator cuff tears and shoulder tightness.

5.         Explain how to differentiate between glenohumeral and scapulo-thoracic movement.

6.         Explain how to clinically evaluate stability of the shoulder joint.

RESOURCES

1        Clinical Orthopaedic Examination McCrae – The shoulder Page 41
The cervical spine Page 27

2        Physical Examination Of The Shoulder. SA Bone & Joint Surgery, Vol no 4, Nov 2000,
Page 12

3        Routine Examination Of Joints. Video 2: The shoulder/Holland CD WE544HOL US Library

4        Orthopaedic Physiotherapy Video cassette: The Examination Of The Shoulder WE810WIN US Library

5        Examination Of The Shoulder/Kelly IG, WE810KEL, US Library

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

The objective of this session is to assist you in taking an appropriate medical history and performing a basic, useful clinical examination in order to identify and differentiate between conditions of the neck and shoulder.

A lecture demonstration will be presented on the clinical examination methods of the neck and shoulder girdle. In preparation therefore you should review the osteology of the neck Phase II, Theme 2, Session 1 and Phase II, The Musculoskeletal System, Theme 4.

Please complete the assignment that was supplied to you.

THEME 2: CLINICAL EXAMINATION METHODS

Outcomes

At the end of this session, you should be able to do the following:

1.       Describe the normal contour, as well as the extent of movement, of the thoracolumbar spine.

2.       Describe how to measure chest wall expansion and explain what the loss thereof means.

3.       Explain the importance of the pelvic tilt.

4.       Describe how to identify a kyphosis and explain the importance thereof.

5.       Describe how to identify scoliosis and explain the importance thereof.

6.       Describe how to clinically evaluate the neurological and vascular components of the lower limbs.

7.       Describe how to examine the sacro-iliac joints.

RESOURCES

1.          Clinical Orthopaedic Examination McCrae – The Thoracic And Lumbar Spine Page 113

2.         Routine Examination Of Joints. Video 5 – The Spine/Holland CD WE544HOL, US Library

3.         Orthopaedic Physiotherapy: Examination Of The Lumbar Spine WE750WIN, US Library

4.         Concise System Of Orthopaedics And Fractures. A Graham Apley/Louis Solomon
Chapter 18, The Back. Page 157

ANYTHING SPECIFIC YOU SHOULD DO?

The objective of this session is to assist you in taking an appropriate medical history and performing a basic, useful clinical examination in order to identify and differentiate between conditions of the throacolumbar spinal column.

Before starting this session, you should review the functional anatomy of the spinal cord.

Lecture demonstration

During this session, the normal contour and normal movements of the thoracic vertebrae will be demonstrated. Anomalies of posture and deformities, such as scoliosis and kyphosis, will be discussed.

At the end of this session, you must complete the assignment with the help of the lecturer.

THEME 2: CLINICAL EXAMINATION METHODS

Outcomes

At the end of this session, you should be able to do the following:

1.       Describe the normal movements of the elbow, wrist, metacarpophalangeal and interphalangeal joints.

2.       Name the stabilising structures in all of these joints.

3.       Name the muscles mainly responsible for the movement of these joints.

4.       Describe the myotome innervation of the upper arm, forearm and hand, and explain how to distinguish between movements of muscles innervated by the median, ulnar and radial nerve.

5.       Describe the dermatome sensory distribution of the hand and forearm.

6.       Describe the course of the main nerves in the upper limb.

7.       Describe the course of the main arteries in the upper limb.

8.       Differentiate between the functions of the various tendons in the fingers.

RESOURCES

1.          Neurovascular Assessment Of The Hand. CME July 1996, Vol 14, no 7, Page 1007.

2.         Clinical Orthopaedic Examination McCrae
Segmental And Peripheral Nerves Of The Upper Limb Page 13
The elbow Page 61
The wrist Page 77
The hand Page 95

3.         Routine Examination Of Joints. Video I: Part. 1 The hand, Part. 2 The elbow/Holland CD WE544HOL, US Library

4.         Neurovascular Examination Of The Hand/Mennen U, WE830MEN, US Library

5.         S A Bone & Joint Elbow Vol X No. 3 Aug 2000, Shoulder Vol X Nol 4, Nov 2000

ANYTHING SPECIFIC YOU SHOULD DO?

The objective of this session is to assist you in taking an appropriate medical history and performing a basic, useful clinical examination in order to identify and differentiate between conditions of the elbow, forearm and hand.

Pre-study

Before starting this lecture, you are expected to review the functional anatomy of the arm, as well as the content of the muscle compartments of the upper arm, forearm and hand. Phase II, The Musculoskeletal System, Sessions 3, 4, 5 and 6.

Lecture

A 45-mintue lecture demonstration will be presented. The clinical examination of the elbow and forearm joints will be discussed. The examination of the median, ulnar and radial nerves will be discussed by means of a demonstration. The function of the most important tendons in the hand will also be discussed.

At the end of this session, you should be able to complete the assignment that has been provided.

THEME 2: CLINICAL EXAMINATION METHODS

Outcomes

At the end of this session, you should be able to do the following:

1.       Describe the normal extent of movements of the hip.

2.       Explain how to evaluate muscle spasm of the hip.

3.       Describe the normal extent of movements of the knee.

4.       Describe the examination techniques used to evaluate cruciate ligaments, collateral ligaments, unstable patella or a meniscus injury.

RESOURCES

1.          Clinical Orthopaedic Examination McCrae
The hip Page 155
The knee Page 189

2.         Routine Examination Of Joints Video 3: The hip / Holland CD, WE544 HOL, US Library

3.         Routine Examination Of Joints Video 4: The knee / Holland CD WE544HOL, US Library

4.         Clinical Examination Of The Knee/Ireland J, WE870IRE, US Library

Lecture

The objective of this session is to assist you in taking an appropriate medical history and performing a basic, useful clinical examination in order to identify and differentiate between conditions of the hip and knee joint.

During this session, there will be a 45-minute lecture demonstration on examination techniques of the knee and hip joints. At the start of this lecture, you are expected to have revised the functional anatomy of the knee and hip joints. Phase II, The Muskuloskeletal System, M4607 and M4617.

At the end of this lecture, you should complete the assignment supplied to you.

THEME 2: CLINICAL EXAMINATION METHODS

     Outcomes

At the end of this session, you should be able to do the following:

1.       Describe the normal movements of the ankle and foot joints.

2.       Describe how to examine the function of the tendons of the foot and ankle.

3.       Describe how to examine instability of the ankle joint.

4.       Describe how to localise nerve pressure of the foot.

RESOURCES

1.          Clinical Orthopaedic Examination McCrae.

-                 The Ankle Page 239

-                 The Foot Page 253

2.         Routine Examination Of Joints Video 6, The Ankle And Foot/Holland CD WE544HOL,
US Library

3.       Movements Of The Ankle And Foot/Waugh W WE880WAU, US Library

ANYTHING SPECIFIC YOU SHOULD DO?

The objective of this session is to assist you in taking an appropriate medical history and performing a basic, useful clinical examination in order to identify and differentiate between conditions of the foot and ankle.

At the start of this lecture, you should have revised the functional anatomy of the foot and ankle. Phase II, The Muskuloskeletal System M4632, M4512, M4515.

Lecture/Slide show

A lecture will be presented, using the slide projector, to demonstrate the clinical examination methods of the foot and ankle.

At the end of the lecture, an assignment will be provided for completion.

THEME 3:
IMAGING INVESTIGATIONS OF THE
MUSCULOSKELETAL SYSTEM

AIM OF THE THEME

At the end of this theme, you should know the indications for requesting a normal X-ray to diagnose musculoskeletal conditions and be able to evaluate and interpret the X-ray systematically in order to reach the diagnosis.

You should also be aware of the musculoskeletal conditions, which do not justify unnecessary radiological investigations.

You should know the indications for requesting additional imaging investigations (e.g. conventional tomography, nuclear medicine, computerized tomography and magnetic resonance), as well as the relevance, possible side-effects and costs thereof.

Overview of the theme

THEME 3: IMAGING INVESTIGATIONS OF THE MUSCULOSKELETAL SYSTEM

ANYTHING SPECIFIC YOU SHOULD DO?

Before this session, you should read up on the indications and advantages of X-rays of the spinal cord in patients with backache. Is it always necessary to take X-rays? Reference: Rational Investigating UPDATE, June 2000, Page 35.

OUTCOMES

1.       You should know when X-rays are indicated in a patient presenting with backpain

2.       Useful imaging investigations must be requested

3.       Knowledge of the dangers of radiation of patients

THEME 3: IMAGING INVESTIGATIONS OF THE MUSCULOSKELETAL SYSTEM

Outcomes

At the end of this session, you should be able to do the following:

Radiological session:

Objectives: The following topics will be discussed:

1.       Discussion of the radiological characteristics of common as well as less common fractures.

2.       Discussion of the radiological characteristics of dislocations

3.       Discussion of the radiological characteristics of degenerative, rheumatoid, infective, neoplastic, dysplastic and common metabolic conditions.

4.       Radiological characteristics of avascular necrosis.

5.       Radiological characteristics of benign and malignant tumours.

6.       Dangers of repeated radiological investigations.

RESOURCES

Principles Of Fractures Treatment. Apleys System Of Orthopaedics And Fractures. Chapter 23,
Pages 516, 563

Journal Of American Family Physicians, Cervical Spine X-Ray, Jan 15, 1999, Page 331

Journal Of American Family Physicians, Radiographic Assessment of OA, July 15, 2001, Page 279

Journal Of American Family Physicians, Radiological Examination Upper Extremity Fractures 1
March 1998, Page 995

Journal Of American Family Physicians, Radiological Examination Lower Limb Traums,
15 March, 1998, Page 1314

Website www.aafp.org/afp

ANYTHING SPECIFIC YOU SHOULD DO?

Self-study assignment

Before starting the lecture, you are expected to tabulate Perkins’ rules with regards to taking X-rays in trauma and to bring this to the lecture for discussion. Reference: Apleys System Of Orthopaedics And Fractures Page 520.

Lecture

During this session, there will be a slide lecture demonstrating the most important radiological characteristics of traumatic and non-traumatic conditions of the skeleton.

At the end of this lecture, 10 minutes will be devoted to small group discussions on taking unnecessary X-rays (Previously self-study assignment).

THEME 3: IMAGING INVESTIGATIONS OF THE MUSCULOSKELETAL SYSTEM

Outcomes

At the end of this session, you should be able to do the following:

1.          Describe the pathophysiological basis of skeletal scintigraphy.

2.         List the most common indications for skeletal scintigraphy.

3.         Explain how the skeletal scintigram will be conducted to a patient referred therefor.

4.         List the advantages of skeletal scintigraphy.

5.         Explain the role of skeletal scintigraphy in sports medicines to your patient.

RESOURCES

1.          Phase 2 notes on the physiology of the skeleton

2.         Class notes

3.       Textbook of Nuclear Medicine. Wilson MA, Lippincott-Raven Publishers, Philadelphia, 1998

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

The aim of this session is to enable you to implement Nuclear Medicine selectively and purposefully in order to diagnose or confirm musculoskeletal conditions.

Before attending the lecture, please review your Phase 2 notes on the physiology of the skeleton. The subject will  be covered during an interactive lecture.

THEME 4:
INFECTIVE CONDITIONS OF THE
MUSCULOSKELETAL SYSTEM

AIM OF THE THEME

During this theme, you will learn to recognize the most common infective conditions of the musculoskeletal system. You will also learn how to treat these conditions. Of particular importance is an understanding of the underlying anatomy and pathology, which results in the principles of therapy being somewhat different than for other organ systems.

Overview of the theme

THEME 4: INFECTIVE CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

     Outcomes

At the end of these sessions, you should be able to do the following:

1.          Define acute and chronic osteomyelitis, tuberculous osteomyelitis and infective arthritis.

2.         Name the most important causes of osteomyelitis.

3.         Discuss the sequential changes in the pathogenesis of osteomyelitis.

4.         Discuss and identify the morphological changes of osteomyelitis.

5.         Explain the clinico-pathological correlations of osteomyelitis.

6.         Name the most important causes of infective arthritis.

7.         Discuss the pathogenesis and morphological changes of septic and tuberculous arthritis.

8.         Explain the distinguishing clinico-pathological correlations of septic and tuberculous arthritis.

BACKGROUND KNOWLEDGE

It is important that you review the principles and outcomes of acute and chronic infections, as well as granulomatous infections (refer again to the Phase 2 module: Basis of Disease Processes). Ensure that you are familiar with the morphological manifestations of infection, including suppuration, abscess formation, spreading infections such as cellulitis and erysipelas, and necrotizing infection. You must also review tissue repair and the local and systemic factors influencing this (Refer again to the Phase 2 module: Basis of Disease Processes; especially Themes 16 and 21).

ANYTHING SPECIFIC YOU SHOULD DO?

Read pages 792-793 and 813-814 in Underwood before attending the lecture. You will  also benefit by glancing at pages 222-224, especially the illustrations and tables. During the lecture, the lecturer will explain and illustrate the theory underlying the outcomes and provide relevant guidelines for further study.

Lecture with appropriate images and illustrations

1.          Make supplementary notes to your textbook and class notes.

2.         The lecture is available at the following webaddress:
http://www.sun.ac.za/healthsciences/schools/basic_appl_health/anat_path/ppt/ppt.html

THEME 4: INFECTIVE CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

RESOURCES

-        Underwood, 1996. Pages 792-793 and pages 813-814

-        Own notes made during contact sessions

-        Class notes

-        Examples of specimens that you can study in your own time will be made available in the

pathology demonstration hall on the 4th floor in the Education Block. A list of cases is attached at the end of this theme.

-        Computer-assisted guidance: This website offers a number of examples, illustrations and tutorials that are not available elsewhere.

ANYTHING SPECIFIC YOU SHOULD DO?

Self-study

Answer the following questions during your self-study:

1.          Define acute and chronic pyogenic osteomyelitis

2.         Name the most important causes of osteomyelitis and of infective arthritis.

3.         Discuss the sequential changes in the pathogenesis of pyogenic osteomyelitis.

4.         Discuss the morphological changes of pyogenic osteomyelitis and explain their clinico-pathological correlations (Study figure 25.6 on page 794 in Underwood)

5.         Discuss the clinico-pathological characteristics of tuberculous osteomyelitis and arthritis.  Refer specifically to the most important differences between this and pyogenic osteomyelitis and arthritis. Make a sketch illustrating the differences. Refresh your thoughts by looking at the figure and description of pages 232-236 and 241-243 in Underwood.

6.         Name other important non-infective causes of arthritis.

7.         Discuss the pathogenic and morphological changes of septic arthritis and tuberculous arthritis.

8.         Explain the distinctive clinico-pathological correlations of septic and tuberculous arthritis.

Briefly discuss the clinico-pathological characteristics of gonococcal arthritis, spirochaetal arthritis and viral arthritis.

9.       Take note that the following examples of skeletal and soft tissue pathology will be available for study in you own time. The location will be made known to you. This opportunity is provided in order to help you; the specimens will not be part of your assessment.
You are encouraged to formulate questions and direct them to Prof Schneider at jws2@sun.ac.za

* AS32, AS21, AS22          :Osteomyelitis

* AS31                                :Bone - syphilitic osteitis

* AV23                               :Paget’s disease

* JV 3                                 :Femur - haemolytic anaemia

* AS40                               :Echinococcus cyst (bone)

Wet specimens

* PM382/88, 137/89          - Tuberculosis

THEME 4: INFECTIVE CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

Outcomes

At the end of this session, you should know the following:

1.       Tabulate the common organisms responsible for acute bone and joint infections.

2.       Tabulate the organisms responsible for chronic bone and joint infections.

3.         Tabulate the organisms responsible for soft tissue infections.

4.         Discuss the pathogenesis of bone and joint infections.

5.         Discuss the role of the laboratory in the diagnosis of bacterial infections.

6.       Name the antimicrobial drugs and doses used in the treatment of common musculoskeletal infections.

7.       Discuss the most important characteristics and diagnosis of musculoskeletal tuberculosis.

8.       Tabulate the drugs used in the treatment of musculoskeletal tuberculosis, as well as the dose, duration and side-effects thereof.

BACKGROUND KNOWLEDGE

Before starting the session, the student should have the following background knowledge:

1.          The classification of bacteria

2.         Basis of pathogenesis and bacterial virulence

3.         Basis of antimicrobial action

At the end of the lecture, an assignment will be handed out for completion.

RESOURCES

-                 Myint: Medical Microbiology Made Memorable, 1999. Chapter 27, Page 64

-                 Inglis: Microbiology and Infection, 1998. Chapter 13, Page 131, Chapter 6, Pages 57-58

-                 Class notes

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

Objectives: This session deals with the most important characteristics of the general organisms that give rise to acute and chronic infections of soft tissue, bones and joints.

You must also know about the less common organisms that give rise to musculoskeletal infection.

THEME 4: INFECTIVE CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

AIM OF THE THEME

This session focuses on the different pharmacological aspects of antibiotics that are commonly used to treat musculoskeletal infections

Outcomes

At the end of the session,you should be able to complete the following:

1.          The fomulation of a clinical diagnosis of a microbial infection.

2.         The formulation of a microbial diagnosis.

3.         Determination of the benefit for empirical antibiotics.

4.         A systematic approach to emperical antibiotics.

5.         Pharmacodynamic and pharmacokinetic factors of therapy.

6.         Antimicrobial drug toxicity and the management thereof.

7.         The importance and place of combination therapy.

8.         Antimicrobial prophylaxis.

Resources

Rang, Dale&Ritter, Pharmacology, 4th Ed., (1999)

THEME 4: INFECTIVE CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

Outcomes

At the end of this session, you should be able to do the following:

1.       Explain how to make the clinical diagnosis of an acute septic arthritis and an acute osteomyelitis, as well as how to distinguish between the two and superficial soft tissue infections.

2.       Explain how to diagnose and treat a subacute bone and joint infection.

3.       Name the necessary special investigations, as well as the interpretation thereof in order to diagnose bone and joint infections.

4.       Describe when a bone and joint infection requires surgical treatment.

5.       Describe the particular clinical presentation of musculoskeletal infections

in the neonate.

6.       Tabulate the complications of septic arthritis of the hip.

7.       Tabulate the complications of acute infections of bone and joints.

8.       Tabulate the appropriate antibiotic doses, as well as the duration of treatment for acute septic arthritis and osteomyelitis.

9.       Tabulate the ways in whch soft tissue infections may present.

10.     Describe the clinical presentation of an abscess and the drainage technique.

11.        Describe cellulitis and the treatment thereof.

12.       Briefly describe the entities of discitis and the clinical presentation thereof.

RESOURCES

-                 Acute Pyogenic Bone And Joint Infection In Children. S A Bone and Joint Surgery
Nov 1997 Vol VII No 4 Page 24

-        Infection Apleys System Of Orthopaedics And Fractures – Chapter 2

ANYTHING SPECIFIC YOU SHOULD DO?

Self-study

In preparation, you should please review Session 2 of this theme on Staphylococcus aureus. Please complete the assignment during this session.

Lecture

During this session you will learn how musculoskeletal infections may present systemically and locally. You will also be told how to differentiate between soft tissue and bony infections as well as how to apply the principles in the treatment thereof.

This 45-minute lecture demonstration will cover clinical presentation, radiological evaluation, appropriate side-room investigations and the treatment of acute septic arthritis and osteomyelitis.

THEME 4: INFECTIVE CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

     Outcomes

At the end of this session, you should be able to do the following:

1.       Describe the incidence and clinical presentation of musculoskeletal Tuberculosis.

2.       Explain how to distinguish between an acute septic arthritis and a tuberculous arthritis clinically, with side-room investigations and radiologically.

3.       Explain when tuberculosis of the spinal cord would be suspected clinically and describe the radiological signs thereof.

4.       Describe the natural course of tuberculosis of the spinal cord, the possible neurological complications, and the treatment thereof.

5.       Tabulate the choices of medications for the treatment of skeletal tuberculosis, as well as the dosages and period of treatment.

6.       Explain the guidelines used to evaluate the patient’s environment, as well as to ensure continued medication.

7.       Describe the signs of drug-resistance.

8.       Name the bursae that can be affected by tuberculosis.

9.       Describe the presentation and treatment of cold abscesses.

RESOURCES

-        The Challenge Of Tuberculosis Current Orthopaedics 2000 14 Page 18

-        TB Arthritis – Current Orthopaedics 2000 14 Page 197

-        Tuberculosis – Apleys System Of Orthopaedics And Fractures – Page 47

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

At the end of this session, you should understand the most important aspects with regards to the presentation, incidence and spread of musculoskeletal tuberculosis. It is important that you know about the clinical presentation, radiological interpretation and the useful special investigations, as well as about the the recommended treatment modalities.

This session, lasting approximately 45 minutes, will be used to discuss the presentation and anatomical spread of musculoskeletal tuberculosis. Tuberculosis of the spinal cord and common large joints will be discussed.

Please complete the assignment during this session.

THEME 4: INFECTIVE CONDITIONS OF THE MUScULOSKELETal SYSTEM

Outcomes

At the end of these two sessions, you should be able to do the following:

1.          Tabulate the factors resulting in chronic osteomyelitis

2.         Tabulate and recognise the radiological characteristics of a chronic osteomyelitis.

3.         Discuss the role of antibiotics in the treatment of chronic osteomyelitis.

4.         Tabulate the complications of chronic osteomyelitis.

5.         Describe a Brodies abscess.

RESOURCES

-        Chronic Osteomyelitis. Apleys System of Orthopaedics and fractures Page 40

ANYTHING SPECIFIC YOU SHOULD DO?

Self-study and self-assessment

The aim of this self-study session is meaningfully analyse the clinical problem of chronic osteomyelitis. You are expected to be able to make the diagnosis, interpret the X-rays meaningfully and know how to treat chronic osteomyelitis.

Using the recommended references, you must solve the following problem and complete the assignment:

A 40-year old man presents with a draining sinus of the lower leg.

1.          Tabulate the possible causes

2.         Describe the probable radiological appearances.

3.         Briefly discuss the organisms responsible therefor.

4.       Tabulate the possible complications

Check your answers during a group discussion.

At 12.00, you should meet again in Lecture Hall 1 to discuss the answers with the lecturer.

THEME 4: INFECTIVE CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

     Outcomes

At the end of this session, you should be able to do the following:

1.          Describe the clinical signs of a Paronechia and explain how to drain this.

2.       Describe the clinical signs of a web space infection and describe how this should be drained.

3.         Describe the clinical signs of a septic arthritis of the hand and describe how this should be drained.

4.         Describe the clinical signs of a Tenovaginitis.

5.         Tabulate common organisms causing hand infections, as well as the appropriate antibiotics and dosages.

6.         Describe the local anaesthetic methods for drainage of hand infections.

7.       Discuss the most important aspects in the rehabilitation of the hand after an infection.

RESOURCES

-                 Treatment Of Hand Infections CME Aug 1991 Vol 9 No 8 Page 978

-                 Hand Infections CME July 1996 Vol 14 No 7 Page 943

-                 How To Drain An Absess Modern Medicine Vol 22 No 8 Aug 97 Page 66

ANYTHING SPECIFIC YOU SHOULD DO?

Pre-study

Please review the anatomy of the hand with specific reference to the spaces and synovial shadows. Phase II Module The Musculoskeletal System M4769 M4770

Lecture

After completing this session, you should be able to identify the presentation and localisation of the most common hand infections, and distinguish these from each other. You should know the basic principles of treatment, including the performance of simple surgical procedures on a primary health level.

This lecture also deals with the areas of localisation of the various hand infections. The methods of drainage of each infection will be discussed. You will also receive information on how to admnister local anaesthethic.

Self-study

After completing this session, the student should read the references regarding the basic principles of rehabilitation of a hand after drainage of an infection, and then tabulate this.

theme 5: APPROACH TO POLYARTHRITIS

AIM OF THE THEME

At the end of this theme, the student should have an understanding of the basic principles used to make a diagnosis of the more common rheumatological conditions. At the same time, they should have insight into the implications of a chronic disease for the individual, and the importance of paramedical interventions in these conditions. They should also have a knowledge of the concept of autoimmune diseases and the broad principles involved in their diagnosis.

OVERVIEW OF THE THEME

theme 5: APPROACH TO POLYARTHRITIS

AIM OF THE THEME

Required reading: Prior to starting this theme, the student is expected to have revised the following:

i)          The basic mechanisms of inflammation.

ii)         The basic physiology of pain.

iii)       The basic structure of the joint and its nourishment.

OUTCOMES

At the end of this theme, the student should have:

i)          An understanding of pain as a symptom.

ii)         A recognition of the importance of the pattern of pain during assessment of arthritis.

iii)       An ability to use an algorithmic approach.

iv)        An understanding of the difference between inflammatory and mechanical pain.

v)         An approach to the patient with polyarthritis.

vi)        A recognition of how rheumatoid arthritis is diagnosed.

vii)       Insight into the importance of the development of a patient/doctor collaboration with the treatment of chronic diseases and the importance of patient education in this process.

theme 5:APPROACH TO POLYARTHRITIS

Practical session in listening to patients trained in the taking and giving of history, and examination of the joint.

OUTCOMES

At the end of the session, the student should have:

i)       An approach to important characteristics in the history in order to differentiate between organic and functional diseases and between active and inactive rheumatoid arthritis.

ii)      An introduction to the important clinical characteristics used to differentiate between active synovitis and pre-existing damage.

Self-study – Project 1

Identify 8 questions which you would ask the doctor if you suffered with RA, and then:

Write a 1-2 A4 page brochure that you can disperse to patients which would answer these questions.

THIS PROJECT MUST BE HANDED IN BEFORE THE END OF THIS MODULE AND WILL COUNT FOR 30% OF YOUR FINAL MARK.

Self-assessment

Answer the following questions

a)         Give a list of 4 important symptoms for a patient with rheumatoid arthritis.

b)         Give a lost of 4 imprtant signs in a patient with RA.

c)         What percentage of patients have a positive rheumatoid factor?

d)         Give a list of five other conditions which may be associated with a positive RF.

e)         What percentage of patients develop erosive disease?

f)         Give a list of four symptoms which may be misleading during the diagnosis of RA.

Theme 6: APPROACH TO a PATIENT
WITH GENERALISED pain

OVERVIEW OF THE THEME

Theme 6: APPROACH TO a PATIENT WITH GENERALISED pain

OUTCOMES

At the end of this theme, the student should have the following:

i)          An approach to a patient with generalised pain.

ii)         An approach to the differentiation between organic and functional symptoms.

iii)       A knowledge of the symptoms which do not only characterize fibromyalgia but also a number of organic conditions. They should also have an approach to the differentiation between organic and functional pathology.

iv)        A broad superficial overview of the theory of the pathophysiology of fibromyalgia.

v)         A superficial understanding of the difference between fibromyalgia and regional pain syndrome.

vi)        An approach to the examination of the patient with fibromyalgia and the physical signs which assist with the diagnosis.

vii)       An approach to the choice and interpretation of special investigations.

viii)     A rational approach to treatment.

ix)       An overview of the prognosis.

x)         A recognition for the importance of rehabilitation with chronic diseases.

xi)       An understanding of the value of family education.

xii)      Insight into the stresses that the individual and family experience when a family member suffers from a disease which results in debilitation or deformity.

Theme 6: APPROACH TO a PATIENT WITH GENERALISED pain

OUTCOMES

At the end of this session, the student will have:

i)       An appreciation for taking a full history, including

·                symptoms of depression,

·                psychosomatic complaints,

·                household circumstances.

ii)      Recognition for the role of the paramedical services with regards to:

a)       Treatment of inflammatory diseases

b)      Treatment of soft tissue diseases

c)       Patient training on when to exercise and when to rest

d)      Exercise programme

e)       Appropriate joint rest /use

f)       The value of the getting the family involved

g)       Social factors

h)      Home environment

i)       Patient’s ability and willingness to work together.

anything specific YOU SHOULD do?

The groups from the previous small group session will be maintained and students will be addressed by a Physiotherapist, Occupational Therapist, Social Worker and Patient.

Paramedical services will enlighten students on the concept of rehabilitation and the necessity for diminishing worsening factors in chronic diseases.

Lecturers will demonstrate the importance of splints/exercise/social intervention.

Theme 6: APPROACH TO a PATIENT WITH GENERALISED pain

Self-assessment

a)         Describe (in writing) your worst feeling in the morning after a heavy party. If you have never had such a feeling, discuss it with someone in your class who has had such an experience.

b)         Try to convince yourself that everything will worsen for 24 hours and then try to convince yourself that everything is going very well. Do you think that your mood can be influenced by your physical health?

c)       Describe in writing the most severe recent muscle pain that you have experienced. You will be expected to hand this in.

d)      The next time that you exercise to exhaustion, tke a warm bath and describe how your body responded.

ANYTHING SPECIFIC YOU SHOULD DO?

The groups from the previous small group session will be maintained and students will be addressed by a Physiotherapist, Occupational Therapist, Social Worker and Patient.

Paramedical services will enlighten students on the concept of rehabilitation and the necessity for diminishing worsening factors in chronic diseases.

Lecturers will demonstrate the importance of splints/exercise/social intervention.

THEME 7: APPROACH TO THE PATIENT
WITH MONO/OLIGO ARTHRITIS

Required reading work:   Pathophysiology of gout and osteoarthritis.

Clinical characteristics of gout and osteoarthritis.

OVERVIEW OF THE THEME

THEME 7: APPROACH TO THE PATIENT WITH MONO/OLIGO ARTHRITIS

OUTCOMES

At the end of this theme, the student will be able to do the following:

i)          Differentiate betwee acute and chronic mono /oligo arthritis

ii)         Recognize the importance of age/sex in diagnosis

iii)     Recognize the importance of joint involvement at diagnosis

Approach the problem of degenerative arthritis, including

a)         Risk factors

b)         Primary and secondary conditions

c)         Main joints involved

d)         Treatment, including the importance of rehabilitation

e)         Indications for surgery

i            Have an approach to crystal arthritides, including

a)         The risk factors

b)         Primary and Secondary gout

c)         Phases of gout

d)         Syndrome X

e)         Indications for treatment.

ii          Have a basic knowledge of the treatment of these conditions.

Self-study

Read Sydenham’s description of acute gout.

Visit the Renal Transplant unit and ask to speak with a patient with tophic gout.

Visit the "Hip Clinic" and speak with a patient that is waiting for a hip or knee replacement as a result of osteoarthritis.

Please ensure that the whole class does not visit this clinic at one time.

Please co-ordinate this visis with the class representative. Not more than 10 students may be present at any one time.

THEME 7: APPROACH TO THE PATIENT WITH MONO/OLIGO ARTHRITIS

OUTCOMES

At the end of this theme, the student will have the following:

i)          An understanding of the term enthesitis.

ii)         An understanding of the term “reactive arthritis” and its relationship with “Reiter’s Syndrome”.

iii)       Know the importance of the ability of certain organisms to induce a chronic inflammatory response

iv)        A superficial understanding of the importance of genetic predisposition

v)         The ability to differentiate between mechanical and inflammatory backpain

vi)        A good knowledge of the symptoms and clinical characteristics of the following conditions:

a)         Ankylosing spondylitis, including the importance of peripheral joint involvement and the systemic characteristics.

b)         The radiological characteristics that differentiate this condition from degenerative back disease.

c)         The importance of uveitis and other eye pathology in seronegative spondarthropathy.

d)         Reactive arthritis

e)         Psoriatic arthropathy and its connection with skin disease.

f)         The AIDS virus and the presentation of arthritis.

vii)     A superficial knowledge of the treatment of the above-named conditions.

THEME 7: APPROACH TO THE PATIENT WITH MONO/OLIGO ARTHRITIS

OUTCOMES

At the end of the lectures on Mono-Arthritis and Seronegative Spondarthropathy, the class will be divided up into groups. The size of the groups will depend on the number of Rheumatology personel available. Each group will be given at least 2 cases to study. The cases will include short summaries of the patients, as well as their symptoms and signs. Certain critical information may be withheld. During this session the group must identify what information has been omitted. They must also draw up an algorithm to enable to group to make a diagnosis or differential diagnosis. Critical special investigations must be included.

THEME 7: APPROACH TO THE PATIENT WITH MONO/OLIGO ARTHRITIS

OUTCOMES

During this session, the group must be prepared to present their findings to a Rheumatologist. This will be followed by a discussion, based on the group’s deductions. The last 15 to 20 minutes will be allocated to a short presentation of one of the cases from each group. During this presentation, the group leader will be expected to highlight the signs used to reach a diagnosis.

Theme 8: approach to the patient with
non-specific systemic diseases

OVERVIEW OF THE THEME

Theme 8: approach to the patient with non-specific systemic diseases

OUTCOMES

At the end of this theme, the student should be able to:

i)          Understand the concept of Auto-Immune Diseases.

ii)         Recognise the role of sex hormones in these conditions.

iii)       Understand the importance of criteria and their role in diagnosis, including their strengths and weaknesses.

iv)        Recognise the importance of different skin rashes as markers of underlying
systemic diseases.

v)         Have an understanding of the wide scope of presentation of Auto-Immune Diseases.

vi)        Recognise the problems associated with differentiating constitutional symptoms from organic symptoms.

vii)       Recognise key signs with the diagnosis of Auto –Immune Diseases.

viii)     Recognise the importance and limitations of Serology.

ix)       Recognise the importance of hands as indicators of systemic diseases.

x)         Recognise the importance of early referrals for these cases.

xi)       Recognise the warning signs of SLE flare-ups.

Theme 8: approach to the patient with non-specific systemic diseases

OUTCOMES

At the end of the theme, the student will be able to:

i)          Understand the fundamentel basis of this group of diseases.

ii)         Recognise warning skin signs for these group of diseases.

iii)       Recognise the most important systemic components.

iv)        Understand the importance of Raynauds as a sign of systemic diseases.

CASE discussions

The class will be divided into small groups (4-6 groups). Each group will be given a number of cases to study. Certain key points in the scenarios will be omitted. During your study periods, you will be expected to identify points in the history and examination which you regard as important in or der to fully assess the case.

When you return to the klas, the group will be expected to present the case with

·                Further details of the history,

·                Critical characteristics during the examination,

·                Special diagnostic investigations that will be required in order to make a diagnosis or differential diagnosis. Lecturers will be on hand to guide you should you require assistance.

Theme 8: approach to the patient with non-specific systemic diseases

At the end of the lectures on the patient with non-specific systemic diseases, the class will be divided into groups. The size of the groups will depend on the number of Rheumatology personel available. Each group will be given at least 2 cases to study. The cases will include short summaries of the patients, as well as their symptoms and signs. Certain critical information may be withheld. During this session the group must identify what information has been omitted. They must also draw up an algorithm to enable to group to make a diagnosis or differential diagnosis. Critical special investigations must be included.

Theme 8: approach to the patient with non-specific systemic diseases

During this session, the group must be prepared to present their findings to a Rheumatologist. This will be followed by a discussion, based on the group’s deductions. The last 15 to 20 minutes will be allocated to a short presentation of one of the cases from each group. During this presentation, the group leader will be expected to highlight the signs used to reach a diagnosis.

Theme 9:other topics in rheumatology

OVERVIEW OF THE THEME

Theme 9: other topics in rheumatology

OUTCOMES

At the end of these sessions, the student should be able to understand the following:

i)          The  core signs of the most important forms of juvenile arthritis

ii)         The criteria on which this diagnosis is based

iii)       The morbidity associated with these conditions and the importance of making a diagnosis.

iv)        The critical clinical signs of the different conditions

Theme 9: other topics in rheumatology

OUTCOMES

At the end of this session, you should be able to do the following:

1.          Discuss the mechanism of action of the anti-inflammatory, anti-gout and immunosuppressant drugs.

2.         Explain the pharmacological differences between the above-named medications.

3.         Discuss the anti-inflammatory and analgesic effects of the non-steroidal anti-inflammatory drugs (NSAID’s)

4.         Name side effects of the anti-inflammatory, anti-gout and immunosuppressant drugs and explain steps that can be taken to limit these unfavourable effects.

5.         Discuss the clinical use of anti-inflammatory, anti-gout and immunosuppressant drugs.

Resources

Rang, Dale & Ritter, Pharmacology, 4^th Ed, (1999). Chapter 13

Theme 9: other topics in rheumatology

This session is a revision of the Rheumatology sessions. Slides will be shown to highlight the important points.

Theme 9: other topics in rheumatology

Slides will be shown and one or two questions asked, based on the lectures. This test will account for 10% of the final Rheumatology mark.

THEME 10:
CONGENITAL AND DEVELOPMENTAL
CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

AIM OF THE THEME

At the end of this theme, you should have a broad knowledge with regards to the natural course of rotation and angular anomalies of the lower limbs as a result of physiological reasons in the growing child and you should also be able to recognise this presentation clinically. You should also be able to identify pathological anomalies and deformities of the musculoskeletal system, for example the most common metabolic and dysplastic which give rise to angular and rotational deformities.

You will also learn about the general osteochondroses as causes of a painful lower limb, in addition to their natural causes. You should be able to identify and treat normal leg pain in the growing child.

You should be able to reach a differential diagnosis with regards to a child with a painful or limping gait.

You should be able to recognise the general congenital anomalies of the lower limbs in the newborn. You should also know about developmental conditions, such as Perthe's disease and sliding proximal femoral epiphysis of the hip, and their natural course.

Overview of the theme

THEME 10: CONGENITAL AND DEVELOPMENTAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

Outcomes

At the end of this session, you should be able to do the following:

1.          Describe/recognize/accurately document linear and rotational deformities of the lower limbs in children, and explain how these can be distinguished from metabolic and dysplastic conditions.

2.         Give the diagnostic criteria for Blount ‘s disease (tibia vara) and describe the natural course thereof.

3.         Describe the clinical characteristics of rickets and tabulate the radiological presentation thereof.

4.         Explain how the diagnosis of osteochondrosis can be made in the growing child, name the different sites as well as the ages in which it may present.

5.         Compare the characteristics of normal and pathological leg pain, and explain what is meant by referred leg pain.

RESOURCES

1.       Growing Pains. CME March 1991, Vol 9, No 3, Page 257.

2.         The Osteochondroses – Apleys System Of Orthopaedics And Fractures Page 103

3.         Journal Of American Family Physicians Osteochondritis Desicans, Jan 1, 2000 Page 151

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

During this session there will be a lecture demonstration (40 minutes) discussing rotational and linear deformities of the lower limbs, as well as their natural course and their distinction from pathological conditions. Leg pains in children will be discussed.

Pre-study

Read up on osteochondroses of the lower limb, and, during the last 10 minutes of the lecture, complete the assignment provided to your after consultation with the lecturer.

THEME 10: CONGENITAL AND DEVELOPMENTAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

Outcomes

At the end of this session, you should be able to do the following:

1.       Describe the clinical characteristics and principles of treatment of congenital clubfeet, and be able to discuss the functional and cosmetic prognosis with the parents.

2.       Describe the clinical presentation of a metatarsus adductus and the be able to name the differentiating features from a club foot.

3.       Write down the instructions for the mother on how to manipulate clubfeet as well as a metatarsus adductus.

4.         Describe the clinical elements of a flat foot, tabulate the most important causes and describe how to clinically distinguish between a rigid and a mobile flat foot.

5.         Name aids that can be utilised for the treatment of flat feet.

6.         Describe the clinical elements of a cavus foot and tabulate the other conditions with which cavus feet can be associated.

RESOURCES

1.          The Foot Of The Child. CME Feb 1997, Vol 15, No 2, Page 129.

2.         Deformities Of The Foot – Apleys System Of Orthopaedics And Fractures Page 473

3.         Clinical Orthopaedic Examination – McRae Page 264

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

The objective of this session is to enable you to recognize, identify and distinguish between the general foot anomalies occurring in children.

During this session, there will be a 40-minute lecture demonstration. The distinction between clubfeet and metatarsus adductus will be discussed. Flat feet in the child will be discussed with reference to the causes at different ages, as well as the natural progression. Cavus feet will also be discussed.

Selfstudy assignment

After this lecture, you will be expected to research and tabulate the most common neurological causes of Cavus feet.

THEME 10: CONGENITAL AND DEVELOPMENTAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

Outcomes

At the end of this session, you should be able to do the following:

1.          Tabulate the most important characteristics of the high risk baby for a congenital hip dislocation, and describe and explain the clinical investigations as applicable to various age groups.

2.         Tabulate the treatment modalities and explain the application thereof.

3.         Write down the radiological characteristics of a congenitally dislocated hip and recognise the this condition on xray.

4.         Define the entity of a transitory synovitis, and explain the causes and natural course.

5.         Define Perthe’s disease, describe the clinical presentation and tabulate and the radiological signs.

6.         Describe the treatment modalities as well as the natural course of the condition.

7.         Define a sliding proximal femoral epiphysis, describe the clinical presentation, tabulate the radiological signs and recognise this condition on xray.

8.         Describe the treatment of a sliding proximal femoral epiphysis.

9.         Define the entity of idiopathic chondrolysis and briefly describe the natural course thereof.

RESOURCES

-                 The Limping Child Journal Of Bone And Joint Surgery (B) Nov. 1999 Page (6) 1029

-                 Journal Of American Family Physician, Evaluation Of Acute Limping Child, Feb 15, 2000

-                 Journal Of American Family Physicians, Slipped Capital Femoral Epiphysis, May 1, 1998,
Page 1231

ANYTHING SPECIFIC YOU SHOULD DO?

Preparation

Refer to "The Limping Child."

Lecture

The objective of this session is to highlight the common congenital and developmental conditions of the hip in the growing kind, from birth to adolescence.

You should be able to describe the clinical diagnosis a congenital hip disclodation in the neonate.

You will be introduced to developmental conditions of the hip peculiar to children, for example Perthe's disease and sliding proximal femoral epiphysis, their presentation, the age of distribution, as well as the modalities of examination applicable in these cases.

During this session, there will be a 40-minute lecture demonstration wherein the aetiology, diagnosis and treatment of hip dysplasia will be discussed. The appearance, clinical presentation, natural course and complications of Perthe’s disease of the hip, as well as slipped proximal femoral epiphyses will also be discussed.

The last 10-minutes will be spent on the completion of an assignment on the differential diagnosis of hip pain in the growing child from birth to adolescence.

THEME 10: CONGENITAL AND DEVELOPMENTAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

Outcomes

At the end of this session, you should be able to do the following:

1.       Tabulate the different types of cerebral palsy and describe their functional properties.

2.       Name the causes of contractures and deformities and briefly describe the functional abilities thereof.

3.       Tabulate the possible therapeutic modalities for for cerebral palsy and briefly describe the applications of each.

4.         Describe the functional properties of spina bifida and myelomeningocoele.

5.         Name the sensory implications of spina bifida and myelomeningocoele and explain the motor implications for the lower limbs.

6.         Tabulate the musculoskeletal implications of poliomyelitis, congential multiplex arthrogryposis and Duchenne’s muscular dystrophy.

RESOURCES

1.       The Physically Disabled Child. CME June 1994, Vol 12, No 6, Page 721

2.       Neuromuscular Disorders – Apleys System Of Orthopaedics And Fractures Chapter 10
Page 192

3.       Orthopaedic Surgery In Cerebral Palsy: Assessment Treatment And Management, WS342ORT, US Library

ANYTHING SPECIFIC YOU SHOULD DO?

During this session, you will be informed of the orthopaedic aspects of general neuromuscular disease conditions in the growing child, as well as the treatment modalities that are applied to improve locomotor abilities and prevent back and limb deformities. You must have sufficient insight to inform parents of these conditions.

Pre-study

1        Please review the assignment of muscle power and spasticity grading. Sessions 2 & 3, Theme 2.

2        Before commencing this lecture, you should review the differences between an upper and lower motor neuron lesion. Refer to Sessions 2 & 3, Theme 2.

You will be expected to give feedback during this session.

Feedback

10 Minute feedback on Sessions 2 and 3.

Lecture

This lecture demonstration deals with the clinical evaluation of the locomotor system in cerebral palsy. The functional abilities and natural course will also be discussed. The therapeutic modalities to control of muscle spasticity will also be discussed. You should tabulate these modalities and make necessary annotations. The important musculoskeletal aspects of the less common neuromuscular conditions will also be discussed.

THEME 11:
ONCOLOGICAL CONDITIONS OF THE
MUSCULOSKELETAL SYSTEM

AIM OF THE THEME

At the end of this theme, you should know the principles pertaining to the classification, morphological spectrum, clinicopathological importance and diagnosis of tumours and tumourlike conditions of the skeleton and soft tissues.

Overview of the theme

THEME 11: ONCOLOGICAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

Outcomes

At the end of this session, you should be able to:

1.          Give a basic classification of skeletal and soft tissue tumours.

2.         Discuss the most important morphological characteristics and clinicopathological importance of the common benign and malignant bone tumours with reference to the age and sexual distribution thereof, preferential anatomical positions of different tumours, and their biological behaviour and prognosis.

3.         Discuss the pathology of metastatic tumours to bone.

4.         Explain the concept of clinical-pathological-radiological correlation in the diagnosis of bone tumours.

5.         Briefly discuss the more common tumour-like conditions of bone and soft tissue, including fibrous dysplasia, fibromatosis, nodular fasciitis and myositic ossificans.

RESOURCES

-        Underwood, 1996 Pages 798-802 and 825-827

-        Make supplementary notes during contact sessions

-        Class notes

-        Examples of specimens that you can study in your own time will be made available. The location will be given to you. A list of cases is attaced at the end of this theme.

-        Computer-assisted guidance: This website offers numerous examples, illustrations and tutorials which you will be able to access elsewhere.

ANYTHING SPECIFIC YOU SHOULD DO?

Revision

It is important that you review the principles of carcinogenesis and neoplasia in order to have a good understanding of tumour nomenclature, the differences between benign and malignant neoplasia, tumour differentiation, and grading and staging. Review carcinogenesis and refer especially to the principles of carcinogensis, neplastic transformation of cells, and host factors that play a role in neoplasia. Take note of the specific aspects that are important with regards to tumours of bone and soft tissue. Ensure that you review the concept of paraneoplastic syndrome and the clinical importance of local and systemic consequences of tumours (refer again to Phase II module: Basis of Disease Processes; Theme 21).

Lecture

1.          Read pages 798 to 802, and 825 to 827 in Underwood before attending the lecture. You will benefit greatly by reviewing pages 246 to 258, and 284 to 290; pay attention to the illustrations and tables. During the lecture, the lecturer will explain the theory underlying the outcomes, and provide illustrations and appropriate guidelines for further study.

2.         Make supplementary notes to your textbook and class notes.

3.         The lecture is available at the following web address:

Assignments for further directed self-study

Answer the following questions during your self-study:

1.          Classify tumours of the skeleton and soft tissue. Ensure that you have a logical approach with respect to the principles of tumour nomenclature. Page 799 in Underwood.

2.         Discuss the most important morphological characteristics and clnicopathological importance of the more common benign and malignant bone tumours, and refer to the importance of age, sex, and anatomical position in the differentiation of the various tumours.

3.         Discuss the prognostic importance of the most important skeletal tumours.

4.         Discuss metastatic tumours to bone and highlight the common tumours which are prone to develop skeletal metastases.

5.         Explain the importance of clinical-pathological-radiological correlation in the diagnosis of bone tumours. Refer to osteosarcoma and giant cell tumour of bone to illustrate your answer.

6.         Explain the diagnostic value and dangers of biopsies of bone tumours. Refer to the role of a general medical practitioner in the diagnosis of bone tumours.

Take note that the following examples of skeletal and soft tissue pathology are available for study purposes. The location will be made known to you. This opportunity is available for assistance but will not form part of your assessment. You are encouraged ao formulate questions and direct these to Prof Schneider at jws2@sun.ac.za

* AU23, AU24, AU32         :Osteosarcoma

* AU30                               :Neoplastic giant cell tumour of bone

* AU27                               :Skull metastases

* AU28                               :Carcinoma metastases (femur)

* AU26                               :Vertebrae - sarcoma metastases

* AU22                               :Vertebrae - metastases

* AU29                               :Tibia - fibrosarcoma

* AU43                               :Synovial sarcoma (hand)

* AU3                                 :Hand - synovial sarcoma

* JU41                                :Vertebra, kidney and spleen -myelomatosis

* JW2                                :Femur - acute leukaemia

* AU25                               :Vertebrae - lymphoma

Wet specimens

* SD1845-6/81, 14452/89,               - Osteosarcoma

* SD8164/86, 1298/90, 4536/90     - Osteosarcoma

* SD2121-24/89, 10278/90              - Osteosarcoma

* PM94/90                                        - Osteosarcoma with lung metastases

* SD5403/89                                    - Angiosarcoma

* SD4174/88                                    - Leiomyosarcma

THEME 11: ONCOLOGICAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

       Outcomes

At the end of this session, you should be able to do the following:

1.       Recognize and tabulate the radiological characteristics of benign and malignant bone lesions.

2.       Tabulate the spread of common benign bone lesions.

3.       Tabulate the age of presentation and localisaton of primary bone tumours.

4.       Name the most common benign bone tumours, as well as their localisation and natural course.

5.       Make a radiological diagnosis of metastatic bone tumours and tabulate the tumours which commonly metastasize to bone.

6.       Define pathological fractures and describe the treatment thereof.

7.       Know the supplementary special investigations used to stage tumours.

8.       Describe the most important aspects pertaining to biopsies of bone lesions.

9.       Describe the applicaton of the various treatment of primary bone tumours.

10.     Know the prognosis of different tumours and be able to inform the patient thereof.

RESOURCES

System of Orthopaedics and Fractures A. Graham Appley – Butterworths Chapter 9 Page 162

Journal of American family Physicians, Pigmental villonodular synovitis, Aug 1, 1999, Page 1909

ANYTHING SPECIFIC YOU SHOULD DO?

During this session, the clinical and radiological aspects of the common primary and secondary tumours of bone and joints will be covered. You should be aware if the incidence, presentation and distribution of these tumours, as well as realize the importance of age and localisation in the differentiation. You should be able to differentiate between primary and secondary bone tumours, as well as between benign and malignant bone tumours.

The acitivities of Session 3 include 2 clinical problems to solve.

45 minute lecture demonstration

45 minute self-study

Self-study

Four clinical problems will be presented for discussion. You will be expected to discuss and solve each problem together during the session with the assistanc of your lecturer and tabulate the approach with reference to the relevant clinical history, appropriate xrays and special investigations. A differential diagnosis and therapeutic guidelines must be reached.

Lecture

The lecture will include the following important clinical problems:

1.          Common benign bone tumours

2.         Common malignant bone and joint tumours. Emphasis should be placed on the age of presentation.

3.         Recommendations should be made to stage a tumour with the assistance of special investigations.

4.         Discuss the treatment of benign tumours.

5.         Emphasis will be placed on metastatic diseases of the bony skeleton and metastatic tumours. Occult metastases will be discussed as well as the diagnosis thereof.

The role of prophylactic internal fixation will be discussed.

THEME 11: ONCOLOGICAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM

Outcomes

At the end of the session you should be able to:

1.          Describe the pathological characteristics of the common soft tissue tumours.

2.         Describe the clinical presentation.

3.         Tabulate the most important diagnostic investigations.

4.         Discuss the basic guidelines for the most important treatment modalities.

5.         Describe the prognosis and course of the most important tumours.

RESOURCES

1.          Preparatory reading – Hohn DC: Soft Tissue Sarcomas, in: Way LW (Ed): Current Surgical Diagnosis and treatment; 10th ed., Pages 1253 – 1256

2.         Pathology – MacSween, Whaley K (Eds): soft Tissue Tumors and Tumor-like Lesions in: Muir’s Textbook of Pathology, 13th edition, Pages 1001 – 1009

3.         Further Reading – Eberlein TJ: Soft-Tissue Sarcomas. Surg Clin Norh Am. 2000
Apr; 80(2): 687 – 708.

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

This session will be useful in learning to suspect soft tissue tumours of the musculoskeletal system as well as formulating a reference framework.

This session will discuss the approach to a patient that presents with a soft tissue mass of the musculoskeletal system. The appropriate special investigations will be discussed, as well as the relevant pathology. You will also be informed of the various therapeutic modalities. The specific tumours that will be discussed are aggressive fibromatosis, lipoma and liposarcoma, fibrosarcoma and variants, as well as synovial sarcoma.

THEME 12:
CONDITIONS OF THE PELVIS AND SPINAL COLUMN

Aim of the theme

This theme will cover the examination methods relevant to the spinal column and pelvis which are appplicable to disease conditions of tis area. You will be instructed on how to evaluate a patient with neck or backpain in order to reach a diagnosis and to formulate a therapeutic plan. The first two sessions deal with general deformities of the throacolumbar vertebrae in children, namely postural, scoliosis and kyphosis. The causes and natural course will be discussed. You will also be instructed on ow to differentiate between backpain in children.

Overview of the theme

THEME 12: CONDITIONS OF THE PELVIS AND SPINAL COLUMN

Outcomes

At the end of this session, you should be able to do the following:

1.       Define and tabulate the clinical characteristics of scoliosis and kyphosis of the spinal cord.

2.       Discuss the neurological examination of a back patient.

3.       Tabulate the causes of a kyphosis.

4.       Tabulate the causes of scoliosis and define an idiopathic scoliosis.

5.       Tabulate the difference between a structural and functional scoliosis.

6.       Discuss the natural progression of scoliosis and know the reference guidelines for treatment.

7.       Be able to inform the parents of the condition of scoliosis and be able to discuss possible therapeutic options.

8.       Tabulate the possibilities that can give rise to back pain in children.

RESOURCES

1.       Scheuermanns Disease And Postural Kyphosis. SA Bone & Joint Surgery. Vol VIII, No 3, Aug 1998, Page 48.

2.         Assessing Structural Scoliosis. Modern Medicine. (Practical Procedure) Vol 22, No 9, Sept 1997, Page 58.

3.         Concise System Of Orthopaedics And Fractures, Chapter 18. Page 157. A Graham Apley/
L Solomon.

4.         Journal Of American Family Physicians, Managing Osteomyelitis Adolescent Idiopathic Scoliosis, July 1, 2001

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

During this session, a lecture will be presented on how to make a clinical and radiological diagnosis of scoliosis or kyphosis of the thoracolumbar vertebrae. The causes thereof at different ages will also be discussed. The therapeutic modalities for these conditions will be discussed and the role of the general practitioner highlighted.

Backpain in children is unusual and the causes will be discussed, as well as the ways of presentation.

Self-study

The schoolteacher refers a girl with a poor posture to your practice. Discuss your evaluation and tabulate the possible causes. The class will divide into smaller groups to discuss this assignment.

You are expected to give a brief feedback during Session 2.

THEME 12: CONDITIONS OF THE PELVIS AND SPINAL COlumn

Outcomes

At the end of this session, you should be able to do the following:

1.          Identify referred pain from the neck.

2.         Evaluate the extent of movement of the neck and muscle spasm.

3.         Tabulate the most important causes of Torticollis.

4.         Make the diagnosis of cervical and lumbar spondylosis and propose the appropriate treatment thereof.

5.         Make the diagnosis of cervical and lumbar disc lesion, and know the indications for surgery.

6.         Discuss the infective conditions that may involve the neck and lumbar vertebrae.

7.         Discuss the neoplastic conditions that may affect the neck and lumbar vertebrae.

8.         Know the role of neck and lumbar braces and physiotherapy in the treatment of neck and back conditions.

RESOURCES

1.          Concise System Of Orthopaedics And Fractures/A Graham Apley/L Solomons, Chapter 17, Page 150

2.         Clinical Orthopaedic Examination – McRae

3.         Journal Of American Family Physicians, Cervical Spine X-ray, Jan 15, 1999 Page 331

ANYTHING SPECIFIC YOU SHOULD DO?

Revision

Please revise the examination of the neck and back before attending the session. (Theme 2 Session 3)

RESOURCES

-                 Concise System Of Orthopaedics And Fractures. Chapter 18 Page 157. A Graham Apley/
L Solomons

-                 Mechanical Low Lumbar Back Pain - Modern Medicine, Vol 26 No. 6 June 2001 Page 56

-                 Low Back Pain – An Algorithmic Approach – Modern Medicine Vol 25, No. 6, June 1999,
Page 39

-                 Journal Of American Family Physicians, Lumbar Spine Stenosis, Apr 15, 1998, Page 1825

-                 Journal Of American Family Physicians, Backache Diagnosis OA, March 15, 2000 Page 1795

-                 Journal Of American Family Physicians, Management Of Acute Lower Backache, March 15, 2000 Page 1779

-                 Backache: Causes And Prevention, WE720BAC, US Library

-                 Journal Of American Family Physicians, Evaluation And Treatment Of Herniated Lumbar Disc, Feb 1, 1999

-                 Backache – Ian McNab

Rational investigating Update June 2000 Page 35

Self-study

Please read up on back pain in the workplace. References:

1.          Concise System Of Orthopaedics And Fractures

2.         Notes: Prof GJ Vlok

3.         Backache: Ian Macnab

THEME 13:
CONDITIONS AND DEFORMITIES OF THE UPPER LIMB

Aim of the theme

The aim of these two sessions is to make you aware of the clinical signs of a brachial plexus, as well as the extent and prognosis of the injury and to ensure that you are able to relay this to the patient. You will also be instructed on clinical examination methods of the shoulder girdle and how to apply this in order to distingish between rotator cuff lesions, pressure conditions, instability and arthritis.

This theme will also assist you in applying the clinical examination methods pertaining to the upper limb in order to identify disease conditions and deformities and thus make a diagnosis and formulate a therapeutic plan.

Overview of the theme

THEME 13: CONDITIONS AND DEFORMITIES OF THE UPPER LIMB

Outcomes

At the end of this session, you should know:

1.          The sensory and motor dermatome and myotome patterns of the upper limb.

2.         The reflex pathways.

3.         The clinical signs of a radiculopathy.

4.         The clinical signs of an upper and lower radial median and ulnar nerve injury.

5.         The importance and performance of the tinel test.

RESOURCES

-        Modern Medicine Assessment Of Nerve Root Function In The Upper & Lower Limb (Practical procedures) Vol 24, No 1, Jan 1999, Page 21.

-                 Apleys System Of Orthopaedics And Fractures, Peripheral Nerve Injuries. Chapter II,
Page 221

-        Clinical Orthopaedic Examination – McRae Page 10

THEME 13: CONDITIONS AND DEFORMITIES OF THE UPPER LIMB

Outcomes

At the end of this session, you should be able to do the following

1.       Tabulate the causes of a brachial plexus lesion.

2.       Sketch the anatomy of the brachial plexus.

3.       Clinically localise the level of a brachial plexus lesion.

RESOURCES

-        Modern Medicine Assessment Of Nerve Root Function In The Upper & Lower Limb (Practical procedures) Vol 24, No 1, Jan 1999, Page 21

-                 Apleys System Of Orthopaedics And Fractures, Peripheral Nerve Injuries. Chapter II,
Page 221

-        Clinical Orthopaedic Examination – McRae Page 10

ANYTHING SPECIFIC YOU SHOULD DO?

Self-study

Before starting this session, you should review your knowledge on the functional anatomy of the upper limb, as well as the brachial plexus. You should know the origin and insertion, as well as the functions, of the important muscle groups. You should also revise the nerve supply of the upper limb. Refer to Phase II module The Musculoskeletal System Theme 5, Sessions 2, 3, 4, 5 and 6.

This self-study period is devoted to the completion of the schematic presentation of the brachial plexus that will be handed out to you.

You must refer to Greens Hand Surgery textbook in order to tabulate the causes of a brachial plexus lesion and to distinguish between a high and a low brachial plexus lesion and the functional implications thereof.

Lastly, you should tabulate the special investigations that may be helpful in assessing the prognosis of the lesion.

Please complete the assignment.

THEME 13: CONDITIONS AND DEFORMITIES OF THE UPPER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1.          Tabulate the causes of referred pain to the shoulder joint.

2.         Describe the characteristics and localisation of shoulder pain.

3.         Recognise rotator cuff lesions with reference to a diagnostic and therapeutic approach.

4.         Discuss shoulder instability.

5.         Define and discuss adhesive capsulitis.

ANYTHING SPECIFIC YOU SHOULD DO?

Pre-study

The Shoulder, Clinical Orthopaedic Examination – Mc Rae, Chapter 4, Page 41

The last 10 minutes of this session will be devoted to the completion of an assignment of the area of local infiltration for the management of shoulder problems.

Lecture

This lecture deals with the approach to the patient with a painful shoulder, and discusses the soft tissue conditions peculiar to the shoulder joint and the clinical and radiological distinction thereof.

The natural course and outcome of each condition will also be discussed.

RESOURCES

-                 The Painful Shoulder. CME March 1991 Vol. 9 No. 3, Page 275

-                 Intractble Shoulder Pain – Update Feb 2000, Page 36

-                 Tackling Painful Shoulder Problems - Update Aug 1998, Page 41

-                 Physical Examination Of The Shoulder. SA Bone & Joint Surgery Vol. X, No. 4 Nov 2000, Page 12

-                 Common Causes Of Shoulder Pain – A Guide For GP’s – Modern Medicine Of SA, May 1998, Page 9

-                 The Shoulder: Apleys System Of Orthopaedics And Fractures, Chapter 13, Page 261

-                 Shoulder Problems: A Guide To Common Disorders CME (Cover Story) Vol 25, No. 8,
Aug 2000, Page 14

-                 Journal Of American Family Physicians, Painful Shoulder Part 1, March 15, 2000,
Page 3079

-                 Journal Of American Family Physicians, Painful Shoulder Part II, June 1, 2000, p. 3291

-                 Journal Of American Family Physicians, Shoulder Impingement And Rotator Cuff Tears, Feb 15, 1998, Page 667

-                 Journal Of American Family Physicians, Shoulder Instability In Young Athletes,
May 15, 1999

THEME 13: CONDITIONS AND DEFORMITIES OF THE UPPER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1.          Tabulate the causes of referred pain to the elbow joint.

2.         Tabulate pressure neuropathies of the elbow and discuss the treatment and natural course thereof.

3.         Explain the entities of medial and lateral epicondylitis, and discuss the causes and treatment thereof.

4.         Tabulate the causes of an olecranon bursitis and discuss the clinical presentation and treatment thereof.

5.         Discuss the use of local corticosteroid injections into the elbow.

6.         Define a ganglion of the wrist joint and explain the differentiation from other swellings of the wrist joint.

7.         Define and discuss De Quervain’s tenosinovitis.

8.         Define and briefly discuss Kienbock’s disease.

9.         Define carpal instability and discuss the implications thereof.

10.       Explain the implications of osteoarthritis of the wrist joint.

ANYTHING SPECIFIC YOU SHOULD DO?

This session will assist you in making a differential diagnosis for a patient presenting with a painful elbow. You will also be able to differentiate between intra-articular and extra-articular pathology and referred pain to the elbow.

Pre-study

Preparatory studies include revision of the functional anatomy of the elbow, as well as the contents of the flexor and extensor compartments of the forearm. Phase II module The Musculoskeletal System M4795 and Theme 5 Sessions 4 and 5.

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of this session is to enable you to evaluate a painful wrist. You will be instructed on how to differentiate between intra-articular causes of pain and surrounding tenosinovitis and pressure syndromes. You will also be able to recognise deformities of the wrist joint, as well as limited movement thereof, and to couple this to a diagnosis.

Pre-study

You must review the examination of the wrist – Theme 2 of this module. You must also revise the functional anatomy of the wrist joint – the course of the tendons through the wrist, and also the wrist bones – refer to Phase II module The Musculoskeletal System.

Lecture

This lecture deals with the approach and differential diagnosis of an patient with a painful wrist. The entity of ganglions and swellings will be discussed, as well as their differentiation. The diagnosis and treatment of osteoarthritis of the wrist will be discussed. You will also learn about Kienböck’s disease and the implications thereof.

RESOURCES

Elbow pain: CME March 1991 Vol 9 Nol 3 Page285

-                 Clinical Orthopaedic Examination: Mcrae – The Elbow, Chapter 5, Page 61

-                 Apleys System Of Orthopaedics And Fractures – The Elbow, Chapter 14, Page 286

-                 Journal Of American Family Physicians, Evaluation Of Overview Elbow Injuries,
Feb 1, 2000

-        The Painful Hand And Wrist. CME March 1991 Vol. 9, No. 3 Page 300

-                 Apleys System Of Orthopaedic And Fractures: The Wrist – Chapter 15, Page 296

-                 Clinical Orthopaedic Examination: The Wrist – Chapter 6, Page 77

THEME 13: CONDITIONS AND DEFORMITIES OF THE UPPER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1.          Discuss the characteristic pattern of wrist involvement.

2.         Describe the characteristic deformities of the wrist and hand and explain the causes thereof.

3.         Discuss the soft tissue and tendon involvement of the wrist and the hand.

4.         Explain the basic principle in the treatment of a rheumatoid wrist and hand.

RESOURCES

-        Apleys System Of Orhtopaedics And Fractures. Chapter 3 And Chapter 16

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of this session is to ensure that you become aware of the extent to which rheumatoid arthritis may affect the wrist and hand joints. You will be able to recognise the characteristic deformities of the hand and wrist, and discuss the natural course and treatment.

Self-study

During this self-study session, you should be able to tabulate the hand deformities associated with Rheumatoid arthritis. You should be able to name the probable causes and briefly discuss the treatment of each deformity.

This information will be checked by the lecturer during Session 6.

THEME 13: CONDITIONS AND DEFORMITIES OF THE UPPER LIMB

     Outcomes

At the end of this session, you should be able to do the following:

1.          Make the diagnosis of a carpal tunnel syndrome, tabulate the causes, perform the necessary clinical investigations and discuss the treatment.

2.         Discuss the indications for and the results of surgery.

3.         Make the diagnosis of carpometacarpal osteoarthrosis of the thumb and prescribe treatment. Discuss the surgical indications.

4.         Describe the general presentation of congenital anomalies of the hand and fingers, for example syndactile, campodactile and clinodactile.

5.         Define a trigger finger and discuss the treatment.

6.         Describe a Boutonniere deformity, a swan neck deformity and a “mallet finger”, and discuss the causes and treatment thereof.

7.         Describe a Dupuytrans contracture of the hand, tabulate its associations and discuss the possible treatment modalities.

RESOURCES

-        Wrist And Hand Disorders Update Febr 1999, Page 93

-        Apleys System Of Orthopaedics And Fractures: The Wrist, Chapter 15, Page 296

-        Clinical Orthopaedic Examination: The Wrist, Mcrae, Chapter 6, Page 77

-        Ultrasound Treatment May Relieve Carpel Tunnel Syndrome, Modern Medicine, Vol 23,
No 10, Oct 1998, Page 58

-                 The Fase II Module The Musculoskeletal Sisteem Theme 5 Session 6

-                 Trigger Finger And Thumb – CME March 1991 Vol. 9 No 3 Page 364

-                 Apleys System Of Orthopaedics And Fractures. The Hand, Chapter 16, Page 311

-                 Clinical Orthopaedic Examination, Mcrae, The Hand, Chapter 7, Page 95

-                 Journal Of American Family Physicians, Nails And Nail Disorders In Children And Adults,
May 1, 1997

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of this session is to enable you to identify and evaluate carpal tunnel syndrome, and formulate a treatment protocol.

Pre-study

You must review the anatomy and content of the carpal tunnel.

Lecture

This lecture deals with the causes, clinical diagnosis and treatment of carpal tunnel syndrome. Compression of the ulnar nerve will also be discussed.

Degenerative and inflammatory conditions of the carpometacarpal joints will be discussed.

Overview of common congenital finger and hand deformities.

Deformities of the hand due to inflammatory and degenerative conditions will be discussed. (refer back to Session 4) The common finger deformities such as “mallet finger”, Boutonniere and swan neck deformities will be discussed in depth.

ANYTHING SPECIFIC YOU SHOULD DO?

This session will ensure that you can identify the most common deformities of the hand and fingers, formulate a possible aetiological diagnosis, and describe the course and treatment thereof.

THEME 14:
CONDITIONS AND DEFORMITIES OF THE
LOWER LIMB

AIM OF THE THEME

This theme will enable you to recognise and evaluate the clinical examination methods and radiological investigations pertaining to the lower limb as applicable to disease conditions and deformities thereof, and to formulate a meaningful therapeutic plan.

Overview of the theme

THEME 14: CONDITIONS AND DEFORMITIES OF THE LOWER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1.          Tabulate the causes of osteoarthritis of the hip.

2.         Tabulate the causes of avascular necrosis of the hip.

3.         Describe the clinical presentation of degenerative diseases of the hip.

4.         Discuss the conservative treatment of osteoarthritis of the hip.

5.         Tabulate the indications and contra-indications for a total hip replacement, and discuss the implications of this operaton.

6.         Explain an osteotomy of the hip.

7.         Explain an arthrodesis of the hip.

After this session, you should have sufficient information to advise a middle-aged patient with a grade III painful hip and osteosrthritis about the advantages and disadvantages of surgery to the hip, as well as the conservative modalities available.

RESOURCES

Osteoarthritis Update Febr 1999 Page 98

-                 The Painful Hip CME March 1991 Vol 9 No. 3 Page 311

-                 Apleys System Of Orthopaedics And Fractures – Chapter 5, Page 9, Chapter 19, Page 414

-                 Journal Of American Family Physicians, Anterior Hip Pain, Oct 15, 1999 Page 1657

-                 Journal Of American Family Physicians, Anterior Hip Pain In Athletes, Apr 1, 2000,
Page 2109

-                 How I Examine The Hip, Vol 14, No. 4 July 2000 Page 262

-        Osteo-arthritis Update Febr 1999 Page 98

-                 The Painful Hip CME March 1991 Vol 9 No. 3 Page 311

-                 Apleys System Of Orthopaedics And Fractures – Chapter 5, Page 9, Chapter 19, Page 414

ANYTHING SPECIFIC YOU SHOULD DO?

This session will enable you to evaluate osteoarthritis of the hip joint by appropriate clinical methods, and to recommend appropriate treatment on the grounds of history and special investigations.

Revision

Please read the radiological signs of osteoartritis and avascular necrosis. Theme 3.

Lecture

This lecture deals with the possible causes of osteoarthritis of the hip; the radiological findings as well as the clinical presentation. The causes of avascular necrosis of the hip will be discussed and the radiological differentiation of osteoarthritis will be covered. You will be instructed about the conservative treatment of osteoarthritis, as well as the indications for a total hip replacement and the natural course thereof. In additon, the indications and suitability of osteotomies and artrodeses of the hip will b discussed.

ANYTHING SPECIFIC YOU SHOULD DO?

The objective of this self-study session is to enable you to solve specific clinical problem involving a young patient presenting with a severely painful hip joint.

Self-study and clinical problem solving

You are expected, with the aid of your referenes, to solve the following problem to the best of your ability:

A 40 year old man presents with a grade 3 pain in his right hip secondary to avascular necrosis, possibly due to ethanol abuse and secondary osteoarthritis.

Discuss the treatment possibilities with reference to the advantages and disadvantages as relevant to this specific case.

THEME 14: CONDITIONS AND DEFORMITIES OF THE LOWER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1.          Tabulate causes of osteoarthritis of the knee.

2.         Discuss the conservative treatment of osteoarthritis of the knee.

3.         Explain the requirements for a total knee replacement.

4.         Explain the longterm outcomes of knee replacements.

5.         Explain an arthrodesis of the knee.

6.         Briefly discuss osteotomies of the knee.

RESOURCES

The Painful Knee CME March 1991 Vol 9 No 3, Page 320

Apleys System Of Orthopaedics And Fractures. Chapter 20, Page 432

Clinical Orthopaedic Examination – Mcrae Page 160

Journal Of American Family Physicians, Knee OA, Aug 1, 2000, Page 565

Journal Of American Family Physicians, Patello Femoral Pain, Nov 1, 1999, Page 2012

-        How I Examine The Knee, Vol 14, No 3, May 2000 Page 189

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of this session is to ensure that you can identify deformities of the knee joint, diagnose degenerative arthritis of the knee and formulate a treatment strategy.

Revision

Please revise the radiological signs of osteoarthritis and the mechanical axes of the lower limb. Theme 2 and Theme 3.

Lecture

This session deals with the linear deformities of the lower limb in adults which may result in knee pain and degenerative changes. The conservative treatment will be discussed, as well as indications for surgery. In addition, the role of osteotomies, arthrodesis and knee replacements will also be discussed.

Self-study assignment

Tabulate the possible differential diagnosis, as well as the appropriate special investigations that you would use to establish the diagnosis.

THEME 14: CONDITIONS AND DEFORMITIES OF THE LOWER LIMB

     Outcomes

At the end of this session, you should be able to do the following:

1.          Define ileotibial band syndrome, and briefly discuss the diagnosis and treatment thereof.

2.         Define “shin splints” and briefly discuss the clinical presentation and treatment thereof.

3.         Discuss stress fractures of the lower leg with regards to clinical and radiological presentation and natural course.

4.         Briefly discuss chronic compartment syndrome of the lower in terms of the clinical presentation and treatment thereof.

RESOURCES

The ileotibial band friction syndrome

-                 SA Bone And Joint Surgery Vol IX No 1 Feb 1999, Page 10

-                 Bone Stress Injuries In Athletes CME Febr 1999 Vol 17 No. 2 Page 107

-                 Clinics In Physical Therapy. Physical Therapy Of The Foot And Ankle Gary C Hunt
Pages 225-227

-                 Turecks Orthopaedics 1994 Stress Fractures Pages 112-113, 293

-                 Myofascial Pain And Fibromyalgia Syndromes. Peter E Boldry Shin Splints Page 289

-                 Journal Of American Family Physicians, Stress And Insufficiency Fractures, July 1997,
Page 175

-                 Acute And Chronic Knee Injuries In Children CME Jan. 2001 Vol 19, No. 1 Page 27

-                 Apleys System Of Orthopaedics And Fractures Page 676

-                 Clinical Orthopaedic Examination – Mcrae Page 189

ANYTHING SPECIFIC YOU SHOULD DO?

You should be aware of common overuse sports injuries affecting the lower leg, and the clinical and special investigations used to make this differentiation.

Lecture

The following will be dealt with:

1.          Ileotibial band syndrome

2.         “Shin splints”

3.         Lower leg stress fracture

4.         Lower leg chronic compartment syndrome in the sportsman

THEME 14: CONDITIONS AND DEFORMITIES OF THE LOWER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1           Describe ankle instability with referenc to causes, clinical presentation, radiological
evaluation and treatment protocol.

2          Tabulate the causes of ankle arthritis.

3          Discuss the clinical presentation, radiological picture and treatment options.

4          Define osteochondritis dessicans of the talus and briefly describe the condition.

5          Describe the clinical presentation of flatfoor and cavus foor, discuss the implications of a structural deformity and briefly discuss the treatment options.

6          Discuss plantar fasciitis with reference to aetiology, clinical picture, natural course and treatment.

7          Briefly explain tarsals femur neck syndrome.

8          Discuss degenerative rupture of the achilles tendon achilles with reference to aetiology, clinical picture and treatment options.

9          Briefly describe a Mortons neuroma.

10        Discuss hallux valgus and claw toes with reference to causes, clinical picture and treatment options.

11         Discuss ingrown toenails and explain the treatment thereof.

12        Explain hallux rigidus.

RESOURCES

-        The Painful Ankle And Foot CME Vol 9, No 3 March 1991, Page 329

-        Apleys System Of Orthopaedics And Fractures Chapter 21, Page 471

-        Clinical Orthopaedic Examination – McRae, Chapter 14, Page 253

-                 Modern Medicine, How To Treat Corns, Calluses & Plantar Warts Vol 23, No 2, Feb 99,
Page 50

-                 Modern Medicine, Doctor’s Rooms Procedures For Ingrown Toenails (Practical Procedures) Vol 22, No 9, Sept 1997, Page 49

-                 Ganglion Of The Foot Update Feb 1998, page 93

-                 Management Of Ingrowing Toenail Update April 2000, page 40

-                 The Ingrown Toenail And Its Treatment CME Sept 1999 Vol 17, No 9, page 778

-                 Common Foot Problems Febr 1997, Vol 15, No 2 page 141

-                 Arthritis And The Foot CME Feb 1997, Vol 15, No 2, page 157

-                 Subcaleaneal Heel Pain Syndrome S A Bone And Joint Surgery Vol VII, No 2, June 97, page 12

ANYTHING SPECIFIC YOU SHOULD DO?

The objective of this session is to recognise post-traumatic chronic instability and degenerative arthritis of the ankle, and to differentiate between each other. You should also be able to describe the clinical presentation of a flat foot and a cavus foot, and to know the natural course of these foot deformities in adults as well as the basic principles of treatment.

The aim of this session is to enable you to make a meaningful differential diagnosis when a patient presents with heal pain by applying your knowledge of appropriate clinical examination methods. You should also be able to identify the clinical presentation of common fore-foot deformities.

Pre-study

Please revise the examination of the ankle. Theme 2.

Lecture

This session offers a lecture on the causes of chronic instability of the ankle joint and the conservative treatment thereof. The surgical possibilities will be discussed. The causes of degenerative conditions of the ankle will be discussed briefly, as well as cavus feet and flat feet and their associations and natural course in adults.

This session will also discuss tendon rupture and inflammatory conditions of the foot and ankle, nerve entrapment syndrome of the foot and ankle, forefoot and toe deformities.

THEME 15:
GENERAL PRINCIPLES OF RESUSCITATION After TRAUMA AND EMERGENCY TREATMENT OF FRACTURES AND DISLOCATIONS

AIM OF THE THEME

This session deals with the general principles in the emergency treatment of the patient with multiple musculoskeletal injuries.

OVERVIEW OF THE THEME

Outcomes

At the end of this session, you should be able to do the following:

1.          Tabulate and explain the general basic principles of resuscitation (ABC).

2.         Tabulate the principles of radiological evaulation.

3.         Explain the emergency treatment of an injured limb.

4.         Explain emergency immobilisation techniques of the neck, spinal column and limbs.

5.         Discuss and briefly explain the complications of mutiple injuries in a patient.

RESOURCES

-                 Apleys System Of Orthopaedics And Fractures. Chapter 22 Page 501

-                 Practical Fracture Treatment, McRae Pages 31-38

-                 Journal Of American Family Physicians, Radiological Examination Upper Extremity Trauma, March 1, 1998, Pages 995

-                 Journal Of American Family Physicians, Radiological Evaluation Of Lower Extremity Trauma, March 15, 1998, Pages 1314

ANYTHING SPECIFIC YOU SHOULD DO?

Pre-study

Pre-study includes the revision of the general principles of fluid therapy in conditions of shock, as well as blood transfusions.

Lecture

During this session, the general principles of systemic resuscitation will be discussed briefly. The emergency treatment of pelvic and vertebral fractures will be discussed briefly, as well as the emergency treatment of limb fractures and dislocations. In addition, the appropriate radiological investigations in the patient with multiple injuries will be discussed.

THEME 16:
GENERAL PRINCIPLES OF
TRAUMATIC CONDITIONS

AIM OF THE THEME

This theme will enable you at adapt your knowledge pertaining to basic principles in the radiological evaluation of fractures and dislocations in order to meaningfully interpret these types of injuries and thus recommend appropriate treatment, and also to discuss the course and prognosis.

Overview of the theme

THEME 16: GENERAL PRINCIPLES OF TRAUMATIC CONDITIONS

Outcomes

At the end of this session, you should be able to do the following:

1.       Describe and illustrate fracture patterns in children and adults.

2.         Discuss the biological and structural implications of fracture patterns.

3.         Discuss displacement and angulation of fractures.

4.         Discuss fracture healing according to Perkins’ rule.

5.         Classify open fractures and discuss the basic principles of wound debridement.

6.         Briefly discuss the implications of gunshot wounds.

7.         Classify growth plate injuries.

8.         Tabulate combination fractures.

9.       Describe and discuss the basic principles pertaining to application of a cast.

10.     Discuss the principles of a three point pressure system in a cast.

11.      Tabulate and discuss the complications of cast application and the prevention thereof.

12.     Describe how a fracture and/or a dislocation is reduced.

RESOURCES

-        Growth Plate Injuries Specialist Medicine Feb 2001 Page 765

-        Apleys System Of Orthopaedics And Fractures – Chapter 23, Page 515

-        Practical Fracture Treatment, McRae, Chapter 1, Page 3

-                 Apleys System Of Orthopaedics And Fractures

-                 Practical Fracture Treatment;

-        Child Abuse Page 45

-        Closed Reduction And Fixation Of Fractures Chapter 3, Page 47

-                 Head Injuries In Child Abuse, WS 270, HAR, U.S. Library

-                 Journal Of American Family Physicians July 1997, Page 175, Stress Fractures

Lecture

This lecture deals with the general guidelines in traumatic conditions of the musculoskeletal system with regards to clinical evaluation, radiological requests and interpretation, and an estimation of the natural course of the injury. Guidelines will be given with regards to the therapeutic principles of open fractures and growth plate injuries.

This session consists of a lecture demonstration on the reduction of a traumatic fracture and/or dislocation after appropriate analgesia and the application of the basic principles of immobilisation by means of plaster or splints. Non-traumatic fractures will also be discussed.

Self-study assignment

During the session, you must complete the assignment that you received and, in your own time and by referring to the resources, complete the implications of the various growth plate injuries.

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of this session is to ensure that you understand the mechanisms of reduction of fractures and dislocations, as well as how to apply this to the basic principles in immobilisation and plaster technique.

THEME 16: GENERAL PRINCIPLES OF TRAUMATIC CONDITIONS

OUTCOMES

At the end of this session, you should be able to do the following:

1.          Know the causes of this syndrome, as well as the clinical signs, presentation and treatment thereof.

2.         Know the clinical and radiological signs of NAIS.

3.         Diagnose regional pain syndrome/sympathetic dystrophy in a patient.

4.         Taulate the short and longterm complications thereof.

5.         Define and briefly discuss delayed union as well as non-union.

6.         Define and briefly discuss reflex sympathetic dystrophy (Sudeck’s atrophy).

7.         Define and briefly discuss myositis ossificans.

RESOURCES

-                 Practical Fracture Treatment Non-Accidental Injury, McRae, Page 45

-                 Apleys System Of Orthopaedics And Fractures. Principles Of Fractures Chapter 23,
Page 515

-        Practical Fracture Treatment, McRae, Chapter 2 P. 25, Chapter 5, Page 75

ANYTHING SPECIFIC YOU SHOULD DO?

Self-study

The aim of this session is to solve three specific clinical problems that commonly occur after trauma of the musculoskeletal system.

The class divides into 3 groups, each with the task of solving one of the following clinical problems by referring to the resources:

1.          How is the circulation examined clinically the day after plaster application for a fracture?  What is an imminent compartment syndrome?

2.         What do you understand by the term non-accidental injury syndrome (NAIS)? What are the implications of this condition? Briefly describe the clinical aspects thereof. Tabulate the radiological aspects thereof.

3.         “Doctor, it has already been 2 months since my wrist fracture, but my arm is still sore”. Briefly discuss the possible causes thereof.

4.         The three groups must bring along their information on the assignments and share the information with each other. This information will be briefly controlled by the lecturer at the start of Session 4.

The aim of this session is to ensure that you are aware of the complications which may arise during the treatment of fractures and dislocations in general and can thus propose necessary preventative measures.

Lecture

This lecture covers the general complications of fractures and dislocations, the prevention thereof and, briefly, the treatment of the specific complications.

Pre-study

Review the common factors that may give rise to delayed fracture healing and tabulate in your assignment.

THEME 17:
immobilisation techniques of
the upper limb

AIM OF THE THEME

The aim of this theme is to ensure that you know how to apply the basic principles of immobilisation techniques of the upper limbs.

Overview of the theme

THEME 17: immmobilisasie techniques of the upper limb

Outcomes

At the end of this theme, you should be able to do the following:

Apply the various immobilisation techniques.

RESOURCES

-                 Apleys System Of Orthopaedics And Fractures. Principles Of Fractures. Chapter 23,
Page 515

-                 Practical Fracture Management. Chapter 2 Page 25, McRae

-                 Plaster Of Paris Technique WO 170 PLA U.S. Library

-                 Plaster Technique WO 170 BIR U.S. Library

-                 Cast Manual For Adults And Children Freuler: Wiedmer

-                 Fractures In Children Rockwood

-                 Primary Surgery Vol 2, Maurice King and Peter Bewes

-                 Collar-cuff bandage Reference I Page 133, II Page 174

-                 Triangular bandage Reference II Pages 39-40, IV Pages 226

-                 Reversed triangular bandage

-                 “Mastersling” East London Bandgae Reference I, page 119, Reference II pages 115, 147, 174

-                 Figure 8 Bandage Reference I, page 117, III, page 958

-                 U-splint, Reference I, page 125, Reference III, page 915

-                 Thomas splint

-                 Gallow traction

-                 Holter neck traction

-                 Skeletal neck traction

-                 Apleys Systems Of Fractures And Orthopaedics. Principles Of Fractures Chapter 23,
page 515

-        Traction Video Cassette : Checks And Balances, US Library, WE190TRA

THEME 18:
FRACTURES AND DISLOCATIONS OF
THE SPINAL COLUMN AND PELVIS

AIM OF THE THEME

The aim of this theme is to enable you to tabulate the various fracture patterns and dislocations of the spinal column and pelvis, describe the radiological presentation, name the possible complications and discuss the basic principles in the treatment of these injuries.

Overview of the theme

THEME 18: FRACTURES AND DISLOCATIONS OF THE SPINAL COLUMN AND PELVIS

Outcomes

At the end of this session, you should be able to do the following:

1.       Discuss the emergency treatment of an acute spinal column or pelvic injury and tabulate the precautionary guidelines that must be taken before transporting the patient.

2.         Describe the clinical examination of these injuries.

3.         Discuss the radiological evaluation of neck and spinal column injuries.

4.         Tabulate the radiological signs of spinal column instability.

5.         Discuss the basic principles in the treatment of spinal column injuries.

6.         Describe pelvic fractures.

7.         Discuss visceral injuries associated with pelvic fractures.

8.       Precautionary guidelines to protect the patient against further injuries during treatment

9.       The treatment of the patient post-injury

At the end of this session, you should know of the following aspects pertaining to paraplegics and tetraplegics:

1.          Their functional abilities

2.         Their aids and the use thereof in their environment.

3.         The framework of physiotherapists, occupational therapists and social workers required.

4.         The complications of paraplegia, e.g. contractures, fractures, heterotopic ossification, urinary problems, as well as pressure sores.

5.         Know about the drugs that control spasms.

6.         Know about the support network for such patients in the community.

7.         Know what is meant by a central cord syndrome.

8.         Know what is meant by a Brown Sequard syndrome.

RESOURCES

-        Whiplash Injury. Update Sept 1999, Page 50.

-        Whiplash Injury. Specialist Medicine, Feb 2001, Page 777.

-        Concise System Of Orthopaedics And Fractures. Chapter 29, Page 299 A G Apley and Solomon.

-        Practical Fracture treatment McRae:

-        Spinal Injuries Chapter 10, Page 209

-        Pelvis Injuries Chapter 11, Page 239

-        Apleys System of Orthopaedics And Fractures. Spinal Cord Injuries Chapter 25, Page 633

-        Spinal Stabilisation Video Cassette WB 541 SP1 U.S. Library

-        Practical Fracture Treatment – McRae Chapter 10. Spinal Paralysis Page 231

ANYTHING SPECIFIC YOU SHOULD DO?

Revision

Before the start of this session, you are expected to review the neurological evaluation of a patient. You should know the general characteristics of an upper motor neuron lesion, as well as the bulbocavernous reflex.

The aim of these two sessions is to ensure that you can clinically evaluate an acute spinal cord injury and know wich precautionary measures should be taken before transporting the patient. You should also have the necessary knowledge with regards to the longterm multi-disciplinary implications of a paraplegic and a tetraplegic.

Lecture

During this session, a lecture will be given on the clinical presentation and incidence of vertebral fractures. The mechanisms of injury will be discussed. You will be shown how to interpret X-rays and to decide whether or not the fracture/dislocation is stable. Guidelines with regard to specific fracture treatment will also be discussed.

Precautionary measures that must be followed before transporting a patient will also be explained to you.

This lecture also deals with care aspects of paraplegics and quadroplegics in the post-injury period. The rehabilitation program will be discussed, as well as the functional abilities. The general longterm complications associated with these injuries will also be discussed. You will be explained how to prevent pressure sores and how to treat them when present.

During this session, you must make a summary of the clinical and radiological diagnosis of a young rugby player with a C5/C6 bifacet dislocation with a complete neurological lesion.

This problem will be solved, with the help of your lecturer, by means of small group discussions.

Tabulate the precautionary measures that must be followed before transporting the patient. Briefly discuss his prognosis, his future abilities and the potential problems that he can expect.

Please complete the assignment handed out to you.

THEME 18: FRACTURES AND dislocations OF THE SPINAL COLUMN AND PELVIS

OUTCOMES

You should know the following:

1.          Clinical evaluation

2.         Emergency treatment

3.         Radiological investigations and interpretation

4.         Principles of treatment of pelvic fractures

RESOURCES

-        Apleys System Of Orthopaedics And Fractures.

-        Wheeless Textbook of Orthopaedics. Search Google.

THEME 19:
FRACTURES AND DISLOCATIONS OF THE
UPPER LIMB

AIM OF THE THEME

This theme will ensure that you are able to apply the knowledge learnt in the previous themes with regards to the basic principles in fracture management and dislocations to the upper limb. You should be able to describe the appropriate clinical investigations, the radiological interpretation and the necessary treatment.

Overview of the theme

THEME 19: FRACTURES AND DISLOCATIONS of THE UPPER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1.       Classify clavicle fractures and discuss the treatment in children and adults.

2.         Classify acromioclavicular and sternoclavicular dislocations and discuss the treatment thereof.

3.         Classify glenohumeral dislocations, describe the clinical presentation, tabulate the radiological characteristics and possible complications thereof, and discuss the different treatment strategies.

4.         Classify fractures of the proximal 1/3 of the humerus and briefly discuss the treatment of each.

5.         Discuss fractures of the humerus shaft with reference to possible complications and the treatment methods.

RESOURCES

-                 Apleys System Of Orthopaedics And Fractures Chapter 24, Page 566

-                 Practical Fracture Treatment – McRae Chapter 6, Page 99

-                 Orthopaedic Trauma IS de Wet Pages 268-290

-                 Journal Of American Family Physicians, Management Of Clavicle Fracture, Jan 1997

-                 Journal Of American Family Physicians, Shoulder Instability In Young Athletes.
15 May 1999 WWW.aafp.org/afp

-        How I Examine The Shoulder, Vol 14, No 6, Nov 2000 Pages 435

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture demonstration

This lecture deals with fractures and dislocations of the clavicle and the treatment thereof on a primary health level.  Dislocations of the shoulder will be discussed in detail. Guidelines will be given or the conservative treatment of humerus soft fractures and the indications for surgery.

THEME 19: FRACTURES AND DISLOCATIONS OF THE UPPER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1.          Tabulate the appearance of the ossification centre in the elbow.

2.         Describe and interpret the radiological soft tissue signs of the elbow, as well as the necessary lines seen on xray.

3.         Classify supracondylar fractures in children, tabulate the possible complications and discuss the various treatment options.

4.         Describe the radiological presentation as well as the treatment options for epicondylar fractures.

5.         Classify elbow dislocations and discuss the treatment thereof.

6.         Classify radial head fractures and discuss the treatment thereof.

7.         Classify olecranon fractures and discuss the treatment thereof.

8.         Tabulate the possible complications of elbow injuries.

9.       Describe a Monteggia fracture dislocation and discuss the treatment principles in children and adults.

10.     Describe a Galliazi fracture dislocation and discuss the principles of treatment.

11.      Discuss the principles of treatment of mid-shaft forearm fractures.

12.     Discuss the principles of treatment of isolated radius and ulna fractures.

13.     Describe a Colles fracture clinically and radiologically, and discuss the treatment and natural course thereof.

14.     Describe the radiological presentation of a displaced distal radius fracture and discuss the treatment modalities.

15.     Classify growth plate injuries of the distal radius and ulna and discuss the treatment.

16.     Describe a radial styloid fracture and discuss its treatment.

17.     Give a radiological classification of scaphoid fractures, and discuss the treatment and complications thereof.

18.     Classify wrist and carpal dislocations, and discuss the emergency treatment thereof.

19.     Briefly discuss carpal instability.

RESOURCES

-                 Ortopediese Trauma Izak de Wet, H. 12 Pages 231-258

-                 Fractures In Children, Rockwood & Green, Ch. 10, Page 653

-                 Practical Fracture Treatment McRae, Injuries about the elbow, H. 7 Page 129

-                 Apleys System Of Orthopaedics And Fractures Chapter 24, The elbow Page 577

-                 Apleys System of Orthopaedics and Fractures Chapter 24, The Forearm Page 592.

-                 Practical Fracture Treatment McRae. Chapter 7, Page 129

-                 IS de Wet, Ortopediese Trauma 1984, Pages 219-227, 225, 213, 186-190

-                 F Freuler, U Wiedmer, Cast Manual for Adults & Children: Springer-Verlap, 1979,
Pages 28-31

-                 P Saffar. Scaphoid Fractures. Current Orthopaedics (1999) 13, Pages 275-281

-                 IS de Wet. Ortopediese trauma HAUM, 1984, Pages 296-205

-                 F Freuler, U Wiedmer, Cast Manual for Adults and Children Springer-Verlap, 1979,
Pages 38-39, 44-45

-                 CA Rockwood, DP Green, Rockwood & Green’s Fractures in Adults: Lippincott-Raven, 1996, Pages 791-801.

-                 Apleys System Of Orthopaedics And Fractures, Chapter 24, Pages 595

-                 Practical Fracture Treatment McRae, Chapter 8, P. 155 Chapter 9 Page 7 169

-                 Journal Of American Family Physicians, Common Wrist Injuries, Feb 1997, Page 857

-                 www.aafp.org/afp

-                 How I Examine The Wrist, Vol 14, Nol 5 Sept 2000

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of this session is to ensure that you are able to classify common fractures and dislocations of the elbow (presenting in both children and adults) according to radiological presentation and able to discuss treatment options.

The objective of this session is to enable you to classify common fracture patterns in the forearms of both children and adults with reference to the radiological presentation and discuss the treatmnt guidelines for each fracture or fracture/dislocation.

The aim of this session is to ensure that you can classify fractures of the distal radius and ulna according to radiological presentation and accordingly formulate treatment guidelines. You wil also learn how to identify fractures and dislocations of the wrist joint radiologically and apply emergency treatment at a primary health level.

Lecture

This lecture discusses the common fractures and dislocations of the elbow joint. You will learn how to interpret the X-ray. The treatment and methods of reduction of fractures and dislocations will be discussed. The guidelines for surgery will be indicated and the possible complications discussed.

This lecture also deals with common fractures of the forearm.

The fractures and fracture-dislocation patterns of the forearm in adults and children will be discussed.

The aim of this session is to ensure that you can classify the fractures of the distal radius and ulna accoding to radiological presentation and accodingly formulate a treatment strategy. You will also learn how to identify fractures and dislocations of the wrist joint radiologically and apply emergency treatment on primary health level.

Lecture

This lecture covers the clinical diagnosis of common fractures of the distal radius and wrist joint, namely the Colles’ fracture, disrupted distal radius fracture, scaphoid fractures and acute wrist dislocations and instabilities.

The radiological manifestations, conservative treatment and surgical indications will be discussed.

Please complete the assignment given to you during this session.

THEME 19: FRACTURES AND dislocations OF THE UPPER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1.       Discuss the emergency treatment of an acutely swollen hand after an injury.

2.         Classify metacarpal fractures, describe the methods of immobilisation after a displaced fracture, and discuss the clinical and radiological indications for surgery.

3.         Define a Bennett’s fracture, describe the radiological presentation thereof and discuss the treatment thereof.

4.         Define a «boxer» fracture, describe the radiological presentation thereof and discuss the treatment modality.

5.         Give a radiological classification of a phalanx fracture, describe the method of immobilisation and discuss the clinical and radiological indications for surgery.

6.         Classify MP and IP dislocations, describe the methods of reduction and immobilisationand tabulate the indications for surgery.

7.         Discuss finger tip injuries in children in detail.

RESOURCES

-                 Practical Fracture Treatment McRae, Chapter 9, Page 191

-                 Apleys System Of Orthopaedic And Trauma. Page 608

-                 Management Of Hand And Finger Injuries Update July 1999, Page 23

-                 Journal Of American Family Physicians, Fingertip Injuries, May 1, 2001, Page 1961

-                 Journal Of American Family Physicians, Fingertip Amputations, Aug 1 2001, Page 455

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of this session is to ensure that you can classify common fractures and dislocations that occur in the hand and fingers radiologically and formulate appropriate treatment plans.

Lecture

During this lecture, you will be shown how to make a diagnosis of fractures in the hand and fingers. The treatment of the common fractures will be discussed. You willbe sown how to reduce dislocations. The application of a Z-splint and hand ball will be demonstrated.

THEME 20:
FRACTURES AND DISLOCATIONS
OF THE LOWER LIMB

AIM OF THE THEME

This theme will familiarize you with the basic principles of fracture evaluation and treatment in the lower limb. You will be able to describe the appropriate clinical investigations, the radiological interpretation as set out in in Theme 19, as well as the treatment guidelines.

Overview of the theme

THEME 20: FRACTURES AND DISLOCATIONS OF THE LOWER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1.          Discuss the clinical presentation of anterior and posterior hip disclocations, describe the methods of reduction and tabulate the complications thereof.

2.         Give a radiological classification of proximal femur fractures, and desribe the guidelines for treatment of both intra-capsular and extra-capsular femur fractures.

3.         Give a radiological classification for femur shaft fractures, discuss treatment options on both children and adults and tabulate the complications.

4.         Recognize the common injuries associated with femur fractures.

5.         Ba able to place a small child in gallow traction and supervise their nursing.

6.         Be able to place an older child or adult in a Thomas splint and supervise their nursing.

7.         Know which fractures need to be referred for specialist treatment.

8.         Be able to administer emergency treatment prior to patient transport for specialist treatment.

9.         Recognise the various surgical options for treatment of a femur fracture.

RESOURCES

-                 Apleys System Of Orthopaedics And Fractures Chapter 27, Page 651

-        Practical Fracture Treatment Chapter 12, Page 273

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

This session consists of a lecture on traumatic hip dislocations in children and adults.  The clinical presentation of the limb will be discussed, as well as the possible associated injuries, the methods of reduction, follow-up treatment and longterm complications. Femur neck and intertrochanteric fractures in adults will be discussed and the importance of the distinction between intracapsular and extracapsular emphasized. The aim and options of internal fixation will be discussed. The treatment of femur shaft fractures at different ages will be discussed.

THEME 20: FRACTURES AND DISLOCATIONs OF THE LOWER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1.       Classify acute knee dislocations, desribe the emergency treatment thereof and discuss the complications.

2.         Discuss acute patella dislocations.

3.         Give the radiological classification of distal femoral fractures and discuss the treatment guidelines.

4.         Give the radiological classification of proximal tibial fractures and discuss the treatment guidelines.

RESOURCES

-                 The Injured Knee Update April 2000 Page 45

-                 Acute Soft Tissue Injuries Of The Knee Update Nov 1998 Page 22

-                 The Patient With A Painful Knee Update Nov 1998 Page 29

-                 Anterior Cruciate Ligament Injuries CME Feb 1999 Vol 17 No 2 Page 117

-                 Apleys System Of Orthopaedics And Fractures Page 270

-                 Practical Fracture Treatment McRae Page 290

-                 Journal of American family Physicians, Anterior Knee Injuries Dec 1999 Page 2599

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of this session is to ensure that you can classify fractures and dislocations of the knee joint according to the radiological presentation and discuss the treatment modalities of each as applicable.

Lecture

This lecture covers the clinical evaluation of acute traumatic ligament and meniscus injuries of the knee. Background study includes the revision of the examination methods of the knee during Theme 2 of this module. The implication of fractures of the femoral and tibial condyles will be discussed. You will learn how to clinically evaluate patella fractures and to decide which fractures require an operation.

At the end of the lecture, you will, with the help of the lecturer, learn how to evaluate and treat an acute haemarthrosis of the knee in a child and an adult.

Please complete your assignment.

THEME 20: FRACTURES AND DISLOCATIONS OF THE LOWER LIMB

Outcomes

At the end of this session, you should be able to discuss the following aspects:

1.          Should ligaments of the knee and tears of the meniscus be repaired acutely after injury?

2.         When are ligament reconstruction procedures indicated?

3.         What is the rehabilitation program after a knee injury? When can the patient return to sport?

4.         What are the longterm consequences of a knee injury with regards to osteoarthritis?

RESOURCES

Apleys System Of Orthopaedics And Fractures, Page 680

-        Practical Fracture Treatment McRae, Page 295

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of these two self-study sessions is to ensure that you undestand the longterm implications of meniscus and ligament injuries of the knee – collateral and cruciate – so as to be able to explain this to your patient.

Self-study

The class divides into 4 groups. Each group studies a single assignment and exchanges the information.

Using the references provided, read up on the implications of ligament injuries and meniscus injuries of the knee. Then complete the assignment handed out to you.

The lecturer will check the problem in the next session.

THEME 20: FRACTURES AND DISLOCATIONS OF THE LOWER LIMB

     Outcomes

At the end of this session, you should be able to do the following:

1.       Give the radiological classification of tibial shaft and plateau fractures.

2.         Tabulate the indications for conservative treatment and discuss the methods of conservative treatment.

3.         Discuss the treatment of an open tibia fracture.

4.         Discuss the implications of an open tibia fracture, as well as the natural course.

RESOURCES

-                 Apleys Systems Of Orthopaedics And Fractures, Page 689

-        Practical Fracture Treatment McRae, Chapter 13, Page 305

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of this session is to ensure that you can classify tibial shaft fractures both clinically and radiologically and describe the necessary treatment thereof.

Lecture

This lecture deals with the fracture patterns of the tibia and fibula.  You will be shown how to reduce uncomplicated fractures, if necessary, and to apply an appropriate plaster. The treatment of an open fracture – a basic debridement – will be reviewed briefly and you will be shown how to apply an external fixator. The morbidity of open fractures of the tibia will be discussed briefly, as well as the long-term implications.

Self-study assignment

You must please read up on the levels of amputations in the lower limb, the advantages and disadvantages of these levels, as well as the functional abilities of a patient after an amputation.

          Please complete the assignment that was handed out.

The rehabilitation of a lower leg amputation will be discussed during your rotation at Karl Bremer Hospital.

THEME 20: FRACTURES AND DISLOCATIONS OF THE LOWER LIMB

Outcomes

At the end of this session, you should be able to do the following:

1           Define and classify ankle sprains, and discuss the treatment thereof.

2          Classify ankle fractures and discuss the treatment thereof.

3          Discuss the emergency treatment of a severely swollen foot.

4          Describe the treatment guidelines for calcaneus fractures.

5          Tabulate the injuries associated with calcaneus fractures.

6          Classify mid-foot fracture dislocations, and describe the indications for surgery.

7          Classify talus fractures, and briefly discuss their treatment and natural course.

8          Discuss the treatment of phalanx fractures and dislocations.

RESOURCES

-        Journal American Family Physicians Jan 2001

-        Management of Ankle Sprains Update Oct. 1988 Page 18

-        Common Sport Injuries In The Adolescent – Foot and ankle S A Bone and Joint Surgery
Vol. IX No. 1 Febr. 1999 Page 14

-        Implementation Of Ankle Otawa Rules JAMA Marchilo 1994 Vol. 271, No. 11 Page 827

-        Apleys System of Orthopaedics and fractures, Page 696

-        Practical Fracture Treatment, Chapter 14, Page 319

-        Journal Of American Family Physicians, Management Of Ankle Injuries, Jan 1, 2001,
Page 93

-        Journal Of American Family Physicians, Injured Ankles, Feb 1 1998, Page 474

-        Apleys System of Orthopaedics and Fractures

-        Practical Fracture Treatement, P. 707, Chapter 15, Page 345

-        Journal Of American Family Physicians, Lisfranc Injury Of The Foot July 1998, Page 118

-        Journal Of American Family Physicians, Fracture Of Proximal 5th Metatarsal May 1, 1999 Page 2516

ANYTHING SPECIFIC YOU SHOULD DO?

The aim of this session is to ensure that you can classify ankle sprains and fractures and discuss the appropriate treatment options.

The aim of this session is to ensure that you can classify fractures of the tarsal bones, metatarsal bones and phalanges of the foot radiologically and accordingly discuss the treatment and course.

Lecture

This lecture will teach the student how to evaluate and treat a sprained ankle. You will be taught how to apply the Weber classification for ankle fracture dislocations, and thus learn to differentiate between a stable fracture which can be managed by yourself and an unstable fracture requiring surgery.

During this lecture you will be shown how to prevent a severely swollen foot and, if present, how to treat it. Calcaneous fracture patterns, the indications for surgery and the longterm implications thereof will also be dealt with. You will be shown how to apply a plaster for the different fracture patterns and dislocations of the foot. The suspicion and evaluation of a Lisfranc fracture dislocation will be discussed. You will be shown how to reduce dislocations of the foot.

Please complete the work assignment that was provided to you.

THEME 21:
SOFT TISSUE INJURIES OF THE
MUSCULOSKELETAL SISTEEM

AIM OF THE THEME

This theme deals with lacerations and injuries of the skin, as well as the more important deeper structures, suh as muscles, tendons, nerves and blood vessels. You should be able to identify these injuries clinically, know the emergency treatment thereof as well as the referral guidelines for complicated injuries.

Overview of the theme

THEME 21: SOFT TISSUE INJURIES OF THE MUSCULOSKELETAL SYSTEM

Outcomes

1.       After this session, you should be able to identify simple skin lacerations, know the methods of suturing under local anaesthetic, and also know about the after care and bandage techniques of such lacerations.

2.         You should know the basic principles of wound debridement. You should also know about the different suture materials and their properties. You should be able to identify wounds requiring secondary cover.

3.         You should know the implications of penetrating wounds in different anatomical areas.

4.         You should be able to distinguish between rupture of a nerve or tendon.

5.         You should know the prognosis of nerve and tendon injuries.

6.         You should be able to identify a "degloving" injury and realise the implications thereof.

7.       You should know how to treat a penetrating wound in a joint.

8.       You should know how to suture muscle, skin, sinews and nerves.

9.       You should be able to realise the severity of blunt trauma to the musculoskeletal system and identify the systemic complications of "crush" injuries.

RESOURCES

1.       Peripheral Nerve Injuries. SA Bone & Joint Surgery, Vol 7, No 3, Aug 1997, Page 18.

2.       Tendon Injuries. CME, July 1996, Vol 14, No 7, Page 963.

3.         Nerve Compression Syndromes. CME, July 1996, Vol 14, No 7, Page 995.

4.         Wondhegting (Video cassette) WO166 WOM U.S. Library

ANYTHING SPECIFIC YOU SHOULD DO?

Lecture

This session takes the form of a lecture and deals with the identification of lacerations and penetrating wounds of the musculoskeletal system, and the realisation of the importance thereof.

The suturing of skin and muscle lacerations will also be discussed. The diagnosis of arterial nerves and tendon lacerations will be discussed and guidelines will be preented for the treatment of these injuries. "Crush" syndrome and "Degloving" injuries will be briefly rementioned for identification.

THEME 21: SOFT TISSUE INJURIES OF THE MUSCULOSKELETAL SYSTEM

Outcomes

After completion of these sessions, you should:

1.       Understand wound recovery and know the factors influencing this.

2.       Distingush between a hypertrophic wound and a keloid.

3.       Know how to approach an open wound and decide on which wound dressing is appropriate.

4.       Understand the indications and technique of skin transplant.

5.       Know the reconstructive guidelines for wound dressing.

6.       Understand the newly lacerated wound (bandages).

7.       Know the basic principles of ulcer prevention and treatment.

RESOURCES

1.          Mystery of Plastic and Reconstructive Surgery

Editor: Mimis Cohen, First Edition

Volume 1:     Chapter 1              Page 3                  Woundhealth

Chapter 4             Page 45                Skin

Volume 3:    Chapter 132          Page 1828             Leg ulcers

2.         Textbook of Plastic, Maximofacial and Reconstructive Surgery

Editor: Georgindes, First Edition

Volume 1:     Chapter 5             Page 29                Skinwounds

Volume 2:    Chapter 97           Page 1291             Leg ulcers

3.         Basic Wound Care Video Cassette WO185 BAS. US Library

4.         Wound Care Video Cassette WO185 WU US Library

5.         Wondhegting video cassette WO166 WOM US Library

6.         Perform resuscitation of the patient.

7.         Apply emergency treatment of the burn.

8.         Know whether further surgical treatment of the burn is required.

9.         Know whether wound dressings are required in the treatment of burns.

10.       Know how to prevent contractures after burns.

11.        Know the longterm rehabilitation as well as the prognosis of different anatomical areas.

ANYTHING SPECIFIC YOU SHOULD DO?

At the end of this theme, you should understand the anatomy of the skin and should thus be able to recognise skin wounds and complicated skin avulsions.

You should have an approach to the treatment of these wounds, as well as disturbed wound healing.

You should be able to diagnose an ulcer, understand the aetiology and accordingly know ho to treat such an ulcer.

Pre-study

During this session, you should:

·                Revise the anatomy of the skin.

·                Understand the blood supply of the skin.

·                Understand wound healing and the factors influencing this.

·                Compile a list of the various occlusive dressings for casualty.

·                Compile a list of the different causes of ulcers.

Lecture with slides

During this session, wound healing and wound dressing will be described by means of slides and clinical cases.

THEME 22:
THE ROLE OF OCCUPATIONAL THERAPY AND PHYSIOTHERAPY IN REHABILITATION

AIM OF THE THEME

At the end of this theme you should be able to describe the role of the physiotherapist and occupational therapist in the rehabilitation of the most common Orthopaedic conditions.

BACKGROUND KNOWLEDGE

·                Anatomy: Musculoskeletal System

·                Muscle physiology

·                MB ChB IV Musculoskeletal module, Session 1 to 18

Overview of the theme

THEME 22: REHABILITATION, AIDS

Outcomes

At the end of this theme, you should be able to do the following:

·                Name the general goals of a rehabilitation program in terms of Orthopaedics.

·                Discuss the role of the Occupational- and Physiotherapist in Orthopaedic rehabilitation.

·                Recpgnize different types of assistive devices.

 

LECTURE

During the lecture rehabilitation and the use of assistive devices/aids will be explained, as relevant to orthopaedic conditions, and the use of aids will be described by lecturer from the Deparments of Occupational Therapy and Pysiotherapy.

THEME 22: REHABILITATION, AIDS

Outcomes

At the end of this session, you should be able to:

·                Name the indications for referral to Occupational Therapy and Physiotherapy.

·                Write a referral letter to Occupational Therapy and Physiotherapy.

 

 

LECTURE

The lecture will focus on indications for referral and provide guidelines for referral to Physiotherapy and Occupational therapy.  Practical examples will be given based on conditions sessions 1 – 18.

 

RESOURCES:

 

-        University of Sydney, Physiotherapy page

      http://libguides.library.usyd.edu.au/content.php