ORTHOPEDICS FOR INTERNISTS
GOAL: To improve the general internist's ability to appropriately evaluate and manage common disorders of the musculoskeletal system.
CORE COMPETENCIES:
A. Knowledge
1. To demonstrate knowledge about the clinical presentation, diagnosis, and management of the following general musculoskeletal problems:
a. Osteoarthritis
b. Rheumatoid arthritis of the C-spine
c. Thoracic outlet syndrome
d. Cervical sprain/strain
2. To demonstrate knowledge about the clinical presentation, diagnosis, and management of the following shoulder problems:
a. Glenohumeral DJD
b. Rotator cuff syndrome
1. Calcific tendinitis
2. Bursitis
3. Rotator cuff tear
4. Adhesive capsulitis
5. Biceps tendinitis
6. Subacromial impingement
e. Acute rupture of the long head of the biceps tendon
f. Minor sprain, strain, contusion or overuse syndrome
g. Radial nerve palsy (Saturday night palsy)
h. Deltoid tendinitis
i. Sprains, subluxation and dislocation of the AC joint
j. Acute Anterior dislocation of the GH joint
k. Fractures of the clavicle
l. Reflex sympathetic dystrophy ( shoulder/hand syndrome)
3. To demonstrate knowledge about the clinical presentation, diagnosis, and management of the following elbow problems:
a. Lateral Epicondylitis (tennis elbow)
b. Posterior interosseus syndrome (radial tunnel syndrome)
c. Medial epicondylitis vs Ulnar nerve entrapment
d. Little league elbow
e. Olecranon Bursitis
1. Inflammatory/infectious
2. Noninflammatory
g. Pseudogout (calcific periarthritis)
h. Myositis ossificans
4. To demonstrate knowledge about the clinical presentation, diagnosis, and management of the following wrist/hand problems:
a. Carpal tunnel syndrome
(with and without thenar atrophy/weakness)
b. DeQuervan's syndrome
c. Stenosing tenosynovitis of the flexor tendons ( trigger finger / trigger thumb)
d. Ganglion cysts
e. Mucous cysts
f. Duptuytren's contractures
g. Human / animal bites of the hand
h. Paronychia
i. Felon
j. Boutonniere deformity
k. Mallet finger
l. Swan neck deformity
m. Gamekeeper's thumb
n. Avulsion of the flexor digitorum profundus tendon
o. Fingertip injuries
1. Crush / Amputation
p. Colle's fracture
q. Smith and Barton's fractures
r. Carpal bone fractures
1. Scaphoid / avascular necrosis
2. Lunate / Keinbock's disease
3. Hook of hammate
s. Fractures of the metacarpal bones and phalanges
t. Heberden's nodes
u. Bouchard's node
v. Arthritis
6. To demonstrate knowledge about the clinical presentation, diagnosis, and management of the following cervical, thoracic, and lumbar spine problems:
a. Cervical spine problems
1. Neck strain / whiplash
2. Cervical paraspinous muscle spasm
3. Cervical spondylosis
4. Cervical DJD
b. Lumbar spine problems
1. Scoliosis
2. Musculoligamentous strain
3. DJD
4. Acute disk herniation ( L5/S1, L4/L5)
5. Sciatica
6. Facet syndrome
7. Spinal stenosis(pseudoclaudication)
8. Wedge compression/ burst fractures
9. Metastatic disease/ abscess
10. Ankylosing spondylitis
11. Cauda equina syndrome
7. To demonstrate knowledge about the clinical presentation, diagnosis, and management of the following hip problems:
a. Osteoarthritis/Rheumatoid arthritis
b. Aseptic necrosis of the femoral head
c. Septic arthritis
d. Bursitis
1. Trochanteric
2. Ischiogluteal
3. Iliopsoas
e. Pelvic sprains
f. Hip dislocation ( posterior, anterior)
g. Fractures of the hip
8. To demonstrate knoweldge about the clinical presentation, diagnosis, and management of the following knee problems:
a. Osteonecrosis
b. Bursitis
1. Prepatellar (housemaid's knee)
2. Superior infrapatellar
3. Anserine
c. Baker's cyst
d. Tendinitis
1. Patellar
2. Quadriceps
3. Iliotibial tract
4. Popliteus
e. Meniscal injury
f. Ligament injury
1. Medial collateral ligament injury
2. Lateral collateral ligament injury
3. Anterior cruciate ligament injury
4. Posterior cruciate ligament injury
g. Instability of the patella
1. Dislocation
2. Chondromalacia
9. To demonstrate knowledge about the clinical presentation, diagnosis, and management of the following leg/ankle problems:
a. Shin splints
1. Stress fracture
2. Exertional compartment syndrome
3. Tenosynovitis
b. Posterior heel and ankle pain
1. Achilles tendinitis
2. Retrocalcaneal bursitis
3. Posterior calcaneal bursitis
4. Exostosis ("pump bump")
c. Tendon disruptions
d. Major traumatic injuries to the leg and ankle
1. Fracture of the shaft of the tibia/fibula
e. Ankle sprains
f. Fractures of the ankle
10. To demonstrate knowledge about the clinical presentation, diagnosis, and management of the following foot problems:
a. Heel pain
1. Plantar fascitis
2. Posterior tibial tendinitis
3. Subtalar joint pathology
4. Intracalcaneal bursitis
b. Midfoot pain
1. Tarsal boss
2. Ganglion cyst
3. Plantar fibromatosis
c. Forefoot pain
1. Hallux Valgus (bunions)
2. Hallux rigidus
3. Stress fractures (march fracture)
4. Hammertoe (metatarsalgia)
5. Morton's neuroma
6. Synovitis of the metatarsophalangeal joint
7. Onchocryptosis (ingrown toenail)
8. Sesamoid injury
9. Mallet and claw toe
d. Foot manifestations of internal disease
1. Rheumatoid arthritis
2. Gout (podagra)
3. Reiter's syndrome
4. Psoriasis
5. DM (neuropathic ulcers)
e. Fractures of the metatarsals and toes
B. PRACTICE SKILLS AND PROCEDURES:
1. To obtain a directed history of orthopaedic problems:
a. Trauma
b. Location/radiation of pain
c. Limitation of movement
d. Neurologic defects
e. Aggravating/alleviating factors
f. Prior history of problems
g. Therapies
2. To be able to examine the shoulder in a systematic fashion:
a. Gross examination for deformities, asymmetry, discoloration, muscle atrophy
b. Palpation for masses, defects, tenderness
c. Identification of surface anatomy
1. Coracoid process
2. Biceps tendon
3. SC and AC joint
4. Trapezius, deltoids and clavicle
d. Active and passive ROM, crepitus
e. Neurovascular exam
1. Median, radial and ulnar nerves
2. Pulses
f. Wright's maneuver
g. Impingement test
3. To be able to examine the forearm, hand and wrist in a systematic fashion:
a. Gross examination for deformities
b. Palpation for masses, defects, and tenderness
1. Snuff box tenderness
c. Identification of the surface anatomy
1. Carpal bones
2. Compartment anatomy of the hand
d. Active and passive ROM and crepitus
e. Neurovascular exam
1. Median, radial and ulnar nerve function and distribution
2. Pulses ( cyanosis, capillary refill)
f. Finklestein's sign
g. Tinel's sign
h. Phalen's sign
4. To be able to examine the cervical and lumbar spine in a systematic fashion:
a. Gross examination for deformities
b. Palpation for masses, defects and tenderness
c. Pattern of pain radiation
d. Cervical
1. Nerve root testing (C5,C6,C7)
2. ROM
3. Upper extremity DTRs, strength and sensory
e. Lumbar
1. Nerve root testing (L4,L5,S1)
2. Straight leg raising
3. Anal sphincter tone
4. Motor/sensory defects buttocks-feet
5. To be able to examine the hip in a systematic fashion:
a. Resting posture of the hip
b. Pain with and without activity
c. Gait
d. Leg length
e. ROM
6. To be able to examine the knee in a systematic fashion:
a. Examination for effusions
b. Examination of the patella
c. Crepitus
d. Examination of the collateral and cruciate ligaments
e. McMurray test
f. Apley's test
g. Anterior/Posterior drawer sign
h. Varus and Valgus stress testing
i. Lachman's test
j. Pivot shift test
k. Mulder's sign
7. To be able to examine the leg, ankle and foot in a systematic fashion:
a. Examination of position in sitting, walking and standing
b. Observation for swelling, color changes, fixed deformities
c. Presence of calluses, plantar warts, or ulcerations
d. Temperature and pedal pulses (doppler)
e. ROM of ankle and other joints
f. Motor, sensory and DTRs
g. Palpation for tenderness
8. To become skilled at arthrocentesis of shoulder, elbow, wrist, knee, ankle, interphalangeal joints and bursa:
a. Identification of joint/bursal landmarks
b. Sterile field
c. Lidocaine wheal at entry
d. Joint/bursa aspiration
e. Steroid injection
9. To become skilled with use of regional blocks and familiarity with local anesthetics.
10. To order and/or interpret the following laboratory examinations where appropriate
a. CBC, sed rate, rheum factor, etc.
b. Radiological studies
c. Nerve conduction/EMG studies
C. ATTITUDES/LEARNING HABITS:
1. To understand the indications for and the importance of orthopedic consultation for the following procedures
a. Joint prosthesis
b. Arthroscopy
c. Neurovascular compromise of any injured limb
d. Possible fracture or dislocation
2. To gain understanding of the fundamentals of mechanical therapeutics
a. Casts
b. Splints
c. Traction
d. Reduction
e. Complications of immobilization
1. Joint stiffness
2. Cast compartment syndrome
3. Skin necrosis
f. Rehabilitation following musculoskeletal injuries
g. Ambulation aids and gate training
3. To recognize early arterial injury and compartment syndrome
a. Cool extremity
b. Pain on passive stretch of the compartment muscles
c. Parestesias, numbness and muscle weakness are late findings
d. Nail bed changes