Orthopaedics & Sports Medicine

Transcription

1 Maine-Dartmouth Family Practice Residency Curriculum Planning Document, 2000 Resident Outcomes Orthopaedics & Sports Medicine Developed by: Drs. William Alto & Dan Ober The Maine Dartmouth resident will become: an integrative and informed thinker a skilled and artful clinician a responsible and involved health professional a collaborative and efficient manager a creative and practical researcher a clear and effective teacher a self-directed and life-long learner Introduction: Orthopaedics and sports medicine are important specialty areas in family practice. The recognition, management and appropriate referral of orthopaedic problems span the breath of family practice from the newborn to the geriatric age group. In addition, family physicians must be able to screen athletes prior to their beginning a training program and identify and treat common injuries. All orthopedic problems should be viewed in relationship to lifestyle, work, school, and the community of the patient. The overall goals of the orthopedic and sports medicine curriculum are that residents will: Understand anatomy and physiology of musculoskeletal (MS) system Perform appropriate musculoskeletal physical examination Identify appropriate use of ancillary services: x-ray, laboratory, Physical Therapy, Occupational Therapy, and rehabilitation Understand principles and techniques of joint injections, splinting and casting, and pharmacological treatment. Work as part of a team approach to orthopaedic techniques. Conduct age appropriate sports physical.

2 Objectives: Knowledge: Comprehends the musculoskeletal system in regards to the anatomy, function and basic physiology Diagnoses and manages common orthopaedic conditions including those of congenital, developmental, traumatic and degenerative etiologies Recognizes the impact of lifestyle characteristics including nutrition and exercise on orthopedic conditions Understands the pathophysiology of common traumatic disorders such as sprains, strains, and contusions as well as dislocation and subluxation of non weight-bearing bones including the radial head in infants and children, patella, phalanges, and shoulder Discriminates between fractures that are simple and able to be treated by the primary care physician and those which require referral to the orthopedic surgeon Describes fractures using standard orthopedic terminology and definitions Evaluates trauma of the ankle, knee, and spine Understands the pathophysiology of arthritis relating to traumatic disease, inflammatory disease and infectious disease Understands non-articular rheumatic disease, including: shoulder syndromes such as bursitis and tendonitis other tenosynovitis such as tennis elbow other nonarticular problems such as fibrositis, myalgia, muscle pain. Understands the pathophysiology and identifies abnormalities of the vertebral column including disc disease, osteoarthritis, acute/chronic lower back pain, and congenital deformities of the spine such as scoliosis. Understands the pathophysiology of musculoskeletal and connective tissue disorders including: osteoporosis congenital anomalies of the lower limbs: congenital dislocated hip/foot, gait problems, tibial torsion ganglion of joint and tendon sheaths costochondrales including Osgood Schlatter disease and Legg Calve`-Perthes disease, chondromalacia patella, costochondritis, carpal tunnel syndrome, osteomyelitis, neoplasms. Understands a pathophysiological approach to athletic training and injuries as well as rehabilitation.

3 Skills: Knows the appropriate diagnostic techniques utilized to evaluate the above disorders including: x-rays, synovial fluid analysis and specialized radiological procedures including CT scans, bone scans, and myelograms. Identifies the appropriate therapeutic modality available for treatment such as taping, wrapping, casting, physical therapy and exercises. Understands the role and function of an orthopedic surgeon as a consultant. Performs a history and physical exam on the patient presenting with an orthopedic problem with specific attention to evaluation of the back, knee, ankle, and any other areas suspected of bony fracture. Writes an exercise prescription. Reads and describes x-rays and make appropriate use of ancillary testing. Performs an appropriate examination of joints; reduce closed fractures and dislocated joints. Cares for patients with orthopaedic problems when they are uncomplicated: applies plaster or fiberglass cast to extremities applies splints, wraps and tape to extremities manages patients with simple fractures and dislocation, non-operative ankle and knee trauma, back strain, herniated disc excluding surgery treats shoulder and neck pain treats soft tissue injuries manages degenerative and inflammatory disease. Performs aspiration and/or injection of the knee, trochanteric bursa, and trigger points Joint/bursa injection/arthrocentesis. Makes initial diagnosis, management, and referral of patients with: complicated fractures ligamentous tears tears of the meniscus herniated discs congenital orthopaedic problems. Manages a rehabilitation program for patients with the above problems. Conducts a sports physical with particular attention to age and developmental stage of the applicant. Recognizes early and/or potential complications, stabilize patients and utilize appropriate consultation.

4 Attitudes: Understands the psychosocial effects from lack of mobility, which may result in the inability to function in one s previous lifestyle including diminished recreational activities and the impact on the patient s family. Understands the role of specialist and ancillary services (physical therapy, occupational therapy) in the management of orthopaedic conditions. Promotes individual and community healthy lifestyles, exercise activities and fitness training. Encourages patient self-evaluation especially related to pain assessment, physical rehabilitation, and return to work/sports activities. Remains sensitive to the financial considerations that come from diminished capacity to earn a living in the patient s previous context. Resident Experiences throughout the three years: The resident currently spends 138 hours primarily in outpatient time in orthopaedics on Waterville based rotations. Each resident does a four-week rotation in the second year and a two-week block in the third year. The resident has the option of scrubbing in for surgery or going to the orthopaedic office, depending on his/her interests. In the second year, the resident spends six half-days per week with the orthopaedic surgeon. The remaining four half-days per week are spent either at conference (1/2 day) or at the family center (3 ½ days). In the third year, the resident spends four half-days per week with the orthopaedic surgeon (another 1/2 day at sports medicine office and four half-days in the family practice center). In Augusta, the resident spends four half-days with the orthopaedic surgeons during the orthopaedic rotation and one half-day during the orthopaedic/urology rotation or 80 hours. The resident is required to do an 18-hour orthopaedic study program. Residents spend two half-days in both the second and third year rotations with family physician sports trainers who do sports medicine/orthopaedic evaluations at local high schools. We feel this training qualifies for both orthopaedics and sports medicine as joint evaluation is emphasized. Applying half this scheduled time to orthopaedics gives the Augusta based resident 130 hours of orthopaedic training. Orthopaedic conferencing accounts for another 15 hours throughout training. Residents acquire the skills in the appropriate examination of joints in the musculoskeletal system, joint and bursa injections, and arthrocentesis, taping, splinting, and casting of simple fractures, the reading and description of x-rays, writing an exercise prescription, conducting sports physicals, and the appropriate ancillary testing. Residents spend a varying amount of time on sports medicine depending on their interest. Third year residents in Waterville spend 1 half-day per week doing sports medicine during the twoweek orthopaedic rotation. In total, this equals eight hours. In Augusta, residents in both the

5 second and third year rotations spend two half-days with family physician sports trainers, half of which or 16 hours of which is counted as sports medicine (the remainder counted as orthopaedics). There is also an expectation at both locations that residents participate in sports triage by attending sporting events with the sports trainers during the second year orthopaedic rotation. Residents also attend sports medicine conferences, and do pre-athletic/sports physicals. Teaching Conferences: 1. Casting procedure clinics (2 hours per year/family practice center). 2. Orthopaedics conference (Friday morning 7:30-9:00/Waterville). 3. MGMC (Waterville) grand rounds (1-2 hours/year variable). 4. Osteopathy (2 hours per month during Tuesday afternoon session). 5. Noon lectures (6 hours per year) 6. Sports Medicine Clinic Learning Resources: Textbooks and Readings: Hoppenfield S., Hutton, R. Physical Examination of the Spine and Extremities, Prentice Hall, Morrissy, R.T. Pediatric Orthopaedics, 3 rd Edition, Lippincott, Williams & Wilkins, Magee, D.J. Orthopaedic Physical Assessment, 3 rd Edition, W.B. Saunders Co., Mellion, M.B., Walsh, W., Shelton, G.L. The Team Physician s Handbook, 2 nd Edition, Hanley & Belfast, Pre-participation Physical Evaluation, 2 nd Edition, McGraw-Hill, Eiff, M.P., Hatch, R.L., Calbach, W.L. Fracture Management for Primary Care, W.B. Saunders & Co., Connolly, J.F. Fractures and Dislocations, Closed Management, W.B. Saunders Co., Scuderi, G.R., McCann, P.D., Bruno, P.J. Sports Medicine: Principles of Primary Care, Mosby, McNab, I. Backache, Lippincott, Williams & Wilkins Company, Cailliet, R. The Shoulder in Hemiplegia, F.A. Davis Co., DeLisa, J, Gans, B.M., Backenek, W.L. Rehabilitation Medicine: Principles and Practice, 2 nd Edition, Lippincott, Williams & Wilkins, Cailliet, R. Scoliosis: Diagnosis and Management, F.A. Davis Company, 1975.

6 Pfeiffer, G. and Webster, J.A. Workcare a Resource Guide for the Working Person, Workcare Press, Favus, M.J. Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism, 4 th Edition, Lippincott, Williams & Wilkins, Schumacher, H. Primer on Rheumatic Diseases, 9 th Edition, O Donoghue, D. Treatment of Injuries to Athletes, 4 th Edition, Depalma, A. Depalma s The Management of Fractures and Dislocations: An Atlas, 3 rd Edition, W.B. Saunders Co., Reider, B. Sports Medicine the School-Age Athlete, W. B. Saunders Co., Cailliet, R. Hand Pain and Impairment, F.A. Davis Company, Livingstone, C. The Hand, Examination and Diagnosis, 2 nd Edition, Charnley, John. The Treatment of Common Fractures, 3 rd Edition, Churchill Livingston, Snider, Robert K. Essentials of Musculoskeletal Medicine, American Academy of Orthopaedic Surgeons, Audio/visual aids and/or computerized resources: 1. Sports Medicine: An In-depth Review, Audio CME, Kansas City, AAFP Hours, VCR Tapes Orthopaedics. 3. Fairfield/Waterville Orthopaedic Offices: readings/notebooks 4. CD Rom Essentials of Musculoskeletal Medicine. Faculty: Family Practice Orthopaedics (W) Orthopaedics(A) Daniel Ober, DO Marc Gorden, DO Robert Day, MD William Alto, MD Vaughn Collett, MD H. Winston Kipp, MD Catherine Meikle, MD Anthony Mancini, MD Robert Livingston, MD William Rogers, MD Jose Ramirez, MD Resident Assessment: Residents are evaluated formally at the end of the rotation by the faculty and staff orthopaedists, and informally throughout the rotation. Staff orthopaedists are evaluated by the residents in writing at the end of the rotation.

7 Template of a Typical Week: Second year: Three half-days in FP site, one half-day reading or surgery, one half-day education (Tuesday p.m.) and five half-days outpatient orthopaedics. Third year: Four half-days in FP site, one half-day reading or surgery, one half-day education (Thursday p.m.) and five half-days outpatient orthopaedics. For both: Option of one half-day Colby College sports medicine clinic. Fairfield Resident Survival Guide by Stephanie Calkins, MD: Dr. Meikle: Does lots of teaching while seeing patients. Lots of arthritis, joint replacement. Need to ask if you want to do procedures. She will let you, but won t assume you ll do them. Encourages resident to scrub in OR, which I think is a good idea. While in her office, I used her book General Orthopaedics and would read on what we were seeing in between patients while she was dictating. I found this to be a good way to use some of that down time while she was doing her busy work. Dr. Golden & Coulette: Very nice. Their PA does all casts/splints you can assist/do if you ask and are persistent, which I would encourage. Both do quite a bit of teaching, especially on physical exam, while seeing patients.