Microsoft Word F3 Jr 04 Muskuloskeletaal 471 Eng 2006...

MB, ChB Phase III – Theoretic al Modules

2006

Musc uloskeleta l

System 52302 471

2006

EDITOR: Dr DR ICM Robertson

Musc uloskeleta l System 52302 471

MB, ChB Phase III – Theoretic al Modules

2006

MUSCULOSKELETAL SYSTEM

DESCRI PTI ON 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, UMN Lesion and LMN 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

Disorders...................................................................................................................... 13 Session 3: Nuclear Medicine as Imaging Modalities in the Musculoskeletal System...................... 14

THEME 4: INFECTIVE CONDITIONS OF THE MUSCULOSKELETAL SYSTEM ............................ 16 Session 1: General Pathological Principles................................................................................... 16 Session 2: Self-study ................................................................................................................... 17 Session 3: Microbiological Aspects of Bone, Joints and Soft tissue Infection................................. 19 Session 4: Pharmacological Aspects of Antibiotics in Infections.................................................... 20 Session 5: Acute Septic Arthritis and Osteomyelitis ...................................................................... 20 Session 6: Non-Pyogenic Infections of Bone and Joints................................................................ 22 Session 7: Clinical Problem Solving Chronic Osteomyelitis........................................................... 23 Session 8: Hand infections ........................................................................................................... 24

THEME 5:APPROACH TO POLYARTHRITIS ................................................................................. 25 Session 1: Rheumatoid Arthritis ................................................................................................... 25 Session 2: Interactive Small Group Training ................................................................................. 26

THEME 6: APPROACH TO A PATIENT WITH GENERALISED PAIN............................................. 27 Session 1: Soft Tissue/Rheumatic/ Regional Pain Syndrome........................................................ 27 Session 2: Paramedical Role in Rheumatology ............................................................................ 28 Session 3: Self-study ................................................................................................................... 28

THEME 7: APPROACH TO THE PATIENT WITH MONO/OLIGO ARTHRITIS ................................ 30 Session 1 - The Patient with Mono-Arthritis/Oligo-Arthritis ............................................................ 30 Session 2 – Seronegative spondarthropathy / infection and arthritis.............................................. 31 Session 3 – Case study................................................................................................................ 32 Session 4 – Small group Interaction ............................................................................................. 32

THEME 8: APPROACH TO THE PATIENT WITH NON-SPECIFIC SYSTEMIC DISEASES............. 33 Session 1: Auto-Immune Diseases – SLE as a Prototype ............................................................. 33 Session 2: Scleroderma, Dermatomyositis, Vasculitis................................................................... 34 Session 3: Self-study ................................................................................................................... 34 Session 4: Case study.................................................................................................................. 35

THEME 9:OTHER TOPICS IN RHEUMATOLOGY........................................................................... 36 Session 1 : Paediatric Rheumatology ........................................................................................... 36 Session 2: Pharmacology............................................................................................................. 36 Session 3: Slide show/Revision.................................................................................................... 37 Session 4: Slide show portion of Assessment............................................................................... 37

THEME 10: CONGENITAL AND DEVELOPMENTAL CONDITIONS OF THE MUSCULOSKELETAL

SYSTEM ...................................................................................................................... 38 Session 1: Linear and Rotation Deformities of the Lower Limbs, Leg pains in Children and

Osteochondroses ......................................................................................................... 39 Session 2: Congenital Club feet, Metatarsus Adduktus, Cavus Feet and Flat feet in Children ....... 40 Session 3: Congenital Hip Dysplasia, Perthes’ Disease of the Hip and Sliding Proximal Femoral

Epiphysis...................................................................................................................... 41 Session 4: Orthopaedic Aspects of cerebral palsy and Neuromuscular Diseases.......................... 42

THEME 11: ONCOLOGICAL CONDITIONS OF THE MUSCULOSKELETAL SYSTEM................... 44 Session 1: General Pathological Principles................................................................................... 44 Session 2: Primary and Secondary Bone tumours ........................................................................ 46 Session 3: Soft Tissue Tumours................................................................................................... 48

THEME 12: CONDITIONS OF THE PELVIS AND SPINAL COLUMN.............................................. 49 Session 1: Scoliosis and Kyphosis ............................................................................................... 49 Session 2: Neck pain and backpain in Adults................................................................................ 50

THEME 13: CONDITIONS AND DEFORMITIES OF THE UPPER LIMB .......................................... 52 Session 1: Neurological Evaluation of the Upper Limb.................................................................. 53 Session 2: The Brachial Plexus - Self-study.................................................................................. 53 Session 3: Degenerative Arthritis, Rotator cuff lesions and Instability of the Shoulder girdle.......... 54 Session 4: Epicondylitis and Arthritis of the Elbow Joint, Swellings around the Wrist, De

Quervain’s Synovitis, Kienbock’s Disease and Arthritis of the Wrist Joint....................... 55 Session 5: Rheumatoid Arthritis of the Hand................................................................................. 57 Session 6: Carpal Tunnel Syndrome, Conditions and Deformities of the Hand.............................. 58

THEME 14: CONDITIONS AND DEFORMITIES OF THE LOWER LIMB ......................................... 60 Session 1: Osteoarthritis and Avascular Necrosis of the Hip; Painful Hip - Problem Solving.......... 60 Session 2: Angular Deformities of the Knee, Osteotomies and Knee Replacements ..................... 62 Session 3: The Sportsman with (a) a Painful Lower Leg and (b) the Ileotibial Band Syndrome...... 63 Session 4: Chronic Instability of the Ankle Joint, Degenerative Conditions of the Ankle, Cavus

Feet and Flat Feet in Adults .......................................................................................... 64

THEME 15: GENERAL PRINCIPLES OF RESUSCITATION AFTER TRAUMA AND EMERGENCY

TREATMENT OF FRACTURES AND DISLOCATIONS ............................................... 66

THEME 16: GENERAL PRINCIPLES OF TRAUMATIC CONDITIONS ............................................ 68 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............................................................................................................ 68

Session 2: Imminent Compartment syndrome, Non-Accidental Syndrome, Reflex Sympathetic Dystrophy, General Complications of Fractures and Dislocations .................................. 70

THEME 17: IMMOBILISATION TECHNIQUES OF THE UPPER LIMB ............................................ 72 Session 1: Immobilisation techniques of the upper limb ................................................................ 72

THEME 18: FRACTURES AND DISLOCATIONS OF THE SPINAL COLUMN AND PELVIS........... 74 Session 1: Clinical Presentation and Incidence of Vertebral Fractures, The Care of Paraplegics

and Tetraplegics in the Post-Injury Period, Transport of a Tetraplegic ........................... 74 Session 2: Pelvis Fractures .......................................................................................................... 76

THEME 19: FRACTURES AND DISLOCATIONS OF THE UPPER LIMB ........................................ 77 Session 1: Fractures and Dislocations of the Shoulder Girdle ....................................................... 77 Session 2: Fractures and Dislocations around the Elbow and Forearm Fractures ......................... 78 Sessies 3: Fractures and Dislocations around the Wrist Joint, Hand and Fingers.......................... 80

THEME 20: FRACTURES AND DISLOCATIONS OF THE LOWER LIMB ....................................... 82 Session 1: Hip Dislocations, Femur Neck, Intertrochanteric and Femur Shaft Fractures................ 82 Session 2: Fractures of the Distal Femur, Proximal Tibia and Patella............................................ 83 Session 3: The Longterm Consequences of Knee Ligament and Meniscus Injuries ...................... 84 Session 4: Fractures of the Tibia Shaft and Plateau...................................................................... 85 Session 6: Sprains, Fractures and Dislocations of the Ankle, Fractures and Dislocations of the

tarsals, metatarsal bones and phalanges of the foot...................................................... 86

THEME 21: SOFT TISSUE INJURIES OF THE MUSCULOSKELETAL SYSTEM............................ 88 Session 1: Lacerations and Penetrating Skin wounds................................................................... 88 Session 2: Appropriate Wound Healing and Wound Dressing....................................................... 89

THEME 22: REHABILITATION, AIDS.............................................................................................. 91 Session 1: Rehabilitation and Aids ............................................................................................... 91 Session 2: .................................................................................................................................... 92 Session 3: Overall Objectives of a Rehabilitation Program............................................................ 93

TIMETABLE ..................................................................................................................................................................................................................... ERROR! BOOKMARK NOT DEFINED.

Fase III (Teorie): MUSKULOSKELETALE SISTEEM – 52302 471 © Fakulteit Gesondheidswetenskappe, Universiteit Stellenbosch, 2006. Alle regte voorbehou.

i


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


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LECTURERS

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

NAME OFFICE E-MAIL TEL

Prof G Vlok Department of Orthopaedics [email protected] (021) 938 9266

Dr I Robertson Department of Orthopaedics [email protected] (021) 938 5458

Dr H de Jongh Department of Orthopaedics [email protected] (021) 938 5458

Dr A Ikram Department of Orthopaedics [email protected] (021) 938 5458

Dr S Pretorius Department of Orthopaedics [email protected] (021) 938 5458

Dr A Heyns Department of Orthopaedics [email protected] (021) 938 5458

Dr I Terblanche Department of Orthopaedics [email protected] (021) 938 5458

Dr J du Toit Department of Orthopaedics [email protected] (021) 938 5458

Prof P van der Bijl Department of Pharmacology [email protected] (021) 938 9331

Dr JH Lamprecht Department of Pharmacology [email protected] (021) 938 9331

Prof J Schneider Depart.of Anatomical Pathology [email protected] (021) 938 4041

Prof J Apffelstaedt Department of Surgery [email protected] (021) 938 9273

Dr J Odendaal Department of Surgery [email protected] (021) 938 9273

Dr A Graewe Department of Plastic Surgery [email protected] (021) 938 9432

Dr H Orth Department of Microbiology [email protected] (021) 938 5193

Dr J Warwick Department of Nuclear Medicine [email protected] (021) 938 4352

Dr D Whitelaw Department of Rheumatology [email protected] (021) 938 9376

Dr M Manie Department of Rheumatology [email protected] (021) 938 9376

Dr LM du Plessis Department of Rheumatology [email protected] (021) 938 9376

Mev L Crous Department of Physiotherapy [email protected] (021) 938 9300

Me R Lochner Department of Physiotherapy [email protected] (021) 938 9503

Me T Steyn Department of Occupational Therapy [email protected] (021) 938 9291

Contact People

Helga Oldewage, Department of Orthopaedics, Tel: (021) 938 9266, E-mail: [email protected]

Susan Stipp, Department of Rheumatology, Tel: (021) 938 9322, E-mail: [email protected]


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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 - 24 February 2006

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: Monday – 9 October 2006

Time: 09:00 – 12:00

Location: Examination Hall, 5th floor, Education block

Performance mark

The performance mark for these modules are calculated as follows: 50% of the class mark and 50% of

the examination mark. In order to pass the module, you must achieve either a performance mark of

50% or more, or an examination mark of 50% of more. If you pass the examination (examination mark

of 50% of more), you pass the module, even if your calculated performace mark is less than 50%.


iv

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

TI METABLE AND STUDY I NFORMATI ON I N 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

C3

C3

C3

C3

C2

C2

Clinical examination of the child with

angular or rotation anomalies of the

lower limbs

S2


v


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

C2

C1

C1

C3/

C4

C2

C3

C3

C2

C2

C3

C3

C3

C3

C2

C3

S3

S2

C3

C3

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


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Talipes calcaneo valgus

Acute torticollis

Postural torticollis

(Griessel’s Syndrome)

'Moulded Baby' syndrome

Postural scoliosis

C3

C3

C3

C2

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

C2

C2

C3

C3

C3

C2

C2

C3

C3

C3

C4

C3

C2

C4

C4

C3

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

S2

S2

S2

S2

S2


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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

C3

C3

C4

C2

C2

C2

C2

C2

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

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

C2 C3 C3 C3 C3 C4 C4 C4 C3 C2 C3 C4 C4 C4 C3 C2

Examination of the foot Examination of the back The interpretation of Xrays of the spinal column

S4 S4


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Low mechanical back pain Discus degeneration Spondylolisthesis Discus herniation Spinal stenosis Metastases Myelomatosis ORTHOPAEDIC INFECTIONS Acute osteomyelitis Subacute and chronic osteomyelitis Septic Arthritis

C4 C4 C4 C4 C4 C3 C4 C4 C4

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

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

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

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


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C. INFECTION Pyogenic Tuberculosis

C3/C4 C3/C4

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


x


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

C3 C4 C3 C3 C4 C4 C1 C4

Clinical examination of the shoulder Sub-acromial injection Examination of the elbow

S3/S4 S4 S4


xi


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 C1 C3 C3 C3 C4 C3 C3 C3 C2 C2 C4 C4 C3 C3 C3 C4 C4 C3 C4

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

S2 S4 S4 S2 S2


1

THEME 1: MUSCULOSKELETAL TERMI NOLOGY

AND DEFORMI TI ES

AI M OF THE THEME

Dur ing t his t heme, we will build on your knowledge of t er minology acquir ed dur ing t he Phase I I

module on t he Musculoskelet al syst em. You will learn addit ional t er minology t hat will descr ibe

t he most common musculoskelet al anomalies, and t his will enable you t o communicat e accur at ely

wit h colleagues.

OVERVI EW OF THE THEME

Session Dat e Act ivit y Topic Lect ur er

1 06/ 02/ 2006

09:00– 09:45 Self -st udy

Musculoskelet al Terminology

and Def ormit ies Dr J du Toit

OUTCOMES

At t he end of t his session, you should be able t o do t he f ollowing:

1. Descr ibe t he normal post ure, appearance and movement s of t he musculoskelet al syst em.

2. Recognize and descr ibe t he common musculoskelet al anomalies.

I S THERE ANYTHI NG SPECI FI C TO BE DONE?

1. Read t hrough t he piece of work, and complet e by r ef er r ing t o Dor land’s Medical

Dict ionary and t he Module: The musculoskelet al syst em of Phase I I

RESOURCES

- Dor land’s Medical Dict ionar y

Abduct ion :

Adduct ion :

Ankylosis :

Ant algia:

Ar t hr it is :

Ar t hrodesis :


2

Ar t hroplast y:

Ar t hrosis:

Bunion:

Cavus:

Diaphysis:

Dysplasia :

Dyst r ophy :

Dorsif lexion :

Exocyt osis :

Ext ension :

Ext ernal r ot at ion :

Elevat ion:

Epiphysis :

Ever sion:

Physis :

Flexion : Gon-ar t hrosis:

Hallux :

I nt ernal rot at ion :

I nversion :

I nvolucrum :

Kyphosis :

Lysis :

Lordosis :

Met aphysis :

Met at ar salgia :

Olist esis :

Ost eit is :

Ost eochondr it is :

Ost eochondr osis :

Ost eolisis:

Ost eosclerosis:

Ost eophyt e :

Ost eomalacia


3

Ost eomyelit is :

Ost eoclast s :

Ost eot omy:

Plant ar f lexion :

Planus :

Pollux :

Procur vat um :

Pronat ion :

Recur vat um :

Sequest rum:

Circumduct ion:

Sclerosis:

Scoliosis : Spondylolysis :

Spondylolist hesis :

Spondylosis :

Supinat ion :

Tor t icollis : Valgus :

Varus :


4

THEME 2: CLI NI CAL EXAMI NATI ON METHODS

AI M OF THE THEME

The main aim of t his t heme is t o pr epar e you f or t aking a usef ul clinical hist or y and f or

pef orming an appr opr iat e clinical examinat ion of t he musculoskelet al syst em.

You should also be able t o per f orm a complet e, t horough and relevant clinical examinat ion of t he

upper limbs, lower limbs and t he spinal cor d, and be able t o dist inguish t he normal appearance,

post ure, movement and st abilit y f r om physiological, age and pat hological anomalies. You should be

able t o ident if y abnormal gait s and clinically evaluat e dif f er ences in bone lengt h. You must know

t he basic pr inciples of t he examinat ion of a j oint in general.



1 06/ 02/ 2006

10:00-10:45 Lect ur e

Linear and Rot at ional def ormit ies of

t he Limbs, Gait , Dif f er ences in bone lengt h

and t he Examinat ion of a J oint

Dr J du Toit

2 06/ 02/ 2006

11:00-11:45 Self -st udy

Pain St aging, Muscle power , Spast icit y,- Myot ome I nner vat ion,

Dermat ome I nner vat ion,

LMN Lesion and UMN Lesion

Dr J du Toit

3 06/ 02/ 2006

12:00-12:45 Lect ur e Examinat ion of t he Neck and Shoulder Dr H de J ongh

4 06/ 02/ 2006

14:00-14:45 Lect ur e Examinat ion of t he Back Pr of GJ Vlok

5 06/ 02/ 2006

15:00-15:45 Lect ur e

Examinat ion of t he Elbow,

Forearm and Hand Dr S Pr et or ius

6 07/ 02/ 2006

08:00-08:45

Lect ur e

Clinical Examinat ion of t he

Hip and Knee j oint Dr H de J ongh

7 08/ 02/ 2006

09:00-09:45 Lect ur e Examinat ion of t he Foot and Ankle Dr A Heyns


5


SESSI ON 1: LI NEAR AND ROTATI ONAL DEFORMI TI ES OF

THE LI MBS, GAI T, DI FFERENCES I N BONE LENGTH AND THE EXAMI NATI ON OF A

J OI NT

OUTCOMES


1. Name t he most common linear and rot at ional def ormit ies of t he limbs.

2. Name and descr ibe t he 4 most common anomalies of gait of pat ient s, and r ecognize each

on a video.

3. Name t he causes of an apparent dif f erence in bone lengt h.

4. Be able t o evaluat e painf ul and limit ed act ive and passive movement of a j oint .

5. Evaluat e a swollen j oint clinically and dist inguish bet ween an ef f usion and a synovit is.

RESOURCES

1. Clinical Or t hopaedic Examinat ion McCrae, Page 1

2. Ort hopaedic Assessment Video Caset t e, US library, WE 141 Or t

3. Physical examinat ion of t he spine and ext remit ies St anley Hoppenf eld

4. Pecut ra gait s / Buckanon MFG WE103BUC US Librar y


Lect ur e

This lect ure and demonst rat ion demonst r at es t he clinical met hods associat ed wit h t he

examinat ion of a j oint , including normal movement and st abilit y, and dist inguishing t his f rom a

pat hological process. The clinical evaluat ion of dif f er ences in bone lengt hs, normal gait and

anomalies t hereof , as well as r ot at ional and linear def ormit ies of t he limbs will also be discussed.

Please complet e t he assignment t hat was given t o you dur ing t he session.


6


SESSI ON 2: PAI N STAGI NG, MUSCLE POWER,

SPASTI CI TY, MYOTOME I NNERVATI ON, DERMATOME I NNERVATI ON, LMN LESI ON

AND UMN LESI ON

OUTCOMES


1. Explain how t he musculoskelet al syst em is graded.

2. Gr ade muscle power according t o t he Oxf ord scale.

3. Gr ade muscle spasm according t o t he Ashwor t h scale.

4. Descr ibe / sket ch t he neurological inner vat ion of t he myot omes of t he limbs.

5. Descr ibe / sket ch t he sensory inner vat ion of dermat omes.

6. Explain how t o dist inguish clinically bet ween an upper and lower mot or neuron lesion.

RESOURCES

- Clinical Or t hopaedic Examinat ion McRae, Page 13

- Apleys Syst em Of Or t hopaedics And Fract ur es Page 194, 4

- Ort hopaedic Physical Assessment . D Magee 3rd Edit ion Pages 21, 24


Self - st udy

The aim of t his self -st udy is t o give you a good per cept ion of t he degree of pain t hat your

pat ient s exper ience, as well as t he quant if icat ion t hereof and t he degree of mor bidit y. You must

also be able t o quant if y power and spasm of muscles f or t he purpose of f ollow-up document at ion.

I n addit ion, you should be able t o localize neurological lesions anat omically by means of a good

per ipheral limb examinat ion.


7


SESSI ON 3:

EXAMI NATI ON OF THE NECK AND SHOULDER

OUTCOMES


1. Explain how t o examine normal movement s of t he neck.

2. Per f orm an appropr iat e neurological and vascular examinat ion of t he upper limbs.

3. Demonst rat e how t o examine normal movement s of t he shoulder gir dle and explain how t o

ident if y limit ed movement .

4. Descr ibe t he clinical t est s t o ident if y rot at or cuf f t ears and shoulder t ight ness.

5. Explain how t o dif f erent iat e bet ween glenohumeral and scapulo-t hor acic movement .

6. Explain how t o clinically evaluat e st abilit y of t he shoulder j oint .

RESOURCES

1 Clinical Or t hopaedic Examinat ion McCrae – The shoulder Page 41

The cervical spine Page 27

2 Physical Examinat ion Of The Shoulder . SA Bone & Joint Surger y, Vol no 4,

Nov 2000, Page 12

3 Rout ine Examinat ion Of Joint s. Video 2: The shoulder / Holland CD WE544HOL

US Librar y

4 Ort hopaedic Physiot herapy Video casset t e: The Examinat ion Of The Shoulder WE810WI N

US Library

5 Examinat ion Of The Shoulder / Kelly I G, WE810KEL, US Librar y


Lect ure

The obj ect ive of t his session is t o assist you in t aking an appropr iat e medical hist or y and

per f orming a basic, usef ul clinical examinat ion in order t o ident if y and dif f er ent iat e bet ween

condit ions of t he neck and shoulder .

A lect ur e demonst r at ion will be present ed on t he clinical examinat ion met hods of t he neck and

shoulder gir dle. I n preparat ion t heref ore you should r eview t he ost eology of t he neck Phase I I ,

Theme 2, Session 1 and Phase I I , The Musculoskelet al Syst em, Theme 4.

Please complet e t he assignment t hat was supplied t o you.


8


SESSI ON 4:

EXAMI NATI ON OF THE BACK

OUTCOMES


1. Descr ibe t he normal cont our , as well as t he ext ent of movement , of t he t horacolumbar

spine.

2. Descr ibe how t o measure chest wall expansion and explain what t he loss t hereof means.

3. Explain t he impor t ance of t he pelvic t ilt .

4. Descr ibe how t o ident if y a kyphosis and explain t he impor t ance t her eof .

5. Descr ibe how t o ident if y scoliosis and explain t he impor t ance t hereof . 6. Descr ibe how t o clinically evaluat e t he neurological and vascular component s of t he lower

limbs.

7. Descr ibe how t o examine t he sacro- iliac j oint s.

RESOURCES

1. Clinical Or t hopaedic Examinat ion McCrae – The Thoracic And Lumbar Spine Page 113

2. Rout ine Examinat ion Of Joint s. Video 5 – The Spine/ Holland CD WE544HOL, US Library

3. Ort hopaedic Physiot herapy: Examinat ion Of The Lumbar Spine WE750WI N, US Library

4. Concise Syst em Of Or t hopaedics And Fract ures. A Graham Apley/ Louis Solomon

Chapt er 18, The Back. Page 157




condit ions of t he t hroacolumbar spinal column.

Bef or e st ar t ing t his session, you should review t he f unct ional anat omy of t he spinal

cor d.

Lect ur e demonst r at ion

Dur ing t his session, t he normal cont our and normal movement s of t he t horacic ver t ebrae will be

demonst r at ed. Anomalies of post ure and def ormit ies, such as scoliosis and kyphosis, will be

discussed.

At t he end of t his session, you must complet e t he assignment wit h t he help of t he

lect urer .


9


SESSI ON 5: EXAMI NATI ON OF THE ELBOW, FOREARM

AND HAND

OUTCOMES


1. Descr ibe t he normal movement s of t he elbow, wr ist , met acarpophalangeal and

int erphalangeal j oint s.

2. Name t he st abilising st ruct ures in all of t hese j oint s.

3. Name t he muscles mainly responsible f or t he movement of t hese j oint s.

4. Descr ibe t he myot ome innervat ion of t he upper arm, f orearm and hand, and explain how

t o dist inguish bet ween movement s of muscles innervat ed by t he median, ulnar and r adial

ner ve.

5. Descr ibe t he dermat ome sensory dist r ibut ion of t he hand and f orearm.

6. Descr ibe t he cour se of t he main nerves in t he upper limb.

7. Descr ibe t he cour se of t he main ar t er ies in t he upper limb.

8. Dif f er ent iat e bet ween t he f unct ions of t he var ious t endons in t he f ingers.

RESOURCES

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

2. Clinical Or t hopaedic Examinat ion McCrae

Segment al And Per ipheral Nerves Of The Upper Limb Page 13

The elbow Page 61

The wr ist Page 77

The hand Page 95

3. Rout ine Examinat ion Of Joint s. Video I : Par t . 1 The hand, Par t . 2 The elbow/ Holland CD

WE544HOL, US Library

4. Neurovascular Examinat ion 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




condit ions of t he elbow, f orearm and hand.


10

Pre- st udy

Bef ore st ar t ing t his lect ure, you are expect ed t o review t he f unct ional anat omy of t he arm, as

well as t he cont ent of t he muscle compar tment s of t he upper arm, f orearm and hand. Phase I I ,

The Musculoskelet al Syst em, Sessions 3, 4, 5 and 6.

Lect ure

A 45-mint ue lect ure demonst rat ion will be present ed. The clinical examinat ion of t he elbow and

f or earm j oint s will be discussed. The examinat ion of t he median, ulnar and r adial nerves will be

discussed by means of a demonst r at ion. The f unct ion of t he most impor t ant t endons in t he hand

will also be discussed.

At t he end of t his session, you should be able t o complet e t he assignment t hat has been

provided.


SESSI ON 6: CLI NI CAL EXAMI NATI ON OF THE HI P AND

THE KNEE JOI NT

OUTCOMES


1. Descr ibe t he normal ext ent of movement s of t he hip.

2. Explain how t o evaluat e muscle spasm of t he hip.

3. Descr ibe t he normal ext ent of movement s of t he knee.

4. Descr ibe t he examinat ion t echniques used t o evaluat e cruciat e ligament s, collat eral

ligament s, unst able pat ella or a meniscus inj ury.

RESOURCES

1. Clinical Or t hopaedic Examinat ion McCrae

The hip Page 155

The knee Page 189

2. Rout ine Examinat ion Of Joint s Video 3: The hip / Holland CD, WE544 HOL, US Librar y

3. Rout ine Examinat ion Of Joint s Video 4: The knee / Holland CD WE544HOL, US Library

4. Clinical Examinat ion Of The Knee/ I r eland J , WE870I RE, US Libr ar y

Lect ure



condit ions of t he hip and knee j oint .


11

Dur ing t his session, t here will be a 45-minut e lect ure demonst r at ion on examinat ion t echniques

of t he knee and hip j oint s. At t he st ar t of t his lect ure, you ar e expect ed t o have r evised t he

f unct ional anat omy of t he knee and hip j oint s. Phase I I , The Muskuloskelet al Syst em, M4607

and M4617.

At t he end of t his lect ure, you should complet e t he assignment supplied t o you.


SESSI ON 7:

EXAMI NATI ON OF THE FOOT AND ANKLE

OUTCOMES


1. Descr ibe t he normal movement s of t he ankle and f oot j oint s.

2. Descr ibe how t o examine t he f unct ion of t he t endons of t he f oot and ankle.

3. Descr ibe how t o examine inst abilit y of t he ankle j oint .

4. Descr ibe how t o localise nerve pressure of t he f oot .

RESOURCES

1. Clinical Or t hopaedic Examinat ion McCrae.

- The Ankle Page 239

- The Foot Page 253

2. Rout ine Examinat ion Of Joint s Video 6, The Ankle And Foot / Holland CD WE544HOL,

US Librar y

3. Movement s Of The Ankle And Foot / Waugh W WE880WAU, US Libr ary




condit ions of t he f oot and ankle.

At t he st ar t of t his lect ure, you should have revised t he f unct ional anat omy of t he f oot

and ankle. Phase I I , The Muskuloskelet al Syst em M4632, M4512, M4515.

Lect ur e/ Slide show

A lect ure will be present ed, using t he slide proj ect or , t o demonst r at e t he clinical examinat ion

met hods of t he f oot and ankle.

At t he end of t he lect ure, an assignment will be provided f or complet ion.


12

THEME 3: I MAGI NG I NVESTI GATI ONS OF THE


AI M OF THE THEME

At t he end of t his t heme, you should know t he indicat ions f or r equest ing a normal X-r ay t o

diagnose musculoskelet al condit ions and be able t o evaluat e and int erpret t he X-ray

syst emat ically in order t o reach t he diagnosis.

You should also be aware of t he musculoskelet al condit ions, which do not j ust if y unnecessary

r adiological invest igat ions.

You should know t he indicat ions f or r equest ing addit ional imaging invest igat ions (e.g. convent ional

t omography, nuclear medicine, comput er ized t omography and magnet ic r esonance), as well as t he

r elevance, possible side-ef f ect s and cost s t hereof .



1 & 2 07/ 02/ 2006

11:00-11:45 Lect ur e

Usef ul I maging I nvest igat ions

Gener al Radiological Char act er ist ics of

Tr aumat ic and Non-t r aumat ic Bone

and J oint Condit ions

Dr J du Toit

3 07/ 02/ 2006

12:00-12:45 Lect ur e

Nuclear medicine as I maging modalit ies

in t he Musculoskelet al Syst em Dr J Warwick

THEME 3: I MAGI NG I NVESTI GATI ONS OF THE MUSCULOSKELETAL SYSTEM

SESSI ON 1: USEFUL I MAGI NG I NVESTI GATI ONS


Bef ore t his session, you should r ead up on t he indicat ions and advant ages of X-rays of t he

spinal cord in pat ient s wit h backache. I s it always necessary t o t ake X-r ays? Ref erence:

Rat ional I nvest igat ing UPDATE, June 2000, Page 35.


13

OUTCOMES

1. You should know when X-rays are indicat ed in a pat ient present ing wit h backpain

2. Usef ul imaging invest igat ions must be request ed

3. Knowledge of t he dangers of r adiat ion of pat ient s


SESSI ON 2:

GENERAL RADI OLOGI CAL CHARACTERI STI CS OF TRAUMATI C AND NON- TRAUMATI C BONE

AND JOI NT CONDI TI ONS

OUTCOMES


Radiological session:

Obj ect ives: The f ollowing t opics will be discussed:

1. Discussion of t he radiological charact er ist ics of common as well as less common

f r act ures.

2. Discussion of t he radiological charact er ist ics of dislocat ions

3. Discussion of t he r adiological char act er ist ics of degenerat ive, rheumat oid, inf ect ive,

neoplast ic, dysplast ic and common met abolic condit ions.

4. Radiological charact er ist ics of avascular necrosis.

5. Radiological charact er ist ics of benign and malignant t umours.

6. Dangers of repeat ed r adiological invest igat ions.

RESOURCES

Pr inciples Of Fract ures Treat ment . Apleys Syst em Of Or t hopaedics And Fr act ures. Chapt er 23,

Pages 516, 563

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

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

Journal Of Amer ican Family Physicians, Radiological Examinat ion Upper Ext r emit y Fract ures 1

March 1998, Page 995

Journal Of Amer ican Family Physicians, Radiological Examinat ion Lower Limb Traums, 15 March,

1998, Page 1314

Websit e www.aaf p.or g/ af p


14


Self - st udy assignment

Bef ore st ar t ing t he lect ure, you are expect ed t o t abulat e Perkins’ rules wit h r egar ds t o t aking

X-rays in t r auma and t o br ing t his t o t he lect ure f or discussion. Ref erence: Apleys Syst em Of

Or t hopaedics And Fract ur es Page 520.

Lect ure

Dur ing t his session, t her e will be a slide lect ure demonst r at ing t he most impor t ant r adiological

charact er ist ics of t r aumat ic and non-t r aumat ic condit ions of t he skelet on.

At t he end of t his lect ure, 10 minut es will be devot ed t o small gr oup discussions on

t aking unnecessary X-r ays (Previously self -st udy assignment ).


SESSI ON 3: NUCLEAR MEDI CI NE AS I MAGI NG

MODALI TI ES I N THE


OUTCOMES


1. Descr ibe t he pat hophysiological basis of skelet al scint igraphy.

2. List t he most common indicat ions f or skelet al scint igraphy.

3. Explain how t he skelet al scint igram will be conduct ed t o a pat ient r ef er r ed t heref or .

4. List t he advant ages of skelet al scint igraphy.

5. Explain t he role of skelet al scint igraphy in spor t s medicines t o your pat ient .

RESOURCES

1. Phase 2 not es on t he physiology of t he skelet on

2. Class not es

3. Text book of Nuclear Medicine. Wilson MA, Lippincot t -Raven Publishers, Philadelphia, 1998


Lect ure

The aim of t his session is t o enable you t o implement Nuclear Medicine select ively and

pur posef ully in order t o diagnose or conf irm musculoskelet al condit ions.


15

Bef ore at t ending t he lect ur e, please review your phase 2 not es on t he physiology of t he

skelet on. The subj ect will be covered dur ing an int eract ive lect ure.


16

THEME 4: I NFECTI VE CONDI TI ONS OF THE


AI M OF THE THEME

Dur ing t his t heme, you will learn t o r ecognize t he most common inf ect ive condit ions of t he

musculoskelet al syst em. You will also learn how t o t r eat t hese condit ions. Of par t icular

impor t ance is an underst anding of t he under lying anat omy and pat hology, which r esult s in t he

pr inciples of t herapy being somewhat dif f er ent t han f or ot her organ syst ems.


Session Dat e Act ivi t y Topic Lect ur er

1 07/ 02/ 2006

11:00-11:45 Lect ur e Gener al Pat hological Pr inciples Pr of J Schneider

2 07/ 02/ 2006

12:00-12:45 Self -st udy Pr of J Schneider

3 08/ 02/ 2006

08:00-08:45 Lect ur e

Micr obiological Aspect s of Bone,

J oint s and Sof t t issue I nf ect ion Dr H Or t h

4 08/ 02/ 2006

09:00-09:45 Lect ur e

Pharmacological Aspect s of

Ant ibiot ics in I nf ect ions Dr J H Lampr echt

5 08/ 02/ 2006

11:00-11:45 Lect ur e

Acut e Sept ic Ar t hr it is

and Ost eomyelit is Dr A Heyns

6 08/ 02/ 2006

12:00-12:45 Lect ur e

Non-Pyogenic I nf ect ions of Bone

and J oint s Dr A Heyns

7 08/ 02/ 2006

12:00-12:45 Self -st udy

Clinical Pr oblem Solving

Chronic Ost eomyelit is Dr A Heyns

8 08/ 02/ 2006

14:00-14:45 Lect ur e Hand inf ect ions Dr S Pr et or ius

THEME 4: I NFECTI VE CONDI TI ONS OF THE MUSCULOSKELETAL SYSTEM

SESSI ON 1:

GENERAL PATHOLOGI CAL PRI NCI PLES

OUTCOMES

At t he end of t hese sessions, you should be able t o do t he f ollowing:

1. Def ine acut e and chronic ost eomyelit is, t uber culous ost eomyelit is and inf ect ive ar t hr it is.

2. Name t he most impor t ant causes of ost eomyelit is.

3. Discuss t he sequent ial changes in t he pat hogenesis of ost eomyelit is.

4. Discuss and ident if y t he morphological changes of ost eomyelit is.

5. Explain t he clinico-pat hological cor r elat ions of ost eomyelit is.


17

6. Name t he most impor t ant causes of inf ect ive ar t hr it is.

7. Discuss t he pat hogenesis and morphological changes of sept ic and t uber culous ar t hr it is.

8. Explain t he dist inguishing clinico-pat hological cor relat ions of sept ic and t uber culous

ar t hr it is.

BACKGROUND KNOWLEDGE

I t is impor t ant t hat you r eview t he pr inciples and out comes of acut e and chronic inf ect ions, as

well as granulomat ous inf ect ions (r ef er again t o t he Phase 2 module: Basis of Disease Processes).

Ensure t hat you are f amiliar wit h t he morphological manif est at ions of inf ect ion, including

suppurat ion, abscess f ormat ion, spreading inf ect ions such as cellulit is and erysipelas, and

necrot izing inf ect ion. You must also r eview t issue r epair and t he local and syst emic f act ors

inf luencing t his (Ref er again t o t he Phase 2 module: Basis of Disease Processes; especially

t hemes 16 and 21).


Read pages 792-793 and 813-814 in Underwood bef ore at t ending t he lect ure. You will

also benef it by glancing at pages 222-224, especially t he illust r at ions and t ables. Dur ing

t he lect ure, t he lect urer will explain and illust r at e t he t heor y under lying t he out comes and

pr ovide relevant guidelines f or f ur t her st udy.

Lect ure wit h appropr iat e images and illust r at ions

1. Make supplement ary not es t o your t ext book and class not es.

2. The lect ure is available at t he f ollowing webaddr ess:

ht t p:/ / www.sun.ac.za/ healt hsciences/ schools/ basic_appl_healt h/ anat _pat h/ ppt / ppt .ht ml


SESSI ON 2: SELF- STUDY

RESOURCES

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

- Own not es made dur ing cont act sessions

- Class not es

- Examples of specimens t hat you can st udy in your own t ime will be made available in t he

pat hology demonst rat ion hall on t he 4t h f loor in t he Educat ion Block. A list of cases is

at t ached at t he end of t his t heme.

- Comput er -assist ed guidance: This websit e of f ers a number of examples, illust r at ions and

t ut or ials t hat are not available elsewher e.


18

ht t p/ / medst at .med.ut ah.edu/ WebPat h/ html# MENU <Organ Syst em Pat hology>

<Bone and Joint Pat hology>


Self - st udy

Answer t he f ollowing quest ions dur ing your self -st udy:

1. Def ine acut e and chronic pyogenic ost eomyelit is

2. Name t he most impor t ant causes of ost eomyelit is and of inf ect ive ar t hr it is.

3. Discuss t he sequent ial changes in t he pat hogenesis of pyogenic ost eomyelit is.

4. Discuss t he morphological changes of pyogenic ost eomyelit is and explain t heir clinico-

pat hological cor r elat ions (St udy f igure 25.6 on page 794 in Underwood)

5. Discuss t he clinico-pat hological charact er ist ics of t uberculous ost eomyelit is and

ar t hr it is. Ref er specif ically t o t he most impor t ant dif f erences bet ween t his and

pyogenic ost eomyelit is and ar t hr it is. Make a sket ch illust r at ing t he dif f er ences.

Ref r esh your t hought s by looking at t he f igure and descr ipt ion of pages 232-236 and

241-243 in Underwood.

6. Name ot her impor t ant non-inf ect ive causes of ar t hr it is.

7. Discuss t he pat hogenic and morphological changes of sept ic ar t hr it is and t uber culous

ar t hr it is.

8. Explain t he dist inct ive clinico-pat hological cor r elat ions of sept ic and t uber culous

ar t hr it is.

Br ief ly discuss t he clinico-pat hological charact er ist ics of gonococcal ar t hr it is,

spirochaet al ar t hr it is and vir al ar t hr it is.

9. Take not e t hat t he f ollowing examples of skelet al and sof t t issue pat hology will be

available f or st udy in you own t ime. The locat ion will be made known t o you. This

oppor t unit y is provided in order t o help you; t he specimens will not be par t of your

assessment .

You ar e encouraged t o f or mulat e quest ions and direct t hem t o Prof Schneider at

j ws2@sun. ac. za

* AS32, AS21, AS22 :Ost eomyelit is

* AS31 :Bone - syphilit ic ost eit is

* AV23 :Paget ’s disease

* J V 3 :Femur - haemolyt ic anaemia

* AS40 :Echinococcus cyst (bone)

Wet specimens

* PM382/ 88, 137/ 89 - Tuber culosis


19


SESSI ON 3: MI CROBI OLOGI CAL ASPECTS OF BONE,

JOI NTS AND SOFT TI SSUE I NFECTI ON

OUTCOMES

At t he end of t his session, you should know t he f ollowing:

1. Tabulat e t he common organisms r esponsible f or acut e bone and j oint inf ect ions.

2. Tabulat e t he organisms r esponsible f or chronic bone and j oint inf ect ions.

3. Tabulat e t he organisms r esponsible f or sof t t issue inf ect ions.

4. Discuss t he pat hogenesis of bone and j oint inf ect ions.

5. Discuss t he role of t he laborat ory in t he diagnosis of bact er ial inf ect ions.

6. Name t he ant imicrobial drugs and doses used in t he t reatment of common

musculoskelet al inf ect ions.

7. Discuss t he most impor t ant charact er ist ics and diagnosis of musculoskelet al

t uber culosis.

8. Tabulat e t he drugs used in t he t reatment of musculoskelet al t uber culosis, as well as t he

dose, dur at ion and side-ef f ect s t hereof .


Bef ore st ar t ing t he session, t he st udent should have t he f ollowing background knowledge:

1. The classif icat ion of bact er ia

2. Basis of pat hogenesis and bact er ial vir ulence

3. Basis of ant imicrobial act ion

At t he end of t he lect ure, an assignment will be handed out f or complet ion.

RESOURCES

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

- I nglis: Microbiology and I nf ect ion, 1998. Chapt er 13, Page 131, Chapt er 6, Pages 57-58

- Class not es


Lect ure

Obj ect ives: This session deals wit h t he most impor t ant charact er ist ics of t he general organisms

t hat give r ise t o acut e and chronic inf ect ions of sof t t issue, bones and j oint s.

You must also know about t he less common organisms t hat give r ise t o musculoskelet al inf ect ion.


20


SESSI ON 4: PHARMACOLOGI CAL ASPECTS OF

ANTI BI OTI CS I N I NFECTI ONS

AI M OF THE THEME

This session f ocuses on t he dif f erent pharmacological aspect s of ant ibiot ics t hat are commonly

used t o t r eat musculoskelet al inf ect ions

OUTCOMES

At t he end of t he session,you should be able t o complet e t he f ollowing:

1. The f omulat ion of a clinical diagnosis of a microbial inf ect ion.

2. The f ormulat ion of a microbial diagnosis.

3. Det erminat ion of t he benef it f or empir ical ant ibiot ics.

4. A syst emat ic approach t o emper ical ant ibiot ics.

5. Pharmacodynamic and pharmacokinet ic f act ors of t herapy.

6. Ant imicr obial dr ug t oxicit y and t he management t hereof .

7. The impor t ance and place of combinat ion t herapy.

8. Ant imicr obial prophylaxis.

RESOURCES

Rang, Dale&Rit t er , Pharmacology, 4t h Ed., (1999)


SESSI ON 5: ACUTE SEPTI C ARTHRI TI S AND

OSTEOMYELI TI S

OUTCOMES

At t he end of t his session, you should be able t o do t he f ollowing: 1. Explain how t o make t he clinical diagnosis of an acut e sept ic ar t hr it is and an acut e

ost eomyelit is, as well as how t o dist inguish bet ween t he t wo and super f icial sof t t issue inf ect ions.

2. Explain how t o diagnose and t reat a subacut e bone and j oint inf ect ion.

3. Name t he necessar y special invest igat ions, as well as t he int erpr et at ion t hereof in order

t o diagnose bone and j oint inf ect ions.

4. Descr ibe when a bone and j oint inf ect ion r equires surgical t r eat ment .


21

5. Descr ibe t he par t icular clinical present at ion of musculoskelet al inf ect ions

in t he neonat e.

6. Tabulat e t he complicat ions of sept ic ar t hr it is of t he hip.

7. Tabulat e t he complicat ions of acut e inf ect ions of bone and j oint s.

8. Tabulat e t he appr opr iat e ant ibiot ic doses, as well as t he durat ion of t reat ment f or acut e

sept ic ar t hr it is and ost eomyelit is.

9. Tabulat e t he ways in whch sof t t issue inf ect ions may present .

10. Descr ibe t he clinical present at ion of an abscess and t he drainage t echnique.

11. Descr ibe cellulit is and t he t reat ment t hereof .

12. Br ief ly descr ibe t he ent it ies of discit is and t he clinical present at ion t her eof .

RESOURCES

- Acut e Pyogenic Bone And Joint I nf ect ion I n Childr en. S A Bone and Joint Surgery

Nov 1997 Vol VI I No 4 Page 24

- I nf ect ion Apleys Syst em Of Or t hopaedics And Fract ures – Chapt er 2


Self - st udy

I n preparat ion, you should please review session 2 of t his t heme on St aphylococcus aureus.

Please complet e t he assignment dur ing t his session.

Lect ure

Dur ing t his session you will learn how musculoskelet al inf ect ions may present syst emically and

locally. You will also be t old how t o dif f er ent iat e bet ween sof t t issue and bony inf ect ions as well

as how t o apply t he pr inciples in t he t r eat ment t hereof .

This 45-minut e lect ure demonst r at ion will cover clinical present at ion, r adiological evaluat ion,

appropr iat e side-room invest igat ions and t he t r eatment of acut e sept ic ar t hr it is and

ost eomyelit is.


22


SESSI ON 6: NON- PYOGENI C I NFECTI ONS OF BONE AND

JOI NTS

OUTCOMES


1. Descr ibe t he incidence and clinical present at ion of musculoskelet al Tuberculosis.

2. Explain how t o dist inguish bet ween an acut e sept ic ar t hr it is and a t uber culous ar t hr it is clinically, wit h side-r oom invest igat ions and radiologically.

3. Explain when t uber culosis of t he spinal cord would be suspect ed clinically and descr ibe t he r adiological signs t hereof .

4. Descr ibe t he nat ural course of t uber culosis of t he spinal cord, t he possible neurological complicat ions, and t he t r eatment t hereof .

5. Tabulat e t he choices of medicat ions f or t he t r eat ment of skelet al t uber culosis, as well as t he dosages and per iod of t r eat ment .

6. Explain t he guidelines used t o evaluat e t he pat ient ’s environment , as well as t o ensure cont inued medicat ion.

7. Descr ibe t he signs of drug-resist ance.

8. Name t he bursae t hat can be af f ect ed by t uberculosis. 9. Descr ibe t he present at ion and t reatment of cold abscesses.

RESOURCES

- The Challenge Of Tuber culosis Cur rent Or t hopaedics 2000 14 Page 18

- TB Ar t hr it is – Cur rent Or t hopaedics 2000 14 Page 197

- Tuber culosis – Apleys Syst em Of Or t hopaedics And Fract ur es – Page 47


Lect ure

At t he end of t his session, you should under st and t he most impor t ant aspect s wit h r egar ds t o

t he present at ion, incidence and spread of musculoskelet al t uber culosis. I t is impor t ant t hat you

know about t he clinical present at ion, r adiological int er pret at ion and t he usef ul special

invest igat ions, as well as about t he t he r ecommended t reat ment modalit ies.

This session, last ing appr oximat ely 45 minut es, will be used t o discuss t he pr esent at ion and

anat omical spread of musculoskelet al t uber culosis. Tuber culosis of t he spinal cor d and common

large j oint s will be discussed.

Please complet e t he assignment dur ing t his session.


23


SESSI ON 7: CLI NI CAL PROBLEM SOLVI NG CHRONI C

OSTEOMYELI TI S

OUTCOMES

At t he end of t hese t wo sessions, you should be able t o do t he f ollowing:

1. Tabulat e t he f act or s result ing in chronic ost eomyelit is 2. Tabulat e and r ecognise t he r adiological charact er ist ics of a chr onic ost eomyelit is.

3. Discuss t he role of ant ibiot ics in t he t r eatment of chronic ost eomyelit is.

4. Tabulat e t he complicat ions of chronic ost eomyelit is.

5. Descr ibe a Brodies abscess.

RESOURCES

- Chronic Ost eomyelit is. Apleys Syst em of Or t hopaedics and f r act ures Page 40


Self - st udy and self - assessment

The aim of t his self -st udy session is meaningf ully analyse t he clinical pr oblem of chronic

ost eomyelit is. You ar e expect ed t o be able t o make t he diagnosis, int er pret t he X-r ays

meaningf ully and know how t o t reat chronic ost eomyelit is.

Using t he r ecommended r ef er ences, you must solve t he f ollowing problem and complet e t he assignment :

A 4o-year old man present s wit h a draining sinus of t he lower leg.

1. Tabulat e t he possible causes

2. Descr ibe t he probable r adiological appearances.

3. Br ief ly discuss t he organisms r esponsible t heref or .

4. Tabulat e t he possible complicat ions

Check your answers dur ing a group discussion.

At 12.00, you should meet again in Lect ure Hall 1 t o discuss t he answers wit h t he

lect urer .


24


SESSI ON 8:

HAND I NFECTI ONS

OUTCOMES


1. Descr ibe t he clinical signs of a Paronechia and explain how t o drain t his.

2. Descr ibe t he clinical signs of a web space inf ect ion and descr ibe how t his should be

drained.

3. Descr ibe t he clinical signs of a sept ic ar t hr it is of t he hand and descr ibe how t his should

be drained.

4. Descr ibe t he clinical signs of a Tenovaginit is.

5. Tabulat e common organisms causing hand inf ect ions, as well as t he appropr iat e

ant ibiot ics and dosages.

6. Descr ibe t he local anaest het ic met hods f or drainage of hand inf ect ions.

7. Discuss t he most impor t ant aspect s in t he r ehabilit at ion of t he hand af t er an inf ect ion.

RESOURCES

- Treat ment Of Hand I nf ect ions CME Aug 1991 Vol 9 No 8 Page 978

- Hand I nf ect ions CME July 1996 Vol 14 No 7 Page 943

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


Pre- st udy

Please r eview t he anat omy of t he hand wit h specif ic r ef erence t o t he spaces and synovial

shadows. Phase I I Module The Musculoskelet al Syst em M4769 M4770

Lect ure

Af t er complet ing t his session, you should be able t o ident if y t he present at ion and localisat ion of

t he most common hand inf ect ions, and dist inguish t hese f rom each ot her . You should know t he

basic pr inciples of t r eat ment , including t he per f ormance of simple surgical procedures on a

pr imary healt h level.

This lect ur e also deals wit h t he areas of localisat ion of t he var ious hand inf ect ions. The met hods

of drainage of each inf ect ion will be discussed. You will also receive inf ormat ion on how t o

admnist er local anaest het hic.

Self - st udy

Af t er complet ing t his session, t he st udent should read t he ref erences r egarding t he basic

pr inciples of r ehabilit at ion of a hand af t er dr ainage of an inf ect ion, and t hen t abulat e t his.


25

THEME 5: APPROACH TO POLYARTHRI TI S

At t he end of t his t heme, t he st udent should have an under st anding of t he basic pr inciples used

t o make a diagnosis of t he more common rheumat ological condit ions. At t he same t ime, t hey

should have insight int o t he implicat ions of a chronic disease f or t he individual, and t he

impor t ance of paramedical int ervent ions in t hese condit ions. They should also have a knowledge

of t he concept of aut oimmune diseases and t he broad pr inciples involved in t heir diagnosis.


Session Dat e Act ivit y Tit le Lect ur er

1 09/ 02/ 2006

08:00-08:45 Lect ur e Rheumat oid Ar t hr it is D.A. Whit elaw

2 09/ 02/ 2006

09:00-09:45 Pat ient I nt er act ion Rheumat oid Ar t hr it is Pat ient Discussions

THEME 5:APPROACH TO POLYARTHRI TI S

SESSI ON 1: RHEUMATOI D ARTHRI TI S

AI M OF THE THEME

Requir ed r eading: Pr ior t o st ar t ing t his t heme, t he st udent is expect ed t o have r evised t he

f ollowing:

i) The basic mechanisms of inf lammat ion.

ii) The basic physiology of pain.

iii) The basic st ruct ure of t he j oint and it s nour ishment .

OUTCOMES

At t he end of t his t heme, t he st udent should have:

i) An underst anding of pain as a sympt om.

ii) A recognit ion of t he impor t ance of t he pat t ern of pain dur ing assessment of ar t hr it is.

iii) An abilit y t o use an algor it hmic approach.

iv) An underst anding of t he dif f er ence bet ween inf lammat or y and mechanical pain.

v) An approach t o t he pat ient wit h polyar t hr it is.

vi) A recognit ion of how rheumat oid ar t hr it is is diagnosed.

vii) I nsight int o t he impor t ance of t he development of a pat ient / doct or collaborat ion wit h t he

t reatment of chronic diseases and t he impor t ance of pat ient educat ion in t his process.


26

THEME 5:APPROACH TO POLYARTHRI TI S

SESSI ON 2: I NTERACTI VE SMALL GROUP

TRAI NI NG

Pract ical session in list ening t o pat ient s t r ained in t he t aking and giving of hist or y, and

examinat ion of t he j oint .

OUTCOMES

At t he end of t he session, t he st udent should have:

i) An approach t o impor t ant charact er ist ics in t he hist or y in or der t o dif f er ent iat e bet ween

organic and f unct ional diseases and bet ween act ive and inact ive rheumat oid ar t hr it is.

ii) An int r oduct ion t o t he impor t ant clinical charact er ist ics used t o dif f er ent iat e bet ween

act ive synovit is and pre-exist ing damage.

SELF- STUDY – PROJECT 1

I dent if y 8 quest ions which you would ask t he doct or if you suf f ered wit h RA, and t hen:

Wr it e a 1-2 A4 page br ochure t hat you can disperse t o pat ient s which would answer t hese

quest ions.

THI S PROJECT MUST BE HANDED I N BEFORE THE END OF THI S MODULE AND WI LL COUNT FOR 30% OF YOUR FI NAL MARK.

SELF- ASSESSMENT

Answer t he f ollowing quest ions

a) Give a list of 4 impor t ant sympt oms f or a pat ient wit h r heumat oid ar t hr it is.

b) Give a lost of 4 impr t ant signs in a pat ient wit h RA.

c) What percent age of pat ient s have a posit ive r heumat oid f act or?

d) Give a list of f ive ot her condit ions which may be associat ed wit h a posit ive RF.

e) What percent age of pat ient s develop erosive disease?

f ) Give a list of f our sympt oms which may be misleading dur ing t he diagnosis of RA.


27

THEME 6: APPROACH TO A PATI ENT WI TH GENERALI SED PAI N


Session Dat e Act ivit y Tit el Lect ur er

1 09/ 02/ 2006

10:00-10:45 Lect ur e

Sof t t issue Rheumat ic/

Regional pain syndr ome Dr D Whit elaw

2 09/ 02/ 2006

11:00-11:45 I nt er act ion Session Par amedical r ole in Rheumat ology D.A. Whit elaw/ Ot her

3 09/ 02/ 2006

12:00-12:45 Self -st udy


SESSI ON 1: SOFT TI SSUE/ RHEUMATI C/

REGI ONAL PAI N SYNDROME

OUTCOMES

At t he end of t his t heme, t he st udent should have t he f ollowing:

i) An approach t o a pat ient wit h generalised pain.

ii) An approach t o t he dif f erent iat ion bet ween or ganic and f unct ional sympt oms.

iii) A knowledge of t he sympt oms which do not only charact er ize f ibromyalgia but also a

number of organic condit ions. They should also have an approach t o t he dif f erent iat ion

bet ween organic and f unct ional pat hology.

iv) A broad super f icial over view of t he t heor y of t he pat hophysiology of f ibr omyalgia.

v) A super f icial under st anding of t he dif f er ence bet ween f ibr omyalgia and r egional pain

syndr ome.

vi) An approach t o t he examinat ion of t he pat ient wit h f ibr omyalgia and t he physical signs

which assist wit h t he diagnosis.

vii) An approach t o t he choice and int erpret at ion of special invest igat ions.

viii) A rat ional approach t o t reatment .

ix) An overview of t he prognosis.

x) A recognit ion f or t he impor t ance of r ehabilit at ion wit h chronic diseases.

xi) An underst anding of t he value of f amily educat ion.

xii) I nsight int o t he st resses t hat t he individual and f amily exper ience when a f amily member

suf f ers f rom a disease which result s in debilit at ion or def ormit y.


28


SESSI ON 2: PARAMEDI CAL ROLE I N

RHEUMATOLOGY

OUTCOMES

At t he end of t his session, t he st udent will have:

i) An appreciat ion f or t aking a f ull hist ory, including

• sympt oms of depression,

• psychosomat ic complaint s,

• household cir cumst ances.

ii) Recognit ion f or t he role of t he paramedical ser vices wit h r egar ds t o:

a) Treat ment of inf lammat or y diseases

b) Treat ment of sof t t issue diseases

c) Pat ient t r aining on when t o exer cise and when t o r est

d) Exercise programme

e) Appropr iat e j oint r est / use

f ) The value of t he get t ing t he f amily involved

g) Social f act or s

h) Home environment

i) Pat ient ’s abilit y and willingness t o work t oget her .

ANYTHI NG SPECI FI C TO BE DONE?

The groups f rom t he previous small gr oup session will be maint ained and st udent s will be

addressed by a Physiot her apist , Occupat ional Therapist , Social Worker and Pat ient .

Paramedical ser vices will enlight en st udent s on t he concept of r ehabilit at ion and t he necessit y

f or diminishing worsening f act ors in chr onic diseases.

Lect urers will demonst r at e t he impor t ance of splint s/ exer cise/ social int ervent ion.



SELF- ASSESSMENT

a) Descr ibe (in wr it ing) your worst f eeling in t he morning af t er a heavy par t y. I f you have

never had such a f eeling, discuss it wit h someone in your class who has had such an

exper ience.


29

b) Try t o convince yourself t hat everyt hing will wor sen f or 24 hours and t hen t r y t o convince

yourself t hat everyt hing is going ver y well. Do you t hink t hat your mood can be inf luenced

by your physical healt h?

c) Descr ibe in wr it ing t he most severe recent muscle pain t hat you have exper ienced. You will

be expect ed t o hand t his in.

d) The next t ime t hat you exer cise t o exhaust ion, t ke a warm bat h and descr ibe how your

body responded.


The groups f rom t he previous small gr oup session will be maint ained and st udent s will be

addressed by a Physiot her apist , Occupat ional Therapist , Social Worker and Pat ient .

Paramedical ser vices will enlight en st udent s on t he concept of r ehabilit at ion and t he necessit y

f or diminishing worsening f act ors in chr onic diseases.

Lect urers will demonst r at e t he impor t ance of splint s/ exer cise/ social int ervent ion.


30

THEME 7: APPROACH TO THE PATI ENT WI TH MONO/ OLI GO ARTHRI TI S

Requir ed reading work: Pat hophysiology of gout and ost eoar t hr it is.

Clinical charact er ist ics of gout and ost eoar t hr it is.


Session Dat e Act ivi t y Tit le Lect ur er

1 09/ 02/ 2006

14:00-14:45 Lect ur e The pat ient wit h mono-ar t hr it is Dr L du Plessis

2 09/ 02/ 2006

15:00-15:45 Lect ur e

Ser onegat ive Spondar t hr opat hy/

I nf ect ion and Ar t hr it is Dr M Manie

3 10/ 02/ 2006

08:00-08:45 Case st udy

4 10/ 02/ 2006

08:00-08:45 Small Gr oup I nt er act ion Rheumat ology Per sonnel


SESSI ON 1 - THE PATI ENT WI TH MONO-

ARTHRI TI S/ OLI GO ARTHRI TI S

OUTCOMES

At t he end of t his t heme, t he st udent will be able t o do t he f ollowing:

i) Dif f erent iat e bet wee acut e and chronic mono / oligo ar t hr it is

ii) Recognize t he impor t ance of age/ sex in diagnosis

iii) Recognize t he impor t ance of j oint involvement at diagnosis

Approach t he problem of degenerat ive ar t hr it is, including

a) Risk f act ors

b) Pr imary and secondary condit ions

c) Main j oint s involved

d) Treat ment , including t he impor t ance of r ehabilit at ion

e) I ndicat ions f or surgery

i Have an approach t o cr yst al ar t hr it ides, including

a) The r isk f act or s

b) Pr imary and Secondary gout

c) Phases of gout

d) Syndrome X

e) I ndicat ions f or t reatment .

ii Have a basic knowledge of t he t reatment of t hese condit ions.


31

SELF- STUDY

Read Sydenham’s descr ipt ion of acut e gout .

Visit t he Renal Transplant unit and ask t o speak wit h a pat ient wit h t ophic gout .

Visit t he "Hip Clinic" and speak wit h a pat ient t hat is wait ing f or a hip or knee replacement as a

r esult of ost eoar t hr it is.

Please ensur e t hat t he whole class does not visit t his clinic at one t ime.

Please co-ordinat e t his visis wit h t he class r epresent at ive. Not more t han 10 st udent s may be

present at any one t ime.


SESSI ON 2 – SERONEGATI VE SPONDARTHROPATHY / I NFECTI ON AND

ARTHRI TI S

OUTCOMES

At t he end of t his t heme, t he st udent will have t he f ollowing:

i) An underst anding of t he t erm ent hesit is.

ii) An underst anding of t he t erm “r eact ive ar t hr it is” and it s r elat ionship wit h “Reit er ’s

Syndrome”.

iii) Know t he impor t ance of t he abilit y of cer t ain or ganisms t o induce a chronic inf lammat ory

r esponse

iv) A super f icial under st anding of t he impor t ance of genet ic predisposit ion

v) The abilit y t o dif f erent iat e bet ween mechanical and inf lammat ory backpain

vi) A good knowledge of t he sympt oms and clinical charact er ist ics of t he f ollowing condit ions:

a) Ankylosing spondylit is, including t he impor t ance of per ipheral j oint involvement and

t he syst emic charact er ist ics.

b) The r adiological charact er ist ics t hat dif f erent iat e t his condit ion f rom degenerat ive

back disease.

c) The impor t ance of uveit is and ot her eye pat hology in seronegat ive

spondar t hropat hy.

d) React ive ar t hr it is

e) Psor iat ic ar t hropat hy and it s connect ion wit h skin disease.

f ) The AI DS vir us and t he present at ion of ar t hr it is.

vii) A super f icial knowledge of t he t r eat ment of t he above-named condit ions.


32


SESSI ON 3 – CASE STUDY

OUTCOMES

At t he end of t he lect ures on Mono-Ar t hr it is and Seronegat ive Spondar t hropat hy, t he class will

be divided up int o groups. The size of t he groups will depend on t he number of Rheumat ology

personel available. Each group will be given at least 2 cases t o st udy. The cases will include shor t

summar ies of t he pat ient s, as well as t heir sympt oms and signs. Cer t ain cr it ical inf ormat ion may

be wit hheld. Dur ing t his session t he group must ident if y what inf ormat ion has been omit t ed.

They must also draw up an algor it hm t o enable t o group t o make a diagnosis or dif f erent ial

diagnosis. Cr it ical special invest igat ions must be included.


SESSI ON 4 – SMALL GROUP I NTERACTI ON

OUTCOMES

Dur ing t his session, t he group must be prepared t o pr esent t heir f indings t o a Rheumat ologist .

This will be f ollowed by a discussion, based on t he group’s deduct ions. The last 15 t o 20 minut es

will be allocat ed t o a shor t present at ion of one of t he cases f r om each group. Dur ing t his

present at ion, t he group leader will be expect ed t o highlight t he signs used t o r each a diagnosis.


33

THEME 8: APPROACH TO THE PATI ENT WI TH NON- SPECI FI C SYSTEMI C DI SEASES


Session Dat e Act ivi t y Tit le Lect ur er

1 10/ 02/ 2006

09:00-09:45 Lect ur e

Aut o- immune diseases –

SLE as a pr ot ot ype Dr D Whit elaw

2 10/ 02/ 2006

10:00-10:45 Lect ur e

Scler oderma, dermat omyosit is,

vasculit is Dr M Manie

3 10/ 02/ 2006

11:00-11:45 Self St udy

4 10/ 02/ 2006

11:00-11:45 Case st udy Dr D Whit elaw

THEME 8: APPROACH TO THE PATI ENT WI TH NON-SPECI FI C SYSTEMI C DI SEASES

SESSI ON 1: AUTO- I MMUNE DI SEASES – SLE

AS A PROTOTYPE

OUTCOMES

At t he end of t his t heme, t he st udent should be able t o:

i) Underst and t he concept of Aut o-I mmune Diseases.

ii) Recognise t he role of sex hormones in t hese condit ions.

iii) Underst and t he impor t ance of cr it er ia and t heir r ole in diagnosis, including t heir st r engt hs

and weaknesses.

iv) Recognise t he impor t ance of dif f er ent skin rashes as markers of under lying

syst emic diseases.

v) Have an underst anding of t he wide scope of present at ion of Aut o-I mmune Diseases.

vi) Recognise t he problems associat ed wit h dif f er ent iat ing const it ut ional sympt oms f r om

organic sympt oms.

vii) Recognise key signs wit h t he diagnosis of Aut o –I mmune Diseases.

viii) Recognise t he impor t ance and limit at ions of Ser ology.

ix) Recognise t he impor t ance of hands as indicat or s of syst emic diseases.

x) Recognise t he impor t ance of ear ly r ef er r als f or t hese cases.

xi) Recognise t he warning signs of SLE f lar e-ups.


34


SESSI ON 2: SCLERODERMA,

DERMATOMYOSI TI S, VASCULI TI S

OUTCOMES

At t he end of t he t heme, t he st udent will be able t o:

i) Underst and t he f undament el basis of t his gr oup of diseases.

ii) Recognise warning skin signs f or t hese group of diseases.

iii) Recognise t he most impor t ant syst emic component s.

iv) Underst and t he impor t ance of Raynauds as a sign of syst emic diseases.

CASE DI SCUSSI ONS

The class will be divided int o small gr oups (4-6 groups). Each group will be given a number of

cases t o st udy. Cer t ain key point s in t he scenar ios will be omit t ed. Dur ing your st udy per iods, you

will be expect ed t o ident if y point s in t he hist ory and examinat ion which you regard as impor t ant

in or der t o f ully assess t he case.

When you r et urn t o t he klas, t he group will be expect ed t o present t he case wit h

• Fur t her det ails of t he hist ory,

• Cr it ical charact er ist ics dur ing t he examinat ion,

• Special diagnost ic invest igat ions t hat will be r equired in order t o make a diagnosis or

dif f er ent ial diagnosis. Lect urers will be on hand t o guide you should you r equir e assist ance.



At t he end of t he lect ures on t he pat ient wit h non-specif ic syst emic diseases, t he class will be

divided int o groups. The size of t he groups will depend on t he number of Rheumat ology personel

available. Each gr oup wil l be given at least 2 cases t o st udy. The cases will include shor t

summar ies of t he pat ient s, as well as t heir sympt oms and signs. Cer t ain cr it ical inf ormat ion may

be wit hheld. Dur ing t his session t he group must ident if y what inf ormat ion has been omit t ed.

They must also draw up an algor it hm t o enable t o gr oup t o make a diagnosis or dif f erent ial

diagnosis. Cr it ical special invest igat ions must be included.


35


SESSI ON 4: CASE STUDY

Dur ing t his session, t he group must be prepared t o pr esent t heir f indings t o a Rheumat ologist .

This will be f ollowed by a discussion, based on t he group’s deduct ions. The last 15 t o 20 minut es

will be allocat ed t o a shor t present at ion of one of t he cases f r om each group. Dur ing t his

present at ion, t he group leader will be expect ed t o highlight t he signs used t o r each a diagnosis.


36

THEME 9: OTHER TOPI CS I N RHEUMATOLOGY


Session Dat e Act ivit y Tit le Lect ur er

1 13/ 02/ 2006

08:00-08:45 Lect ur e

Paediat r ic

Rheumat ology Dr M Manie

2 13/ 02/ 2006

09:00-09:45 Lect ur e Pharmacology Pr of P vd Bij l

3 13/ 02/ 2006

10:00-10:45 Slide show Revision Dr D Whit elaw

4 13/ 02/ 2006

11:00-11:45 Slide show Assessment Dr D Whit elaw


SESSI ON 1 : PAEDI ATRI C RHEUMATOLOGY

OUTCOMES

At t he end of t hese sessions, t he st udent should be able t o underst and t he f ollowing:

i) The core signs of t he most impor t ant f orms of j uvenile ar t hr it is

ii) The cr it er ia on which t his diagnosis is based

iii) The morbidit y associat ed wit h t hese condit ions and t he impor t ance of making a diagnosis.

iv) The cr it ical clinical signs of t he dif f erent condit ions


SESSI ON 2: PHARMACOLOGY

OUTCOMES


1. Discuss t he mechanism of act ion of t he ant i- inf lammat ory, ant i-gout and

immunosuppressant drugs.

2. Explain t he pharmacological dif f erences bet ween t he above-named medicat ions.

3. Discuss t he ant i-inf lammat or y and analgesic ef f ect s of t he non-st eroidal ant i-

inf lammat or y drugs (NSAI D’s)

4. Name side ef f ect s of t he ant i-inf lammat or y, ant i-gout and immunosuppressant drugs and

explain st eps t hat can be t aken t o limit t hese unf avourable ef f ect s.


37

5. Discuss t he clinical use of ant i- inf lammat ory, ant i-gout and immunosuppressant drugs.

RESOURCES

Rang, Dale & Rit t er , Pharmacology, 4t h Ed, (1999). Chapt er 13


SESSI ON 3: SLI DE SHOW/ REVI SI ON

This session is a r evision of t he Rheumat ology sessions. Slides will be shown t o highlight t he

impor t ant point s.


SESSI ON 4: SLI DE SHOW PORTI ON OF

ASSESSMENT

Slides will be shown and one or t wo quest ions asked, based on t he lect ures. This t est will account

f or 10% of t he f inal Rheumat ology mark.


38

THEME 10: CONGENI TAL AND DEVELOPMENTAL

CONDI TI ONS OF THE MUSCULOSKELETAL SYSTEM

AI M OF THE THEME

At t he end of t his t heme, you should have a broad knowledge wit h regards t o t he nat ural course

of r ot at ion and angular anomalies of t he lower limbs as a r esult of physiological r easons in t he

growing child and you should also be able t o recognise t his present at ion clinically. You should also

be able t o ident if y pat hological anomalies and def ormit ies of t he musculoskelet al syst em, f or

example t he most common met abolic and dysplast ic which give r ise t o angular and r ot at ional

def ormit ies.

You will also learn about t he general ost eochondroses as causes of a painf ul lower limb, in

addit ion t o t heir nat ural causes. You should be able t o ident if y and t r eat normal leg pain in t he

growing child.

You should be able t o reach a dif f er ent ial diagnosis wit h regards t o a child wit h a painf ul or

limping gait .

You should be able t o recognise t he general congenit al anomalies of t he lower limbs in t he

newborn. You should also know about development al condit ions, such as Per t he' s disease and

sliding proximal f emoral epiphysis of t he hip, and t heir nat ural course.



1 13/ 02/ 2006

14:00-14:45 Lect ur e

Linear and Rot at ion Def ormit ies of t he

Lower Limbs, Leg pains

in Childr en and Ost eochondr oses

Dr J du Toit

2 13/ 02/ 2006

15:00-15:45 Lect ur e

Congenit al Club Feet , Met at ar sus Adduct us,

Cavus Feet and Flat Feet in Childr en Dr J du Toit

3 14/ 02/ 2006

08:00-08:45 Lect ur e

Congenit al Hip dysplasia, Per t hes’ Diseases

of t he Hip and Sliding

Pr ox imal Femoral Epiphysis

Dr J du Toit

4 14/ 02/ 2006

09:00-09:45 Lect ur e

Or t hopaedic Aspect s of Cer ebr al Palsy

and Neur omuscular Diseases Dr J du Toit


39

THEME 10: CONGENI TAL AND DEVELOPMENTAL CONDI TI ONS OF THE MUSCULOSKELETAL SYSTEM

SESSI ON 1: LI NEAR AND ROTATI ON DEFORMI TI ES OF

THE LOWER LI MBS, LEG PAI NS I N CHI LDREN

AND OSTEOCHONDROSES

OUTCOMES


1. Descr ibe / r ecognize / accurat ely document linear and r ot at ional def ormit ies of t he lower

limbs in children, and explain how t hese can be dist inguished f r om met abolic and dysplast ic

condit ions.

2. Give t he diagnost ic cr it er ia f or Blount ‘s disease (t ibia var a) and descr ibe t he nat ural

cour se t hereof .

3. Descr ibe t he clinical char act er ist ics of r icket s and t abulat e t he radiological pr esent at ion

t hereof .

4. Explain how t he diagnosis of ost eochondr osis can be made in t he growing child, name t he

dif f er ent sit es as well as t he ages in which it may present .

5. Compare t he charact er ist ics of normal and pat hological leg pain, and explain what is meant

by r ef er red leg pain.

RESOURCES

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

2. The Ost eochondroses – Apleys Syst em Of Or t hopaedics And Fract ures Page 103

3. J ournal Of Amer ican Family Physicians Ost eochondr it is Desicans, J an 1, 2000 Page 151


Lect ure

Dur ing t his session t her e will be a lect ure demonst r at ion (40 minut es) discussing r ot at ional and

linear def ormit ies of t he lower limbs, as well as t heir nat ural course and t heir dist inct ion f r om

pat hological condit ions. Leg pains in childr en will be discussed.

Pre- st udy

Read up on ost eochondroses of t he lower limb, and, dur ing t he last 10 minut es of t he lect ure,

complet e t he assignment provided t o your af t er consult at ion wit h t he lect urer .


40


SESSI ON 2: CONGENI TAL CLUB FEET, METATARSUS

ADDUCTUS, CAVUS FEET AND FLAT FEET I N

CHI LDREN

OUTCOMES


1. Descr ibe t he clinical charact er ist ics and pr inciples of t r eat ment of congenit al clubf eet ,

and be able t o discuss t he f unct ional and cosmet ic prognosis wit h t he parent s.

2. Descr ibe t he clinical present at ion of a met at arsus adduct us and t he be able t o name t he

dif f er ent iat ing f eat ur es f r om a club f oot .

3. Wr it e down t he inst r uct ions f or t he mot her on how t o manipulat e clubf eet as well as a

met at ar sus adduct us.

4. Descr ibe t he clinical element s of a f lat f oot , t abulat e t he most impor t ant causes and

descr ibe how t o clinically dist inguish bet ween a r igid and a mobile f lat f oot .

5. Name aids t hat can be ut ilised f or t he t r eatment of f lat f eet .

6. Descr ibe t he clinical element s of a cavus f oot and t abulat e t he ot her condit ions wit h which

cavus f eet can be associat ed.

RESOURCES

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

2. Def ormit ies Of The Foot – Apleys Syst em Of Or t hopaedics And Fract ures Page 473

3. Clinical Or t hopaedic Examinat ion – McRae Page 264


Lect ure

The obj ect ive of t his session is t o enable you t o recognize, ident if y and dist inguish bet ween t he

general f oot anomalies occur r ing in children.

Dur ing t his session, t here will be a 40-minut e lect ure demonst rat ion. The dist inct ion bet ween

clubf eet and met at arsus adduct us will be discussed. Flat f eet in t he child will be discussed wit h

r ef erence t o t he causes at dif f erent ages, as well as t he nat ur al progr ession. Cavus f eet will also

be discussed.

Self st udy assignment

Af t er t his lect ur e, you will be expect ed t o r esearch and t abulat e t he most common neurological

causes of Cavus f eet .


41


SESSI ON 3: CONGENI TAL HI P DYSPLASI A, PERTHES’ DI SEASES OF THE HI P AND SLI DI NG

PROXI MAL FEMORAL EPI PHYSI S

OUTCOMES


1. Tabulat e t he most impor t ant charact er ist ics of t he high r isk baby f or a congenit al hip

dislocat ion, and descr ibe and explain t he clinical invest igat ions as applicable t o var ious age

groups.

2. Tabulat e t he t reatment modalit ies and explain t he applicat ion t hereof .

3. Wr it e down t he r adiological charact er ist ics of a congenit ally dislocat ed hip and r ecognise

t he t his condit ion on xray.

4. Def ine t he ent it y of a t r ansit or y synovit is, and explain t he causes and nat ural cour se.

5. Def ine Per t he’s disease, descr ibe t he clinical present at ion and t abulat e and t he

r adiological signs.

6. Descr ibe t he t r eat ment modalit ies as well as t he nat ural cour se of t he condit ion.

7. Def ine a sliding pr oximal f emor al epiphysis, descr ibe t he clinical present at ion, t abulat e t he

r adiological signs and recognise t his condit ion on xray.

8. Descr ibe t he t r eat ment of a sliding proximal f emoral epiphysis.

9. Def ine t he ent it y of idiopat hic chondrolysis and br ief ly descr ibe t he nat ural cour se

t hereof .

RESOURCES

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

- J ournal Of Amer ican Family Physician, Evaluat ion Of Acut e Limping Child, Feb 15, 2000

- J ournal Of Amer ican Family Physicians, Slipped Capit al Femoral Epiphysis, May 1, 1998,

Page 1231


Preparat ion

Ref er t o "The Limping Child."

Lect ure

The obj ect ive of t his session is t o highlight t he common congenit al and development al condit ions

of t he hip in t he growing kind, f r om bir t h t o adolescence.

You should be able t o descr ibe t he clinical diagnosis a congenit al hip disclodat ion in t he neonat e.


42

You will be int roduced t o development al condit ions of t he hip peculiar t o children, f or example

Per t he' s disease and sliding proximal f emoral epiphysis, t heir present at ion, t he age of

dist r ibut ion, as well as t he modalit ies of examinat ion applicable in t hese cases.

Dur ing t his session, t here will be a 40-minut e lect ure demonst rat ion wherein t he aet iology,

diagnosis and t r eat ment of hip dysplasia will be discussed. The appear ance, clinical present at ion,

nat ural course and complicat ions of Per t he’s disease of t he hip, as well as slipped proximal

f emoral epiphyses will also be discussed.

The last 10-minut es will be spent on t he complet ion of an assignment on t he dif f erent ial

diagnosis of hip pain in t he growing child f r om bir t h t o adolescence.


SESSI ON 4:

ORTHOPAEDI C ASPECTS OF CEREBRAL PALSY AND NEUROMUSCULAR DI SEASES

OUTCOMES


1. Tabulat e t he dif f erent t ypes of cerebral palsy and descr ibe t heir f unct ional proper t ies.

2. Name t he causes of cont ract ures and def ormit ies and br ief ly descr ibe t he f unct ional

abilit ies t hereof .

3. Tabulat e t he possible t herapeut ic modalit ies f or f or cer ebral palsy and br ief ly descr ibe

t he applicat ions of each.

4. Descr ibe t he f unct ional proper t ies of spina bif ida and myelomeningocoele.

5. Name t he sensory implicat ions of spina bif ida and myelomeningocoele and explain t he

mot or implicat ions f or t he lower limbs.

6. Tabulat e t he musculoskelet al implicat ions of poliomyelit is, congent ial mult iplex

ar t hrogr yposis and Duchenne’s muscular dyst r ophy.

RESOURCES

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

2. Neuromuscular Disorder s – Apleys Syst em Of Or t hopaedics And Fract ures Chapt er 10

Page 192

3. Or t hopaedic Surgery I n Cerebral Palsy: Assessment Treatment And Management ,

WS342ORT, US Library


Dur ing t his session, you will be inf ormed of t he or t hopaedic aspect s of gener al neuromuscular

disease condit ions in t he growing child, as well as t he t r eat ment modalit ies t hat are applied t o


43

improve locomot or abilit ies and prevent back and limb def ormit ies. You must have suf f icient

insight t o inf orm parent s of t hese condit ions.

Pre- st udy

1 Please r eview t he assignment of muscle power and spast icit y grading. Sessions 2 & 3,

Theme 2.

2 Bef ore commencing t his lect ure, you should r eview t he dif f erences bet ween an upper and

lower mot or neuron lesion. Ref er t o sessions 2 & 3, Theme 2.

You will be expect ed t o give f eedback dur ing t his session.

Feedback

10 minut e f eedback on Sessions 2 and 3.

Lect ure

This lect ure demonst rat ion deals wit h t he clinical evaluat ion of t he locomot or syst em in cerebral

palsy. The f unct ional abilit ies and nat ural course will also be discussed. The t herapeut ic

modalit ies t o cont r ol of muscle spast icit y will also be discussed. You should t abulat e t hese

modalit ies and make necessary annot at ions. The impor t ant musculoskelet al aspect s of t he less

common neuromuscular condit ions will also be discussed.


44

THEME 11: ONCOLOGI CAL CONDI TI ONS OF THE


AI M OF THE THEME

At t he end of t his t heme, you should know t he pr inciples per t aining t o t he classif icat ion,

mor phological spect rum, clinicopat hological impor t ance and diagnosis of t umours and t umour like

condit ions of t he skelet on and sof t t issues.



1 14/ 02/ 2006

10:00-10:45 Lect ur e General Pat hological Pr inciples Pr of J Schneider

2 14/ 02/ 2006

11:00-11:45 Lect ur e Pr imar y And Secondar y Bone t umour s Dr I Rober t son

3 14/ 02/ 2006

12:00-12:45 Lect ur e Sof t Tissue Tumour s Pr of J Apf f elst eadt

THEME 11: ONCOLOGI CAL CONDI TI ONS OF THE MUSCULOSKELETAL SYSTEM

SESSI ON 1: GENERAL PATHOLOGI CAL

PRI NCI PLES

OUTCOMES

At t he end of t his session, you should be able t o:

1. Give a basic classif icat ion of skelet al and sof t t issue t umours.

2. Discuss t he most impor t ant morphological charact er ist ics and clinicopat hological

impor t ance of t he common benign and malignant bone t umours wit h r ef erence t o t he age

and sexual dist r ibut ion t hereof , pref erent ial anat omical posit ions of dif f er ent t umours,

and t heir biological behaviour and prognosis.

3. Discuss t he pat hology of met ast at ic t umours t o bone.

4. Explain t he concept of clinical-pat hological-r adiological cor relat ion in t he diagnosis of

bone t umours.

5. Br ief ly discuss t he more common t umour -like condit ions of bone and sof t t issue, including

f ibr ous dysplasia, f ibromat osis, nodular f asciit is and myosit ic ossif icans.


45

RESOURCES

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

- Make supplement ary not es dur ing cont act sessions

- Class not es

- Examples of specimens t hat you can st udy in your own t ime will be made available. The

locat ion will be given t o you. A list of cases is at t aced at t he end of t his t heme.

- Comput er -assist ed guidance: This websit e of f er s numerous examples, illust rat ions and

t ut or ials which you will be able t o access elsewhere.

ht t p/ / medst at .med.ut ah.edu/ WebPat h/ html# MENU <Organ Syst em Pat hology> <Bone and Joint

Pat hology>


Revision

I t is impor t ant t hat you review t he pr inciples of carcinogenesis and neoplasia in order t o have a

good underst anding of t umour nomenclat ure, t he dif f erences bet ween benign and malignant

neoplasia, t umour dif f erent iat ion, and gr ading and st aging. Review car cinogenesis and r ef er

especially t o t he pr inciples of car cinogensis, neplast ic t r ansf ormat ion of cells, and host f act ors

t hat play a r ole in neoplasia. Take not e of t he specif ic aspect s t hat are impor t ant wit h r egards

t o t umours of bone and sof t t issue. Ensure t hat you r eview t he concept of par aneoplast ic

syndrome and t he clinical impor t ance of local and syst emic consequences of t umours (ref er again

t o Phase I I module: Basis of Disease Processes; Theme 21).

Lect ure

1. Read pages 798 t o 802, and 825 t o 827 in Underwood bef ore at t ending t he lect ure. You

will benef it great ly by reviewing pages 246 t o 258, and 284 t o 290; pay at t ent ion t o t he

illust rat ions and t ables. Dur ing t he lect ure, t he lect urer will explain t he t heory

under lying t he out comes, and provide illust rat ions and appropr iat e guidelines f or f ur t her

st udy.

2. Make supplement ar y not es t o your t ext book and class not es.

3. The lect ure is available at t he f ollowing web address:

ht t p:/ / www.sun.ac.za/ healt hsciences/ schools/ basic_appl_healt h/ anat _pat h/ ppt / ppt .html

Assignment s f or f ur t her dir ect ed self - st udy

Answer t he f ollowing quest ions dur ing your self -st udy:

1. Classif y t umours of t he skelet on and sof t t issue. Ensure t hat you have a logical appr oach

wit h r espect t o t he pr inciples of t umour nomenclat ure. Page 799 in Underwood. 2. Discuss t he most impor t ant morphological charact er ist ics and clnicopat hological

impor t ance of t he more common benign and malignant bone t umours, and ref er t o t he impor t ance of age, sex, and anat omical posit ion in t he dif f er ent iat ion of t he var ious

t umours.

3. Discuss t he prognost ic impor t ance of t he most impor t ant skelet al t umours.


46

4. Discuss met ast at ic t umours t o bone and highlight t he common t umours which are prone

t o develop skelet al met ast ases.

5. Explain t he impor t ance of clinical-pat hological-r adiological cor r elat ion in t he diagnosis of

bone t umours. Ref er t o ost eosarcoma and giant cell t umour of bone t o illust r at e your

answer .

6. Explain t he diagnost ic value and dangers of biopsies of bone t umours. Ref er t o t he role

of a gener al medical pract it ioner in t he diagnosis of bone t umours.

Take not e t hat t he f ollowing examples of skelet al and sof t t issue pat hology ar e

available f or st udy purposes. The locat ion will be made known t o you. This oppor t unit y is

available f or assist ance but will not f orm par t of your assessment . You are encour aged

ao f or mulat e quest ions and direct t hese t o Prof Schneider at j ws2@sun. ac. za

* AU23, AU24, AU32 :Ost eosarcoma

* AU30 :Neoplast ic giant cell t umour of bone

* AU27 :Skull met ast ases

* AU28 :Carcinoma met ast ases (f emur )

* AU26 :Ver t ebrae - sar coma met ast ases

* AU22 :Ver t ebrae - met ast ases

* AU29 :Tibia - f ibrosar coma

* AU43 :Synovial sar coma (hand)

* AU3 :Hand - synovial sarcoma

* JU41 :Ver t ebra, kidney and spleen -myelomat osis

* JW2 :Femur - acut e leukaemia

* AU25 :Ver t ebrae - lymphoma

Wet specimens

* SD1845-6/ 81, 14452/ 89, - Ost eosar coma

* SD8164/ 86, 1298/ 90, 4536/ 90 - Ost eosar coma

* SD2121-24/ 89, 10278/ 90 - Ost eosar coma

* PM94/ 90 - Ost eosar coma wit h lung met ast ases

* SD5403/ 89 - Angiosarcoma

* SD4174/ 88 - Leiomyosar cma


SESSI ON 2:

PRI MARY AND SECONDARY BONE TUMOURS

OUTCOMES


1. Recognize and t abulat e t he r adiological charact er ist ics of benign and malignant bone lesions.

2. Tabulat e t he spread of common benign bone lesions.


47

3. Tabulat e t he age of present at ion and localisat on of pr imary bone t umours.

4. Name t he most common benign bone t umours, as well as t heir localisat ion and nat ural

cour se.

5. Make a r adiological diagnosis of met ast at ic bone t umours and t abulat e t he t umours which

commonly met ast asize t o bone.

6. Def ine pat hological f r act ures and descr ibe t he t r eat ment t hereof .

7. Know t he supplement ary special invest igat ions used t o st age t umours.

8. Descr ibe t he most impor t ant aspect s per t aining t o biopsies of bone lesions.

9. Descr ibe t he applicat on of t he var ious t r eatment of pr imary bone t umours.

10. Know t he pr ognosis of dif f erent t umours and be able t o inf orm t he pat ient t hereof .

RESOURCES

Syst em of Or t hopaedics and Fr act ures A. Gr aham Appley – But t erwor t hs Chapt er 9 Page 162

Journal of Amer ican f amily Physicians, Pigment al villonodular synovit is, Aug 1, 1999, Page 1909


Dur ing t his session, t he clinical and radiological aspect s of t he common pr imary and secondary

t umours of bone and j oint s will be covered. You should be aware if t he incidence, present at ion

and dist r ibut ion of t hese t umours, as well as r ealize t he impor t ance of age and localisat ion in t he

dif f erent iat ion. You should be able t o dif f er ent iat e bet ween pr imary and secondary bone

t umours, as well as bet ween benign and malignant bone t umours.

The acit ivit ies of Session 3 include 2 clinical problems t o solve.

45 minut e lect ur e demonst rat ion

45 minut e self -st udy

Self - st udy

Four clinical problems will be present ed f or discussion. You will be expect ed t o discuss and solve

each problem t oget her dur ing t he session wit h t he assist anc of your lect urer and t abulat e t he

approach wit h ref erence t o t he relevant clinical hist ory, appropr iat e xr ays and special

invest igat ions. A dif f erent ial diagnosis and t herapeut ic guidelines must be r eached.

Lect ure

The lect ure will include t he f ollowing impor t ant clinical problems:

1. Common benign bone t umours

2. Common malignant bone and j oint t umours. Emphasis should be placed on t he age of

pr esent at ion.

3. Recommendat ions should be made t o st age a t umour wit h t he assist ance of special

invest igat ions.

4. Discuss t he t reatment of benign t umours.

5. Emphasis will be placed on met ast at ic diseases of t he bony skelet on and met ast at ic

t umours. Occult met ast ases will be discussed as well as t he diagnosis t hereof .


48

The role of prophylact ic int ernal f ixat ion will be discussed.


SESSI ON 3:

SOFT TI SSUE TUMOURS

OUTCOMES

At t he end of t he session you should be able t o:

1. Descr ibe t he pat hological char act er ist ics of t he common sof t t issue t umours.

2. Descr ibe t he clinical present at ion.

3. Tabulat e t he most impor t ant diagnost ic invest igat ions.

4. Discuss t he basic guidelines f or t he most impor t ant t r eat ment modalit ies.

5. Descr ibe t he prognosis and course of t he most impor t ant t umours.

RESOURCES

1. Preparat ory r eading – Hohn DC: Sof t Tissue Sar comas, in: Way LW (Ed): Cur rent Surgical

Diagnosis and t reatment ; 10t h ed., Pages 1253 – 1256

2. Pat hology – MacSween, Whaley K (Eds): sof t Tissue Tumors and Tumor -like Lesions in:

Muir ’s Text book of Pat hology, 13t h edit ion, Pages 1001 – 1009

3. Fur t her Reading – Eber lein TJ : Sof t -Tissue Sar comas. Surg Clin Norh Am. 2000

Apr ; 80(2): 687 – 708.


Lect ur e

This session will be usef ul in learning t o suspect sof t t issue t umours of t he musculoskelet al

syst em as well as f ormulat ing a r ef er ence f r amework.

This session will discuss t he approach t o a pat ient t hat pr esent s wit h a sof t t issue mass of t he

musculoskelet al syst em. The appropr iat e special invest igat ions will be discussed, as well as t he

r elevant pat hology. You will also be inf ormed of t he var ious t herapeut ic modalit ies. The specif ic

t umours t hat will be discussed are aggressive f ibr omat osis, lipoma and liposar coma, f ibr osarcoma

and var iant s, as well as synovial sarcoma.


49

THEME 12: CONDI TI ONS OF THE PELVI S AND SPI NAL COLUMN

AI M OF THE THEME

This t heme will cover t he examinat ion met hods r elevant t o t he spinal column and pelvis which are

appplicable t o disease condit ions of t is area. You will be inst ruct ed on how t o evaluat e a pat ient

wit h neck or backpain in order t o r each a diagnosis and t o f ormulat e a t herapeut ic plan. The f ir st

t wo sessions deal wit h general def ormit ies of t he t hr oacolumbar ver t ebr ae in childr en, namely

post ural, scoliosis and kyphosis. The causes and nat ur al cour se will be discussed. You will also be

inst ruct ed on ow t o dif f er ent iat e bet ween backpain in childr en.



1 15/ 02/ 2006

08:00-08:45 Lect ur e Scoliosis and Kyphosis Pr of G Vlok

2 15/ 02/ 2006

09:00-09:45 Lect ur e Neck pain and Backpain in Adult s Pr of G Vlok


SESSI ON 1:

SCOLI OSI S AND KYPHOSI S

OUTCOMES


1. Def ine and t abulat e t he clinical charact er ist ics of scoliosis and kyphosis of t he spinal

cor d.

2. Discuss t he neurological examinat ion of a back pat ient .

3. Tabulat e t he causes of a kyphosis.

4. Tabulat e t he causes of scoliosis and def ine an idiopat hic scoliosis.

5. Tabulat e t he dif f erence bet ween a st ruct ural and f unct ional scoliosis.

6. Discuss t he nat ural progression of scoliosis and know t he ref erence guidelines f or

t r eat ment .

7. Be able t o inf orm t he parent s of t he condit ion of scoliosis and be able t o discuss possible t her apeut ic opt ions.

8. Tabulat e t he possibilit ies t hat can give r ise t o back pain in children.


50

RESOURCES

1. Scheuermanns Disease And Post ural Kyphosis. SA Bone & Joint Surgery. Vol VI I I , No 3,

Aug 1998, Page 48.

2. Assessing St ruct ural Scoliosis. Modern Medicine. (Pract ical Pr ocedure) Vol 22, No 9, Sept

1997, Page 58.

3. Concise Syst em Of Or t hopaedics And Fract ures, Chapt er 18. Page 157. A Graham Apley/

L Solomon.

4. J ournal Of Amer ican Family Physicians, Managing Ost eomyelit is Adolescent I diopat hic

Scoliosis, July 1, 2001


Lect ure

Dur ing t his session, a lect ure will be pr esent ed on how t o make a clinical and r adiological

diagnosis of scoliosis or kyphosis of t he t horacolumbar ver t ebr ae. The causes t hereof at

dif f erent ages will also be discussed. The t herapeut ic modalit ies f or t hese condit ions will be

discussed and t he role of t he general pract it ioner highlight ed.

Backpain in childr en is unusual and t he causes will be discussed, as well as t he ways of

present at ion.

Self - st udy

The schoolt eacher ref ers a gir l wit h a poor post ur e t o your pract ice. Discuss your evaluat ion

and t abulat e t he possible causes. The class will divide int o smaller groups t o discuss t his

assignment .

You ar e expect ed t o give a br ief f eedback dur ing session 2.


SESSI ON 2: NECK PAI N AND BACK PAI N I N ADULTS

OUTCOMES


1. I dent if y r ef er r ed pain f rom t he neck.

2. Evaluat e t he ext ent of movement of t he neck and muscle spasm.

3. Tabulat e t he most impor t ant causes of Tor t icollis.

4. Make t he diagnosis of cer vical and lumbar spondylosis and pr opose t he appropr iat e

t r eatment t hereof .

5. Make t he diagnosis of cervical and lumbar disc lesion, and know t he indicat ions f or

surger y.

6. Discuss t he inf ect ive condit ions t hat may involve t he neck and lumbar ver t ebrae.


51

7. Discuss t he neoplast ic condit ions t hat may af f ect t he neck and lumbar ver t ebrae.

8. Know t he role of neck and lumbar braces and physiot herapy in t he t reatment of neck and

back condit ions.

RESOURCES

1. Concise Syst em Of Or t hopaedics And Fract ures/ A Graham Apley/ L Solomons, Chapt er 17,

Page 150

2. Clinical Or t hopaedic Examinat ion – McRae

3. J ournal Of Amer ican Family Physicians, Cer vical Spine X-r ay, Jan 15, 1999 Page 331


Revision

Please r evise t he examinat ion of t he neck and back bef ore at t ending t he session. (Theme 2

Session 3)

RESOURCES

- Concise Syst em Of Or t hopaedics And Fr act ur es. Chapt er 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 Algor it hmic Approach – Modern Medicine Vol 25, No. 6, June 1999,

Page 39

- J ournal Of Amer ican Family Physicians, Lumbar Spine St enosis, Apr 15, 1998, Page 1825

- J ournal Of Amer ican Family Physicians, Backache Diagnosis OA, March 15, 2000 Page 1795

- J ournal Of Amer ican Family Physicians, Management Of Acut e Lower Backache, Mar ch 15,

2000 Page 1779

- Backache: Causes And Prevent ion, WE720BAC, US Library

- J ournal Of Amer ican Family Physicians, Evaluat ion And Treatment Of Herniat ed Lumbar

Disc, Feb 1, 1999

- Backache – I an McNab

Rat ional invest igat ing Updat e June 2000 Page 35

Self - st udy

Please read up on back pain in t he workplace. Ref erences:

1. Concise Syst em Of Or t hopaedics And Fr act ur es

2. Not es: Prof GJ Vlok

3. Backache: I an Macnab


52

THEME 13: CONDI TI ONS AND DEFORMI TI ES OF THE UPPER

LI MB

AI M OF THE THEME

The aim of t hese t wo sessions is t o make you aware of t he clinical signs of a br achial plexus, as

well as t he ext ent and prognosis of t he inj ury and t o ensure t hat you ar e able t o r elay t his t o

t he pat ient . You will also be inst r uct ed on clinical examinat ion met hods of t he shoulder gir dle

and how t o apply t his in or der t o dist ingish bet ween r ot at or cuf f lesions, pr essure condit ions,

inst abilit y and ar t hr it is.

This t heme will also assist you in applying t he clinical examinat ion met hods per t aining t o t he

upper limb in order t o ident if y disease condit ions and def ormit ies and t hus make a diagnosis and

f ormulat e a t her apeut ic plan.



1 15/ 02/ 2006

10:00-10:45 Lect ur e

Neur ological Evaluat ion of

t he Upper Limb Dr S Pr et or ius

2 15/ 02/ 2006

10:00-10:45 Self -st udy The Br achial Plexus Dr S Pr et or ius

3 15/ 02/ 2006

11:00-11:45 Lect ur e

Degener at ive Ar t hr it is,

Rot at or cuf f lesions and I nst abi lit y

of t he Shoulder girdle

Dr S Pr et or ius

4 15/ 02/ 2006

11:00-11:45 Lect ur e

Epicondylit is and Ar t hr it is of t he Elbow j oint

Swellings om t he Wr ist ,

De Quer vain Synovit is Kienbock

se Diseases And Ar t hr it is of t he Wr ist j oint

Dr S Pr et or ius

5 15/ 02/ 2006

12:00-12:45 Lect ur e Rheumat oid Ar t hr it is of t he Hand Dr S Pr et or ius

6 15/ 02/ 2006

12:00-12:45 Lect ur es

Car pal Tunnel syndrome, Condit ions and

Def ormit ies of t he Hand Dr S Pr et or ius


53

THEME 13: CONDI TI ONS AND DEFORMI TI ES OF THE UPPER LI MB

SESSI ON 1: NEUROLOGI CAL EVALUATI ON OF THE UPPER

LI MB

OUTCOMES

At t he end of t his session, you should know:

1. The sensory and mot or dermat ome and myot ome pat t erns of t he upper limb.

2. The ref lex pat hways.

3. The clinical signs of a r adiculopat hy.

4. The clinical signs of an upper and lower r adial median and ulnar ner ve inj ury.

5. The impor t ance and per f ormance of t he t inel t est .

RESOURCES

- Modern Medicine Assessment Of Nerve Root Funct ion I n The Upper & Lower Limb

(Pract ical procedures) Vol 24, No 1, Jan 1999, Page 21.

- Apleys Syst em Of Or t hopaedics And Fract ures, Per ipheral Nerve I nj ur ies. Chapt er I I ,

Page 221

- Clinical Or t hopaedic Examinat ion – McRae Page 10


SESSI ON 2:

THE BRACHI AL PLEXUS - SELF- STUDY

OUTCOMES

At t he end of t his session, you should be able t o do t he f ollowing

1. Tabulat e t he causes of a brachial plexus lesion.

2. Sket ch t he anat omy of t he brachial plexus.

3. Clinically localise t he level of a brachial plexus lesion.

RESOURCES

- Modern Medicine Assessment Of Nerve Root Funct ion I n The Upper & Lower Limb

(Pract ical procedures) Vol 24, No 1, Jan 1999, Page 21

- Apleys Syst em Of Or t hopaedics And Fract ures, Per ipheral Nerve I nj ur ies. Chapt er I I ,

Page 221

- Clinical Or t hopaedic Examinat ion – McRae Page 10


54


Self - st udy

Bef ore st ar t ing t his session, you should r eview your knowledge on t he f unct ional anat omy of t he

upper limb, as well as t he brachial plexus. You should know t he or igin and inser t ion, as well as t he

f unct ions, of t he impor t ant muscle groups. You should also r evise t he ner ve supply of t he upper

limb. Ref er t o Phase I I module The Musculoskelet al Syst em Theme 5, Sessions 2, 3, 4, 5 and 6.

This self -st udy per iod is devot ed t o t he complet ion of t he schemat ic present at ion of t he

brachial plexus t hat will be handed out t o you.

You must r ef er t o Greens Hand Sur ger y t ext book in order t o t abulat e t he causes of a brachial

plexus lesion and t o dist inguish bet ween a high and a low brachial plexus lesion and t he f unct ional

implicat ions t her eof .

Last ly, you should t abulat e t he special invest igat ions t hat may be helpf ul in assessing t he

prognosis of t he lesion.

Please complet e t he assignment .


SESSI ON 3: DEGENERATI VE ARTHRI TI S, ROTATOR CUFF

LESI ONS AND I NSTABI LI TY OF THE SHOULDER GI RDLE

OUTCOMES


1. Tabulat e t he causes of ref er r ed pain t o t he shoulder j oint .

2. Descr ibe t he charact er ist ics and localisat ion of shoulder pain.

3. Recognise rot at or cuf f lesions wit h r ef erence t o a diagnost ic and t herapeut ic approach.

4. Discuss shoulder inst abilit y.

5. Def ine and discuss adhesive capsulit is.


Pre- st udy

The Shoulder , Clinical Or t hopaedic Examinat ion – Mc Rae, Chapt er 4, Page 41

The last 10 minut es of t his session will be devot ed t o t he complet ion of an assignment of t he

area of local inf ilt r at ion f or t he management of shoulder problems.


55

Lect ur e

This lect ure deals wit h t he approach t o t he pat ient wit h a painf ul shoulder , and discusses t he

sof t t issue condit ions peculiar t o t he shoulder j oint and t he clinical and r adiological dist inct ion

t her eof .

The nat ural cour se and out come of each condit ion will also be discussed.

RESOURCES

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

- I nt r act ble Shoulder Pain – Updat e Feb 2000, Page 36

- Tackling Painf ul Shoulder Pr oblems - Updat e Aug 1998, Page 41

- Physical Examinat ion 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 Syst em Of Or t hopaedics And Fract ur es, Chapt er 13, Page 261

- Shoulder Problems: A Guide To Common Disorder s CME (Cover St ory) Vol 25, No. 8,

Aug 2000, Page 14

- J ournal Of Amer ican Family Physicians, Painf ul Shoulder Par t 1, Mar ch 15, 2000, Page

3079

- J ournal Of Amer ican Family Physicians, Painf ul Shoulder Par t I I , June 1, 2000, p. 3291

- J ournal Of Amer ican Family Physicians, Shoulder I mpingement And Rot at or Cuf f Tears,

Feb 15, 1998, Page 667

- J ournal Of Amer ican Family Physicians, Shoulder I nst abilit y I n Young At hlet es, May 15,

1999


SESSI ON 4: EPI CONDYLI TI S AND ARTHRI TI S OF THE

ELBOW JOI NT, SWELLI NGS AROUND THE WRI ST, DE QUERVAI N SYNOVI TI S,

KI ENBOCK’S DI SEASE AND ARTHRI TI S OF

THE WRI ST JOI NT

OUTCOMES


1. Tabulat e t he causes of ref er r ed pain t o t he elbow j oint .

2. Tabulat e pressure neuropat hies of t he elbow and discuss t he t reatment and nat ural course

t hereof .


56

3. Explain t he ent it ies of medial and lat eral epicondylit is, and discuss t he causes and

t reatment t hereof .

4. Tabulat e t he causes of an olecranon bursit is and discuss t he clinical present at ion and

t reatment t hereof .

5. Discuss t he use of local cor t icost eroid inj ect ions int o t he elbow.

6. Def ine a ganglion of t he wr ist j oint and explain t he dif f er ent iat ion f r om ot her swellings of

t he wr ist j oint .

7. Def ine and discuss De Quervain’s t enosinovit is.

8. Def ine and br ief ly discuss Kienbock’s disease.

9. Def ine car pal inst abilit y and discuss t he implicat ions t her eof .

10. Explain t he implicat ions of ost eoar t hr it is of t he wr ist j oint .


This session will assist you in making a dif f er ent ial diagnosis f or a pat ient present ing wit h a

painf ul elbow. You will also be able t o dif f erent iat e bet ween int r a-ar t icular and ext ra-ar t icular

pat hology and r ef er red pain t o t he elbow.

Pre- st udy

Preparat or y st udies include r evision of t he f unct ional anat omy of t he elbow, as well as t he

cont ent s of t he f lexor and ext ensor compar t ment s of t he f orearm. Phase I I module The

Musculoskelet al Syst em M4795 and Theme 5 Sessions 4 and 5.


The aim of t his session is t o enable you t o evaluat e a painf ul wr ist . You will be inst ruct ed on how

t o dif f erent iat e bet ween int r a-ar t icular causes of pain and sur r ounding t enosinovit is and

pressure syndromes. You will also be able t o recognise def ormit ies of t he wr ist j oint , as well as

limit ed movement t hereof , and t o couple t his t o a diagnosis.

Pre- st udy

You must r eview t he examinat ion of t he wr ist – Theme 2 of t his module. You must also r evise t he

f unct ional anat omy of t he wr ist j oint – t he course of t he t endons t hrough t he wr ist , and also t he

wr ist bones – r ef er t o Phase I I module The Musculoskelet al Syst em.

Lect ur e

This lect ure deals wit h t he approach and dif f erent ial diagnosis of an pat ient wit h a painf ul wr ist .

The ent it y of ganglions and swellings will be discussed, as well as t heir dif f er ent iat ion. The

diagnosis and t reat ment of ost eoar t hr it is of t he wr ist will be discussed. You will also learn about

Kienböck’s disease and t he implicat ions t hereof .


57

RESOURCES

Elbow pain: CME March 1991 Vol 9 Nol 3 Page285

- Clinical Or t hopaedic Examinat ion: Mcrae – The Elbow, Chapt er 5, Page 61

- Apleys Syst em Of Or t hopaedics And Fract ur es – The Elbow, Chapt er 14, Page 286

- J ournal Of Amer ican Family Physicians, Evaluat ion Of Overview Elbow I nj ur ies, Feb 1,

2000

- The Painf ul Hand And Wr ist . CME March 1991 Vol. 9, No. 3 Page 300

- Apleys Syst em Of Or t hopaedic And Fract ures: The Wr ist – Chapt er 15, Page 296

- Clinical Or t hopaedic Examinat ion: The Wr ist – Chapt er 6, Page 77


SESSI ON 5:

RHEUMATOI D ARTHRI TI S OF THE HAND

OUTCOMES


1. Discuss t he charact er ist ic pat t ern of wr ist involvement .

2. Descr ibe t he charact er ist ic def ormit ies of t he wr ist and hand and explain t he causes

t hereof .

3. Discuss t he sof t t issue and t endon involvement of t he wr ist and t he hand.

4. Explain t he basic pr inciple in t he t r eatment of a rheumat oid wr ist and hand.

RESOURCES

- Apleys Syst em Of Orht opaedics And Fract ur es. Chapt er 3 And Chapt er 16


The aim of t his session is t o ensure t hat you become aware of t he ext ent t o which r heumat oid

ar t hr it is may af f ect t he wr ist and hand j oint s. You will be able t o r ecognise t he char act er ist ic

def ormit ies of t he hand and wr ist , and discuss t he nat ural course and t r eatment .

Self - st udy

Dur ing t his self -st udy session, you should be able t o t abulat e t he hand def ormit ies associat ed

wit h Rheumat oid ar t hr it is. You should be able t o name t he probable causes and br ief ly discuss

t he t r eatment of each def ormit y.

This inf ormat ion will be checked by t he lect urer dur ing Session 6.


58


SESSI ON 6: CARPAL TUNNEL SYNDROME, CONDI TI ONS

AND DEFORMI TI ES OF THE HAND

OUTCOMES


1. Make t he diagnosis of a carpal t unnel syndrome, t abulat e t he causes, per f orm t he

necessar y clinical invest igat ions and discuss t he t r eat ment .

2. Discuss t he indicat ions f or and t he result s of surger y.

3. Make t he diagnosis of car pomet acar pal ost eoar t hrosis of t he t humb and prescr ibe

t reatment . Discuss t he surgical indicat ions.

4. Descr ibe t he general pr esent at ion of congenit al anomalies of t he hand and f inger s, f or

example syndact ile, campodact ile and clinodact ile.

5. Def ine a t r igger f inger and discuss t he t r eat ment .

6. Descr ibe a Bout onnier e def ormit y, a swan neck def ormit y and a “mallet f inger ”, and

discuss t he causes and t r eat ment t hereof .

7. Descr ibe a Dupuyt r ans cont r act ure of t he hand, t abulat e it s associat ions and discuss t he

possible t r eat ment modalit ies.

RESOURCES

- Wr ist And Hand Disorder s Updat e Febr 1999, Page 93

- Apleys Syst em Of Or t hopaedics And Fract ur es: The Wr ist , Chapt er 15, Page 296

- Clinical Or t hopaedic Examinat ion: The Wr ist , Mcrae, Chapt er 6, Page 77

- Ult r asound Treat ment May Relieve Car pel Tunnel Syndrome, Modern Medicine, Vol 23,

No 10, Oct 1998, Page 58

- The Fase I I Module The Musculoskelet al Sist eem Theme 5 Session 6

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

- Apleys Syst em Of Or t hopaedics And Fract ur es. The Hand, Chapt er 16, Page 311

- Clinical Or t hopaedic Examinat ion, Mcrae, The Hand, Chapt er 7, Page 95

- J ournal Of Amer ican Family Physicians, Nails And Nail Disorders I n Childr en And Adult s,

May 1, 1997


The aim of t his session is t o enable you t o ident if y and evaluat e carpal t unnel syndrome, and

f ormulat e a t reatment prot ocol.


59

Pre- st udy

You must review t he anat omy and cont ent of t he carpal t unnel.

Lect ure

This lect ure deals wit h t he causes, clinical diagnosis and t reat ment of car pal t unnel syndr ome.

Compression of t he ulnar ner ve will also be discussed.

Degenerat ive and inf lammat or y condit ions of t he car pomet acarpal j oint s will be discussed.

Overview of common congenit al f inger and hand def ormit ies.

Def ormit ies of t he hand due t o inf lammat or y and degener at ive condit ions will be discussed.

(r ef er back t o Session 4) The common f inger def ormit ies such as “mallet f inger ”, Bout onniere

and swan neck def ormit ies will be discussed in dept h.


This session will ensur e t hat you can ident if y t he most common def ormit ies of t he hand and

f inger s, f ormulat e a possible aet iological diagnosis, and descr ibe t he cour se and t reatment

t her eof .


60

THEME 14: CONDI TI ONS AND DEFORMI TI ES OF THE

LOWER LI MB

AI M OF THE THEME

This t heme will enable you t o recognise and evaluat e t he clinical examinat ion met hods and

r adiological invest igat ions per t aining t o t he lower limb as applicable t o disease condit ions and

def ormit ies t hereof , and t o f ormulat e a meaningf ul t herapeut ic plan.



1 16/ 02/ 2006

08:00-08:45

Lect ur e

Ost eoar t hr it is and Avascular

Necr osis of t he Hip Painf ul Hip – Pr oblem Solving

Dr H de J ongh

2 16/ 02/ 2006

09:00-09:45 Lect ur e

Angular Def ormit ies of t he Knee,

Ost eot omies and Knee r eplacement s Dr H de J ongh

3 16/ 02/ 2006

10:00-10:45 Lect ur e

The Spor t sman wit h (A) A Painf ul Lower leg

(B) The I leot ibial Band Syndr ome Dr I Ter blanche

4 16/ 02/ 2006

11:00-11:45 Lect ur e

Chr onic I nst abilit y of t he Ankle j oint ,

Degener at ive Condit ions of t he Ankle,

Cavus Feet and Flat f eet in Adult s Heel pain and For ef oot Pain,

For ef oot Def ormit ies

Dr A Heyns

THEME 14: CONDI TI ONS AND DEFORMI TI ES OF THE LOWER LI MB

SESSI ON 1: OSTEOARTHRI TI S AND AVASCULAR

NECROSI S OF THE HI P ; PAI NFUL HI P -

PROBLEM SOLVI NG

OUTCOMES


1. Tabulat e t he causes of ost eoar t hr it is of t he hip.

1. Tabulat e t he causes of avascular necrosis of t he hip.

2. Descr ibe t he clinical present at ion of degenerat ive diseases of t he hip.

3. Discuss t he conservat ive t r eat ment of ost eoar t hr it is of t he hip.


61

4. Tabulat e t he indicat ions and cont r a-indicat ions f or a t ot al hip r eplacement , and discuss

t he implicat ions of t his operat on.

5. Explain an ost eot omy of t he hip.

6. Explain an ar t hrodesis of t he hip.

Af t er t his session, you should have suf f icient inf ormat ion t o advise a middle-aged pat ient wit h a

grade I I I painf ul hip and ost eosr t hr it is about t he advant ages and disadvant ages of surgery t o

t he hip, as well as t he conservat ive modalit ies available.

RESOURCES

Ost eoar t hr it is Updat e Febr 1999 Page 98

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

- Apleys Syst em Of Or t hopaedics And Fract ur es – Chapt er 5, Page 9, Chapt er 19, Page 414

- J ournal Of Amer ican Family Physicians, Ant er ior Hip Pain, Oct 15, 1999 Page 1657

- J ournal Of Amer ican Family Physicians, Ant er ior Hip Pain I n At hlet es, Apr 1, 2000, Page

2109

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

- Ost eo-ar t hr it is Updat e Febr 1999 Page 98

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

- Apleys Syst em Of Or t hopaedics And Fract ur es – Chapt er 5, Page 9, Chapt er 19, Page 414


This session will enable you t o evaluat e ost eoar t hr it is of t he hip j oint by appropr iat e clinical

met hods, and t o r ecommend appropr iat e t r eat ment on t he grounds of hist ory and special

invest igat ions.

Revision

Please read t he radiological signs of ost eoar t r it is and avascular necrosis. Theme 3.

Lect ure

This lect ure deals wit h t he possible causes of ost eoar t hr it is of t he hip; t he radiological f indings

as well as t he clinical present at ion. The causes of avascular necrosis of t he hip will be discussed

and t he r adiological dif f erent iat ion of ost eoar t hr it is will be covered. You will be inst ruct ed

about t he conservat ive t reatment of ost eoar t hr it is, as well as t he indicat ions f or a t ot al hip

r eplacement and t he nat ural cour se t hereof . I n addit on, t he indicat ions and suit abilit y of

ost eot omies and ar t rodeses of t he hip will b discussed.


The obj ect ive of t his self -st udy session is t o enable you t o solve specif ic clinical problem

involving a young pat ient present ing wit h a sever ely painf ul hip j oint .


62

Self - st udy and clinical pr oblem solving

You ar e expect ed, wit h t he aid of your r ef er enes, t o solve t he f ollowing problem t o t he best of

your abilit y:

A 40 year old man present s wit h a gr ade 3 pain in his r ight hip secondary t o avascular necrosis,

possibly due t o et hanol abuse and secondary ost eoar t hr it is.

Discuss t he t r eat ment possibilit ies wit h r ef erence t o t he advant ages and disadvant ages as

r elevant t o t his specif ic case.


SESSI ON 2: ANGULAR DEFORMI TI ES OF THE KNEE,

OSTEOTOMI ES AND KNEE REPLACEMENTS

OUTCOMES


1. Tabulat e causes of ost eoar t hr it is of t he knee.

2. Discuss t he conservat ive t r eat ment of ost eoar t hr it is of t he knee.

3. Explain t he requir ement s f or a t ot al knee r eplacement .

4. Explain t he longt erm out comes of knee r eplacement s.

5. Explain an ar t hrodesis of t he knee.

6. Br ief ly discuss ost eot omies of t he knee.

RESOURCES

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

Apleys Syst em Of Or t hopaedics And Fr act ures. Chapt er 20, Page 432

Clinical Or t hopaedic Examinat ion – Mcrae Page 160

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

Journal Of Amer ican Family Physicians, Pat ello Femoral Pain, Nov 1, 1999, Page 2012

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


The aim of t his session is t o ensure t hat you can ident if y def ormit ies of t he knee j oint , diagnose

degenerat ive ar t hr it is of t he knee and f ormulat e a t reatment st r at egy.

Revision

Please r evise t he radiological signs of ost eoar t hr it is and t he mechanical axes of t he lower limb.

Theme 2 and Theme 3.


63

Lect ure

This session deals wit h t he linear def ormit ies of t he lower limb in adult s which may result in

knee pain and degenerat ive changes. The conservat ive t r eat ment will be discussed, as well as

indicat ions f or surger y. I n addit ion, t he role of ost eot omies, ar t hrodesis and knee r eplacement s

will also be discussed.


Tabulat e t he possible dif f erent ial diagnosis, as well as t he appropr iat e special invest igat ions

t hat you would use t o est ablish t he diagnosis.


SESSI ON 3: THE SPORTSMAN WI TH

(A) A PAI NFUL LOWER LEG

(B) THE I LEOTI BI AL BAND SYNDROME

OUTCOMES


1. Def ine ileot ibial band syndrome, and br ief ly discuss t he diagnosis and t r eatment t her eof .

2. Def ine “shin splint s” and br ief ly discuss t he clinical present at ion and t reat ment t hereof .

3. Discuss st r ess f r act ures of t he lower leg wit h regards t o clinical and r adiological

present at ion and nat ural course.

4. Br ief ly discuss chronic compar tment syndrome of t he lower in t erms of t he clinical

present at ion and t r eat ment t hereof .

RESOURCES

The ileot ibial band f r ict ion syndrome

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

- Bone St ress I nj ur ies I n At hlet es CME Febr 1999 Vol 17 No. 2 Page 107

- Clinics I n Physical Therapy. Physical Therapy Of The Foot And Ankle Gary C Hunt

Pages 225-227

- Tur ecks Or t hopaedics 1994 St r ess Fract ur es Pages 112-113, 293

- Myof ascial Pain And Fibromyalgia Syndromes. Pet er E Boldr y Shin Splint s Page 289

- J ournal Of Amer ican Family Physicians, St r ess And I nsuf f iciency Fract ures, July 1997,

Page 175

- Acut e And Chronic Knee I nj ur ies I n Childr en CME Jan. 2001 Vol 19, No. 1 Page 27

- Apleys Syst em Of Or t hopaedics And Fract ur es Page 676

- Clinical Or t hopaedic Examinat ion – Mcrae Page 189


64


You should be aware of common overuse spor t s inj ur ies af f ect ing t he lower leg, and t he clinical

and special invest igat ions used t o make t his dif f erent iat ion.

Lect ur e

The f ollowing will be dealt wit h:

1. I leot ibial band syndrome

2. “Shin splint s”

3. Lower leg st r ess f r act ure

4. Lower leg chronic compar t ment syndrome in t he spor t sman


SESSI ON 4:

CHRONI C I NSTABI LI TY OF THE ANKLE JOI NT, DEGENERATI VE CONDI TI ONS OF THE

ANKLE, CAVUS FEET AND FLAT FEET I N ADULTS

OUTCOMES


1 Descr ibe ankle inst abilit y wit h ref erenc t o causes, clinical pr esent at ion, r adiological

evaluat ion and t reatment prot ocol.

2 Tabulat e t he causes of ankle ar t hr it is.

3 Discuss t he clinical present at ion, r adiological pict ure and t r eat ment opt ions.

4 Def ine ost eochondr it is dessicans of t he t alus and br ief ly descr ibe t he condit ion.

5 Descr ibe t he clinical present at ion of f lat f oor and cavus f oor , discuss t he implicat ions of a

st ruct ural def ormit y and br ief ly discuss t he t reatment opt ions.

6 Discuss plant ar f asciit is wit h r ef er ence t o aet iology, clinical pict ure, nat ural cour se and

t reatment .

7 Br ief ly explain t ar sals f emur neck syndr ome.

8 Discuss degenerat ive rupt ur e of t he achilles t endon achilles wit h ref er ence t o aet iology,

clinical pict ure and t reat ment opt ions.

9 Br ief ly descr ibe a Mor t ons neuroma.

10 Discuss hallux valgus and claw t oes wit h ref erence t o causes, clinical pict ure and

t reatment opt ions.

11 Discuss ingrown t oenails and explain t he t reat ment t hereof .

12 Explain hallux r igidus.


65

RESOURCES

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

- Apleys Syst em Of Or t hopaedics And Fract ur es Chapt er 21, Page 471

- Clinical Or t hopaedic Examinat ion – McRae, Chapt er 14, Page 253

- Modern Medicine, How To Treat Corns, Calluses & Plant ar War t s Vol 23, No 2, Feb 99,

Page 50

- Modern Medicine, Doct or ’s Rooms Procedures For I ngrown Toenails (Pr act ical Pr ocedures)

Vol 22, No 9, Sept 1997, Page 49

- Ganglion Of The Foot Updat e Feb 1998, page 93

- Management Of I ngrowing Toenail Updat e Apr il 2000, page 40

- The I ngrown Toenail And I t s Treatment CME Sept 1999 Vol 17, No 9, page 778

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

- Ar t hr it is And The Foot CME Feb 1997, Vol 15, No 2, page 157

- Subcaleaneal Heel Pain Syndrome S A Bone And Joint Sur ger y Vol VI I , No 2, June 97,

page 12


The obj ect ive of t his session is t o recognise post -t r aumat ic chronic inst abilit y and degenerat ive

ar t hr it is of t he ankle, and t o dif f er ent iat e bet ween each ot her . You should also be able t o

descr ibe t he clinical pr esent at ion of a f lat f oot and a cavus f oot , and t o know t he nat ural course

of t hese f oot def ormit ies in adult s as well as t he basic pr inciples of t reat ment .

The aim of t his session is t o enable you t o make a meaningf ul dif f er ent ial diagnosis when a

pat ient present s wit h heal pain by applying your knowledge of appropr iat e clinical examinat ion

met hods. You should also be able t o ident if y t he clinical pr esent at ion of common f ore-f oot

def ormit ies.

Pre- st udy

Please revise t he examinat ion of t he ankle. Theme 2.

Lect ur e

This session of f ers a lect ure on t he causes of chronic inst abilit y of t he ankle j oint and t he

conservat ive t reat ment t hereof . The surgical possibilit ies will be discussed. The causes of

degenerat ive condit ions of t he ankle will be discussed br ief ly, as well as cavus f eet and f lat f eet

and t heir associat ions and nat ural cour se in adult s.

This session will also discuss t endon rupt ur e and inf lammat ory condit ions of t he f oot and ankle,

ner ve ent rapment syndrome of t he f oot and ankle, f oref oot and t oe def ormit ies.


66

THEME 15: GENERAL PRI NCI PLES OF RESUSCI TATI ON AFTER

TRAUMA AND EMERGENCY TREATMENT OF FRACTURES AND DI SLOCATI ONS

AI M OF THE THEME

This session deals wit h t he general pr inciples in t he emergency t r eat ment of t he pat ient wit h

mult iple musculoskelet al inj ur ies.



1 17/ 02/ 2005

08:00-08:45 Lect ur e

Gener al Pr inciples of Resuscit at ion

af t er Tr auma and Emergency t r eat ment

of Fr act ur es and Dislocat ions

Dr I Ter blanche

OUTCOMES


1. Tabulat e and explain t he general basic pr inciples of r esuscit at ion (ABC).

2. Tabulat e t he pr inciples of radiological evaulat ion.

3. Explain t he emergency t reatment of an inj ured limb.

4. Explain emergency immobilisat ion t echniques of t he neck, spinal column and limbs.

5. Discuss and br ief ly explain t he complicat ions of mut iple inj ur ies in a pat ient .

RESOURCES

- Apleys Syst em Of Or t hopaedics And Fract ur es. Chapt er 22 Page 501

- Pract ical Fract ur e Treatment , McRae Pages 31-38

- J ournal Of Amer ican Family Physicians, Radiological Examinat ion Upper Ext r emit y Trauma,

March 1, 1998, Pages 995

- J ournal Of Amer ican Family Physicians, Radiological Evaluat ion Of Lower Ext r emit y

Trauma, March 15, 1998, Pages 1314


Pre- st udy

Pre-st udy includes t he r evision of t he general pr inciples of f luid t herapy in condit ions of shock,

as well as blood t r ansf usions.


67

Lect ure

Dur ing t his session, t he general pr inciples of syst emic r esuscit at ion will be discussed br ief ly.

The emer gency t r eatment of pelvic and ver t ebral f r act ur es will be discussed br ief ly, as well as

t he emergency t reatment of limb f r act ur es and dislocat ions. I n addit ion, t he appropr iat e

r adiological invest igat ions in t he pat ient wit h mult iple inj ur ies will be discussed.


68

THEME 16: GENERAL PRI NCI PLES OF

TRAUMATI C CONDI TI ONS

AI M OF THE THEME

This t heme will enable you at adapt your knowledge per t aining t o basic pr inciples in t he

r adiological evaluat ion of f r act ures and dislocat ions in order t o meaningf ully int er pret t hese

t ypes of inj ur ies and t hus r ecommend appropr iat e t r eatment , and also t o discuss t he cour se and

prognosis.



1 17/ 02/ 2006

09:00-09:45

Lect ur e

Self -st udy

Fr act ur e Pat t er ns, Open Fr act ur es, Gr owt h plat e I nj ur ies The pr inciples of f r act ur e and dislocat ion

Reduct ion and I mmobilisat ion.

The Pr inciples of Open Reduct ion and I nt er nal Fixat ion

Dr I Ter blanche

2 17/ 02/ 2006

10:00-10:45 Lect ur e

I mminent Compar t ment Syndr ome, Non-Accident al Syndrome,

Ref lex Sympat het ic Dyst r ophy

Common Complicat ions of

Fract ur es And Dislocat ions

Dr I Ter blanche

THEME 16: GENERAL PRI NCI PLES OF TRAUMATI C CONDI TI ONS

SESSI ON 1: FRACTURE PATTERNS, OPEN FRACTURES,

GROWTH PLATE I NJURI ES, THE PRI NCI PLES OF FRACTURE AND DI SLOCATI ON,

REDUCTI ON AND I MMOBI LI SATI ON.

THE PRI NCI PLES OF OPEN REDUCTI ON AND I NTERNAL FI XATI ON

OUTCOMES


1. Descr ibe and illust r at e f r act ure pat t erns in children and adult s.

2. Discuss t he biological and st r uct ural implicat ions of f r act ure pat t erns.

3. Discuss displacement and angulat ion of f r act ures.


69

4. Discuss f ract ure healing according t o Perkins’ r ule.

5. Classif y open f r act ures and discuss t he basic pr inciples of wound debr idement .

6. Br ief ly discuss t he implicat ions of gunshot wounds.

7. Classif y growt h plat e inj ur ies.

8. Tabulat e combinat ion f r act ures.

9. Descr ibe and discuss t he basic pr inciples per t aining t o applicat ion of a cast .

10. Discuss t he pr inciples of a t hree point pressure syst em in a cast .

11. Tabulat e and discuss t he complicat ions of cast applicat ion and t he prevent ion t hereof .

12. Descr ibe how a f r act ure and/ or a dislocat ion is r educed.

RESOURCES

- Growt h Plat e I nj ur ies Specialist Medicine Feb 2001 Page 765

- Apleys Syst em Of Or t hopaedics And Fract ur es – Chapt er 23, Page 515

- Pract ical Fract ur e Treatment , McRae, Chapt er 1, Page 3

- Apleys Syst em Of Or t hopaedics And Fract ur es

- Pract ical Fract ur e Treatment ;

- Child Abuse Page 45

- Closed Reduct ion And Fixat ion Of Fract ures Chapt er 3, Page 47

- Head I nj ur ies I n Child Abuse, WS 270, HAR, U.S. Library

- J ournal Of Amer ican Family Physicians J uly 1997, Page 175, St r ess Fract ures

LECTURE

This lect ure deals wit h t he gener al guidelines in t r aumat ic condit ions of t he musculoskelet al

syst em wit h regards t o clinical evaluat ion, r adiological request s and int er pret at ion, and an

est imat ion of t he nat ural cour se of t he inj ury. Guidelines will be given wit h regards t o t he

t her apeut ic pr inciples of open f r act ures and growt h plat e inj ur ies.

This session consist s of a lect ure demonst rat ion on t he reduct ion of a t raumat ic f r act ure and/ or

dislocat ion af t er appropr iat e analgesia and t he applicat ion of t he basic pr inciples of

immobilisat ion by means of plast er or splint s. Non-t raumat ic f r act ures will also be discussed.


Dur ing t he session, you must complet e t he assignment t hat you r eceived and, in your own t ime

and by ref er r ing t o t he r esources, complet e t he implicat ions of t he var ious growt h plat e inj ur ies.


The aim of t his session is t o ensure t hat you under st and t he mechanisms of r educt ion of

f ract ures and dislocat ions, as well as how t o apply t his t o t he basic pr inciples in immobilisat ion

and plast er t echnique.


70

THEME 16: GENERAL PRI NCI PLES OF TRAUMATI C CONDI TI ONS

SESSI ON 2: I MMI NENT COMPARTMENT SYNDROME, NON-

ACCI DENTAL I NJURY SYNDROME REFLEX SYMPATHETI C DYSTROPHY, COMMON

COMPLI CATI ONS OF FRACTURES AND

DI SLOCATI ONS

OUTCOMES


1. Know t he causes of t his syndrome, as well as t he clinical signs, present at ion and t reatment

t hereof .

2. Know t he clinical and r adiological signs of NAI S.

3. Diagnose r egional pain syndrome/ sympat het ic dyst rophy in a pat ient . 4. Taulat e t he shor t and longt erm complicat ions t hereof . 5. Def ine and br ief ly discuss delayed union as well as non-union. 6. Def ine and br ief ly discuss ref lex sympat het ic dyst r ophy (Sudeck’s at rophy).

7. Def ine and br ief ly discuss myosit is ossif icans.

RESOURCES

- Pract ical Fract ur e Treatment Non-Accident al I nj ur y, McRae, Page 45

- Apleys Syst em Of Or t hopaedics And Fr act ures. Pr inciples Of Fr act ures Chapt er 23 Page

515

- Pract ical Fract ur e Treatment , McRae, Chapt er 2 P. 25, Chapt er 5, Page 75


Self - st udy

The aim of t his session is t o solve t hr ee specif ic clinical problems t hat commonly occur af t er

t r auma of t he musculoskelet al syst em.

The class divides int o 3 groups, each wit h t he t ask of solving one of t he f ollowing clinical

problems by r ef er r ing t o t he r esour ces:

1. How is t he cir culat ion examined clinically t he day af t er plast er applicat ion f or a

f ract ure? What is an imminent compar tment syndrome?

2. What do you underst and by t he t erm non-accident al inj ur y syndrome (NAI S)? What are

t he implicat ions of t his condit ion? Br ief ly descr ibe t he clinical aspect s t her eof .

Tabulat e t he radiological aspect s t hereof .

3. “Doct or , it has already been 2 mont hs since my wr ist f r act ure, but my arm is st ill sore”.

Br ief ly discuss t he possible causes t her eof .


71

4. The t hr ee groups must br ing along t heir inf ormat ion on t he assignment s and share t he

inf ormat ion wit h each ot her . This inf ormat ion will be br ief ly cont r olled by t he lect urer at

t he st ar t of session 4.

The aim of t his session is t o ensure t hat you are aware of t he complicat ions which may ar ise

dur ing t he t r eatment of f r act ur es and dislocat ions in general and can t hus propose necessary

prevent at ive measures.

Lect ur e

This lect ure covers t he general complicat ions of f r act ures and dislocat ions, t he prevent ion

t her eof and, br ief ly, t he t r eatment of t he specif ic complicat ions.

Pre- st udy

Review t he common f act or s t hat may give r ise t o delayed f r act ure healing and t abulat e in your

assignment .


72

THEME 17: I MMOBI LI SATI ON TECHNI QUES OF THE UPPER LI MB

AI M OF THE THEME

The aim of t his t heme is t o ensure t hat you know how t o apply t he basic pr inciples of

immobilisat ion t echniques of t he upper limbs.



1 17/ 02/ 2006

11:00-11:45 Lect ur e Demonst r at ion

I mmobilisat ion Techniques of t he

Upper Limb Dr A Heyns

THEME 17: I MMMOBI LI SASI E TECHNI QUES OF THE UPPER LI MB

SESSI ON 1: I MMOBI LI SATI ON TECHNI QUES OF THE

UPPER LI MB

OUTCOMES

At t he end of t his t heme, you should be able t o do t he f ollowing:

Apply t he var ious immobilisat ion t echniques.

RESOURCES

- Apleys Syst em Of Or t hopaedics And Fract ur es. Pr inciples Of Fr act ures. Chapt er 23,

Page 515

- Pract ical Fract ur e Management . Chapt er 2 Page 25, McRae

- Plast er Of Par is Technique WO 170 PLA U.S. Librar y

- Plast er Technique WO 170 BI R U.S. Librar y

- Cast Manual For Adult s And Childr en Freuler : Wiedmer

- Fr act ures I n Children Rockwood

- Pr imary Sur ger y Vol 2, Maur ice King and Pet er Bewes

- Collar -cuf f bandage Ref erence I Page 133, I I Page 174

- Tr iangular bandage Ref erence I I Pages 39-40, I V Pages 226

- Reversed t r iangular bandage

- “Mast er sling” East London Bandgae Ref er ence I , page 119, Ref erence I I pages 115, 147,

174


73

- Figure 8 Bandage Ref erence I , page 117, I I I , page 958

- U-splint , Ref erence I , page 125, Ref erence I I I , page 915

- Thomas splint

- Gallow t r act ion

- Holt er neck t r act ion

- Skelet al neck t ract ion

- Apleys Syst ems Of Fract ures And Or t hopaedics. Pr inciples Of Fract ures Chapt er 23,

page 515

- Tract ion Video Casset t e : Checks And Balances, US Librar y, WE190TRA


74

THEME 18: FRACTURES AND DI SLOCATI ONS OF

THE SPI NAL COLUMN AND PELVI S

AI M OF THE THEME

The aim of t his t heme is t o enable you t o t abulat e t he var ious f r act ure pat t erns and dislocat ions

of t he spinal column and pelvis, descr ibe t he radiological present at ion, name t he possible

complicat ions and discuss t he basic pr inciples in t he t reatment of t hese inj ur ies.



1 20/ 02/ 2006

08:00-08:45

Lect ur e

Self -st udy

Clinical Pr esent at ion and I ncidence

of Ver t ebr al Fr act ur es The Nur sing aspect s of Par aplegics

and Tet r aplegics in t he Post - I nj ur y Per iod

Tr anspor t of a Tet r aplegic

Dr I Ter blanche

2 20/ 02/ 2006

09:00-09:45 Lect ur e Pelvis Fr act ur es Dr H de J ongh

THEME 18: FRACTURES AND DI SLOCATI ONS OF THE SPI NAL COLUMN AND PELVI S

SESSI ON 1: CLI NI CAL PRESENTATI ON AND I NCI DENCE OF VERTEBRAL FRACTURES, THE CARE OF PARAPLEGI CS AND TETRAPLEGI CS I N THE

POST- I NJURY PERI OD, TRANSPORT OF A TETRAPLEGI C

OUTCOMES


1. Discuss t he emer gency t reatment of an acut e spinal column or pelvic inj ury and t abulat e

t he precaut ionary guidelines t hat must be t aken bef or e t r anspor t ing t he pat ient .

2. Descr ibe t he clinical examinat ion of t hese inj ur ies.

3. Discuss t he r adiological evaluat ion of neck and spinal column inj ur ies.

4. Tabulat e t he r adiological signs of spinal column inst abilit y.

5. Discuss t he basic pr inciples in t he t reatment of spinal column inj ur ies.

6. Descr ibe pelvic f r act ures.


75

7. Discuss visceral inj ur ies associat ed wit h pelvic f r act ures.

8. Precaut ionar y guidelines t o prot ect t he pat ient against f ur t her inj ur ies dur ing t r eat ment

9. The t reatment of t he pat ient post -inj ur y

At t he end of t his session, you should know of t he f ollowing aspect s per t aining t o paraplegics and

t et r aplegics :

1. Their f unct ional abilit ies

2. Their aids and t he use t hereof in t heir envir onment .

3. The f ramework of physiot her apist s, occupat ional t her apist s and social wor ker s r equired. 4. The complicat ions of par aplegia, e.g. cont ract ur es, f r act ures, het erot opic ossif icat ion,

ur inary problems, as well as pr essure sores.

5. Know about t he drugs t hat cont rol spasms.

6. Know about t he suppor t net work f or such pat ient s in t he communit y.

7. Know what is meant by a cent r al cor d syndrome.

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

RESOURCES

- Whiplash I nj ur y. Updat e Sept 1999, Page 50.

- Whiplash I nj ur y. Specialist Medicine, Feb 2001, Page 777.

- Concise Syst em Of Or t hopaedics And Fr act ures. Chapt er 29, Page 299 A G Apley and

Solomon.

- Pract ical Fract ur e t r eat ment McRae:

- Spinal I nj ur ies Chapt er 10, Page 209

- Pelvis I nj ur ies Chapt er 11, Page 239

- Apleys Syst em of Or t hopaedics And Fract ures. Spinal Cor d I nj ur ies Chapt er 25, Page 633

- Spinal St abilisat ion Video Casset t e WB 541 SP1 U.S. Library

- Pract ical Fract ur e Treatment – McRae Chapt er 10. Spinal Paralysis Page 231


Revision

Bef ore t he st ar t of t his session, you ar e expect ed t o r eview t he neurological evaluat ion of a

pat ient . You should know t he gener al char act er ist ics of an upper mot or neuron lesion, as well as

t he bulbocavernous r ef lex.

The aim of t hese t wo sessions is t o ensure t hat you can clinically evaluat e an acut e spinal cord

inj ury and know wich precaut ionar y measures should be t aken bef ore t r anspor t ing t he pat ient .

You should also have t he necessar y knowledge wit h r egards t o t he longt erm mult i-disciplinary

implicat ions of a paraplegic and a t et raplegic.

Lect ur e

Dur ing t his session, a lect ure will be given on t he clinical present at ion and incidence of ver t ebral

f ract ures. The mechanisms of inj ur y will be discussed. You will be shown how t o int erpret X-r ays


76

and t o decide whet her or not t he f r act ure/ dislocat ion is st able. Guidelines wit h r egar d t o

specif ic f r act ure t r eat ment will also be discussed.

Precaut ionary measures t hat must be f ollowed bef or e t r anspor t ing a pat ient will also be

explained t o you.

This lect ure also deals wit h care aspect s of par aplegics and quadroplegics in t he post -inj ury

per iod. The r ehabilit at ion program will be discussed, as well as t he f unct ional abilit ies. The

general longt erm complicat ions associat ed wit h t hese inj ur ies will also be discussed. You will be

explained how t o prevent pressure sores and how t o t r eat t hem when present .

Dur ing t his session, you must make a summary of t he clinical and r adiological diagnosis of a young

r ugby player wit h a C5/ C6 bif acet dislocat ion wit h a complet e neurological lesion.

This pr oblem will be solved, wit h t he help of your lect urer , by means of small group discussions.

Tabulat e t he precaut ionar y measures t hat must be f ollowed bef or e t r anspor t ing t he pat ient .

Br ief ly discuss his prognosis, his f ut ure abilit ies and t he pot ent ial problems t hat he can expect .

Please complet e t he assignment handed out t o you.

THEME 18: FRACTURES AND DI SLOCATI ONS OF THE SPI NAL COLUMN AND PELVI S

SESSI ON 2: PELVI C FRACTURES

OUTCOMES

You should know t he f ollowing:

1. Clinical evaluat ion

2. Emergency t reatment

3. Radiological invest igat ions and int er pret at ion

4. Pr inciples of t r eat ment of pelvic f r act ures

RESOURCES

- Apleys Syst em Of Or t hopaedics And Fract ur es.

- Wheeless Text book of Or t hopaedics. Sear ch Google.


77

THEME 19: FRACTURES AND DI SLOCATI ONS OF THE

UPPER LI MB

AI M OF THE THEME

This t heme will ensure t hat you are able t o apply t he knowledge learnt in t he previous t hemes

wit h r egards t o t he basic pr inciples in f r act ure management and dislocat ions t o t he upper limb.

You should be able t o descr ibe t he appropr iat e clinical invest igat ions, t he r adiological

int erpr et at ion and t he necessary t reatment .



1 20/ 02/ 2006

10:00-10:45 Lect ur e

Fr act ur es and Dislocat ions

of t he Shoulder girdle Dr A I kr am

2 20/ 02/ 2006

11:00-11:45 Lect ur e


om t he Elbow

For earm Fr act ur es

Dr A I kr am

3 20/ 02/ 2006

12:00-12:45 Lect ur e


om t he Wr ist j oint , Hand and Finger s Dr A I kr am

THEME 19: FRACTURES AND DI SLOCATI ONS OF THE UPPER LI MB

SESSI ON 1: FRACTURES AND DI SLOCATI ONS OF THE

SHOULDER GI RDLE

OUTCOMES


1. Classif y clavicle f ract ures and discuss t he t r eatment in children and adult s.

2. Classif y acromioclavicular and st ernoclavicular dislocat ions and discuss t he t reatment

t hereof .

3. Classif y glenohumeral dislocat ions, descr ibe t he clinical present at ion, t abulat e t he

r adiological charact er ist ics and possible complicat ions t her eof , and discuss t he dif f er ent

t reatment st r at egies.

4. Classif y f r act ures of t he pr oximal 1/ 3 of t he humerus and br ief ly discuss t he t reatment

of each.

5. Discuss f r act ures of t he humerus shaf t wit h ref erence t o possible complicat ions and t he

t reatment met hods.


78

RESOURCES


- Pract ical Fract ur e Treatment – McRae Chapt er 6, Page 99

- Ort hopaedic Trauma I S de Wet Pages 268-290

- J ournal Of Amer ican Family Physicians, Management Of Clavicle Fract ure, Jan 1997

- J ournal Of Amer ican Family Physicians, Shoulder I nst abilit y I n Young At hlet es.

15 May 1999 WWW.aaf p.org/ af p

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


Lect ure demonst r at ion

This lect ure deals wit h f r act ures and dislocat ions of t he clavicle and t he t r eat ment t hereof on a

pr imary healt h level. Dislocat ions of t he shoulder will be discussed in det ail. Guidelines wil l be

given or t he conser vat ive t reatment of humerus sof t f ract ur es and t he indicat ions f or surger y.


SESSI ON 2: FRACTURES AND DI SLOCATI ONS OF THE

ELBOW AND FOREARM FRACTURES

OUTCOMES


1. Tabulat e t he appearance of t he ossif icat ion cent r e in t he elbow.

2. Descr ibe and int er pret t he r adiological sof t t issue signs of t he elbow, as well as t he

necessar y lines seen on xray.

3. Classif y supracondylar f r act ures in children, t abulat e t he possible complicat ions and

discuss t he var ious t r eat ment opt ions.

4. Descr ibe t he radiological present at ion as well as t he t r eat ment opt ions f or epicondylar

f ract ures.

5. Classif y elbow dislocat ions and discuss t he t r eat ment t hereof .

6. Classif y r adial head f r act ures and discuss t he t r eat ment t hereof .

7. Classif y olecranon f ract ures and discuss t he t reatment t hereof .

8. Tabulat e t he possible complicat ions of elbow inj ur ies.

9. Descr ibe a Mont eggia f r act ur e dislocat ion and discuss t he t r eat ment pr inciples in childr en

and adult s.

10. Descr ibe a Galliazi f ract ure dislocat ion and discuss t he pr inciples of t reatment .

11. Discuss t he pr inciples of t r eat ment of mid-shaf t f or earm f r act ur es.


79

12. Discuss t he pr inciples of t r eat ment of isolat ed r adius and ulna f ract ures.

13. Descr ibe a Colles f r act ure clinically and r adiologically, and discuss t he t r eat ment and

nat ural cour se t hereof .

14. Descr ibe t he r adiological present at ion of a displaced dist al r adius f r act ure and discuss t he

t reatment modalit ies.

15. Classif y growt h plat e inj ur ies of t he dist al r adius and ulna and discuss t he t r eat ment .

16. Descr ibe a radial st yloid f r act ure and discuss it s t reat ment .

17. Give a r adiological classif icat ion of scaphoid f ract ures, and discuss t he t r eatment and

complicat ions t her eof .

18. Classif y wr ist and car pal dislocat ions, and discuss t he emergency t reatment t her eof .

19. Br ief ly discuss carpal inst abilit y.

RESOURCES

- Ort opediese Trauma I zak de Wet , H. 12 Pages 231-258

- Fr act ures I n Children, Rockwood & Green, Ch. 10, Page 653

- Pract ical Fract ur e Treatment McRae, I nj ur ies about t he elbow, H. 7 Page 129

- Apleys Syst em Of Or t hopaedics And Fract ur es Chapt er 24, The elbow Page 577

- Apleys Syst em of Or t hopaedics and Fract ures Chapt er 24, The Forearm Page 592.

- Pract ical Fract ur e Treatment McRae. Chapt er 7, Page 129

- I S de Wet , Or t opediese Trauma 1984, Pages 219-227, 225, 213, 186-190

- F Freuler , U Wiedmer , Cast Manual f or Adult s & Childr en: Spr inger -Ver lap, 1979, Pages

28-31

- P Saf f ar . Scaphoid Fract ures. Cur r ent Or t hopaedics (1999) 13, Pages 275-281

- I S de Wet . Or t opediese t rauma HAUM, 1984, Pages 296-205

- F Freuler , U Wiedmer , Cast Manual f or Adult s and Children Spr inger -Ver lap, 1979, Pages

38-39, 44-45

- CA Rockwood, DP Green, Rockwood & Green’s Fr act ures in Adult s: Lippincot t -Raven, 1996,

Pages 791-801.

- Apleys Syst em Of Or t hopaedics And Fract ur es, Chapt er 24, Pages 595

- Pract ical Fract ur e Treatment McRae, Chapt er 8, P. 155 Chapt er 9 Page 7 169

- J ournal Of Amer ican Family Physicians, Common Wr ist I nj ur ies, Feb 1997, Page 857

- www.aaf p.or g/ af p

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


The aim of t his session is t o ensure t hat you are able t o classif y common f r act ures and

dislocat ions of t he elbow (present ing in bot h childr en and adult s) according t o r adiological

present at ion and able t o discuss t r eatment opt ions.

The obj ect ive of t his session is t o enable you t o classif y common f ract ure pat t erns in t he

f or earms of bot h children and adult s wit h ref erence t o t he r adiological present at ion and discuss

t he t r eatmnt guidelines f or each f ract ure or f r act ure/ dislocat ion.


80

The aim of t his session is t o ensure t hat you can classif y f r act ures of t he dist al r adius and ulna

according t o r adiological present at ion and accordingly f ormulat e t r eat ment guidelines. You wil

also learn how t o ident if y f ract ur es and dislocat ions of t he wr ist j oint radiologically and apply

emergency t r eat ment at a pr imary healt h level.

Lect ure

This lect ure discusses t he common f ract ures and dislocat ions of t he elbow j oint . You will learn

how t o int erpret t he X-r ay. The t r eatment and met hods of r educt ion of f r act ur es and

dislocat ions will be discussed. The guidelines f or sur ger y will be indicat ed and t he possible

complicat ions discussed.

This lect ure also deals wit h common f r act ures of t he f orearm.

The f r act ures and f r act ure-dislocat ion pat t erns of t he f orearm in adult s and children will be

discussed.

The aim of t his session is t o ensure t hat you can classif y t he f r act ures of t he dist al r adius and

ulna accoding t o r adiological pr esent at ion and accodingly f ormulat e a t r eatment st r at egy. You

will also learn how t o ident if y f r act ures and dislocat ions of t he wr ist j oint r adiologically and

apply emergency t r eat ment on pr imary healt h level.

Lect ure

This lect ure covers t he clinical diagnosis of common f r act ur es of t he dist al radius and wr ist

j oint , namely t he Colles’ f ract ure, disrupt ed dist al r adius f ract ure, scaphoid f r act ures and acut e

wr ist dislocat ions and inst abilit ies.

The radiological manif est at ions, conservat ive t r eatment and surgical indicat ions will be

discussed.

Please complet e t he assignment given t o you dur ing t his session.


SESSI ON 3: FRACTURES AND DI SLOCATI ONS OM THE

WRI ST JOI NT, HAND AND FI NGERS

OUTCOMES


1. Discuss t he emergency t r eatment of an acut ely swollen hand af t er an inj ury.

2. Classif y met acar pal f r act ures, descr ibe t he met hods of immobilisat ion af t er a displaced

f ract ure, and discuss t he clinical and radiological indicat ions f or surger y.

3. Def ine a Bennet t ’s f r act ure, descr ibe t he radiological present at ion t hereof and discuss

t he t r eat ment t hereof .


81

4. Def ine a « boxer » f r act ure, descr ibe t he radiological present at ion t hereof and discuss

t he t r eat ment modalit y.

5. Give a r adiological classif icat ion of a phalanx f ract ure, descr ibe t he met hod of

immobilisat ion and discuss t he clinical and r adiological indicat ions f or surgery.

6. Classif y MP and I P dislocat ions, descr ibe t he met hods of reduct ion and immobilisat ionand

t abulat e t he indicat ions f or surgery.

7. Discuss f inger t ip inj ur ies in childr en in det ail.

RESOURCES

- Pract ical Fract ur e Treatment McRae, Chapt er 9, Page 191

- Apleys Syst em Of Or t hopaedic And Trauma. Page 608

- Management Of Hand And Finger I nj ur ies Updat e July 1999, Page 23

- J ournal Of Amer ican Family Physicians, Finger t ip I nj ur ies, May 1, 2001, Page 1961

- J ournal Of Amer ican Family Physicians, Finger t ip Amput at ions, Aug 1 2001, Page 455


The aim of t his session is t o ensure t hat you can classif y common f r act ures and dislocat ions t hat

occur in t he hand and f inger s r adiologically and f ormulat e appropr iat e t reat ment plans.

Lect ure

Dur ing t his lect ure, you will be shown how t o make a diagnosis of f r act ures in t he hand and

f inger s. The t r eat ment of t he common f r act ures will be discussed. You willbe sown how t o

r educe dislocat ions. The applicat ion of a Z-splint and hand ball will be demonst r at ed.


82

THEME 20: FRACTURES AND DI SLOCATI ONS

OF THE LOWER LI MB

AI M OF THE THEME

This t heme will f amiliar ize you wit h t he basic pr inciples of f r act ure evaluat ion and t r eatment in

t he lower limb. You will be able t o descr ibe t he appropr iat e clinical invest igat ions, t he

r adiological int erpret at ion as set out in in Theme 19, as well as t he t reatment guidelines.



1 21/ 02/ 2006

08:00-08:45

Lect ur e

Hip dislocat ions, Femur neck,

I nt er t r ochant er ic and Femur shaf t Fract ur es Dr I Rober t son

2 21/ 02/ 2006

09:00-09:45

Lect ur e

Fr act ur es of t he Dist al Femur ,

Pr ox imal Tibia and Pat el la Dr I Rober t son

3 21/ 02/ 2006

10:00-10:45

Lect ur e

Acut e Knee Dislocat ions,

Knee Ligament inj ur ies and t he Longt erm

consequences of knee Ligament and meniscus inj ur ies

Dr I Rober t son

4 21/ 02/ 2006

11:00-11:45 Lect ur e Fr act ur es of t he Tibia shaf t and plat eau Dr I Rober t son

5 21/ 02/ 2006

12:00-12:45 Lect ur e

Spr ains, Fr act ur es And dislocat ions of t he Ankle, Fr act ur es and dislocat ions of t he t ar sals,

met at ar sal bones and f alankse of t he f oot

Dr I Rober t son

THEME 20: FRACTURES AND DI SLOCATI ONS OF THE LOWER LI MB

SESSI ON 1: HI P DI SLOCATI ONS, FEMUR NECK,

I NTERTROCHANTERI C AND FEMUR SHAFT

FRACTURES

OUTCOMES


1. Discuss t he clinical present at ion of ant er ior and post er ior hip disclocat ions, descr ibe t he

met hods of reduct ion and t abulat e t he complicat ions t hereof .

2. Give a r adiological classif icat ion of proximal f emur f r act ures, and desr ibe t he guidelines

f or t reatment of bot h int r a-capsular and ext r a-capsular f emur f r act ures.


83

3. Give a r adiological classif icat ion f or f emur shaf t f r act ures, discuss t r eat ment opt ions on

bot h children and adult s and t abulat e t he complicat ions.

4. Recognize t he common inj ur ies associat ed wit h f emur f r act ures.

5. Ba able t o place a small child in gallow t r act ion and supervise t heir nursing.

6. Be able t o place an older child or adult in a Thomas splint and supervise t heir nur sing.

7. Know which f ract ures need t o be r ef er r ed f or specialist t r eatment .

8. Be able t o administ er emergency t reatment pr ior t o pat ient t ranspor t f or specialist

t reatment .

9. Recognise t he var ious surgical opt ions f or t r eat ment of a f emur f r act ure.

RESOURCES


- Pract ical Fract ur e Treatment Chapt er 12, Page 273


Lect ure

This session consist s of a lect ure on t raumat ic hip dislocat ions in childr en and adult s. The

clinical present at ion of t he limb will be discussed, as well as t he possible associat ed inj ur ies, t he

met hods of r educt ion, f ollow-up t r eatment and longt erm complicat ions. Femur neck and

int er t r ochant er ic f ract ures in adult s will be discussed and t he impor t ance of t he dist inct ion

bet ween int r acapsular and ext racapsular emphasized. The aim and opt ions of int er nal f ixat ion

will be discussed. The t r eat ment of f emur shaf t f ract ures at dif f er ent ages will be discussed.


SESSI ON 2: FRACTURES OF THE DI STAL FEMUR,

PROXI MAL TI BI A AND PATELLA

OUTCOMES


1. Classif y acut e knee dislocat ions, desr ibe t he emergency t r eatment t her eof and discuss

t he complicat ions.

2. Discuss acut e pat ella dislocat ions.

3. Give t he radiological classif icat ion of dist al f emor al f ract ures and discuss t he t r eatment

guidelines.

4. Give t he radiological classif icat ion of proximal t ibial f r act ures and discuss t he t r eat ment

guidelines.


84

RESOURCES

- The I nj ured Knee Updat e Apr il 2000 Page 45

- Acut e Sof t Tissue I nj ur ies Of The Knee Updat e Nov 1998 Page 22

- The Pat ient Wit h A Painf ul Knee Updat e Nov 1998 Page 29

- Ant er ior Cruciat e Ligament I nj ur ies CME Feb 1999 Vol 17 No 2 Page 117

- Apleys Syst em Of Or t hopaedics And Fract ur es Page 270

- Pract ical Fract ur e Treatment McRae Page 290

- J ournal of Amer ican f amily Physicians, Ant er ior Knee I nj ur ies Dec 1999 Page 2599


The aim of t his session is t o ensure t hat you can classif y f r act ures and dislocat ions of t he knee

j oint accor ding t o t he r adiological pr esent at ion and discuss t he t r eat ment modalit ies of each as

applicable.

Lect ure

This lect ure cover s t he clinical evaluat ion of acut e t r aumat ic ligament and meniscus inj ur ies of

t he knee. Background st udy includes t he r evision of t he examinat ion met hods of t he knee dur ing

Theme 2 of t his module. The implicat ion of f r act ures of t he f emor al and t ibial condyles will be

discussed. You will learn how t o clinically evaluat e pat ella f r act ures and t o decide which

f ract ures r equire an operat ion.

At t he end of t he lect ure, you will, wit h t he help of t he lect urer , learn how t o evaluat e and

t r eat an acut e haemar t hrosis of t he knee in a child and an adult .

Please complet e your assignment .


SESSI ON 3: THE LONGTERM CONSEQUENCES OF KNEE LI GAMENT AND MENI SCUS I NJURI ES

OUTCOMES

At t he end of t his session, you should be able t o discuss t he f ollowing aspect s:

1. Should ligament s of t he knee and t ears of t he meniscus be repair ed acut ely af t er inj ur y?

2. When are ligament r econst r uct ion pr ocedures indicat ed?

3. What is t he rehabilit at ion progr am af t er a knee inj ury? When can t he pat ient r et urn t o

spor t ?

4. What are t he longt erm consequences of a knee inj ur y wit h r egards t o ost eoar t hr it is?


85

RESOURCES

Apleys Syst em Of Or t hopaedics And Fr act ures, Page 680

- Pract ical Fract ur e Treatment McRae, Page 295


The aim of t hese t wo self -st udy sessions is t o ensure t hat you undest and t he longt erm

implicat ions of meniscus and ligament inj ur ies of t he knee – collat eral and cruciat e – so as t o be

able t o explain t his t o your pat ient .

Self - st udy

The class divides int o 4 groups. Each group st udies a single assignment and exchanges t he

inf ormat ion.

Using t he r ef erences provided, r ead up on t he implicat ions of ligament inj ur ies and meniscus

inj ur ies of t he knee. Then complet e t he assignment handed out t o you.

The lect urer will check t he problem in t he next session.


SESSI ON 4: FRACTURES OF THE TI BI A SHAFT AND

PLATEAU

OUTCOMES


1. Give t he r adiological classif icat ion of t ibial shaf t and plat eau f ract ures.

2. Tabulat e t he indicat ions f or conser vat ive t reatment and discuss t he met hods of

conservat ive t r eatment .

3. Discuss t he t reatment of an open t ibia f r act ure.

4. Discuss t he implicat ions of an open t ibia f r act ure, as well as t he nat ural course.

RESOURCES

- Apleys Syst ems Of Or t hopaedics And Fr act ures, Page 689

- Pract ical Fract ur e Treatment McRae, Chapt er 13, Page 305


86


The aim of t his session is t o ensur e t hat you can classif y t ibial shaf t f ract ures bot h clinically

and r adiologically and descr ibe t he necessary t reatment t hereof .

Lect ur e

This lect ure deals wit h t he f ract ure pat t erns of t he t ibia and f ibula. You will be shown how t o

r educe uncomplicat ed f r act ures, if necessar y, and t o apply an appropr iat e plast er . The

t r eatment of an open f ract ure – a basic debr idement – will be r eviewed br ief ly and you will be

shown how t o apply an ext ernal f ixat or . The morbidit y of open f r act ures of t he t ibia will be

discussed br ief ly, as well as t he long-t erm implicat ions.


You must please r ead up on t he levels of amput at ions in t he lower limb, t he advant ages and

disadvant ages of t hese levels, as well as t he f unct ional abilit ies of a pat ient af t er an amput at ion.

Please complet e t he assignment t hat was handed out .

The r ehabilit at ion of a lower leg amput at ion will be discussed dur ing your r ot at ion at Kar l

Bremer Hospit al.


SESSI ON 6: SPRAI NS, FRACTURES AND DI SLOCATI ONS

OF THE ANKLE, FRACTURES AND DI SLOCATI ONS OF THE TARSALS ,

METATARSAL BONES AND PHALANGES OF THE FOOT

OUTCOMES


1 Def ine and classif y ankle sprains, and discuss t he t reatment t hereof . 2 Classif y ankle f r act ures and discuss t he t r eat ment t hereof .

3 Discuss t he emergency t r eatment of a severely swollen f oot .

4 Descr ibe t he t r eat ment guidelines f or calcaneus f r act ures.

5 Tabulat e t he inj ur ies associat ed wit h calcaneus f ract ures.

6 Classif y mid-f oot f r act ure dislocat ions, and descr ibe t he indicat ions f or surger y.

7 Classif y t alus f ract ur es, and br ief ly discuss t heir t reatment and nat ural cour se.

8 Discuss t he t reatment of phalanx f r act ures and dislocat ions.


87

RESOURCES

- J ournal Amer ican Family Physicians J an 2001

- Management of Ankle Sprains Updat e Oct . 1988 Page 18

- Common Spor t I nj ur ies I n The Adolescent – Foot and ankle S A Bone and Joint Surgery

Vol. I X No. 1 Febr . 1999 Page 14

- I mplement at ion Of Ankle Ot awa Rules JAMA Marchilo 1994 Vol. 271, No. 11 Page 827

- Apleys Syst em of Or t hopaedics and f ract ures, Page 696

- Pract ical Fract ur e Treatment , Chapt er 14, Page 319

- J ournal Of Amer ican Family Physicians, Management Of Ankle I nj ur ies, Jan 1, 2001, Page

93

- J ournal Of Amer ican Family Physicians, I nj ured Ankles, Feb 1 1998, Page 474

- Apleys Syst em of Or t hopaedics and Fract ures

- Pract ical Fract ur e Treat ement , P. 707, Chapt er 15, Page 345

- J ournal Of Amer ican Family Physicians, Lisf r anc I nj ury Of The Foot July 1998, Page 118

- J ournal Of Amer ican Family Physicians, Fract ure Of Proximal 5t h Met at ar sal May 1, 1999

Page 2516


The aim of t his session is t o ensure t hat you can classif y ankle sprains and f ract ures and discuss

t he appropr iat e t r eat ment opt ions.

The aim of t his session is t o ensure t hat you can classif y f r act ures of t he t ar sal bones,

met at ar sal bones and phalanges of t he f oot radiologically and accor dingly discuss t he t r eatment

and cour se.

Lect ur e

This lect ure will t each t he st udent how t o evaluat e and t r eat a sprained ankle. You will be t aught

how t o apply t he Weber classif icat ion f or ankle f ract ur e dislocat ions, and t hus learn t o

dif f erent iat e bet ween a st able f ract ure which can be managed by your self and an unst able

f ract ure r equir ing surgery.

Dur ing t his lect ur e you will be shown how t o prevent a severely swollen f oot and, if pr esent , how

t o t r eat it . Calcaneous f r act ure pat t er ns, t he indicat ions f or surger y and t he longt erm

implicat ions t hereof will also be dealt wit h. You will be shown how t o apply a plast er f or t he

dif f erent f r act ur e pat t erns and dislocat ions of t he f oot . The suspicion and evaluat ion of a

Lisf r anc f r act ure dislocat ion will be discussed. You will be shown how t o r educe dislocat ions of

t he f oot .

Please complet e t he work assignment t hat was provided t o you.


88

THEME 21: SOFT TI SSUE I NJ URI ES OF THE

MUSCULOSKELETAL SI STEEM

AI M OF THE THEME

This t heme deals wit h lacerat ions and inj ur ies of t he skin, as well as t he more impor t ant deeper

st r uct ures, suh as muscles, t endons, ner ves and blood vessels. You should be able t o ident if y

t hese inj ur ies clinically, know t he emer gency t reatment t hereof as well as t he r ef er ral

guidelines f or complicat ed inj ur ies.



1 21/ 02/ 2006

14:00-14:45 Lect ur e Demonst r at ion

Lacerat ions And

Penet r at ing Skin wounds

Dr J Odendal

2 21/ 02/ 2006

15:00-15:45

Self -st udy

Lect ur e Demonst r at ion

Appr opr iat e Wound healing

And Wound dr essing Dr F Graewe

THEME 21: SOFT TI SSUE I NJURI ES OF THE MUSCULOSKELETAL SYSTEM

SESSI ON 1: LACERATI ONS AND PENETRATI NG SKI N

WOUNDS

OUTCOMES

1. Af t er t his session, you should be able t o ident if y simple skin lacerat ions, know t he met hods

of sut ur ing under local anaest het ic, and also know about t he af t er care and bandage

t echniques of such lacer at ions. 2. You should know t he basic pr inciples of wound debr idement . You should also know about

t he dif f er ent sut ure mat er ials and t heir proper t ies. You should be able t o ident if y wounds r equir ing secondary cover .

3. You should know t he implicat ions of penet r at ing wounds in dif f er ent anat omical areas.

4. You should be able t o dist inguish bet ween rupt ur e of a ner ve or t endon.

5. You should know t he prognosis of nerve and t endon inj ur ies.

6. You should be able t o ident if y a "degloving" inj ury and realise t he implicat ions t hereof .

7. You should know how t o t r eat a penet r at ing wound in a j oint .

8. You should know how t o sut ure muscle, skin, sinews and nerves.

9. You should be able t o r ealise t he sever it y of blunt t r auma t o t he musculoskelet al syst em

and ident if y t he syst emic complicat ions of "crush" inj ur ies.


89

RESOURCES

1. Per ipheral Nerve I nj ur ies. SA Bone & Joint Surgery, Vol 7, No 3, Aug 1997, Page 18.

2. Tendon I nj ur ies. CME, July 1996, Vol 14, No 7, Page 963.

3. Nerve Compression Syndromes. CME, July 1996, Vol 14, No 7, Page 995.

4. Wondhegt ing (Video casset t e) WO166 WOM U.S. Libr ar y


Lect ure

This session t akes t he f orm of a lect ure and deals wit h t he ident if icat ion of lacer at ions and

penet r at ing wounds of t he musculoskelet al syst em, and t he r ealisat ion of t he impor t ance

t her eof .

The sut ur ing of skin and muscle lacer at ions will also be discussed. The diagnosis of ar t er ial

ner ves and t endon lacerat ions will be discussed and guidelines will be pr eent ed f or t he t reatment

of t hese inj ur ies. "Crush" syndrome and "Degloving" inj ur ies will be br ief ly rement ioned f or

ident if icat ion.

THEME 21: SOFT TI SSUE I NJURI ES OF THE MUSCULOSKELETAL SYSTEM

SESSI ON 2: APPROPRI ATE WOUND HEALI NG AND WOUND

DRESSI NG

OUTCOMES

Af t er complet ion of t hese sessions, you should:

1. Underst and wound recovery and know t he f act ors inf luencing t his.

2. Dist ingush bet ween a hyper t r ophic wound and a keloid.

3. Know how t o approach an open wound and decide on which wound dressing is appropr iat e.

4. Underst and t he indicat ions and t echnique of skin t r ansplant .

5. Know t he reconst ruct ive guidelines f or wound dressing.

6. Underst and t he newly lacerat ed wound (bandages).

7. Know t he basic pr inciples of ulcer prevent ion and t r eat ment .

RESOURCES

1. Myst ery of Plast ic and Reconst ruct ive Surgery

Edit or : Mimis Cohen, Fir st Edit ion

Volume 1: Chapt er 1 Page 3 Woundhealt h

Chapt er 4 Page 45 Skin

Volume 3: Chapt er 132 Page 1828 Leg ulcers


90

2. Text book of Plast ic, Maximof acial and Reconst ruct ive Sur ger y

Edit or : Georgindes, Fir st Edit ion

Volume 1: Chapt er 5 Page 29 Skinwounds

Volume 2: Chapt er 97 Page 1291 Leg ulcers

3. Basic Wound Care Video Casset t e WO185 BAS. US Library

4. Wound Care Video Casset t e WO185 WU US Library

5. Wondhegt ing video casset t e WO166 WOM US Library

6. Per f orm resuscit at ion of t he pat ient .

7. Apply emer gency t r eat ment of t he burn.

8. Know whet her f ur t her surgical t r eat ment of t he burn is r equir ed.

9. Know whet her wound dressings are r equir ed in t he t r eat ment of burns.

10. Know how t o pr event cont r act ures af t er burns.

11. Know t he longt erm rehabilit at ion as well as t he prognosis of dif f er ent anat omical areas.


At t he end of t his t heme, you should under st and t he anat omy of t he skin and should t hus be able

t o r ecognise skin wounds and complicat ed skin avulsions.

You should have an approach t o t he t reatment of t hese wounds, as well as dist urbed wound

healing.

You should be able t o diagnose an ulcer , underst and t he aet iology and accor dingly know ho t o

t r eat such an ulcer .

Pre- st udy

Dur ing t his session, you should:

• Revise t he anat omy of t he skin.

• Underst and t he blood supply of t he skin.

• Underst and wound healing and t he f act ors inf luencing t his.

• Compile a list of t he var ious occlusive dr essings f or casualt y.

• Compile a list of t he dif f er ent causes of ulcer s.

Lect ur e wit h slides

Dur ing t his session, wound healing and wound dr essing will be descr ibed by means of slides and

clinical cases.


91

THEME 22: REHABI LI TATI ON, AI DS

AI M OF THE THEME

At t he end of t his t heme, you should be able t o descr ibe t he t r eat ment of t he most common

Or t hopaedic condit ions by Occupat ional Therapist s and Physiot herapist s, wit h special r ef er ence

t o aspect s of rehabilit at ion and aids.


• Anat omy: musculoskelet al syst em

• Muscle physiology

• MB ChB I V Musculoskelet al module, session 1 t o 18



1 22/ 02/ 2006

08:00-08:45 Lect ur e Rehabili t at ion and Aids Ms D Er nst zen

2 22/ 02/ 2006

09:00-09:45 Group wor k Ms D Er nst zen

3 22/ 02/ 2006

10:00-10:45 Lect ur e

Over all Obj ect ives of

a Rehabilit at ion Progr am Ms D Er nst zen


SESSI ON 1:

REHABI LI TATI ON AND AI DS

OUTCOMES

At t he end of t his t heme, you should be able t o do t he f ollowing:

• Name t he common obj ect ives of a r ehabilit at ion progr am

• Discuss t he f ollowing:

o t he prerequisit es f or a rehabilit at ion pr ogram

o t he component s of a r ehabilit at ion progr am

o t he dif f er ent t ypes of rehabilit at ion programs

o t he r ole of t he Physiot her apist and Occupat ional Therapist in or t hopaedic

r ehabilit at ion

• Discuss t he pr inciples of r ehabilit at ion wit h r ef erence t o or t hopaedic condit ions

• Name t he indicat ion, choice and use of aids wit h r ef er ence t o r ehabilit at ion.


92


Lect ure

Dur ing t he lect ure, r ehabilit at ion, as relevant t o or t hopaedic condit ions, and t he use of aids will

be descr ibed by lect urer f r om t he Deparment s of Occupat ional Therapy and Pysiot herapy.


SESSI ON 2:

OUTCOMES

At t he end of t his session, you should be able t o complet e t he f ollowing wit h r ef er ence t o t he

list of common Or t hopaedic condit ions below:

• Descr ibe t he general Physiot her apy and Occupat ional t herapy management of an individual

wit h an or t hopaedic condit ion at t he dif f erent levels of rehabilit at ion.

• Give indicat ions f or r ef er r als t o Occupat ional t herapy and Physiot herapy.

• Wr it e a successf ul r ef er r al t o Occupat ional t herapy and Physiot herapy.

RESOURCES

- Br ukner , P & Khan, K. (2001). Clinical Spor t s Medicine (Second Edit ion). McGraw Hill

Companies.

- Mennen, Ulr ich. (1994). The Handbook: A Pract ical Approach To Common Hand Problems

(Second Edit ion). Nat al: J L of Schaik Publishers.

- Neist adt , Maureen E. & Crepeau, Elizabet h Blesedell. (1998). Willard & Spackman’s

Occupat ional Therapy (Nint h Edit ion). Philidelphia: Lippencot t -Raven Publisher s.

- Pedret t i, Lor r aine Williams & Ear ly, Mary Bet h. (2001). Occupat ional Therapy: Pract ice

Skills For Physical Dysf unct ion (Fif t h Edit ion). Missour i: Mosby I ncorporat ed.

- Twomey, L & Taylor , J . (1994). Physical Ther apy Of The Low Back (Second Edit ion).

Chur chill Livingst one.

OTHER RESOURCES

• Medline -ht t p:/ / www.ncbi.nlm.nih.gov/ PUBMED/

• Physiot her apy Global Links - ht t p:/ / www.net spot .unisa.edu.au/ pt / index.html


93


Lect ure

I nt eract ive lect ure in t he f orm of a discussion wit h Physiot herapy and Occupat ional Ther apy

t r eatment . This will be based on condit ions t r eat ed in MB, ChB I V Musculoskelet al modules,

Session 1 t o 18 and previous video pr esent at ion.


SESSI ON 3: OVERALL OBJECTI VES OF A REHABI LI TATI ON PROGRAM

GENERAL OBJECTI VES OF A REHAB PROGRAM

Rehab has been def ined as “a process aimed at enabling persons wit h disabilit ies t o r each and

maint ain t heir opt imal physical, sensor y, int ellect ual, psychiat r ic and/ or social f unct ional levels,

t hus providing t hem wit h t ools t o change t heir lives t o a higher level of independence. I t may

include measures t o provide and/ or rest ore f unct ions, or compensat e f or loss or absence of

f unct ion or f or a f unct ional limit at ion. The r ehabilit at ion process does not involve init ial medical

care…”

RM Wat son, Should Rehabilit at ion Be Redef ined?. SA Journal of OT, May 1997

Rehab at var ious levels and not only in t he hospit aal.

- I nst it ut ion-based r ehab

- Out r each rehab services

- Communit y based rehab

Component s of rehab: - Whit e Paper

- Medical r ehab – t her apy

- Psychological rehab

- Educat ional r ehab

- Vocat ional r ehab

- Social rehab

- Assist ive devices

What is t hus t he obj ect ives of a r ehab program in SA? - Whit e Paper

- To enable people wit h disabilit ies t o r each and maint ain t heir opt imal physical, sensory,

int ellect ual, psychiat r ic and/ or socail f unct ional levles

- To provide people wit h disabilit ies wit h t he t ools t o change t heir lives and t o give t hem a

gr eat er degree of independence

- To prevent secondary disabilit ies or t o r educe t he ext ent of disabilit y

- To t ake int o account t he specif ic needs of dif f er ent disabilit y groupings.

Nat ional rehab policy t hus est ablished


94

What ar e t he prerequisit es f or a r ehab progr am?

- Rehab ser vices in place

- I nt er sect oral collabor at ion

- Human r esour ces

- Financial and ot her resour ces

Component s of a r ehab progr am?

- Disabilit y prevent ion and healt h educat ion

- I dent if icat ion and diagnosis

- Treat ment and t herapeut ic aids

- Educat ion

- Assist ive devices

- Vocat ional guidance and pre-employment t raining

- Employment

AT WHAT LEVEL DO DOCTORS, WHO SEE ORTHO PROBLEMS, WORK?

Rehab pr inciples as applicable t o Or t ho pat ient s:

WHAT ARE THE REHAB PRI NCI PLES?

Use of aids:

Assist ive devices can be divided int o t he f ollowing cat egor ies:

They may enhance mobilit y, communicat ion, daily living

Or t ho especially wit h r egards t o mobilit y and ADL


95

TI METABLE

Unless ot herwise indicat ed wit hin t he st udy gide, all act ivit ies will t ake place in Lect ure Hall 8

of t he Educat ion Block.

WEEK 1: 6 – 10 FEB 2006

TI ME

MONDAY

06/ 02/ 2006

TUESDAY

07/ 02/ 2006

WEDNESDAY

08/ 02/ 2006

THURSDAY

09/ 02/ 2006

FRI DAY

10/ 02/ 2006

08:00-08:45 Welcoming

& Review

T2 (S6) Lect ur e

T4 (S3) Lect ur e

T5 (S1) Lect ure

T7 (S3,4) Case St udy

09:00-09:45 T1 (S1)

Self -st udy T2 (S7) Lect ur e

T4 (S4) Lect ur e

T5 (S2) Lect ure

T8 (S1) Lect ure

10:00-10:45 T2 (S1) Lect ur e

T6 (S1) Lect ure

T8 (S2) Self -st udy

11:00-11:45 T2 (S2)

Self -st udy T3 (S1,2) Lect ur e

T4 (S5) Lect ur e

T6 (S2) I nt eract ion

T8 (S3,4) Case st udy Self -st udy

12:00-12:45 T2 (S3) Lect ur e


T4 (S6,7)

Lect ur e

Self -st udy


13:00-13:45 LUNCH

14:00-14:45 T2 (S4) Lect ur e

T4 (S1) Lect ur e

T4 (S8) Lect ur e

T7 (S1) Lect ure

15:00-15:45 T2 (S5)

Lect ure Demo T4 (S2) Self st udy

T7 (S2) Lect ure

16:00-16:45

17:00-17:45


96

WEEK 2: 13 – 17 FEB 2006

TI ME

MONDAY

13/ 02/ 2006

TUESDAY

14/ 02/ 2006

WEDNESDAY

15/ 02/ 2006

THURSDAY

16/ 02/ 2006

FRI DAY

17/ 02/ 2006

08:00-08:45 T9 (S1) Lect ur e

T10 (S3) Lect ur e

T12 (S1)

Lect ure

T14 (S1) Lect ure

T15 (S1) Lect ure

09:00-09:45 T9 (S2) Lect ur e

T10 (S4) Lect ur e

T12 (S2)

Lect ure

T14 (S2) Lect ure

T16 (S1)

Lect ure

Self -st udy

10:00-10:45 T9 (S3) Revision

T11 (S1) Lect ur e

T13 (S1,2) Lect ure

Self -st udy

T14 (S3) Lect ure

T16 (S2)

Lect ure

11:00-11:45 T9 (S4)

Assessment T11 (S2) Lect ur e

T13 (S3,4) Lect ure

Self -st udy

T14 (S4) Lect ure

T17 (S1) Lect ure

12:00-12:45 T11 (S3) Lect ur e

T13 (S5,6)

Lect ure

Self -st udy

13:00-13:45 LUNCH

14:00-14:45 T10 (S1) Lect ur e

15:00-15:45 T10 (S2)

Lect ur e

16:00-16:45

17:00-17:45


97

WEEK 3: 20 – 24 FEB 2006

TI ME

MONDAY

20/ 02/ 2006

TUESDAY

21/ 02/ 2006

WEDNESDAY

22/ 02/ 2006

THURSDAY

23/ 02/ 2006

FRI DAY

24/ 02/ 2006

08:00-08:45 T18 (S1) Lect ur e

Self -st udy

T20 (S1) Lect ur e

T22 (S1) Lesing

St udy

09:00-09:45 T18 (S2) Lect ur e

T20 (S2) Lect ur e

T22 (S2) Gr oup Work

10:00-10:45 T19 (S1)

Lect ur e

T20 (S3)

Lect ur e

Self -st udy

T22 (S3) Lect ure

11:00-11:45 T19 (S2) Lect ur e

T20 (S4) Lect ur e

Assessment

12:00-12:45 T19 (S3)

Lect ur e

T20 (S5)

Lect ur e

13:00-13:45 LUNCH

14:00-14:45 T21 (S1) Lect ur e

15:00-15:45 T21 (S2)

Lect ur e

16:00-16:45

17:00-17:45

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