Chapter 1: Orthopaedics in Perspective

Being involved in medical training is always overwhelming, especially when you begin a new field of study and realize how much there is to learn. Orthopaedic surgery is no exception—it is a huge field spanning all age groups and affecting all parts of the body in the musculoskeletal (MSK) system.

All the various disease processes can affect the MSK system and enter into the differential diagnosis. Historically, traumatic and infectious disorders and their sequelae (such as polio or tuberculosis) have caused most of the pathology in orthopaedics. We can take a step back in time in orthopaedic care if we travel to the developing world today. In the developed world, we still have trauma and its sequelae producing our caseloads, but degenerative disorders, rather than infection, now dominate our elective practices.

People are living longer and are healthier at older ages than they were a generation ago. Now, people’s hips and knees are routinely replaced in order to maintain mobility, even though their parents may have been resigned to sit in a wheelchair because there were no other viable treatment options. The average age of hip-fracture patients continues to rise due to improved medical management of co-morbidities such as diabetes, heart disease, and lung disease.

Medicine will never be free from infection and its sequelae, but primary osteomyelitis or septic arthritis is now uncommon. Today, infection presents in situations where immunity is somehow compromised or in the patient with an orthopaedic implant.

Fortunately, in orthopaedics, primary bone tumours are rare and death is uncommon. Metastatic pathological fractures can be fixated and radiated, with gratifying results for patients, and are rarely terminal events. There is, however, a significant one-year mortality rate in elderly hip-fracture patients (15%-25%) due to complications from the original injury. Most of these patients die outside of hospital.

What specialists in this area do have to deal with is chronic disability. Almost every orthopaedic condition affects a person’s mobility and ability to work or to pursue his or her vocation in life. Recovery from elective orthopaedic surgery and from most fractures takes 3-6 months. Recovery from a fractured hip or multiple trauma takes at least one year and may never be complete. In addition, a healed fracture alone does not always equate with a successful outcome.

Patient expectations vary widely: work demands, activity levels, and hobbies all come into play and are of particular importance in orthopaedics. Young patients with high-energy traumatic injuries in particular need to be told as soon as possible that they may be unable to achieve their pre-injury levels of work or sport, even once the fracture is healed.

Outcomes are also affected by timely access to care. What is an appropriate wait time for hip replacement or fractured ankle surgery? When does an elective condition become urgent? What does urgent—or emergent—care mean? Ideally, most displaced fractures or dislocations, and most significant infections, should be treated within 12-24 hours. Minimally displaced fractures can be treated within 5-7 days, provided they have been well splinted. Elective orthopaedic surgeries should be performed within 3 months of surgical consultation. The longest wait, generally, is for the initial consultation, with patients often waiting up to 2 years. The whole area of wait times in medical care has become a hot political issue for politicians and hospital administrators in recent years since public funding is involved. So-called “benchmarks for care” are being developed for health care delivery across jurisdictions.

Energy Level and Age of the Patient

In my years of orthopaedic practice, I have found that two factors, more than any others, predict what pathology/injury will be found and what the likely outcome will be. The first is the age of the patient; the second is the amount of energy involved in the original injury.

First, the age of the patient predicts the weak link when force is applied to a joint or extremity. As the bones and joints develop, grow, mature, and then degenerate, one can predict where they will fail at each stage when a pathological force is applied. I have found this to be very useful clinically. A valgus blow to the lateral knee, for example, will cause a Salter II fracture of the distal femur in a 15-year-old, an MCL tear in a 25-year-old, and a lateral tibial plateau fracture in a 70-year-old. In non-traumatic conditions, age predicts patterns we see repeatedly: hypermobility joint issues in the young, overuse conditions in adults, and degenerative conditions in the older age group.

Second, the amount of energy involved in the trauma, or the sequelae of the trauma, significantly predicts the outcome. As the energy rises, the fracture becomes more fragmented, there is more soft tissue damage, and multiple body areas can be involved. These fractures are more difficult to fix initially, take longer to heal, and have more early and late complications. Even if you are seeing a patient years later with a post-traumatic degenerative condition, the amount of energy involved in the original accident can predict the outcome and potential reconstruction challenges. Orthopaedic histories may be brief, but one must get an idea of how much energy was involved in producing the injury.

In summary then, the conditions we see and the treatments we use in orthopaedic practice are evolving over time. Disability is a significant issue and patients are less tolerant of their limitations than previous generations. Finally, the energy level involved in the injury and the age of the patient will predict where the weak link around the bone and joint resides and what fracture pattern and outcome one will likely see.