Orthopaedics 101

My fellow Steemians,

As a resident physician, I am constantly learning and working to perfect my practice of orthopedics. It's funny that about half the time I tell people I practice "orthopedics" I get, "Oh right! Kids!". I usually grin and tell them that's actually Pediatrics.

Orthopedics is the study of bones and the skeletal system. When a BMX rider crashes over the handle bars and breaks their wrist, we're the ones who fix it. When Adrian Peterson tears his ACL, we're the ones that reconstruct it. When your grandma can't walk because of her knee or hip pain, we're the ones that replace it. The umbrella of orthopedics is actually quite broad. So broad in fact that many orthopedic surgeons consider it to be 8 different sub specialties.

For the most part, orthopedics can be broken down into the following areas:

• Spine: diseases/disorders of the central/peripheral nervous system as well as bony deformity of the spine (spinal cord tumors and anything inside the skull is usually handled by a neurosurgeon)
• Reconstruction: hip and knee replacements, not just the first time around but complicated ones (e.g infection, multiple surgeries on the same joint, or complex deformity)
• Sports: typically this involves ACLs, shoulders and elbow. However, most sports surgeons do a large amount of general as well
• Pediatrics (yes actual kids): children, this is pretty broad from foot deformity to complex spine for scoliosis
• Tumor: exactly like it sounds, cancers and benign tumors of the skeletal and muscle systems
• Foot and Ankle: deformity such as bunions as well as fractures of the foot and ankle
• Hand: anything from the elbow to the finger tips (usually), although some surgeons don't do from the wrist to elbow
• Trauma: car accidents, slips and falls, etc. These surgeons go pretty much anywhere in the body but are particularly adept at complex pelvis fractures and complex fractures of long bones (think shin, ankle, and femur).

Many of these specialties overlap with each other. For example, an ankle fracture can be treated by a trauma surgeon, a foot and ankle surgeon, or even a general orthopedist (simple ankle fractures are bread and butter orthopedics). So, when should you seek out a specialist? The easy answer is when that doctor tells you "I don't do that", duh! However, you can ask yourself or your referring doctor if there is a specialist they recommend. These days most graduates of orthopedic programs in the US go on to sub-specialize in one of those 8 general categories so true generalists are becoming fewer and further between. Most surgeons won't schedule you for an appointment if you are telling them you have a problem they don't see.

A more important distinction is what residency did the surgeon complete? There are several non-orthopedic surgeons that overlap with the specialties listed above. This is not to say that one is necessarily better than the other but for an orthopedic problem I would rather see an orthopedist. Below are the other specialists that may practice on the same part of the body along with what I would do for, say, a close family member.

• Spine: orthopedics and neurosurgery, NOT CHIROPRACTICS
  -- For most disorders of the spine (bony abnormalities) I would hands down choose an orthopedic surgeon over a neurosurgeon. The only exception is with a tumor of the spinal cord itself. Most neurosurgeons, except those that have done specialized spine training, will take care of problems other than spine. They're not true specialists. I have seen patients who have been operated on by neurosurgeons that even the first year resident could tell was not done properly. Neurosurgeons take care of the spine as part of their training but so do orthopedists. You shouldn't go to a general orthopedist for the spine and you shouldn't go to a general neurosurgeon for it either. Orthopedists are more adept at correcting deformity, and stabilizing the spine by virtue of their training only after they have completed an extra year of focused training in spine.
  -- Chiropractors are not medical doctors by any stretch of the imagination. They may call themselves "doctors" but they are doctors through education, not through medicine. They have no formal medical training and should not be looked to for any type of medical advice. Lately I've seen the term "chiropractic orthopedics" this is a ruse term to make them sound more marketable. There is little to no high quality research that chiropractics provides any medical benefit for conditions of the spine. You can show me all the YouTube videos of miracle worker chiropractors you want to but until there is an objective study using the scientific method that demonstrates that I will roll my eyes every time a patient tells me "my chiropractor....". You wouldn't go to a bike shop for your motorcycle.
  -- For a family member of mine, unless there's a spinal cord tumor, I'm making sure they're seen by an orthopedic surgeon. If there were a spinal cord tumor the neurosurgeon is doing the tumor part and I'm finding an orthopedist to do the bony work.

• Hand: orthopedics, plastic surgery, general surgery
  -- Proper care of the hand is very important. It is a highly mobile part of the body that is very detrimental when not functioning properly. Care of the hand does not just involve bones; blood vessels, tendons, and nerves are important structures that may need repair. In my experience hand surgeons from all backgrounds are well equipped to handle disorders of the hand. The general surgeon is probably the biggest outsider in this group due to the fact that they don't do specific hand surgery during their residency but the principles of management and surgical technique are applicable to the hand. One important thing to keep in mind is that the rehab is as important, if not more important than the surgery itself.
  -- For a family member of mine, I'm making sure they are either orthopedics or plastics trained surgeon.

• Foot and Ankle (F&A): orthopedics and podiatry
  -- Podiatrists also care for the feet and go to special school for care of the foot. They are trained in a more medical model than chiropractors and also receive surgical training. However, their scope is limited to just the lower extremity and they receive less overall training than their orthopedic counterparts. Podiatrists are required to complete a 2-year residency after completing 4 years of podiatry school. Orthopedic F&A surgeons have completed 4 years of medical school, 5 years of residency, followed by 1 additional year of specific F&A training.
  -- For a family member of mine, I am making sure they are seen by an orthopedic surgeon unless it's for a diabetic foot ulcer. Any surgical problem would be handled by an orthopedist.

Most people are not just going to go find an orthopedist when they have a problem, they will get a referral from their primary doctor. That's where knowing these specialties comes in handy. If you know that you are having a hand problem, why not go see a hand specialist? My thoughts exactly! However, you don't know to ask for one unless you know they're out there, and that's the whole point of this article. Education. Patient education is one of the most important things when it comes to getting a good outcome from anything you do in medicine.

Next, don't be afraid to get a second opinion. If you don't feel confident that you understand exactly what is going on, why it is going on, and what the plan is to address it then find another opinion. You will be surprised how many ways there are at handling the same problem in medicine. For most situations the first time you are seen by an orthopedist surgery is not the first thing they try or recommend. In fact, a great question to ask them is "What harm is done by a trial of non-operative management?" The answer to this question will tell you what might happen if surgery is not performed so that you may understand the risk of not operating.

Because the medical system is so complex, in every way, one way to address this knowledge gap in medicine is through "Board Certification". This is a standardized metric that all physicians within a given specialty evaluate each other to ensure quality within a given field. With that said, any board certified physician within a specialty is more than well equipped to care for the problems within that field. After that it comes down to their bedside manner and how much you trust and connect with them. You should ALWAYS feel as though you are being heard and educated by your physician. If you ever feel as though you are being talked at or brushed off then it's time to find another who may be a better fit for you. Shared and informed decision making between a physician and patient leads to the best outcome.

What are your thoughts? Feel free to let me know in the comments below!