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A mailed survey questionnaire was distributed to the North Carolina Academy of Family Physicians to assess their orthopedic training and their opinions of the orthopedic training of resident physicians in family practice. Approximately 300 questionnaires were analyzed and the spectrum of orthopedic activities in office, hospital, and community were tabulated. There was no significant geographic variation in practice within the state for these variables, but there were statistis in their management and referral practice of several patient problems. Seventy percent of respondents thought that their training in orthopedics was appropriate to their present practice, but half felt that their training was inadequate. Most of the respondents (57 percent) had less than one month of postgraduate training in orthopedics. The majority (68 percent) recommended some postgraduate training in orthopedics, with about 50 percent recommending one to three months of postgraduate training. The mail survey questionnaire is proposed as a useful aid in curricular design in family practice.
The spectrum of orthopedic problems encountered by family physicians in everyday practice has received little study in the past. This paper presents and analyzes the incidence and distribution of orthopedic problems in general/family practice based on four sources of secondary data. These sources include the National Ambulatory Medical Care Survey, a Family Practice Service in a large military teaching hospital, a state wide study in Virginia, and two community-based family practice settings in Washington State. Orthopedic problems constitute about ten percent of all office visits in family practice. Over one half of these involve chronic, nontraumatic musculoskeletal problems. Major differences are noted in the distribution of sprains, strains, and fractures in adults and children. Fractures of the hand, foot, forearm, lower leg, and clavicle comprise between 50 and 80 percent of fractures seen in the settings under study. This kind of information should be helpful in better defining goals and methods for graduate training of family practice residents in orthopedics.
The history of orthopedic surgery in Canada is briefly reviewed. It appears that the problems which were posed in the 1960s and early 1970s have diminished in importance. They related to the shortage of orthopedic manpower and to the lack of a sound scientific base within universities. There appears now to be an adequate number of orthopedic surgeons to handle the needs of the population, and Canadian training programs are providing replacements at an appropriate rate. Future problems will in all probability relate to the interrelationship between society and the medical profession. Academic freedom and mobility of medical manpower must be preserved at all costs and the orthopedic profession must adapt to an ever-changing situation if future developments are to be as satisfying as our very exciting past.
Craniomaxillary orthopedic correction of the skeletal imbalance of Class II malocclusions is often the desired method of treatment in these cases. The ability to apply a "pure" orthopedic force to the maxillary complex has so far eluded research efforts. However, the use of a maxillary splint with a high-pull extraoral traction assembly has been shown to be most effective in reducing Class II skeletal dysplasias through a combination of dentoalveolar and basal bone changes. Force delivery to the maxillary complex in Class II skeletal jaw disharmonies is through the teeth. The philosophy behind the use of the maxillary splint is that if the force delivered to the upper jaw involved the use of all the upper teeth (and hard palate) rather than only the maxillary first molars, as in conventional extraoral orthodontic therapy, the effect on the jaws would be more orthopedic than orthodontic in nature. The advantages of the use of the maxillary splint in the younger patient with a severe Class II malocclusion are that it reduces the vulnerability of the maxillary incisors to accidental fracture, while concomitantly reducing the Class II dysplasia, thereby effectively shortening the later-stage multiband corrective time and procedures. Further advantages of the maxillary splint described are ease of construction and clinical application, which makes it an attractive appliance for use in dental clinics or institutions in which patient volume, infrequent visits, and ecomomic factors are major considerations. This preliminary report on the philosophy of treatment procedure and description of the appliance design is to be followed by a further cephalometric and clinical evaluation of results achieved with its use.
Part 1 of an introductory overview of orthopedic manual therapy is presented, covering evaluation and treatment of the extremities. The first section defines introductory concepts about passive movement, including types of movement, limitations of movement, and types of treatment movements. The remaining four sections cover general concepts, evaluation schemes, and treatment procedures of four practitioners belonging to different schools of thought in orthopedic manual therapy: James Cyriax, MD, MRCP; Freddy Kaltenborn, DO, RPT; Geoffrey Maitland, MAPA, FCSP; and John McM Mennell, MD. The conclusion stresses the importance of developing skills in evaluation, as well as treatment, prior to practicing orthopedic manual therapy.
Neuro-orthopedic examination was carried out on 429 patients suffering from LBP, and on 271 controls. Neurological deficit was found in 49 LBP but in none of the controls. Of the orthopedic signs, the most significant indicators of LBP were hypolordosis, scoliosis, limitation of movement and contracted paraspinal muscles. Various degrees of affection of the hip joints were found in 49 LBP as against 4 controls; the majority of these patients complained of LBP and not of hip disorders. It is stressed that an early and thorough neuro-orthopedic examination is essential for diagnosis and therapy and has important legal implications, mainly with regard to the time factor.
This study compared personality characteristics of children with cleft lip and palate to another group of children with different observable physical impairment (orthopedic disability) and speech difficulties. It was hypothesized that different types of observable physical stigmata may result in different personality adaptations. Forty-five children from each of two groups (25 males and 20 females) were matched for sex, age, and intelligence. They were compared using the Missouri Children's Picture Series, a non-verbal personality test, on the following dimensions: Conformity, Masculinity/Femininity, Maturity, Agression, Inhibition, Activity Level Sleep Disturbance and Somatization. The results indicate that males with cleft lip and palate are significantly higher on Maturity and Inhibition while Orthopedically Disabled males are higher on Agression, Activity Level, and Somatization. Cleft lip and palate females are significantly higher on Maturity and Inhibition while Orthopedically Disabled females are higher on Masculinity. The results indicate differential personality adaptations in the two different types of observable physical impairments. Results are discussed in terms of their relationship to selected psychosocial variables.
To compare 99mTc-polyphosphate and 18F for use in orthopedics, 79 patients were examined with both. Fifty cases were suitable for analysis. While the extraskeletal uptake of 18F was found to be negligible, 99mTc-polyphosphate may accumulate considerably in pathologic soft tissue, e.g., in soft-tissue tumors and in inflamed synovial tissue. This soft-tissue Tc accumulation may obscure the osseus uptake, notably in the examination of joint regions, commonly the regions of interest in orthopedics. After simultaneous administration of both agents, quantitative measurements were performed on specimens of bone and synovial tissue from diseased joints in human patients and in rabbits. The uptake of 99mTc-polyphosphate in synovial tissue was shown to be about seven times that of 18F, while their uptakes in bone were equal. In short, 99mTc-polyphosphate, a valuable tracer in general, is hardly the agent of choice in orthopedics.
Wound irrigates and tissue samples were cultured from clean orthopedic wounds at the conclusion of 280 orthopedic operations. The surgeons used a laminar flow unit and took extra precautions against wound contamination although personnel exhaust systems were not used. It was possible to culture residual organisms but difficult to trace the source of these by bacteriological methods. Artificial or "tracer" particles which could be applied to patient or surgeon were retrieved from the wound and suitably stained. Using albumin microspheres it was possible to identify and differentiate "patient-derived particles" from "surgeon-derived particles" in the majority of all wounds. Contamination from the surgeon was significant even under near optimum operating room conditions. These techniques are useful for development of control measures for residual wound contamination in orthopedic operating rooms.
Deposition of 67Ga in bone does not explicitly imply osteomyelitis. Osteomyelitis complicating insertion of orthopedic devices is manifested by lack of congruence in the distribution patterns of 99mTc-PP and 67Ga. Congruent patterns can reflect the increased bone reaction to implantation or loosening of the device, not necessarily osteomyelitis. Both (a) nonseptic synovitis secondary to reactive bursa formation and (b) cellulitis exhibit an affinity for 67Ga and virtually none for 99mTc-PP, whereas the reverse is true for heterotopic bone. Thus combined sequential 99mTc-PP/67Ga imaging is necessary for evaluation of complications associated with internal orthopedic devices.
This study describes the orthopedic treatment and utilization of health care obtained by 2,333 patients in the population of Rochester, Minnesota, who suffered 2,519 limb fractures during the period 1969 through 1971. Overall, 24% of fracture occurrences required patient hospitalization, the remainder involving care on an ambulatory basis only. The mean number of physician visits was 4.5 per fracture, with the visits occurring during an interval of 103 days from the time of first evaluation. Fifteen percent of limb fractures were subject to at least one surgical operative procedure as part of their orthopedic treatment. The frequency of operative treatment increased markedly with patient age. Seventeen percent of patients with limb fractures received physiotherapy or occupational therapy or both, 4% were ambulatory patients, and the remainder were hospital inpatients. Fractures of the head and neck of the femur constituted only about 7% of fractures in the series, yet utilized an inordinate proportion of health care resources. Hip fractures were responsible for 27% of the hospital admissions, 52% of all bed days utilized, and 56% of the physiotherapy sessions.
In order to apply adequate postoperative management of patients in the orthopedic surgery, the in vivo effects of the operations were investigated in the present study, from various viewpoints such as circulatory functions, metabolism of proteins, and hepatic and renal functions. In addition, the circulating blood volumes were determined in order to know the variations in the amount of blood loss from the operated regions during and after operations so as to improve the operative and postoperative management. On the basis of the results, the countermeasures against the adverse variations in blood volume were also investigated. Pediatric patients were found to be prone to develop more appreciable systemic postoperative reactions than those in adult ages, especially so in those of circulatory system, peripheral blood, hepatic functions, and protein metabolism, and also prone to be more affected by operative procedures. Senile patients were found to be prone to have less reserve capacity in circulation, peripheral blood, renal functions, and protein metabolism, and also prone to show delayed postoperative reactions and slower recoveries. The results of measurement of circulating blood volume in pre- and postoperations revealed that the loss of circulating blood in most patients was greater than the bleeding weight during the operation measured by gause count, and that, on the day following the operation, the blood volume was reduced by about 10-15% than those immediately after the operation. It was concluded that, as a whole, no changes causing serious deviation from the normal physiological ranges occur except in pediatric and senile patients. On the basis of the above findings, most appreciable systemic postoperative reactions of the operative procedures in orthopedic surgery would be attributed to by loss of blood volume during operations and that the postoperative hemorrhage from bone structure (which is usually difficult to control) or the postoperative hemorrhage after removal of air tourniquet would be almost negligible.
This paper describes the various technics of orthopedic surgery currently used to correct scoliosis and maintain correction. Among corrective methods they illustrate the use of the Cotrel plaster corset (E.D.F.) preceded by passive bipolar traction and autoelongation. Once correction is achieved, it must be maintained to the end skeletal growth; this is done with various types of orthopedic corsets (Lyonnais, La Padula, Milwaukee), which are used according to the patient's age and anatomical type of deformity. The authors discuss in particular the forces that are applied to the occiput and mandible with the Milwaukee corset (Logan, Cochran and Waugh), the values being recorded in diverse situations including the upright stance, ambulation, sitting position, position, supine position, and sleep (Galante, 1970). The authors also made a comparative study of the conventional Milwaukee corset (with broad chin bearing) versus the Milwaukee with hyoid bearing; and finally they illustrate the results obtained by Andriacchi and his associates in selecting the Milwaukee corset for patients with idiopathic scoliosis on the basis of the mathematical model of the rachis.